Every finding on record at Woods Health Services

Based on interviews, and record reviews, the facility failed to report suspected abuse, for one of one sampled resident (Resident 1), to the California Department of Public Health (CDPH, a government [state] agency that promotes and protects the health of all people and their communities) and to the police department within two hours in accordance with the facility's policy and procedure (P&P), titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating.This deficient practice resulted in the delay of notification to the state agency and the police department and had the potential to result in Resident 1 being subjected to further abuse.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 diagnosis that included Alzheimer's disease (irreversible progressive mental deterioration, a condition that occurs later in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion), dementia (a decline in mental ability severe enough to interfere with daily life) and restlessness and agitation (a state of severe restlessness, tension, and excessive physical or mental activity). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 7/2/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were severely impaired. The MDS indicated Resident 1, was dependent (helper does all the work) with oral/toilet/personal hygiene, upper and lower body dressing, rolling from left-to-right, sit-to-standing position. During a review of Resident 1's [Situation, Background, Assessment, Recommendation] SBAR (a structured four-step communication framework used primarily in healthcare to quickly, clearly, and concisely convey critical resident information) Communication Form, dated 8/12/2026, indicated [Certified Nurse Assistant 5 (CNA 5)] reported an unwitnessed injury of unknown origin on Resident 1's left arm. The SBAR indicated Resident 1 had a large, raised area of dark purple/black discoloration over the left elbow/proximal forearm with extensive surrounding red-purple ecchymosis (bruise) and additional scattered bruising along the forearm. The SBAR indicated Resident 1 was minimally verbal and unable to provide details regarding the cause of the injury.During a review of Resident 1's Wound Assessment, dated 8/12/2026 at 9:37 am, the assessment indicated Resident 1 had a hematoma (a localized collection of mostly clotted blood that forms outside of the blood vessels, usually caused by an injured or damaged vessel) measuring on Resident 1's left forearm.During an interview on 8/25/2026 at 10:56 am with the Director of Staff Development (DSD), the DSD stated the morning of 8/12/2026, CNA 5 reported to licensed nurses Resident 1 had a hematoma and bruising. The DSD stated because the origin of the injuries were unknown, abuse was suspected, and the incident should have been reported within two hours of staff becoming aware of it. The DSD stated the facility sent an initial written report to the state agency on 8/20/206. The DSD stated allegations of abuse should be reported timely for the safety of the residents; for residents to be protected from it [abuse].During a concurrent interview and record review on 8/25/2026 at 11:24 am with Registered Nurse (RN) 1, the facility's abuse investigation regarding Resident 1 was reviewed, RN 1 stated on 8/12/2026 at 9:00 am, RN 2 informed RN 1 Resident 1 had hematoma on the left elbow. RN 1 stated on 8/13/2026, RN 1 called to notify the Ombudsman (an independent, neutral official who investigates complaints and helps people resolve problems) [of suspected abuse]. RN 1 stated the state agency and the police department were not notified. RN 1 stated it was important to follow the facility's policy regarding reporting suspected abuse, so nothing fell between the cracks. RN 1 stated the suspected abuse should have been reported to the state agency sooner to ensure the safety of the residents.During an interview with the Administrator (ADM), on 8/25/2026 at 4:09 pm, the ADM stated [suspected] abuse reporting should be done in a timely manner because the facility was not the final decision maker of what constituted as abuse and to protect the residents from abuse.During a review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, reviewed 5/30/2025, the P&P indicated all reports of resident abuse (including injuries of unknown origin) . are reported to the local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The P&P indicated the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible surveying/licensing the facility; law enforcement. The P&P indicated, immediately is defined as with in two-hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for three of three sampled residents (Residents 6, 32, & 42) when:1.Resident 6's lack of bowel movement (BM) was not addressed in a timely manner when Resident 6 was at risk for constipation and did not have a BM from 5/13/2026 to 5/19/2026.2.The facility failed to ensure their process for over the counter (OTC - medicines you can get without a prescription) product self-administration (the process where patients manage and take their own medications) was followed for Resident 32 when on 5/19/2026 Resident 32 had multiple non-legend (drugs that can be purchased OTC without a prescription) products at Resident 32's bedside without a self-administration assessment or a physician's order.3. Resident 42's right arm sling was not positioned properly following a shoulder injury.This failure had the potentials to result in serious medical complications and discomfort for Residents 6, 32, and 42. There were potentials for:Constipation and bowel impaction (a serious, life-threatening condition where a large mass of dry stool gets permanently stuck in the colon or rectum) to Resident 6. Misuse and side effects (SE -unwanted, unintended, or secondary effect that occurs in addition to the desired therapeutic effect of a drug) of OTC drugs for Resident 32 and the potential for OTC product sharing with other residents (in general) by Resident 32.No arm support, delayed healing, and further injury to Resident 42's arm. Findings: 1. During a review of Resident 6's admission Record (AR), the AR indicated the facility originally admitted Resident on 9/18/2012 and readmitted the resident on 12/3/2020 with diagnoses including difficulty in walking and osteoarthritis (a condition where the cushioning between the joints wears down over time, causing pain, stiffness, and swelling). During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 2/9/2026, the MDS indicated Resident 6's cognitive (the ability to think and process information) skills for daily decision making were severely impaired (never/rarely makes decisions). The MDS indicated Resident 6 required setup or clean-up assistance with eating and oral hygiene, required partial/moderate assistance with upper body dressing, and was dependent on toileting, showering, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 6 required substantial/maximal assistance with toilet transfer. The MDS indicated Resident 6 was always incontinent of bowel (the inability to control bowel movements). During a review of Resident 6's History and Physical (H&P), dated 9/28/2026, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's Order Summary Report (OSR), dated active as of 5/22/2026, the OSR indicated Resident 6 had a physician's order, start date of 5/2/2022, for bisacodyl suppository (a medication that causes a bowel movement)10 milligrams (mg-a unit of measurement) as needed for daily bowel management. During a review of Resident 6's Medication Administration Records (MAR), dated 5/1/2026 – 5/31/2026, the MAR indicated Resident 6 had received a bisacodyl suppository on 5/20/2026. During a review of Resident 6's Care Plan (CP), initiated 9/13/2022, the CP indicated Resident 6 has bowel incontinence [related to the] use of opioid possible [side effects], impaired mobility, and at Resident 6 was at risk for constipation. The CP's interventions indicated bisacodyl suppository 10 mg, intervention initiated 1/14/2023 and observe pattern of incontinence, and initiate toileting schedule if indicated, intervention initiated 9/13/2022. During a concurrent interview and record review on 5/22/2026 at 9:16 AM with Registered Nurse (RN) 1, Resident 6's undated Bowel Elimination task sheet was reviewed. The task sheet indicated Resident 6 had a BM on 5/12/2026 and did not have another BM until 5/20/2026. RN 1 stated Resident 6's lack of BM should have been addressed after three days but was not addressed until 5/20/2026. RN 1 stated a lack of BM greater than three days could increase Resident 6's risk for bowel impaction which is a medical emergency. Additionally, RN 1 stated the lack of BM could have caused Resident 6 discomfort. During a review of the facility's Policy and Procedure (P&P) titled, Bowel (Lower Gastrointestinal Tract) Disorders-Clinical Protocol, dated 3/17/2025 the P&P's assessment and recognition indicated, Examples of lower gastrointestinal tract conditions and symptoms include: fecal incontinence and resident taking antidiarrheal medications or medications related to bowel motility. The P&P's Treatment/Management indicated, The physician will identify and order pertinent cause-specific and symptomatic interventions; for example.institute a regimen to prevent constipation. The P&P's monitoring and follow-up indicated, The staff and physician will monitor the individual's response to interventions and overall progress; for example.frequency and consistency of bowel movements. 2. During a review of Resident 32's AR, the AR indicated Resident 32 was admitted to the facility on [DATE] with multiple diagnoses including acute (sudden) myocardial infarction (MI – heart attack), and colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) status. During a review of Resident 32's H&P, dated (unintelligible), the H&P indicated Resident 35 had the capacity to understand and make decisions. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 32 was dependent (helper does all of the effort) to requiring setup or clean-up assistance (helper sets up or cleans up) with activities of daily living (ADL – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 32 had an ostomy (including urostomy, ileostomy, and colostomy) appliance and was not rated for bowel continence (resident had an ostomy or did not have a bowel movement for the entire 7 days). During a concurrent observation and interview on 5/19/2026 at 11:37 AM with Resident 32 in Resident 32's room, Resident 32 was in bed doing a puzzle. Resident 32 had a four (4) ounce (oz - a unit of weight) CVS (retail pharmacy chain) Arthritis (pain, swelling, stiffness, and inflammation in your joints) Pain Relief Cream and a 2.7 oz IcyHot Pain Relief Lidocaine cream at the bedside credenza. Resident 32 stated, Resident 32 used to use the Lidocaine cream, but the cream had a smell and did not last long (effectiveness). Resident 32 stated Resident 32 had been using the Arthritis pain relief cream for Resident 32's arthritis. Resident 32 stated, the Arthritis Pain Relief Cream and the IcyHot Lidocaine patch had the same lidocaine ingredient. Resident 32 stated, Resident 32 was getting $150.00 worth of whatever I need, every three months from Resident 32's insurance company. Resident 32 stated, Resident 32 ordered the OTC drugs over the phone from CVS and CVS mailed the OTC drugs directly to Resident 32. Resident 32 stated, Resident 32 had more OTC drugs, stool softener, diaper rash ointment, inside Resident 32's bedside drawer. Resident 32's bedside drawer had multiple OTC products including multiple supplies of stool softener, Zinc oxide ointment, ear drops, nasal spray, sore throat spray, and Desitin diaper rash ointment. Resident 32 stated, Resident 32 did not know if the facility pay any attention to Resident 32's OTC products. During a review of Resident 32's OSR, active orders as of 5/19/2026, the OSR indicate multiple medications including Lidocaine (fast acting numbing medicine) external patch 4%, apply to affected area topically as needed for pain QD (every day) PRN (as needed). The OSR did not indicate Resident 32's OTC drugs kept at Resident 32's bedside. During a concurrent interview and record reviewed on 5/20/2026 at 2:44 PM with RN 1 and Licensed Vocational Nurse (LVN) 2, Resident 32's medical records were reviewed. RN 1 stated, residents (in general) were allowed to have OTC drugs at the bedside if residents were physically and mentally able (per an assessment) to self-administer OTC drugs, but [self-administration] required a physician's order. RN 1 stated, the facility was not aware of Resident 32's OTC drugs and [the OTC drugs] should not have been stored at Resident 32's bedside. LVN 2 stated, Resident 32 had no records of physician orders or [self-administration] assessments for Resident 32's OTC drugs. RN 1 stated, obtaining a physician's order and [conducting] OTC self-administration assessments was important to prevent adverse reactions, overdosing, and Resident 32 from sharing the OTC drugs with other residents. LVN 2 stated, staff should be communicating with the residents upon admission [and inquire what is] kept at Resident 32's bedside. LVN 2 stated staff should be checking and monitoring the resident's bedside (for OTC drugs). During an interview on 5/20/2026 at 3:21 PM with the Director of Nursing (DON), the DON stated, residents could have OTC drugs when [the OTC drugs] were ordered by the physician and a self-administration assessment was completed. The DON stated [the self-administration] should also be care planned (CP). The DON stated, following the [self-administration] process was important to prevent double dosing, overdosing and side effects. The DON stated, the facility was not aware of Resident 32's OTC drugs and staff should be checking resident's bedside (for OTC drugs). During a review of the facility's P&P titled, Administering Medications, date reviewed 3/17/2025, the P&P indicated residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that they had the decision-making capacity to do. During a review of the facility's P&P titled, Self-Administration of Medications, date reviewed 4/7/2025, the P&P indicated residents had the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. The P&P indicated self-administered medications were stored in a safe and secure place, which was not accessible to other residents. The P&P indicated any medications found at the bedside that were not authorized for self-administration were turned over to the nurse in charge for return to the family or responsible party. 3. During a review of an AR, the AR indicated Resident 42 was re-admitted to the facility on [DATE] with diagnoses that included congestive heart failure (heart muscle is too weak or stiff to pump blood efficiently), and generalized muscle weakness. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was cognitively intact. The MDS indicated that Resident 42 required maximal assistance (helper does more than half the effort) with ADLs such as lower body dressing and bathing. During a review of Resident 42's OSR, the OSR indicated a physician's order dated 5/17/2026, the order indicated right arm and shoulder sling monitor for placement every shift. The residents will be immobilized in a sling for one week. During a review of Resident 42's CP, initiated on 5/17/2026, the CP indicated Resident 42 had a right arm and shoulder sling, the CP's goal indicated Resident 42 would be free from complications related to right arm and shoulder sling. The CP's interventions indicated to monitor [sling] placement every shift and to monitor for sling placement. During a review of Resident 42's physician's Progress Notes (PN), dated 5/19/2026, the PN indicated x-rays (pictures of the inside of your body) were taken at an acute hospital and the report read possible for anterior (toward the front of a body) subluxation (partial dislocation) of the humeral head (the ball-like top of the humerus [the long bone in your upper arm]). During an observation and concurrent interview on 5/19/2026 at 9:54 AM of Resident 42, at the resident's bedside, Resident 42 was wearing a sling on the right arm, and both sling straps were positioned in the front of the resident's neck and right shoulder. Resident 42 stated I need to wear this [points at the sling] for a few weeks. Resident 42 stated I cannot move my neck, let alone my shoulder. It hurts. During an observation and concurrent interview on 5/19/2026 at 10:33 AM with Certified Nursing Assistant (CNA 5), Resident 42 had a sling on the right arm. CNA 5 stated Resident 42's right arm sling was not placed correctly because one of the straps needed to be placed behind the resident's neck and shoulder. During an observation and concurrent interview on 5/19/2026 at 10:35 AM with RN 1, RN 1 stated Resident 42's cushion back of the resident's sling was not placed correctly for the sling to give support to the shoulder and arm. RN 1 stated slings must be placed correctly, if not, it could further dislocate the should and not provide support due to instability. During an interview on 5/22/2026 at 1:42 PM with the Director of Nursing (DON), the DON stated placing slings correctly on the residents was important for alignment and proper positioning (of the shoulder). During a review of the facility's P&P titled Safety and Supervision of Residents, reviewed 3/17/2025, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 17 and Received 20) received proper respiratory (relating to breathing) care by failing to date or properly date Resident 17 and Resident 20's nasal cannula (NC - a small plastic tube that fits into the person's nostrils and used to provide supplemental oxygen [02 - a colorless, odorless, tasteless gas essential for living) tubing.This deficient practice could potentially result in the facility using old or expired NC tubing leading to bacterial and mold growth and skin irritation to Resident 17 and Resident 20.Findings:During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long-standing lung disease causing difficulty in breathing), unspecified, and essential (primary) hypertension (HTN - high blood pressure).During a review of Resident 17's Care Plan (CP), initiated [DATE], the CP indicated Resident 17 was at risk for COPD complication. The CP's interventions indicated administration of 02 at 4 Liters/Minute (L/min - the speed or volume of oxygen a device delivers to you) via NC continuously. The CP indicated 02 tubing and humidifier change every night shift every Sunday.During a review of Resident 17's History and Physical Examination (H&P), dated [DATE], the H&P indicated Resident 17 had the capacity to understand and make decisions.During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 17's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 17 was dependent (helper does all of the effort) to requiring setup or clean-up assistance (helper sets up or cleans ups) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 17 was on continuous 02 therapy on admission and while a resident at the facility.During a review of Resident 17's Order Summary Report (OSR), active orders as of [DATE], the OSR indicated a physician's order, dated [DATE], indicating to change oxygen tubing and humidifier every night shift, every Sunday and an order for oxygen administration at 4 L/min via N/C continuous every shift.During a review of Resident 20's AR, the AR indicated, Resident 20 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (a medical emergency where the lungs suddenly fail to get enough oxygen into the blood causing severe shortness of breath), and dependence on supplemental 02.During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20's cognitive skills for daily decision making were intact. The MDS indicated Resident 20 was dependent to requiring supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact assistance as resident completes activity) with ADLs. The MDS indicated Resident 20 was receiving 02 therapy while a resident at the facility.During a review of Resident 20's OSR, active orders as of [DATE], the OSR indicated a physician's order, dated [DATE], for oxygen at 2 L/min via NC continuous every shift.During a concurrent observation and interview on [DATE] at 9:30 AM with Resident 17, Resident 17 was awake, alert, and lying in bed. Resident 17 was receiving 02 4 L/min via NC and was hooked up to an 02 humidifier (a small medical device, often a refillable bottle, attached to a 02 machine or tank used to add moisture to supplemental 02) and 02 concentrator (a medical device that delivers pure, concentrated oxygen). Resident 17 stated Resident 17 always, 24/7 used 4 L/min of 02. Resident 17's 02 humidifier was dated [DATE] and the NC tubing was undated. Resident 17's nebulizer (a device that turns liquid medicine into mist breathed in through a mask or mouthpiece) was inside a bag labeled with Resident 17's name and dated [DATE], the bag was stored hanging off the 02 concentrator. Resident 17 stated Resident 17 was getting a breathing treatment through the nebulizer only as needed.During a concurrent observation and interview on [DATE] at 11:13 AM with Licensed Vocational Nurse (LVN) 2, inside Resident 20's room, Resident 20 was sitting up in a wheelchair at Resident 20's bedside. Resident 20 was being administered 02 via NC and connected to a 02 concentrator positioned behind Resident 20's wheelchair. The NC tubing had a sticker indicating date [DATE] (the date indicates when the tubing was changed). LVN 2 stated Resident 20's NC tubing was dated [DATE], it's over a month and [the tubing] should have been changed. LVN 2 stated the facility's night shift (10:45 PM - 7:15 AM) nurse (in general) changed [and dated] NC tubing every Sunday and the facility's day shift (6:45 AM - 3:15 PM) nurse checked and verified [the change and the tubing's date] every Monday morning. LVN 2 stated changing and dating the 02 NC tubing was important to ensure the 02 NC was changed (every Sunday) and for infection control.During a concurrent observation and interview on [DATE] at 11:23 AM with LVN 2, in the physical therapy room, Resident 17 was using an exercise machine. Resident 17 was receiving 02 via NC. LVN 2 stated, Resident 17's 02 NC tubing was not labeled (undated).During an interview on [DATE] at 3:45 PM with Infection Preventionist (IP) 1 in the presence of the Director of Nursing (DON), IP 1 stated 02 NC tubing (in general) needed to be labeled with the resident's name, room number, and dated. IP 1 stated, the night shift changed the 02 set up (NC and humidifier) every Sunday and the day shift either the nurse supervisor (in general) or charge nurse (in general) verified the change every Morning. IP 1 stated, IP 1 was the last staff who checked [verified the change] every Monday. IP 1 stated, changing the 02 set up every week was important for staff to know when the 02 set up was changed and for infection control. IP 1 stated the nebulizer did not need to be changed every week if the breathing treatment was administered as needed. IP 1 stated the 02 NC cannula (tubing and humidifier) must be changed every week. IP 1 stated, the humidifier and the NC tubing were 2 separate devices.During a review of the facility's P&P titled, Oxygen Administration, date reviewed [DATE], the P&P's purpose indicated to provide guidelines for safe 02 administration. The P&P indicated one of the preparations was to review the resident's care plan to assess for any special needs of the resident.

