Every finding on record at Westminster Baldwin Park

Based on interview, and record review, the facility failed to provide assessment, and notification of physician for a symptomatic resident having chest pain after cardiac surgery, for one of one resident reviewed for hospitalizations, out of a total sample of 21 residents, (#20).Findings: Resident #20 was admitted to the facility from an acute care hospital on [DATE] following aortic heart valve repair surgery. She had diagnoses that included coronary artery disease (CAD), atrial fibrillation (A-Fib), pulmonary fibrosis, asthma, and generalized muscle weakness. Review of State Agency Form 3008 dated 10/29/25, revealed resident #20 was capable to make her own healthcare decisions and was transferred to the skilled care facility for continuation of care and rehabilitation services post aortic valve replacement. Review of resident #20's medical record revealed a care plan initiated on 10/30/25 for risk of cardiac complications related to diagnoses that included of A-Fib, CAD, arteriosclerotic heart disease, arrythmia, and post cardioversion. The goal was for the resident to have no symptoms of acute cardiac event and interventions included monitoring vitals and observation of the resident for symptoms of cardiac complications, such as chest pain, abnormal pulse, and abnormal blood pressure. The care plan did not specify what staff needed to do if the resident displayed cardiac complications. On 1/21/26 at 12:17 PM, resident #20 stated, via phone interview, that she was admitted to the facility for rehabilitation services and skilled nursing care after cardiac surgery. She said she believed the facility was not appropriate for the level of care that she required. Resident #20 recalled on the early morning of 10/30/25 she was not feeling well, and her heart rate was elevated. She said she informed the nurse and when her vitals were taken her blood pressure and heart rate were elevated. She said the nurse told her they would wait to see if the blood pressure came down on its own, but the nurse did not seem concerned. She stated she contacted her cardiologist, who recommended she go to the emergency room right away, so she called emergency services (EMS) 911 and was transferred to the hospital. She said she preferred not to return to the facility. Review of resident #20's vitals summary dated 1/22/26, revealed on 10/29/25 at 7:41 PM, her blood pressure (BP) was 123/62, heart rate (HR) 72, and oxygen saturations (O2 sats) on room air was 94%. On 10/30/25 at 10:50 AM, her BP was 150/100, HR 133, and O2 sats at 7:20 AM were 91%. Signs of a failing heart valve replacement were usually similar to those experienced prior to receiving a new valve. Some of the most common signs included: chest pain or discomfort, fainting or lightheadedness, rapid heartbeats, and shortness of breath. It was recommended for patients to call 911 immediately as these could be signs of a medical emergency, (retrieved from www.healthline.com on 2/02/26). Review of the resident's medical record revealed there was no change of condition assessment documented or a nursing progress note to show the physician was notified, family was notified, and emergency services were called after the abnormal vital signs on 10/30/25. The facility was unable to provide any documentation regarding the event other than a baseline care plan and a handwritten order from the Advanced Practice Registered Nurse (APRN) dated 10/30/25, that indicated, sent to ER (emergency room) for evaluation of chest pain/hypertensive crisis. On 1/22/26 at 11:00 AM, the Director of Nursing (DON) stated resident #20 was evaluated by the nurse when she complained of chest pain and was transferred to the hospital immediately. She acknowledged there was no documentation to show an assessment was completed by the nurse or that the nurse notified the physician, family, and emergency services. She stated her expectation was for staff to recognize changes in condition and prevent delays in care. Review of the hospital records for resident #20 dated 10/31/25, revealed she arrived via EMS after she called them due to heart palpitations. The facility did not have a policy on changes in condition.

Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 2 of 5 residents reviewed for hospitalization, of a total sample 21 residents, (#7 and #20). Findings: Cross reference F684 1. Resident #7 was admitted to the facility on [DATE] with diagnosis including one-sided paralysis and weakness following stroke affecting left non-dominant side, , spontaneous hypotension, nerve pain and osteoporosis. A review of the resident's electronic medical record revealed a progress note dated 1/14/26 at 3:40 AM, indicating that the resident was found kneeling on her floor mat beside her bed. The resident stated she was trying to go to the bathroom, and she thought she could make it herself. The note detailed the resident had no injuries and noted neurological checks were initiated. Another progress note made later that day, on 1/14/26 at 11:54 AM, revealed the resident was transferred to the hospital in an ambulance. A review of resident #7's assessments revealed no change in condition or Situation, Background, Assessment, and Recommendation (SBAR) assessment present that documented the event leading up to the hospitalization on 1/14/26. On 1/22/26 at 9:53 AM, the Director of Nursing (DON) acknowledged there was no documentation in the resident's electronic medical record to describe the series of events that led up to the resident's transfer to the hospital on 1/14/26. The DON stated that the resident had an acute change of altered metal status with difficulty in her speech and was therefore transferred to the hospital. She confirmed there was no change in condition assessment, nor a progress note documented about the event until it was brought to their attention during the survey. The DON said her expectation was for the nursing staff to document a change in condition assessment or a SBAR assessment at the time of the event. The DON explained that the residents' medical record should tell a story and contain all of the information needed to tell the entire story. 2. Resident #20 was admitted to the facility from an acute care hospital on [DATE] following aortic heart valve repair surgery. She had diagnoses that included coronary artery disease (CAD), atrial fibrillation (A-Fib), pulmonary fibrosis, asthma, and generalized muscle weakness. Review of State Agency Form 3008 dated 10/29/25, revealed resident #20 was capable to make healthcare decisions and was transferred to the skilled care facility for continuation of care and rehabilitation services post aortic valve replacement. Review of resident #20's medical record revealed a baseline care plan dated 10/31/25 which stated, resident transferred to the ER (emergency room) 10/30/25, verbal consent given. Review of physician orders in resident #20's electronic medical record revealed no orders to transfer the resident to the hospital ER. During the survey, on 1/21/26 a paper copy of an order was provided by the DON which had not been scanned into the system. The order, which was dated 10/30/25 and signed by the Advanced Practice Registered Nurse (APRN) stated, Sent to ER for evaluation of chest pain/hypertensive crisis. Resident #20's medical record revealed no skilled assessment, progress note, change of condition, or hospital transfer note that provided an explanation for the resident's change of condition. The medical record did not identify when the physician was made aware of resident #20's change in condition or whether family was notified of her transfer to the ER. On 1/22/26 at 11:00 AM, the DON acknowledged there was no documentation to show that an assessment was completed by the nurse or that the nurse notified the physician, family, and/or emergency services. She said the expectation was for staff to ensure documentation was accurate and complete. The facility policy, Documentation Policy last revised June 2025, indicated each resident's medical record should contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation.

