Every finding on record at Ahmc Seton Medical Center

Based on observation, interview, and record review, the facility failed to ensure one of the 26 sampled residents (Resident 97) bed/side rail was raised up while the resident was in bed. This failure resulted in Resident 97 falling out of bed and sustain a fracture (broken bone) through the right femur (thigh bone).During an observation on 8/11/25, at 10:04 AM, Resident 97 was asleep in bed. The right and left upper bed/side rails were raised.During an interview on 8/13/25, at 10:08 AM, Registered Nurse (RN) 4 stated that the bed/side rails were raised up when Resident 97 is in bed for positioning. RN 4 further stated Resident 97 leans to one side. A review of the facility's Informed Consent for Bedrail Use - Facility verification Form indicated the consent was obtained on 6/29/23.A review of the care plan with a start date of 6/30/23, indicated Resident 97 was at risk for fall or injury. The care plan interventions to address fall or injury included having the bed / side rails up when the resident is in bed and to anticipate resident's needs. A review of the Minimum Data Set (a standard assessment tool) dated 3/13/25, indicated diagnoses for Resident 97 included dementia (decline in memory or other thinking skills), diabetes (abnormally high blood sugar level) and hypertension (abnormally high blood pressure). Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function including memory recall and decision-making ability) indicated moderately impaired cognition (decisions poor, supervision required). Functional status indicated Resident 97 was dependent (helper does all the effort. Resident does none to complete the activity) with all activities of daily living including bed mobility (the ability to turn and reposition in bed) and transfer (ability to transfer in and out of bed). A review of the Interdisciplinary Team (IDT, a group of professionals who work together to provide resident care) notes dated 4/24/25, indicated Resident 97 fell out of bed during ADL care. The IDT notes indicated that the two Certified Nurse Assistants (CNA 1 and CNA 2) did not put the side rail up when they left the resident's bedside. A review of the facility investigation dated 4/24/25, indicated CNA 1 stated that while (with CNA 2) were in the bathroom, they heard a thump and saw the resident on the floor. The facility investigation further indicated CNA 1 and CNA 2 transferred Resident 97 from the floor to bed and continued providing care. A review of the facility investigation indicated on 4/24/25, Resident 97 complained of pain and was transferred to the emergency department (ED). The facility investigation further indicated that on 4/25/25, staff observed Resident 97 was grimacing (a facial expression to non-verbally communicate pain) when moving their legs. More grimacing was observed when the right hip was touched. The Xray (a test that produces pictures of the inside of the body) result indicated a non-displaced impacted fracture (when the bone is broken but the bone fragments remain aligned) through the right femur and osteopenia (fragile bones). During an interview on 8/13/25, at 12:12 PM, the Director of Nursing stated that the CNA's should have put the side rail up before they left the resident. The DON stated that there was no other incident that occurred after the fall incident. The DON further stated that the two CNAs have terminated their employment. A review of the facility Policy and Procedure titled Major neurocognitive disorder (formerly known as dementia) - Patient Care with a revised date 5/2025, indicated, . Purpose: To ensure patients/residents who are diagnosed with Major neurocognitive disorder or have an established diagnosis of Major neurocognitive disorder, are managed according to acceptable standards of care. Residents will be free of injury on a daily basis. A review of the facility Policy and Procedure titled, Post Acute Fall Prevention and Management dated 6/2025, indicated, .All residents are considered universally at a fall risks, regardless of their individual fall risk assessment, due to chronic health conditions, physical decline, mobility difficulties, cognitive impairment and pharmaceutical drug regimens which characterize the resident population. Each care setting shall be assessed to determine the needs for resident specific assessment and reassessments. The level of assessed risk shall determine the degree and/or frequency of resident specific risk assessment and interventions.

Based on interview and record review, the facility failed to identify on-going systemic issues, develop, implement, and evaluate its plan of action to correct the identified deficiencies when:The facility failed to report an alleged abuse incident involving Resident J within the required 2-hour timeframe. Additionally, the facility did not conduct a thorough investigation of the alleged abuse incident. (Cross reference to F609 and F610)The facility failed to report the results of investigation within five (5) working days of the incident for two reported abuse allegations involving Resident J, Resident L, and Resident M. (Cross reference to F609)The facility failed to evaluate, develop, and implement interventions after Resident A was identified with a significant weight loss. (Cross reference to F656 and F692)The facility did not ensure valid copy of the Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that assists people in making decisions about medical treatment and life saving measures during end-of-life care or medical crisis) for Resident 5 had complete and accurate information. (Cross reference to F578)Audit logs were not completed as stated in the plan of correction. The facility failed to ensure hand hygiene was performed between resident care. (Cross reference to F880)The cumulative effect of these failures to implement the plan of correction for the identified deficiencies resulted in repeated noncompliance, which could jeopardize the health, safety, and well-being of the residents.Quality Assurance and Performance Program (QAPI) program is a data driven and proactive approach to quality improvement to ensure services provided are meeting quality standards and assuring care reaches a certain level.Review of the facility's QAPI Meeting Minutes from September 2025 to November 2025 indicated, .Continue with POC (plan of correction) . During an interview on 12/10/25 at 4:40 PM, Chief Clinical & Quality Officer (CCQO) stated that the Director of Nursing (DON) and Manager of the Subacute were responsible for the implementation of the plan of correction. 1. Review of the facility's QAPI Meeting Minutes from September 2025 to November 2025 indicated, .Continue with POC (plan of correction) . Review of the facility's plan of correction (POC) with a completed date of 9/22/25, indicated, .D. In order to maintain and sustain the corrective action, the DON/designee will ensure that the abuse and neglect log is current and will conduct an audit of all allegations of abuse and neglect on a monthly basis to determine compliance with timely reporting. The expectation is 100% compliance – that every allegation of abuse will be reported to the Ombudsman and CDPH within 2 hours. Results of the audit will be presented and discussed during the QAPI meetings . During an interview on 12/10/25 at 2:03 PM, the DON confirmed that the allegation was not reported within the required timeframe due to Resident J's allegation was not clear to her (DON). 2. During an interview on 12/10/25 at 3:05 PM, the DON confirmed that the result of investigation was not completed and faxed to CDPH within the required timeframe of 5 working days after the incident. 3. During a concurrent interview and record review with RN 1 on 12/9/25 at 9:51 AM, Resident A's clinical record including progress notes, assessments, and care plan was reviewed. RN 1 did not find documentation of a change of condition, nutritional assessment, or care plan after Resident A's significant weight loss on 10/7/25. RN 1 confirmed there was a Risk for Altered Nutrition Status care plan, however, none of the care plan addressed Resident A's actual weight loss. Furthermore, RN 1 confirmed that a change of condition and care plan should have been completed, and weekly weights should have been initiated. During an interview on 12/11/25 at 11:37 AM, Registered Nurse (RN) 2 stated that the staff were not made aware of the facility's approved plan of correction thus, they did not know what needs to be implemented in the POC. RN 2 stated, I don't know what was added in the POC. Review of the facility's Quality Assurance and Performance Improvement, revised 9/25, indicated, The purpose of performance improvement (PI) is to provide a comprehensive data based program that continually assess the Quality of Care provided to the residents, and provides feedback that enables the facility to identify adjustments needed to improve residents care. From the Board to the bedside, the focus is providing patient centered care rooted in evidence based practice and ensuring Medicare Condition of Participation (COPs) are followed . The QAPI program is an ongoing, comprehensive, integrated program that provides a transparent view of the Quality of Services provided . It ensures that established policies, procedures, and guidelines are followed in the provision of care (including state, federal, accreditation, and professional standards) . Objectives: . To support ongoing implementation of newer and known safe practices; to examine potential adverse events and redesign care processes and systems to improve response and outcome . To use standardized tools and methodology to demonstrate improvement. Evaluate the adequacy of clinical documentation utilizing standardized audit tools . Identify opportunities for improvement and evaluate the effectiveness and safety of services . Monitor and evaluate compliance with regulatory requirements . 4. A review of facility's plan of correction (POC) dated 9/18/2025, POC indicated, .B. all residents have the potential to be affected by the practice. The Direction of Nursing (DON) and or designee will review the POLST form of each resident to ensure accuracy, completion, and to determine the need of revision.Discrepancies and omissions will be corrected upon discovery, and POLST will be updated. During a concurrent interview and record review on 12/9/2025 at 10:30 AM with the Director of Nursing (DON), the DON reviewed Resident 5's POLST to verify completion of the form. The DON confirmed that the form was not fully completed, the signature and date of the physician/nurse practitioner/physician assistant and the signature and mailing address of the legally recognized decision maker were left blank. During a concurrent interview and record review on 12/9/2025 at 11:49 AM with the Assistant Director of Nursing (ADON), the ADON reviewed Resident C's POLST to verify completion of the form. The POLST indicated that the date the form was prepared was 11/19/2023. Section D showed that the physician/nurse practitioner/physician assistant signed and dated the form on 11/22/2024, and the patient or legally recognized decision maker signed on 12/10/2024. The ADON stated, I don't know what happened here; it took a year to complete the form. Review of the facility's policy and procedure titled, POLST-Physician Orders for Life -Sustaining Treatment, revised 9/2025, indicated, .3. Completing a POLST form with the patient.E. In order to be valid, the POLST must be signed by a physician, and by the patient. Review of Resident 5's POLST dated 8/30/2025 indicated, .A copy of the signed POLST form is legally valid physician order.To be valid a POLST form must be signed by (1) physician, or by a nurse practitioner.and (2) the patient or decision maker. 5. A review of facility's plan of correction (POC) dated 9/18/2025, POC indicated, .B. all residents within the facility have the potential to be affected. The facility will ensure that all residents' personal possessions are safeguarded. Residents belongings are inventoried on admission, entered into the residents Belonging List, signed by the resident/RP, and countersigned by witnessing staff. Record review, facility's plan of correction (POC) dated 9/18/2025, POC indicated, .D. The DON and or designee will audit 10 resident valuables listed remain safe and are not misplaced/lost. The DON and/or designee will document discrepancies. During a concurrent interview and record review on 12/9/2025 at 2:38 PM with Assistant Director of Nursing (ADON), the ADON reviewed Resident G's patient belongings record, which indicated valuable: a cellphone with a quantity of one (1). The ADON stated, We never saw any cellphone before or during our audit, and the facility's audit form shows none. Although we understood that we should have reviewed the residents' belongings inventory, we instead proceeded to check directly in each resident's room. We only did what was instructed. An interview on 12/9/2025 at 2:44PM Resident D stated, Yes, they came to check every day my belongings, do I need a copy of the belongings record? Because I don't have a copy of it. An interview on 12/9/2025 at 2:55PM Resident E stated, yes, it's true that they are checking on my stuff every day, I have phone, tablets, tv. But I don't have a copy of my belongings record. An interview on 12/9/2025 at 3:08PM with Resident F stated, Resident F stated they come to check my things every single time, but I don't have a copy of my belonging record. Review of Resident E's Patient Belonging Record undated, indicated, no signature and undated on patient or responsible party and witness. Review of Resident F's Patient Belonging Record undated, indicated, no signature and undated on patient or responsible party and witness. A review of facility's policy titled Loss and Theft- Residents Personal Belongings, revised 9/2025, indicated, .Residents Valuable Form, All residents or their responsible parties are provided a Residents Belonging Record form for signature upon admission.The resident Valuables form requires the signature of the resident or the resident's responsible party on admission and on discharge. Receipt for valuables.the copy of the receipt is given to the resident or responsible party to serve as a claim check for the release of the valuables.

Based on interview and record review, the facility failed to ensure governing body oversight of the facility's Quality Assurance Program (QAPI) program and activities when plan of action to correct identified deficiencies were not implemented and maintained. This failure had the potential to negatively affect the care and services rendered to the residents, including their quality of life. Review of the facility's QAPI Meeting Minutes from September 2025 to November 2025 indicated, .Continue with POC (plan of correction) . The QAPI Meeting Minutes did not show any oversight of how the plan of action was being implemented to address the identified deficiencies. During an interview on 12/10/25 at 4:40 PM, Chief Clinical & Quality Officer (CCQO) stated that the Director of Nursing (DON) and Manager of the Subacute were responsible for the implementation of the plan of correction. During an interview on 12/11/25 at 11:37 AM, Registered Nurse (RN) 2 stated that the staff were not made aware of the facility's approved plan of correction thus, they did not know what needs to be implemented in the POC. RN 2 stated, I don't know what was added in the POC.Review of the facility's Quality Assurance and Performance Improvement, revised 9/25, indicated, .From the Board to the bedside, the focus is providing patient centered care rooted in evidence based practice and ensuring Medicare Condition of Participation (COPs) are followed . Objectives: To support and maintain a culture of safety throughout the facility. To support a strong internal, non-punitive reporting through the IMP system. And, to encourage a culture of reporting to support improvement learning . To support ongoing implementation of newer and known safe practices; to examine potential adverse events and redesign care processes and systems to improve response and outcome. To increase communication and promote an environment where collaboration and teamwork thrive . Monitor and evaluate compliance with regulatory requirements . Assist operations with developing performance improvement projects (PIPs) when gaps are identified between current and desired status . Governing Body: Ultimate responsibility for the QAPI plan and the care that is provided. Oversees the development, implementation, and assessment of the plan . Evaluates the effectiveness of the plan. Quality, Risk, Safety, and Compliance Department: . Maintain oversight of on-going organization wide QAPI program. Ensure the integrity of data collection and reporting .

Based on observation, interview, and record review, the facility failed to ensure the Interim Dietary Director (IDD), who is also a registered dietitian and oversees the kitchen, was fully sufficient when she did not ensure that auditing of the dish machine logs and cooling (Cooling is the specific method and guideline used to rapidly lower the temperature of cooked food to a safe storage level, preventing bacterial growth. Improper cooling is a major factor in causing foodborne illness. Taking too long to chill potentially hazardous food, which means food that requires time/temperature control for safety to limit the growth of pathogens, has been consistently identified as one factor contributing to foodborne illness. Foods that have been cooked and held at improper temperatures promote the growth of disease-causing microorganisms that may have survived the cooking process (e.g., spore-formers). Cooked potentially hazardous foods that are subject to time and temperature control for safety are best cooled rapidly within 2 hours, from 135 F to 70 F, and within 4 more hours to the temperature of approximately 41 F. The total time for cooling from 135 F to 41 F should not exceed 6 hours.) logs was done in the kitchen. This failure had the potential for inadequate supervision of the dietary department which serves food for the entire facility. During a concurrent observation and interview on 8/12/25 at 3:29 PM with IDD in the kitchen, the facility's dish machine was observed. IDD stated, their dish machine is a high-temperature dishwasher. IDD stated, the wash temperature should be above or equal to 160 F, and the final rinse temperature should be above or equal to 180 F for the dish machine. During a concurrent interview and record review on 8/12/25 at 3:33 PM with Food Service Aide (FSA) 2 in the kitchen, the facility's log titled, DISHMACHINE TEMPERATURES in June 2025 and August 2025 were reviewed. The DISHMACHINE TEMPERATURES in June 2025 indicated, the dish machine temperatures did not reach 180 F for final rinse on the following dates: 1) 6/9/25; 2) 6/10/25; 3) 6/11/25; 4) 6/12/25; 5) 6/13/25; 6) 6/24/25; 7) 6/25/25; 8) 6/26/25; 9) 6/30/25. The DISHMACHINE TEMPERATURES in August 2025 indicated, the dish machine temperatures did not reach 180 F for final rinse on the following dates: 1) 8/3/25; 2) 8/4/25; 3) 8/5/25; 4) 8/6/25; 5) 8/11/25; 6) 8/12/25. During a concurrent interview and record review on 8/12/25 at 3:38 PM with IDD in the kitchen, the facility's log titled, DISHMACHINE TEMPERATURES in June 2025 and August 2025 were reviewed. IDD stated, It did not reach the temperature when asked if the dish machine temperatures reached 180 F for final rinse on the following dates: 1) 6/9/25; 2) 6/10/25; 3) 6/11/25; 4) 6/12/25; 5) 6/13/25; 6) 6/24/25; 7) 6/25/25; 8) 6/26/25; 9) 6/30/25; 10) 8/3/25; 11) 8/4/25; 12) 8/5/25; 13) 8/6/25; 14) 8/11/25; 15) 8/12/25. Review of the facility's policy and procedure (P&P) titled, FOOD SAFETY STANDARDS revised in May 2025 indicated, . Dishmachine Procedure . Final rinse temperature and flow pressure gauges are accurate only when a rack enters the final rinse area and water is flowing. The acceptable temperature range for the wash cycle is 160 F and Final Rinse is 180 F-195 F . Review of the facility's P&P titled, IC 8-F: INFECTION CONTROL-NUTRITION AND FOOD SERVICES revised in December 2022 indicated, . D. Dishwashing . 2. Final rinse must be 180-195 degrees Fahrenheit . During a concurrent interview and record review on 8/13/25 at 10:50 AM with Interim Dietary Director (IDD) and Cook, the facility's document titled, COOKING AND COOLING LOG dated 7/28/25 was reviewed. The log indicated, it took 3 hours to check the porridge temperature, from 6 AM to 9 AM. IDD stated, food temperatures should be checked in 2 hours to ensure it reaches 70 F when asked about cooling procedures from the initial cooling temperature. IDD stated, That's 3 hours when asked how many hours from 6 AM to 9 AM. IDD and [NAME] acknowledged, the porridge temperature was not checked in 2 hours when asked. The log also indicated, it took 5 more hours to check the porridge temperature, from 9 AM to 2 PM. In addition, the gravy temperature was 112 F at 9 AM after the first 2 hours, starting from the initial cooling temperature of 180 F at 7 AM. Then it was blank after 9 AM. IDD acknowledged, 112 F at 9 AM meant it did not reach 70 F in 2 hours. IDD stated, It should be below 70 ( F). The log also indicated, the tomato soup temperature was checked at 9:30 AM, then after that, it was also blank. IDD further stated, They didn't do the follow up when asked about the gravy and tomato soup. IDD acknowledged, the kitchen staff did not follow cooling procedures when asked. IDD stated, I will give them in-service. During a concurrent interview and record review on 8/13/25 at 10:55 AM with IDD, the COOKING AND COOLING LOG dated 7/30/25 was reviewed. The log indicated, the rice temperature was 110 F at 9 AM, two hours after starting to cool from the initial temperature of 175 F at 7 AM. IDD stated, The temperature was not right, when asked about 110 F at 9 AM. During a concurrent interview and record review on 8/13/25 at 10:57 AM with IDD, the COOKING AND COOLING LOG dated 8/3/25 was reviewed. The log indicated, the porridge temperature was checked at 8 AM after 4:48 AM when the initial cooling temperature was checked. IDD stated, That's 3 hours, when asked. During a concurrent interview and record review on 8/13/25 at 11 AM with IDD, the COOKING AND COOLING LOG dated 8/8/25 was reviewed. The log indicated, the porridge temperature was 110 F at 8:50 AM two hours after starting to cool from the initial temperature of 173 F at 6:50 AM. IDD stated, The temperature was not low enough when asked if the porridge temperature 110 F at 8:50 AM was good enough. During a concurrent interview and record review on 8/13/25 at 11:04 AM with IDD, the COOKING AND COOLING LOG dated 8/12/25 was reviewed. The log indicated, the porridge temperature was 78 F at 8 AM after the initial cooling temperature was 179 F at 5 AM. IDD stated, It's wrong. It should be reached 70 ( F) within 2hours, when asked. During a concurrent interview and record review on 8/13/25 at 11:05 AM with IDD, COOKING AND COOLING LOG dated 8/13/25 was reviewed. The log indicated, the porridge temperature was 68 F at 8 AM after the initial cooling temperature was 179 F at 5 AM. IDD stated, It's 3 hours. Below 70 ( F) within 2 hours, when asked how many hours from 5 AM to 8 AM. During a concurrent interview and record review on 8/13/25 at 1:12 PM with IDD, the COOKING AND COOLING LOG from July 2025 to August 2025 were reviewed. The logs indicated, INSTRUCTIONS . Internal temperature must reach 70 F within 2 hours of reaching 140 F . Internal temperature must reach 41 F or below within 4 hours of reaching 70 F . IDD stated, This form needs to be changed. It's confusing, when asked about the instructions on the logs. During an interview on 8/13/25 at 1:19 PM with IDD, IDD acknowledged, they did not follow cooling procedures when asked. IDD also acknowledged, the instructions on the COOKING AND COOLING LOG were not correct. During an interview on 8/13/25 at 1:56 PM with IDD, IDD stated, they can spread infection to the entire facility if they continue to use the dish machine when it did not reach 180 F for the final rinse, when asked. IDD stated, . I started on June 16th (in 2025) . when asked. IDD verified, she is the registered dietitian. IDD stated, she oversees the kitchen when asked what her role is. IDD stated, There is no supervisor to audit in the kitchen . when asked if she audits the logs. IDD stated, the facility needs to have a supervisor to do audits because she is too busy dealing with whatever comes up in the kitchen to do an audit herself. During an interview on 8/14/25 at 9:25 AM with Diet Clerk II, Diet Clerk II verified, the kitchen does not have the supervisor below IDD when asked. Diet Clerk II stated, IDD is only a temporary and nobody is auditing the logs such as DISHMACHINE TEMPERATURES and COOKING AND COOLING LOG to check if the kitchen staff are checking the right temperatures regarding the dish machine and cooling procedures. Diet Clerk II stated, they should have somebody who will audit to remind the kitchen staff about the correct temperatures and to correct the kitchen staff's wrong practices. During an interview on 8/14/25 at 9:50 AM with IDD, IDD verified, Not right now when asked again if the facility has a supervisor below her who can audit the logs. During a concurrent interview and record review on 8/14/25 at 9:55 AM with IDD, the facility's log titled, DISHMACHINE TEMPERATURES in June 2025 was reviewed. The log indicated, the wash temperatures and final rinse temperatures were not documented on the following dates: 1) 6/1/25; 2) 6/2/25; 3) 6/3/25; 4) 6/4/25; 5) 6/5/25; 6) 6/6/25; 7) 6/7/25; 8) 6/8/25; 9) 6/9/25 AM; 10) 6/27/25; 11) 6/28/25; 12) 6/29/25. There was no evidence that the kitchen staff checked the dish machine temperatures on these days when asked. Review of the facility's policy and procedure (P&P) titled, FOOD SAFETY STANDARDS revised in May 2025 indicated, . Dishmachine Procedure . Temperature of wash and rinse cycle should be checked for adequacy before use . Review of the facility's document titled, Organizational Chart Post Acute Care undated indicated, IDD was under ACOO (Associated Chief Operation's Officer), and there should be a food service supervisor under IDD. Review of the facility's Job description titled, JOB TITLE: Certified Dietary Manager undated indicated, . Reports to: Director of Food & Nutrition JOB SUMMARY: Responsible for the daily operations of the foodservice department in accordance with facility policy and procedures as well as federal and state regulations. Provide leadership and guidance to ensure that food quality, safety standards, and client expectations are satisfactorily met . Foodservice Management . Manage staff to ensure compliance with safety and sanitation regulations, including safe receiving, storage, preparation, and service of food .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when: 1. Multiple small packs of butter in a black container in the kitchen refrigerator had no expiration dates.2. Multiple small packs of butter in a stainless-steel container in the kitchen refrigerator were expired.3. The freezer temperature for the ice cream in the kitchen was out of range. 4. Six packs of MY OWN MEAL FLORENTINE LASAGNA in the kitchen storage room were expired. 5. The dish machine temperature log indicated the final rinse temperature was below 180 F (degrees Fahrenheit, a scale for measuring temperature) for multiple days in June and August 2025.6. The dish machine temperature was not checked for multiple days in June 2025. 7. The cooling log indicated, the facility did not follow cooling procedures for multiple days in July and August 2025. These failures were likely to result in putting residents at risk for foodborne illness (diseases caused by consuming contaminated food or drink).1. During a concurrent observation and interview on 8/11/25 at 9:57 AM with Dietary Clerk (DC) 1 in the kitchen, multiple small packs of butter were stored in a black container in the refrigerator, but there were no expiration dates. DC 1 did not answer when asked if she could see the expiration date. DC 1 acknowledged, there was no label indicating the expiration date when asked again. Review of the facility's policy and procedure (P&P) titled, IC 8-F: INFECTION CONTROL-NUTRITION AND FOOD SERVICES revised in December 2022 indicated, . L. Storage of Foods . d. All food will be label (sic) and dated . 2. During a concurrent observation and interview on 8/11/25 at 9:58 AM with DC 1 in the kitchen, multiple small packs of butter were stored in a stainless-steel container in the refrigerator. The label on the stainless-steel container indicated, . Butter . Prep Date (the date when food is initially prepared or processed) 6-26-25 (June 26th, 2025) Use By 7-26-25 (July 26th, 2025) . DC 1 stated, It's like an expiration (date) . supposed to be the last day . when asked what the Use By date means. She acknowledged, July 26th, 2025, was last month when asked. During a concurrent observation and interview on 8/11/25 at 10:38 AM with [NAME] in the kitchen, the pictures of the multiple small packs of butter in the stainless-steel container with the label of Use By 7-26-25 in the kitchen refrigerator were shown to him. [NAME] stated, Expired when asked. [NAME] stated, Yes when asked whether it was correct that food should not be used past its Use By date. [NAME] acknowledged, the butters were expired and should not be used. During a concurrent observation and interview on 8/11/25 at 10:53 AM with Food Service Aide (FSA) 1 in the kitchen, the pictures of the multiple small packs of butter in the stainless-steel container labeled Use By 7-26-25 in the kitchen refrigerator were shown to her. FSA 1 stated, It means that it's expired when asked what Use By 7-26-25 means for the butter. FSA 1 stated, the butters should have been thrown away after their Use By date. During an interview on 8/13/25 at 1:40 PM with Interim Dietary Director (IDD), IDD stated, they should not use food after the Use By date when asked what Use By date means. IDD acknowledged, food consumed after the Use By date has the risk of foodborne illness. During a concurrent interview and record review on 8/14/25 at 9:20 AM with Diet Clerk II, the facility's policy and procedure (P&P) titled, FOOD SAFETY STANDARDS revised in May 2025 was reviewed. The P&P indicated, . 19. Spoiled or contaminated food will not be served in any manner . Diet Clerk II, stated, the food past the Use By date can be considered spoiled or contaminated if it is used after this date when asked. Diet Clerk II acknowledged, there is a risk of foodborne illness to the residents if the kitchen staff do not follow the food safety standards in the kitchen. 3. During a concurrent observation and interview on 8/11/25 at 10:15 AM with DC 1 in the kitchen, the ice cream freezer temperature was 35 F. DC 1 stated, Yes when asked if it was the freezer. DC 1 stated, 35 ( F) when asked what temperature the freezer was at. The ice cream in the small packs were not completely frozen in the freezer. The Strawberry Flavored Ice Cream indicated, . NET 4 FL OZ (fluid ounce, a unit of volume used to measure liquids) (118ml) . BEST USED BY 01/10/26, and the Vanilla Flavored Ice Cream indicated, . NET 4 FL OZ (118ml) . BEST USED BY 07/01/26. But they were not frozen hard when pressed. DC 1 acknowledged, the ice creams were not frozen hard when asked. The ice creams were so soft and squishy that they leaked a little when they were pressed. So, DC 1 brought some wipes to clean the leaked ice cream. During a concurrent observation and interview on 8/11/25 at 10:30 AM with [NAME] in the kitchen, the ice cream freezer temperature was still 35 F. [NAME] stated, I think it's below negative 5 when asked about the appropriate temperature for the freezer. [NAME] stated, No when asked if the ice creams were frozen. [NAME] acknowledged, the freezer temperature for the ice cream in the kitchen was out of range. [NAME] stated, 26 for strawberry flavored ice cream and 15 for vanilla flavored ice cream when asked how many unfrozen ice creams there were. [NAME] stated, the ice creams should be frozen when asked, then he threw out all ice creams. During a concurrent interview and record review on 8/13/25 at 1:43 PM with IDD, the facility's policy and procedure (P&P) titled, FOOD SAFETY STANDARDS revised in May 2025 was reviewed. The P&P indicated, . ce cream and frozen foods 0 F or less . IDD stated, Yes, it is ice cream, when asked what ce cream means. IDD acknowledged, the freezer temperature above 0 F was out of range and ice cream should be frozen hard in the freezer. Review of P&P titled, IC 8-F: INFECTION CONTROL-NUTRITION AND FOOD SERVICES revised in December 2022 indicated, . K. Chilling of Foods . Freezer temperatures are held at below 0 degrees Fahrenheit . 4. During a concurrent observation and interview on 8/11/25 at 11:15 AM with [NAME] in the kitchen storage room, there were 6 packs of MY OWN MEAL FLORENTINE LASAGNA on a shelf, labeled [DATE]/23. [NAME] stated, [DATE]/23 means the kitchen received the lasagna packs in October 2023 when asked. The lasagna packs themselves indicated, . FULLY COOKED & READY TO EAT . NO REFRIGERATION NEEDED . BEST BY 07/2025 . [NAME] stated, BEST BY 07/2025 means they should have used the lasagna until July 2025 when asked. [NAME] acknowledged, all 6 packs of MY OWN MEAL FLORENTINE LASAGNA were expired when asked. [NAME] stated, I need to throw away, then he threw all of them away. [NAME] stated, all 6 packs of MY OWN MEAL FLORENTINE LASAGNA should not be used. During an interview on 8/15/25 at 3:11 PM with Infection Preventionist (IP), IP stated, the food past the Use By or Best By dates should be discarded when asked. IP stated, there is a risk of infection, such as foodborne illnesses, if residents eat food past the Use By or Best By dates. 5. During a concurrent observation and interview on 8/12/25 at 3:29 PM with Interim Dietary Director (IDD) in the kitchen, the facility's dish machine was observed. IDD stated, their dish machine is a high-temperature dishwasher. IDD stated, the wash temperature should be above or equal to 160 F, and the final rinse temperature should be above or equal to 180 F for the dish machine. During a concurrent interview and record review on 8/12/25 at 3:33 PM with Food Service Aide (FSA) 2 in the kitchen, the facility's log titled, DISHMACHINE TEMPERATURES in June 2025 and August 2025 were reviewed. The DISHMACHINE TEMPERATURES in June 2025 indicated, the dish machine temperatures did not reach 180 F for final rinse on the following dates: 1) 6/9/25; 2) 6/10/25; 3) 6/11/25; 4) 6/12/25; 5) 6/13/25; 6) 6/24/25; 7) 6/25/25; 8) 6/26/25; 9) 6/30/25. The DISHMACHINE TEMPERATURES in August 2025 indicated, the dish machine temperatures did not reach 180 F for final rinse on the following dates: 1) 8/3/25; 2) 8/4/25; 3) 8/5/25; 4) 8/6/25; 5) 8/11/25; 6) 8/12/25. During a concurrent interview and record review on 8/12/25 at 3:38 PM with IDD in the kitchen, the facility's log titled, DISHMACHINE TEMPERATURES in June 2025 and August 2025 were reviewed. IDD stated, It did not reach the temperature when asked if the dish machine temperatures reached 180 F for final rinse on the following dates: 1) 6/9/25; 2) 6/10/25; 3) 6/11/25; 4) 6/12/25; 5) 6/13/25; 6) 6/24/25; 7) 6/25/25; 8) 6/26/25; 9) 6/30/25; 10) 8/3/25; 11) 8/4/25; 12) 8/5/25; 13) 8/6/25; 14) 8/11/25; 15) 8/12/25. During a concurrent observation and interview on 8/13/25 at 1:01 PM with Territory Representative of ***** (Name of the company regarding dishmachine) in the kitchen, the dish machine temperature reached 180 F for final rinse. The representative verified, there was no issue with the dish machine. During an interview on 8/13/25 at 1:17 PM with IDD, IDD stated, They should be better, when asked about the kitchen staff's practices on the dish machine temperatures logs in June 2025 and August 2025. IDD stated, Dishwasher needs 30 minutes recovery from time of fill. IDD further stated, the kitchen staff should not use the dish machine until the correct temperatures reach. IDD stated, They need to wait, when asked. During an interview on 8/13/25 at 1:56 PM with IDD. IDD stated, they can spread infection to the entire facility if they continue to use the dish machine when it did not reach 180 F for the final rinse, when asked. Review of the facility's policy and procedure (P&P) titled, FOOD SAFETY STANDARDS revised in May 2025 indicated, . Dishmachine Procedure . Final rinse temperature and flow pressure gauges are accurate only when a rack enters the final rinse area and water is flowing. The acceptable temperature range for the wash cycle is 160 F and Final Rinse is 180 F-195 F . Review of the facility's P&P titled, IC 8-F: INFECTION CONTROL-NUTRITION AND FOOD SERVICES revised in December 2022 indicated, . D. Dishwashing . 2. Final rinse must be 180-195 degrees Fahrenheit . 6. During a concurrent interview and record review on 8/14/25 at 9:55 AM with IDD, the facility's log titled, DISHMACHINE TEMPERATURES in June 2025 was reviewed. The log indicated, the wash temperatures and final rinse temperatures were not documented on the following dates: 1) 6/1/25; 2) 6/2/25; 3) 6/3/25; 4) 6/4/25; 5) 6/5/25; 6) 6/6/25; 7) 6/7/25; 8) 6/8/25; 9) 6/9/25 AM; 10) 6/27/25; 11) 6/28/25; 12) 6/29/25. There was no evidence that the kitchen staff checked the dish machine temperatures on these days when asked. Review of the facility's policy and procedure (P&P) titled, FOOD SAFETY STANDARDS revised in May 2025 indicated, . Dishmachine Procedure . Temperature of wash and rinse cycle should be checked for adequacy before use . 7. Cooling is the specific method and guideline used to rapidly lower the temperature of cooked food to a safe storage level, preventing bacterial growth. Improper cooling is a major factor in causing foodborne illness. Taking too long to chill potentially hazardous food, which means food that requires time/temperature control for safety to limit the growth of pathogens, has been consistently identified as one factor contributing to foodborne illness. Foods that have been cooked and held at improper temperatures promote the growth of disease-causing microorganisms that may have survived the cooking process (e.g., spore-formers). Cooked potentially hazardous foods that are subject to time and temperature control for safety are best cooled rapidly within 2 hours, from 135 F to 70 F, and within 4 more hours to the temperature of approximately 41 F. The total time for cooling from 135 F to 41 F should not exceed 6 hours. 2022 Food Code from U.S. Food and Drug Administration (FDA) indicated, . Improper cooling remains a major contributor to bacterial foodborne illness . Cooked hot food should be discarded immediately if the food is: Above 70 F and more than two hours into the cooling process; or Above 41 F and more than six hours into the cooling process . During a concurrent interview and record review on 8/13/25 at 10:50 AM with Interim Dietary Director (IDD) and Cook, the facility's document titled, COOKING AND COOLING LOG dated 7/28/25 was reviewed. The log indicated, it took 3 hours to check the porridge temperature, from 6 AM to 9 AM. IDD stated, food temperatures should be checked in 2 hours to ensure it reaches 70 F when asked about cooling procedures from the initial cooling temperature. IDD stated, That's 3 hours when asked how many hours from 6 AM to 9 AM. IDD and [NAME] acknowledged, the porridge temperature was not checked in 2 hours when asked. The log also indicated, it took 5 more hours to check the porridge temperature, from 9 AM to 2 PM. In addition, the gravy temperature was 112 F at 9 AM after the first 2 hours, starting from the initial cooling temperature of 180 F at 7 AM. Then it was blank after 9 AM. IDD acknowledged, 112 F at 9 AM meant it did not reach 70 F in 2 hours. IDD stated, It should be below 70 ( F). The log also indicated, the tomato soup temperature was checked at 9:30 AM, then after that, it was also blank. IDD further stated, They didn't do the follow up when asked about the gravy and tomato soup. IDD acknowledged, the kitchen staff did not follow cooling procedures when asked. IDD stated, I will give them in-service. During a concurrent interview and record review on 8/13/25 at 10:55 AM with IDD, the COOKING AND COOLING LOG dated 7/30/25 was reviewed. The log indicated, the rice temperature was 110 F at 9 AM, two hours after starting to cool from the initial temperature of 175 F at 7 AM. IDD stated, The temperature was not right, when asked about 110 F at 9 AM. During a concurrent interview and record review on 8/13/25 at 10:57 AM with IDD, the COOKING AND COOLING LOG dated 8/3/25 was reviewed. The log indicated, the porridge temperature was checked at 8 AM after 4:48 AM when the initial cooling temperature was checked. IDD stated, That's 3 hours, when asked. During a concurrent interview and record review on 8/13/25 at 11 AM with IDD, the COOKING AND COOLING LOG dated 8/8/25 was reviewed. The log indicated, the porridge temperature was 110 F at 8:50 AM two hours after starting to cool from the initial temperature of 173 F at 6:50 AM. IDD stated, The temperature was not low enough when asked if the porridge temperature 110 F at 8:50 AM was good enough. During a concurrent interview and record review on 8/13/25 at 11:04 AM with IDD, the COOKING AND COOLING LOG dated 8/12/25 was reviewed. The log indicated, the porridge temperature was 78 F at 8 AM after the initial cooling temperature was 179 F at 5 AM. IDD stated, It's wrong. It should be reached 70 ( F) within 2hours, when asked. During a concurrent interview and record review on 8/13/25 at 11:05 AM with IDD, COOKING AND COOLING LOG dated 8/13/25 was reviewed. The log indicated, the porridge temperature was 68 F at 8 AM after the initial cooling temperature was 179 F at 5 AM. IDD stated, It's 3 hours. Below 70 ( F) within 2 hours, when asked how many hours from 5 AM to 8 AM. During a concurrent interview and record review on 8/13/25 at 1:12 PM with IDD, the COOKING AND COOLING LOG from July 2025 to August 2025 were reviewed. The logs indicated, INSTRUCTIONS . Internal temperature must reach 70 F within 2 hours of reaching 140 F . Internal temperature must reach 41 F or below within 4 hours of reaching 70 F . IDD stated, This form needs to be changed. It's confusing, when asked about the instructions on the logs. During an interview on 8/13/25 at 1:19 PM with IDD, IDD acknowledged, they did not follow cooling procedures when asked. IDD acknowledged, the instructions on the COOKING AND COOLING LOG were not correct. During a concurrent interview and record review on 8/14/25 at 9:45 AM with IDD, the facility's P&P titled, FOOD SAFETY STANDARDS revised in May 2025 was reviewed. The P&P indicated, . Cool food down rapidly to 41 F within 4 hours . If food temperature is more than 70 F after 2 hours, move to freezer to finish . Cooling and check after 4 hours . If food temperature is above 41 F after 4 hours, discard . IDD verified, it is not the right practice when asked about If food temperature is more than 70 F after 2 hours, move to freezer to finish. IDD stated, they should not use the food if its temperature exceeds 70 F after 2 hours from the initial cooling temperature. IDD acknowledged, the P&P was not fully correct. IDD stated, she will check 2022 Food Code from FDA, and change the P&P. IDD stated, she stopped the cooling procedure in the kitchen currently. IDD stated, the kitchen staff need in-service first before restarting the cooling procedure.