Based on interview and record review, the facility failed to ensure one of three sampled nursing staff (Certified Nursing Assistant [CNA] 3), had the appropriate competencies and skills sets necessary to care for the residents' (in general) needs when the facility failed to ensure CNA 3 met the clinical skill (the practical, hands-on tasks and critical-thinking abilities nurses use to deliver patient care) of reporting unusual occurrences.This deficient practice had the potential to result in compromised resident safety and physical declines to the residents under CNA 3's care. Findings:During a concurrent interview and record review on 5/22/2026 at 10:48 AM with the Director of Staff Development (DSD), CNA 3's employee personnel file was reviewed. The DSD stated CNA 3 was hired on 2/23/2024. The DSD stated, staff's (in general) clinical skills were conducted annually. A review of CNA 3's CNA Back to Basics Clinical Skills Checklist (CSC), date completed 5/15/2026, was reviewed with the DSD. The CSC indicated CNA 3 needed improvement in the skills of choking intervention and vital signs blood pressure. The CSC indicated the skill of reporting unusual occurrences was not completed. The DSD stated the DSD wanted to wait for all the staff's annual clinical skills to be completed so the DSD could give an in-service to all the staff at the same time. The DSD stated the DSD should have provided CNA 3 a one-on-one (1:1) in-service, as soon as possible, to ensure CNA 3 was competent to provide proper care, because resident safety is first.During an interview on 5/22/2026 at 12:12 PM with the Director of Nursing (DON), the DON stated, when a staff did not meet requirements for a clinical skill during the annual skills, the skill needed to be reviewed and a 1:1 in-service should be provided to the staff, on the spot during the skills check, this was important so staff did the right thing, staff was aware of the proper policy and procedure (P&P), and for staff to be better to improve and provide the correct care for resident safety.During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, reviewed 4/7/2025, the P&P indicated the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The P&P indicated licensed nurses and certified nursing assistants were available 24 hours a day, seven (7) days a week to provide competent resident care services including assuring resident safety and responding to resident needs.

Based on observation, interview, and record review, the facility failed to ensure the facility was free of five percent or greater medication error rate. The facility had two total medication errors in 25 opportunities for errors during medication pass (process through which medication is administered [the act of giving a treatment, such as a drug, to a patient]) for one of two sampled residents (Resident 35) which yielded an eight percent total error rate when: a. Licensed Vocational Nurse (LVN) 2 prepared and attempted to administer the wrong dose of Fluoxetine (an anti-depressant [prescribed medication used to treat depression - a mood disorder that causes a persistent feeling of sadness and loss of interest]) to Resident 35. b. LVN 2 forgot to prepare and administer Resident 35's Estradiol Vaginal Cream 0.01% (cream used to relieve common physical discomforts caused by menopause [when a woman permanently stops having menstrual periods]) that was due to be administered during the 09:00 AM medication pass. These failures had the potential to result in ineffective treatment to Resident 35 and the potential for symptoms to persist with no optimal treatment results to Resident 35.Findings:During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM II - adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications, and depression, unspecified.During a review of Resident 35's History and Physical Examination (H&P), dated 2/18/2026, the H&P indicated Resident 35 had the capacity to understand and make decisions.During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool), dated 3/8/2026, the MDS indicated Resident 35's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 35 required substantial/maximal assistance (helper does more than half the effort) to setup or clean-up assistance (helper sets up or cleans up) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 35 was taking an antidepressant.During a review of Resident 35's Care Plan (CP), revised 5/15/2026, the CP indicated Resident 35 used antidepressant medication r/t (related to) depression m/b (manifested by) verbalizing sadness. The CP's interventions indicated Prozac (brand name for Fluoxetine) as ordered.During a review of Resident 35's Phone Orders (TO), dated 5/4/2026 and timed at 3:43 PM, the TO indicated, a physician's order for Estradiol Vaginal Cream 0.01%, insert 0.5 gram vaginally one time a day for vaginal dryness, apply pea sized amount to vaginal opening daily. The TO indicated an order, dated 5/20/2026 and timed at 7:32 PM, the TO indicated an order for Prozac oral capsule (Fluoxetine HCL) give 30 mg (milligrams - metric unit of measurement, used for medication dosage and/or amount) by mouth one time a day for depression m/b verbalization of sadness due to multiple medical conditions.During a review of Resident 35's Medication Administration Record (MAR), dated 5/1/2026 - 5/31/2026, the MAR indicated Resident 35 had 9:00 AM scheduled medications that included Prozac oral capsule, 30 mg by mouth one time a day for depression m/b verbalization of sadness due to multiple medical conditions. The MAR indicated the Estradiol Vaginal Cream 0.01%, insert 0.5 gram vaginally one time a day.was due to be administered in the AM.During a medication pass observation on 5/21/2026 at 8:14 AM, LVN 2 started preparing Resident 35's medications that were due at 9:00 AM by placing each medication in a 30 ml (milliliter - a metric unit of volume) medicine cup and marked each cup with the medication name. LVN 2 took one capsule from Resident 35's Prozac 20 mg medication bubble pack (a customized packaging method where pills are organized by day in sealed, clear plastic compartments). LVN 2 did not prepare Resident 35's Estradiol Vaginal Cream. LVN 2 proceeded to administer Resident 35's medications one at a time while explaining each medication to Resident 35. LVN 2 was in the act of administering Resident 35's Prozac and Resident 35 refused. Resident 35 stated Resident 35's physician (unidentified) spoke to Resident 35, yesterday about adjusting the dose of the Prozac. Resident 35 stated, Resident 35 was getting Prozac 20 mg before but Resident 35's physician changed the dose to 30 mg. During an interview on 5/21/2026 at 8:45 AM with LVN 2, LVN 2 stated, LVN 2 completed Resident 35's 9:00 AM medication pass. LVN 2 stated, LVN 2 would have missed Resident 35's Estradiol Vaginal Cream if the surveyor had not inquired with LVN 2 about the Estradiol Vaginal Cream, I forgot about that. LVN 2 stated, medications due in the AM were administered by the day [shift] nurse. LVN 2 stated administering medications at the right dose was important so residents did not get an adverse drug reaction (ADR, unwanted, unintended, or secondary effect that occurs in addition to the desired therapeutic effect of a drug) and received the right dose (as ordered by Resident 35's physician).During an interview on 5/22/2026 at 12:12 PM with the Director of Nursing (DON), the DON stated, the five rights to medication administration were right patient, right medication, right dose, right route, and right time. The DON stated medications due in the AM were due every morning, every day and administered at 9:00 AM by the day shift nurse.During a review of the facility's undated Medication Pass Time Schedule (MPTS), the MPTS indicated the medication pass time for QD (every day) was at 9:00 AM.During a review of the facility's policy and procedures (P&P) titled, Administering Medications, date reviewed 3/17/2026, the P&P indicated medications were administered in a safe and timely manner, and as prescribed. The P&P indicated the individual administering the medication checked 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 observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1) when the following was observed:1. [NAME] 1 (CK 1) and the dietary manager (DM) were not wearing beard covers while preparing food for the residents of the facility.2. On 5/21/2026, two of three sampled sanitizing solution buckets (SB) did not have the correct concentration required to effectively kill bacteria (microscopic single-celled organisms some can make people sick) and organisms from kitchen surfaces as indicated in the facility's policy.These deficient practices had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) or foodborne illness (a sickness caused by eating or drinking food and beverages contaminated with harmful germs, parasites, or toxic chemicals) to the residents consuming the facility's food.Findings: 1. During an observation in Kitchen 1 on 5/21/2026 at 11:51 AM, the DM was in Kitchen 1's food preparation area scooping soup from the soup kettle. The DM had a beard and was not wearing a beard cover. During an observation in Kitchen 1 at 12:00 PM, CK 1 was in Kitchen 1's food preparation area, CK 1 was wearing a beard net that was not fully covering the CK 1's beard, hair stubbles were protruding outside the beard cover. During an interview with the Facility Dietician (FD) on 5/21/2026 at 12:19 PM, the FD stated wearing hair/beard covers was important to avoid facial hair falling onto the food served to the residents. The FD stated hair in the food placed residents at risk [for foodborne illness].During an interview with the DM on 5/21/2026 at 12:34 PM, the DM stated beard covers should always be worn correctly if the person [Kitchen 1 staff] had a beard because hair follicles could fall into the resident's food.During a review of the facility's policy and procedure (P&P) titled Uniform Dress Code, revised on 1/2025, the P&P indicated personal cleanliness and a neat appearance are essential for the food service worker. The P&P indicated facial hair must be kept neatly trimmed. The P&P indicated associates working with food: restrain all facial hair with a bear net/restraint when handling food.2. During an observation of Kitchen 1's solution buckets with Kitchen Aid 1 (KA 1), on 5/21/2026 at 12:25 PM, two of three solution buckets were tested on the dishwashing area by KA 1 and read 100 parts per million [ppm, unit of measurement]). KA 1 stated the sanitizing solution should be within the correct range (200-400 ppm) to avoid any cross-contamination.During an interview with the FD, on 5/21/2026 at 12:30 PM, the FD stated solution buckets should be within recommended ranges to avoid bacterial growth.During an interview with the DM, on 5/21/2026 at 12:34 PM, the DM stated solution buckets should be within the correct range to properly clean and sanitize Kitchen 1 areas where food was prepared.During a review of the facility's P&P titled Sanitizing Food Contact Surfaces, revised on 1/2025, the P&P indicated each work area shall be equipped with sanitizing solution. The P&P indicated red buckets change sanitizer solution whenever it becomes heavily soiled and/or falls out of the effective usage range (200-400 ppm).

Based on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to: a. Ensure two of five sampled residents' (Resident 55 and Resident 20) nasal cannula (N/C - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen [a colorless, odorless, and tasteless gas essential for life]) tubing was not on the floor b. Label a personal care item stored inside the shared restroom for two of two sampled residents (Resident 57 and Resident 26). These deficient practices had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections to Residents 20, 26, 55 and 57. Findings: a1. During a review of Resident 55's admission Record (AR), the AR indicated, Resident 55 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) with acute [sudden] exacerbation, and dependence on supplemental oxygen. During a review of Resident 55's Skilled admission History and Physical (H&P), dated 5/19/2026, the H&P indicated, Resident 55 had the capacity to understand and make decisions. During a review of Resident 55's Order Summary Report (OSR), active orders as of 5/19/2026, the OSR indicated, an order on 5/18/2026 for oxygen (02) at two (2) liters/minute (L/min - the speed or volume of oxygen a device delivers to the person) via N/C continuous every shift, with an order date of 5/18/2026. During a review of Resident 55's Care Plan Report (CP - provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan), initiated on 5/18/2026, for The resident has COPD, the CP indicated a goal that Resident 55 would be free from signs and symptoms (s/sx) of respiratory infections through review date. During an observation on 5/19/2026 at 9:54 AM, Resident 55 was awake and alert lying in bed, with 02 on via N/C connected to a 02 concentrator (a medical device that delivers pure, concentrated oxygen). Resident 55's 02 concentrator was positioned about three (3) feet away from Resident 55 with the N/C tubing on the floor. a2. During a review of Resident 20's AR, the AR indicated, Resident 20 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (a medical emergency where the lungs suddenly fail to get enough 02 into the blood causing severe shortness of breath), and dependence on supplemental oxygen. During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 3/22/2026, the MDS indicated, Resident 20's cognitive skills (ability to think and process information) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated, Resident 20 was on 02 therapy while a resident at the facility. During a review of Resident 20's OSR, active orders as of 5/19/2026, the OSR indicated an order for 02 at 2 L/min via N/C continuous every shift with an order date of 12/11/2025. During a concurrent observation and interview on 5/19/2026 at 11:13 AM with Licensed Vocational Nurse (LVN) 2, inside Resident 20's room, Resident 20 was sitting up in a wheelchair at Resident 20's bedside. Resident 20 had 02 on via N/C connected to a 02 concentrator positioned behind Resident 20's wheelchair with the N/C tubing on the floor. LVN 2 stated, Resident 20's N/C tubing was on the floor. During an interview on 5/20/2026 at 3:45 PM with the Infection Preventionist (IP) in the presence of the Director of Nursing (DON), the IP stated, 02 N/C tubing (in general) should not be on the floor for infection control. The IP stated, the IP even provided a holder for the N/C tubing close to the resident's (in [NAME]) bed for the 02 N/C cannula to be off the floor. b1. During a review of Resident 57's AR, the AR indicated, Resident 57 was admitted to the facility on [DATE] with multiple diagnoses including pneumonia (an infection/inflammation in the lungs), and severe sepsis (a life-threatening blood infection) without septic shock (the most severe, life-threatening stage of sepsis). During a review of Resident 57's H&P, dated 5/13/2026, the H&P indicated, Resident 57 had the capacity to understand and make decisions. During a review of Resident 26's AR, the AR indicated, Resident 26 was admitted to the facility on [DATE] with multiple diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), and Type 2 Diabetes Mellitus (DM II - adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications. During a review of Resident 26's H&P, dated 5/2/2026, the H&P indicated, Resident 26 had the capacity to understand and make decisions. During a review of Resident 26's MDS, dated 5/8/2026, the MDS indicated, Resident 26's cognitive skills for daily decision making was intact. The MDS indicated, Resident 26 required substantial/maximal assistance (helper does more than half the effort) to setup or clean-up assistance (helper sets up or cleans up) for activities of daily living (ADLs). During an interview on 5/19/2026 at 10:16 AM with Resident 26, Resident 26 stated, Resident 57 used the shared restroom and Resident 26 was able to use the shared restroom with help. During a concurrent observation and interview on 5/19/2026 at 10:28 AM with Certified Nursing Assistant (CNA) 1 inside Resident 57 and Resident 6's shared restroom, the restroom had two wall niches. The top wall niche was labeled with an A letter and belonged to Resident 57's roommate. The bottom wall niche was labeled with a letter B and belonged to Resident 57. An unlabeled eight (8) fl oz (fluid ounce - a measurement of volume) of [NAME] (brand name) Perineal & Skin Cleanser Rinse-Free was stored on the top wall niche that belonged to Resident 57's roommate. CNA 1 stated, the perineal and skin cleanser was considered a personal care item and belonged to Resident 57. The CNA stated all perineal care items should be labeled with resident's room number and bed to ensure there was no cross contamination. During an interview on 5/21/2026 at 11:55 AM with the IP, the IP stated the perineal and skin cleanser was considered a personal care item used for resident's private area. The IP stated personal care items should be labeled with the resident's room and bed number to identify to which resident item belonged so the personal item will not be used by the wrong resident, especially when it's a two bed. The IP stated this will prevent cross contamination and for an infection control. The IP stated Resident 57 was ambulatory and very independent and if Resident 57 could not reach the top wall niche that belongs to Resident 57's roommate. During a review of the facility's policy and procedures (P&P), titled Policies and Practices - Infection Control, reviewed on 2/24/2025, the P&P indicated, the facility's infection control P&P were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. During a review of the facility's P&P, titled Cleaning and Disinfecting Non-Critical Resident-Care Items, reviewed on 3/17/2025, the P&P indicated, single resident use items are for single resident use only and should be marked with the resident's name and/or room number and discard upon transfer or discharge.