Based on observation, interview, and record review, the facility failed to adhere to proper infection control practices related to transmission-based precautions and personal protection equipment (PPE) use for 1 of 5 residents reviewed, of a total sample of 21 residents, (#4).Findings:Resident #4's was admitted to the facility on [DATE] with diagnoses including infection to the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus (MRSA) infection, type 2 diabetes with nerve pain, bacteremia (bacteria in the blood), and chronic kidney disease stage 3A.Review of a physician consult from 12/29/25 revealed at the hospital prior to admission the resident's right ankle wound was cultured and tested positive for MRSA infection.Review of resident #4's physician orders revealed an order to maintain contact isolation for MRSA in the right foot which started on 12/24/25.MRSA is a type of staphylococcus bacteria that can be resistant to several antibiotics and can be spread through contact from one person to another. MRSA can live on hands and objects in the environment. Interventions like Contact Precautions aim at decreasing the transmission of the bacteria to other residents or staff. Based on the current evidence, CDC recommends the use of Contact Precautions for MRSA-colonized or infected patients, (retrieved from https://www.cdc.gov/mrsa/about/index.html on 1/23/26).On 1/21/26 at 7:54 AM, Registered Nurse (RN) A was observed at her medication cart outside resident #4's room. On the wall outside the resident room was a contact precaution sign and a plastic container with PPE. The sign outside the room stated that everyone must wear a gown and gloves before entering the resident room. RN A knocked and entered resident #4's room without donning gloves nor a gown. She then placed the resident's cup of medication down on top of his dresser which was located in the middle of the room. Resident #4 was seated in his wheelchair next to the dresser. RN A then walked back towards the door, applied hand sanitizer and then donned gloves. She then retrieved a gown from the plastic bin located on the outside of the room. After donning the gown, she returned to the medicine cup on top of the dresser and administered the medications to the resident. The nurse then disposed of the medicine cup and doffed PPE into a trashcan located by the residents door and exited the room.On 1/21/26 at 8:53 AM, RN A stated for residents on contact isolation, staff were required to don gloves and a gown before entering the room in order to prevent the spread of infection. She acknowledged she applied a gown and gloves after she had already entered resident #4's room and placed his medication cup on top of his dresser. She stated her hands were full so she needed to place the meds down before she could gown up. She acknowledged she should have applied the gown before entering the room.On 1/22/26 at 1:18 PM, while observing the location of the dresser in the residents room, the Director of Nursing (DON) acknowledged RN A should have been wearing a gown and gloves before entering the resident's room and placing the medication cup on top of his dresser.The facility policy titled Transmission-Based (Isolation) Precautions (TBP) revised June 2025 indicated it was the facility's policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. TBP referred to the precautions implemented in addition to standard precautions that are based upon the means of transmission in order to prevent or control infections. Contact precautions referred to the measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment.

Based on observation, interview, and record review, the facility failed to practice appropriate infection control during medication administration and per facility policy and procedures to prevent cross-contamination for 1 of 3 residents reviewed for medication administration, of a total sample of 18 residents. Findings: Resident #320 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, diabetes mellitus, and hypertension. A review of the physician orders for December 2024 revealed, vital signs every day and evening shift and Coreg oral tablet 12.5 [milligrams] two times a day for hypertension. On 12/09/24 at 4:11 PM, Registered Nurse (RN) A was observed during medication pass after she cleaned the portable blood pressure machine after taking vital signs on a resident. RN A completed cleaning the machine, covered it with a plastic bag, removed her gloves but did not perform hand hygiene. She then walked to the medication cart and picked up a medicine cup for resident #320. RN A handed the medicine cup to resident #320, who took the medication. RN A returned to the medication cart to perform documentation and resume her medication pass. RN A validated that she did not perform hand hygiene after removing her gloves after cleaning the portable vital sign machine. Hand hygiene is needed before and after performing procedures such as before and after handling invasive medical devices, performing aseptic tasks like wound care, and after removing gloves, (retrieved on 12/19/20 from www.cdc.gov). On 12/10/24 at 3:05 PM, the Director of Nursing stated that she expected staff to perform hand hygiene after removing gloves, after cleaning equipment and between administration of medication. A review of the facility's policy and procedure for Hand Hygiene, revised on 7/2023, revealed that all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The procedure described that if the task required gloves, hand hygiene should be performed prior to donning the gloves and immediately after removing the gloves.

Based on interview, and record review, the facility failed to demonstrate the effectiveness of a Performance Improvement Plan related to wound care for 1 of 1 resident reviewed for non-pressure skin-condition out of a total sample of 21 residents, (#3). Findings: Cross reference to F684 On 7/20/23 at 5:03 PM, the facility's Administrator stated the Quality Assessment and Assurance(QAA) committee looked at the reported trends in skin care, and had informal communication with residents, and team members. He stated the Performance Improvement Plan (PIP) is what the team could do immediately to address system changes, and which monitoring tools could be used to ensure changes are implemented. He stated every a PIP has to have a measurable tool. He explained the Director of Nursing (DON) had brought wound care to the forefront and submitted weekly reports starting about 2 months ago. He added, Wound care was discussed in May 2023 and the PIP was started in June 2023 for wound treatment plans, treatment supplies, new admission treatment orders, weekly wound documentation, and wound care consults. Review of the facility's PIP for Weekly Wound Assessments, Initiation of Treatments, Treatment Supply Implementation revealed based on a compliance audit, staff are not in compliance for following wound treatment protocol, wound care consults ., and documentation. The audit to be completed, to establish baseline education needs and ongoing opportunities include new admission treatment initiation, weekly wound documentation, and wound care consults. The action step started on 6/1/23 showed identify the number of residents with wounds in need of weekly documentation, consults, and initiation of treatments upon admission. On 7/20/22 at 5:55 PM, a request was made to review the facility's audits, in-service education covered with nursing staff, and signature pages. The DON stated there was no education yet and education would be starting on 8/01/23 for nursing staff. She provided copies of the physician weekly wound round notes dated 6/1/23 through 7/14/23. She stated this is what was used for audits. The forms revealed the resident's name, dressing in place, room number, wound location, treatment, facility acquired, or community acquired, and status of improved or resolved. Observation of the form did not show new admission treatment initiation or wound care consults performance measures by/from direct care staff. On 7/20/23 at 6:25 PM, the administrator stated every PIP in place had a measurable tool. He stated they were setting a baseline of where we are and where we want to be, from a monthly perspective, it is done on a monthly basis. The DON explained an audit was to identify the residents that needed to be seen were seen for that week. She stated that wound treatments were entered in the electronic health record when the wound rounds were done to make sure the resident had a treatment in place, and documentation was in place. The facility failed to demonstrate the effectiveness of the PIP started on 6/1/23. The facility did not provide documentation of education to staff regarding action steps initiated on 6/1/23 for consults and initiation of treatments upon admission. The facility provided no audit forms showing new admission treatment initiation, wound care consults, elements audited, evidence of accuracy, compliance, and the survey team investigation revealed non-compliance with wound care treatment not being provided as ordered for resident #3 after PIP start date of 6/1/23. Review of the facility's Quality Assurance & Performance Improvement (QAPI) Plan dated 2023 revealed guiding principle number 6 which showed the organization set goals for performance and measures progress towards those goals. Feedback, data systems and monitoring will include using performance indicators to monitor a wide range of care process and outcomes, and reviewing findings against benchmarks and /or goals the facility has established for performance. Review of the Facility assessment dated [DATE], revealed the facility provides general care for skin integrity and specific care or practices for pressure injury prevention, and care, skin care, and wound care (surgical, other skin wounds).