Based on interview and record review, the facility failed to ensure valid copy of the Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that assists people in making decisions about medical treatment and life saving measures during end-of-life care or medical crisis) for two of 26 sampled residents (Resident 5 and Resident 6) had complete and accurate information.1. For Resident 5, the POLST indicated Do Not Attempt Resuscitation (DNR, a medical order instructing healthcare professionals not to perform CPR (chest compressions, cardiac drugs, or intubation) if a person's heart stops or they stop breathing) and Selective Treatment, which conflicted with the physician's order stating, FULL CODE-DNR-Comfort Focused Treatment, resulting in inconsistent documentation regarding the resident's code status.2. For Resident 6, the POLST was missing required information of the resident, physician, and legally recognized decision maker. The deficient practice may result in Resident's end-of-life choices not being honored.1. Review of Resident 5's admission record indicated, was admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), drug induced subacute dyskinesia (a disorder of involuntary, repetitive muscle movements of the face, body, or limbs caused by medications), anxiety (a natural emotion that becomes a disorder when persistent worry interferes with daily life), and mild neurocognitive disorder due to known physiological condition with behavioral disturbance (indicates a decline in cognitive abilities (like memory, language, or problem-solving) that is noticeable but doesn't significantly impair daily functioning, and is caused by an identified medical condition, with accompanying behavioral changes). During further review, the admission record indicated there was no advance directive stored in Resident 5's clinical record. Review of Resident 5's active orders for [DATE] indicated an order dated [DATE], FULL CODE -DNR-Comfort Focused Treatment - No artificial nutrition, including feeding tubes.During a concurrent interview and record review on [DATE] at 10:39 AM, Registered Nurse (RN) 3 stated Resident 5 has no advance directive. RN 3 then reviewed Resident 5's POLST to verify code status. The POLST indicated the Date Form Prepared section was left blank (undated). The undated POLST indicated, Do Not Attempt Resuscitation/DNR.Selective Treatment.No artificial means of nutrition, including feeding tubes.Advance Directive not available. The undated POLST was signed by the Nurse Practitioner on [DATE] and the legally recognized decision maker on [DATE]. Review of the Social Services Quarterly assessment dated [DATE] for Resident 5 indicated, the code status was FULL CODE-DNR-Comfort Focused Treatment - No artificial nutrition, including feeding tubes.During an interview on [DATE] at 11:29 AM, Social Worker (SW) 1 stated that Resident 5's daughter did not attend the care conference meeting on [DATE] and was not able to verify the code status. During a concurrent interview and record review on [DATE] at 4:32 PM, the Director of Nursing (DON) reviewed Resident 5's POLST and physician's order for code status. The DON confirmed the two documents were inconsistent and stated that FULL CODE and DNR are conflicting orders. 2. Review of Resident 6's admission record indicated, was admitted on [DATE] with diagnoses including peripheral vascular disease (PVD - refers to reduced blood circulation in the limbs and organs other than the heart and brain, most commonly caused by atherosclerosis, or the narrowing and hardening of blood vessels due to fatty plaque buildup), stroke, and functional quadriplegia (complete immobility of all four limbs due to a severe physical disability or frailty from a condition other than a spinal cord injury).During a concurrent interview and record review on [DATE] at 10:39 AM, RN 2 reviewed Resident 6's POLST to verify code status. The Date Form Prepared was left blank (undated) and Section D of the POLST indicated no signature and mailing address of the legally recognized decisionmaker. Additionally, second page of the POLST form lacked the required information, including the resident's name, date of birth , gender; the physician's name; name and phone number of the Resident 6's additional contact; and the preparer's name and phone number. During concurrent interview, RN 2 stated the form was not fully completed. Review of Resident 6's undated POLST indicated, .A copy of the signed POLST form is a legally valid physician order . To be valid a POLST form must be signed by (1) physician, or by a nurse practitioner.and (2) the patient or decisionmaker.Review of the facility's policy and procedure titled, POLST - Physician Orders for Life Sustaining Treatment, revised 6/20, indicated, .3. Completing a POLST Form with the Patient . B. A health care provider such as a nurse or social worker can explain the POLST form the patient's legally recognized health care surrogate decision maker . D. The POLST form is to be completed based on the patient's expressed treatment preferences and medication condition. If the patient lacks surrogate decision-making capacity and the POLST form is completed with the patient's legally recognized health care surrogate decision maker, it must be consistent with the known desires of and in the best interests of the patient.

Based on interview and record review, the facility failed to safeguard the personal property for one of 3 sampled residents (Resident 63) whose cellphone was reported missing on 2/9/25. Additionally, the facility failed to ensure the missing cellphone was replaced in accordance with the facility's Theft and Loss Policy. These failures resulted in the loss of Resident 63's cellphone; and may disrupt communication with family and friends and decrease sense of safety and trust in the facility's ability to protect residents and their belongings. Review of Resident 63's admission record indicated, was admitted on [DATE] with diagnoses including high blood pressure and vascular dementia with behavioral disturbance (a form of cognitive decline caused by reduced blood flow to the brain, often resulting from strokes or other vascular issues where a person experiences significant functional limitations and exhibits behavioral changes).Review of the quarterly Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 2/8/25 indicated, Resident 63 presents with moderate cognitive (mental action or process of acquiring knowledge and understanding) impairment.Review of Resident 63's Patient's Belongings Record dated 11/9/23 indicated that one (1) cellphone with charger was documented.Review of the Resident Progress Notes dated 2/9/25 indicated, During rounds with checking patient personal gadget/belonging, observed cellphone is missing.Cellphone includes in personal belonging lists upon admission. Tried to look on patients closet, bag, drawer, and dresser unable to find cellphone.per RP (resident representative) cellphone was a gift from the student. Theft/loss form completed and submitted.During an interview on 8/13/25 at 11:06 AM, confirmed that Resident 63's missing cellphone was listed on the belongings inventory and stated that they were unable to find the cellphone. Review of the Interdisciplinary Team (IDT - a group of professional disciplines that combine knowledge, skills, and resources to provide the greatest benefit to the resident) Note dated 2/9/25 indicated that Resident 63's missing cellphone was discussed. The IDT Note indicated the incident was reported to the police and appropriate state agencies. Additionally, the IDT Note indicated that Resident 63's former student visited the facility and provided the value of the cellphone, which was reported as $130.00 with a monthly payment of $15.00. Resident 63's former student and the facility attempted to contact the cellphone but were unsuccessful. During an interview on 8/13/25 at 11:12 AM, the Director of Nursing (DON) stated that the facility did not replace Resident 63's missing cellphone because the cellphone could not be located. The DON further explained that, according to the facility's Theft and Loss Policy, the Social Worker (SW) will arrange for replacement if the missing item is listed in the inventory list.During an interview on 8/13/25 at 3:14 PM, SW 1 stated that if a missing item is listed on the resident's inventory list, it will be reimbursed. If the item is not listed, efforts must be made to locate it.Review of the facility's policy and procedure titled, Theft and Loss, revised 8/20, indicated, The hospitals will provide for the safeguarding of the personal possessions of both residents and staff . 6. The Social Worker arranges for replacement if needed.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported immediately, not later two (2) hours after the allegation was made, as required by regulation involving resident 77.This failure resulted in a delay in reporting an abuse allegation and had potential to place all residents at risk for further abuse.A review of Resident 77 clinical document, titled Nurses Notes, dated 5/6/2025 at 12:14PM, the Nurses Noted indicated, incident dated 4/26/2025: redness under the left eye) Bruise? Reported to law enforcement asked the case number then she said that the police will come to investigate. SOC 341 was faxed to the following: Ombudsman - 650 364 5399, State - # 415 330 6350 Social worker ([NAME]) was informed that the IDT team decided to report the incident and CARE CONFERENCE (IDT) needed to cover regarding the incident that occurred on 4/26/2025A review of SOC 341(a form used in California for reporting suspected elder or dependent adult abuse) dated 5/6/2025. SOC 341 indicated, Date Completed 5/6/2025. Date/Time of incident 4/26/2025, E. Abuse resulted in other: discoloration under the left eye (red in color). F. When the pt's son came to visit he noticed a reddish discoloration under the left eye (Bruise?) (0.5cm x 2.8cm), Skin intact, no swelling, then he said who punched my mom?. Investigation started.During an interview on 08/15/2025 at 3:14 PM with Nurse Manager (NM)1, NM1 stated, I know we had a wrong Judgement about the incident, I know that we should report it in 2 hours.During an interview on 8/15/2025 at 4:43PM with Registered Nurse (RN)1, RN1, stated, When the son of resident 77 saw that there was a bruise or discoloration under the eye, the nurse supervisor started to investigate, it was not reported because the son was satisfied of the plan of care, but it should be reported right away.

Based on interview and record review, the facility failed to conduct a thorough investigation on an allegation involving physical and emotional abuse for one of 2 sampled residents (Resident J). Failure to thoroughly investigate an allegation of abuse did not ensure other residents were protected from abuse. A review of the face sheet indicated Resident J was admitted with diagnoses including injury to cervical (neck) spine, quadriplegia (loss of movement and sensation to arms and legs), osteoporosis (fragile bones), osteoarthritis (pain, swelling of the bones and joints), bipolar disorder (a mental illness that affects a person's energy, thoughts, and unusual shifts in mood from extremely highs [manic episode] to lows [depression], and anxiety (excessive, persistent feeling of worry and nervousness). A review of the minimum data set (MDS, a standard assessment tool) brief interview of mental status (BIMS, a brief memory test to help determine cognitive ability [ability to remember and make decision]) score of 14 indicated Resident J was cognitively intact. Under functional status, Resident J required physical assistance from two staff for dressing, mobility, and transfer. During an interview on 12/9/25, at 1:52 PM, Resident J stated that on 10/5/25, she was awakened by CNA 1's loud voice. Resident J stated CNA1 was upset that the day shift CNA put to her bed on her street clothes. Resident J stated CNA 1 was complaining and talking about it repeatedly. Resident J stated CNA 1 was tagging her, pushing and grabbing her. Resident J stated she kept interrupting CNA1, but CNA 1 was so upset and did not hear her when she asked her to stop. Resident J stated that CNA 1spoke in Tagalog during the incident. Resident J further stated that she asked CNA 1 to not care for her any further. Resident J stated CNA 2 who was assisting CNA 1 during the incident did not intervene. During an interview on 12/9/25, at 3:04 PM, Social Services Director (SSD) stated that the allegation of abuse on 10/5/26 was addressed to her on 10/9/25. SSD reviewed her notes dated 10/13/25 which indicated Resident [NAME] stated that the CNA held her tightly and quickly while providing care and that the CNA appears mad. SSD visit notes dated 10/14/25, indicated Resident stated everything was okay and has no further issues. During an interview on 12/10/25, at 2:03 PM, the DON stated that she had multiple interviews with Resident J. The DON stated that she checked Resident J's left hand and, There was nothing. During a concurrent interview on 12/10/25, at 3:46 PM, the DON reviewed the facility investigation summary, dated 10/23/25, which indicated that on 10/9/25, the physician (medical doctor) was notified of the abuse allegation and gave an order to monitor Resident J's feeling upset about the incident. The Assistant Director of Nursing (ADON) reviewed Resident J's record and stated the physician order was not carried out and monitoring for Resident J was not started. A review of the facility Policy and Procedure titled, Abuse, Elder and Dependent Adult, dated 9/2025, indicated, .This procedure relates to anonymous, vague and/or unverified reports alleging that abuse has occurred as well as substantiated abuse. All staff members are responsible for reporting any witnessed or alleged abuse. Do not assume that someone else has reported the incident. If the incident was witnessed, take measures to protect the residents immediately. Remove the resident from the area to a safe place or instruct the individual in question to leave the room or the area. If the incident was not witnessed but reported by a resident, calm the resident before leaving resident to report it. Notify the DON, Nurse Manager, Charge Nurse or Administrative Nurse Supervisor of the incident. Be as detailed as possible about the incident. Note time, where it happened, witnesses who may have seen something, the condition of the resident, and any other details related to the incident. Complete an event report including all the above-mentioned details. For Physical abuse, complete a physical assessment of the resident including vital signs and document in medical record any signs of injury that might have occurred. Request physical assessment by a physician.

Based on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 26 sampled residents (Resident 56) who had a significant change in status on 1/20/25. The deficient practice may result in delayed provision of care, treatment, and services for Resident 56. Review of Resident 56's admission record indicated, was readmitted to the facility on [DATE] with diagnoses including stroke, gastrostomy (stomach) status (refers to the presence of a gastrostomy tube [G-tube] surgically created opening in the stomach through which a tube can be inserted for feeding or other purposes), high blood pressure, kidney disease, osteoarthritis (joint disease that causes pain, stiffness, and swelling), and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability). Review of the Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated, Resident 56 had a SCSA with an Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) of 1/28/25. The MDS SCSA indicated that the assessment was signed as complete by the Registered Nurse (RN) Assessment Coordinator on 2/14/25. During concurrent interview and record review on 8/15/25, at 10:22 AM, MDS Coordinator (MDSC) 1 reviewed Resident 56's MDS assessments and stated Resident 56 was determined to have had a significant change in status when he was readmitted on [DATE] with a G-tube. MDSC 1 reviewed Resident 56's SCSA with an ARD of 1/28/25 and confirmed the assessment was completed on 2/14/25, four (4) days late. MDSC 1 stated that Resident 56's SCSA should have been completed on 2/10/25. Furthermore, MDSC 1 stated that a significant change in status assessment should be completed 14 days after a significant change in status was determined. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, dated October 2024, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline . A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan . The ARD must be less than or equal to 14 days after the IDT's determination that the criteria for an SCSA are met (determination date + 14 calendar days). The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than .