Based on interview and record review the facility failed to provide documentation regarding advance directives (AD-a legal document explaining a resident's health care wishes if he or she cannot speak for themselves) for four of four sampled residents (Residents 8, 20, 21, & 35) when:1. Resident 8 and Resident 21 were not provided with information regarding ADs.2. Facility failed to ensure a copy of Resident 20's AD was in Resident 20's medical record when Resident 20's medical records indicated Resident 20 had a POA (Power of Attorney - a legal document that allows someone else to act on your behalf to manage your financial, legal, or medical affairs).3. Resident 35's AD signature page was not included in Resident 35's medical record.This failure resulted in Residents 8 and 21 being uninformed of their health care rights and had the potential to result in conflict regarding Residents' 8, 20, 21, & 35's choices regarding health care decisions. Findings: 1. During a review of an admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (elevated blood pressure) and vascular dementia (decline in mental ability—such as memory, thinking, and reasoning). During a review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/27/2026, the MDS indicated Resident 8's cognition (ability to think and make decisions) was severely impaired. The MDS indicated Resident 8 required maximal assistance (helper does less than half the effort) with toilet hygiene, showers, and bathing. During a concurrent interview and record review on 5/22/2026 at 8:27 AM with the Social Services Director (SSD), Resident 8's POA, notarized 3/21/2026, was reviewed. The SSD stated Resident 8's POA addressed the financial portion but did not address Resident 8's health. The SSD stated it was important for Resident 8 or the resident's responsible party to be informed regarding an Advanced Directive (AD) to address the residents' wishes regarding healthcare decisions. During a review of Resident 21's AR, the AR indicated Resident 21 was admitted to the facility on [DATE] with diagnosis that included sepsis (a life-threatening blood infection), due to enterococcus (bacteria [microscopic single-celled organisms some can make people sick] in the stomach), and urinary tract infection (UTI, bacteria in the urinary tract). During a review of Resident 21's History and Physical (H&P), dated 5/13/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21's cognition was intact. During a concurrent interview and record review on 5/22/2026 at 12:46 PM with the Admissions Coordinator (AC), Resident 8's California Standard admission Agreement For Skilled Nursing Facilities and Intermediate Care Facilities [AA], dated 6/12/2023, and Resident 21's AA, dated 4/15/2022, were reviewed. The AC stated Resident 8 and Resident 21's admission agreement did not address an AD [was offered]. The AC stated Resident 8 and Resident 21's AA was outdated and did not address an AD. The AC stated it was important for the residents or their representatives to get information about ADs because it was their right. During an interview with the Director of Nursing (DON) on 5/22/2026 at 2:02 PM, the DON stated offering ADs was important to know the resident's wishes when they (residents) were able to make that decision. During a review of the facility's policy and procedure (P&P) titled Advance Directives, revised on 4/7/2025, the P&P indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and formulate an advance directive if he or she chooses to do so. The P&P indicated written information will include a description of the facility 's policies to implement advance directives and applicable state law. The P&P indicated if the resident is incapacitated and unable to receive information about his or her right to formulate and advance directive, the information may be provided to the resident's legal representative. 2. During a review of Resident 20's AR, the AR indicated, Resident 20 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (a medical emergency where the lungs suddenly fail to get enough oxygen [a colorless, odorless, and tasteless gas essential for life] into the blood causing severe shortness of breath), and dependence on supplemental oxygen. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 20 was dependent (helper does all of the effort) to requiring supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact assistance as resident completes activity) with activities of daily living (ADL – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review on 5/22/2026 at 8:00 AM with the SSD, Resident 20's medical records were reviewed. The SSD stated an AD documented a resident's wishes regarding life sustaining treatment or medical wishes when a resident became incapacitated. A review of Resident 20's Physician Orders for Life Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated 2/23/2025, the POLST did not indicate information regarding an AD. The SSD stated the POLST was not [did not substitute] an AD. A review of Resident 20's Social Services History & Initial Assessment (SSIA), dated 12/15/2026, timed at 3:32 PM, the SSIA indicated, Resident 20 had a POA (Health Care Authority) and the facility would ask for a copy. The SSIA indicated, Resident 20 reported that advanced care planning had been completed. The SSD stated the SSD was the one responsible for ensuring a copy of an AD was [obtained and] kept in the resident's (in general) medical record. The SSD stated Resident 20 did not have an AD or a POA on file in Resident 20's medical record. A review of Resident 20's Social Services Quarterly Note (SSQN), dated 3/23/2026, timed at 10:18 AM, the SSQN indicated, Resident 20 had no change in status related to an AD. The SSD stated the information (on the forms) was not accurate and not updated. The SSD stated ensuring the information was accurate was important to clarify whether Resident 20 had an AD or not to avoid confusion about Resident 20's medical wishes. During a review of the facility's P&P titled, Advance Directives, date reviewed 4/7/2025, the P&P indicated, information about whether or not the resident had executed an advance directive should be displayed prominently in the medical record. 3. During a review of Resident 35's AR, the AR indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] and on 2/28/2025 with diagnoses including muscle weakness and type 2 diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) without complications. During a review of Resident 35's H&P, dated 2/18/2026, the H&P indicated Resident 35 had the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 35 required setup or clean-up assistance with oral hygiene and eating, required supervision or touching assistance with upper body dressing, required partial/moderate assistance with lower body dressing, and required substantial/maximal assistance with toileting hygiene, showering, putting on/taking off footwear, and personal hygiene. During a concurrent interview and record review on 5/22/2026 at 8 AM and 8:58 AM with the SSD, Resident 35's undated AD was reviewed. The SSD stated an AD was a list of the residents (in general) medical wishes and ensured that the residents (in general) medical wishes were upheld. The SSD stated Resident 35's AD should have a signature page but did not. The SSD stated it was important to have a signature included in Resident 35's AD to verify that Resident 35 gave consent regarding Resident 35's medical wishes. During a review of the facility's P&P titled, Advance Directives, dated 4/7/2025, the P&P's policy statement indicated, Advance directives will be respected in accordance with state law and facility policy. The P&P's policy interpretation and implementation indicated, Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on interview and record review, the facility failed to submit and transmit the discharge Minimum Data Set (MDS, a standardized assessment and care-screening tool) assessment within 14 days after the MDS completion for one of one sampled resident (Resident 2) as indicated in the Centers for Medicare & Medicaid Services (CMS, is a federal agency that administers major public health insurance programs and sets the regulatory standards for the United States healthcare system) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manual.This deficient practice resulted in a late completion and transmission of Resident 2's MDS assessment to CMS's Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system.Findings:During a review of a History and Physical (H&P), dated 12/15/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Order Summary Report (OSR), the OSR indicated a physician's order, dated 2/19/2026, indicating it indicated Resident 2 was discharged from the facility on 2/23/2026 with out-patient physical therapy.During a review of an admission Record (AR), indicated Resident 2 was re-admitted to the facility on [DATE] with diagnosis that included Alzheimer's Disease (irreversible progressive mental deterioration, a condition that occurs later in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion) and hypertension (elevated blood pressure).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's discharge assessment was completed on 3/10/2026.During a review of a document titled Point Click Care - (MDS 3.0) Summary, the document indicated Resident 2's assessment information had a target date of 2/23/2026. The document's MDS status was completed but the submit requirement indicated Do not submit to CMS.During an interview and concurrent record review on 5/22/2026 at 11:04 AM with the Minimum Data Set Nurse (MDSN), Resident 2's medical record (chart) was reviewed with the MDSN, the MDSN stated Resident 2 was discharged from the facility on 2/23/2026. The MDSN stated Resident 2's MDS assessment was completed and during the process of sending, instead of triggering to send, I triggered do not send. The MDSN stated it was important for MDS's to be submitted in a timely manner per RAI guidelines to give CMS a proper picture of the residents, how they were doing, and the progress the residents were making.During an interview with the Administrator (ADM) on 5/22/2026 at 1:48 PM, the ADM stated the facility followed RAI rules and regulations regarding MDS.During a review of the MDS RAI Version 3.0 Manual, Chapter 2: Assessment for the RAI, dated 10/2025, the manual indicated the Part A PPS discharge assessment must be completed within 14 days after the end date of most recent Medicare stay. The manual indicated that Part A PPS discharge assessment must be submitted within 14 days after the MDS completion date.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan (CP) was developed for one of one sampled resident (Resident 40) in accordance with the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered.This failure had the potential to result in unmet individualized needs for Resident 40 and the potential to affect Resident 40's physical and psychosocial well-being.Findings:During a review of Resident 40's admission Record (AR), the AR indicated Resident 40 was admitted to the facility on [DATE] with multiple diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, with other behavioral disturbance, and type 2 diabetes mellitus (DM II - adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) without complications.During a review of Resident 40's History and Physical Examination (H&P), dated 10/12/2025, the H&P indicated Resident 40 did not have the capacity to understand and make decisions.During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 40's cognitive skills (ability to think and process information) for daily decision making were severely impaired. The MDS indicated, Resident 40 was dependent (helper does all of the effort) to requiring partial/moderate assistance (helper does less than half the effort) for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 40's Order Summary Report (OSR), active orders as of 5/20/2026, the OSR indicated, a physician's order, dated 2/21/2026 for artificial tears ophthalmic (relating to the eye) solution, instill one drop in the left eye one time a day everyday Monday, Wednesday, and Friday to lubricate/moisten the eye.During a concurrent observation and interview on 5/19/2026 at 2:43 PM with Resident 40 in Resident 40's room, Resident 40 was sitting up in a wheelchair at Resident 40's bedside. Resident 40's left lower eyelid was red. Resident 40 stated, Resident 40 did not know why Resident 40's left lower eyelid was red and asked, is it alright, honey?During an interview on 5/20/2026 at 2:18 PM with Certified Nursing Assistant (CNA) 2, CNA 2 stated, CNA 2 noticed Resident 40's left eye was still red. CNA 2 stated, a while ago Resident 40's left eye was glued shot. CNA 2 stated Resident 40 was receiving medication on Resident 40's left eye and Resident 40's left eye got better.During a concurrent interview and record review on 5/20/2026 at 2:27 PM with Licensed Vocational Nurse (LVN) 2, Resident 40's CP, initiated 12/28/2024, was reviewed with LVN 2. The CP indicated Resident 40 had impaired visual function r/t (related to) infection (the invasion and growth of germs in the body) conjunctivitis. LVN 2 stated, Resident 40's conjunctivitis was treated with an ointment (Erythromycin - an antibiotic used to treat bacterial infection of the eye) for ten days. LVN 2 stated, Resident 40 did not have an active CP for Resident 40's ongoing redness in the left eye and [creating a CP] was important to have a goal, interventions, and to monitor Resident 40's progress.During an interview on 5/20/2026 at 2:42 PM with the Physician (MD -medical doctor), the MD stated, the MD was aware of Resident 40's left eyelid redness that was something chronic (a health condition that is persistent, long-lasting, or constantly recurring), and was being treated with an eyedrop (artificial tears). The MD stated, Resident 40's left eyelid redness would eventually go away.During a concurrent interview and record review on 5/20/2026 at 2:44 PM with Registered Nurse (RN) 1, Resident 40's CP, initiated 12/28/2024, was reviewed with RN 1. The CP indicated Resident 40 had impaired visual function r/t (related to) infection (the invasion and growth of germs in the body) conjunctivitis. RN 1 stated, the CP was resolved since Resident 40 no longer was getting eye ointment (intervention) but a CP should still have been created for Resident 40's ongoing redness in the left eye.During an interview on 5/20/2026 at 3:21 PM with the Director of Nursing (DON), the DON stated, Resident 40's left eyelid, is so red was considered a problem and it was important to [create] a CP to have a plan of care and interventions to ensure and prevent worsening of the chronic left eye redness or complications (goal).During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, reviewed 5/19/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs were developed and implemented for each resident. The P&P indicated assessments of residents were ongoing, and care plans are revised as information about the residents and the residents' condition changes.

Based on interview and record review, the facility failed to ensure irregularities identified from the Monthly Drug Regimen Review (MDRR), reported by the facility's pharmacist were acted upon for one of five sampled residents (Resident 5).These deficient practices had the potential to result in unnecessary medication administration and physical harm to Resident 5.Findings:During a review of an admission Record (AR), the AR indicated Resident 5 was re-admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (DM II - adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (high concentration of fats or lipids in the blood) and long term use of insulin (an essential hormone produced by the pancreas that regulates your blood sugar levels).During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 3/25/2026, the MDS indicated Resident 5's cognition (ability to think and make decisions) was severely impaired and Resident 5 was dependent (helper does all the effort) with toilet and personal hygiene, showers/baths.During a review of Resident 5's Note to Attending Physician/Prescriber ([NAME]), a note from the facility's pharmacist, date printed 3/12/2026, the note indicated to please consider ordering the following labs that corresponded with the Resident 5's medications: CMP (a routine blood test that measures 14 different substances in the blood), fasting lipid panel (a blood test that measures the levels of cholesterol and triglycerides in the blood), and A1c (blood test that measures the average blood sugar levels over the past 2 to 3 months). The [NAME]'s Physician/Prescribers Response, was left blank and did not indicate any documentation from Resident 2's physician indicating if the physician agreed or disagreed with the pharmacist's recommendation.During a concurrent interview and record review on 5/22/2026 at 10:18 AM, with Infection Preventionist (IP) 1, Resident 5's medical record was reviewed with IP 1, IP 1 stated IP 1 did not see a physician's order or any documentation indicating labs were ordered to follow the pharmacist's recommendations with date printed 3/12/2026. During an interview and concurrent record review on 5/22/2026 at 11:34 AM, with Registered Nurse (RN 1), RN 1 stated it was important to inform Resident 2's physician of the pharmacist's recommendations to provide [to the physician] an overall view of Resident 5's care from all aspects of the medical team.During an interview on 5/22/2026 at 1:58 PM, with the Director of Nursing (DON), the DON stated recommendations from the pharmacist were important to ensure medications were taken and monitored.During a review of the facility's policy and procedure (P&P) titled Medication Regimen Reviews, revised 5/2019, the P&P indicated the goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risk associated with medication: inadequate monitoring for adverse consequences. The P&P indicated an irregularity referred to the use of medication that is inconsistent with accepted pharmaceutical service standards of practice, is not supported by medical evidence or impedes or interferes with achieving the intended outcomes; it may also include the use of medication without adequate monitoring. The P&P indicated the attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it.

Based on interview and record review, the facility failed to ensure medical records were complete for one of three sampled residents' (Resident 4). Resident 4's Inventory of Personal Effects (IPE) form was not signed or dated to indicate Resident 4's personal belongings were picked up by Resident 4's family when Resident 4 was discharged from the facility.This failure resulted in inaccuracy of Resident 4's IPE after Resident 4 left the facility.Findings:During a review of Resident 4's admission Record (AR), the AR indicated, Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long standing lung disease causing difficulty in breathing) with acute (sudden) exacerbation (flare up), and essential (primary) hypertension (HTN - high blood pressure).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 3/7/2026, the MDS indicated Resident 4's cognitive skills (ability to think and process information) for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 4's History and Physical Examination (H&P), dated 3/2/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 40's Phone Order (TO, physician order), dated 5/5/2026, timed at 1:40 PM, the TO indicated, ok to send out Resident 40 via 911 (a telephone number used to reach emergency medical, fire, and police services) due to SOB (short of breath)/wheezing (a high-pitched sound made when breathing is restricted/obstructed in the lungs).During a review of Resident 4's undated IPE, the IPE indicated to use the [check symbol] columns to indicate that all personal belongings were accounted for [upon discharge]. The IPE indicated Resident 4 had items of specific value including one wallet, 1 cell/mobile phone and charger, 1 computer/laptop/e-reader, 1 right and 1 left hearing aids, and 1 eyeglass on admission to the facility. The IPE was signed by Resident 4 on admission on ly. The IPE's certification of receipt on admission was undated and signed by Resident 4. The IPE's certification of receipt on discharge was blank (not signed or dated).During a concurrent interview and record review on 5/21/2026 at 2:30 PM with Registered Nurse (RN) 1, Resident 4's Progress Notes (PN), dated 5/4/2026, timed at 6:18 PM was reviewed with RN 1. The PN indicated Resident 4 was transferred out [on 5/4/2026] to the General Acute Care Hospital (GACH) for SOB. RN 1 stated Resident 4 did not return to the facility. RN 1 stated Resident 4's family (unnamed) came to the facility (date unknown) to collect Resident 4's personal belongings and the family notified the facility Resident 4 was not returning to the facility. RN 1 could not find Resident 4's IPE at time of investigation and stated, ensuring a record of resident's (in general) IPE was signed was important so personal belongings brought to the facility were accounted for and returned to the resident when resident left the facility.During a concurrent interview and record review on 5/22/2026 at 12:12 PM with the Director of Nursing (DON), Resident 4's undated IPE was reviewed. The DON stated Resident 4 went to a board and care ([unnamed] - a small, residential care facility) because Resident 4 used up Resident 4's benefit days (days a nursing home stay is covered by your insurance) and did not return to the facility. The DON stated Resident 4's family came to the facility to collect Resident 4's personal belongings. The DON stated, the IPE was not signed, nobody signed it, either by Resident 4, Resident 4's family or staff. The DON stated, signing the IPE was important for staff to have accountability and ensure Resident 4 received all of Resident 4's personal belongings back.During a review of the facility's policy and procedure titled (P&P), the P&P indicated the resident's personal belongings and clothing were inventoried and documented upon admission and updated as necessary.During a review of the facility's P&P titled, Charting and Documentation, reviewed 4/3/2026, the P&P indicated documentation in the [resident's] medical record will be objective, complete, and accurate.

Based on interview and record review, the facility failed to promptly notify the physician of a change in condition for one (1) of three (3) sampled residents (Resident 1) when Resident 1's new onset buttocks pain following a fall on 4/23/2026 was not communicated to Resident 1's primary physician.This deficient practice had the potential to delay further assessment, timely diagnostic evaluation, and timely interventions related to the resident's change in condition and possible injury.Cross reference F689 and F684During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/24/2026, with diagnoses including displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing (broken bones on both sides of the right ankle/lower leg that were out of place, currently healing normally after treatment), unspecified abnormalities of gait and mobility (difficulty walking, balancing, or moving safely), and generalized muscle weakness.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort to complete the activity) for showering/bathing, lower body dressing, and with mobility (moving around in bed, transferring in and out of chair/bed, and to sit to stand).During a review of a Change in Condition Evaluation (CCE), with an effective date of 4/23/2026 and timed at 9:29 AM, the CCE indicated Resident 1 had a fall. The CCE indicated CNA (unidentified) called Charge Nurse (unidentified) into Resident 1's room and upon arrival at resident 1's room, the Charge Nurse found Resident 1 sitting in an upright position (on the floor).During a review of Resident 1's Progress Notes (PN), dated 4/23/2026, the PN indicated Resident 1 was administered Hydrocodone-Acetaminophen (a narcotic pain medication used to treat moderate to severe pain) oral tablet 5-325 milligrams (mg-a unit of measurement used to show the amount or strength of medication) at 12 PM, due to Resident 1's complaint of pain on a numeric pain scale (a rating system where the resident rates pain from zero (0) to ten (10), with 0 meaning no pain and 10 meaning the worst pain possible) rating of 7/10 to the right ankle and buttocks.During a review of Resident 1's Medication Administration Record (MAR), dated 4/23/2026, the MAR indicated that Resident 1 was administered Hydrocodone-Acetaminophen oral tablet 5-325 mg at 12 PM. The MAR indicated the physician's order was to give Resident 1 Hydrocodone-Acetaminophen 5-325 mg 1 tablet by mouth every four (4) hours as needed for moderate (4-6) to severe (7-10) pain and to hold if respiration rate less than twelve (12).During a review of Resident 1's Post Fall Assessment (PFA), dated 4/23/2026 and timed at 2:24 PM, the PFA indicated Resident 1 had a fall on 4/23/2026 at 9:15 AM and Resident 1 required two (2) person assistance with transfers. The PFA indicated Resident 1's physician and family/responsible party were notified of Resident 1's fall on 4/23/2026. The PFA also indicated Resident 1's pain rating was 0/10.During a review of Resident 1's Interdisciplinary Team Conference Record (ITCR), dated 4/24/2026, the ITCR indicated the Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care) discussed Resident 1's fall incident which occurred on 4/23/2026 during the stand-up meeting (brief meeting to discuss resident status updates and resident care coordination), with no injury identified at that time. The ITCR indicated Licensed Vocational Nurse 1 (LVN 1) documented on 4/23/2026 at 9:15 AM that Certified Nursing Assistant 2 (CNA 2) called the Charge Nurse (LVN 1) into Resident 1's room. Upon LVN 1's arrival in Resident 1's room, Resident 1 was observed sitting upright (on the floor). Assessment findings indicated Resident 1 was able to move the upper and lower left extremities with the right boot (a medical device worn to immobilize and protect the foot or ankle after surgery or an injury) in place. Vital (measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature) were stable. Equal hand grips were noted, and the resident was assisted into a wheelchair with a two-person assist. Resident 1's primary physician (MD 1) was notified of the fall and neurological checks (neurological exam, a check of how well the brain, nerves, and muscles work often performed after a suspected head injury) were initiated. Resident 1's family member (FM 1) was also notified. The ITCR also indicated according to CNA 1's statement, Resident 1 had just had a shower and was transported back to the room in a shower chair due to a scheduled beauty salon appointment. CNA 1 stated the plastic bag placed on Resident 1's right boot to prevent the boot from getting wet was removed and the floor was wiped dry prior to asking Resident 1 to stand so Resident 1's bottom could be dried. The shower chair brakes were locked when Resident 1 stood. The resident stood with assistance from CNA 1 and was supported on Resident 1's right side while bearing weight on the left foot due to non-weight-bearing (NWB-unable to put weight on the affected foot/leg) orders to the right foot. CNA 1 stated the incident occurred quickly and Resident 1 slipped while CNA 1 attempted to lower the resident safely to the floor. The resident landed on the buttocks and reportedly lightly hit the head on the shower chair. CNA 1 called for assistance from CNA 2, who was at the nurses' station at the time, and then notified LVN 1. LVN 1 assessed Resident 1 and with CNA 2, assisted the resident back into the wheelchair. Documentation indicated there was no change in level of consciousness (alertness and awareness) and Resident 1 denied pain at that time.During an interview and concurrent record review on 5/5/2026 at 11:15 AM with Registered Nurse (RN) 1, Resident 1's MAR, PN, PFA, and CCE were reviewed. RN 1 stated Resident 1's medical records revealed Resident 1 had received Hydrocodone-Acetaminophen 5-325 mg on 4/23/2026 for complaint of 7/10 right ankle and buttocks pain following the fall. RN 1 stated that further review failed to reveal documentation the physician was notified of the Resident 1's new onset buttocks pain following the fall. RN 1 stated that new onset pain following a fall should be assessed and reported to the physician, as it had indicated a change in condition or possible injury requiring further evaluation and intervention. RN 1 stated that failure to notify Resident 1's physician of Resident 1's new onset buttocks pain following the fall resulted in delayed medical evaluation, delayed early diagnostic testing, and delayed timely treatment of a possible injury following Resident 1's fall.During an interview on 5/5/2026 at 4:05 PM, with the Director of Nursing (DON), the DON stated Resident 1's new onset pain following the fall should have been immediately assessed and promptly reported to the physician, as it represented a significant change in condition and potential injury requiring timely evaluation and intervention. During a review of the facility's Policy and Procedures (P&P) titled, Woods Health Services - Change in a Resident's Condition or Status, reviewed 7/31/2025, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident and.significant change in the resident's physical/emotional/mental condition.A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and.requires interdisciplinary review and/or revision of the care plan.During a review of the facility's P&P titled, Pain - Clinical Protocol, revised dated 3/2018, the P&P indicated the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. During a review of the facility's P&P titled, Woods Health Service - Pain Assessment and Management, revised dated 3/2020, the P&P indicated to:Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary with the pain management program.Report the following information to the physician or practitioner: Significant changes in the level of the resident's pain.