Based on record review, and interview, the facility failed to obtain admission physician orders for glucose monitoring for 1 of 1 resident, (#6), and for care and services of a sling for 1 of 1 resident, (#15) reviewed for admission orders, out of a total sample of 21 residents. Findings: 1. Review of the electronic medical record revealed resident #6 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes, anemia, hyperlipidemia, and atrial fibrillation. Review of the physician orders for the month of June and July 2023 showed no physician orders for accuchecks or blood sugar monitoring for resident #6. A Care Plan for risk of hyperglycemia and hypoglycemia initiated on 7/2/23, included interventions to check blood sugars, as ordered and administer insulin as ordered. Review of the Medication Administration Records (MAR) for June and July 2023 noted physician orders for Humalog insulin solution 100 unit/ml inject 5 units subcutaneously before meals and at bedtime ordered 6/28/23. A space on the MARs for documentation of blood sugar four times a day had no physician order date. The MARs showed blood sugar monitoring was done a total of 74 times in 20 days in June and July without physician orders. On 7/19/23 at 9:52 AM, the Director of Nursing (DON) stated, we review the new admission orders in the morning meeting. At 1:36 PM, the DON noted new admissions and physician orders were checked by her and the interim DON. The DON reviewed the resident's physician orders and acknowledged there were no orders for blood sugar monitoring four times per day. She did not explain how nurses were checking blood sugars four times per day without physician orders. 2. Review of resident #15's medical record revealed she was readmitted to the facility on [DATE] with an original admitted [DATE]. The resident's diagnoses included chronic obstructive pulmonary disease, diabetes, adult failure to thrive, and metabolic encephalopathy. On 7/17/23 at 11:12 AM, 7/18/23 at 4:53 PM, 7/19/23 at 12:28 PM, and 7/19/23 at 1:52 PM, the resident was noted with a sling to her right arm. A review of the resident's medical record noted no physician orders for the care of the right arm sling. On 7/19/23 at 10:44 AM, Registered Nurse (RN) C confirmed there were no physician orders for the right arm sling for resident #15. She stated it was usually therapy staff that applied and removed the residents' slings. On 7/19/23 at 12:47 PM, Certified Nursing Assistant (CNA) D stated therapy staff applied and removed the resident slings. On 7/19/23 at 1:00 PM, the Therapy Director stated if a resident was admitted from the hospital with a sling, then nursing addressed it. If therapy received a referral, or if the sling was ordered for therapy, or if we recommend it, then we will address the resident's sling. On 7/19/23 at 1:36 PM, review of resident #15's admission physician orders with the DON revealed no physician orders to instruct staff in the care of resident's right arm sling. The DON validated there was no physician order for the sling. She stated new admission orders were checked by herself and the interim DON. She stated ultimately the DON was responsible for checking admission physician orders. Review of the facility's policy for Medication Orders revised on 7/23 showed documentation of medication orders includes entering a new order on the MAR and to ensure the new order is in the electronic MAR. Review of the Facility Assessment initiated January 2023 revealed the facility's main health care service was providing care for residents that were discharged from the hospital, and provide general care for therapy management of braces and splints.

Based on observation, interview, and record review, the facility failed to ensure wound care and treatment services were provided for 1 of 1 resident reviewed for non-pressure related skin conditions from a total sample of 21 residents, (#3). Findings: A review of the medical record revealed resident #3 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of stage 3 pressure wound of the sacrum, skin tear wound of the right elbow, anemia, cancel, and limitation of activities due to disability. The Minimum Data Set admission assessment with Assessment Reference Date 7/04/2023 noted the resident scored 15 out of 15 on the Brief Interview For Mental Status that indicated she was cognitively intact. The assessment showed the resident did not reject care, required extensive staff assistance for activities of daily living, had 1 stage 3 pressure wound that was present on admission, skin tears, and she received anticoagulant (blood thinner) and antibiotic medication for 2 of 7 days during the look back period. On 7/17/2023 at 12:53 PM, resident #3 was observed in her room lying in bed. There was a 3 by 3-inch adhesive bandage on her right arm/elbow that noted a date of 7/13. The resident said she had asked the nursing staff to see the nurse practitioner as she was concerned the bandage had not been changed since a week ago. Review of the Physician Wound Evaluation reports dated 7/06/2023 and 7/13/2023 showed the resident was evaluated for a full thickness skin tear of the right elbow. It was noted the wound care provider recommended wound treatment and dressing changes for a total of 30 days. The Order Summary Report showed physician's orders dated 7/14/23 that read, Cleanse right elbow wound with normal saline, pat dry, apply Xeroform gauze and cover with dry dressing every day shift and every 8 hours as needed for wound care. The Comprehensive Care Plan dated 7/08/23 for altered skin integrity related to a stage 3 pressure ulcer on her sacrum and a skin tear on her right elbow with risk for further alteration with interventions for staff to, Administer treatments as ordered and monitor for effectiveness . follow facility policies/protocols for the prevention/treatment of skin breakdown. During a joint observation on 7/17/2023 at 1:24 PM, Licensed Practical Nurse (LPN) B checked the dressing located on resident #3's right arm and acknowledged it was changed and dated 7/13/2023. LPN B checked resident #3's physician's orders and stated the dressing should have been changed at least once daily. LPN B explained she noticed a slight malodor and drainage from the wound when she earlier provided wound care treatment to the resident's right arm. She said the malodor was likely due to the dressing not being changed, and it was important for nurses to provide skin treatments ordered by physicians to prevent infection and complications. On 7/18/2023 at 3:14 PM, the Director of Nursing (DON) checked resident #3's medical record and acknowledged wound care orders to the right elbow was not written by the physician until 7/14/23. She explained LPN B informed her on 7/17/2023, the resident had not received wound care treatment for her right elbow for 4 days. On 7/19/2023 at 11:58 AM, the DON said resident #3 had a skin tear wound on her right arm when she was admitted from the hospital, and the wound doctor evaluated her on 7/06/2023 and noted treatment orders. She explained the orders should have been implemented on 7/06/2023, but they were missed by a nurse who assisted with wound care rounds. She said orders were entered 7 days later on 7/14/2023. Review of the facility's policy titled Wound Treatment Management dated July 2023 read, 6. c. The facility will follow specific physician orders for providing wound care. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. The Facility assessment dated [DATE], pages 5 and 6 read, 'PART 2: Services and Care We Offer Based on our Residents' Needs . Skin Integrity Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds).

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices of items stored in the medication cart and failed to disinfect a rubber septum before piercing the medication bottle for administration of insulin for 1 of 1 resident out of a total sample of 6 residents during medication administration pass observation, (#6). Findings: 1. Review of the medical record revealed resident #6 was admitted to the facility on [DATE], with diagnoses of osteoarthritis right hip, type 2 diabetes, prosthetic heart valve, and chronic kidney disease. On 7/17/23 at 12:18 PM, during a medication observation pass with Registered Nurse (RN) A, on the 100 unit, RN A removed Humalog injection solution bottle from the medication cart to be administered subcutaneously to resident #6. RN A then proceeded to [NAME] the rubber septum of the Humalog insulin bottle with the insulin syringe and withdrew 5 units of insulin from the bottle. RN A did not disinfect the rubber septum of the insulin bottle before withdrawing the 5 units of Humalog insulin. A physician order dated 6/28/23 read, Humalog insulin solution 100 units/milliliter inject 5 units subcutaneously before meals and at bedtime. RN A then proceeded to resident #6's room, and prepared to give the resident the insulin injection. She cleansed the resident's left arm with an alcohol pad, removed the cap from the insulin syringe to administer the 5 units of Humalog insulin, and was stopped by the surveyor. After exiting resident #6's room with RN A, she acknowledged she did not clean the rubber septum on the Humalog insulin bottle before withdrawing the insulin. She stated, sorry, yes, am aware the bottle is to be wiped, disinfected before withdrawing the insulin medication. 2. On 7/17/23 at 11:27 AM, 7/17/23 at 12:02 PM, 7/17/23 at 12:18 PM, and 7/17/23 at 1:14 PM, a clear water bottle and a black drinking cup was noted inside the large drawer of the medication cart on the 100 unit. RN A said, yes, my water bottle and cup inside the medication cart. She acknowledged the personal water bottle and drinking cup should not be inside the medication cart along with residents' medications. She explained she was an agency nurse and could not remember the last time she received education in the facility about infection control. On 7/11/23 at 1:07 PM, the Assistant Director of Nursing (ADON) validated insulin rubber septum should be disinfected before withdrawal of the medication. She stated, it is my understanding that it is best practice, and there should not be any drinks inside the medication cart. On 7/17/23 at 2:22 PM, Director of Nursing (DON) explained that no personal items of staff should be in the medication carts. Review of healthcare staffing education of proper injections techniques and documentation signed by RN A on 1/01/23 revealed infection control and prevention emphasize the importance of infection control measures to minimize the risk of healthcare-associated infections. This includes proper hand washing, wearing gloves, using sterile equipment, and following aseptic techniques during injection administration. Review facility Policy Administration of Injections with a revision date of 6/21/23 showed aseptic technique is used when preparing and administrating all injections. It is a practice to prevent contamination includes disinfecting the rubber septum of a vial with alcohol before inserting any devise (i.e. needle) into the vial. This also applies when a new vial is opened.