Based on observation, interview, and record review, the facility failed to ensure one of 26 sampled resident's (Resident 97) Minimum Data Set (MDS, a standard assessment tool) included the medical diagnosis of osteopenia (fragile bones).This facility failure resulted in inaccurate MDS to reflect the current health status for Resident 97. A review of the physician progress notes dated 4/24/25, indicated the diagnoses for Resident 97 included dementia (decline in memory or other thinking skills), diabetes (abnormally high blood sugar level) and hypertension (abnormally high blood pressure). A review of the facility reported incident dated 5/4/25, indicated on 4/25/25, Resident 97 fell out of bed and sustained a fracture (broken bone) through the right femur (thigh bone). A review of the facility reported incident dated 5/4/25, the result of the imaging (a procedure used to create a picture of the inside of the body) that was completed on 4/25/25, indicated Resident 97 has osteopenia (fragile bones). A review of the Minimum Data Set (MDS, a standard assessment tool, used to provide an individualized, resident centered care) dated 7/29/25, did not indicate osteopenia for Resident 97. During an interview on 8/15/25, at 2:38 PM, the MDS Coordinator (MDSC) 1 reviewed the electronic record for Resident 97 and acknowledged osteopenia was not entered in the MDS. MDSC 1 further stated, addressing osteopenia is significant because the resident is at risk for injury and fracture. A review of the facility Policy and Procedure titled, Assessment - MDS and CAA dated 9/2011, indicated, .There shall be a process in place for resident assessment on admission and ongoing reassessment which includes the completion of the MDS and Care Area Assessment . Residents are reassessed following a significant change in condition and/or as needed, and at a regularly scheduled times, example (i.e.) weekly by the assigned Team Leader, quarterly, and annually by the entire IDT .

Based on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 97) had a comprehensive care plan completed to address osteopenia (fragile bones). This facility failure had potential for Resident 97 to not receive necessary care and services.A review of the physician progress notes dated 4/24/25, indicated the diagnoses for Resident 97 included dementia (decline in memory or other thinking skills), diabetes (abnormally high blood sugar level) and hypertension (abnormally high blood pressure). A review of the facility reported incident dated 5/4/25, indicated on 4/25/25, Resident 97 fell out of bed and sustained a fracture (broken bone) through the right femur (thigh bone). A review of the facility reported incident dated 5/4/25, the result of the imaging (a procedure used to create a picture of the inside of the body) that was completed on 4/25/25, indicated Resident 97 has osteopenia (fragile bones). A review of the Minimum Data Set (MDS, a standard assessment tool, used to provide an individualized, resident centered care) dated 7/29/25, did not indicate osteopenia for Resident 97. During an interview on 8/15/25, at 2:38 PM, the MDS Coordinator (MDSC) 1 reviewed the electronic record for Resident 97 and acknowledged there was no comprehensive care plan completed to address osteopenia and stated, addressing osteopenia is significant because the resident is at risk for injury and fracture. The MDS Coordinator further stated the nurses are responsible in completing the residents care plan and the MDS reviews the completed care plan. A review of the facility Policy and Procedure titled Nursing Process, Plan of Care and Documentation dated 7/2017. Indicated, .The plan of care is individualized for each resident (patient) based on the information gathered through the nursing process. In addition, nurses must review physician progress notes to become familiar with the medical treatment plan as well as any changes in condition.As resident's needs are identified, it is the responsibility of the healthcare team to prioritize, and service delivered to assure that the residents needs are met. While the physician is recognized as being responsible for the prioritization of medical as well as overall care of the resident, each discipline likewise prioritizes the provision of their services respective to their level of involvement in the resident's care.The multidisciplinary Plan of Care may be initiated, reviewed or revised by other professional health care disciplines.

Based on interview and record review, the facility failed to effectively assess, evaluate, and implement interventions consistent with the nutritional status for one of three sampled residents (Resident A) when:1. The facility did not initiate a change of condition report to address Resident A's weight loss of 7.8 pounds (lbs.) within a month after it was identified on 10/7/25. 2. The facility failed to develop a care plan to address Resident A's weight loss of 7.8 pounds as identified on 10/7/25.3. Weekly weight evaluations were not implemented in accordance with the facility's policy.4. There was no documented follow up assessment, actions, or interventions by a Registered Dietitian (RD, a health professional with special training in diet and nutrition) to address Resident A's weight loss. These failures had the potential to result in continued weight loss and poor nutritional status, which could negatively impact Resident A's overall health and well-being.Review of Resident A's admission record indicated, was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), schizoaffective disorder (s a mental health condition that includes symptoms of both schizophrenia and mood disorders), drug induced subacute dyskinesia (a neurological disorder characterized by involuntary movements of the face and jaw), and unspecified dementia (a group of symptoms affecting memory, thinking and social abilities).Review of the progress note titled SBAR (a communication framework for sharing information with teams and stands for Situation, Background, Assessment, and Recommendation or Requests), dated 10/1/25, indicated, Situation: Resident has been noted with episodes of refusing meals, mostly breakfast or lunch, and/or medications intermittently for the past 4 days.Resident has extensively history of self-restricting food intake due to preference where in resident engages in periods of fasting for religious and personal reasons.Recommendations: MD (medical doctor) [name] made aware and ordered MVI (multivitamins) with minerals daily for supplement as recommended by pharmacy. Continue to monitor self-restricting food behavior and refusal of medications. Consult with Registered Dietitian for any further recommendation regarding food preference. RP (responsible party) made aware. Care plan updated.Review of Resident A's Nutrition/Dietary Note dated 10/7/25 indicated, .Summary: Resident present with significant weight loss of 11.3% in 6 months. Weight loss likely due to resident refusing meals x 9 days to which he claims is because he is 'fasting' RD met with resident to encourage resident to eat and to obtain food preferences, however resident continues to refuse.ONS (oral nutrition supplement) with meals for wt. (weight) maintenance and overall status d/t (due to) age and dx (diagnosis).Goals for resident ar to maintain nutrition status and weight without significant changes with PO intake >75%. Will cont. (continue) to monitor nutritional parameters, weights, honor preferences, and f/u per MNT protocol.Weight Hx (history) -4.8% in 1 mo (month), -5.4% in 3 mon, -11.3% in 6 mo.Nutrition Recommendations: 1. Cont. with diet order + ONS. 2. Encourage intake/fluids and honor food preferences. 3. Monitor wt, intake, and other nutrition parameters for any significant changes.Review of Resident A's Nursing Note dated 10/7/25 indicated, .resident has significant weight loss. (per resident he is fasting).Pt (patient) has hx of self-restricting meals sec. (secondary) to fasting, Dx. schizophrenia and Dementia.During a concurrent interview and record review with Registered Nurse (RN) 2 on 12/8/25 at 4:30 PM, the weights and vitals summary for Resident A was reviewed. The weights and vitals summary indicated that Resident A's weight had decreased from 161.5 lbs. on 9/5/25 to 153.7 lbs. on 10/7/25. RN 2 stated that Resident A had not been eating due to self-imposed fasting. Review of Resident A's weights and vitals summary from August 2025 to December 2025 indicated the following weights: 08/02/2025 01:42 131 lbs. (Standing); 09/05/2025 08:09 161.5 lbs. (Standing); 10/07/2025 08:24 153.7 lbs. (Mechanical Lift); 11/04/2025 10:48 135.2 lbs. (Standing); 11/11/2025 12:56 153.7 lbs. (Standing); 11/28/2025 15:24 153.7 lbs. (Standing); 12/04/2025 10:42 147.5 lbs. (Standing).During an interview on 12/8/25 at 4:42 PM, RN 2 confirmed that the indicated weight of 153.7 lbs. taken on 10/7/25 was the only recorded weight for October 2025. RN 2 stated that no weekly weights were taken after 10/7/25 despite Resident A experiencing a significant weight loss. During a concurrent interview and record review with RN 1 on 12/9/25 at 9:51 AM, Resident A's clinical record including progress notes, assessments, and care plan was reviewed. RN 1 stated that a change in condition (referring to SBAR) was completed on 10/1/25 due to Resident A refusing meals and medications. RN 1 also stated that the RD made a note regarding Resident A having a significant weight loss on 10/7/25. During a record review, RN 1 did not find documentation of a change of condition, nutritional assessment, or care plan after Resident A's significant weight loss on 10/7/25. RN 1 confirmed there was a Risk for Altered Nutrition Status care plan, however, none of the care plan addressed Resident A's actual weight loss. Furthermore, RN 1 confirmed that a change of condition and care plan should have been completed, and weekly weights should have been initiated.Review of the Health Status Note dated 10/8/25 indicated, IDT (Interdisciplinary Team- a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents): Care Conference with Brother.Resident is fasting for 2 weeks now. Resident has history of fasting yearly but this year it's more frequent. Recommendation: 1. Continue with diet as ordered. 2.encourage and offer food daily. 3. Provide fluid often and offer snack often as schedule. 4. Psyche as needed. 5. Nursing will continue to monitor behavior q shift. During an interview on 12/9/25 at 10:08 AM, RN 1 stated that the Interdisciplinary Team (IDT- a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) did not address Resident A's weight loss during the care conference meeting with Resident A's brother. RN 1 further stated that the IDT's recommendations did not include a plan to address the weight loss.Review of the physician's progress note dated 10/28/25 indicated, .10/22/2025.noted with persistent poor intake. Psychiatry service will continue to follow him. Assessment and Plan: .Noted with poor p.o. intake.Dietitian to reevaluate for nutrition support.During an interview and record review with the Charge Nurse (CN) on 12/9/25 at 1:55 PM, the nutritional assessment for Resident A was reviewed. The Charge Nurse did not find any follow-up assessment or notes on Resident A's weight loss. The last dietitian note for Resident A was a readmission note dated 7/14/25. During an interview on 12/9/25 at 3:01 PM, the RD confirmed Resident A's weight loss of 7.8 lbs. from 9/5/25 (161.5 lbs.) to 10/7/25 (153.7 lbs.). The RD stated that Resident A was placed on weekly weight checks and intake monitoring after the weight loss. However, the RD could not provide documentation of a follow-up assessment or re-evaluation of interventions for the weight loss.Review of the facility's policy and procedure titled Nursing Assessments, revised 4/25, indicated, A nursing assessment will be completed by staff for each admission, quarterly, annual and change of condition. These assessments will provide a data base from which to construct individualized treatment plans based on the strengths, deficits, and behavioral needs of residents . Documentation of Nursing Assessment will include: .Nutritional screen.Review of the facility's policy and procedure titled Weight Monitoring and Weight Variance, revised 8/25, indicated, Purpose: Residents are weighed regularly to monitor significant changes and/or changes in condition . Procedure. 5. Significant weight changes are defined as following: A. 3 pounds in one month for residents weighing less than 100 pounds; 5 pounds in one month for residents weighing >100 pounds. B. 5.0% total body weight in one month. C. 7.5% total body weight in three months. D. 10.0% total body weight in six months. 6. Significant weight changes initiate the following actions: A. Weekly weights for four weeks . C. Licensed nurses initiate a Change of Condition (COC). D. Interdisciplinary Weight Variance Team (IDT) reviews all weight changes . 9. Residents on weight variance are reviewed weekly until weight stabilizes .

Based on observation, interview, and record review, the facility failed to ensure staff followed their infection control policy and procedure (P &P), when a Licensed Vocational Nurse (LVN) did not perform hand hygiene between glove changes during medication administration.This failure had the potential to expose residents to cross contamination and increase the risk of infection.During medication administration observation on 8/13/2025 at 10:04AM, room [ROOM NUMBER], LVN1 was preparing medications wearing gloves, LVN 1 was observed removing her gloves, checking the computer and donning a new pair of gloves without performing hand hygiene.During an interview on 8/13/2025 at 10:15 AM, LVN 1 acknowledged forgot to do hand hygiene before putting on a new pair of gloves, yes I know I should perform hand hygiene first.During a review of the facility's policy and procedure (P & P) titled, IC 2-I: Hand Hygiene, dated 5/2019, the P & P, indicated, To prevent the spread of infection to patients and healthcare workers by breaking the cycle of infection. Skin is a significant source of microbial contamination. To be in compliance with the Guidelines for Hand Hygiene in Health Care Settings from the Centers for Disease Control and Prevention . C. Hand sanitation with an alcohol-based hand sanitizing product (liquid, gel or foam) may be performed when hands are not visibly soiled. 11.Before and after preparing and administering medications.12.Before putting on gloves.13.After removing gloves.

Based on observation, interview, and record review, four problems were identified regarding the facility's fall prevention program: 1. The facility did not regularly conduct a thorough investigation regarding the primary causes of falls for Resident 1. 2. The facility did not conduct a fall risk assessment for two of Resident 1's falls. 3. The facility continued using a tab alarm (an alarm that clips onto a resident's clothing) to alert staff for unassisted transfers for Resident 1 who has a history of unclipping the tab alarm from her clothing. The facility did not evaluate if a tab alarm was appropriate for Resident1 in decreasing her fall risks. 4. Staff did not consistently implement interventions within Resident 1 's care plans to minimize fall risks for Resident 1 (application of tab alarm or activation of bed alarm). These failures resulted in four falls for Resident 1, one of two sample residents within four months (April to August 2024). On 08/05/2024, Resident 1 fell and fractured all five of her right toes. Findings: Review of Resident 1's medical records titled MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated 02/11/2025, indicated Resident 1: 1. Had memory problems and was moderately impaired in decision making and problem solving. 2. Needed substantial/maximal assistance with toileting and chair/bed to chair transfers. 3. Had no voluntary control over bowel and bladder functions. Review of Resident 1's medical records titled Event Report, dated 08/08/2024, indicated Resident 1 had multiple diagnoses including: dementia (a progressive decline in mental abilities, impacting memory, thinking, and behavior); Parkinson's disease (a progressive brain and spinal cord disorder affecting movement, causing tremors, stiffness, and slow movement, as well as non-movement symptoms like sleep problems and mood changes); depression (a mental health condition with display of persistent low mood, loss of interest, and low energy) ; anxiety (feelings of uneasiness, worry, or dread, often accompanied by increased heart rate, sweating, and tension); osteoarthritis (progressive break down of joint tissues over time); extrapyramidal and movement disorder (a drug-induced movement disorders causing involuntary movements, muscle contractions, and other motor problems). Review of Resident 1's medical record titled Morse Fall Scale (a fall risk assessment tool), dated 04/26/2024, indicated she was assessed as at high risk for falls. Review of Resident 1's medical record titled Care Plan History, dated 03/01/2024, indicated .Resident has bed alarm when on bed/ tab alarm when up on wheelchair; at risk for fall . Review of Resident 1's medical record titled Event Report, dated 04/05/2024, indicated .(Resident 1) SLIDE FROM HER WHEELCHAIR DOWN TO THE FLOOR. FALL IS UNWITNESSED. WHILE ON BED, BED .(ALARM) IS ON AND TAB ALARM IS ATTACHED-SO . WILL NOT FORGET TO PUT ON WHILE ON .(wheelchair). During an observation of Resident 1 on 04/28/2025 at 12:17 PM with the Assistant Director of Nursing (ADON), Resident 1 was seated in her wheelchair out in the hallway. Resident 1 was able to unclip her tab alarm unassisted. During a concurrent interview and record review on 04/28/2025 at 12:36 PM, the Director of Nursing (DON) stated after a fall, she expected staff to conduct a huddle (meeting) to discuss the fall, identify potential causes of the fall, and formulate interventions. The DON stated these huddles were documented in their IDT (interdisciplinary= a group of health care professionals with various areas of expertise who work together in providing resident care) notes. The DON reviewed the IDT note for the 04/05/2024 fall. After reviewing the IDT note, the DON stated the IDT charting was unclear regarding if: 1. A tab alarm was applied by staff while Resident 1 was in her wheelchair. 2. The tab alarm was removed by Resident 1. The DON stated Resident 1 has a history of removing her tab alarms. 3. The tab alarm malfunctioned. The DON stated the tab alarm may not have been applied prior to the fall on 04/05/2024 as one of the interventions(s) documented was attachment of the tab alarm while in bed so staff will not forget to put tab alarm on while on wheelchair. The DON was asked: 1. For documented evidence staff were reminded to apply Resident 1's tab alarm when she was in her wheelchair. The DON was unable to provide the requested document. 2. If staff knew Resident 1 had the ability to unclip her tab alarm, should staff have considered using a different device to manage her fall risk? The DON stated yes. 3. What other interventions staff could have implemented? The DON stated it would have been more appropriate to use a tamper proof alarm such as a seat belt alarm that alarms when unbuckled. Review of Resident 1's medical record titled Resident Progress Notes, IDT, dated 04/21/2024, indicated at 4:10 AM .while writer making rounds, found resident sitting on the floor with her wet beddings all around her and wet pads and diapers all around her. Asked resident why she's on the floor, resident unable to directly relate why she's on the floor . Writer . presumed, resident walk to the bathroom .and upon returning to bed, trying to look for a pad and ended on the floor. Writer and other staff hadn't heard . (Resident 1 fall). During a concurrent interview and record review on 04/28/2025 at 12:36 PM, after reviewing the IDT note for the 04/21/2024 fall, the DON stated it was not clearly documented if Resident 1's bed alarm was activated and/or malfunctioned. The DON was unable to provide evidence if staff investigated after the fall to see if the bed alarm was activated prior to the fall or if the bed alarm was functioning. Review of Resident 1's medical record titled Resident Progress Notes, IDT, dated 07/04/2024, indicated At around 11 am . heard .(Resident 1) shouting and found .(Resident 1) on the floor in her bathroom.(Resident 1) on her left side facing the wall. As per .(Resident 1) she was trying to get up from the toilet seat and fell . Noted that .(Resident 1's) walker is outside the bathroom and .(Resident 1) removed the tab alarm. Review of Resident 1's medical record titled Resident Progress Notes, IDT, dated 07/04/2024, indicated there was IDT meeting after her fall. Staff documented .(non-compliant) regarding the call light even she is reminded to use .(her call light) and .(Resident 1) many times remove the tab alarm . During a concurrent interview and record review on 04/28/2025 at 12:36 PM, after reviewing the IDT note for the 07/04/2024 fall, the DON stated Resident 1 was either forgetful and/or non-compliant with using her call light to ask for assistance with transfers. The DON stated reminders to use call lights or reminding Resident 1 to ask for assistance may not be the most effective way to decrease her fall risks. The DON stated more frequent checks to assess toileting needs and/or more frequent supervision might have been more appropriate. Review of Resident 1's medical record titled Resident Progress Notes, IDT, dated 08/6/2024, indicated .Around .(10:15 PM, on 08/05/2024), Reported by .(staff) - Resident was found sitting on the floor in her room, legs extended. Per resident, ' I thought it was . (Hannukah=a late December religious Jewish holiday) so I was trying to get to dinner and then I fell ' . Resident with confusion Resident's walker was beside her bed. Review of Resident 1's Medical record titled X-ray of the right foot, dated 08/07/2024, indicated Fractures of the distal necks of the 2nd through 5th metatarsals (2nd, 3rd, 4th and 5th toes) and fracture of the medial aspect (middle/center section) of the head of the metatarsal of the great toe appear acute (sudden onset). During a concurrent interview and record review on 04/28/2025 at 12:36 PM, after reviewing the IDT note for the 08/05/2024 fall, the DON stated the IDT notes failed to identify if the bed alarm was activated or was not functioning properly. The DON stated staff at the Quality department may have more information regarding this fall. The DON stated she will ask the department to send over more information. Review of a document titled FRAMEWORK FOR ROOT CAUSE ANALYSIS AND CORRECTIVE ACTIONS, dated 08/05/2024, indicated staff did a root cause analysis of the fall on 08/05/2024 and concluded .Bed alarm was not utilized . During an interview on 04/28/2025 at 3:48 PM, the Clinical Quality Analyst (CQA) stated she only conducted a root cause analysis on Resident 1's fall dated 08/05/2024. The CQA stated she did not conduct a root cause analysis on Resident 1's other falls on 04/05/2024, 04/21/2024, and 07/04/2024. Review of the facility's policy titled Fall Prevention and Management, revised on January 2025, indicated . PURPOSE .Appropriate interventions used to reduce falls and fall-related injuries A fall risk assessment . will be conducted by the registered nurse and documented in the medical record . After a fall . During a concurrent record review and interview on 05/14/2025 at 1:00 PM, the ADON was asked to provide documented evidence fall risk assessments were conducted after Resident 1's falls on 04/05/2024, 04/21/2024, 07/04/2024, and 08/05/2024. The ADON searched Resident 1's medical records and was unable to provide documented evidence a fall risk assessment was conducted after Resident 1 fell on [DATE] and 07/04/2024. During an interview on 05/15/2025 at 1:50 PM, the DON stated her expectation was staff should conduct a fall risk assessment after each fall within 72 hours. The DON also stated falls regardless of injuries are treated as unusual occurrences and should be thoroughly investigated to determine root cause(s) and appropriate intervention(s) implemented to reduce fall risks.

Based on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization ) to four of four sampled residents (Resident 1, 2, 3, and 4) or their responsible party (RP) at the time of transfer to acute care hospital. This failure could result in residents and/or their RP not being fully informed of their right to request a bed hold and to return to the facility after hospitalization , potentially leading to inappropriate discharge. Findings: 1. Resident 1 was initially admitted on [DATE] and was readmitted on [DATE], with diagnoses that include encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body) and urinary tract infection (an infection in any part of the urinary system). During a concurrent interview and record review on 5/8/25 at 3:37 PM, the Assistant Director of Nursing (ADON) reviewed the facility document, titled Admit/Discharge Report (ADR), dated 12/1/24 to 1/31/25. The ADR indicated Resident 1 was hospitalized on [DATE] and returned to the facility on [DATE]. During an interview on 5/8/25 at 4:36 PM, Resident 1's RP was sent to the emergency roiagnom on [DATE]. Resident 1's RP stated, They (facility) never gave a 7 (seven) - day hold notice (bed hold notice). She was not given anything. Neither was I. During a concurrent interview and review of Resident 1 ' s electronic health record (EHR) on 5/14/25 at 10:04 AM, Registered Nurse (RN) 1 was unable to find evidence that a written notice of bed hold was given to Resident 1 or their RP. 2. Resident 2 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that include left femoral neck fracture (a break in the upper part of the thigh bone that connects the rounded ball of the hip joint to the long shaft of the thigh bone). During a concurrent interview and record review on 5/8/25 at 11:12 AM, the ADON reviewed the ADR. The ADR indicated Resident 2 was transferred to the hospital on 1/5/25 and was discharged to another facility on 1/13/25. During an interview on 5/8/25 at 2:34 PM, Resident 2 ' s RP was asked if the facility gave a written notice of bed hold during Resident 2 ' s hospitalization on [DATE]. Resident 2 ' s RP stated, No. I don ' t remember seeing a bed hold notice .they (facility) did not give us a copy. Resident 2's RP further stated, I didn ' t know she (Resident 2) can come back (to the facility) after going to the hospital even after it ' s past 7 days. During a concurrent interview and record review on 5/14/25 at 9:50 AM, RN 1 reviewed Resident 2 ' s EHR. RN 1 was unable to find documentation that a written notice of bed hold was given to Resident 2 ' s RP. RN 1 stated, No, when asked if Resident 2 ' s RP was given a written notice of bed hold. 3. Resident 3 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that include congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs) and hypertensive heart disease with heart failure (damage to the heart muscle due to long-term high blood pressure leading to heart failure). During a concurrent interview and record review on 5/8/25 at 10:25 AM, the ADON reviewed Resident 3 ' s EHR. The ADON stated Resident 3 was hospitalized on [DATE] and returned to the facility on [DATE]. The ADON was unable to find evidence that a written notice of bed hold was given to Resident 3 ' s RP. When asked how bed hold notification is given to the resident or their RP, the ADON stated, Usually verbal because they ' re (RP) not here during transfer to acute care (hospital). The ADON added, We fax it (bed hold notice) to the billing office. It ' s available if they (resident or RP) want a copy. 4. Resident 4 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that include acute bronchitis (a short-term inflammation of the bronchi, the tubes that carry air to your lungs). During a concurrent interview and record review on 5/8/25 at 10:56 AM, the ADON reviewed the ADR. The ADR indicated Resident 4 was transferred to the hospital on 1/29/25 and returned to the facility on [DATE]. During a concurrent interview and record review on 5/14/25 at 9:26 AM, RN 1 stated Resident 2 ' s family members were notified of the transfer to the hospital via phone. When asked if a written notice of bed hold was given to Resident 2 ' s RP, RN 1 stated, No. Review of the facility policy, titled Bed Hold, revised on 8/2020 and 3/2025, indicated Policy: Residents who require transfer to an acute facility for hospitalization , have the right to request a bed hold. The facility will provide information to the residents/responsible party regarding bed hold during the admission process. When a resident is transferred for acute hospitalization , written notice of his/her right to request a bed hold will be given to the resident/responsible party. Within 24 hours of receipt of the notice, the resident/responsible party shall notify the facility of the request for a bed hold.