Based on interview and record review the facility failed to provide cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and manual or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) to one of three sampled residents (Resident 3) in accordance with the facility's Policy and Procedure (P&P) titled Emergency Procedure- Cardiopulmonary Resuscitation, dated [DATE], when: 1. Rescue breaths were not provided to Resident 3 on [DATE] at 12:35 PM. 2. An artificial manual breathing unit (Ambu bag, a handheld medical device used to manually force air or oxygen into a person's lungs) and a non-rebreather oxygen mask (a medical device used in emergencies to deliver high concentrations of oxygen) were available for use in the facility's emergency cart on [DATE] 12:35 PM. These deficient practices resulted in an inadequate emergency lifesaving response for Resident 3 and placed other residents in the facility at risk for inadequate emergency care.During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included myocardial infarction ([heart attack] occurs when a blood clot blocks blood flow to the heart) and cerebral infarction (pathological process that results in an area of necrotic tissue in the brain caused by disrupted blood supply and restricted oxygen supply). During a review of Resident 3's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Nursing Progress Notes (NPN), dated [DATE] and timed at 1:44 PM, the NPN indicated on [DATE] at 12:35 PM, Certified Nursing Assistant (CNA) 3 entered Resident 3's room and found Resident 3 unresponsive. The NPN indicated Licensed Vocational Nurse (LVN) 2 found Resident 3 unresponsive and LVN 2 assessed for respirations and they were absent. The NPN indicated LVN 2 assessed Resident 3's carotid pulse (rhythmic heartbeat felt by pressing fingers against the carotid artery in the neck) and it was non-palpable (unable to be felt), and LVN 2 initiated CPR. The NPN indicated at 12:40 PM rescue breaths were administered to Resident 3 via an Ambu bag from the emergency cart (crash cart). Resident 3's Minimum Data Set (MDS - a resident assessment tool) was unavailable on [DATE] because Resident 3 had only been admitted to the facility on [DATE]. During an interview on [DATE] at 11:08 a.m. with LVN 2, LVN 2 stated LVN 2 entered Resident 3's room and Resident 3 was cold to touch and Resident 3's skin color was gray. LVN 2 stated when LVN 2 entered Resident 3's room, CNA 3 was providing chest compressions (a lifesaving emergency procedure used when a person's heart stops beating; a rhythmic, downward pressure on the center of the chest to manually pump blood to vital organs). LVN 2 stated LVN 2 checked Resident 3's left carotid pulse and left radial pulse (heartbeat felt by pressing the radial artery against the wrist bone) and they were both absent. LVN 2 stated LVN 2 started CPR with 30 chest compressions. LVN 2 stated LVN 2 did not provide rescue breaths ([mouth-to-mouth resuscitation] a first-aid technique where a rescuer breathes directly into an unresponsive person's mouth to deliver oxygen to their lungs) because LVN 2 did not have an artificial AMBU bag or a mouth cover. LVN 2 stated LVN 2 was supposed to provide mouth-to-mouth rescue breaths but only with a mouth cover and LVN 2 did not have one at that time. During an interview on [DATE] at 1:12 p.m. with LVN 3, LVN 3 stated LVN 3 entered Resident 3's room and saw LVN 2 doing chest compressions. LVN 3 stated Resident 3 looked pale and had no pulse. LVN 3 stated LVN 3 relieved LVN 2 from performing CPR, LVN 3 performed 30 chest compressions and did not perform rescue breathing. LVN 3 stated LVN 3 performed more than five rounds of chest compressions. LVN 3 stated LVN 3 did not provide rescue breaths because LVN 3 did not have an Ambu bag. LVN 3 stated the emergency cart did not have an Ambu bag. During an interview on [DATE] at 1:50 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated CNA 3 found Resident 3 pale in color, with no pulse and CNA 3 started chest compressions. CNA 3 stated CNA 3 performed chest compressions but did not perform rescue breathing. CNA 3 stated rescue breaths were not provided to Resident 3 because nursing staff (in general) did not have an Ambu bag or a mouth cover. CNA 3 stated CNA 3 was relieved from performing chest compressions by LVN 2. During an interview on [DATE] at 3:40 p.m. with Registered Nurse (RN) 1, RN 1 stated RN 1 entered Resident 3's room and saw nursing staff (LVN 2 and LVN 3) performing CPR. RN 1 stated an emergency cart was in the room and the CPR backboard was still on the emergency cart. RN 1 stated RN 1 asked nursing staff to put the backboard under Resident 3's torso to facilitate CPR. RN 1 stated Resident 3 was on oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) and RN 1 increased oxygen to 6 liters per minute (l/min). RN 1 stated Resident 3 had a nasal cannula because the emergency cart did not have a non-rebreather oxygen mask. RN 1 stated RN 1 left the room to get an Ambu bag because the emergency cart did not have one. RN 1 stated RN 1 checked if Resident 3 had a pulse and Resident 3 did not have a pulse. RN 1 stated Resident 3 did not have a blood pressure cuff (a medical device, placed around arm, inflated to temporarily stop blood flow, then slowly deflated while pressure changes are recorded) on and RN 1 asked someone to get one. RN 1 checked residents' blood pressure (measuring the maximum pressure exerted against artery walls when the heart contracts and pushes blood out) and it was 80/50 (low blood pressure, it may indicate that brain and vital organs are not receiving enough blood flow). RN 1 stated RN 1 delivered 2 rescue breaths with Ambu bag after the 30 chest compressions. RN 1 stated nursing staff had not provided Resident 3 any rescue breaths only chest compressions. RN 1 stated Resident 3 did not have a blood pressure cuff on or a pulse oximeter (medical device that measures heart rate and how much oxygen the blood has) during CPR and did not know how resident vital signs were monitored. RN 1 stated it was important to provide rescue breathing because it helped expand lungs between chest compressions. RN 1 stated if rescue breathing was not delivered to a resident there was a risk of not providing proper oxygenation to resident and blood circulation to the resident during CPR. During an interview on [DATE] at 3:58 p.m. with the Director of Nursing (DON), the DON stated nursing staff were required to check residents' vital signs and provide 30 chest compression and 2 rescue breaths during CPR. The DON stated nursing staff (in general) must use an Ambu bag to deliver rescue breaths to prevent the spread of infection. The DON stated nursing staff were required to provide rescue breaths by mouth-to-mouth resuscitation (a first-aid technique where a rescuer breathes directly into an unresponsive person's mouth to deliver oxygen to their lungs) before emergency cart arrived in the room. The DON stated CPR should not be performed without a backboard. The DON stated a backboard must be placed under resident's torso during CPR for CPR to be effective to residents. DON stated the risk of performing CPR without a backboard was resident would not receive the correct recoil (the natural expansion of the chest wall after a compression during CPR) from chest compression. During a review of facility's Policy and Procedure (P&P) titled Emergency Procedure- Cardiopulmonary Resuscitation, dated [DATE], the P&P indicated the facility must maintain equipment and supplies necessary for CPR/BLS in the facility. The P&P indicated if an individual was found unresponsive, staff must check for breathing and pulse, and staff would initiate basic life support (BLS) sequence of events. The P&P indicated after 30 chest compressions, 2 breaths must be provided via Ambu bag or manually with a CPR shield (mouth cover). The P&P further indicated, Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2.

Based on interview and record review, the facility failed to ensure adequate safety precautions during activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care for one (1) of three (3) sampled residents (Resident 1) by failing to ensure:A. A safe environment during post-shower care on 4/23/2026 by allowing Resident 1 to stand while the floor remained wet.B. Safe ADL care practices were implemented during post-shower care on 4/23/2026 by allowing Resident 1 to stand while clothing remained positioned at the resident's knees, creating increased instability and fall risk.C. Two (2) staff assisted Resident 1 to get up and stand from the shower chair on 4/23/2026.These deficient practices resulted in Resident 1 sustaining a fall to the floor during ADL care and experiencing pain on 4/23/2026, placing the resident at increased risk for continued pain and injury, including, head injury, fracture, and further decline in functional status.Cross reference F580 and F684During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/24/2026, with diagnoses including displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing (broken bones on both sides of the right ankle/lower leg that were out of place, currently healing normally after treatment), unspecified abnormalities of gait and mobility (difficulty walking, balancing, or moving safely), and generalized muscle weakness.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort to complete the activity) for showering/bathing, lower body dressing, and with mobility (moving around in bed, transferring in and out of chair/bed, and to sit to stand).During a review of Resident 1's Fall Risk Evaluation (FRE), dated 3/24/2026, the FRE indicated Resident 1 was assessed as a high fall risk.During a review of Resident 1's Physician Order Report (POR), dated 3/25/2026, the POR indicated to keep Resident 1 non-weight bearing (NWB-unable to place weight or stand on the affected foot or leg) on the right foot for 4 to 6 weeks.During a review of Resident 1's Bowel and Bladder Program Screener (BBPS), dated 3/28/2026, the BBPS indicated that Resident 1 was immobile (unable to move), or required a two-person assist with the ability to get to the bathroom, transfer to toilet, commode, urinal, adjust clothing, and wipe.During a review of a Change in Condition Evaluation (CCE), with an effective date of 4/23/2026 and timed at 9:29 AM, the CCE indicated Resident 1 had a fall. The CCE indicated CNA (unidentified) called Charge Nurse (unidentified) into Resident 1's room and upon arrival at resident 1's room, the Charge Nurse found Resident 1 sitting in an upright position (on the floor).During a review of Resident 1's Progress Notes (PN), dated 4/23/2026, the PN indicated Resident 1 was administered Hydrocodone-Acetaminophen (a narcotic pain medication used to treat moderate to severe pain) oral tablet 5-325 milligrams (mg-a unit of measurement used to show the amount or strength of medication) at 12 PM, due to Resident 1's complaint of pain on a numeric pain scale (a rating system where the resident rates pain from zero (0) to ten (10), with 0 meaning no pain and 10 meaning the worst pain possible) rating of 7/10 to the right ankle and buttocks.During a review of Resident 1's Interdisciplinary Team Conference Record (ITCR), dated 4/24/2026, the ITCR indicated the Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care) discussed Resident 1's fall incident which occurred on 4/23/2026 during the stand-up meeting (brief meeting to discuss resident status updates and resident care coordination), with no injury identified at that time. The ITCR indicated Licensed Vocational Nurse 1 (LVN 1) documented on 4/23/2026 at 9:15 AM that Certified Nursing Assistant 2 (CNA 2) called the Charge Nurse (LVN 1) into Resident 1's room. Upon LVN 1's arrival in Resident 1's room, Resident 1 was observed sitting upright (on the floor). Assessment findings indicated Resident 1 was able to move the upper and lower left extremities with the right boot (a medical device worn to immobilize and protect the foot or ankle after surgery or an injury) in place. Vital signs (measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature) were stable. Equal hand grips were noted, and the resident was assisted into a wheelchair with a two-person assist. Documentation indicated there was no change in Resident 1's level of consciousness (alertness and awareness) and Resident 1 denied pain at that time. Resident 1's primary physician (MD 1) was notified of the fall and neurological checks (neurological exam, a check of how well the brain, nerves, and muscles work often performed after a suspected head injury) were initiated. Resident 1's family member (FM 1) was also notified. The ITCR also indicated according to CNA 1's statement, Resident 1 had just had a shower and was transported back to the room in a shower chair due to a scheduled beauty salon appointment. CNA 1 stated the plastic bag placed on Resident 1's right boot to prevent the boot from getting wet was removed and the floor was wiped dry prior to asking Resident 1 to stand so Resident 1's bottom could be dried. The shower chair brakes were locked when Resident 1 stood. The resident stood with assistance from CNA 1 and was supported on Resident 1's right side while bearing weight on the left foot due to non-weight-bearing (NWB-unable to put weight on the affected foot/leg) orders to the right foot. CNA 1 stated the incident occurred quickly and Resident 1 slipped while CNA 1 attempted to lower the resident safely to the floor. The resident landed on the buttocks and reportedly lightly hit the head on the shower chair. CNA 1 called for assistance from CNA 2, who was at the nurses' station at the time, and then notified LVN 1. LVN 1 assessed Resident 1 and with CNA 2, assisted the resident back into the wheelchair.During a review of Resident 1's Addendum (a document added to an existing contract or agreement after it has been drafted, used to include new information, clarify details, or make minor changes) Radiology Report (ARR), dated 4/28/2026 and timed at 5:43 AM, the ARR indicated that the cortical step off/angulation (misalignment or abnormal bend) of the distal coccyx (tailbone area closest to the tip) is suspicious for a fracture (possible broken bone), although as noted in the report there is normal variation in the appearance of the coccyx (tailbone can naturally vary in shape). The ARR also indicated fracture could be confirmed with bone scan (special imaging test that looks for bone injury) or MRI (detailed imaging scan using magnets) if indicated and fractures of the coccyx (tailbone) are often best evaluated clinically (based on direct observation, examination, and treatment of the resident) rather than radiographically (based only on X-ray imaging).During an interview on 5/1/2026 at 10:43 AM with Resident 1, Resident 1 stated that CNA 1 wheeled Resident 1 back to the room in a shower chair after assisting Resident 1 with a shower. Resident 1 stated CNA 1 was assisting with drying and dressing Resident 1 for an appointment. Resident 1 stated Resident 1had NWB orders to the right foot and was wearing a controlled ankle motion (CAM-a protective walking boot used to limit movement and help the foot or ankle heal) boot to the right foot at the time. Resident 1 stated CNA 1 removed the protective bag covering the CAM boot prior to asking Resident 1 to stand. Resident 1 stated Resident 1 was barefoot on the left foot and had pants and brief around the knees when asked to stand from the shower chair. Resident 1 stated standing on one foot was difficult due to Resident 1's inability to bear weight on the right foot and because Resident 1's pants were around Resident 1's knees. Resident 1 stated the floor may still have been wet and recalled slipping and falling on Resident 1's buttocks.During a telephone interview on 5/1/2026 at 11:30 AM with CNA 1, CNA 1 stated that on 4/23/2026 at approximately 9:30 AM, after completing Resident 1's shower, CNA 1 asked Resident 1, who had NWB orders to the right foot, to stand while CNA 1 dried Resident 1's buttocks area. CNA 1 stated Resident 1's pants and brief remained around Resident 1's knees at the time Resident 1 stood, and no additional staff were present to assist. CNA 1 stated Resident 1 slipped and fell while standing, landing on Resident 1's buttocks. CNA 1 stated that although CNA 1 had dried the floor prior to having Resident 1 stand, CNA 1 observed water residue on the floor after the fall, which may have been caused by water dripping from Resident 1 or from the wet shower chair. CNA 1 stated CNA 1 should have ensured the floor was completely dry and safe prior to asking Resident 1 to stand. CNA 1 stated that having Resident 1 stand with pants and brief around the knees despite NWB orders increased Resident 1's risk for slipping and falling and assistance from another CNA would have been a safer approach.During an interview on 5/1/2026 at 12:40 PM with LVN 1, LVN 1 stated Resident 1 had known NWB orders to the right lower foot and required two-person assistance for transfers. LVN 1 stated residents with mobility limitations should receive assistance from additional staff during post-shower care and transfers. LVN 1 stated staff should ensure the floor is completely dry and free from hazards prior to asking a resident to stand. LVN 1 stated LVN 1 observed and noted water on the floor when LVN 1 responded to the incident involving Resident 1's fall. LVN 1 stated having pants and undergarment around Resident 1's knees while asking Resident 1 to stand created a safety concern and increased the risk for fall. LVN 1 stated the safest and most appropriate method would have been to obtain assistance from another staff member or complete Resident 1's dressing and care while the resident remained seated or in bed, rather than having the resident stand on one foot despite known NWB orders to the right foot.During an interview on 5/1/2026 at 1:57 PM with CNA 2, CNA 2 stated that CNA 1 had previously notified CNA 2 that assistance would be needed for Resident 1's post-shower transfer. CNA 2 stated Resident 1 had known NWB orders to the right foot and wore a CAM boot to the right foot when out of bed. CNA 2 stated Resident 1 was already on the floor prior to CNA 2 arriving to assist. CNA 2 stated upon entering the room, Resident 1 was seated upright on the floor, CNA 2 noted that the floor was wet, and Resident 1 had Resident 1's pants around the knee area. CNA 2 stated Resident 1's left foot was barefoot, and Resident 1 was not wearing non-skid socks (socks with grips on the bottom to help prevent slipping) or shoes on that left foot at the time of the incident. CNA 2 stated residents with NWB orders and mobility limitations should have another staff member present during transfers and post-shower care. CNA 2 stated the safest practice would have been to ensure the floor was dry and assistance was present prior to asking Resident 1 to stand.During an interview on 5/5/2026 at 4:05 PM with the Director of Nursing (DON), the DON stated staff were expected to ensure floors were dry and free from hazards prior to asking a resident to stand following showers. The DON stated residents with NWB orders and balance limitations are at increased risk for falls and should have additional staff assistance during transfers and post-shower care. The DON stated having another staff member present was the safest practical approach to reduce the risk of slips and falls during standing and transfers.During a review of the facility's Policy and Procedure (P&P) titled, Woods Health Services - Safety and Supervision of Residents, dated 3/17/2025, the P&P indicated that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated:Our facility-oriented approach to safety addresses risks for groups of residents.Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and the adjust interventions accordingly.During a review of the facility's P&P titled, Woods Health Services - Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated environmental factors that contribute to the risk of falls include wet floors.

Based on interview and record review, the facility failed to provide necessary care and services to one (1) of three (3) sampled residents (Resident 1) when:A. Licensed Nurses failed to assess and accurately document Resident 1's pain status following a fall on 4/23/2026.B. Resident 1's new onset buttocks pain following a fall on 4/23/2026 was not communicated to Resident 1's primary physician.These deficient practices had the potential to result in inaccurate pain assessment, delayed recognition of worsening conditions or injury, and ineffective pain management interventions for Resident 1.Cross reference F580 and F689During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/24/2026, with diagnoses including displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing (broken bones on both sides of the right ankle/lower leg that were out of place, currently healing normally after treatment), unspecified abnormalities of gait and mobility (difficulty walking, balancing, or moving safely), and generalized muscle weakness.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort to complete the activity) for showering/bathing, lower body dressing, and with mobility (moving around in bed, transferring in and out of chair/bed, and to sit to stand).During a review of a Change in Condition Evaluation (CCE), with an effective date of 4/23/2026 and timed at 9:29 AM, the CCE indicated Resident 1 had a fall. The CCE indicated CNA (unidentified) called Charge Nurse (unidentified) into Resident 1's room and upon arrival at resident 1's room, the Charge Nurse found Resident 1 sitting in an upright position (on the floor).During a review of Resident 1's Glasgow Coma Scale ( a tool used to measure a person's alertness and level of consciousness by checking their eye, speech, and movement responses) Assessment Flowsheet (GCSAF), dated 4/23/2026, the GCSAF indicated Resident 1's numeric pain scale rating (a rating system where the resident rates pain from zero (0) to ten (10), with 0 meaning no pain and 10 meaning the worst pain possible) was 0/10 at 11:20 AM.During a review of Resident 1's Daily Skilled Charting (DSC), dated 4/23/2026, the DSC indicated that Resident 1's numeric pain scale rating was 7/10 at 12:00 PM.During a review of Resident 1's Progress Notes (PN), dated 4/23/2026, the PN indicated Resident 1 was administered Hydrocodone-Acetaminophen (a narcotic pain medication used to treat moderate to severe pain) oral tablet 5-325 milligrams (mg-a unit of measurement used to show the amount or strength of medication) at 12 PM, due to Resident 1's complaint of pain rating of 7/10 to the right ankle and buttocks.During a review of Resident 1's Medication Administration Record (MAR), dated 4/23/2026, the MAR indicated that Resident 1 was administered Hydrocodone-Acetaminophen oral tablet 5-325 mg at 12 PM. The MAR indicated the physician's order was to give Resident 1 Hydrocodone-Acetaminophen 5-325 mg 1 tablet by mouth every four (4) hours as needed for moderate (4-6) to severe (7-10) pain and to hold if respiration rate less than twelve (12).During a review of Resident 1's GCSAF, dated 4/23/2026, the GCSAF indicated that Resident 1's numeric pain scale rating was 0/10 at 12:20 PM.During a review of Resident 1's Post Fall Assessment (PFA), dated 4/23/2026 and timed at 2:24 PM, the PFA indicated Resident 1 had a fall on 4/23/2026 at 9:15 AM and Resident 1 required two (2) person assistance with transfers. The PFA indicated Resident 1's physician and family/responsible party were notified of Resident 1's fall on 4/23/2026. The PFA also indicated Resident 1's pain rating was 0/10.During a review of Resident 1's Interdisciplinary Team Conference Record (ITCR), dated 4/24/2026, the ITCR indicated the Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care) discussed Resident 1's fall incident which occurred on 4/23/2026 during the stand-up meeting (brief meeting to discuss resident status updates and resident care coordination), with no injury identified at that time. The ITCR indicated Licensed Vocational Nurse 1 (LVN 1) documented on 4/23/2026 at 9:15 AM that Certified Nursing Assistant 2 (CNA 2) called the Charge Nurse (LVN 1) into Resident 1's room. Upon LVN 1's arrival in Resident 1's room, Resident 1 was observed sitting upright (on the floor). Assessment findings indicated Resident 1 was able to move the upper and lower left extremities with the right boot (a medical device worn to immobilize and protect the foot or ankle after surgery or an injury) in place. Vital signs (measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature) were stable. Equal hand grips were noted, and the resident was assisted into a wheelchair with a two-person assist. Documentation indicated there was no change in Resident 1's level of consciousness (alertness and awareness) and Resident 1 denied pain at that time. Resident 1's primary physician (MD 1) was notified of the fall and neurological checks (neurological exam, a check of how well the brain, nerves, and muscles work often performed after a suspected head injury) were initiated. Resident 1's family member (FM 1) was also notified. The ITCR also indicated according to CNA 1's statement, Resident 1 had just had a shower and was transported back to the room in a shower chair due to a scheduled beauty salon appointment. CNA 1 stated the plastic bag placed on Resident 1's right boot to prevent the boot from getting wet was removed and the floor was wiped dry prior to asking Resident 1 to stand so Resident 1's bottom could be dried. The shower chair brakes were locked when Resident 1 stood. The resident stood with assistance from CNA 1 and was supported on Resident 1's right side while bearing weight on the left foot due to non-weight-bearing (NWB-unable to put weight on the affected foot/leg) orders to the right foot. CNA 1 stated the incident occurred quickly and Resident 1 slipped while CNA 1 attempted to lower the resident safely to the floor. The resident landed on the buttocks and reportedly lightly hit the head on the shower chair. CNA 1 called for assistance from CNA 2, who was at the nurses' station at the time, and then notified LVN 1. LVN 1 assessed Resident 1 and with CNA 2, assisted the resident back into the wheelchair.During an interview and concurrent record review on 5/5/2026 at 11:15 AM with Registered Nurse (RN) 1, Resident 1's GCSAF, DSC, MAR, PN, PFA, and CCE were reviewed. RN 1 stated Resident 1's records which were reviewed revealed repeated documentation of 0/10 pain assessments following the fall. However, the PN dated 4/23/2026 and timed at 12:30 PM documented administration of Hydrocodone-Acetaminophen oral tablet 5-325 mg to Resident 1 for complaint of 7/10 right ankle and buttocks pain. RN 1 stated pain documentation should accurately reflect the resident's pain complaints, location of pain, and reassessment findings. RN 1 further stated inconsistent pain documentation could make it difficult to accurately monitor the resident's pain status, evaluate effectiveness of interventions, and identify changes in the resident's condition following the fall.During an interview on 5/5/2026 at 4:05 PM, with the Director of Nursing (DON), the DON stated Resident 1's new onset pain following the fall should have been immediately assessed and promptly reported to the physician, as it represented a significant change in condition and potential injury requiring timely evaluation and intervention. The DON stated pain assessments should be accurately and consistently documented to ensure staff are able to appropriately monitor the resident's condition, identify changes in pain status, evaluate effectiveness of interventions, and ensure continuity of care. The DON stated staff are expected to accurately document residents' reported pain level, location of pain, and reassessment findings, especially following a fall or change in condition. The DON further stated inconsistent or inaccurate pain documentation could result in difficulty determining the resident's actual pain status and could affect clinical decision-making and resident care follow-up.During a review of the facility's Policy and Procedures (P&P) titled, Woods Health Services - Change in a Resident's Condition or Status, reviewed 7/31/2025, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident and.significant change in the resident's physical/emotional/mental condition.A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and.requires interdisciplinary review and/or revision of the care plan.During a review of the facility's P&P titled, Pain - Clinical Protocol, revised dated 3/2018, the P&P indicated the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.During a review of the facility's Policy and Procedure (P&P) titled, Woods Health Services - Pain Assessment and Management, revised 3/2020, the P&P indicated:Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program.Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record.