Based on interview and record review, the facility failed to ensure the medical record accurately reflected Advanced Directives related to Do Not Resuscitate Order (DNRO) over a four month period, for 1 of 1 resident reviewed for Advanced Directives of a total sample of 26 residents, (#12). Findings: Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) significant change assessment with assessment reference date of [DATE] revealed resident #12 had a Brief Interview for Mental Status score of 8 which indicated she had moderate cognitive impairment. Review of resident #12's demographic information in the electronic medical record (EMR) identified her Advanced Directive as Full Code or full resuscitation efforts. Review of the resident's paper chart on the nursing unit revealed a laminated green sheet that read, Full Code. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #12's Advanced Directive as Full Code. Review of the Order Summary Report revealed active orders for Full Code dated [DATE]. An order dated [DATE] for Do Not Hospitalize even for acute issues, directed nurses to contact family for approval prior to any hospital transfer. Review of the Social Services Notes dated [DATE] and [DATE] read, She is a DNR. Reviewed and explained Resident Rights to resident. A note dated [DATE] indicated resident #12's Advanced Directive status changed. It read, She is a full code. Reviewed and explained Resident Rights to resident. A note dated [DATE] read, She is a DNR. Reviewed and explained Resident Rights to resident. The Advanced Directives care plan initiated [DATE] and revised [DATE] identified resident #12's Advanced Directive as Full Code. The interventions included do not hospitalize, honor Advanced Directives and In the event of cardiac and/or respiratory arrest, honor resident's wishes. On [DATE] at 4:32 PM, in a telephone interview, resident #12's daughter stated her mother did not want life saving measures in the event of cardiac or respiratory arrest. She stated her mother's Advanced Directives had been given to the facility upon admission. On [DATE] at 4:36 PM, the Social Services Director (SSD) stated she was responsible for reviewing and discussing residents' Advanced Directives with them or their representatives upon admission and regularly throughout their stay. The SSD stated she spoke to resident #12 and her family the day before and to her knowledge they did not want a DNRO. The SSD was informed of the telephone interview with resident #12's daughter who had just expressed her mother did not wish to be resuscitated. The SSD placed a call to the resident's daughter who again confirmed her mother did not want any life saving measures. The daughter informed the SSD the resident's Advanced Directives including a Living Will and a DNRO were provided upon admission three years ago. During review of the Social Services Notes with the SSD, she confirmed the discrepancies in her documentation regarding resident #12's code status. She said, It is very disturbing not to have the correct code status documented. On [DATE] at 4:55 PM, the Medical Records staff provided resident #12's overflow chart and explained these pages had been thinned from the paper chart over the years. During review of the overflow chart, the Medical Records staff discovered a yellow paper DNRO dated [DATE] signed by resident #12 and her physician. The Medical Records staff stated resident #12 had been to the hospital several times and the DNRO was probably removed and not pulled forward on readmission. On [DATE] at 5:05 PM, the Director of Nursing (DON) was informed that resident #12's medical record did not reflect the correct code status. The DON reviewed current and discontinued orders in the EMR and explained the full code order was entered off-site on [DATE] during an EMR transition from one software provider to another. During review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON explained this discrepancy was missed during reconciliation. On [DATE] at 10:41 AM, Registered Nurse (RN) B stated she was regularly assigned to care for resident #12. RN B stated if she found the resident unresponsive and without vitals, she would pull up the EMR demographic sheet and check the medical chart to verify code status before initiating Cardio Pulmonary Resuscitation (CPR). RN B said, If the code status was wrong, that would be a big mistake. On [DATE] at 11:13 AM, resident #12 emphasized she did not want to be resuscitated. On [DATE] at 11:28 AM, Licensed Practical Nurse (LPN) C/Nursing Supervisor stated DNROs should never be thinned from the medical chart. She confirmed she regularly cared for resident #12 and acknowledged if the resident's heart stopped beating, she would have checked the chart and performed CPR as there was a full code order. On [DATE] 2:51 PM, Medical Records staff confirmed she was responsible for thinning the medical charts. She stated an active DNRO should never be thinned from the chart. The facility's policy and procedure for Residents' Rights Regarding Treatment and Advanced Directives dated [DATE] read, Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives.

Based on interview and record review the facility failed to ensure baseline care plan summaries were reviewed with resident or resident representative for 7 of 30 newly admitted residents out of a total sample of 26 residents, ( #127, #125, #126, #128, #2, #19, and #174). Findings: 1. Resident #127 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record revealed a Clinical Admission Evaluation was signed and dated on 1/05/22 by the Assistant Director of Nursing (ADON 100 hall). A Baseline Care Plan could not be found in the electronic or paper medical record. On 1/20/22 at 3:16 PM, the Medical Records Director stated the new residents did not have a baseline care plan but they had an assessment. She stated they did not do baseline care plans, only comprehensive care plans were done. She said, Yes, aware the residents are supposed to have a baseline care plan and nursing is supposed to do the baseline care plans. Further review of the resident's paper chart and electronic medical record with the Director of Nursing (DON) revealed the Summary of Signatures for the Baseline Care Plan Assessment form dated 1/05/22 and 1/06/22 were signed by ADON 100 hall, the Therapy Manager and Social Services Director (SSD). The section for resident or representative signature and date were blank. On 1/20/22 at 6:13 PM, resident #127 was observed laying in bed watching TV. She stated the facility had not reviewed a baseline care plan or review any of her medications with her. 2. Resident #125 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic medical record revealed Clinical Admission Evaluation signed and dated on 1/05/22 by Registered Nurse (RN) L. The evaluation identified concerns with cardiovascular status, incontinence requiring assistance with pericare, walker needed for unsteady gait and noted resident #125 participated in physical, occupational and speech therapy. The Baseline Care Plan dated 1/05/22 and 1/6/22 revealed signatures by ADON 200 hall, SSD and Therapy Manger. The signature for resident/representative was missing indicating the resident and representative were not provided a review or copy of the baseline care plan. 3. Resident #126 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record reflected the Clinical Admission Evaluation was completed on 1/11/22 and signed by RN M. The evaluation indicated left and right pedal [CONDITION(S)], modified diet consistency, poor balance, and a manual wheelchair to be used for assistive device. On 1/20/22 at 3:16 PM, the DON stated that baseline care plans were completed within 48 hours of admission and reviewed with the resident or their representative. On 1/20/22 at 6:15 PM, resident #126 said, I did not sign anything. He stated the facility did not discuss anything with him, they just put me in the room. Review of the medical record revealed no signatures or date from resident or representative attesting to reviewing summary of the Baseline Care Plan or medications. 4. Resident #128 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the record showed Clinical Admission Evaluation dated 1/17/22 completed and signed by ADON 200 hall. The assessment reflected assistance needed with [CONDITION(S)] pericare, assistive device of a grab bar, low bed manual wheelchair, walker and upper extremity impairment on one side. Further review of the medical record revealed a baseline care plan dated and signed by ADON 200 hall on 1/17/22 and by the Therapy Manager and SSD on 1/18/22. The section noting the baseline care plan was reviewed with the resident and or resident representative was blank. On 1/20/22 at 3:45 PM, the DON stated nursing staff were responsible for initiating the baseline care plan on admission and then other departments would complete their section of the care plan. She said the manager would then review the care plan, print it along with the medication list and review it with the resident and/or representative. After the review, the resident/representative would sign it. On 1/20/22 at 6:08 PM, resident #128 stated she did not discuss or sign any care plan. She said there was no discussion of her plan of care or medications. She added that she would have liked a list of her medications and discuss her plan of care with the staff. 5. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record revealed Clinical Admission Evaluation signed and dated on 1/3/22 by RN N. The medical record did not reveal any signed or dated review of the baseline care plan summary with the resident/representative. On 1/20/22 at 3:16 PM, the DON stated the facility had a check system in the electronic record. She stated when the baseline care plan summary was reviewed and signed by the resident/representative, it was locked in the electronic system. She explained it was her responsibility to ensure baseline care plans were completed and reviewed with the resident/representative within the required timeframe. Review of the medical record paper chart and electronic chart with the DON revealed the signature from resident #2 was blank which indicated the plan had not been reviewed with the resident/representative. 6. Resident #19 was admitted to the facility on [DATE]. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence the resident and/or her representative were provided a review or copy of the Baseline Care Plan. On 1/20/22 at approxiamtely 3:45 PM, the DON reviewed the resident's medical record and acknowledged there was no evidence that either the resident or her representative were provided a summary of the Baseline Care Plan. 7. Resident #174 was admitted to the facility on [DATE] and the resident's Baseline Care Plan was completed on 1/7/22. A review of the resident's medical record did not show any evidence the resident and/or his representative received a summary of the Baseline Care Plan. On 1/20/22 at 3:45 PM, the DON could not provide any evidence the Baseline Care Plan summary was given to the resident or his representative. Review of the facility's Baseline Care Plan Policy showed under Policy Explanation and Compliance Guidelines: #3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. #4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand .

Based on interview and record review, the facility failed to administer blood pressure medication according to physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications of a total sample of 26 residents, (#11). Findings: Resident #11 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], Congestive Heart Failure, hypertension and Peripheral Vascular Disease. Review of the Minimum Data Set admission assessment with assessment reference date of 12/27/21 revealed resident #11 had medically complex conditions. Review of the Order Summary Report for January 2022 revealed resident #11 had a physician order for [MEDICATION(S)] 10 milligrams (mg) to be given two times a day for hypertension. The order included parameters to hold the medication if resident #11's heart rate was less than 60 beats per minute (bpm). [MEDICATION(S)] is a medication which slows the heart rate and decreases blood pressure and the workload of the heart. This medication requires blood pressure and heart rate to be checked as ordered by the physician. Adverse reactions could include lethargy, drowsiness, fatigue, low blood pressure, confusion and heart failure (retrieved on 1/25/22 from www.drugs.com). Review of the Medication Administration Record (MAR) for December 2021 and January 2022, revealed over a 27-day period in facility, five nurses administered [MEDICATION(S)] to resident #11 outside of specified parameter. Documentation showed resident #11 received this medication on 9 days when his heart rate was less than 60 beats per minute. The medication was administered on 12/26 with a heart rate of 55 bpm, on 1/04/22 with a heart rate of 58 bpm, on 1/05/22 with a heart rate of 51 bpm, on 1/08/22 with a heart rate of 55 bpm, on 1/11/22 with a heart rate of 59 bpm, on 1/12/22 with a heart rate of 56 bpm, on 1/13/22 with a heart rate of 55 bpm, on 1/15/22 with a heart rate of 55 bpm, and on 1/16/22 with a heart rate of 59 bpm. On 1/09/22, resident #11's heart rate was 61 bpm, but his scheduled dose of [MEDICATION(S)] was held despite a heart rate within parameter. Review of Progress Notes for December 2021 and January 2022 revealed no associated documentation for the above dates to explain why the [MEDICATION(S)] was given and held for heart rate outside of the physician ordered parameter. On 1/19/22 at 5:20 PM, the Director of Nursing (DON) reviewed resident #11's MAR and confirmed that doses of [MEDICATION(S)] were not held according to physician ordered parameter. She confirmed the medication should have been held as it could further lower the heart rate. The DON explained nurses were expected to check residents' vital signs at the bedside prior to administering medications and should only administer medications according to physician orders. On 1/20/22 at 10:59 AM, Registered Nurse (RN) B confirmed she held resident #`11's [MEDICATION(S)] on 1/09/22. She noted the medication should have been given as ordered as his heart rate was above 60 bpm. RN B acknowledged she administered [MEDICATION(S)] on 1/13/22 when it should have been held due to a low heart rate. RN B said, You don't want to administer the medication if heart rate is less than 60 because the medication will drop the heart rate even lower. On 1/20/22 at 11:22 AM, Licensed Practical Nurse (LPN) C/Nursing Supervisor confirmed she administered resident #11's [MEDICATION(S)] on three occasions when it should have been held. She reviewed the medical record and acknowledged it was an error. On 1/20/22 at 11:35 AM, the DON stated the facility's consultant pharmacist reviewed all medications once monthly but did not identify any irregularities related to resident #11's [MEDICATION(S)]. Review of the Consultant Pharmacist's Medication Regimen Review for January 2022 revealed no recommendations for resident #11. On 1/20/22 at 1:05 PM, during a telephone interview, the consultant pharmacist stated she periodically spot-checked medications with parameters during her monthly audits. The consultant pharmacist explained physician's ordered parameter for [MEDICATION(S)] was to ensure the medication would be held if the heart rate was too low. She explained administration of this medication outside the parameter could be dangerous. The facility's policy and procedure for Medication Administration dated July 2020 included guidelines to .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Review of the job description for Licensed Practical Nurse dated May 2012, revealed essential job functions included, Ensure that residents are receiving their medication based on doctor's orders/complete medication pass. Review of the job description for Registered Nurse dated December 2018, revealed the RN would provide direct nursing care. Review of the Facility Assessment tool revised 12/08/21 revealed the facility would admit residents with heart/circulatory diseases which included hypertension, [CONDITION(S)], and Congestive Heart Failure. The document indicated staff were trained annually on Medication Administration.

Based on observation, interview and record review, the facility failed to notify the physician and resident representative of signs and symptoms of a skin infection for 1 of 1 resident reviewed for notification of change of condition out of a total sample of 26 residents, (#12). Findings: Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .nih.gov) Review of the Minimum Data Set (MDS) significant change in status assessment with assessment reference date of 1/10/22 revealed resident #12 had a Brief Interview for Mental Status score of 8 which indicated she had moderate cognitive impairment. The document indicated the resident had no venous or arterial ulcers but had skin tears. A care plan for altered skin integrity was initiated on 10/12/21 and revised 1/18/22. Interventions included to monitor for and document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #12's electronic medical record demographic information revealed the resident's daughter was listed as the authorized Emergency Contact #1 and as her power of attorney for care. On 1/18/22 at 11:15 AM, resident #12 stated she had pain in her left leg and had a low-grade fever for the last couple of days. On 1/19/22 at 11:29 AM, Licensed Practical Nurse (LPN) C/Nurse Supervisor stated resident #12 had a fall in December. She stated the resident had been seen by a wound care specialist in the past for a leg wound. She described the area as still being red. On 1/19/22 at 11:46 AM, during observation of resident #12's left lower leg with LPN C, she confirmed there was an area of redness and inflammation that was warm to the touch. There were two scabbed areas above the resident's ankle that were each approximately one centimeter in diameter. The area of redness around the scabbed areas was ten centimeters wide and covered the circumference of her lower leg. There was no wound dressing in place. On 1/19/22 at 12:01 PM, LPN C stated she was assigned to care for resident #12 on Monday, 1/17/22. She confirmed the resident's left lower leg had been red and inflamed on that day. LPN C acknowledged the change in the resident's condition of her leg was significant and should have been reported to the physician. She acknowledged she had not completed any change in condition documentation nor notified the physician and the family. On 1/19/22 at 12:15 PM, the facility's Registered Nurse Consultant (RNC) and LPN C spoke with the Advanced Practice Registered Nurse (APRN) and informed her of the area on resident #12's left lower leg that was inflamed and warm to the touch. The APRN gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/19/22 at 12:22 PM, the Director of Nursing assessed resident #12's left lower leg and validated the presence of redness and inflammation. She confirmed the condition of the resident's leg should have been identified by all staff assigned to the resident and reported as a change in condition. On 1/20/22 at 11:19 AM, Certified Nursing Assistant (CNA) A confirmed she saw the red area on resident #12 left lower leg on Tuesday, 1/18/22. She stated the area had been red for a while and had been reported to the nurse. Review of the progress notes for the entire month of January 2022 did not reveal any documentation regarding signs and symptoms of infection to resident #12's left lower leg and no documentation of reporting of a change in condition. Review of the job description for Licensed Practical Nurse dated May 2012, revealed the LPN's essential job functions included evaluation of resident needs, notification of changes to physician and obtaining appropriate orders. The facility's policy and procedure for Notification of Changes dated July 2020 read, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. The guidelines indicated circumstances which required notification and included change in resident's physical condition and a need to implement a new treatment.