Based on observation, interview and record review, the facility did not thoroughly investigate a grievance regarding administration of tube feeding formula as ordered by the physician for Resident 1, one of three sample residents. The facility ' s investigation was not thorough because they failed to : 1. Consider the maximum rate their tube feeding pump could run at (295 ml/hr, mililiter per hour, milliliter= unit of fluid measurement). 2. Identify an unclear tube feeding physician order. The tube feeding order directed staff to administer each feeding (325 ml) within an hour. Given the maximum rate of the pump, it was impossible to infuse the ordered amount with the pump alone within the time frame specified. 3. During the investigation, staff failed to measure the total amount of tube feeding within an enclosed bag and staff failed to measure tube feeding formular remaining in the bag lack after the third feeding. Without this information, it would be difficult to conclude if the ordered amount of tube feeding was being administered. 4. During the investigation, staff failed to uncover their tube feeding pumps had a plus/minus 10% error rate according to the pump manufacturer. The lack of a thorough investigation resulted in the facility unilaterally declaring the grievance resolved without following up with the complainant. Findings: During an interview with Resident 1 ' s RP on 04/23/2025 at 10:36 AM, the RP stated that she has looked at Resident 1 ' s tube feeding order, and it stated he should be receiving 325 ml of tube feeding to be infused within one hour at 6 AM, 11 AM, 4 PM and 8 PM. The RP stated she called the company providing the enclosed tube feeding bags and the company told her that they fill these bags to exactly 1000 ml of tube feeding solution. The RP stated if staff were administering the tube feeding correctly, the bag should be almost empty when they are done with the third tube feeding. There should only be 25 ml of formula after three episodes of feeding ( 325 ml X 3 sessions = 975 ml; 1000 ml -975 ml = 25 ml). The RP provided one photo dated 01/04/2025 which shows the bag with more than 25 ml of formula left after the third session. The RP alleged she noticed formula left inside these bags five months ago and has complained to facility regarding this issue. The RP alleged she also involved the ombudsman because facility staff refused to believe they were delivering less than the ordered amount of formula to Resident 1. Review of Resident 1 ' s records titled tube feeding order, printed on 04/23/2025, confirmed that Resident 1 should be receiving 325 ml (milliliter) of tube feeding at 6 AM, 11 AM, 4 PM and 8 PM. During a concurrent observation and interview on 04/24/2025 at 11:15 AM with the Unit Manager (UM) and Biomedical technician (BT, a staff responsible for calibrating and inspecting medical equipment), the UM confirmed documentation on Resident 1 ' s tube feeding bag indicated the first feeding session was started on 04/23/2025 at 8:00 PM (yesterday). The UM and BT reviewed Resident 1 ' s tube feeding orders and acknowledged only 25 ml should be remaining in the bag after the third feeding session (04/24/2025 at 11:00 AM) . After the third feeding, total content in the bag was measured to be 165 ml. This observation confirmed staff failed to administer 145 ml of formula to Resident 1 (165 ml - 25 ml= 145 ml) because, the entire content of a new enclosed tube feeding bag was measured and the UM confirmed these bags were filled to 1000 ml (as reported to the RP by the manufacturer). During an interview on 04/25/2025 at 11:00 AM, the BT stated after conducting calibration measurements on the tube feeding pumps from the unit and communicating with the tube feeding pump manufacturers, the Biomed tech concluded the pumps were functioning as intended. However, these pumps have a plus/minus 10% error rate. For example, if programmed to deliver 975 ml of solution, the pump could be delivering 877.5 ml to 1072.5 ml of solution. The BT confirmed the pumps could be delivering less than the programmed amount of tube feeding as observed on 04/24/2025. During an interview on 04/25/2025 at 11:43 AM the Registered Dietitian (RD) confirmed she was the one responsible for calculating tube feeding rates and amount to meet Resident 1 ' s nutritional needs. The RD stated she was not aware these tube feeding pumps had an error rate of plus/minus 10% and had the potential to deliver less than the programmed amount of tube feeding to a resident. During an interview on 04/29/2025 at 3:44 PM, the UM confirmed that Resident 1 ' s RP had been complaining about staff not giving the full amount of formula as ordered by the RD. The UM thought the issue was resolved as currently, the RP had not been complaining about this particular issue. The UM stated she was not aware the tube feeding pumps had a plus/minus error rate of 10% and had the potential to deliver less (or more) than the programmed amount of tube feeding formula. The UM was made aware if a thorough investigation had been conducted, she would have uncovered the plus/minus 10% error and provided the RP with an accurate explanation of why there were formula left after each third feeding session. The UM did not comment on this statement. During an interview on 05/06/2024 at 11:59 AM the UM was made aware the facility ' s tube feeding grievance investigation was not a thorough investigation because the facility ' s investigation did not uncover these issues: 1. The order for the tube feeding was 325 ml to be infused within 1 hour. The maximum rate of the facility ' s tube feeding pumps was 295 ml/hr. There was no way for staff to fulfill this order using only their current tube feeding pumps. The UM agreed nurses administering tube feeding since 12/28/2024 to now should have questioned/clarified the order. 2. Staff did not verify if these enclosed tube feeding bags were filled to 1000 ml. Because if these bags were filled to more than 1000 ml, this may account for the RP ' s continual observation/complain of excessive tube feeding formula left in the bag after the third feeding. 3. Staff were not aware these tube feeding pumps had an error rate of plus minus 10%. It was only after this CDPH investigation that BT asked the tube feeding pump manufacturers about error rates. Staff were not aware if their tube feeding pumps were programmed by staff to deliver 325 ml for three feedings (total of 975 ml) that the actual amount delivered might be as low as 877.5 ml. this may account for RP ' s continual observation/complain of excessive tube feeding formula left in the bag after the third feeding. 4. During the facility ' s investigation, staff did not measure to verify if the formular left in the bag after three feedings was 25 ml. Review of a document titled RESIDENT GRIEVANCE/COMPLAINT FORM, dated 01/09/2025, indicated the facility resolved this grievance: Administrative Follow-up/Resolution: Complainant Notified on March 2025 by RN .(manager) .Complete Resolution/Satisfied . During an Interview with the Ombudsman and RP on 05/06/2025 at 9:00 AM, they both stated the facility never followed up with them regarding this grievance, the problem continued and was never resolved. The Ombudsman stated that was why she escalated this issue to CDPH. The UM was asked on 05/06/2025 at 1:01 PM to provide documented evidence the facility met or notified the ombudsman and RP. The UM was asked to also provide documented evidence the ombudsman and RP agreed with the facility ' s findings/intervention regarding their grievance. The facility was unable to provide the requested information. Review of the facility ' s policy titled PATIENT COMPLAINTS AND GRIEVANCES, revised on January 2025, indicated .The party filing the grievance will be provided written notification of the outcome of the grievance review and investigation including: a. The name of the hospital contact person b. The steps taken on behalf of the patient to investigate the grievance c. The results of the grievance process and d. The date of completion .If a resolution cannot be completed within 7 calendar days, an acknowledgment letter will be provided to the complainant within 7 calendar days of receipt of the grievance, stating that a resolution letter will be sent within 30 calendar days. This communication will be managed by Risk Management.

Based on interview and record review, the facility failed to ensure three of eight sampled residents (Residents 409, 70, and 86) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when the facility did not ensure: 1.Resident 409 a. was free from side effects due to the use of Haldol. Haldol is an anti-psychotic drug used to treat symptoms of psychosis. Symptoms of psychosis includes hallucinations (perceiving sights, sounds, smells, tastes, or touches that are not real), delusions (false beliefs), and dementia (loss of the ability to think, remember, learn, make decisions, and solve problems). b. Aggressive behaviors were managed via non-medication means such as modifying smoking rules. c. Haldol dosage was not lowered for 96 days when side effects were first identified. 2. Resident 70 a. there was no clinical indication for the use of Citalopram (an antidepressant drug). b. order for Ativan (also known as lorazepam, a medication used to treat anxiety [a condition characterized by extreme fear and worry that interferes with daily activities]) PRN (as needed) did not have a stop date. 3. Resident 86 a. there was no clinical indication for the use of Risperdal (an antipsychotic medication). b. order for Ativan PRN did not have a stop date. These failures led to Resident 409 developing side effects from the use of Haldol and being put on Ingrezza. Ingrezza is a medication to counteract the side effects of Haldol. For Residents 70 and 86 these failures had the potential for them to receive unnecessary psychotropic medications, be exposed to adverse health consequences from the medications, which could negatively impact the residents' mental, physical, and psychosocial well-being (having to do with the mental, emotional, and social aspects of a resident's life). Findings: 1. Review of Resident 409's record titled Minimum Data Set assessment (MDS - a standardized resident assessment tool), dated 01/11/2024, indicated he had multiple admissions and discharges to the facility. The last admission was dated 12/27/2023. He was admitted to the facility with multiple diagnoses including anxiety disorder, vascular dementia with behavioral disturbances (blood vessel related loss of intellectual ability manifested by verbal or physical aggression, agitation and/or wandering). According to his MDS, he scored 6 out of 10 on his Brief Interview for Mental Status assessment (BIMS - assessment tool used to determine mental status and memory). A BIMS score of 6 indicated, Resident 409 had severe problems with reasoning and memory. His MDS indicated he had no physical behavior directed towards others (hitting, kicking, pushing, grabbing), no verbal behavior directed towards others (threatening others, screaming or cursing at others) and no other behaviors not directed toward others. Review of Resident 409's record titled Physician Orders, dated 1/1/2023, indicated, he has been on Haldol 5 mg (milligram) twice a day since 1/1/2023, to treat a major neurocognitive disorder with behavioral disturbances continues screaming; yelling. Major neurocognitive disorder is a decreased mental function due to a medical disease other than a mental illness. Review of Resident 409's record titled Medication Regimen Review (MRR), dated 10/18/2021, indicated, .NUMEROUS REPORTS OF AGRESSION, SCREAMING AND YELLING-TYPICALLY IN SETTING OF WANTING TO SMOKE. Review of Resident 409's record titled Consult Note - Psychiatry, dated 10/30/2021, indicated, .Psychiatry re-consulted after episode of agitation, via telephone today, when .(resident) was refusing to respond to limits set and escalated, refusing .(to) allow lighter to be taken away and refusing to listen to RN (Registered Nurse). During an interview on 2/14/2024 at 7:48 AM, RN 3 stated Resident 409's aggressive behaviors seem to be centered around smoking. During an interview on 2/14/2024 at 8:01 AM, Certified Nursing Assistant (CNA) 3 stated Resident 409 can be .anxious when you are like not on time with what he wants. He doesn't really want to wait. to be change or for his medications. when he pushes the call light, he wants it immediately. CNA 3 was asked if Resident 409's aggressive behaviors were centered around not getting his cigarettes on time, running out of cigarettes, and an inability to keep his own lighter, CNA 3 stated, Yes. During an interview on 2/14/2024 at 9:50 AM, the Director of Infection Prevention (DIP) stated, We were cited previously for not having a structured smoking program in place to make sure residents were safe. So, we put one in place and this is the consequence of that. Some residents can get agitated, when there's a change. The above record reviews and staff interviews were shared with the DIP. The DIP agreed that issues around smoking appear to be a trigger for Resident 409's aggressive behaviors. The DIP was asked if the facility was medicating Resident 409 for a facility imposed smoking restrictions such as: scheduled smoking times, restrictions to cigarettes, and giving up his lighter, the DIP did not verbally answer and just shrugged his shoulders. Review of Resident 409's record titled PHARMACY SERVICES MRR CHART REVIEW, dated 03/23/2023, indicated, Resident 409 had side effects associated with Haldol. Staff charted Resident 409 was on .(Haldol) 5MG . (twice a day).RESIDENT OBSERVED WITH JAW GRINDING AND CLENCHING, SIALORRHEA. (excessive saliva production and drooling) HALDOL IS KNOWN TO CAUSE SIALORRHEA, DYSPHAGIA, AND SWALLOWING ISSUES. Review of Resident 409's record titled Prescription Order, dated 6/27/2023, indicated he was not started on Ingrezza, a medication to treat Haldol's side effects, until 6/27/2023. During an interview on 2/14/2024 at 9:49 AM, Pharmacist 1 stated that there was a delay in starting Ingrezza as this was a specialty medication that required a third party approval. Pharmacist 1 was asked if decreasing Haldol dosage while waiting for the Ingrezza to be approved was a viable clinical option, Pharmacist 1 said Yes, the team would recommend that. Review of Resident 409's records titled History and Physical, dated 1/23/2023, and Initial Medication Regimen Review, dated 1/11/2024, indicated Resident 409's Haldol has not been lowered. Resident 409 has been on Haldol 5 mg twice a day for this entire time. 38066 2. Resident 70 was admitted on [DATE] with diagnoses including dementia, delusional disorders and anxiety disorder. Review of Resident 70's Physician Order Report dated from 2/1/24 through 2/29/24 indicated, .Start Date 11/30/23 .Citalopram 10 mg (milligram) 1 tab (tablet) oral once a day . Review of Resident 70's Medication Administration Record for December 2023 indicated, .Citalopram 10 mg 1 tab oral once a day . was administered on 12/1/23 through 12/31/23 at 8 AM. Review of Resident 70's Medication Administration Record for January 2024 indicated, .Citalopram 10 mg 1 tab oral once a day . was administered on 12/1/23 through 12/31/23 at 8 AM. Review of Resident 70's Medication Administration Record for January 2024 indicated, .Citalopram 10 mg 1 tab oral once a day . was administered on 1/1/24 through 1/31/24 at 8 AM. Review of Resident 70's admission MDS dated [DATE] and quarterly MDS dated [DATE] indicated, Resident 70 was admitted with diagnoses including dementia and anxiety disorder. Diagnosis of depression was not coded on the MDS. During a concurrent interview and record review on 2/7/24 at 2:16 PM with Registered Nurse (RN)3, Resident 70's History and Physical was reviewed. RN3 stated, I cannot find any diagnosis of depression. Review of Resident 70's Physician Order Report dated from 2/1/24 through 2/29/24 indicated, .Start date: 7/13/23 .End date: open-ended .lorazepam 0.5 mg every 4 hours PRN . During an interview on 2/5/24 at 3:14 PM with Pharmacist 1, Pharmacist 1 said, MRR is done monthly, and all medications are reviewed. Identified irregularities are communicated to the RN and the physician. For psychotropic medications, Pharmacist 1 said, PRN medications are recommended for 14 days and should be renewed after. 3. Resident 86 was admitted on [DATE] with diagnoses including mood disorder (described by marked disruptions in emotions), major depressive disorder (medical illness that negatively affects how you feel, the way you think and how you act). Review of Resident 86's Physician Order Report dated 12/1/23 through 12/31/23 indicated, .Start date 11/27/23 Risperdal (Risperidone) 1 mg 1 tab oral at bedtime .for mood disorder . Review of Resident 86's Pharmacy Services: MRR dated 11/26/23 and 12/13/23 indicated, .D (diagnosis): Mood Disorder (need to be more specific): Risperidone 0.5 mg .Irregularities: Mood Disorder is not an appropriate diagnosis for antipsychotic use .it may be viewed as a chemical restraint especially when used in the post-acute care (long term care, skilled nursing facilities) . Review of Resident 86's admission MDS dated [DATE] indicated, Resident 86 was admitted with diagnoses including stroke and depression. Diagnosis of psychotic disorder was not coded on the MDS. During an interview on 2/5/24 at 11:16 AM with RN3, RN3 stated, I don't see any diagnosis of psychosis, only depression and mood disorder. Review of Resident 86's Physician Order Report dated 2/1/24 through 2/29/24 indicated, .Start date: 12/13/23 .End date: open ended .lorazepam 0.5 mg BID (twice a day) PRN . Review of Resident 86's Pharmacy Services: MRR dated 12/13/23 indicated, .D: Anxiety: Lorazepam 0.5 mg ordered as PRN and without frequency .Need to have specific frequency and duration of therapy . During an interview on 2/5/24 at 3:14 PM with Pharmacist 1, Pharmacist 1 acknowledged that identified irregularities for the use of Lorazepam by Resident 86 were uncorrected by the physician.

Based on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure ulcer (PU) for one of 14 sampled residents (Resident 22) when interventions were not implemented to avoid skin breakdown for Resident 22. This deficient practice resulted in the development of Stage 2 PU for Resident 22. Definition/Stages for Pressure Ulcer/Pressure Injury (also called a bed sore, is an injury to skin and underlying tissue resulting from prolonged pressure on the skin. Stage I: Intact skin with a localized area of non-blanchable redness (non-blanchable: redness persists and does not fade or turn white after removal of fingertip pressure). Stage II: Partial-thickness loss of skin with exposed upper skin layer. The wound bed is pink. May also present as an intact or ruptured blister. Fat tissue and deeper tissues (muscle, tendons, bone) are not visible. Findings: Resident 22 was admitted on [DATE] with diagnoses including hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) and diabetes (abnormally high sugar level in the blood). The facility assessed Resident 22 as high risk for developing pressure ulcers. Review of Resident 22's Minimum Data Set (MDS - an assessment tool) dated 7/6/23 indicated, Resident 22 needed extensive assistance with bed mobility, was always incontinent with bladder and bowel functions, and had impairment on one side of both upper and lower extremities. Resident 22 had no pressure injuries on admission. During an initial tour observation on 01/29/24 at 3:04 PM, Resident 22 was lying in bed with pillow under his head, watching on his laptop. There was no device to offload pressure from his coccyx (tailbone). During a concurrent interview and record review on 2/2/24 at 11:31 AM with RN 2, Resident 22's Wound Management Detail Report (WMDR) dated 8/9/23 was reviewed. The WMDR indicated, Resident 22 was observed on 8/4/23 to have a PU on the coccyx with a measurement of 1 centimeter by 1 centimeter (1 cm x 1 cm). RN 2 said, the Stage 2 PU was discovered on 8/2/23 and was facility acquired. Review of Resident 22's WMDR dated 8/11/23 indicated, Resident 22 had a Stage 2 injury on his coccyx with a measurement of 2.5 cm x 1 cm, with irregular wound edges and declining wound healing status. The facility was waiting for the delivery of the low air low mattress (LAL - mattress designed to prevent and treat pressure wounds). Review of Resident 22's WMDR dated 9/1/23 indicated, Resident 22 was observed on 8/31/23 to have a Stage 2 injury on his coccyx measuring 3 cm x 1.4 cm x 0.2 cm, irregular wound edges with slight maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) and declining wound healing status. The facility was waiting for the delivery of the LAL mattress. Review of Resident 22's Physician Order Report dated 8/1/23 through 8/31/23 indicated, Resident 22 had an order for LAL mattress related to (r/t) pressure ulcer and to prevent further skin breakdown every shift with a start date of 6/29/23. Review of Resident 22's Treatment Administration Record (TAR) dated 7/1/23 through 7/31/23, 8/1/23 through 8/31/23, and 9/1/23 through 9/12/23 indicated, order for LAL mattress was not administered pending delivery of the mattress. Review of Resident 22's Interdisciplinary Team (IDT) Note dated 8/18/23 indicated, Resident 22 had a Stage 2 PU on coccyx with new measurement of 2 cm x 3 cm and excoriation on bilateral buttocks with redness throughout the area observed. The facility was waiting for LAL mattress to get installed. During a concurrent interview and record review on 2/5/24 at 10:12 AM, with RN 3, Resident 22's Progress Notes (PN) was reviewed. The PN dated 6/29/23 through 7/30/23 did not indicate RN was notified of a change in Resident 22's skin condition. The PN dated 8/2/23 indicated, CNA (Certified Nursing Assistant) reported wound on resident's coccyx area, a Stage 2 PU and an excoriated bilateral buttock. RN 3 said, Stage 1 pressure injury was not identified, and stated, I don't see any report if there's redness, excoriation before it turned to Stage 2. RN 3 added, If it was identified at an early stage, we could have prevented it going to Stage 2. During a concurrent wound care observation and interview on 2/5/24 at 11:18 AM, with the Treatment Nurse (TN), the TN explained that she will do wound treatment on the resident's coccyx. Resident 22 was lying in bed with a pillow under his head, watching on his laptop. There was no device implemented to offload pressure from his coccyx. TN said, Resident 22's coccyx had an open wound with scant amount of pink drainage. During a concurrent observation and interview on 2/13/24 at 11:22 AM, with CNA 2, Resident 22 was in bed, lying on his back with a pillow under his head. There was no device implemented to offload pressure from his coccyx. CNA 2 said Resident 22 has a wound on his back and stated, We usually put a pillow when he's on his side or when on his back. CNA 2 acknowledged that there was no pillow placed under his back. Review of Resident 22's Care Plan (CP) edited on 12/22/23, indicated the following: .Problem: Risk for Skin Breakdown secondary to (s/t) Pressure Injury r/t diagnosis (DX), disease process . Goal: Patient will remain free from skin breakdown or any pressure injury x 90 days .target date: 4/3/24. Approach: Assess the overall condition of the skin every shift. Report to MD if new skin issue; Patient on special mattress (LAL); Remind the CNA to report to Team Leader (TL)/RN if there's any skin issues noted especially during activities of daily living (ADL) care .created 8/4/23 . Review of Resident 22's CP created on 2/2/24, indicated the following: .Problem: Resident's skin has actual impairment: Stage 2 Pressure Ulcer on coccyx .Problem start date: 8/2/23 . Goal: Will have no complications through the review date .target date: 4/2/24. Approach: Monitor for increase in size and any changes in wound appearance; Wound Care follow up; Off-load affected area. Reposition every 2 hours or as needed; Administer treatment as ordered . Review of facility policy titled Skin Care, Pressure Injury, and Wound Management last revised on 1/22 indicated, .II. Skin Inspection .B. Monitoring:1. The CNA checks the patient's/resident's skin during skin and routine care and turning schedules and reports any new skin issues to licensed nurses .III. Interventions .B. Care and Interventions: 1. The care and intervention for skin breakdown/wounds is intended to prevent wound advancement and/or additional skin breakdown .3. Wound Care Nurse .b. Nursing driven treatments may include .use of therapeutic support surfaces, and offloading measures . The Journal of Legal Nurse Consulting, Volume 23 Spring 2012 indicated, Pressure ulcers occur over bony prominences like the heels, sacrum, ischial tuberosities (sitting bones) or the greater trochanters (hip bones). Pressure, coupled with other comorbid states (medical conditions that are simultaneously present in a patient) such as diabetes, can further complicate treatment and increase risk. Pressure can be lessened by implementing an appropriate pressure-redistribution support surface to both the seated and recumbent (lying) surfaces that the patient's body contacts at the first sign of risk.

Based on interviews and record reviews, facility staff failed to treat three out of 24 sampled residents with dignity (Residents 6, 82, and 408) when these residents have to wait 30-45 minutes for staff to answer their request/call light for assistance. Failure to answer a resident's call light in a timely manner did not ensure these residents were treated in a dignified manner. Findings: 1. Review of Resident 6's Minimum Data Set(MDS-an assessment tool) dated 11/09/2023, indicated he was admitted to the facility on [DATE], had multiple diagnoses including: respiratory failure, obesity, kidney failure leading to dialysis, wound near the tail bone. His MDS indicated he has a urinary catheter and was incontinent of bowel. During an interview on 02/06/2024 at 10:04 AM. Resident 6's responsible party stated .my dad would have a BM and I would be on the phone with him and sometimes it could be as long as 45 minutes before they get to him. Staff would tell us that they were short staff and that they were taking care of other patients before they could come help my dad. 2. Review of Resident 408's MDS assessment, dated 11/22/2023, indicated she was admitted to the facility on [DATE]. Her MDS indicated she had multiple diagnoses including: paraplegia (paralysis of arms or legs), depression, respiratory problems, anxiety, chronic pain, and arthritis. Her MDS indicated she was always incontinent (unable to control) of urine and bowel. During an interview on 01/29/2024 at 12:16 PM, Resident 408 stated she had to wait for 45-30 minutes (regarding her call lights). she feels that the newly transferred residents were treated like second class citizens compared to the rest of the residents here. 3. Review of Resident 82's MDS assessment, dated 10/26/2023, indicated he was admitted to the facility on [DATE]. His MDS indicated he had multiple diagnoses including: cancer, malnutrition, breathing problems, and stomach feeding tube. His MDS indicated he needed supervision with transfers and sitting to standing. During an interview on 02/02/2024 at 2:09 PM, Resident 82 stated it could be 5 minutes to 35 minutes for staff to respond to his call light. Interviews with direct care staff indicated that the facility had a problem with staffing and answering call lights in a timely manner: 1. During an interview on 1/29/24 at 12:38 PM, CNA (Certified Nursing Assistant) 4 stated the facility was short at least three CNA at times at the other facility. 2. During an interview on 02/02/2024 at 11:14 AM, RN 9 stated sometimes they were short of CNA and LVN (Licensed Vocational Nurse) sometimes short 1 sometimes short 2 staff. 3. During an interview on 02/02/2024 at 11:50 AM, RN 5 stated the facility was usually short of direct care staff 2-3 days a week.