Based on interview and record review, the facility failed to ensure nursing staff demonstrated and maintained competency to safely provide care and services in accordance with professional standards, as evidenced by: 1. Facility did not ensue Certified Nursing Assistants (CNAs) maintained a current cardiopulmonary resuscitation ([CPR] an emergency procedure used when a person's breathing or heartbeat stops) certification while working at the facility. 2. Facility did not ensure CNAs were evaluated annually for patient care competencies and skills. 3. Facility did not ensure licensed nurses had a complete competency and evaluation checklist on file. 4. Facility did not ensure Registered Nurse (RN1) was evaluated by competent licensed nurse. 5. Facility did not ensure licensed nurses were competent during a resident emergency. These deficient practices created a risk to resident safety, delayed care, and an inappropriate emergency response. Findings: 1. During a review of Certified Nursing Assistance (CNA) employee files, CNAs employee files indicated 16 CNAs out of 34 CNAs did not have a current CPR certification. During an interview on [DATE] at 2:12 p.m. with Director of Staff Development (DSD), DSD stated the facility did not require CNAs to have a current CPR certification. DSD stated CNAs were hired with a valid CPR certification and they would let it expire because it was not required for them to have it. The DSD stated DSD has not provided any mock codes (a simulated emergency drill designed to replicate a real-life medical emergency, such as cardiac arrest) to employees and there was no documentation in employees' files of last mock codes. During an interview on [DATE] at 2:35 p.m. with DON, the DON stated DON did not know if CNAs were required to be CPR certified. DON stated CNAs should be CPR certified because they work with residents and need to be able help residents in an emergency. The DON stated the risk of CNAs not being CPR certified is it might lead to residents' death. During a review of facility's Job description, titled Certified Nursing Assistant, dated 2024, the job description indicated qualification was to be CPR trained after employment. The Job description indicated CPR certification must be maintained. 2. During a review of CNAs employee files on [DATE], CNAs employee files indicated CNAs had their last competency skills evaluated in 2024. During an interview on [DATE] at 2:33 p.m. with DSD, DSD stated DSD had not completed competency evaluations for CNAs. DSD stated the last completed CNA competency evaluation on file was dated 2024. DSD stated skills competency should be completed annually because it was the method to determine if a CNA was competent to work. During an interview on [DATE] at 2:43 p.m. with DON, the DON stated the DSD was responsible for performing yearly competency evaluations for CNAs. The DON stated it was important to evaluate CNAs competency yearly to make sure they are up to date with their skills. The DON stated if competency evaluations are not performed yearly, there might be a risk of CNAs doing patient care not according to facility's policy and procedures (P&P). 3. During a review of employee files, Licensed Nurse Evaluation, the Licensed Nurse Evaluations (a structured assessment tool or checklist used to measure a nurse's clinical proficiency, competency, and confidence in performing essential tasks) were not complete for one RN and four LVNs. The Licensed Nurse Skill Evaluation did not have evaluator initials, employee's initials, and the date the employee was evaluated. During an interview and record review on [DATE] at 2:35 p.m. with DON, five Licensed Nurse Skill Evaluations were reviewed. The Licensed Nurse Skill Evaluations indicated tasks were not dated and had no employee and evaluator initials. The DON stated the Licensed Nurse Skill Evaluation must be filled out with initials and dates for it to be a valid evaluation of skills. The DON stated licensed nurses get evaluated to make sure their skills are up to date and that they have not forgotten their skills. The DON stated she was not aware that Licensed Nurse Skill Evaluations were not completely filled out. 4. During a review of Licensed Nurse Skill Evaluation for Registered Nurse (RN 1), the Licensed Nurse Skill Evaluation indicated RN 1 was evaluated for intravenous therapy ([IV] a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) by an LVN. During an interview and concurrent record review on [DATE] at 2:35 p.m. with DON, Licensed Nurse Skill Evaluation for Registered Nurse (RN 1) was reviewed. Licensed Nurse Skill Evaluation for Registered Nurse indicated RN 1 was evaluated for IV therapy by an LVN. The DON stated LVNs were not allowed to work with IVs because it was out of their scope of practice. The DON stated she had an LVN to help DON perform yearly Licensed Nurse Skill Evaluation because DON needed the help. During a review of facility's job description, titled Director of Clinical Services, dated 2020, the job description indicated the DON was responsible to ensure all nursing personnel received competency training annually. 5. During an interview on [DATE] at 3:58 p.m. with RN 1, RN 1 stated RN 1 was notified by LVN 1 that Resident 1 had low oxygen saturation (a measurement of how much oxygen [a gas essential for life] blood is carrying). RN 1 stated RN 1 did not attempt to check Resident 1's vital signs (measurements of the body's most basic functions to detect or monitor medical problems: body temperature, pulse rate [heart rate], respiration rate [breathing rate], oxygen saturation, and blood pressure). RN 1 stated RN 1 left Resident 1's bedside and went to call 911 (universal emergency telephone number in the United States and Canada, connecting callers to the police, fire, or ambulance services). RN 1 stated RN 1 did not return to Resident 1's room. RN 1 stated RN 1 left LVN 1 in Resident 1's room. RN 1 stated RN 1 did not check Resident 1's vital signs because LVN 1 had checked oxygen saturation and resident's heart rate (number of times heart beats per minute). RN 1 stated RN 1 should have taken full vital signs and delivered oxygen to Resident 1 from five to 10 liters/min (L/min) of oxygen. RN 1 stated RN 1 did not document any vital signs taken before oxygen administration, resident assessments, and vital signs taken after oxygen administration. During an interview on [DATE] at 4:38 with LVN 1, LVN 1 stated Resident 1 did not look good and LVN 1 checked Resident 1's oxygen saturation. LVN 1 stated Resident 1's oxygen saturation was 89 percent (low blood oxygen, below the normal range of 95%-100%) and LVN 1 left Resident 1's bedside to get help. LVN 1 stated LVN 1 left Resident 1's bedside one additional time to get the crash cart (a mobile, locked, and organized cart containing essential emergency medical supplies, medications, and equipment needed to stabilize a resident during a life-threatening crisis, such as cardiac arrest, until emergency medical services [EMS] arrive). LVN 1 stated LVN 1 administered oxygen (refers to medical process of providing extra oxygen to the resident with equipment) to Resident 1 at 2 L/min. LVN 1 stated LVN 1 did not remember if LVN 1 rechecked Resident 1's oxygen saturation. LVN 1 did not increase oxygen administered to Resident 1. LVN 1 stated LVN 1 did not check Resident 1's blood pressure because LVN 1 was busy. LVN 1 stated it was important to check resident's blood pressure because it indicated if oxygen reached to all extremities. LVN 1 stated facility provided walkie talkies (a handheld, portable, battery-operated two-way radio transceiver used for wireless communication) to call for help without leaving resident rooms, LVN1 stated LVN 1 could have used walkie talkie to call for help but instead left resident alone to get help. LVN stated LVN 1 did not document any vital signs taken before oxygen administration, resident assessments, and vital signs taken after oxygen administration. During an interview on [DATE] at 2:09 p.m. with DON, the DON stated during an emergency, the role of an RN was to assess residents and delegate tasks to other staff. The DON stated vital signs had to be taken to set a baseline and to make sure if a resident was stable or unstable. The DON stated during an emergency residents should not be left alone because their heart could stop and staff must start CPR. The DON stated staff have walkie talkies that they are supposed to use when there is an emergency. The DON stated she expected licensed nursing staff to reassess resident's vital signs and deliver more oxygen if vital signs have not improved. During a review of facility's P&P, titled Emergency Procedure - Cardiopulmonary Resuscitation, dated [DATE], the P&P indicated the requirement of personnel to have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS). The P&P indicated the facility would provide mock codes (simulation of an actual cardiac arrest) for training purposes. During a review of facility's P&P, titled Oxygen Administration, dated [DATE], the P&P indicated the residents would be assessed before administering oxygen and while resident receive oxygen therapy. The P&P indicated vital signs would be checked and lung sounds. The P&P indicated the date and time of oxygen therapy and the rate of oxygen flow and route would be documented. The P&P indicated all assessment data obtained before, during and after oxygen therapy would be documented.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was properly assessed and monitored upon experiencing a change in condition when:1. Resident 1's oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) was not reassessed after oxygen was administered to Resident 1 on [DATE] after Resident 1 was found unresponsive with an O2 sat of 89% (normal O2 sat level for most healthy adults is between 95% and 100%).2. Resident 1's blood pressure (BP) and respiratory/breathing rate (RR) were not assessed on [DATE] when Resident 1 was found unresponsive at 11 pm.These failures resulted in an incomplete assessment of Resident 1 while Resident 1 was experiencing a change in condition and had the potential to result in Resident 1 not receiving rescue breathing and CPR (cardiopulmonary resuscitation, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) immediately and timely.During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on [DATE] with diagnoses which included traumatic subdural hemorrhage (bleeding in the area between the brain and the skull caused by head injury) without loss of consciousness, repeated falls, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness (a lack of muscle strength).During a review of Resident 1's History & Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], 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 [DATE], the MDS indicated Resident 1 was dependent (helper does all the effort to complete the activity) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Progress Note (PN) titled Incident Note (IN), dated [DATE] and timed at 1:17 am, the IN indicated on [DATE] at 11 pm, the charge nurse (Licensed Vocational Nurse 1 [LVN 1]), noticed that Resident 1 was unresponsive. The IN-indicated staff (unidentified) went to Resident 1's room right away and was unable to arouse Resident 1. The IN indicated Resident 1 was breathing but Resident 1's respiratory/breathing rate (RR) was not documented. The IN indicated Resident 1's temperature was 97.5, Resident 1's pulse was 61 and Resident 1's BP was not taken due to staff (unidentified) rushing to do emergency implementation. The IN indicated Resident 1's blood sugar was assessed, and it was 292. The IN indicated oxygen was administered to Resident 1 for O2 sat of 89% and Resident 1's O2 sat was not assessed after oxygen administration. The IN indicated the paramedics came at 11:07 pm, and after the paramedics assessed Resident 1, the paramedics started CPR on Resident 1. The IN indicated Resident 1's spouse was informed of Resident 1's change in condition and informed that CPR was being performed on Resident 1 by paramedics. The IN indicated the paramedics stopped CPR at 12 am on [DATE] and Resident 1 was pronounced dead.During a review of Resident 1's PN titled eINTERACT SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) Summary for Providers, dated [DATE] and timed at 1:53 am, the SBAR indicated on [DATE] at 11 pm Resident 1 was found unresponsive, breathing, with low oxygen saturation level of 89%. The SBAR indicated oxygen was administered to Resident 1 and 911 (emergency number to request the services of the police, fire department, paramedics, ambulance) was called. The SBAR indicated Resident 1's BP and Resident 1's RR were not obtained and the SBAR did not indicate what Resident 1's O2 sat was after oxygen was administered to Resident 1. The SBAR indicated Resident 1's pulse or heart rate was 61 beats per minute and Resident 1's temperature was 97.5 F (Fahrenheit - measure of temperature) on [DATE] at 2:04 am. The SBAR indicated Resident 1's O2 sat on room air was 96% on [DATE] at 1:44 am. The SBAR indicated Resident 1's blood sugar was 292 mg/dl (milligrams [weight measurement] per deciliter [volume measurement]) on [DATE] at 2:05 am. The SBAR indicated Resident 1's primary physician was informed of Resident 1's change in condition on [DATE] at 11:37 pm.During an interview with Registered Nurse 1 (RN 1) on [DATE] at 3:15 pm, RN 1 stated on [DATE] at around 11 pm, All staff (unidentified) were in Resident 1's room, O2 sat was at 89%, I told each staff to get oxygen, nonrebreather mask, called 911 around 11:10 pm and paramedics came right away. RN 1 stated oxygen was given first and because of the commotion staff did not take Resident 1's blood pressure instead took Resident 1's blood sugar.During a telephone interview with the Director of Nursing (DON) on [DATE] at 1:42 pm, the DON stated, Resident 1 was found unresponsive, but breathing with a heart rate of 60, and O2 saturation of 89% at 11 pm on [DATE]. The DON stated the priority, and main focus of the staff (in general) for Resident 1 on [DATE] was to do the ABCs (Airway, Breathing, and Circulation - assessment framework used to identify and treat life-threatening conditions immediately), so oxygen was given by the staff first to Resident 1 and staff also called 911. The DON stated the DON did not know if Resident 1's oxygen saturation went up after Resident 1 received oxygen. The DON reviewed Resident 1's medical record and stated she did not see any O2 saturations documented after staff gave oxygen to Resident 1 on [DATE]. The DON did not know if the oxygen saturation went up or down from the 89% indicated in the SBAR, dated [DATE] and timed at 1:53 am. The DON stated it was important to get a full set of vital signs (Temperature, heart rate/pulse, RR , 02 Sat, BP) and finger stick glucose, if indicated, as part of Resident 1's assessment during a change of condition, but since it was a medical emergency, the priority was to give oxygen to Resident 1 and call 911; no blood pressure was taken because staff were focused on giving oxygen and calling 911.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, reviewed [DATE], the P&P indicated, Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.During a review of the SBAR Communication Form, the form indicated, Before Calling MD (Medical Doctor)/NP (Nurse Practitioner)/PA (Physician Assistant): Evaluate the Resident: Complete relevant aspects of the SBAR form below. Check Vital Signs: BP, pulse, and/or apical heart rate, temperature, respiratory rate, oximetry, and finger stick glucose, if indicated.

Based on interview and record review, the facility failed to implement the comprehensive person-centered care plan for one of three sampled residents (Residents 1) when Certified Nurse Assistant (CNA) 1 failed to use 2 staff persons while transferring (moving a resident from one flat surface to another) Resident 1 with an EZ Stand (a transfer-assist device) according to Resident 1's Care Plan Report (CPR), undated.This failure had the potential for Resident 1 to fall and sustain injuries while being transferred.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), muscle wasting and atrophy (loss of muscle tissue), and dementia (a group of thinking and social symptoms that interferes with daily functioning).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing, dressing, toileting hygiene, oral hygiene, and personal hygiene.During a telephone interview on [DATE] at 12:20 PM with Resident 1's Responsible Party (RR 1), RR 1 stated that on [DATE], while RR 1 was visiting Resident 1 at the facility, CNA 1 used the EZ stand by herself to assist Resident 1 to the bathroom.During a telephone interview on [DATE] at 12:46 PM with CNA 1, CNA 1 stated that on [DATE], around 7:40 PM, CNA 1 used the EZ stand by herself to assist Resident 1 to the bathroom.During a concurrent interview and record review on [DATE] at 9:49 AM with the Director of Nursing (DON), Resident 1's Care Plan Report (CPR), undated, was reviewed. the CPR indicated the facility created a care plan for Resident 1 on [DATE] and revised the care plan on [DATE], related to Resident 1 being at high risk of falling due to confusion and balance problems. The CPR indicated an intervention to prevent Resident 1 from falling was, Use 2-person assist for all transfers with EZ stand. The DON stated the purpose of a care plan was to communicate the interventions staff should use to address a resident's (in general) need. The DON stated interventions created to address a resident's (in general) risk for falling should be followed by staff (in general) to prevent the resident (in general) from falling. The DON stated the DON retrained CNA 1 to use 2 persons when using the EZ Stand following the incident with Resident 1 on [DATE].During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered revised [DATE], the P&P indicated, 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.