Based on observation, interview, and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .nih.gov). Review of the Minimum Data Set significant change in status assessment with assessment reference date of 1/10/22 revealed resident #12 had a Brief Interview for Mental Status score of 8 which indicated she had moderate cognitive impairment. The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #12 had skin conditions including skin tears which required nonsurgical dressings. A care plan for at risk for altered skin integrity was initiated on 10/12/21. Interventions included follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed nurses to perform wound care and apply wound treatments to the residents left anterior leg as ordered. Review of resident #12's medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for January 2022 revealed nursing documentation to validate resident #12's wound treatment was applied as ordered. Review of a Wound Evaluation & Management Summary dated 12/08/21 revealed resident #12's left anterior leg wound was resolved on 12/08/21. However, review of Weekly Skin Inspection forms dated 12/31/21 and 1/07/22 indicated resident's skin was not intact but the areas noted were not new. A form dated 1/14/22 revealed resident #12's skin was intact. On 1/19/22 at 11:46 AM, during observation of resident #12's left lower leg with Licensed Practical Nurse (LPN) C, she confirmed there was an area of redness and inflammation that was warm to the touch. There were two scabbed areas above the resident's ankle that were each approximately one centimeter in diameter. The area of redness around the scabbed areas was ten centimeters wide and covered the circumference of her lower leg. There was no wound dressing in place. On 1/19/22 at 12:01 PM, LPN C stated she was assigned to care for resident #12 on Monday, 1/17/22. She confirmed the resident's left lower leg had been red and inflamed on that day. LPN C acknowledged the change in the resident's condition of her leg was significant and should have been reported to the physician. She acknowledged she had not completed any change in condition documentation nor notified the physician and the family. On 1/19/22 at 12:22 PM, the Director of Nursing assessed resident #12's left lower leg and validated the presence of redness and inflammation. She confirmed the condition of the resident's leg should have been identified by all staff assigned to the resident and reported to the physician. There was no wound dressing in place. On 1/20/22 at 11:13 AM, resident #12's left lower leg remained red and inflamed. There was no wound dressing noted as directed by the plan of care. On 1/20/22 at 4:25 PM, resident #12's assigned nurse, Registered Nurse (RN) D stated he was aware of a wound on the resident's left lower leg. He stated he applied ordered wound treatment to the area during the evening shift. Review of the TAR with RN D revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of resident #12's leg with RN D revealed there was still no dressing in place. Resident #12 stated nurses applied wound dressings sometimes. She said, If they put a small one on, it falls off by itself. If they put a large one, sometimes it stays. On 1/20/22 at 4:33 PM, the DON was informed there was a wound treatment order for resident #12. She expressed surprise and stated she was not aware of any active wound treatment orders. She stated during a discussion with the Advanced Practice Registered Nurse (APRN) yesterday, she stated she no longer wanted a dressing applied to the area. The DON was informed during observation on 1/19/22 and 1/20/22, resident #12 did not have a dressing in place. The DON confirmed the new order to discontinue the treatment was never transcribed to the medical record. On 1/20/22 at 5:02 PM, the DON stated she contacted RN B who documented application of wound dressing for resident #12 on 4 days the previous week. She said RN B informed her she did not recall doing a dressing. Review of the job description for Licensed Practical Nurse dated May 2012, revealed the LPN's essential job functions included implementing resident care based on physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the job description for Registered Nurse dated December 2018, revealed the RN would provide direct nursing care to residents and supervise day-to-day nursing activities performed by nursing assistants in accordance with state and federal standards. Review of the Facility Assessment tool revised 12/08/21 revealed the facility would admit residents with skin integrity issues and provide skin and wound care.

Based on interview and record review, the facility failed to provide a discharge summary which included a recapitulation of the resident's stay including diagnoses, course of illness/treatment, therapy, and pertinent lab, radiology and consultation results for 1 of 1 sampled resident of a total sample of 26 residents, (#18). Findings: Resident #18 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents' Admission Minimum Data Set (MDS) dated [DATE] indicated he had moderate cognitive impairment and planned to be discharged to his home. The Social Service Director (SSD) initial assessment dated [DATE] reflected resident #18's anticipated length of stay would be four weeks, then return home with home health care services. A review of resident #18's discharge care plan revealed the resident wished to return home upon discharge. The goal included communicating required assistance post-discharge and the services required to meet needs before discharge. Resident #18's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical Therapy (PT) 5 times per week for 4 weeks, with treatment to include therapeutic exercises, neuromuscular re-education, therapeutic activities, patient/caregiver education, and discharge planning. Speech Therapy (ST) to evaluate and treat as indicated 5 times per week for 4 weeks for dysphagia for diet trials/modifications, compensatory strategy training. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #18's medical record revealed the discharge summary did not include a recapitulation of the resident's stay that included diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. On 1/20/22 at 2:26 PM, the Director of Nursing (DON) acknowledged a recapitulation of stay was not done. The DON noted that recapitulation of stay should have included a summary of the resident's care and ensured appropriate care after discharge. A review of the facility's policy and procedure for Discharge Summary and Plan of care revealed, 3) Upon discharge of a resident (other than in emergency to hospital or death), a Discharge Summary will be provided to the receiving care provider. The Discharge Summary should include a. An overview of the resident's stay that includes but is not limited to: diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.

Based on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to fingernail care for 1 of 1 resident reviewed for ADLs, of a total sample of 26 residents, (#11). Findings: Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Admission Assessment with assessment reference date of 12/27/21 revealed resident #11 required limited assistance of one-person for personal hygiene. Section E0800 revealed resident #11 had not exhibited any behaviors for rejection of care. A Self-Care Deficit care plan was initiated on 1/01/22. Interventions included Provide assistance to ADLs as indicated/documented.Bathing/showering per facility protocol and [as needed]. These interventions were transcribed to the Certified Nursing Assistant (CNA) Kardex or care plan. Review of nursing progress notes for January 2022 revealed no documentation for resident #11 related to refusal of nail care. On 1/19/22 at 10:46 AM, resident #11 was observed in bed. His fingernails were approximately 0.5 centimeters long. There was dark brown to black substance noted underneath all nails. Resident #11 was unable to recall when he last received nail care. On 1/19/22 at 10:50 AM, CNA A stated she was responsible for providing ADL care for her assigned residents. During observation of resident #11's fingernails with CNA A, she acknowledged all fingernails were long and dirty. CNA A stated she did not take care of residents' fingernails as it was the nurse's responsibility. On 1/20/22 at 10:59 AM, Registered Nurse (RN) B stated she was not aware she was supposed to do nail care. On 1/20/22 at 11:05 AM, during observation of resident #11's fingernails with RN B, she confirmed his fingernails were long and had dark brown/black substance underneath all nails. Resident #11's wife was at the bedside, and stated she visited every day. She said, I noticed his fingernails were dirty. She explained she was told by a staff member that staff could not use nail clippers because they were too dangerous. Resident #11's wife retrieved an orange stick from her purse and explained she brought these items in herself. She said she would never allow her husband's fingernails to look like that if he were at home. On 1/20/22 at 11:09 AM, CNA A validated she did not attempt to clean resident #11's fingernails after being made aware they were dirty the previous day. She did not offer an explanation why she had not offered nail care. CNA A acknowledged she was responsible for providing all personal hygiene care for her assigned residents, and nail care was part of personal hygiene care. On 1/20/22 at 11:22 AM, Licensed Practical Nurse (LPN) C/Nursing Supervisor stated all nursing staff were responsible for fingernail care. She acknowledged CNA A should have provided resident #11's nail care when made aware the previous day. She explained hand hygiene should be provided for all residents at a minimum before and after meals and on shower days. On 1/20/22 at 11:35 AM, the Director of Nursing (DON) stated CNAs were expected to do nail care during daily ADL care and at mealtimes. She stated nurses could also cut fingernails or instruct CNAs to perform nail care as indicated. The DON acknowledged resident #11's nails should have been trimmed by CNA A when she was made aware of the issue the previous day. On 1/20/22 at 2:50 PM, the DON confirmed the CNA Kardex did not list nail care as a specific task as it was considered an expectation of basic personal hygiene care. Review of the job description for Certified Nursing Assistant dated May 2012, revealed the CNA would provide routine daily nursing care. The CNA's essential job functions included, Assist patients/residents with Activities of Daily Living such as bathing, dressing, grooming, eating, transferring, ambulating, toileting, and other resident needs. Review of the job description for Registered Nurse dated December 2018, revealed the RN would provide direct nursing care to residents and supervise day-to-day nursing activities performed by nursing assistants. The facility's policy and procedure for Nail Care dated July 2020 read, The purpose of this procedure is to provide guidelines for the provisions of care to a resident's nails for good grooming and health. The guidelines included.3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis; 4. Routine nail care, to include trimming and filing, will be provided as needed; and 6. Procedure: .c. Gently clean underneath nails with orange stick. Review of the Facility Assessment tool revised on 12/08/21 revealed the facility would provide required assistance with ADL care.