Based on observation, interview, and record review, the facility failed to maintain a sanitary, comfortable and homelike environment when: 1. The linoleum flooring in Room 403's bathroom were torn, cracked, and peeling off around the base of the toilet exposing the subfloor and had a pungent musty odor. 2. 20 of 41 resident bathroom flooring (Rooms 101, 105, 111, 201, 206, 208, 301, 302, 305, 306, 308, 309, 310, 311, 401, 403, 406, 407, 408 and 410) were damaged and discolored. 3. There was an evidence of stagnant, dark colored liquid in the shower room (number) 3 with pungent musty odor on the missing tiles. The pungent musty odor had caused Resident 91 to feel sick and want to throw up. In addition, exposure to unpleasant odor, unsanitary, unkempt, and uncomfortable environment could affect mood, anxiety and stress level of other residents, staff, families, and visitors in the facility. Findings: 1. During the initial tour, on 2/7/22, at 9:58 AM, in Room 403, Resident 91 was sitting on his wheelchair by the bed watching television. Resident 91 expressed his concerns regarding the damaged linoleum flooring and the pungent odor coming from the bathroom. Resident 91 stated, The linoleum is broken. It was not fixed. They cover it with the rug and it smells. Review of Resident 91's clinical record indicated, he was admitted in the facility on 10/25/13. The Minimum Data Set (MDS, a resident assessment tool) dated 1/4/22 indicated Resident 91 was cognitively intact. During an observation, on 2/7/22, at 10:05 AM, in Room 403's bathroom, the linoleum flooring was torn and ripped around the base of the toilet, exposing the subfloor. A black, rectangular scraper mat was placed over the areas with torn and ripped linoleum. The mat appeared wet with a pungent musty odor. The linoleum behind the base of the toilet was bulging and tearing apart. Portion of the caulking (a material used to seal joints or seams against leakage in various structures and piping) at the base of the toilet was missing and had a build-up of red-orange, dark brown, and black colored matter. During an interview, on 2/7/22, at 10:08 AM, Resident 91 stated, It's been like that for a long time. They never fixed it (refering to the damaged bathroom floor). During an interview, with Certified Nursing Assistant (CNA) 2 on 2/7/22, at 10:10 AM, CNA 2 acknowledged the damaged linoleum flooring in Room 403's bathroom and stated, The toilet bowl is leaking and the floor is rotten. It's been like that for years. No action. During an interview, on 2/8/22, at 9:46 AM, Resident 91 stated, It smells like pee and poop. It makes me feel sick. I want to throw up. Resident 91 added, the pee and poop smell is more notable in the afternoon and at night. Resident 91 further stated, the smell of the bathroom and the torn linoleum flooring in his bathroom (Room 403) and other resident bathrooms were discussed in the previous resident council meetings. Resident 91 added, the nurses, Environmental Services Supervisor (EVSS), engineering, maintenance, previous Director of Nursing (DON) and Executive Director for Continuum Care (EDCC) were all aware of the issue. During an interview, on 2/8/22, at 9:54 AM, CNA 5 stated, It's been like that since I started working here (referring to the broken linoleum flooring in Room 403's bathroom). CNA 5 also stated he's been working at the facility for more than two months now and has not seen someone fixed the flooring. During an interview, on 2/8/22, at 10:13 AM, the Environmental Services Technician (EVST) 1 stated he was aware of the damaged linoleum flooring in Room 403 and was instructed to clean and mop the bathroom floor with Clorox bleach (a brand of disinfecting solution) every morning. EVST 1 further stated, I don't know about the mat. I did not put it there. During an observation, on 2/8/22, at 10:18 AM, in Room 403's bathroom, the EVSS lifted the black mat covering the exposed subfloor showing a build-up of white, gray, green, and black colored matter underneath. During concurrent interview, the EVSS stated, This (referring to the torn linoleum flooring) started about a year ago when the toilet was leaking on and off. That area (pointing at the subfloor and surrounding base of the toilet) is rotten. That's from the leak. The EVSS explained, there were missing caulking around the base of the toilet. The water started to leak and seeped through the cracks causing the bubble and moisture under the linoleum flooring. In addition, the EVSS acknowledged that he personally placed the black mat on the torn linoleum flooring to prevent the urine from dripping on the subfloor which will further the rot. The EVSS acknowledged Resident 91 has verbalized about the pungent odor coming from the bathroom and stated, the EVS staff cleaned the bathroom daily and changed the mat two to three times a week. According to an article titled, Odors and health, retrieved from https://www.health.ny.gov/publications/6500/index.htm, dated October 2019, indicated, . In some cases, odors can be used to tell whether there is a problem that needs to be fixed. For instance, mold problems, sewage backups and gas leaks in the home can all be detected by their odor, even if they can't be seen . Exposure to odors could result in health effects ranging from none, to mild discomfort, to more serious symptoms. Some chemicals with strong odors may cause eye, nose, throat or lung irritation. Strong odors may cause some people to feel a burning sensation that leads to coughing, wheezing or other breathing problems. People who smell strong odors may get headaches or feel dizzy or nauseous. If an odor lasts a long time or keeps occurring, it also could affect mood, anxiety and stress level . Try to find the source if you have unpleasant indoor odors . If you have a musty smell, check for moisture problems that could lead to mold growth. The way to control indoor odors is to find the source and remove it, or contain it in some way so that it doesn't release odors . 2a. During an observation, on 2/7/22, at 10:28 AM, in Room 407's bathroom, the caulking and linoleum around the base of the toilet were chipped, cracked, peeling off, bulging with a buildup of dark brown, black and dark red-orange colored matter. The linoleum surrounding the base of the toilet had a grayish-black and brown colored markings. During an observation, on 2/8/22, at 10:38 AM, in Room 406's bathroom, the caulking and linoleum around the base of the toilet were torn, cracked, bulging and pulling away from the floor exposing the subfloor. The linoleum close by the baseboard and the wall was bulging and had a light brown stains or markings. There was a buildup of dark brown and black colored matter around the base of the toilet and in between cracks and tears of the linoleum. During an observation, on 2/8/22, at 10:40 AM, in Room 408 and 410's shared bathroom, the caulking around the base of the toilet were missing and had a buildup of dark brown and black colored matter. The linoleum surrounding the base of the toilet had a white, yellowish-brown markings and gray discoloration. During an observation, on 2/8/22, at 10:43 AM, in Room 401's bathroom, there was a buildup of dark brown, black, and dark orange colored matter on the caulking and around the base of the toilet. The linoleum around the toilet and close to the baseboard were cracked and bulging. The bolts anchoring the base of the toilet had a crusty orange and brown colored matter. During a concurrent interview, and record review, on 2/8/22, at 11:01 AM, the undated Service Requester form indicated, Submit Service Request . Priority: 2-Normal . Short Description: remove and replace broken floor in r/r rms 403, and 406. The EVSS stated there were two bathrooms that needed new floor and that includes Room 406. When asked for the date of the service request was submitted, the EVSS stated, I just sent it out today (2/8/22). The EVSS then wrote 2/8/22 at the bottom right of the Service Requester form to indicate the date it was submitted. When asked for the maintenance log, the EVSS was unable to provide one. He acknowledged he did not have a log for the work order or service request submitted through the Service Requester. During an interview, on 2/8/22, at 11:48 AM, the EDCC stated the Director of Facilities has the access to the work order log in the main hospital and should be responsible in following up the work orders. The EDCC acknowledged she was aware of the bathroom floor issues and stated a ticket was sent to the corporate to get a quote for the new floor. Review of the letter document dated and signed on 2/8/22 by the EDCC, indicated, Plan for fixing 403 and 406: Director of Facilities (and team) will get a new quote for fixing both bathroom floors by 2/15. Submit for local and corporate approval 2/17. Start work as soon as materials arrive. During an interview, on 2/14/22, at 10:42 AM, the Maintenance Supervisor (MS) stated he was verbally made aware of the leak and broken floor in Room 403 by the EVSS. The work order don't go to me. Nursing will report verbally. The MS further explained, all staff have access to the work order email through Maintenance Connection online system in case there is something that needed to be fixed or replaced. When asked if a work order was submitted for Room 403, MS stated he cannot remember when it was submitted. The MS acknowledged he does not have a log nor access of the pending work orders until he get a notification from the Director of Facilities or engineering department that a service request had been fixed and/or completed. During an interview, on 2/14/22, at 11:44 AM, the EDCC stated the EVS, Director of Facilities, Chief/Assistant Chief of Engineering, and Nursing conduct the environmental rounds every quarter. The EDCC further stated, the identified list of things needed to be fixed and will be prioritized accordingly. During an interview, on 2/14/22, at 12:09 PM, the Medical Director (MD) stated, I am not aware of the floor issues before. I just knew it now. We don't talk about it in QAPI (Quality Assurance and Performance Improvement) but will do it now. I'm embarrassed. Review of the facility document titled, Work Order Status, dated 8/1/21 to 2/9/22, indicated, .Work order # - SMCCS- 5 - remove and replace broken floor tile in r/r/rms 403, and 406 . The document did not indicate the status and date the work order was submitted. Review of the facility's policy and procedure titled, Maintenance Strategies and Frequencies, dated 6/5/17, indicated, .A work order system is used to manage planned maintenance activities. Work orders are issued for maintenance performed by the Facilities Department in-house staff and by contractors. The Facilities Director manages the worker order generation and completion process. 1. A Facilities Engineer performs assigned activities and return completed documentation to managers. Activities completed by contractors are tracked to assure the activities are completed in accordance with the terms of a contract . 4. The Facilities Director provides weekly assignments for all tasks schedule dint he system. Components maintained by corrective maintenance will be repaired on request, by work orders. 5. The Facilities Director will provide regular reports to determine percentage of activities completed, and identify problems associated with the individual work assignments and departmental and equipment trends . 7. All documentation of the maintenance activity will be completed by the Facilities Engineer, reviewed by the appropriate supervisor, and filed or the information entered into the work order system. Work orders for maintenance activities not completed will remain open until finalized. 2b. During an observation, on 2/10/22, at 10:42 AM, in Room 111's bathroom, observed black and brownish liquid substance surrounding the base of the toilet bowl. The black and brownish substance was seeping out from the base of the toilet bowl. The bolts anchoring the base of the toilet had a crusty orange and brown colored matter. During an observation, on 2/10/22, at 10:44 AM, the base of the toilet in Room 105's bathroom, had a flaking white grout. Observed brownish liquid substance seeping out from the base of the toilet bowl. During an observation on 2/10/22, at 10:47 AM, the base of the toilet in Room 101's bathroom, had a flaking white grout. Observed brownish liquid substance seeping out from the base of the toilet bowl. 2c. During a concurrent observation and interview, on 2/14/22, at 10:47 AM, observed a sign at the door of room 201 indicated room out of order: don't use. CNA 1 stated room 201's bathroom is out of order, and they moved the resident to another room yesterday (2/13/22). There were two holes on the wall near the shower head exposing the pipes. Also observed the bathroom floor linoleum with bubble like raised areas. During an interview with the EVSS, on 2/14/22, at 11:42 AM, the EVSS stated there was a leakage which started around mid January (1/17/22). He stated, the engineer came the same day, had to cut through the wall to find the source of the leakage and had done the repair, but they are waiting for the engineer to come patch the holes. The EVSS stated he had no documentation regarding the repairs as it was more of a verbal thing. During an observation on 2/14/22, at 11:25 AM, in the room 206 bathroom, observed a blackish substance around the base of the toilet bowl. Also observed the linoleum flooring with greyish stains. During an observation on 2/14/22, at 11:45 AM, in the room 208 bathroom, observed a defined blackish substance around the base of the toilet bowl. Also observed a dark colored raised area on the floor linoleum, under the sink pipe. Also observed that the Formica covering the bathroom's sink cabinet was chipped at the edges. 2d. During observations on 2/14/22, at 10:15 AM, in Room 301, 302, 305, 306, 308, 310, and 311 bathrooms, the linoleum flooring at the junction of the base of the toilet bowl and the flooring, had gaps around the base of the toilet bowl. The gaps contained a buildup of dark brown colored substance. During an interview with EVST 4, on 2/14/22, at 10:20 AM, EVST 4 acknowledged that rooms 301, 302, 305, 306, 308, 310, and 311 bathrooms had a dark colored substance at the junction of the base of the toilet bowl and the linoleum flooring. He stated that the Skilled Nursing Facility (SNF) trained staff to use bleach to clean the flooring gaps at the junction of the base of the toilet bowl and the flooring in the bathrooms. He said, afternoon environmental services staff are required to terminally clean shower rooms every afternoon. 3. During observations on 2/14/22, at 9:30 AM, in the company of EVSS, the SNF placed a sign outside the door of Shower Room #3 indicating that staff not use the shower room to shower residents. EVSS used a tape measure to measure the size of the missing tiles on the floor. He counted 21 missing tiles each measuring 1/2 x 1/2 inches (in) size. The missing tiles were located next to each other in the form of a square and next to the drainage plate and were visible upon entering Shower Room #3. The floor space missing tiles contained sheer stagnant liquid with pungent smell. A black substance was visible through the sheer liquid, at the bottom of the floor spaces missing the tiles. During concurrent interview on with EVSS on 2/14/22, at 9:45 AM, EVSS acknowledged that the floor of Shower Room #3 had 21 ceramic tiles, 1/2 x 1/2 in size missing from the floor. He agreed that the space where the tiles were missing contained sheer stagnant liquid with a black substance visible at the bottom of the space missing the tiles. He stated that the SNF contracted with few bidders for the opportunity to work in replacing the missing tiles. He said the facility was aware that the tiles were missing, was trying to replace the missing tiles, and was waiting for contract bidders to give the SNF requested bids. He stated, the main SNF has documentation of the requested contractor bids. During an interview with CNA 3, on 2/14/22 at 4:30 PM, in Shower Room #3, CNA 3 stated, I would not shower my residents in the moldy shower room. She said CNAs working during the day shift showered resident in the shower room with the tiles missing on the floor of the shower room. During an interview with Registered Nurse (RN) 4, on 2/14/22, at 4:35 p. m, in Shower Room #3, RN 4 acknowledged that CNAs showered residents in Shower Room #3 while the tiles were missing from the floor. She stated that the SNF trained staff to submit a work order to replace the missing floor tiles, and to continue to use the shower room to shower residents while waiting for the SNF to replace the missing tiles. During a review of undated facility document titled, Work-order Status. SMCC Open Work Order List, the Work Order Status. SMCC Open Work Order List indicated that the SNF documented (1) on 9/16/21, at 12:01 PM, Third request to replace missing floor tile in Shower #3 in 300 hall, (2) on 12/7/21, at 9:01 AM, Leaking water from the shower cap on Shower 3 at 300 hall. Please check out, (3) on 1/13/22, at 8:04 AM, 300 shower drain plugged. and (4) on 1/18/22, at 10:45 AM, Shower drain clogged in 300 hallway.

Based on observation, interview, and record review, the facility failed to ensure resident comfort is achieved in accordance with comprehensive person-centered care plan when physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice resulted in Resident 33 having a headache and discomfort, and had the potential to cause further brain tissue injury and increase intracranial pressure (pressure inside the skull). Findings: Review of Resident 33's History and Physical Report dated 12/13/21, indicated, Resident 33 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] i. Right-sided hemorrhagic stroke (a condition in which a blood vessel breaks and bleeds into the brain), ii. Right hemicraniectomy on 6/26/19 (a surgical procedure where a large flap of the skull is removed to give space for the swollen brain to bulge and reduces the intracranial pressure), iii. [CONDITION(S)] (a sudden, uncontrolled electrical disturbance in the brain) and iv. Constantly recurring left-sided pain. The Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment dated [DATE], indicated Resident 33 was cognitively intact. Under Section J 400, the pain assessment indicated, Resident 33 was frequently in pain and was receiving routine and as needed pain medications for pain management. During an observation on 2/10/22, at 10:33 AM, a sign posted on the wall by the left side of the bed indicated, NURSING ALERT (PLEASE READ BEFORE GIVING CARE). Another sheet was attached after the nursing alert sign, it indicated, DO NOT TURN PATIENT TO THE RIGHT SIDE. During a concurrent interview, Resident 33 stated she reminded Certified Nursing Assistant (CNA) 4 not to turn her on the right side but continued to do so. Resident 33 stated, It happened during diaper change. I was pushed to the left side and right side. My left side does not work (referring to weakness on left side of the body) and it (left side of the body) hurts all the time. I have something on my head (pointing at the bulging area on the right side of her head). The History and Physical Report dated 12/13/21, indicated, .Her craniotomy on the right side is without the scalp plate and she is wearing a protective helmet at the movement . At present, the patient's main issue is her chronic pain on the left side of her body, for which she was referred to Pain Clinic. She was also referred to Neurosurgery Specialty Clinic in (Name of facility) and (Name of facility) Neurosurgery Department to cover for her right craniotomy with a scalp plate . Head: Bulging of the right side of the head. Soft, nontender, no [CONDITION(S)], no discharge . During an interview on 2/10/22, at 10:42 AM, Charge Nurse (CN) 2 stated Resident 33 had a right hemicraniectomy and should not be turned on her right side. CN 2 explained that a Nursing Alert sign of do not turn patient on right side was posted on the wall as a reminder for the staff providing care for Resident 33. CN 2 confirmed during the evening shift on 5/19/21, Resident 33 complained of a headache after CNA 4 turned her on the right side. CN 2 stated, She's not supposed to be turned on her right side. There's no bone in there (referring to the bulging area on the right side of her head). During an interview on 2/10/22, at 2:35 PM, Resident 33 was asked how she felt after she was turned on her right side on 5/19/21, Resident 33 stated, I was in pain. There's a sign do not turn on right side but she kept going. My right side hurt. My head hurt. During an interview on 2/14/22, at 4:38 PM, CNA 4 stated she was told by Resident 33 not to turn on her right side during care on 5/19/21. CNA 4 acknowledged she did not know Resident 33 cannot be turned on her right side. CNA 4 stated, I did not see the note posted on the wall. I was told by other CNAs not to turn on her right side after she complained of pain on the head. I was not aware of the care plan. I have not read her care plan. Review of the Patient Care Notes, dated 5/20/21, indicated, .CNA (referring to CNA 4) pushed her on her R (right) side even when she's telling the CNA (referring to CNA 4) to stop & don't turn on the right side . Pt. c/o (patient complained of) slight pain on her R side, the head & shoulder. Review of the 5-DAY INVESTIGATION SUMMARY, dated 5/24/21, indicated, .On 5/20/2021 at approximately 0830, (Resident 33) reported to the charge nurse . the CNA (Certified Nursing Assistant) from the night before (5/19/2021), pushed her hard to the right side lying position even if she had just told her that she did not want to be turned . (Resident 33) mentioned to CNA that there are instructions posted that she cannot be turned to the right . after CNA pushed her, she felt pain on the right shoulder and right side of neck . Review of Resident 33's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 33's care plan indicated the following: a. The Activities of Daily Living (ADL) care plan, started on 12/5/19 and revised on 6/2/21, indicated, .13. No turning on right side as ordered. b. The Pain care plan, started on 12/8/19 and revised on 6/2/21, indicated, Potential for pain and discomfort r/t (related to) Right hemorrhagic stroke . right hemi craniotomy with left side [CONDITION(S)] (paralysis of one side of the body), chronic left side pain . 1. Check pain level Q (every) shift and medicated per pain scale . Check patient 30-60 minutes after medication if relieved or not. 2. Repositioning/turning for comfort to relieve pressure . Review of the facility's policy and procedure titled, Plan of Care, dated 9/2019, indicated, . (Name of the facility) must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care . 1. The comprehensive plan of care shall include: a. The frequency at which care, services, treatments, and interventions will occur b. The IDT member(s) responsible for providing the care, treatment, interventions . d. Current needs, problems, goals, care, treatment and services . 3. The evaluation of the resident's progress is made based upon the care plan goals and the resident's plan of care, treatment and services.