Based on interview and record review, the facility failed to complete an annual performance review for four of four sampled Certified Nursing Assistants (CNA).This failure had the potential to result in the CNA's giving the residents improper care, making clinical errors, and causing resident injury.Findings:During a review of CNA 1's employment record, the record indicated CNA 1 was hired on 4/25/2024. CNA 1's last performance review was done on 11/4/2024. The record did not indicate a performance review was done in 2025.During a review of CNA 2's employment record, the record indicated CNA 2's last performance review was done on 12/30/2024. The record did not indicate a performance review was done in 2025.During a review of CNA 4's employment record, the record indicated CNA 4 was hired on 7/19/2007. CNA 4's last performance review was done on 12/28/2023. The record did not indicate a performance review was done in 2024 and 2025.During a review of CNA 5's employment record, the record indicated CNA 5 was hired on 10/16/2023. CNA 5's last performance review was done on 2/12/2024. The record did not indicate a performance review was done in 2025.During an interview on 2/10/2026 at 1:45 pm with the Director of Staff Development (DSD), the DSD stated performance reviews should be done every year. The DSD stated she has not completed any performance reviews for the CNAs since starting in April 2025.During a review of the facility's policy and procedure (P&P) titled, Job Descriptions and Performance Evaluations, dated September 2020, the P&P indicated performance reviews will be done with the employee's direct supervisor annually.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received wound (an injury to living tissue caused by a cut) care and treatment in accordance with the facility's Policies and Procedures (P&P) titled, admission Assessment and Follow Up: Role of the Nurse, when: a. Registered Nurse (RN) 1 failed to conduct a complete wound assessment (a thorough examination of both the wound itself and the resident's overall health to understand the wound's status, identify any factors hindering healing, and develop an effective treatment plan) and document Resident 1's left hip surgical wound (a cut through the skin made during surgery [a procedure to remove or repair a part of the body]) upon admission to the facility on 2/18/2025. b. RN 1 failed to obtain a treatment order for Resident 1's left hip surgical wound upon admission on [DATE]. The facility did not obtain the treatment order until 2/28/2025. c. Licensed Vocational Nurse (LVN) 3 and LVN 4 failed to carry out (implement) the treatment order for Resident 1's left hip surgical wound on 4/13/2025, 4/14/2025, and 4/15/2025. These failures resulted in an infection (the invasion and growth of germs/bacteria [a microorganism (an organism that can be seen only through a microscope such as bacteria), especially one which causes disease] in the body) to Resident 1's left hip surgical wound. Resident 1 was transferred to General Acute Care Hospital (GACH) 2 where Resident 1 received treatment for the infected (contaminated with harmful organisms such as bacteria) left hip surgical wound on 4/25/2025. (Cross Reference F656 and F842) Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/18/2025 with diagnoses including acute (sudden) osteomyelitis (bone infection) of the left femur (thigh bone), infection and inflammatory reaction due to internal left hip prosthesis (artificial body part), and dysphagia (difficulty swallowing foods or liquids). The AR indicated Resident 1 was discharged to GACH 2 on 4/25/2025. During a review of Resident 1's History and Physical (H&P), dated 2/19/2025, the H&P indicated Resident 1 had a healing wound on the left hip. During a review of Resident 1's Interdisciplinary Team [IDT, a team of health care professions who work together to establish plans of care for residents] Conference Record (IDT Record), dated2/24/2025, the IDT Record indicated Resident 1 was admitted to the facility following left wound care and osteomyelitis. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated2/25/2025, the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) were intact. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene and dressing. The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort) assistance from staff for oral and personal hygiene. The MDS indicated Resident 1 had a surgical wound and required surgical wound care. During a review of Resident 1's Emergency Department Reports (EDR), dated 4/25/2025, the EDR indicated Resident 1 was transferred to GACH 2's Emergency Department on 4/25/2025 due to increased swelling and drainage (the process of removing excess water and moisture from an area) on Resident 1's left hip wound for one week (specific dates were not indicated). The EDR indicated Resident 1's left hip wound was noted to have erythema (redness of the skin), tenderness (sensitivity to pain), and drainage. The EDR indicated Resident 1's left hip surgical wound was infected. The EDR indicated Resident 1 was given Zosyn (antibiotic medication used to treat infections) via intravenous piggyback (IVPB, a method of administering medication through an IV [IV, a soft flexible tube placed inside a vein, usually in the hand or arm and used to give a person medicine or fluids line]). The EDR indicated Resident 1 was admitted to the telemetry unit (a unit in the hospital dedicated to patients who require monitoring of the heart) at GACH 2 on 4/25/2025. During a review of Resident 1's GACH 2 Laboratory Report (LR, a document that conveys the methods, results, and conclusions of a testing sample of a substance from the body), dated 4/25/2025, the LR indicated a lab culture (a laboratory test to identify the presence and type of microorganisms, aiding in diagnosing infections) was collected from Resident 1's wound on Resident 1's left hip on 4/25/2025. The LR indicated Resident 1's wound contained staphylococcus aureus (bacteria that can cause wound infections). During a review of Resident 1's GACH 2 Progress Notes (PN), signed 4/27/2025, the PN indicated Resident 1 had a severely infected left arthroplasty (a surgical procedure to replace part of the hip joint with a prosthetic implant). The PN indicated Resident 1 admitted to GACH 2 with developing skin breakdown over Resident 1's left hip flap (healthy skin and tissue that is partly detached and moved to cover a nearby wound). During a review of Resident 1's GACH 2 Infectious Disease Progress Note (IDPN), signed 4/28/2025, the IDPN indicated Resident 1's left hip surgical wound was infected. The IDPN indicated Resident 1 was receiving Meropenem (antibiotic medication used to treat infections caused by bacteria) and Vancomycin (powerful antibiotic medication used to treat a variety of serious bacterial infections) via IV. During an interview on 5/14/2025 at 12:01 p.m. with Resident 1's Representative (RR) 1, RR 1 stated Resident 1 fell in 2022 (do not recall exact dates) and broke Resident 1's left hip at RR 1's home. RR 1 stated Resident 1 had surgery for the broken left hip, but the surgery was not successful. RR 1 stated Resident 1 underwent multiple surgeries and Resident 1's latest surgery was on 11/11/2024. RR 1 stated the surgery on 11/11/2024 left Resident 1 with a gaping (split open) surgical wound from Resident 1's left knee to the left hip. RR 1 stated Resident 1 received wound care treatment for Resident 1's left hip surgical wound and the wound was healing while Resident 1 resided at GACH 1. RR 1 stated Resident 1's left hip surgical wound was treated and kept covered with a bandage (a strip of material used to bind a wound) while at GACH 1. RR 1 stated Resident 1 was transferred from GACH 1 to the facility on 2/18/2025. RR 1 stated Resident 1's left hip surgical wound needed daily care for the wound to continue to heal. RR 1 stated RR 1 had to fight with facility staff (unable to identify) to take care of Resident1's left hip surgical wound. RR 1 stated on one occasion; facility staff (unable to identify) had not changed Resident 1's wound bandage for 2 days (unable to recall the dates). RR 1 stated on 4/17/2025, Resident 1's left hip wound had drainage and a foul (bad) smell. RR 1 stated RR 1 sent a picture of Resident 1's left hip surgical wound to MD 1 on 4/17/2025 and RR 1 told MD 1 the wound looked worse (bad/poorer). RR 1 stated MD 1 replied to continue with wound care. RR 1 stated RR 1 wanted a second opinion so RR 1 went to Resident 1's Surgeon (MD 2) and showed MD 2 pictures of Resident 1's left hip surgical wound on 4/23/2025. RR 1 stated MD 2 informed RR 1 that Resident 1's left hip surgical wound was infected. RR 1 stated RR 1informed MD 1 that Resident 1's left hip surgical wound was infected, and MD 1 agreed to transfer Resident 1 to GACH 2 where MD 2 could treat Resident 1's infected wound. RR 1 stated Resident 1's left hip surgical wound became infected because the facility did not give Resident 1 the right wound care and treatment. During a concurrent interview and record review on 5/15/2025 at 9:31 a.m. with the Director of Nursing (DON), Resident 1's Order Details (OD), dated 2/28/2025 and 4/16/2025 were reviewed. The OD, dated 2/28/2025 indicated MD 1 ordered, Change dressing to left hip with abdominal pad (ABD, pad used to absorb fluid from wounds), secure with paper tape in the evening [daily] and change as needed if becomes saturated. The treatment was to be done every evening. The OD, dated 4/16/2025 indicated MD 1 ordered a wound consultation and [wound] treatment. The DON stated when residents (in general) were admitted to the facility, a [licensed] nurse (in general) assessed the resident (in general). The DON stated when the resident had a surgical wound, the admitting nurse carried out the wound treatment orders from the sending facility. The DON stated if Resident 1 did not have wound treatment orders, the admitting nurse (RN 1) needed to obtain an order from MD 1or the surgeon (MD 2). The DON stated when Resident 1 was admitted with a surgical wound, a wound consultation needed to be obtained to ensure assessment and treatment of the wound by the Wound Care Specialist (WCS). The DON stated Resident 1 was admitted to the facility on [DATE] but the facility did not get a treatment order for Resident 1's left hip surgical wound until 2/28/2025 (10 days after Resident 1's admission). The DON stated a wound consultation was not obtained for Resident 1 until 4/16/2025. The DON stated on 4/16/2025, Licensed Vocational Nurse (LVN) 1 informed the DON the treatment order for Resident 1's left hip surgical wound was not carried out [by LVN 3 and LVN 4] on 4/13/2025, 4/14/2025, and 4/15/2025. The DON stated the treatment orders were not carried out on those days (4/13/2025, 4/14/2025, and 4/15/2025). The DON stated RN 1 possibly missed Resident 1's admission surgical wound assessment (on 2/18/2025) because the assessment was not found in Resident 1's medical record. During a concurrent interview and record review on 5/15/2025 at 12:01 p.m. with LVN 2, Resident 1's Medication Administration Record (MAR) for the month of April 2025 was reviewed. The MAR indicated to cleanse Resident 1's wound with Normal Saline (NS, salt solution), pat dry, cover with ABD pad and secure with paper tape. The MAR dated 4/13/2025, 4/14/2025 and 4/15/2025 were left blank (no staff initial indicated the wound treatment was done on these dates). LVN 2 stated on 4/16/2025 at around 8:20 a.m., the WCS was in Resident 1's room changing Resident 1's left hip surgical wound dressing and was there to teach RR 1 how to perform dressing changes for Resident 1. LVN 2 stated LVN 2 saw the old dressing on Resident 1's left hip surgical wound was dated 4/12/2025, indicating the dressing was last changed on 4/12/2025 (indicating staff did not change Resident 1's dressing on 4/13/2025, 4/14/2025, and 4/15/2025). During a concurrent interview and record review on 5/15/2025 at 3:25 p.m. with RN 1, Resident 1's Clinical admission (CA), dated 2/18/2025 was reviewed. The CA did not indicate Resident 1 had a left hip surgical wound and the area indicating surgical wounds was left blank. RN 1 stated Resident 1 was admitted to the facility with a left hip surgical wound. RN 1 stated the left hip surgical wound was dry and did not look infected on admission. RN 1 stated when Resident 1 was admitted to the facility with a wound, RN 1 (the admitting nurse) needed to document Resident 1' s wound assessment in the CA. RN1 stated RN 1 did not measure Resident 1's left hip surgical wound. RN 1 stated a wound assessments needed to be documented so the condition of the wound could be monitored. RN 1 stated RN 1did not obtain a treatment order, upon Resident 1's admission to the facility on 2/18/2025, from MD 1 for Resident 1's left hip surgical wound. RN 1 stated RN 1 did not feel a need for it due to Resident 1's wound bed (the base of floor of a wound) looking dry and no scab (dry rough protective crust that forms over a cut or wound during healing) over the wound. RN 1 stated RN 1 did not think Resident 1's wound needed a dressing over the wound (uncovered). During a telephone interview on 5/15/2025 at 4:02 p.m. with the WCS, the WCS stated the first time the WCS saw Resident 1 was on 4/16/2025. The WCS stated on 4/16/2025, the WCS saw Resident1's left hip surgical wound dressing was not changed for several days (4/13/2025, 4/14/2025, and4/15/2025). The WCS stated the WCS saw Resident 1 one more time on 4/23/2025 [the wound was fragile and discolored]. The WCS stated facility staff (unable to identify) were not consistent in treating Resident 1's left hip surgical wound. The WCS stated there should have been a treatment order for Resident 1's left hip surgical wound from the first day Resident 1 arrived at the facility (on 2/18/2025). The WCS stated a wound bed needed to have some measure of moisture to promote healing. The WCS stated Resident 1's wound should not be left uncovered (without the ABD pad) (left uncovered since 2/18/2025 to 2/28/2025) until it [the wound] was fully closed. The WCS stated since there was no treatment order for Resident 1's left hip surgical wound until 2/28/2025 (10 days after Resident 1's admission), and facility staff were inconsistent in following the treatment orders after 2/28/2025, the facility could have caused Resident 1's wound to become infected. The WCS stated when Resident 1's left hip surgical wound was left uncovered, microorganisms and/or bodily fluids could have caused the wound to become infected. During an interview on 5/19/2025 at 10:49 a.m. with the Infection Preventionist (IP), the IP stated when Resident 1 was admitted to the facility with a surgical wound, the facility should ensure there was a treatment order for Resident 1's wound. The IP stated when Resident 1's wound had a wound bed, the wound should be kept covered to prevent germs (bacteria) from linens and blankets from touching the wound bed (transferring bacteria from the linens and blankets to the wound bed). During a telephone interview on 5/19/2025 at 10:49 a.m. with MD 1, MD 1 stated Resident 1 was admitted to the facility from GACH 1 with an open surgical wound. MD 1 stated there should have been a treatment order for Resident 1's left hip surgical wound upon Resident 1's admission to the facility (on 2/18/2025). MD 1 stated MD 1 sent Resident 1 to GACH 2 (on 4/25/2025) because Resident 1's left hip surgical wound was not healing. During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, revised September 2012, the P&P indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, . The P&P indicated, Conduct an admission assessment (history and physical), including: .A summary of the individual's recent medical history, including hospitalizations, acute illnesses, and overall status prior to admission Relevant medical, social, and family history .A list of active medical diagnoses and patient problems . Current medication and treatments. The P&P indicated, Conduct a physical assessment, including the skin. The P&P indicated, Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. The P&P indicated, The following information should be recorded in the resident's medical record: . All relevant assessment data obtained during the procedure. During a review of the facility's P&P titled, Charting and Documentation, revised July 2017, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to prevent a fall for one of three sampled residents (Resident 1) who had a history of falls by failing to implement the physician (MD) order dated 1/7/2024 to place bilateral floor mats (a cushioned pad placed to absorb the force when a resident falls) on each side of the bed and a silent bed/chair alarm (a sensor pad device placed under a resident's bottom that triggers an alarm when it detected a change in pressure and was used as an early alert that a resident was trying to get out of bed or chair) for Resident 1. These failures resulted in Resident 1 sustaining a fall resulting in a fracture (partial or complete break in the bone) of the right femoral neck of the hip (hip fracture of the thigh bone below the ball of the ball-and-socket hip joint). Resident 1 was transferred and admitted to the General Acute Care Hospital (GACH) on 2/24/2024. Resident 1 underwent a right hip hemiarthroplasty (surgical procedure that replaced only the ball portion of the hip joint) surgery on 2/26/2024 and discharged from GACH on 2/27/2024. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to muscle weakness, falls, abnormalities of gait (manner of walking) and mobility. During a review of Resident 1's Order Summary Report (OSR) for February 2024, the OSR indicated Resident 1 had an active MD order initiated on 1/7/2024 to place floor mats on each side of Resident 1's bed to prevent injury during a fall and a silent bed/chair alarm. During a review of Resident 1's Fall Risk Evaluation (FRE) dated 1/8/2024, timed at 10:44 PM, the FRE indicated Resident 1 had a fall risk score of seven out of 10 due to Resident 1's history of 1-2 falls in the past 3 months, had balance problem while standing, and required the use of assistive devices such as a walker (a device that gave support to maintain balance or stability while walking). The FRE indicated a score of 10 or higher was consider a high risk for falls. During a review of Resident 1's untitled Care Plan (CP) revised on 1/15/2024, the CP indicated Resident 1 was at risk for falls related to gait/balance problems and had a history of falls. The CP indicated the goal was for Resident 1 to not sustain a serious injury. The approached interventions were for staff (in general) to anticipate and meet Resident 1's needs. During a review of Resident 1's Minimum Data Set, (MDS, a standardized comprehensive assessment and care screening tool) dated 1/25/2024, the MDS indicated Resident 1's cognitive abilities (ability to think, learn, and process information) were intact. The MDS indicated Resident 1 required the use of a walker and required partial assistance with indoor ambulation. The MDS indicated Resident 1 required substantial assistance with toileting hygiene, and Resident 1 used a bed alarm, chair alarm, and floor mats daily. During a review Resident 1's Post Fall Assessment (PFA) dated 2/24/2024, timed at 1:06 AM, the PFA indicated Resident 1's Physician (MD) 1 was notified regarding Resident 1's fall. During a review of Resident 1's Interdisciplinary Team Conference Record (IDT, team comprised of professionals from various disciplines who collaborate to address a residents multiple physical and psychological needs) dated 2/26/2024, at 10:12 AM, the IDT record indicated on 2/24/2024 at 12 AM, Resident 1 was yelling for help and Certified Nursing Assistant (CNA) 1 found Resident 1 on the floor. The IDT record indicated Resident 1 complained of pain (unrated) in the right leg when staff (unidentified) tried to assist Resident 1 back to bed. During a review of Resident 1's Radiology (X-ray, pictures of bones and soft tissues) Report dated 2/24/2024, at 11:15 AM, the RR indicated Resident 1 had an acute right femoral neck fracture with mild displacement (bone shifts out of alignment). During a review of Resident 1's Situation, Background, Assessment, Recommendation Communication Form (SBAR, standardized form to communicate information about a resident's conditions, needs, or problems) dated 2/24/2024, the SBAR indicated Resident 1 was transferred to a GACH on 2/24/2024 at 1 PM after the X-ray result indicated an acute right femoral neck fracture. During a review of Resident 1's GACH AR dated 2/24/2024, the AR indicated Resident 1 was admitted to the GACH on 2/24/2024 at 8:16 PM. During a review of Resident 1's Orthopedic (branch of medicine that specializes in correction or prevention of deformities, disorders, or injuries of bones) Surgery Progress Note (OSP) dated 2/27/2024, timed at 7:32 AM, the OSP note indicated Resident 1 was post-operative (after surgery) day (POD) 1 for a right hip hemiarthroplasty. During a review of Resident 1's Facility Transfer Checklist (FTC) dated 2/27/2024, the FTC indicated Resident 1 was transferred from the GACH back to the facility on [DATE] at 7 PM. During a concurrent observation of Resident 1 in Resident 1's room and an interview with Resident 1 on 3/11/2024 at 9:55 AM, Resident 1 was lying in bed with both legs elevated on a pillow. Resident 1 stated on 2/24/2024 (unable to recall exact time) Resident 1 got up and used Resident 1's front wheeled walker (FWW, walker with wheels in the front leg) to use the restroom. Resident 1 stated Resident 1 lost her footing (slip, stumble, fall during an activity), fell straight onto the floor, and broke Resident 1's hip. Resident 1 stated Resident 1 was alone in the room during the fall. Resident 1 stated Resident 1 was calling for help while on the floor when staff (unable to identify) arrived. Resident 1 stated there were no floor mats around the bed and no bed alarm was present when Resident 1 fell on [DATE]. Resident 1 stated, I feel sad about the fall .now I have to start all over again. During an interview on 3/11/2024 at 11:42 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 2/24/2024 at around 12 AM CNA 1 reported to LVN 1 that Resident 1 was found on the floor. LVN 1 stated LVN 1 notified MD 1 of Resident 1's fall and Resident 1's complaint of pain (unrated) in the right leg. LVN 1 stated MD 1 ordered an X-ray of the hips and Resident 1 was transferred to the GACH after the X-ray result indicated Resident 1 had a right hip fracture. During an interview on 3/11/2024 at 11:44 AM with CNA 1, CNA 1 stated on 2/24/2024 CNA 1 heard yelling from Resident 1's room in the middle of the night (midnight) and CNA 1 found Resident 1 sitting on the floor. CNA 1 stated Resident 1 was shaken up (felt shocked and upset). During an interview on 3/11/2024 at 1:03 PM, CNA 1 stated CNA 1 did not hear a bed alarm sound when Resident 1 was found sitting on the bare floor. CNA 1 stated CNA 1 heard Resident 1 yelling for help and Resident 1 called out Resident 1's room number. During an interview on 3/11/2024 at 2:22 PM with LVN 1, LVN 1 stated there were no floor mats next to Resident 1's bed and no bed alarm was found on Resident 1's bed when Resident 1 fell on [DATE]. During a concurrent interview and record review on 3/11/2024 at 2:57 PM with Registered Nurse (RN) 1, Resident 1's OSR dated 1/7/2024 was reviewed. The OSR indicated Resident 1 had an active MD order dated 1/7/2024 for placement of floor mats on each side of Resident 1's bed to prevent injury and a silent bed/chair alarm. RN 1 stated she did not realize both orders (floor mats and silent bed/chair alarm) were active. RN 1 stated from 1/7/2024 to 2/27/2024 the physician ordered floor mats and silent bed/chair alarm but the floor mats, and silent bed alarm were not in place (in the appropriate or usual position) for Resident 1. During a review of the facility's policy and procedure (P&P) titled, Silent Pad Alarms, dated 1/4/2024, the P&P indicated the pad alarm is a pressure pad device ordered by a physician that emits an audible alert at a remote monitoring unit when triggered by movement. During a review of the facility's undated P&P titled, Fall Management Program, the P&P indicated Falls and related injuries are the most frequent adverse occurrence in Skilled Nursing Facilities. There are many interventions that can help prevent injury and may also reduce the number of falls.