Based on observation, interview, and record review, the facility failed to follow the Registered Dietitian's (RD) recommendations for fluid administration for 1 of 1 resident reviewed for tube feeding of a total sample of 26 residents, (#280). Findings: Resident #280 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A gastrostomy tube is a tube that is surgically inserted through the skin directly into the stomach. It is used to provide nourishment and water for people who cannot swallow correctly or do not take enough food by mouth to stay healthy (retrieved on 1/27/22 from www.medlineplus.gov) Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 1/05/22 revealed resident #280 had a Brief Interview for Mental Status score of 14 which indicated she had intact cognition. The document indicated resident #280 was diagnosed with malnutrition and had a feeding tube. The assessment revealed the resident received 501 milliliters per day or more via tube feeding. Review of resident #280's medical record revealed a care plan for risk for fluid volume deficit initiated on 1/09/22. The interventions included administer tube feeding and water flushes as ordered, and to monitor and report signs and symptoms of dehydration. A tube feeding care plan dated 1/05/22 indicated resident #280 was dependent on tube feeding and water flushes. The care plan directed nurses to follow physician orders. Review of a Medication Review Report revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record (MAR) dated January 2022 revealed nursing documentation to validate resident #280 received 125 ml of water once every shift, three times daily, instead of every 6 hours, or four times daily, as ordered. Review of a Nutrition Dietary note dated 1/14/22 revealed a recommendation by the RD to decrease resident #280's water flushes to 125 ml every six hours. On 1/18/22 at 12:19 PM, resident #280 was observed with very dry lips that stuck to her teeth as she talked. Resident #280 repeatedly picked at the peeling dried skin on her lips. On 1/19/22 at 1:24 PM, the Consultant RD explained residents that needed tube feeding required water flushes as tube feeding alone did not provide an adequate amount of fluid. She confirmed she reviewed resident #280's labs and made a recommendation for an appropriate amount of water flush to meet the resident's needs. The RD reviewed her progress notes and recommendations and validated resident #280 should receive 125 ml of water every six hours. She was prompted to review the MAR and acknowledged the documentation showed resident #280 received 375 ml of additional water daily instead of 500 ml required. The RD confirmed that receiving an inadequate amount of fluid could cause dry lips. On 1/19/22 at 1:47 PM, Licensed Practical Nurse (LPN) C/Nurse Supervisor confirmed the physician ordered 125 ml water flush for resident #280 every six hours. She reviewed the medical record and confirmed nurses had been administering water once every eight-hour shift rather than every six hours as ordered. LPN C stated she was regularly assigned to resident #280 and had administered the flush once per shift as she had not noticed the discrepancy. She stated the resident could become dehydrated without the proper amount of water administered. On 1/19/22 at 3:31 PM, resident #280 stated she was still thirsty and her lips felt dry. On 1/20/22 at 10:54 AM, Registered Nurse (RN) B acknowledged she had administered the 125 ml water flush on her shift for resident #20 but did not notice the order was entered incorrectly. The facility's policy and procedure for Appropriate Use of Feeding Tubes dated July 2020 read, It is a policy of this facility to ensure that a resident maintains acceptable parameters of nutritional and hydration status. Guidelines indicated residents who were dependent on tube feeding would receive the appropriate treatment and services to prevent complications with tube feeding including but not limited to dehydration.

Based on observation, interview and record review, the facility failed to ensure oxygen was administered as ordered for 1 of 1 resident reviewed for respiratory care, of a total sample of 26 residents, (#12). Findings: Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) significant change assessment with assessment reference date of 1/10/22 revealed resident #12 had a Brief Interview for Mental Status score of 8 which indicated she had moderate cognitive impairment. She did not exhibit any behavioral symptoms and did not reject care that was necessary to achieve her goals for health and well-being. The document revealed the resident experienced shortness of breath when lying flat and she received oxygen therapy. A care plan for Potential for ineffective breathing related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, Apply oxygen per [physician] orders, Monitor for signs/symptoms of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, [shortness of breath] at rest, cyanosis, somnolence. Resident #12 had a care plan for behavior problems including removing oxygen tubing that was initiated 10/13/21 and revised on 01/05/22. The care plan did not include any intervention or approaches to address the resident's removal of oxygen tubing. Review of Post Fall Screen assessment dated [DATE] revealed resident had a fall on 12/05/21 with an intervention to check the resident every two hours to ensure patient has oxygen on. Review of resident #12's medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 8/31/21 directed nurses to check the resident's oxygen saturation level and assess, document and notify the physician if less than 90%. A normal oxygen saturation level is 95% to 100%. Values under 90% are considered low and could cause confusion, lethargy, shortness of breath, anxiety, slow heart rate and coma (retrieved 1/26/22 from www.cdc.gov). On 1/19/22 at 11:18 AM, resident #12 was in bed, lying flat and did not have oxygen cannula in place. Resident stated she did not feel good. The oxygen tubing was draped over the oxygen concentrator approximately five feet away from bed on the other side of the resident's nightstand. Resident #12 was slightly confused and was not aware she did not have her nasal cannula in place. She said, The staff seem to think that if I don't have it on, I will pass out and die. On 1/19/22 at 11:20 AM, Licensed Practical Nurse (LPN) C/Nurse Supervisor was informed resident #12's nasal cannula was not in place. LPN C validated the resident's nasal cannula was not in place and noted it was draped over the concentrator and touched the floor. She explained resident #12 was bedbound and could not have placed the nasal cannula that far away from the bed. On 1/19/22 at 11:25 AM, Certified Nursing Assistant (CNA) A stated she obtained resident #12's oxygen saturation level earlier that morning and obtained a reading of 90%. She could not recall if the reading was obtained with or without oxygen in place. CNA A was asked to check the resident's oxygen saturation level and discovered it was 88%. On 1/19/22 at 11:29 AM, LPN C stated when she last saw resident #12 at 9:30 AM, the nasal cannula was in place. LPN C stated resident #12 required oxygen due to a history of respiratory failure. She explained the resident needed continuous oxygen therapy at 5 L/min. She acknowledged the nasal cannula should have been in place and worn continuously. On 1/20/22 at 10:41 AM, Registered Nurse (RN) B confirmed resident #12 was prescribed oxygen at 5 L/min continuously but would sometimes take her nasal cannula off and drop it on the floor next to the bed. RN B explained the resident needed oxygen due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RN B stated without oxygen, the resident could become confused, disoriented and short of breath. RN B stated an oxygen saturation level of less than 90% was considered low and would be concerning. A review of Progress Notes from 12/01/21 through 1/19/22 revealed no nursing documentation regarding resident #12 removing her nasal cannula. The facility's policy and procedure for Oxygen Administration dated July 2020 read, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The document's guidelines indicated oxygen was to be administered according to physician orders.