Based on observation, interview, and record review, the facility failed to provide preventative treatment, equipment, and services to maintain, improve, and prevent further decline in range of motion (ROM) and/or mobility when: 1. The physician's order for hand splint and rolled bath blanket at lumbar spine were not implemented for Resident 33. The deficient practice resulted in pain, further increase in contractures, and decline in ROM for Resident 33. A contracture is a condition of shortening and hardening of muscles, tendon or other tissue, often leading to deformity and rigidity of joints which limit and interfere with daily functioning. 2. The Physical Therapist (PT) recommendation to ambulate with staff supervision was not implemented for Resident 46. The deficient practice could potentially contributed to Resident 46's decline in range of motion, mobility and pressure injuries on left and right foot. 3. The physician's order for hand splint was not implemented for Resident 44. The deficient practice could potentially worsen the stiffness of Residdent's 44 hands and further decline in ROM. 4. Residents 65 and 127 missing splints were not promptly replaced. The deficient practice could potentially worsen the contractures and decline in ROM for Resident 65 and Resident 127. 5. The physician's order for range of motion exercise was not implemented for Resident 76. The deficient practice could potentially resulted in pain, further increase in contractures, and decline in ROM for Resident 76. 6. There was no evidence Resident 111's private caregivers was given education and training in performing ROM excersice and the use of Active Passive Trainer (APT, a unique exercise rehabilitation trainer for the upper or lower limbs) machine to aid in improving the ROM. In addition, there is no evidence a physician's order was obtained, an assessment and care plan were completed prior to the use of APT machine. The deficient practice could potentially contribute in further pain and increase in contractures of Resident 111. 7. The physician's order for hand roll was not implemented for Resident 66. This deficient practice had the potential for Residents 66's contractures to worsen and cause further decline in ROM. A hand roll is a rubber device or rolled washcloth used to maintain joint positioning and further prevent joint deformity. 8. PT and Occupational Therapy (OT) initial and/or quarterly evaluation assessment was not completed for Resident 100, 11, and 133. The deficient practice could result residents not receiving the proper services or treatment to address their needs. 9. Resident-centered and individualized ROM exercises was not provided in accordance to facility policy. The deficient practice prevents the residents from attaining their maximum functional potential and from achieving or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings: 1A. Resident 33 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 33's history and physical (H&P) report dated 12/13/21 indicated, . The patient's physical condition has been stable for the last 2 years. The patient was able to participate in her physical therapy and occupational therapy program. She continues to require assistance . Has complaints of chronic left-sided continues pain . EXTREMITIES: Weak left upper extremity and left lower extremity secondary to [CONDITION(S)] ([CONDITION(S)], also known as stroke). Good range of motion on the right upper extremity and right lower extremity . Review of Resident 33's physician's order for May 2022 indicated the following orders: i. 5/29/21 - Continue OOB (out of bed) daily. PROM LUE/LLE daily if patient allows. ii. 9/16/21 - OT order: Place rolled bath blanket at lumbar spine when up in wheelchair. iii. 10/18/21 - OT order: Left hand splint wearing schedule ON during the day when up in wheelchair and PRN (as needed) per pt (patient) preference to decrease loss of ROM. iv. 4/30/22 - Clarification PT order cont. (continue) 1x1 month for 1 month include there-ex (therapeutic exercise), there-act (therapeutic activity), neuromuscular ex due to generalized weakness. During an observation on 5/2/22, at 10:06 AM, in the activity room, Resident 33 was sitting in a wheelchair with the left arm resting on the armrest. Resident 33's left hand and fingers were bent and curled inward. Resident 33 did not have a splint on the left hand and did not have a rolled bath blanket to support the lumbar spine During concurrent interview, Resident 33 stated she's been having pain on the left side of her body. Resident 33 was observed tearing up while verbalizing, The pain never goes away. Resident 33 acknowledged she's been given pain medications and stated, It's not helping my pain. During an interview with Licensed Vocational Nurse (LVN) 6 on 5/2/22 at 2:15 PM, LVN 6 stated Resident 33 has pain on her left side of the body and is on pain management which includes, repositioning and ROM. LVN 6 also stated Resident 33 has a splint on the right leg and left hand PRN (as needed). During an interview with the Rehab Staff (RS) on 5/3/22, at 11:05 AM, RS stated, Certified Nursing Assistant (CNA) supposed to apply the splint to the resident when she's up on a wheelchair but there are times when Resident 33 does not want to wear the splint. RS also explained that ROM should be done during ADLs (activities of daily living) and stated Usually it's not done. During an observation on 5/4/22 at 11:10 AM, in the activity room, Resident 33 was sitting in a wheelchair with the left arm/hand resting on the arm rest. Resident 33's left hand and fingers were bent and curled up. During observation, there was no hand splint on Resident 33's left hand and no rolled bath blanket on her lower back. During an interview with Certified Nursing Assistant (CNA) 5 on 5/4/22 at 11:50 AM, CNA 5 stated, She (Resident 33) has no splint. I'm not sure if she has a splint. CNA 5 also stated he provides 5 to 8 minutes of ROM exercises for both the upper and lower extremities for Resident 33 during ADL care such as dressing. CNA 5 added that the ROM exercises were not fully performed due to Resident 33's constant complaints of pain on the left side arm and hand. Review of Resident 33's care plan for ADL Functional/Rehabilitation Potential last revised on 2/23/22 did not include the use of hand splint and range of motion exercise. During an interview on 5/4/22, at 11:56 AM, LVN 6 acknowledged the care plan for ADL Functional/Rehabilitation Potential did not include the use of hand splint and range of motion exercises. During an interview with Resident 33's Responsible Party (RP) on 5/4/22, at 2:31 PM, the RP stated, She's (Resident 33) not getting enough therapy. She's only doing standing in parallel bars once a week and her toes started to curl up. She needed more assistance than before. She's deteriorating and her quality of life is not improving at all. During an interview with CNA 13 on 5/4/22, at 2:50 PM, CNA 13 stated, She's (Resident 33) total care. She declined a little. She complained of pain when putting on the splint. Review of Resident 33's progress notes from the pain clinic dated 3/2/22 indicated, .Patient reports she gets PT 1x/week and states standing up is the only time she feels ok. She mentions she has worsening [CONDITION(S)] throughout the left side . She reports she doesn't sleep well, either, as a result of pain . Assessments . May have chronic intractable pain on left side of her body due to [CONDITION(S)] vs. central pain . Treatment . 1d. Consider increasing [MEDICATION(S)] (used to treat muscle spasm) to 4 mg po BID (milligrams by mouth twice a day) as patient reports worsening spasms . 2. Mobilize with PT as much as possible and HEP (home exercise program) . Review of Resident 33's Minimum Data Set (MDS, an assessment tool) dated 11/30/21 indicated, Resident 33 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing. The MDS assessment dated [DATE] indicated, total dependence (full staff performance) with dressing, upper extremity (UE) impairment on one side, and lower extremities (LE) impairment on both sides. 2. Resident 46 was admitted to facility on 11/26/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 46's physician's order for May 2022 indicated, Recommendation from PT 9/15/21: Ambulate with walker by staff supervision and assistance. During an observation on 5/3/22, at 8:45 AM, Resident 46 was awake in bed wearing foam booties on both feet. During an interview with the Wound Care Nurse (WCN) 1 on 5/3/22, at 9:03 AM, WCN 1 stated Resident 46 used to get up on the wheelchair and wheel around the unit. WCN 1 further stated, Resident 46 experienced a change in condition on 4/23/22. Resident 46 developed four deep tissue injury (DTI, an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) on the left and right foot. During an observation on 5/4/22, at 3:19 PM, CNA 2 was feeding Resident 46 in bed with the head of bed elevated and foam booties on both feet. During concurrent interview, CNA 2 stated Resident 46 was wearing foam booties to protect the wounds on his feet. CNA 2 stated Resident 46 used to wheel himself around and into other resident's room but recently, Resident 46 had been staying in bed. CNA 2 added, Resident 46 had a decline in ADL function, he used to require limited assistance but now requires total assistance. During an interview with CNA 2 on 5/4/22, at 3:22 PM, CNA 2 stated, He's (Resident 46) not ambulatory. He was evaluated by PT/OT but no recommendation. CNA 2 further stated, he provides ROM exercises (stretching) to Resident 46 during ADL care for a total of two to three minutes on both UE/LE. During a concurrent interview and record review with LVN 2 on 5/5/22, at 11:35 AM, Resident 46's care plan was reviewed. LVN 2 was unable to find a care plan addressing Resident 46's ROM exercises and PT's recommendation for ambulation. LVN 2 stated he was not aware of Resident 46's recommendation for ambulation. LVN 2 added, He's not ambulatory. Review of Resident 46's MDS dated [DATE] indicated, Resident 46 was independent with bed mobility and locomotion (how resident moves in and out of the unit) and required limited assistance with transfer. Under ROM, indicated no impairment of upper extremities (UE) and impairment on both sides of lower extremities (LE). Under Restorative Nursing Program indicated 0 on walking. Review of Resident 46's MDS significant change assessment dated [DATE] indicated, Resident 46 required total assist with bed mobility, transfer, eating, and hygiene while locomotion and walking activity did not occur. Under Section M, Skin Condition indicated Resident 46 has four DTIs. During an interview with MDS Coordinator (MDSC) 1 on 5/5/22, at 3:15 PM, MDSC 1 acknowledged and stated, a significant change assessment was completed for Resident 46 due to a decline in ADL function and development of DTI. MDSC 1 added, Resident 46 now requires more assistance with ADLs. Review of Resident 46's Occupational Therapy Initial Evaluation/Discharge Summary dated 5/5/22 indicated, the prior level of function was I (independent) propel w/c (wheelchair), min (minimum) assist with ADL's. Resident 46's current level of function indicated dependent. The Occupational Therapy Initial Evaluation/Discharge Summary indicated, the upper extremity assessment indicated decreased AROM on the shoulder and increased rigidity in tone. The overall assessment indicated, Impaired ADL ability. Impaired functional mobility/transfers. Impaired ADL endurance. Impaired standing/sitting balance. At risk for deconditioning/contractures/skin breakdown. Seating and positioning needs not met. Review of Resident 46's ADL Function/Rehabilitation Potential care plan dated 5/6/22 indicated, .Pt has increased weakness and requires total assist with ADL's . Review of facility's policy and procedure titled, Change in Resident Condition, revised on 10/2021, indicated, .2b. A significant change reassessment must be done when a decline or improvement occurs in 2 or more of the following areas: c. Decline: 1) Any decline in ADL/physical functioning where a resident is newly coded as 3 (extensive assistance), 4 (total dependency), or 8 (activity did not occur) . 8) Emergence of a condition/disease in which the resident is judged to be unstable. 9) Emergency of a pressure ulcer at Stage II or higher, when no ulcers were present at Stage II or higher. 10) Overall deterioration of a resident's condition or resident receives more support, e.g., in ADLs or decision-making . 3. Resident 44 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 44's physician's order dated 3/10/22 indicated, DON (put on) RIGHT HAND SPLINT with foam under wrist 4 hours every day from 10 AM to 2 AM. Check for redness and skin irritation. During an observation on 5/5/22, at 10:45 AM, Resident 44 was on his wheelchair and did not have a hand splint on the right arm/wrist. The hand splint was observed on top of the bedside drawer. During concurrent interview, Resident 44 stated his hand is very stiff and that he does not wear the splint every day. Resident 44 added, Nobody helps me (referring to splint application). During an interview with CNA 5 on 5/5/22 at 10:52 AM, CNA 5 stated, I'm not sure when the resident wears the splint. I will ask the OT. During a follow up interview with CNA 5 on 5/5/22 at 11:14 AM, CNA 5 stated Resident 44 should wear the splint 4 hours a day from 10 AM to 2 PM according to the OT instruction. During concurrent interview and record review with LVN 2 on 5/5/22 at 2:45 PM, Resident 44's OT's progress notes for March 2022 indicated there was no assessment and documentation regarding the hand splint that was ordered on 3/10/22. LVN 2 acknowledged the OT progress notes dated 3/31/22 did not mention about the hand splint and stated, I don't see any. Resident 44's care plan was also reviewed and LVN 2 was unable to find a care plan addressing use of hand splint and range of motion exercise. Review of Resident 44's MDS dated [DATE] indicated, one side of upper extremities (UE) was impaired. Under section O, Restorative Nursing Program indicated, 0 on splint or brace assistance which means splint was not applied. 4A. Resident 65 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 65's MDS dated [DATE] indicated, the staff assessment for mental status indicated Resident 65 was cognitively impaired. The functional limitation in ROM indicated, both sides of upper and lower extremities (UE/LE) were impaired. Review of Resident 65's physician's order for May 2022 indicated the following orders: a. 4/2/19 - RUE (right upper extremity) Splints: Wear when in bed. remove when up in chair. Remove splints to perform ADLs . b. 10/8/20 - RLE (right lower extremity) Splints: Wear in bed. Place towel around upper thigh and lower leg under Velcro attachments to decrease risk of skin breakdown. Remove splint if any skin irritation or redness. During an interview with CNA 4 on 5/3/22, at 4:14 PM, CNA 4 stated Resident 65 has a splint on the right arm and right thigh to prevent contractures when in bed. During an observation on 5/3/22 at 4:15 PM, Resident 65 was in bed, asleep and did not have a splint on the right arm thigh. During concurrent interview, CNA 4 acknowledged Resident 65 was not wearing a splint on the right arm and right thigh. CNA 4 went to check Resident 65's bedside drawer and closet but was unable to find the splint. CNA 4 stated, I don't know where it is (referring to the splint). I will look for it. During an interview with CNA 5 on 5/4/22, at 11:43 AM, CNA 5 stated, [Resident 65] has a splint but not anymore. The splint is missing. Review of Resident 65's TAR for February 2022 indicated under comments, 2/10/22 8AM CNA reported cannot find pt (patient) R (right) hand splint . CN (Charge Nurse) and physical therapy made aware. The comments dated 2/13/22, 2/14/22, 2/17/22, 2/22/22, 2/24/22, 2/26/22, and 2/27/22 (seven days) indicated RUE and RLE splint were missing. The TAR for March 2022, April 2022, and May 2022 indicated, RUE splint . FYI MISSING 2/10/22 OT AWARE. Review of Resident 65's OT progress notes dated 2/10/22 indicated, RUE splint reported missing by nursing. Nursing to look for splint prior to OT replacing. OT progress notes dated 3/1/22, CNA reports RUE/LE splint missing to OT. OT progress notes dated 5/4/22 indicated, LATE ENTRY FOR 3/16/22 Quarterly Assessment . Severe tone RUE/LE with decreased ROM . RUE/LE splint reordered . During an inteview with RS on 5/5/22, at 10:02 AM, RS acknowledged Resident 65's RUE and RLE splints were missing and stated she did not have a back up supply of the splint. Resident 65's care plan was reviewed, LVN 2 was unable to find a care plan addressing the use of splint. LVN 2 stated, The splint should be care planned. There should be an alternative approach for the missing splint. 4B. Resident 127 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 127's Interim History and Physical, dated 6/12/21 indicated Resident 127 had .no right upper extremity movement . Review of Resident 127's Physician's orders for May 2022 indicated, Date prescribed .5-22-2018 . Resting splint to right hand . with a Wearing Schedule indicating Resident 127 was to wear the splint from 10 AM to 6 PM, and 10 PM to 8 AM. Review of Resident 127's MDS, dated [DATE], indicated Resident 127 had functional limitations on both upper extremities and was totally dependent on nursing staff for all his activities of daily living; the same MDS also indicated that a splint or brace assistance was not applied to Resident 127. During a concurrent observation and interview on 5/4/22 at 2:47 PM with CNA 2, Resident 127 was lying in bed and slightly turned to his right side. Resident 127 had a contracture of the right hand with his wrist bent inwards towards his forearm Resident 127 did not have a splint applied to his right hand. CNA 2 stated, He (Resident 127) does not have a splint, only towel roll (referring to hand roll) on the right hand . CNA 2 proceeded to get a washcloth, rolled it, and applied it on Resident 127's right hand. CNA 2 stated he was not sure which hand needed a splint and was not aware of Resident 127's wearing schedule for the splint. CNA 2 stated, I don't know the order. The splint, nobody told me. The wearing schedule of the splint was not posted in Resident 127's room. During a concurrent observation and interview with RN 6 on 5/5/22 at 11:30 AM, Resident 127 was lying bed with his eyes open he did not have a splint applied to his right hand. During an interview on 5/5/22 at 11:45 AM, the Registered Nurse (RN 6) stated, Nobody reported that it (splint) has been missing. They (nursing staff) said it's been missing a long time, about a month ago. They (nursing staff) can't tell me specifically when. RN 6 stated that the use of splint for Resident 127 is to prevent further flexion and more contractures. During an interview on 5/6/22 at 11:32 AM, the RS stated that the use of splint to Resident 127's right hand was to limit him (Resident 127) from going into further decline and to prevent his fingers from going into his skin. During an interview on 5/6/22 at 11:53 AM, the Director of Nursing (DON) stated that not applying the splint to residents as prescribed could contribute to further contractures. Review of the facility policy and procedure titled, Splinting, revised on 4/17 indicated, Splinting is used to protect joints and surrounding soft tissue. This can be accomplished by maintaining joints at position of rest, preventing positions that contribute to contracture and/or deformity, protecting the system of arches within the hand and increasing or maintaining ROM in the joint . The Occupational Therapist shall assess patient's need for splints with the following considerations: To protect joints and surrounding soft tissue; To increase hand function; To maintain range of motion . The Occupational Therapists shall then evaluate for type of splint required by patient . A splint handout with precautions and wearing schedule will be posted in resident's room . The Occupational Therapists shall train nursing staff/patient/caregivers/family members on donning/doffing the splint, cleaning of the splint, precautions (reddened areas) and wearing schedule . 5. Resident 76 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 76's MDS dated [DATE] indicated, Resident 76 has impairment on one side of UE and both sides of LE. Under section O, Restorative Nursing Program indicated 0 on both AROM and PROM, splint or brace assistance. Review of OT's quarterly assessment dated [DATE] indicated, .R (right) hand contractures [with] limited use of L (left) hand. R feet plantar [check mark symbol] contractures LUE shoulder [check mark symbol] AROM 0-120, RUE PROM 0-90 . During an observation on 5/2/22, at 11:17 AM, Resident 76 was in bed with a rolled towel on the right hand. Resident 76's right hand and fingers were bent and curled inward. Review of Resident 76's physician's order for May 2022 indicated, Range of Motion exercise to right upper extremity daily for flexion of contractures was ordered on 12/3/19. During an interview with CNA 9 on 5/4/22, at 2:53 PM, CNA 9 stated she provide ROM exercises five to eight minutes for both upper and lower extremities to Resident 76 during ADL care. CNA 9 added, Resident 76 has pain on the right arm/hand due to contractures and a rolled towel is applied every day. Review of Resident 76's care plan for pain revised on 3/13/22 indicated, Potential for pain or discomfort r/t (related to) Disease processes, Limited Mobility . Approach . Moving hands and feet a little . Review of the TAR for May 2022 indicated, an FYI (for your information) under the treatment order Range of Motion exercise to right upper extremity daily for flexion of contractures. During interview with LVN 2 and concurrent review Resident 76's care plan on 5/4/22, at 3:05 PM, LVN 2 was unable to find a care plan addressing the application of rolled towel on the right hand and range of motion exercises. LVN 2 acknowledged and stated the care plan should indicate the interventions provided to the resident. Review of the facility's policy and procedure titled, Range of Motion, revised on 8/2020, indicated, Purpose: 1. To maintain and improve muscle strength and tone . 3. To prevent contractures . Procedure/Responsibilities 1. Licensed personnel are to supervise nursing assistants in ROM. 2. Physical Therapy is to be called for initial evaluation, if necessary. ROM is a nursing measure . 4. ROM exercise doe not take the place of position change and support for dependent parts . 7. Do not bring the joint/limb motion to the point of pain . 9. Each joint is moved through its range 3-5 times per treatment . In-Service Education: 1. All nursing staff are instructed in the techniques of active and passive ROM . 2. All resident will receive ROM every 4 hours between the hours of 0900 and 2100 every day. 3. Passive ROM may be ordered as a nursing order . Documentation: CNA Flowsheet. Review of facility's policy and procedure titled, Plan of Care, revised on 9/2019, indicated, . 1. The comprehensive plan of care shall include: a. the frequency at which care, services, treatments, and interventions will occur . d. Current needs, problems, goals, care, treatment and services . 3. The evaluation of the resident's progress is made based upon the care plan goals and the resident's plan of care, treatment and services. 6. Resident 111 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 111's MDS dated [DATE] indicated both sides of upper and lower extremities (UE/LE) were impaired. Under Restorative Nursing Program indicated, 0 on both AROM and PROM, splint or brace assistance. During an observation on 5/4/22, at 3:08 PM, Resident 111's Private Caregiver (PCG) 1 was observed putting on a white rolled towel on resident's right hand. Resident 111's wrist/hand were bent and his fingers were curled inward. During concurrent interview, PCG 1 explained he's putting a hand roll for Resident 111 due to contractures on the hands and fingers. PCG 1 also stated she provide ROM exercises to Resident 111 at night during ADL care. During an interview with Resident 111's PCG 2 on 5/5/22, at 8:55 AM, PCG 2 stated he used to assist Resident 111 with ROM exercises using the Active Passive Trainer (APT, are electric exercise machines used for the improvement of physical abilities and can be operated in either active or passive mode) machine. PCG 2 pointed at the APT machine behind the privacy curtain. PCG 2 stated the APT machine was last used few months ago. PCG 2 also stated, [Resident 111] contractures became harder. The exercise hurts him. PCG 2 explained that they are waiting for the special shoes for Resident 111 prior to resuming use of APT machine. PCG 2 added, the shoes the resident had was hurting him. During an interview with LVN 2 on 5/5/22, at 9:01 AM, LVN 2 stated Resident 111 has a private caregiver doing passive ROM and mostly providing care for the resident. LVN 2 added, I don't know about that machine (referring to the APT machine). The family provided it. I will ask the caregiver. During an interview with RN 6 on 5/5/22, at 9:30 AM, RN 6 stated, [Name of Resident 111] family provided the APT machine. The private caregivers were assisting him (referring to Resident 111) with the exercise. RN 6 also stated the private caregivers reported they stopped using the APT machine due to increased stiffness of the upper and lower extremities. During an interview with RN 6 on 5/5/22, at 9:32 AM, RN 6 stated the rehab provided PROM training to the caregivers and the use of APT machine. During concurrent record review, RN 6 was unable to find training records on the use of APT machine for Resident 111's private caregivers (PCG 1 and PCG2). RN 6 stated, I don't see their names in chart. During concurrent interview and further review of Resident 111's record, on 5/5/22, at 9:34 AM, RN 6 was unable to find an order, assessment, and care plan for the use of APT machine. RN 6 stated, I don't see about the machine over here (referring to the OT progress notes). It's not in the order. It's not in the care plan. It's not mentioned in the OT assessment. During an interview with RS on 5/5/22, at 9:55 AM, RS stated Resident 111 had a decline with ROM on 1/27/22. RS explained Resident 111 has APT machine in the room for home exercise which helps maintain ROM of the resident. RS added, The nursing staff has nothing to do with the home exercise program (referring to APT machine). The caregivers assist him (Resident 111) with it (APT machine). RS further stated, [Name of a caregiver] is using the APT but not PCG 2. RS stated she provides training to the private caregivers on how to perform ROM exercise and the use of APT machine for Resident 111. RS acknowledged the training was not documented in Resident 111's chart. Review of the Active Passive Trainer user's manual revised on 01/2020, indicated, . 3.1 Indications: The Active Passive Trainers are intended to be operated by persons of most physiques and ages. In case the user has limited strength in the arm or cognitive impairment, it is required to have an attendant present during exercise . 3.3 Contraindications . In case of any disease or physical complaints, a healthcare provider should be consulted before participating in any exercise program . In case of recurring discomforts, consult with a health care provider . Review of facility's policy and procedure titled, Education for Patient and Caregiver, revised on 4/2017, indicated, The Therapist and Therapist Assistant will instruct patient, family, and caregiver regarding home exercise programs and safe assistance techniques for functional mobility . The Therapist and Therapist Assistant will complete the following: 1. Provide on-going patient education during treatment sessions regarding safe techniques for home exercise and functional mobility . 3. Provide written instructions with pictures for patient and family when appropriate. The handout will be signed by the therapist/assistant and a contact number will be provided . 5. Document all patient/family education and training in progress notes. include the name and relationship of the family member/caregiver that was instructed. 6. Monitor and document the patient's or caregiver's ability to understand and follow through accurately. Request return demonstration of patient's/caregiver's when appropriate . 7. Resident 66 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 66's MDS, dated [DATE], indicated Resident 66 had functional limitations on one side of the upper extremities and on both lower extremities and was totally dependent on nursing staff for all his activities of daily living. Review of Resident 66's Physician's orders for May 2022 indicated, 01-16-2018 . Apply hand roll to: Left hand contracture to prevent further limitations .Q (every) shift . During an observation and interview with CNA 2 on 5/4/22 at 11 AM, Resident 66 was in bed, awake, and turned to his left side. Resident 66 had a contracture of the left hand with his fingers bent inwards towards his palm. CNA 2 stated Resident 66 is unable to stretch his left fingers and use his left hand. There was no hand roll applied to the left hand or fingers of Resident 66. CNA 2 stated, He (Resident 66) does not have it. We don't have a hand roll. During a concurrent review of clinical records of Resident 66 and interview on 5/4/22 at 11:16 AM, RN 6 reviewed Resident 66's ADL Functional/Rehabilitation Potential care plan (CP), dated 3/12/22. The CP did not include interventions addressing ROM and/or hand roll application to Resident 66's left hand. RN 6 stated, It (use of hand roll) should be there (CP). RN 6 acknowledged Resident 66's CP did not indicate the specific interventions prescribed to Resident 66. A review of the facility policy, titled Hand Rolls, revised on 7/94 indicated, Purpose: To help maintain correct hand position of residents suffering loss of hand sensation, loss of hand mobility, or resident who is unconscious. Policy: It is the policy of the facility to provide for the use of hand rolls for those residents assessed as needing them. Equipment .B. Improvised had roll, made of rolled washcloth. Procedure .5. Position hand roll within affected hand/hands . A review of facilit [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide preventative treatment, equipment, and services to maintain, improve, and prevent further decline in range of motion (ROM) and/or mobility when: 1. The physician's order for hand splint and rolled bath blanket at lumbar spine were not implemented for Resident 33. The deficient practice resulted in pain, further increase in contractures, and decline in ROM for Resident 33. A contracture is a condition of shortening and hardening of muscles, tendon or other tissue, often leading to deformity and rigidity of joints which limit and interfere with daily functioning. 2. The Physical Therapist (PT) recommendation to ambulate with staff supervision was not implemented for Resident 46. The deficient practice could potentially contributed to Resident 46's decline in range of motion, mobility and pressure injuries on left and right foot. 3. The physician's order for hand splint was not implemented for Resident 44. The deficient practice could potentially worsen the stiffness of Residdent's 44 hands and further decline in ROM. 4. Residents 65 and 127 missing splints were not promptly replaced. The deficient practice could potentially worsen the contractures and decline in ROM for Resident 65 and Resident 127. 5. The physician's order for range of motion exercise was not implemented for Resident 76. The deficient practice could potentially resulted in pain, further increase in contractures, and decline in ROM for Resident 76. 6. There was no evidence Resident 111's private caregivers was given education and training in performing ROM excersice and the use of Active Passive Trainer (APT, a unique exercise rehabilitation trainer for the upper or lower limbs) machine to aid in improving the ROM. In addition, there is no evidence a physician's order was obtained, an assessment and care plan were completed prior to the use of APT machine. The deficient practice could potentially contribute in further pain and increase in contractures of Resident 111. 7. The physician's order for hand roll was not implemented for Resident 66. This deficient practice had the potential for Residents 66's contractures to worsen and cause further decline in ROM. A hand roll is a rubber device or rolled washcloth used to maintain joint positioning and further prevent joint deformity. 8. PT and Occupational Therapy (OT) initial and/or quarterly evaluation assessment was not completed for Resident 100, 11, and 133. The deficient practice could result residents not receiving the proper services or treatment to address their needs. 9. Resident-centered and individualized ROM exercises was not provided in accordance to facility policy. The deficient practice prevents the residents from attaining their maximum functional potential and from achieving or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings: 1A. Resident 33 was admitted on [DATE] with diagnoses including stroke, hemiplegia (paralysis of one side of the body) and chronic pain (persistent pain that lasts weeks to years). Review of Resident 33's history and physical (H&P) report dated 12/13/21 indicated, . The patient's physical condition has been stable for the last 2 years. The patient was able to participate in her physical therapy and occupational therapy program. She continues to require assistance . Has complaints of chronic left-sided continues pain . EXTREMITIES: Weak left upper extremity and left lower extremity secondary to CVA (cerebrovascular accident, also known as stroke). Good range of motion on the right upper extremity and right lower extremity . Review of Resident 33's physician's order for May 2022 indicated the following orders: i. 5/29/21 - Continue OOB (out of bed) daily. PROM LUE/LLE daily if patient allows. ii. 9/16/21 - OT order: Place rolled bath blanket at lumbar spine when up in wheelchair. iii. 10/18/21 - OT order: Left hand splint wearing schedule ON during the day when up in wheelchair and PRN (as needed) per pt (patient) preference to decrease loss of ROM. iv. 4/30/22 - Clarification PT order cont. (continue) 1x1 month for 1 month include there-ex (therapeutic exercise), there-act (therapeutic activity), neuromuscular ex due to generalized weakness. During an observation on 5/2/22, at 10:06 AM, in the activity room, Resident 33 was sitting in a wheelchair with the left arm resting on the armrest. Resident 33's left hand and fingers were bent and curled inward. Resident 33 did not have a splint on the left hand and did not have a rolled bath blanket to support the lumbar spine During concurrent interview, Resident 33 stated she's been having pain on the left side of her body. Resident 33 was observed tearing up while verbalizing, The pain never goes away. Resident 33 acknowledged she's been given pain medications and stated, It's not helping my pain. During an interview with Licensed Vocational Nurse (LVN) 6 on 5/2/22 at 2:15 PM, LVN 6 stated Resident 33 has pain on her left side of the body and is on pain management which includes, repositioning and ROM. LVN 6 also stated Resident 33 has a splint on the right leg and left hand PRN (as needed). During an interview with the Rehab Staff (RS) on 5/3/22, at 11:05 AM, RS stated, Certified Nursing Assistant (CNA) supposed to apply the splint to the resident when she's up on a wheelchair but there are times when Resident 33 does not want to wear the splint. RS also explained that ROM should be done during ADLs (activities of daily living) and stated Usually it's not done. During an observation on 5/4/22 at 11:10 AM, in the activity room, Resident 33 was sitting in a wheelchair with the left arm/hand resting on the arm rest. Resident 33's left hand and fingers were bent and curled up. During observation, there was no hand splint on Resident 33's left hand and no rolled bath blanket on her lower back. During an interview with Certified Nursing Assistant (CNA) 5 on 5/4/22 at 11:50 AM, CNA 5 stated, She (Resident 33) has no splint. I'm not sure if she has a splint. CNA 5 also stated he provides 5 to 8 minutes of ROM exercises for both the upper and lower extremities for Resident 33 during ADL care such as dressing. CNA 5 added that the ROM exercises were not fully performed due to Resident 33's constant complaints of pain on the left side arm and hand. Review of Resident 33's care plan for ADL Functional/Rehabilitation Potential last revised on 2/23/22 did not include the use of hand splint and range of motion exercise. During an interview on 5/4/22, at 11:56 AM, LVN 6 acknowledged the care plan for ADL Functional/Rehabilitation Potential did not include the use of hand splint and range of motion exercises. During an interview with Resident 33's Responsible Party (RP) on 5/4/22, at 2:31 PM, the RP stated, She's (Resident 33) not getting enough therapy. She's only doing standing in parallel bars once a week and her toes started to curl up. She needed more assistance than before. She's deteriorating and her quality of life is not improving at all. During an interview with CNA 13 on 5/4/22, at 2:50 PM, CNA 13 stated, She's (Resident 33) total care. She declined a little. She complained of pain when putting on the splint. Review of Resident 33's progress notes from the pain clinic dated 3/2/22 indicated, .Patient reports she gets PT 1x/week and states standing up is the only time she feels ok. She mentions she has worsening spasticity throughout the left side . She reports she doesn't sleep well, either, as a result of pain . Assessments . May have chronic intractable pain on left side of her body due to spasticity vs. central pain . Treatment . 1d. Consider increasing tizanidine (used to treat muscle spasm) to 4 mg po BID (milligrams by mouth twice a day) as patient reports worsening spasms . 2. Mobilize with PT as much as possible and HEP (home exercise program) . Review of Resident 33's Minimum Data Set (MDS, an assessment tool) dated 11/30/21 indicated, Resident 33 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing. The MDS assessment dated [DATE] indicated, total dependence (full staff performance) with dressing, upper extremity (UE) impairment on one side, and lower extremities (LE) impairment on both sides. 2. Resident 46 was admitted to facility on 11/26/19 with diagnoses including schizophrenia (a disorder that affects the ability to think, feel, and behave clearly) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 46's physician's order for May 2022 indicated, Recommendation from PT 9/15/21: Ambulate with walker by staff supervision and assistance. During an observation on 5/3/22, at 8:45 AM, Resident 46 was awake in bed wearing foam booties on both feet. During an interview with the Wound Care Nurse (WCN) 1 on 5/3/22, at 9:03 AM, WCN 1 stated Resident 46 used to get up on the wheelchair and wheel around the unit. WCN 1 further stated, Resident 46 experienced a change in condition on 4/23/22. Resident 46 developed four deep tissue injury (DTI, an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) on the left and right foot. During an observation on 5/4/22, at 3:19 PM, CNA 2 was feeding Resident 46 in bed with the head of bed elevated and foam booties on both feet. During concurrent interview, CNA 2 stated Resident 46 was wearing foam booties to protect the wounds on his feet. CNA 2 stated Resident 46 used to wheel himself around and into other resident's room but recently, Resident 46 had been staying in bed. CNA 2 added, Resident 46 had a decline in ADL function, he used to require limited assistance but now requires total assistance. During an interview with CNA 2 on 5/4/22, at 3:22 PM, CNA 2 stated, He's (Resident 46) not ambulatory. He was evaluated by PT/OT but no recommendation. CNA 2 further stated, he provides ROM exercises (stretching) to Resident 46 during ADL care for a total of two to three minutes on both UE/LE. During a concurrent interview and record review with LVN 2 on 5/5/22, at 11:35 AM, Resident 46's care plan was reviewed. LVN 2 was unable to find a care plan addressing Resident 46's ROM exercises and PT's recommendation for ambulation. LVN 2 stated he was not aware of Resident 46's recommendation for ambulation. LVN 2 added, He's not ambulatory. Review of Resident 46's MDS dated [DATE] indicated, Resident 46 was independent with bed mobility and locomotion (how resident moves in and out of the unit) and required limited assistance with transfer. Under ROM, indicated no impairment of upper extremities (UE) and impairment on both sides of lower extremities (LE). Under Restorative Nursing Program indicated 0 on walking. Review of Resident 46's MDS significant change assessment dated [DATE] indicated, Resident 46 required total assist with bed mobility, transfer, eating, and hygiene while locomotion and walking activity did not occur. Under Section M, Skin Condition indicated Resident 46 has four DTIs. During an interview with MDS Coordinator (MDSC) 1 on 5/5/22, at 3:15 PM, MDSC 1 acknowledged and stated, a significant change assessment was completed for Resident 46 due to a decline in ADL function and development of DTI. MDSC 1 added, Resident 46 now requires more assistance with ADLs. Review of Resident 46's Occupational Therapy Initial Evaluation/Discharge Summary dated 5/5/22 indicated, the prior level of function was I (independent) propel w/c (wheelchair), min (minimum) assist with ADL's. Resident 46's current level of function indicated dependent. The Occupational Therapy Initial Evaluation/Discharge Summary indicated, the upper extremity assessment indicated decreased AROM on the shoulder and increased rigidity in tone. The overall assessment indicated, Impaired ADL ability. Impaired functional mobility/transfers. Impaired ADL endurance. Impaired standing/sitting balance. At risk for deconditioning/contractures/skin breakdown. Seating and positioning needs not met. Review of Resident 46's ADL Function/Rehabilitation Potential care plan dated 5/6/22 indicated, .Pt has increased weakness and requires total assist with ADL's . Review of facility's policy and procedure titled, Change in Resident Condition, revised on 10/2021, indicated, .2b. A significant change reassessment must be done when a decline or improvement occurs in 2 or more of the following areas: c. Decline: 1) Any decline in ADL/physical functioning where a resident is newly coded as 3 (extensive assistance), 4 (total dependency), or 8 (activity did not occur) . 8) Emergence of a condition/disease in which the resident is judged to be unstable. 9) Emergency of a pressure ulcer at Stage II or higher, when no ulcers were present at Stage II or higher. 10) Overall deterioration of a resident's condition or resident receives more support, e.g., in ADLs or decision-making . 3. Resident 44 was admitted on [DATE] with diagnoses including stroke and hemiplegia. Review of Resident 44's physician's order dated 3/10/22 indicated, DON (put on) RIGHT HAND SPLINT with foam under wrist 4 hours every day from 10 AM to 2 AM. Check for redness and skin irritation. During an observation on 5/5/22, at 10:45 AM, Resident 44 was on his wheelchair and did not have a hand splint on the right arm/wrist. The hand splint was observed on top of the bedside drawer. During concurrent interview, Resident 44 stated his hand is very stiff and that he does not wear the splint every day. Resident 44 added, Nobody helps me (referring to splint application). During an interview with CNA 5 on 5/5/22 at 10:52 AM, CNA 5 stated, I'm not sure when the resident wears the splint. I will ask the OT. During a follow up interview with CNA 5 on 5/5/22 at 11:14 AM, CNA 5 stated Resident 44 should wear the splint 4 hours a day from 10 AM to 2 PM according to the OT instruction. During concurrent interview and record review with LVN 2 on 5/5/22 at 2:45 PM, Resident 44's OT's progress notes for March 2022 indicated there was no assessment and documentation regarding the hand splint that was ordered on 3/10/22. LVN 2 acknowledged the OT progress notes dated 3/31/22 did not mention about the hand splint and stated, I don't see any. Resident 44's care plan was also reviewed and LVN 2 was unable to find a care plan addressing use of hand splint and range of motion exercise. Review of Resident 44's MDS dated [DATE] indicated, one side of upper extremities (UE) was impaired. Under section O, Restorative Nursing Program indicated, 0 on splint or brace assistance which means splint was not applied. 4A. Resident 65 was admitted on [DATE] with diagnoses including stroke and hemiplegia. Review of Resident 65's MDS dated [DATE] indicated, the staff assessment for mental status indicated Resident 65 was cognitively impaired. The functional limitation in ROM indicated, both sides of upper and lower extremities (UE/LE) were impaired. Review of Resident 65's physician's order for May 2022 indicated the following orders: a. 4/2/19 - RUE (right upper extremity) Splints: Wear when in bed. remove when up in chair. Remove splints to perform ADLs . b. 10/8/20 - RLE (right lower extremity) Splints: Wear in bed. Place towel around upper thigh and lower leg under Velcro attachments to decrease risk of skin breakdown. Remove splint if any skin irritation or redness. During an interview with CNA 4 on 5/3/22, at 4:14 PM, CNA 4 stated Resident 65 has a splint on the right arm and right thigh to prevent contractures when in bed. During an observation on 5/3/22 at 4:15 PM, Resident 65 was in bed, asleep and did not have a splint on the right arm thigh. During concurrent interview, CNA 4 acknowledged Resident 65 was not wearing a splint on the right arm and right thigh. CNA 4 went to check Resident 65's bedside drawer and closet but was unable to find the splint. CNA 4 stated, I don't know where it is (referring to the splint). I will look for it. During an interview with CNA 5 on 5/4/22, at 11:43 AM, CNA 5 stated, [Resident 65] has a splint but not anymore. The splint is missing. Review of Resident 65's TAR for February 2022 indicated under comments, 2/10/22 8AM CNA reported cannot find pt (patient) R (right) hand splint . CN (Charge Nurse) and physical therapy made aware. The comments dated 2/13/22, 2/14/22, 2/17/22, 2/22/22, 2/24/22, 2/26/22, and 2/27/22 (seven days) indicated RUE and RLE splint were missing. The TAR for March 2022, April 2022, and May 2022 indicated, RUE splint . FYI MISSING 2/10/22 OT AWARE. Review of Resident 65's OT progress notes dated 2/10/22 indicated, RUE splint reported missing by nursing. Nursing to look for splint prior to OT replacing. OT progress notes dated 3/1/22, CNA reports RUE/LE splint missing to OT. OT progress notes dated 5/4/22 indicated, LATE ENTRY FOR 3/16/22 Quarterly Assessment . Severe tone RUE/LE with decreased ROM . RUE/LE splint reordered . During an inteview with RS on 5/5/22, at 10:02 AM, RS acknowledged Resident 65's RUE and RLE splints were missing and stated she did not have a back up supply of the splint. Resident 65's care plan was reviewed, LVN 2 was unable to find a care plan addressing the use of splint. LVN 2 stated, The splint should be care planned. There should be an alternative approach for the missing splint. 4B. Resident 127 was admitted on [DATE] with diagnoses that include vegetative state secondary to subarachnoid bleed (bleeding in the space between your brain and the surrounding membrane) from cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain) and chronic extremity contractures. Review of Resident 127's Interim History and Physical, dated 6/12/21 indicated Resident 127 had .no right upper extremity movement . Review of Resident 127's Physician's orders for May 2022 indicated, Date prescribed .5-22-2018 . Resting splint to right hand . with a Wearing Schedule indicating Resident 127 was to wear the splint from 10 AM to 6 PM, and 10 PM to 8 AM. Review of Resident 127's MDS, dated [DATE], indicated Resident 127 had functional limitations on both upper extremities and was totally dependent on nursing staff for all his activities of daily living; the same MDS also indicated that a splint or brace assistance was not applied to Resident 127. During a concurrent observation and interview on 5/4/22 at 2:47 PM with CNA 2, Resident 127 was lying in bed and slightly turned to his right side. Resident 127 had a contracture of the right hand with his wrist bent inwards towards his forearm Resident 127 did not have a splint applied to his right hand. CNA 2 stated, He (Resident 127) does not have a splint, only towel roll (referring to hand roll) on the right hand . CNA 2 proceeded to get a washcloth, rolled it, and applied it on Resident 127's right hand. CNA 2 stated he was not sure which hand needed a splint and was not aware of Resident 127's wearing schedule for the splint. CNA 2 stated, I don't know the order. The splint, nobody told me. The wearing schedule of the splint was not posted in Resident 127's room. During a concurrent observation and interview with RN 6 on 5/5/22 at 11:30 AM, Resident 127 was lying bed with his eyes open he did not have a splint applied to his right hand. During an interview on 5/5/22 at 11:45 AM, the Registered Nurse (RN 6) stated, Nobody reported that it (splint) has been missing. They (nursing staff) said it's been missing a long time, about a month ago. They (nursing staff) can't tell me specifically when. RN 6 stated that the use of splint for Resident 127 is to prevent further flexion and more contractures. During an interview on 5/6/22 at 11:32 AM, the RS stated that the use of splint to Resident 127's right hand was to limit him (Resident 127) from going into further decline and to prevent his fingers from going into his skin. During an interview on 5/6/22 at 11:53 AM, the Director of Nursing (DON) stated that not applying the splint to residents as prescribed could contribute to further contractures. Review of the facility policy and procedure titled, Splinting, revised on 4/17 indicated, Splinting is used to protect joints and surrounding soft tissue. This can be accomplished by maintaining joints at position of rest, preventing positions that contribute to contracture and/or deformity, protecting the system of arches within the hand and increasing or maintaining ROM in the joint . The Occupational Therapist shall assess patient's need for splints with the following considerations: To protect joints and surrounding soft tissue; To increase hand function; To maintain range of motion . The Occupational Therapists shall then evaluate for type of splint required by patient . A splint handout with precautions and wearing schedule will be posted in resident's room . The Occupational Therapists shall train nursing staff/patient/caregivers/family members on donning/doffing the splint, cleaning of the splint, precautions (reddened areas) and wearing schedule . 5. Resident 76 was admitted on [DATE] with diagnoses including stroke, hemiplegia (paralysis of one side of the body) and chronic pain (persistent pain that lasts weeks to years). Review of Resident 76's MDS dated [DATE] indicated, Resident 76 has impairment on one side of UE and both sides of LE. Under section O, Restorative Nursing Program indicated 0 on both AROM and PROM, splint or brace assistance. Review of OT's quarterly assessment dated [DATE] indicated, .R (right) hand contractures [with] limited use of L (left) hand. R feet plantar [check mark symbol] contractures LUE shoulder [check mark symbol] AROM 0-120, RUE PROM 0-90 . During an observation on 5/2/22, at 11:17 AM, Resident 76 was in bed with a rolled towel on the right hand. Resident 76's right hand and fingers were bent and curled inward. Review of Resident 76's physician's order for May 2022 indicated, Range of Motion exercise to right upper extremity daily for flexion of contractures was ordered on 12/3/19. During an interview with CNA 9 on 5/4/22, at 2:53 PM, CNA 9 stated she provide ROM exercises five to eight minutes for both upper and lower extremities to Resident 76 during ADL care. CNA 9 added, Resident 76 has pain on the right arm/hand due to contractures and a rolled towel is applied every day. Review of Resident 76's care plan for pain revised on 3/13/22 indicated, Potential for pain or discomfort r/t (related to) Disease processes, Limited Mobility . Approach . Moving hands and feet a little . Review of the TAR for May 2022 indicated, an FYI (for your information) under the treatment order Range of Motion exercise to right upper extremity daily for flexion of contractures. During interview with LVN 2 and concurrent review Resident 76's care plan on 5/4/22, at 3:05 PM, LVN 2 was unable to find a care plan addressing the application of rolled towel on the right hand and range of motion exercises. LVN 2 acknowledged and stated the care plan should indicate the interventions provided to the resident. Review of the facility's policy and procedure titled, Range of Motion, revised on 8/2020, indicated, Purpose: 1. To maintain and improve muscle strength and tone . 3. To prevent contractures . Procedure/Responsibilities 1. Licensed personnel are to supervise nursing assistants in ROM. 2. Physical Therapy is to be called for initial evaluation, if necessary. ROM is a nursing measure . 4. ROM exercise doe not take the place of position change and support for dependent parts . 7. Do not bring the joint/limb motion to the point of pain . 9. Each joint is moved through its range 3-5 times per treatment . In-Service Education: 1. All nursing staff are instructed in the techniques of active and passive ROM . 2. All resident will receive ROM every 4 hours between the hours of 0900 and 2100 every day. 3. Passive ROM may be ordered as a nursing order . Documentation: CNA Flowsheet. Review of facility's policy and procedure titled, Plan of Care, revised on 9/2019, indicated, . 1. The comprehensive plan of care shall include: a. the frequency at which care, services, treatments, and interventions will occur . d. Current needs, problems, goals, care, treatment and services . 3. The evaluation of the resident's progress is made based upon the care plan goals and the resident's plan of care, treatment and services. 6. Resident 111 was admitted on [DATE] with diagnoses including hemorrhagic stroke (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and quadriplegia (paralysis of both sides of the body). Review of Resident 111's MDS dated [DATE] indicated both sides of upper and lower extremities (UE/LE) were impaired. Under Restorative Nursing Program indicated, 0 on both AROM and PROM, splint or brace assistance. During an observation on 5/4/22, at 3:08 PM, Resident 111's Private Caregiver (PCG) 1 was observed putting on a white rolled towel on resident's right hand. Resident 111's wrist/hand were bent and his fingers were curled inward. During concurrent interview, PCG 1 explained he's putting a hand roll for Resident 111 due to contractures on the hands and fingers. PCG 1 also stated she provide ROM exercises to Resident 111 at night during ADL care. During an interview with Resident 111's PCG 2 on 5/5/22, at 8:55 AM, PCG 2 stated he used to assist Resident 111 with ROM exercises using the Active Passive Trainer (APT, are electric exercise machines used for the improvement of physical abilities and can be operated in either active or passive mode) machine. PCG 2 pointed at the APT machine behind the privacy curtain. PCG 2 stated the APT machine was last used few months ago. PCG 2 also stated, [Resident 111] contractures became harder. The exercise hurts him. PCG 2 explained that they are waiting for the special shoes for Resident 111 prior to resuming use of APT machine. PCG 2 added, the shoes the resident had was hurting him. During an interview with LVN 2 on 5/5/22, at 9:01 AM, LVN 2 stated Resident 111 has a private caregiver doing passive ROM and mostly providing care for the resident. LVN 2 added, I don't know about that machine (referring to the APT machine). The family provided it. I will ask the caregiver. During an interview with RN 6 on 5/5/22, at 9:30 AM, RN 6 stated, [Name of Resident 111] family provided the APT machine. The private caregivers were assisting him (referring to Resident 111) with the exercise. RN 6 also stated the private caregivers reported they stopped using the APT machine due to increased stiffness of the upper and lower extremities. During an interview with RN 6 on 5/5/22, at 9:32 AM, RN 6 stated the rehab provided PROM training to the caregivers and the use of APT machine. During concurrent record review, RN 6 was unable to find training records on the use of APT machine for Resident 111's private caregivers (PCG 1 and PCG2). RN 6 stated, I don't see their names in chart. During concurrent interview and further review of Resident 111's record, on 5/5/22, at 9:34 AM, RN 6 was unable to find an order, assessment, and care plan for the use of APT machine. RN 6 stated, I don't see about the machine over here (referring to the OT progress notes). It's not in the order. It's not in the care plan. It's not mentioned in the OT assessment. During an interview with RS on 5/5/22, at 9:55 AM, RS stated Resident 111 had a decline with ROM on 1/27/22. RS explained Resident 111 has APT machine in the room for home exercise which helps maintain ROM of the resident. RS added, The nursing staff has nothing to do with the home exercise program (referring to APT machine). The caregivers assist him (Resident 111) with it (APT machine). RS further stated, [Name of a caregiver] is using the APT but not PCG 2. RS stated she provides training to the private caregivers on how to perform ROM exercise and the use of APT machine for Resident 111. RS acknowledged the training was not documented in Resident 111's chart. Review of the Active Passive Trainer user's manual revised on 01/2020, indicated, . 3.1 Indications: The Active Passive Trainers are intended to be operated by persons of most physiques and ages. In case the user has limited strength in the arm or cognitive impairment, it is required to have an attendant present during exercise . 3.3 Contraindications . In case of any disease or physical complaints, a healthcare provider should be consulted before participating in any exercise program . In case of recurring discomforts, consult with a health care provider . Review of facility's policy and procedure titled, Education for Patient and Caregiver, revised on 4/2017, indicated, The Therapist and Therapist Assistant will instruct patient, family, and caregiver regarding home exercise programs and safe assistance techniques for functional mobility . The Therapist and Therapist Assistant will complete the following: 1. Provide on-going patient education during treatment sessions regarding safe techniques for home exercise and functional mobility . 3. Provide written instructions with pictures for patient and family when appropriate. The handout will be signed by the therapist/assistant and a contact number will be provided . 5. Document all patient/family education and training in progress notes. include the name and relationship of the family member/caregiver that was instructed. 6. Monitor and document the patient's or caregiver's ability to understand and follow through accurately. Request return demonstration of patient's/caregiver's when appropriate . 7. Resident 66 was admitted on [DATE] with diagnoses that include ischemic stroke (occurs when a vessel supplying blood to the brain is obstructed) with left hemiplegia (paralysis on side of the body). Review of Resident 66's MDS, dated [DATE], indicated Resident 66 had functional limitations on one side of the upper extremities and on both lower extremities and was totally dependent on nursing staff for all his activities of daily living. Review of Resident 66's Physician's orders for May 2022 indicated, 01-16-2018 . Apply hand roll to: Left hand contracture to prevent further limitations .Q (every) shift . During an observation and interview with CNA 2 on 5/4/22 at 11 AM, Resident 66 was in bed, awake, and turned to his left side. Resident 66 had a contracture of the left hand with his fingers bent inwards towards his palm. CNA 2 stated Resident 66 is unable to stretch his left fingers and use his left hand. There was no hand roll applied to the left hand or fingers of Resident 66. CNA 2 stated, He (Resident 66) does not have it. We don't have a hand roll. During a concurrent review of clinical records of Resident 66 and interview on 5/4/22 at 11:16 AM, RN 6 reviewed Resident 66's ADL Functional/Rehabilitation Potential care plan (CP), dated 3/12/22. The CP did not include interventions addres[TRUNCATED]