Based on observation, interview, and record review, the facility failed to provide nursing services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 1), who had a history of multiple falls, by failing to: Ensure Resident 1's silent bed alarm system (an assistive electronic device that makes alerts/sounds to warn caregivers when the resident tries to get up from the bed while keeping the patient's/resident's environment free of noise/alarm sounds) was plugged into the electrical outlet and was functioning on 11/24/23. As a result, on 11/24/23, Resident 1 got up from Resident 1's bed unnoticed/unaware by staff (in general), fell from Resident 1's bed and sustained pelvis (ring of bones located between the spine and the legs) fractures (broken bones). Resident 1 required transfer to a General Acute Care Hospital (GACH) via Emergency Medical Services (EMS, a system that responds to emergencies in need of highly skilled pre-hospital clinicians). Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/21/23 and was readmitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified fall, lack of coordination, abnormalities of gait (walk) and mobility, and difficulty in walking. During a review of Resident 1's Order Summary Report (OSR), the OSR dated 9/6/23, indicated there was a physician's order for Resident 1 to have a silent bed alarm. During a review of Resident 1's Care Plan for Actual Fall (CP), dated 10/26/23, the CP indicated Resident 1 had a fall on 10/24/23, and the nursing interventions including for Resident 1 to have a silent bed alarm and chair alarm (device containing sensors that trigger an alarm or warming light when it detects a change in pressure). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/1/23, the MDS indicated Resident 1 was severely impaired (never/rarely made decisions) in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper provided more than half the effort) from staff for toileting and bathing. The MDS indicated Resident 1 required the use of bed and chair alarms. The MDS indicated Resident 1 had fallen at the facility three times (dates were not indicated). During a review of Resident 1's CP titled, Unwitnessed Fall on 11/20/23, dated 11/21/23, the CP indicated nursing interventions including for Resident 1 to have bed alarm and continue with fall safety precautions. During a review of Resident 1's Progress Notes, the note indicated on 11/24/23 at 9 p.m. Registered Nurse (RN) 1 heard Resident 1 from the Nurses' Station and RN 1 rushed (ran) over to Resident 1's room and saw Resident 1 lying on the floor. The note indicated Resident 1 complained of pain in the hip (unindicated left or right hip) and the head. The note indicated Emergency services were notified and the paramedics (persons trained to give emergency medical care to people who are injured or ill) took Resident 1 to the GACH. During a review of Resident 1's Post fall Assessment, dated 11/24/23, the assessment indicated Resident 1 fell on [DATE] at 9 p.m. The assessment indicated Resident 1's bed alarm did not sound at the Nurses' Station. During a review of Resident 1's Emergency Department (ED) Note Physician, dated 11/24/23, the note indicated Resident 1 presented to the GACH emergency roiagnom on [DATE]. The note indicated Resident 1 was brought in by paramedics via EMS from the facility due to right hip pain after sustaining a fall. The note indicated Resident 1 was admitted to the GACH for hip pain (unrated) after a fall. During a review of Resident 1's Computed Tomography (CT scan, a diagnostic imaging exam), dated 11/25/23, the CT result showed Resident 1 had fractures of the pelvis. During a review of Resident 1's Consultation Notes, dated 11/25/23, the note indicated Resident 1 complained of pelvic pain (unrated). The note indicated the orthopedic surgeon (doctor who specializes in surgery of the bones, joints, and muscles) diagnosed Resident 1 with fractures of the pelvis. The note indicated if Resident 1 was able to do physical therapy and walk with good pain control then Resident 1 would not need surgery. During an interview on 12/11/23 at 9:42 a.m. with the Director of Nursing (DON), The DON stated Resident 1 fell in Resident 1's room on 11/24/23. The DON stated Resident 1 was sent to GACH after Resident 1 fell and would not be returning to the facility. During an interview on 12/11/23 at 10:16 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 would try to get up on his (Resident 1's) own. CNA 1 stated Resident 1 had fallen multiple times while at the facility (unable to recall the dates). During an interview on 12/11/23 at 11:16 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 saw Resident 1 asleep in bed before Resident 1 fell on [DATE]. LVN 1 stated Resident 1 had a bed alarm in place. LVN 1 stated the bed alarm would sound at the Nurses' Station when Resident 1 moved around. LVN 1 stated RN 1 needed to sit at the desk to monitor the bed alarms. LVN 1 stated it was the facility practice for the Registered Nurse Supervisor (in general) to sit at the Nurses' Station to monitor the alarm system (bed/chair and wheelchair alarm system). During a concurrent interview and record review on 12/11/23 at 12:59 p.m. with the DON, Resident 1's Interdisciplinary Team Conference Record (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident, Record), dated 11/21/23 was reviewed. The IDT indicated on 11/20/23 at 11:15 p.m., there was a loud bang, all nurses went to Resident 1's room and found Resident 1 lying on the fall mat (safety feature that are placed on the floor along the side of the bed). During an interview on 12/11/23 at 1:50 p.m. with RN 1, RN 1 stated Resident 1 fell from Resident 1's bed on 11/24/23. RN 1 stated Resident 1's bed alarm did not sound at the Nurses' Station. RN 1 stated RN 1 did not think Resident 1 would have fallen if the alarm had sounded at the Nurses' Station. RN 1 stated RN 1 checked the alarm system after Resident 1 fell and discovered the alarm module/system at the Nurses' Station was unplugged into the electrical outlet. RN 1 stated the alarm module/system must be plugged into the electrical outlet for the alarms to sound at the Nurse's Station. RN 1 stated Resident 1 tried to get up [out of bed] often because Resident 1 was very confused. During a concurrent observation and interview on 12/12/23 at 12:28 p.m. with LVN 3, the facility's Wireless Central Monitoring Unit (alarm module) was observed sitting on top of the counter and located next to a computer in the Nurse's Station. LVN 3 stated the alarm module would sound when residents (in general) got up from their beds or wheelchairs. LVN 3 stated if the alarm module was not plugged into the electrical outlet the alarm would not sound and residents could fall and hurt themselves without staff noticing. During a concurrent interview and record review on 12/12/23 at 1:10 p.m. with the DON, the facility's policy, and procedure (P&P) titled, Falls Management Program, dated 1/16/14 was reviewed. The P&P indicated, the primary goal of this program was to implement measures that will help reduce fall frequency and injury severity. The P&P indicated, interventions were predicated on residents needs and their unique intrinsic factors and directed toward the resident's fall risk indicators. The P&P indicated for potential or actual falls related to confusion, the facility should consider, the use of bed and chair alarms that the resident cannot remove. The DON stated the purpose of the facility's Falls Prevention Program was to identify residents who were at high risk of falling and assist in preventing falls by implementing safety interventions. The DON stated the purpose of the interventions was to prevent falls and mitigate injuries from falls. The DON stated for Resident 1, the facility had safety interventions including bed alarm and a wheelchair alarm (fall prevention product that monitors the movement of residents who are in a wheelchair). The DON stated the alarms alerted the staff when Resident 1 needed assistance and was getting out of bed or out of the wheelchair. The DON stated bed and wheelchair alarms were used to decrease falls and decrease injuries if falls occurred. The DON stated when the alarm module at the Nurses' Station was not plugged in the electrical outlet or was not working, then staff were not alerted when Resident 1 attempted to get up unassisted. The DON stated Resident 1 could fall if he got out of bed unassisted. During an interview on 12/13/23 at 10:00 a.m. with the Administrator (ADM) regarding how often nursing staff (in general) needed to check the bed/wheelchair alarm system for its functioning, the ADM stated the facility did not have a P&P for bed/wheelchair alarms.

Based on interview and record review, the facility failed to notify the physician for one of three sampled residents (Resident 1) who had a change in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), that started on [DATE]. On [DATE] at 6:04 am, Licensed Vocational Nurse 1 (LVN 1) administered 7 units of [MEDICATION(S)] (fast-acting, insulin-a hormone that works by lowering levels of glucose/sugar in the blood) and 20 units of [MEDICATION(S)] (long-acting insulin) to Resident 1 when Resident 1 ' s blood sugar level was 59 milligram per deciliter (mg/dl a unit of measurement) {abnormally low, blood sugar level below 70 mg/dl is considered low}. On [DATE] at 7:45 am, Resident 1 was found unresponsive, with a blood sugar of 24 mg/dl (abnormally low), limp, and would only open her eyes to painful stimuli. LVN 1, LVN 5, and Registered Nurse Supervisor 1 (RNS 1), did not inform Medical Doctor 1 (MD 1) of the medication error (causes the resident discomfort or jeopardizes his or her health and safety) and Resident 1 ' s blood sugar levels. These deficient practices resulted in Resident 1 ' s blood sugar dropped to a life-threatening level of 25 mg/dl and the resident became unresponsive without medical treatment. Cross Reference F760 Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] under Hospice services (a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s History and Physical dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1 ' s untitled care plan dated [DATE], indicated the resident had diabetes and the interventions were to monitor and report any signs of [CONDITION(S)] (low blood sugar level), such as sweating, confusion, increased heart rate, slurred speech, and lack of coordination. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool), dated [DATE], indicated the resident required extensive assistance for eating and personal hygiene. A review of Resident 1 ' s Unstable Blood Glucose care plan dated [DATE], indicated to monitor the resident for signs and symptoms of [CONDITION(S)] (critically low blood sugar level). The care plan did not indicate any signs and symptom of [CONDITION(S)]. A review of Resident 1 ' s Blood Sugar Summary dated [DATE], timed at 5:49 am, indicated the resident ' s blood sugar level was 59 mg/dl (normal adult blood sugar level is from 90 to 150 mg/dl.) A review of Resident 1 ' s Medication Administration Record: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s Change of Condition Evaluation form dated [DATE], timed at 7:45 am, indicated Resident 1 had [CONDITION(S)] with a blood sugar level of 24 (abnormally low). The form did not indicate LVN 1 administered [MEDICATION(S)] 7 units SQ and [MEDICATION(S)] 20 units SQ at 6:04 am. The form indicated Resident 1 was unresponsive, not eating, flaccid (limp), and would only open her eyes to painful stimuli. The form indicated Resident 1 ' s blood sugars levels were 25 mg/dl at 7:45 AM, 29 mg/dl at 8:00 AM, 39 mg/dl at 8:15 AM, and 32 mg/dl at 8:30 AM. The form indicated the resident was administered orange juice, powder sugar, and 2 sugar packets as tolerated. A review of Resident 1 ' s Blood Sugar Summary dated [DATE], timed at 7:45 am, indicated the resident ' s blood glucose level was 25 mg/dl. A review of Resident 1 ' s Blood Sugar Summary dated [DATE], timed at 8 am, indicated the resident ' s blood glucose level was 29 mg/dl. A review of Resident 1 ' s Blood Sugar Summary dated [DATE] at 8:15 am, indicated the resident ' s blood glucose level was 39 mg/dl. A review of Resident 1 ' s Blood Sugar Summary dated [DATE] at 8:30 am, indicated the resident ' s blood glucose level was 32 mg/dl. During an interview on [DATE] at 12:21 pm, Resident Representative 1 (RR 1) stated on [DATE], Hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) Nurse (HSP 1) called RR 1 to inform her Resident 1 was going to die because she was in a deep coma (a profound or deep state of unconsciousness). RR 1 stated she was not informed Resident 1 was given insulin. RR 1 stated if HSP 1 informed about the insulin administration, RR 1 would have accepted intravenous (IV, into a vein) glucose because the coma and condition was not a natural part of the dying process. RR 1 repeated I was led to believe the drop in blood glucose was part of the natural process and never informed they had given her insulin. RR 1 stated she then told the facility to transfer Resident 1 to another facility. During an interview and record review on [DATE] at 6:45 am, LVN 1 stated she cared for Resident 1 from 11 pm on [DATE] to 7 am on [DATE]. LVN 1 stated that on [DATE] at 5:49 am Resident 1 ' s blood sugar level was 59 mg/dl. LVN 1 stated she administered [MEDICATION(S)] 7 units SQ and [MEDICATION(S)] 20 units SQ to Resident 1 on [DATE] at 6:04 am. LVN 1 stated the blood glucose was 59 mg/dl on [DATE] at 5:49 am. LVN 1 stated she did not correlate the resident ' s blood sugar that was low and the effects of insulin on the blood sugar level. LVN1 stated since the orders did not have parameters on when to hold the insulin, she administered the insulin. LVN 1 stated she left for the day shortly after administering the insulin to Resident 1 and did not check on the resident after the insulin administration. LVN 1 stated administering insulin to a resident with a low blood sugar level would cause the blood sugar levels to drop and the resident could go into a coma and die. LVN 1 stated symptoms of low blood sugar included unresponsiveness and was a life-threatening medical emergency. During an interview on [DATE] at 8 am, Registered Nurse Supervisor 1 (RNS 1) stated on [DATE] at 7:45 am, LVN 5 notified RNS 1 that Resident 1 ' s blood sugar level was low. RNS 1 stated she assessed Resident 1 who was found to have all the symptoms of [CONDITION(S)] (low blood sugar); clammy, cold, and unresponsive. RNS 1 stated she attempted to give the resident orange juice and powdered sugar. RNS 1 stated she did not call Resident 1 ' s physician regarding of the resident ' s low blood sugar. RNS 1 stated on that day, she was not aware LVN 1 administered insulin to Resident 1 when the resident ' s blood sugar was 59 mg/dl. RNS 1 stated she did not check when the last insulin administration was for Resident 1 and confirmed she did not document the information on the COC form. RNS 1 stated when a COC was identified, nurses needed to assess the resident and contact the physician and notify the family, update the orders, and the resident ' s care plan. During an interview on [DATE] at 9:48 am, HSP 1 stated on [DATE] around 8 am, the facility called HSP 1 to report Resident 1 had a blood sugar level in the 20 ' s. HSP 1 stated she arrived at the facility shortly after the call and took over attempting to administer powdered sugar to the resident. HSP 1 stated at one point the resident ' s blood sugar level went up to the high 30 ' s and then 10 minutes later dropped to the low 30 ' s. During an interview and record review on [DATE] at 11 am, the Director of Nursing (DON) reviewed Resident 1 ' s Progress Notes, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 1 should not have been administered insulin with a blood glucose level of 59 mg/dl. The DON stated LVN 1 should have used her nursing judgement to prevent the resident from becoming even more hypoglycemic. The DON confirmed the care plan did not give examples of the signs and symptoms of [CONDITION(S)]. The DON stated knowing insulin was given which caused the blood sugar to drop would have changed the course of treatment. The DON confirmed the licensed nurses did not check when the last time insulin was administered to Resident 1 and should have done so. The DON stated the physician, hospice nurse, and Resident Representative 1 (RR 1) should have been informed of the medication error. The DON stated, RR 1 would have been aware and would likely wanted something done. The DON stated, I know she is hospice, but we have options, the family might change their decisions, this is not part of the dying process. The DON stated the lack of communication led to medications and treatment being withheld. The DON stated, This is pretty bad, she could have died . During an interview on [DATE] at 4:40 pm, the Hospice Patient Care Administrator (HPCA) stated it was the hospice company ' s expectation that the facility would notify the hospice nurse if any vital signs or assessment findings were out of normal range. The HPCA stated if a resident had insulin orders it was expected the facility to notify the hospice nurse with any abnormal values. The HPCA stated the hospice company kept a log of all calls received and stated no calls were received from the facility regarding Resident 1 from [DATE] to [DATE]. During a telephone interview on [DATE] at 10:19 am, Medical Doctor 1 (MD 1) stated if insulin orders did not have indicated parameters standards of practice, should be utilized. MD 1 stated he preferred hospice residents to have higher blood sugar levels and would not recommend insulin be administered if the blood sugar was under 100 mg/dl. MD 1 stated if a resident ' s blood sugar was found to be below 60 mg/dl, the resident ' s conditions needed to be assessed and efforts to raise blood sugar levels done according to the condition. MD 1 stated if the resident was awake and able to swallow effectively then orange juice could be given, if a resident was unresponsive and unable to swallow effectively an IV bolus of dextrose (sugar) could be administered or [MEDICATION(S)] (sugar raising medication). MD 1 denied being notified of Resident 1 ' s low blood sugar levels or condition on [DATE] and stated he was notified the next day ([DATE]) after the blood sugars had returned to normal. MD 1 denied being notified about the medication error and stated, he Didn ' t hear anything until weeks and weeks later. MD 1 stated if a resident ' s blood sugar level is 59 mg/dl, insulin should not be administered. MD 1 stated It ' s kind of like a commonsense thing at that point. MD 1 stated Resident 1 ' s low blood sugar of 25 mg/dl level on [DATE] at 7:45 am was not a normal part of the dying process and was caused by the insulin that was given with a low blood sugar level. During a concurrent interview and review of Resident 1 ' s Progress Notes and Situation -Background-Assessment -Recommendation form (SBAR, communication form uses between members of the health care team) on [DATE] at 12 pm, the DON stated according to the facility ' s procedure for physician notification during a change of condition, facility nurse notifies hospice nurse for any change in condition and hospice nurse notifies MD. The DON reviewed Resident 1 ' s progress notes, SBAR forms and stated there was no documentation that a charge nurse (unidentified) directly notified MD 1. The DON stated the facility did not notify MD 1 or the facility ' s Medical Director of Resident 1 ' s change of condition on [DATE] or of the medication error. The DON stated, Facility does not notify MD directly because everything is being communicated to the hospice company. A review of the undated facility ' s policy and procedure, titled Medication Errors and Drug Reaction, indicated medication errors must be reported to the resident ' s physician immediately and keep the resident under constant observation. The policy indicated the nurse administering medications should be familiar with drug reactions, reaction effects and contraindications. A review of the undated facility ' s policy and procedure, titled Blood Sugar Monitoring Protocol, indicated the protocol to follow for a conscious resident with a blood glucose below 60 was to: i) Provide resident with 4 to 6 ounces of fruit juice or non-diet soda, or 1 cup of milk. ii) Repeat blood glucose test after ,d+[DATE] minutes. If blood glucose level does not return to within normal limits (which are 70 to 110), call the resident's physician for direction. If unavailable and symptomatic, call 911. The policy indicated If a resident is UNCONSCIOUS, call 911. The policy indicated severe symptoms of [CONDITION(S)] caused low glucose impairs brain function. A review of the undated facility ' s policy, titled Notification of Change in Status, indicated In the event that there is a change in the resident's physical, mental or emotional state, the Charge Nurse or Director of Service shall be responsible for notifying the attending physician. The attending physician will determine if the family or responsible party should be notified and determine who shall be responsible for this notification. The policy indicated the attending physician was to be notified if any error in administration of medicine or treatment to a patient which is life-threatening or presents a risk to health, safety, or security of the patient. A review of the undated facility ' s document, titled Terminal Patient Care, indicated Treat the dying patient with the same importance as the patient who will recover.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors (causes the resident discomfort or jeopardizes the resident health and safety) according to professional standards of practice and facility ' s policy and procedure. Licensed Vocational Nurse 1 (LVN 1) administered [MEDICATION(S)] (fast-acting, insulin-a hormone that works by lowering levels of glucose/sugar in the blood) when Resident 1 ' s blood sugar level was 59 milligram per deciliter (mg/dl, a unit of measurement) [A blood sugar level below 70 mg/dl is considered low and can harm the resident). On [DATE] at 6:04 am, LVN 1 administered 7 units of [MEDICATION(S)] and 20 units of [MEDICATION(S)] (long-acting insulin) to Resident 1 when Resident 1 ' s blood sugar level was 59 mg/dl. On [DATE] at 7:45 am, Resident 1 was found unresponsive, with a blood sugar level of 24 mg/dl, limp, and would only open her eyes to painful stimuli. The facility staff and Hospice (a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) Nurse (HSP 1) presumed the resident was naturally dying and were not aware LVN 1 administered insulin with low blood sugar. The facility and Hospice team did not provide emergency services. These deficient practices resulted in Resident 1 ' s blood sugar to drop to a life-threatening level of 25 mg/dl (blood sugar below 55mg/dl is considered severely low) and became unresponsive without medical treatment. Cross Reference F580 Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] under Hospice services with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s History and Physical dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1 ' s untitled care plan dated [DATE], indicated the resident had diabetes and the interventions were to monitor and report any signs of [CONDITION(S)] (low blood sugar), such as sweating, confusion, increased heart rate, slurred speech, and lack of coordination. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool), dated [DATE], indicated the resident required extensive assistance for eating and personal hygiene. A review of Resident 1 ' s Unstable Blood Glucose care plan dated [DATE], indicated to monitor the resident for signs and symptoms of [CONDITION(S)] (critically low blood sugar level). The care plan did not indicate any signs and symptom of [CONDITION(S)]. A review of Resident 1 ' s Blood Sugar Summary dated [DATE], timed at 5:49 am, indicated LVN 1 checked the resident ' s blood sugar and the level was 59 mg/dl. A review of Resident 1 ' s Medication Administration Record: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s Change of Condition Evaluation form dated [DATE], timed at 7:45 am, indicated Resident 1 had [CONDITION(S)] with a blood sugar level of 24 (abnormally low). The form did not indicate LVN 1 administered [MEDICATION(S)] 7 units SQ and [MEDICATION(S)] 20 units SQ at 6:04 am. The form indicated Resident 1 was unresponsive, not eating, flaccid (limp), and would only open her eyes to painful stimuli. The form indicated Resident 1 ' s blood sugars levels were 25, 29, 39, 32. The form indicated the HSP 1 notified Resident Representative 1 (RR 1) medical doctor 1 (MD 1) and the doctor ordered all current medication to be discontinued and the resident to be started on comfort measures (care plan that is focused on symptom control, pain relief, and quality of life). A review of Resident 1 ' s Blood Sugar Summary dated [DATE], timed at 7:45 am, indicated the resident ' s blood glucose level was 25 mg/dl. A review of Resident 1 ' s Blood Sugar Summary dated [DATE], timed at 8 am, indicated the resident ' s blood glucose level was 29 mg/dl. A review of Resident 1 ' s Blood Sugar Summary dated [DATE] at 8:15 am, indicated the resident ' s blood glucose level was 39 mg/dl. A review of Resident 1 ' s Blood Sugar Summary dated [DATE] at 8:30 am, indicated the resident ' s blood glucose level was 32 mg/dl. During an interview on [DATE] at 12:21 pm, RR 1 stated on [DATE] the HSP 1 called RR 1 to inform her Resident 1 was going to die because she was in a deep coma (a profound or deep state of unconsciousness). RR 1 stated she was not informed Resident 1 was given insulin. RR 1 stated if HSP 1 informed about the insulin administration, RR 1 would have accepted intravenous (IV, into a vein) glucose because the coma and condition was not a natural part of the dying process. RR 1 repeated I was led to believe the drop in blood glucose was part of the natural process and never informed they had given her insulin. RR 1 stated she then told the facility to transfer Resident 1 to another facility. During an interview and record review on [DATE] at 6:45 am, LVN 1 stated she cared for Resident 1 from 11 pm on [DATE] to 7 am on [DATE]. LVN 1 stated that on [DATE] at 5:49 am, Resident 1 ' s blood sugar level was 59. LVN 1 stated she administered [MEDICATION(S)] 7 units SQ and [MEDICATION(S)] 20 units SQ to Resident 1 [DATE] at 6:04 am. LVN 1 stated at the time she checked the blood sugar ([DATE] at 5:49 AM) she did not correlate the low blood sugar level and the effects of insulin. LVN 1 stated since the orders did not have parameters on when to hold the insulin, she administered the insulin. LVN 1 stated she left for the day shortly after administering the insulin to Resident 1 and did not check on the resident after the insulin administration. LVN 1 stated administering insulin to a resident with a low blood sugar level would cause the blood sugar levels to drop and the resident could go into a coma and die. LVN 1 stated symptoms of low blood sugar included unresponsiveness and was a life-threatening medical emergency. During an interview on [DATE] at 8 am, Registered Nurse Supervisor 1 (RNS 1) stated on [DATE] at 7:45 am, LVN 5 notified RNS 1 that Resident 1 ' s blood sugar level was low. RNS 1 stated she assessed Resident 1 who was found to have all the symptoms of [CONDITION(S)] (low blood sugar) such as clammy, cold, and unresponsive. RNS 1 stated she attempted to give the resident orange juice and powdered sugar. RNS 1 stated at 8 am Resident 1 ' s blood sugar level was rechecked and was even lower at which point she called the HSP 1. RNS 1 stated HSP 1 arrived at the facility and assisted in trying to get the resident to drink orange juice (while unresponsive). RNS 1 stated since the blood sugar level was not going up HSP 1 called the hospice physician and informed the physician Resident 1 was hypoglycemic. RNS 1 stated she was not aware Resident 1 was given insulin on [DATE] at 6:04 am and did not check the time of the last insulin administration. RNS 1 stated Honestly, I did not look. RNS 1 stated HSP 1 was not aware Resident 1 had been given insulin. RNS 1 stated HSP 1 informed RR1 that Resident 1 was dying, and RR 1 wanted the dying process to happen naturally. RNS 1 stated RR 1 was not informed Resident 1 was administered insulin with a low blood sugar level. RNS 1 reviewed Resident 1 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RNS 1 stated Resident 1 ' s low blood sugar level was treated as if it was part of the dying process but was a medication error and the facility did not identify or address the medication error. RNS 1 stated Resident 1 ' s low blood sugar would have been treated differently if the medication error had been identified. RNS 1 stated IV glucose could have been administered or 911 (emergency services) called. RNS 1 stated RR 1 should have been informed and given the choice on how to treat the resident. RNS 1 stated RR 1 should have been given the opportunity to provide additional care or transfer to the hospital, because the resident ' s condition was not a natural part of the dying process, it was because of a medication error. During the same interview and record review on [DATE] at 8 am, RNS 1 stated insulin was a critical medication and needed to be given carefully. RNS 1 stated if an insulin order did not have parameters the nurse needed to utilize nursing judgement on when to administer or hold the insulin. RNS 1 stated insulin should not be given with a blood sugar level below 60, Don ' t want them to bottom out, blood sugar will go even lower, can be life threatening for sure, could lead to coma or death. During an interview on [DATE] at 9:48 am, HSP 1 stated on [DATE] around 8 am, the facility called HSP 1 to report Resident 1 had a blood sugar level in the 20 ' s. HSP 1 stated she arrived at the facility shortly after the call and took over attempting to administer powdered sugar to the resident. HSP 1 stated at one point the resident ' s blood sugar level went up to the high 30 ' s and then 10 minutes later dropped to the low 30 ' s. HSP 1 called RR 1 to inform her there was a definite chance Resident 1 was going to pass away. HSP 1 stated she then called and informed the physician of Resident 1 ' s condition and received orders to discontinue all medications and begin comfort measures (allow the resident to pass away with no intervention). HSP 1 stated the facility never informed her Resident 1 was given insulin on [DATE] at 6:04 am and became aware once the resident stabilized. During an interview and record review on [DATE] at 11 am, the Director of Nursing (DON) reviewed Resident 1 ' s Progress Notes, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 1 should not have been administered insulin with a blood glucose level of 59 mg/dl. The DON stated LVN 1 should have used her nursing judgement to prevent the resident from becoming even more hypoglycemic. The DON stated knowing insulin was given which caused the blood sugar to drop would have changed the course of treatment. The DON stated the physician, hospice nurse, and RR 1 should have been informed of the medication error. The DON stated RR 1 would have been aware and would likely wanted something done. The DON stated, I know she is hospice, but we have options, the family might change their decisions, this is not part of the dying process. The DON stated the lack of communication led to medications and treatment being withheld. The DON stated, This is pretty bad, she could have died . During a telephone interview on [DATE] at 10:19 am, Medical Doctor 1 (MD 1) stated if insulin orders did not have indicated parameters standards of practice, should be utilized. MD 1 stated he preferred hospice residents to have higher blood sugar levels and would not recommend insulin be administered if the blood sugar was under 100 mg/dl. MD 1 stated if a resident ' s blood sugar was found to be below 60, the resident ' s condition needed to be assessed and efforts to raise blood sugar levels done according to the condition. MD 1 stated if the resident was awake and able to swallow effectively then orange juice could be given, if a resident was unresponsive and unable to swallow effectively an IV bolus of dextrose (sugar) could be administered or [MEDICATION(S)] (sugar raising medication). MD 1 denied being notified of Resident 1 ' s low blood sugar levels or condition on [DATE] and stated he was notified the next day ([DATE]) after the blood sugars had returned to normal. MD 1 denied being notified about the medication error and stated, Didn ' t hear anything until weeks and weeks later. MD 1 stated if a resident ' s blood sugar level is 59 mg/dl, insulin should not be administered. MD 1 stated It ' s kind of like a common-sense thing at that point. MD 1 stated Resident 1 ' s low blood sugar of 25 mg/dl level on [DATE] at 7:45 am was not a normal part of the dying process and was caused by the insulin that was given with a low blood sugar level. A review of the undated facility ' s Policy and Procedure, titled Medication Errors and Drug Reaction, indicated the nurse administering medications should be familiar with drug reactions, reaction effects and contraindications. A review of the undated facility ' s policy, titled Blood Sugar Monitoring Protocol, indicated the protocol to follow for a conscious resident with a blood glucose below 60 was to: i) Provide resident with 4 to 6 ounces of fruit juice or non-diet soda, or 1 cup of milk. ii) Repeat blood glucose test after ,d+[DATE] minutes. If blood glucose level does not return to within normal limits (which are 70 to 110), call the resident's physician for direction. If unavailable and symptomatic, call 911. The policy indicated If a resident is UNCONSCIOUS, call 911. The policy indicated severe symptoms of [CONDITION(S)] caused low glucose impairs brain function. The policy indicated profound symptoms of [CONDITION(S)] caused low glucose levels arrest metabolism (stop body functions). A review of the undated facility ' s document, titled Terminal Patient Care, indicated Treat the dying patient with the same importance as the patient who will recover. According to the American Diabetes Association, https://diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/[CONDITION(S)], do not inject insulin (it will lower the person's blood glucose even more), do not provide food or fluids (they can choke). Low blood glucose is when the blood glucose levels have fallen low enough that a person will need to [MEDICATION(S)] to bring them back to your target range. This is usually when the blood glucose is less than 70 mg/dL.