Based on interview and record review, the facility failed to ensure the physician showed justification for the continued use of a [CONDITION(S)] medication ([MEDICATION(S)]) on an as needed (PRN) basis for 1 of 5 residents reviewed for unnecessary medication usage of a total sample of 26 residents, (#20). Findings: Resident #20 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, hypertension and depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status, (BIMS) of 4 indicating severe cognitive impairment. The assessment revealed the resident did not have [CONDITION(S)], no behavioral symptoms or refusal of care. The assessment showed the resident received 10 doses of anti anxiety medication from 12/28/21-1/18/22. On 01/18/22 at 12:18 PM, resident #20 sat in recliner chair next to her bed, eating lunch, and listening to music. She was unable to answer any questions. Review of the resident's medical record revealed an active order dated 12/11/21 for [MEDICATION(S)] 0.5 milligrams (mg) give 1 tablet by mouth every 24 hours PRN for anxiety with no stop date. Review of the medication administration record (MAR) revealed the resident continued to receive [MEDICATION(S)] PRN, for anxiety past the allowable 14 days. There was no documentation by the physician from December 26, 2021-January 19, 2022 to justify the continuation of [MEDICATION(S)] past the 14 days. On 1/19/22 at 5:39 PM, the Director of Nursing (DON) stated PRN [CONDITION(S)] medications were only for 14 days then they must be discontinued. She added if the resident required the PRN medication longer than 14 days, the physician must provide a justification for use and the resident must be monitored by the physician and psychologist. On 1/20/22 at 9:54 AM, the DON stated the Pharmacy Consultant checked residents' medications once per month. The DON noted resident #20's [MEDICATION(S)] medication order was stopped on 12/9/21 and restarted on PRN basis on 12/11/21. She acknowledged the order dated 12/11/21 had no stop date and the resident received the medication after the 14 days. She acknowledged there was no documentation from the physician for continued use of [MEDICATION(S)]. On 1/20/22 at 1:06 PM, the Pharmacy Consultant indicated anti-psychotic medications ordered PRN were for 14 days and required a stop date. Review of facility policy Use of [CONDITION(S)] Drugs revision date 7/20 revealed Policy Explanation and Compliance Guidelines: number 8 showed PRN orders for [CONDITION(S)] drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e.14 days). A. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on observation, interview and record review, the facility failed to implement a system for infection prevention and control to conduct required screenings for symptoms of Coronavirus disease (COVID-19), risk factors for transmitting the disease and recent exposure to [MEDICAL CONDITION], prior to permitting visitors to enter the facility for 2 of 2 visitors, (State Survey Agency staff). Findings: On Saturday, 11/07/20 at approximately 10:02 AM, the facility's automatic sliding front doors were unlocked, and the receptionist's desk was unattended. There were no staff members noted in the lobby or nearby hallways. At 10:06 AM, the receptionist walked towards the front desk. She was asked to notify the supervisor of State Survey Agency (SSA) staff presence. On 11/07/20 at approximately 10:08 AM, the Assistant Director of Nursing (ADON), Registered Nurse (RN) A and the weekend nursing supervisor arrived in the lobby. They stated they would arrange for security to unlock a room to be used as workspace. While awaiting arrival of security staff, neither the ADON, RN A or the receptionist provided screening questionnaires to identify signs and symptoms of COVID-19 or possible recent exposure to [MEDICAL CONDITION], or checked temperature of SSA staff. On 11/07/20 at 11:32 AM, the Administrator stated the receptionist was responsible for screening all staff and visitors in the lobby. He explained the screening process was to be completed at the front desk and no one should leave the lobby area unless this was done. The Administrator said, Our policy is that nobody should enter the facility without being screened. He explained security staff was responsible for screening from 6:00 AM until 8:00 AM when the receptionist arrived. The Administrator confirmed the screening process was essential, and the purpose was to prevent anyone with COVID-19 infection from entering the facility. The Director of Nursing (DON) stated receptionists received appropriate training on conducting screening for COVID-19 symptoms. The DON and Administrator were informed SSA staff had been permitted to tour all resident care areas and interact with residents and staff without being screened for signs and symptoms of COVID-19 and recent exposure to [MEDICAL CONDITION]. On 11/07/20 at 11:41 AM, the Administrator observed as SSA staff requested screening questionnaires from the receptionist. She stated she forgot to screen SSA staff and acknowledged she should have provided the questionnaires and checked temperatures earlier that morning. The receptionist confirmed she was responsible for reviewing responses on the questionnaires to verify whether visitors should be allowed to enter the facility. On 11/07/20 at 11:46 AM, the Administrator stated the lobby and front desk should never be unattended. He acknowledged the situation was a concern as it impacted the health and well-being of residents. Review of the facility's policy and procedure for Coronavirus Surveillance revised in February 2020 read, The facility will implement heightened surveillance activities for Coronavirus illness . The document revealed visitors and staff would be screened for signs and symptoms of respiratory infection, contact with someone confirmed or suspected to have COVID-19 and exposure to [MEDICAL CONDITION] through travel or community-spread. The policy indicated screening criteria would be used to make decisions on whether to grant or deny entry to the facility.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for dementia care, and [MEDICAL CONDITION] medication for 1 of 5 residents reviewed for unnecessary medications, (#130). Finding: Resident #130 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. [MEDICATION NAME] is known as an anti-psychotic drug. It works by helping to restore the balance of certain natural substances (neurotransmitters) in the brain. (WebMD.com) On 09/09/20 at 4:19 PM, Licensed Practical Nurse (LPN) A, stated that resident #130's [DIAGNOSES REDACTED]. On 09/09/20 at 4:21 PM, Registered Nurse (RN) B stated, that resident #130 usually stayed in his room. The RN said that for continuity of care, the same Certified Nursing Assistant (CNA) would be assigned to him to help decrease confusion. The RN stated that an individualized care plan should be initiated for residents with dementia. On 9/10/20 at 10:40 AM, the Director of Nursing (DON) stated that on admission, a baseline care plan would be initiated for residents based on their admission data, and physician orders. Resident #130's baseline, and admission care plans were reviewed with the DON. She said that a care plan for dementia care, and [MEDICAL CONDITION] medication was not initiated for resident #130. The DON indicated that on the baseline care plan/summary, there was an area under nursing/safety for key medications to be documented. The baseline care plan/summary did not show any documentation of the medication [MEDICATION NAME]. The DON stated, that a care plan for dementia care, and the [MEDICAL CONDITION] medication, [MEDICATION NAME] should have been developed and implemented for resident #130. On 09/10/20 at 11:18 AM, the Minimum Data Set (MDS) coordinator stated that baseline care plans were completed by nursing, therapy, and the social services director (SSD). The MDS coordinator, said baseline care plans should address key medications the resident was receiving. He verbalized that [MEDICATION NAME] was considered a key medication. The MDS coordinator noted that the resident's baseline care plan/summary did not address cognition issues and key medications. The facility's policy for Baseline Care Plan reviewed/revised 06/20 read, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the resident that meet professional standards of quality care. The baseline care plan will: Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: initial goals based on admission orders [REDACTED]. Interventions shall be initiated that address the resident's current needs . Review of the facility's policy, Use of [MEDICAL CONDITION] Drugs reviewed/revised 07/20, revealed the following: Residents are not given [MEDICAL CONDITION] drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).