Based on observation, interview and record review, the facility failed to provide adequate supervision and monitoring for one resident (Resident 1) in a sample size of one resident. The resident was at high risks for falls. This failure resulted in one resident (Resident 1) having four falls within one week. The fourth fall resulted in a left lower leg fracture on 12/1/16. Findings: Record review of Resident 1's Long Term Care Admission Data Base indicated admittance to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident 1 was noted to have generalized weakness, be on medications known to cause orthostatic [MEDICAL CONDITION] (dizziness when transitioning from laying to sitting to standing) and was at high risk for falls. Review of Interdisciplinary Team notes on 11/3/16 at 1600 (2:00pm) indicated the resident was sent to the emergency room due to increased weakness, confusion and decreased appetite. Review of resident care plan indicated no changes were made to care plans upon return from the hospital. Concurrent review of the resident's quarterly Minimum Data Set Report (a care assessment and planning tool) dated 11/22/16 indicated the resident was cognitively intact and required minimal assistance with bed mobility, transfers, walking, locomotion, eating and toileting hygiene. Review of Patient Care Notes indicated the following falls: 1. on 11/26/16 at 1330 (1:30pm) indicated Resident 1 had a fall while using his walker and was found sitting on the floor by the shower room. Resident was only able to stand up with a two person assist. 2. on 11/29/16 at 0500 (5:00am) indicated resident was sitting on his walker and fell to the ground. Notes further indicate this fall left resident with discoloration to left buttock 3. on 11/30/16 at 1330 (1:30pm) indicated the resident had an episode of confusion. At 1335 (1:35pm) the resident was ambulating down the hallway with his walker backwards, attempted to stand up and reposition himself and fell to the floor. This fall was witnessed. Resident hit left buttock area and slightly hit left side of head. Patient denied pain. 4. on 12/1/16 at 0100 (1:00am) indicated resident was found on the floor of the chapel yelling for help. The resident had ambulated from his room to the fireside lounge with his walker and then ambulated to the chapel without his walker. Unwitnessed, the resident was found when the chapel altar structure fell on the resident , and sustained injury on his left leg. He was assessed and sent to the ER. Review of Resident 1's emergency room Discharge Summary on 12/1/16 indicated a fall with leg fracture. Findings noted minimally displaced [MEDICATION NAME] fractures through the proximal tibia and fibula. Review of the patient's Care Plan Potential for Falls and Injury related to Weakness, Depression/Anxiety, [MEDICAL CONDITION] Meds indicated a revision on 11/27/16 to include: extreme risk for fall, frequent monitoring, low bed with alarm and total assist with transfer. There is no record available to indicate frequent monitoring was done until 12/1/16. Review of Post Fall assessment dated [DATE] indicated Resident 1's risk level prior to fall was Extreme and the resident was assessed to have a change in mental status with noted episodes of confusion. During an interview on 4/20/18 at 10:00am, the Director of Nursing (DON) stated the patient was non-compliant with care and difficult to manage. He was constantly wandering despite being put on strict bed rest. He confirmed the patient was originally in room [ROOM NUMBER] in view of the nursing station before being moved to room [ROOM NUMBER] when placed on Hospice. On 12/1/16, the resident ambulated from his room with his walker to the opposite side of the building, past the nursing station to the Fireside Lounge where he left his walker and ambulated without assistance to the chapel, fell and sustained a leg injury. During concurrent observation and review of the facility floor plan, room [ROOM NUMBER] is on the far opposite side of the building from the entrance reception desk and chapel. When asked if there were any documents to indicate frequent monitoring was done according to the interventions in the updated care plan date 11/27/16, the DON stated he could not find any in the record prior to the fall on 12/1/16. Review of the facilities Policy and Procedure for Fall Prevention stated that a resident considered an extreme or high risk for falls should include all appropriate standard/moderate interventions plus all interventions may be deployed to further prevent a fall including but not limited to the following: Move the patient to a room closer to the nurses' station, (and) Use of a sitter. Furthermore, the policy states D. Patients assessed/reassessed as a risk for fall shall have said assessment/reassessment documented in their medical record. The medical record should also reflect documentation of interventions deployed to prevent a fall.

Based on observation, interview, and record review, the facility failed to prevent one of one sampled resident ((Resident 1) from developing avoidable pressure ulcers when: 1. The facility failed to do a comprehensive periodic skin assessment and evaluation of Resident 1 to prevent the development of pressure ulcers. 2. The facility failed to develop and implement a turning schedule for Resident 1 who was a high risk for developing pressure ulcers. The deficient practice resulted in harm to Resident 1, who was admitted without a pressure ulcer and developed a stage II pressure ulcer on the right ear and two stage III pressure ulcers on the sacrum area (a large triangular bone at the base of the spine) within seven days of admission. Findings: Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the Admission Database form dated 11/6/15, indicated Resident 1 was non-verbal, has memory deficit and had bilateral stiffness of joints. He had an indwelling catheter (a tube inserted into the bladder to remove urine). The document also indicated, skin: .pressure ulcer, none noted or reported. Review of a section titled: Braden Scale (a tool predicting pressure sore risk developed to foster early identification of patients at risk for forming pressure sores) showed Resident 1 had a total score of 9 that indicated severe risk related to the following risk factors including Perception: completely limited. Moisture: constantly moist. Activity: bedfast. Mobility: completely immobile. Nutrition: probably inadequate. Other contributing factors: fecal incontinence, poor circulation . Record review of an admission Minimum Data Set MDS, (an assessment tool), dated 11/18/15, indicated Resident 1 was determined to be on a persistent vegetative state with no discernible consciousness, and was totally dependent of staff for activities of daily living such as bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing; always incontinent of bowel. Section M Skin Conditions indicated existence of one Stage II pressure ulcer dated 11/13/15 that was not present upon admission, and under Number of unstageable pressure ulcers with suspected deep tissue injury . it had an entry of 2, and not present during admission. Record review of an undated and unsigned Interdisciplinary Care Review Conference form listed 4 items under Needs/ Problems, all dated 11/9/15. None of the items referenced pressure ulcers risk. Review of the progress notes dated 11/17/15, documented finding a of .sacral deep tissue injury and .right ear stage 2 . Review of Weekly Wound/ Impaired Skin Assessment form dated 11/21/15 described a right sacral pressure ulcer .wound length x width 1.1-2 sq (square) cm (centimeters) , depth 0.3 cm . An entry dated 11/22/15 stated: Left sacral pressure ulcer .wound length x width 1.1-2 cm sq .depth 0.3 cm . Record review of the care plan for Resident 1 indicated a care plan for Impaired skin integrity with an initial date of 11/11/15 and updated on 12/17/15 and 1/8/16. Under Needs/Problems it stated: .Actual deep tissue injury sacral, right ear pressure ulcer, stage II sacral wound. Under Short Term Objective/ Goal: Patients skin will healed (sic) and intact without infection x 14. The care plan did not identify pressure ulcer risk level or individualized interventions addressing prevention, measurable objectives or approximate time frames; and did not identify specific interventions per each revision dates. The care plan did not identify the three pressure ulcer sites Resident 1 developed after admission. During an interview on 12/30/15 9:30 AM, the Director of Nursing (DON) stated that Resident 1 .came in with no pressure ulcers and then developed two pressure ulcers in our subacute unit . (A Subacute Unit generally includes two types of patients - those who are receiving short-term rehabilitation, and those with multiple medical illnesses who are receiving care for a longer period of time). DON acknowledged that a care plan identifying interventions for severe risk factors related to moisture, activity, mobility, friction, incontinence and nutrition for pressure ulcers was not developed and a care plan was opened after pressure ulcers developed 11 days after admission. When asked for records of periodic Braden scale assesments, DON stated: .I could not find any other than the one completed on admission . When asked about records of Resident 1 turning-repositioning schedules and the timeline for a pressure relieving bed, DON stated: There was not any turning schedule prior to event (pressure ulcers developing) . and added: .the special bed (pressure releiving bed) was ordered and in place by the evening of November 15th . Record review of the facility's policy titled Skin Care, Pressure Ulcer and Wound Management stated under Procedure/Responsibilities .1. B. Indicate risk level in the care plan, e.g, mild, moderate, high or very high risk . Under 2. Assess and document stage of wounds, if present .C. Subsequent Assessment and Documentation: 1) Skin assessment shall occur every shift and per unit standard . Under Stage 2 Pressure Ulcer Guideline Prevention and Treatment 2. A. Prevention: Initiating preventative care to patients who are at risk for skin injury include: the elderly .patients with severe illness, chronic illness ., and under 5. Prevention A. Complete risk assessment tool B. Inspect skin q (every) shift- esp (especially) bony promineneces .