Based on observation, interview and record review, the facility failed to provide necessary care treatment and services to prevent the development of an avoidable pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence), for one of 19 sampled residents (Resident 5), from stage 1 pressure injury (skin is redden, no breaks or tears in the skin ) to stage III pressure injury (full thickness tissue loss with slough, a yellow, tan, gray or brown discharge that may be present on the wound bed). The facility failed to: 1. accurately assess, identify, monitor and evaluate the skin treatments for Resident5 with skin redness. 2. adequately document the skin condition and characteristic of the wound. 3. follow up and report the discovery of the pressure ulcers. 4. properly train the primary Licensed Vocational Nurse (LVN 1) to identify, document and/or report skin breakdown. 5. develop and implement an intra disciplinary team ((IDT) number of people in a similar field of interest to discuss a resident's wellbeing) and plan of care to determine the care and treatments necessary to promote wound healing. As a result of these deficiencies Resident 5 developed two Stage III pressure injuries on the her left upper medial (toward the middle of the body) buttocks that were not previously identified by the treatment nurse. Findings: During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/5/17 at 2:58 p.m., LVN 1 stated Resident 5 has a history of a stage II (partial thickness loss of skin with a shallow open ulcer, pink wound bed without slough) pressure injury on her buttocks, but does not have one now. She only has redness, no pressure sores. A review of the admission record (Face Sheet) for Resident 5 indicated resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) assessment and care screening tool), dated 9/1/17, indicated Resident 5 had impaired short term and long term memory recall problems. Resident 5 required extensive assistance (staff provide weight support) with bed mobility (how resident moves to and from lying position, turn side to side while in bed/alternate sleep furniture) and dressing (resident puts on, fastens and takes off all items of clothing). Resident 5 was totally dependent (full staff assistance during the entire 7 day period) on staff for transfer (moves to and from bed or wheelchair), locomotion (moves between locations), hygiene (brush teeth, comb hair), bathing, and was always incontinent of bowel and bladder (lack of voluntary control over bowel movements and urination). Resident 5 was assessed to have one stage II pressure ulcer upon admission on 2/24/12. A review of a Braden Scale for Predicting Pressure Sore Risk (a skin assessment tool which uses a scoring system to evaluate a residents' risk of developing a pressure ulcer), dated 8/31/17, indicated Resident 5 had a score of 13 (score of 13 14 indicates a risk for pressure ulcer development). Resident 5's risks for pressure ulcer were due to the resident's limited sensory perception, activity, mobility, and a problem with friction and shear (when skin, with gravity, continuously rub with a surface the result will be a superficial, partial thickness skin injury that looks like an abrasion). During multiple observations on 9/5/17 at 1:10 p.m., on 9/6/17 at 8:03 a.m., 10:17 a.m., 1:35 p.m., 3:40 p.m., and on 9/7/17 at 8:00 a.m.,10:10 a.m., 2:30 p.m., 4:30 p.m., Resident 5 was observed lying on her back in bed with neck deviated to the left. On 9/6/17 at 3:40 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she was responsible for pressure sore and wound treatments for Resident 5 and resident does not have a pressure sore, just an excoriation (loss of the superficial layer of skin) and redness on her buttocks. On 9/6/17 at 3:42 p.m., during a review of the clinical record for Resident 5, a document titled Treatment Sheet dated 9/2/17, indicated Resident 5 had right buttocks excoriation and left buttocks redness. In a concurrent interview LVN 1 stated, I don't do measurements, I just treat the wound and sign the treatment sheet that it's done. He stated that the Registered Nurses (RN's) assesses and stage the wounds on a weekly basis. On 9/6/17 at 3:45 p.m., during an interview and record review, Registered Nurse 5 (RN 5) stated the facility does not have a wound specialist (health care professionals trained to care and treat all types of wounds), the LVN's do the treatments, assess the wound daily, and confirms with the RN supervisor daily. The RN's assess the progression of the wound weekly and document on the Skin and Wound Progress Report. Upon further review of the clinical records titled Skin and Wound Progress Report, dated from May 2017 to September 2017, for Resident 5's left buttocks, documentation were: 5/20/17 redness; 6/3/17 excoriation; 6/24/17 redness; 7/1/17 Stage II measuring 1.5 centimeters (cm) x 1.0 cm pink in color; 7/8/17 Stage II measuring 1.0 cm x 0.2 cm, pink in color; 7/15/17 excoriation; 7/29/17 redness; 9/7/17 Stage II: site 1 measures 0.5 cm x 0.5 cm, slough color and site 2 measures 1.0 cm X 1.0 cm, slough in color. RN 5 acknowledged wound assessment and documentation was incomplete, missing wound size, depth, drainage, color and odor. On 9/7/17 at 4:30 p.m., during a treatment observation with RN 5. Resident 5 was observed with two open crater like wounds, both on the left medial upper buttocks, with slough noted. RN 5 stated the wounds look like stage II, it is on a bony area of the left buttocks/sacral area, is deep with some kind of yellow bed, maybe slough. Wound 1 was 0.5 cm (L) X 0.5 cm (W) and wound 2 was 1.0 cm (L) X 1.0 cm (W). RN 4 did not measure depth. In a concurrent interview, RN 4 could not define the characteristics of a Stage III from a Stage II pressure ulcer. On 9/7/17 at 5:00 p.m., an interview with the, Director of Nursing (DON) was conducted while reviewing the medical records of Resident 5. DON stated protocol for wound documentation is the RN's assess and stage the wound, document the size, exact location, drainage, what layer of skin is exposed and the overall progression of the wound. On 9/8/17 at 12:24 p.m., during an interview, Certified Nursing Assistant 3 (CNA 3) stated she had been taking care of Resident 5 for the last six months. CNA 3 stated, She had redness on the buttocks for the last 6 months and six days ago (9/2/17) I told the charge nurse (LVN 1) that there were two tiny open holes on the right buttocks that were pink with some white in it. The charge nurse just said, Oh, ok. A written declaration dated 9/8/17 and timed at 12:24 p.m. was obtained from CNA 3 indicating the above statement. A review of Resident 5's physician telephone order dated 9/2/17 at 11:00 a.m. indicated to treat right buttock excoriation and left buttock redness with [MEDICATION NAME] dressing (medicated dressings ideal for removal of dead, damaged or infected wounds) every other day and as needed for 30 days. On 9/8/17 at 11:30 a.m., during an interview and wound observation, the Director of Staff Development/Clinical Specialist (RN 1) stated LVN's are responsible for wound treatments and daily assessment and RNs perform a weekly assessment and documentation of the wound. If there is a change in condition, RNs are made aware and reports to the physician. Direct patient care staff periodically receive in service training and education on pressure ulcers, repositioning, risk factors, and wound assessment (size, location, color, and odor). During Resident 5's wound observation with RN 1, Resident 5's left medial upper buttock/sacral area was observed with two Stage III wounds; site 1 was measured 0.5 cm (L) x 0.5 cm (W) with small amount of yellow slough on wound bed. Site 2, measured 1.0 cm (L) x 1.0 cm (W), wound bed covered with slough. RN 1 stated the wounds are Stage III pressure sores, not Stage II as previously assessed by RN 4; yellow slough is present on the wound bed. RN 1 stated, The wounds progressed to a Stage III due to lack of repositioning and the failure to assess and properly document the wounds. An accurate assessment should have been done and reported as soon as the wounds were discovered. On 9/8/17 at 3:00 p.m., during an interview and record review, RN 1 stated the Skin and Wound Progress Report for Resident 5's left and right buttocks, dated from January 2017 to September 2017, was incomplete. The size, depth, width, color, order and wound progression are missing. Record reviews of the staff in service training records for pressure ulcer prevention was reviewed with RN 1. The in service sign in sheet roster titled Pressure Ulcer Prevention, dated 1/11/17; LVN/RN Pressure Injury Classification, dated 6/14/17; and Pressure Ulcer, dated 9/8/17 did not include LVN 1's name as an attendee. RN 1 stated LVN 1 does not possess specialized wound care credentials and did not receive wound care in service training. RN 1 stated she would definitely start an in service training regarding wounds and require all licensed personnel to attend. A review of Resident 5's plan of care titled Impaired Skin Integrity related to (R/T) excoriation/open wound on right buttock, dated 1/12/17 and re evaluated on 7/3/17, indicated a goal for the resident's skin condition will be assessed and identified and resolved by 14 days. Staff intervention included to turn and reposition for pressure relief at least every 2 hours and to assess and record wound progress. However, no care plan was found regarding Resident 5's two Stage III pressure ulcers on the right upper medial buttock/sacrum. There was no IDT documentation or plans of care addressing Resident 5's Stage III wounds to determine the proper care and treatments to promote wound healing. A review of the facility's undated policy 2.128a, titled Skin Integrity, indicated Residents are properly evaluated and assessed by a licensed nurse; care plans are developed to prevent pressure ulcers and other breaks in skin. Physicians will be informed and updated on changes in the skin. Furthermore, nursing staff are to inspect skin daily and any skin conditions (skin breakdown, abrasions, bruises, and rashes) documented each shift. Pressure wound documentation includes site, stage of wound, size, depth, order and treatment.