Based on interview and record review, the facility failed to ensure that Resident A received proper treatment and care for [MEDICAL CONDITION] care when the Passy-Muir Valve was removed from the [MEDICAL CONDITION] with the cuff still inflated on Resident-A. According to manufacturer's specifications and hospital policy, failure to deflate the [MEDICAL CONDITION] cuff while the Passy-Muir Valve is attached would result in an airway obstruction and consequently the patient would be unable to breathe. On [DATE], Resident-A was found by the staff in her room pulseless, and without respirations while her Passy-Muir Valve was still attached to her non-fenestrated [MEDICAL CONDITION] which still had the cuff inflated. Resident-A died on [DATE] due to [MEDICAL CONDITIONS] secondary to [MEDICAL CONDITION]. Findings: Resident-A was admitted from a long term care facility to the hospital on [DATE] for management and treatment of [REDACTED]. Additional [DIAGNOSES REDACTED]. Subsequently, Resident-A was placed on a ventilator(a machine that supports breathing) on [DATE], and on [DATE], the resident had a [MEDICAL CONDITION] (a surgical procedure to create an opening through the neck into the trachea (windpipe). The resident was eventually weaned off the ventilator but because of profound swallowing dysfunction, the patient required a permanent [MEDICAL CONDITION]. Resident-A did not have difficulties moving her upper extremities on her own but she was unable to walk, and was totally dependent on staff for her ADL's (Activities of Daily Living e.g. bathing, toileting, dressing etc.). Resident-A received all her nutritional support via a PEG tube (a feeding tube through the stomach). Resident-A knew to use the call light for her basic needs but had short term memory deficits and was moderately impaired with decision making She was able to verbally communicate via the Passy-Muir Valve(PMV) which she was able to use daily since [DATE]. The physician order [REDACTED]. The resident was stable at her baseline state until [DATE]. During an interview on [DATE] 9:45 AM, Staff-1 stated she completed Resident-A's evening care which took about 15 minutes, and left her bedside approximately 8:45 PM on [DATE]. Staff-1 stated she was confident that she removed Resident-A's Passy-Muir Valve and reinflated the [MEDICAL CONDITION] cuff after the evening care. Staff-1 stated she stored the PMV in the resident's night stand drawer which was across the foot of Resident A's bed where it was unreachable by the resident. Staff-1 stated Resident-A was alert and was not in distress when she left the resident's room. During an interview on [DATE] at 1:03 PM, Staff-2 who assisted Staff-1 with the Resident-A's evening care on [DATE] stated although she did not witness Staff-1's actions, she remembered Staff-1 verbally informing her that she stored the PMV in the resident's night stand and that she reinflated [MEDICAL CONDITION] before they left Resident-A's room. Record review on [DATE] of the facility's documented staff interviews showed that on [DATE] at 8:52 PM, the resident was found unresponsive in her bed. But the Code Blue was not called to the hospital operator until 9:04 PM. During an interview on [DATE] starting 9:30 AM, Administrator-1 stated the Code Blue was delayed because the resident's code status was unclear. The hospital policy for patients to wear the Do Not Resuscitate(DNR) purple wrist band was not practiced on the unit hence contributing to the delayed resuscitation efforts of Resident-A. During an interview on [DATE] starting 10:17 AM, Staff-3 stated on the evening of [DATE], she was asked by another employee (Staff-4) to check on Resident-A who was "not breathing, pulseless & gray colored". Then, Staff-1 entered the room and asked why the PMV was on the resident. At that moment, Staff-3 noticed [MEDICAL CONDITION] was inflated so she deflated the cuff. Record review on [DATE] of the facility's documented staff interviews showed that Staff-3 stated the following: "She was positive cuff was inflated stated, 'That's my job' ", and, " Asked why she did not start CPR right away since there was no purple DNR band. She stated that on this floor residents rarely have DNR bands on". Additionally, Staff-3 indicated that, "There were 3 PMV containers in her drawer, but only 2 PMV's were found, (she) wondered if resident had one hidden which she could have put in herself". During the interview on [DATE] at 9:45 AM, Staff-1 stated that she noticed the PMV was not properly placed in [MEDICAL CONDITION] the Resident-A was found unresponsive, and the drawer of the night stand where the PMV was stored was open and appeared sloppy which is not how she left it after she was done with the evening care. Staff-1 stated she remembered only seeing two PMV containers after she stored the valve. During an interview on [DATE] at 10:47 AM, Staff-4 went to Resident A-'s roommate on the evening of [DATE]. Staff-4 described Resident-A as pale and he tried to wake her up. Staff-4 stated Resident-A was panting (short of breath). Staff-4 saw Staff-3 and told her to check the patient. During the interview on [DATE] at 9:30 AM, Administrator-1 stated that their internal investigation did not discover who could have placed the Passy-Muir Valve without deflating [MEDICAL CONDITION] on Resident-A. Administrator-1 stated there was no nursing care plan and patient education regarding the Passy-Muir Valve and acknowledged there should have been a care plan. As a result, there was no documentation by the clinicians caring for Resident-A that demonstrated consistent and standardized care was delivered to ensure an otpimum level of care was given toward the care of a patient with a Passy-Muir Valve. The American Nurses Association (2015), a professional organization representing registered nurses and is involved in establishing standards of nursing practice, states, " Based on the assesment and diagnosis, the nurse sets measurable and achievable short and long range goals for the patient..., Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it. Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient's record". Without a specific document delineating the plan of care, important issues may be neglected. During the same interview on [DATE] at 9:30 AM, Administrator-1 stated the policy and procedure for the Passy-Muir Speaking Valve was updated since the incident occured with Resident-A. Record review on [DATE] showed the updated policy revised ,[DATE] included the following new procedures: "B. Removing Passy-Muir Valve: 1. Clear both tracheal and oral secretions by having resident cough or by suctioning, if necessary, 2. Twist valve counterclockwise and remove, 3. Inflate cuff to prevent aspiration, 4. Wash valve, dry and store in Passy-Muir Valve container. Documentation: 1. The speaking valve will be care planned as method of communication, 2. Duration, frequency and tolerance of the Passy-Muir speaking valve when used by the resident will be documented on the resident's treatment sheet and electronic medical record with each appication and removal. Once resident is comfortable with use of Passy-Muir, use of Passy-Muir will be documented on treatment sheet with initials of licensure attending resident during the shift...". During an interview on [DATE] at 10:58 AM, Physician-1 stated that he instructed Resident-A regarding the PMV when she first got it but he wasn't sure if the staff performed education with Resident-A on her PMV. During an interview on [DATE] at 11:40 AM, Staff-5 stated there is no formal check-list for training with patients or family regarding Passy-Muir Valves. During the same interview, when asked if residents get education when they have a PMV, Staff-6 stated, " Usually the speech therapist initially educates the resident". The History and Physical Report by Physician-2 dated [DATE] indicated, "On the evening of ([DATE]), the circumstances surrounding the event are somewhat unclear, however, apparently, the patient had respiratory arrest on the ward secondary to complications of retract [MEDICAL CONDITION] deflation of the cuff. The patient subsequently then developed a [MEDICAL CONDITION] asystole. The patient was resuscitated per ACLS protocol for approximately 25 minutes and subsequently, a sustainable pulsatile and circulating rhythm was returned..., Diagnostic Impression: ... 2. Primary respiratory arrest secondary to BiCAP placement without cuff deflation...". Record review on [DATE] showed Physician-3 dictated the following on [DATE]: " The patient was apparently down for at least 20 to 25 minutes. She received a CPR as per ACLS protocol with her return of spontaneous circulation. She was subsequently transferred to the ICU, where she underwent hypothermic treatment for 24 hours. However, despite return of circulation and hypothermia treatment, she sustained significant hypoxic and brain damage and did not regain her prior cognitive function. After an extensive discussion with the family about her prognosis, decision was made to withdraw care and stop supportive treatment on the 20th. Subsequently, she was taken off the ventilator. All diagnostic lab draws and IV medications were stopped. She was put on [MEDICATION NAME] drip for pain and dyspnea...". Resident-A was transferred back to the original unit she came from. Record review on [DATE] showed Physician-1 dictated in his discharge summary dated [DATE] the following: "Diagnosis: [REDACTED]. She was transferred (back to the unit she came from) for ongoing management. The family did not want any blood tests or any aggressive interventions performed. The patient was maintained comfortably. She expired on the afternoon of [DATE]. The cause of death is [MEDICAL CONDITIONS] secondary to [MEDICAL CONDITION]". During the interview on [DATE] at 10:58 AM, Physician-1 stated the coroner declined the case on [DATE] regarding Resident-A's death so an investigation as to the manner or cause of death or autopsy was not performed. The facility's policy and procedure titled, "Passy-Muir Speaking Valve", date revised ,[DATE], indicated the following: " ...Scope: Respiratory Care Practitioners, registered nurses and licenses vocational nurses..., Hazard/Complications/Precautions, 1. Do not use with inflated cuff...". On an interview on [DATE] at 9:45 AM, Administrator-1 stated the registered nurses, licensed vocational nurses and clinical nursing assistants were retrained about the facility policy and procedures regarding the Passy-Muir Valve. On an interview on [DATE] at 11:40 AM, Staff-7 stated the licensed practitioners on the unit Resident-A resided are required to do a one time, four hour respiratory orientation with a respiratory therapist that includes a checklist titled, "Passy-Muir [MEDICAL CONDITION] & Ventilator Speaking Valve Competency Checklist". This checklist has the clinician return demonstrate skills on how to "deflate cuff on [MEDICAL CONDITION] slowly & completely...". An [MEDICAL CONDITION] used together with the PMV would cause an airway obstruction and the patient would be unable to breathe. The Director of Staff Development provided documentation that every licensed staff on the unit successfully passed and completed this orientation and competency spanning from [DATE] to [DATE]. According to the Passy-Muir Valve manufacturer's product description titled, "Passy-Muir [MEDICAL CONDITION] and Ventilator Speaking Valve Resource Guide" developed by Passy-Muir Inc. [DATE]: "Contraindications for Use of the Passy-Muir Speaking Valve, A. Inflated [MEDICAL CONDITION] Cuff: Controlling ventilation and gross aspiration are the two main issues that influence the decision to utilize a cuffed [MEDICAL CONDITION]. If, for either of these reasons, the cuff cannot be deflated, then the PMV cannot be used as the cuff would cause an obstruction to exhaled air flow and the patient would be unable to exhale/breath..., If the patient has a cuffed [MEDICAL CONDITION], it is imperative that the cuff be fully deflated prior to PMV placement...". Record review showed the last [MEDICAL CONDITION] change on Resident-A was on [DATE] at 5:04 PM. The tube was a [MEDICATION NAME] 8.0mm cuffed trach. Administrator-1 stated on a fax report dated [DATE] at 4:22 PM, [MEDICATION NAME] tubes are not fenestrated. With the PMV attached to [MEDICAL CONDITION] a fully inflated cuff, Resident-A would have been unable to breathe. The hospital failed to follow their policy and procedure, and the manufacturer's recommendations for a Passy-Muir Valve that was left on a non-[MEDICAL CONDITION] an inflated cuff on Resident-A.

Based on observation, interview and record review, the facility failed to ensure that one sampled resident (Resident 1) was free from abuse, when, a Certified Nurse Assistant (CNA 1) touched Resident 1's breasts in an inappropriate manner on 11/19/13. This failed practice resulted in Resident 1's feeling very upset, insulted and angry. Findings: During review of the History and Physical Form dated 6/12/12, it indicated that Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) dated 10/23/13, indicated that Resident 1 was able to hear with no difficulty, had a clear speech, able to make herself understood and usually understood others. A review of the facility document titled: "Progress Notes" of the Social Service Aide (SSA) dated 11/22/13, "Subject: Suspected abuse - late entry, indicated, Reported by nursing that (name of staff), CNA (Certified Nurse Assistant), was observed putting her hands on resident's breasts (Resident 1's) in an inappropriate manner. The incident occurred on 11/19/13 at approximately 12:00 pm in the Fireside Room during lunch, and witnessed by (name of staff), LVN (Licensed Vocational Nurse) and name of staff (name of CNA). ... ." In an interview with the Nurse Manager (NM) on 12/3/13 at 9:50 a.m., NM was asked what "inappropriate manner" meant, NM stated, "anybody touching area not to be touched. Anybody who approach, (a resident), other than giving care, I have a problem". Continued interview with the NM on 12/3/13 at 10:02 a.m., NM stated that, the incident happened in the TV (Television) Room, there was a camera, it was clear, that CNA 1's action was "more than a friendly behavior". When asked what happened, NM explained that CNA 1 walked in the room towards Resident 1 who was sitting in a wheelchair, CNA 1"reached down" to Resident 1. Resident 1 slapped her (CNA1) away. CNA 1 "laughed", Resident 1 kicked (CNA1) out. CNA 1 started "laughing". When asked if there were other residents in the TV Room at that time, NM stated, about four or five other residents and a total of four other facility staff "who stood by and did not do anything". NM stated that the CNA 1 was terminated following an administrative leave and the other facility staff received disciplinary action. During an interview with the Nurse Manager on 12/3/13 at 10:03 a.m., NM stated, Resident 1 was "very upset, did not eat lunch and did not take her medications after the incident", but, was "fine" now and "later that evening". In an interview with the Minimum Data Set (MDS 1) Coordinator on 12/3/13 at 11:45 a.m., MDS 1 Coordinator stated, Resident 1's primary language was non-English and she responded better with an Interpreter. During an observation and concurrent interview, in the presence of the Interpreter, on 12/3/13 at 11:59 p.m., Resident 1 was awake, sitting on a wheelchair. The Interpreter was asked to inquire if Resident 1 recalled the incident that happened to her on 11/19/13. The Interpreter stated Resident 1 said, "I do remember when the young girl touched my breast". The Interpreter was again asked to inquire how Resident 1 felt when her breast was touched. The Interpreter talked to Resident 1 who stated that, CNA 1 "insulted her (Resident 1)", Resident 1 "felt anger". Review of the document titled: "Patient Care Notes" dated 11/19/13 at 1:00 p.m., it indicated, "TL (Team Leader) notified CN (Charge Nurse) that resident was upset because CNA (initial of the CNA) touch pt breast. I ask TL if she really witness CNA (CNA 1) touch the breast & (and) she said yes & a few other staff that was @ (at) the TV room. I told TL to report it & I will report to Nurse Mgr.(Manager). Reported to Nurse Mgr.(Manager) & she talk to the TL. Pt (patient) (checked mark sign) appears ok". signed by the facility staff. In a phone interview on 8/27/14 at 12:38 p.m., RN 1 was asked to read the Patient Care Notes dated 11/19/13 at 1:00 p.m. RN 1 stated she was the Charge Nurse (CN) on 11/19/13 and was the staff who wrote the note, and signed the note. During a phone interview with Licensed Vocational Nurse 1 (LVN 1) on 8/27/14 at 12:40 p.m., LVN 1 acknowledged she was the Team Leader (TL) who was present during the incident on 11/19/13 at 12:00 p.m. When asked what happened, TL 1 stated, "CNA 1 came hyper, prying, very out- going at that moment". CNA 1 touched Resident 1's two breasts with her (CNA 1) hand back and forth. CNA 1 stopped for a while, came back and touched Resident 1 again." In a phone interview with Certified Nurse Assistant (CNA) 2 on 8/27/14 at 1:30 p.m., CNA 2 acknowledged he was present in the TV Room during the incident on 11/19/13 at 12:00 p.m. CNA 2 stated that CNA 1 was "holding, tickling" Resident 1's breasts. CNA 2 stated that Resident 1 was upset. Review of the facility Policy and Procedure, Abuse, Elder and Dependent Adult, Issue date: 12/93, Revision date: ... 8/13. POLICY: Any Alleged instances of ... or abuse, ... are reported immediately to the Director of Nursing. The Director/designee will notify the ... California Department of Public Health (CDPH) by telephone within 24 hours of the incident. ... The following types of abuse are considered reportable: 5. SEXUAL: Includes ... fondling of breasts ... PROCEDURE: 5. INVESTIGATION, C. If the incident was witnessed, take measures to protect the resident immediately. Remove the resident from the area to a safe place or instruct the individual in question to leave the room or the area. ... ".

Based on interview and record review the facility failed to ensure one patient who had a [MEDICAL CONDITION] (Resident A) received proper respiratory care when: 1. There was no documented evidence of Resident A's oxygen saturation (SaO2) levels on ,[DATE], ,[DATE], and [DATE] to ensure it was maintained at or greater than 93 %. 2. The facility failed to maintain the resident's airway patent when a staff (LVN 1) did not remove the cap from the expiratory port of a T-piece which is a part of a medical device known as the KimVent Turbo-Cleaning Closed Suction System attached to Resident A's [MEDICAL CONDITION]. The deficient practice caused the death of Resident A on [DATE] due to asphyxiation as a result of obstruction of the [MEDICAL CONDITION]. Findings: Resident A, an [AGE] year old female was admitted to the facility on [DATE] for ongoing management of chronic [MEDICAL CONDITION] with a [MEDICAL CONDITION] ( surgical breathing hole in neck). Record review of Resident A's History and Physical Report dated [DATE] indicated she had a history of [REDACTED]. Resident A was not responsive to verbal stimuli and was in a persistent vegetative state (wakeful unconscious state that lasts longer than a few weeks). Resident A's eyes would open but she was not alert or oriented and was unable to communicate or follow commands. The patient was breathing spontaneously via a [MEDICAL CONDITION]. She required a [MEDICAL CONDITION] (a breathing tube surgically inserted into the neck) for protection of her airway. She was totally dependent on staff for her activities of daily living. According to the annual Minimum Data Set ((MDS) dated [DATE], and the latest quarterly MDS dated [DATE], under Special Treatments, Procedures and Programs, the following Respiratory Treatments were performed on the patient: oxygen therapy, suctioning and [MEDICAL CONDITION] care. Record review of a Nursing Care Plan, dated [DATE] and updated on [DATE], indicated: "Problems...Impaired airway clearance related to [MEDICAL CONDITION] and [MEDICAL CONDITION], Goal: Resident's airway will remain patent X 90 days- as evidenced by a SaO2 above 93%" (oxygen saturation-a measurement that indicates adequate oxygen is being taken into the body for life, measured by a bedside device). According to the Nursing Care Plan updated on [DATE], it indicated under Needs/ Problems section that Patient A had potential problem for aspiration secondary to presence of [MEDICAL CONDITION] and tube feeding. The Action Plan was to: Auscultate lungs q (every) shift and prn (whenever necessary), Report changes in lung sounds to MD, ..." Record review of Treatments Sheet for [DATE]- [DATE] indicated a treatment order dated [DATE] to "suction q (every) 2 H (hours) and prn. It also indicated an order to "Keep SaO2 at 93% or greater at all times." and "Trach. care Q (every) shift and prn (when necessary)..." Record review of Resident A's Long Term Clinical Care Flowsheet for [DATE], [DATE], [DATE], and [DATE] indicated that the box for recording the SaO2 was left blank. There was no documented evidence that nursing staff had checked Patient A's SaO2. In an interview, on [DATE] at 11 A.M., the Risk Manager 1 (RM 1) and the Chief of Respiratory Therapy acknowledged that the nursing staff did not routinely measure Patient A's SaO2 on [DATE], [DATE], and [DATE] before this reported incident. Record review of a physician progress notes [REDACTED]. Objective: Vital Signs...blood pressure ,[DATE]...Chest: No wheezing... Assessment: [MEDICAL CONDITIONS], gastrotomy, no ventilator dependency..." Record review of Progress Notes dated [DATE] at 3:23 P.M., indicated: "RN 1 called to inform that patient was found pale, non-responsive, Vital Signs (blood pressure and pulse) could not be appreciated, no spontaneous breathing. Rapid Response team called , but canceled due to patient's DNR (do not resuscitate)." Record review of a physician progress notes [REDACTED].M., indicated: "Called by nursing staff to pronounce patient who they say died at 3:15 P.M.. Patient is in fact dead with dilated pupils no respiratory effort and is pulseless. A T-piece is attached to a [MEDICAL CONDITION]. The expirator port is occluded with a plastic cover." In an interview, on [DATE] at 11 A.M. the facility's RM 1 provided a summary of the reported adverse event as follows: "On [DATE] at 3:15 P.M. LVN 1 (Licensed Vocational Nurse) went into Patient A's room to change the T-piece suction set up attached to the [MEDICAL CONDITION]. The T-piece is a closed device that is attached to the [MEDICAL CONDITION] for suctioning (method of removing secretions that accumulate in the lungs and wind pipe). Patient A was not on a ventilator (breathing machine) but was breathing humidified air and oxygen through this T-piece on her own. When the T-piece comes in the package for changing it comes with a cap on the expiration port. The cap must be removed prior to use when the patient is breathing on her own. Essentially, LVN 1 did everything right except she left the cap on. She said she took the cap off. When another nurse (LVN 2) came in to check on Patient A , she saw the cap was on the T-piece expiration port and the patient was not breathing on her own. LVN 2 immediately removed the cap and began bagging ( device used to provide rescue breathing ) the patient. Patient A never started breathing on her own again...since she was DNR, she was pronounced dead." In an interview on [DATE] at 11:30 A.M., Respiratory Therapist 1 (RT 1) (a respiratory therapist helps evaluate, treat and assist the health care team with patients with respiratory disease) who assisted LVN 2 in the above described incident was asked if Patient A was a spontaneously breathing patient. RT-1 said, "Patient A was not on a ventilator. She was breathing on her own. The white cap should have been off of the T-Piece. There should have been a little plastic tube connected to the T-piece so the patient could exhale." In an interview on [DATE] at 12:27 P.M., LVN 1 was asked about changing the T-piece on Patient A. LVN 1 said, "I remember coming in to Patient A's room with LVN 3 at about ten minutes to three to change the T-piece. The T-piece was used to suction the patient through [MEDICAL CONDITION], we change it every three days. Since this patient was on oxygen and breathing on her own we took the white cap off. I remember changing the T-piece. Everything was all right with the patient when I left the room." LVN 1 was then asked if she remembered who took the white cap off of the T-piece expiration port. LVN 1 said, "Honestly, I can't remember." In an interview on [DATE] at 1:15 P.M., LVN 2 who discovered Patient A was not breathing on 6/ ,[DATE], was asked to describe what happened. LVN 2 said," It was a Friday at about five minutes to 3 P.M., I was going on my rounds and checking on Patient A in her room. Looking at her I did not think she was breathing. I shook her and I saw right away that the T-piece had a cap on it and she was not breathing so I called for help, took the T-piece completely off and started bagging her." The surveyor asked LVN 2: "When you took the T-piece off the [MEDICAL CONDITION] of Resident A, was the white cap on or off ?" LVN 2 said, "That cap was on, it should have been off." LVN 2 was asked what would happen to the patient if the cap was left on. LVN 2 explained, "If the white cap was left on, the patient cannot exhale and breathe on her own." Review of Resident A's San Mateo County Coroner's Office combined Autopsy Report and Pathology Report dated [DATE], indicated: "Conclusion: The cause of death listed was asphyxiation due to obstruction of [MEDICAL CONDITION]. Patient A was in a persistent vegetative state after suffering a [MEDICAL CONDITION] in 2009...Patient A was a patient at the hospital...On Friday, [DATE] at approximately 1500 hours (3 P.M.), the subject's [MEDICAL CONDITION] was replaced, but the cap was not properly removed preventing oxygen to the subject. Based on information obtained in the Coroner's Investigation Report and Autopsy Report, I have determined that the manner of death to be an accident." Review of the manufacturer's directions for use of the Kimberly-Clark KimVent Turbo-Cleaning Closed Suction System dated 2007, indicated: "Warning: Cap on KimVent T-Piece prevents continuous flow therapy (oxygen is administered through a tube to a breathing patient with a [MEDICAL CONDITION]). Remove cap before starting continuous flow therapy. Failure to remove cap prior to continuous flow therapy may result in serious injury or death." Review of the LVN 1's competency Action Plan, dated [DATE], indicated : "In-line Suction Catheter/White Cap Set-up... Ensure all licensed Respiratory Care Practitioners and licensed Nursing personnel on the Subacute Unit clearly understand the two different set -ups, for the in-line suction catheter when used with a ventilator and when used on a spontaneously breathing patient i.e.,without a ventilator. Additionally, ensure the aforementioned staff understands why the white cap is not to be placed on the in-line suction catheter when the patient is not on the the ventilator." In an interview, on [DATE] at 11:30 AM, the Chief Respiratory Therapist was asked if there was a facility policy and procedure that described the training and the operation of the Kim Vent T-piece device. The Chief Respiratory Therapist said, " No, I checked with Nursing. The only policy is the Action Plan competency check list that Respiratory Care uses to train the nurses who use the KimVent." In a phone interview, on [DATE], the Kimberly Clark manufacturer's clinical care representative was asked to explain why the white cap needed to be removed from the T-piece part of the Kimberly-Clark KimVent Turbo-Cleaning Closed Suction System when it was used on a spontaneously breathing patient. The clinical care representative said, "When the patient is breathing on her own through the T-piece, if the white cap is not off the patient cannot exhale. It is like suffocating the patient." In a phone interview, on [DATE] at 2:44 P.M., LVN 3 was asked what she remembered about changing Patient A's T-Piece on [DATE]. LVN 3 said, "LVN 1 asked me to help her change the tubing. LVN 1 handled the T-Piece. I was in the back of the bed changing the oxygen tubing and water bottle. LVN 1 was in front of Patient A. I handed her the tubing and she connected to the T-Piece. Then she connected it to Patient A. I then left the room. LVN 3 was then asked if she had removed the white cap from the T-Piece. LVN 3 said, "No." LVN 3 was then asked if LVN 1 had removed the white cap from the T-Piece. LVN 3 said,"I don't remember. Patient A was breathing on her own when I left the room." The facility failed to ensure that Patient A who had a [MEDICAL CONDITION], received proper respiratory care when: 1. There was no documented evidence of Patient A's oxygen saturation (SaO2) levels on ,[DATE], ,[DATE], and [DATE] to ensure it was maintained at or greater than 93%. 2. The facility failed to maintain the resident's airway patent when a staff (LVN 1) did not remove the cap from the expiratory port of a T-piece which is one part of a medical device known as the KimVent Turbo-Cleaning Closed Suction System attached to Patient A's [MEDICAL CONDITION]. The deficient practice caused the death of Patient A on [DATE] due to asphyxiation as a result of obstruction of the [MEDICAL CONDITION]. The facility's failure presented an imminent danger to the patient and was a direct proximate cause of death of the patient.