Every finding on record at Alcott Rehabilitation Hospital

Based on interview and record review, the facility failed to maintain the rights exercised by the resident's representative (RP) for one of three sampled residents (Resident 1). For Resident 1, the facility failed to obtain consent from Resident 1's responsible party (RP) before cutting Resident 1's hair on 12/9/25.This deficient practice resulted in a violation of Resident 1's RP's right to make decisions on behalf of Resident 1.During a review of Resident 1's admission Record, indicated the facility admitted Resident 1 on 11/21/25 with diagnoses including dementia (a progressive state of decline in mental abilities) fracture of right femur (break in thigh bone), lack of coordination, and dysphagia (difficulty swallowing).During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/26/25 indicated Resident 1 had severely impaired cognitive skills for daily decision making. Resident 1 was dependent on staff for toileting hygiene, shower/bathe, lower body dressing and putting on/taking off footwear. Resident 1 needed substantial assistance (helper does more than half the effort) with eating, oral hygiene, upper body dressing and personal hygiene. During a review of Resident 1's History and Physical (H&P, a description of the resident's condition and course of care) dated 11/26/25 indicated Resident 1 does not have the capacity to understand and make decisions. During a telephone interview on 12/15/25 at 1:51 p.m., Resident 1's RP stated the facility gave Resident 1 a haircut on 12/9/25. Resident 1's RP stated she did not give consent for Resident 1 to have a haircut. During an interview on 12/23/25 at 8:42 a.m., the Activities Director (AD) stated the facility's hairdresser gave Resident 1 a haircut on 12/9/25. AD stated a consent was not obtained from Resident 1's RP before cutting Resident 1's hair on 12/9/25. AD stated, It was a mistake, sorry about that. AD stated facility needs to get consent from Resident 1's RP before cutting Resident 1's hair. During an interview on 12/23/25 at 11:33 a.m., the Social Services Designee (SSD) stated Resident 1's RP did not give consent before Resident 1 was given a haircut on 12/9/25. During a review of the facility's policy and procedure (P&P) titled, Resident's Rights, revised on 5/2/25 indicated the resident representative has the right to exercise the resident's right to the extent those rights are delegated to the resident representative. The same Policy indicated the resident had the right to be informed in advance of the care to be furnished and the type of care giver or professional that will furnish the care.

Based on observation, interview and record review, the facility failed to ensure residents who were dependent on staff for showers and feedings were provided those services for two of three sampled residents (Resident 1 and Resident 2).1.For Resident 1, who had a shower scheduled every Monday and Thursday, the facility failed to give Resident 1 shower on 11/24/25 (Monday), 11/27/25 (Thursday) and 12/1/25 (Monday). The facility also failed to notify Resident 1's responsible party (RP) when Resident 1 did not receive the showers on Resident 1's scheduled shower days. 2.For Resident 2, the facility failed to assist Resident 2 timely during breakfast on 12/23/25. Resident 2's breakfast tray was observed at the bedside table at 7:25 a.m. Resident 2 was not fed until 8:02 a.m.These deficient practices had the potential for Resident 1 to develop including unpleasant odor, skin condition and for Resident 2's food to become cold and lose its palatability.1.During a review of Resident 1's admission Record, indicated the facility admitted Resident 1 on 11/21/25 with diagnoses including dementia (a progressive state of decline in mental abilities) fracture of right femur (break in thigh bone), lack of coordination, and dysphagia (difficulty swallowing).During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/26/25 indicated Resident 1 had severely impaired cognitive skills for daily decision making. Resident 1 was dependent on staff for toileting hygiene, shower/bathe, lower body dressing and putting on/taking off footwear. Resident 1 needed substantial assistance (helper does more than half the effort) with eating, oral hygiene, upper body dressing and personal hygiene. During a review of Resident 1's Care Plan revised on 11/26/25, indicated Resident 1 had self-care deficit related to, including dementia and fracture of the right femur. The care plan goal indicated Resident 1 will be groomed and dressed daily and the Activities of Daily Living (ADL, activities such as bathing, dressing and toileting a person performs daily) needs will be met daily for three months. The care plan intervention included shower, shampoo and nail care two times a week as scheduled and as needed.During a concurrent interview and record review with Assistant Director of Nursing (ADON) on 12/23/25 at 9:56 a.m., Resident 1's Task: ADL-Bathing dated 11/24/25 to 12/23/25 was reviewed with the ADON. ADON stated Resident 1's shower schedule was on Monday and Thursday. ADON stated Resident 1 was not given shower on 11/24/25 (Monday), 11/27/25 (Thursday) and 12/2/25 (Monday). Resident 1 was given a shower on 12/4/2025. ADON stated she was unable to find documentation why Resident 1 was not given shower on Resident 1's scheduled shower days. During an interview on 12/23/25 at 10:48 a.m., Certified Nurse Assistant (CNA 1) stated Resident 1 was not given a shower because Resident 1 . fights. CNA1 stated she informed the Registered Nurse Supervisor (RNS) and the RNS told CNA 1 not to give Resident 1 a shower for safety reasons. CNA 1 stated a bed bath was given to Resident 1 instead. During an interview on 12/23/25 at 11:33 a.m., the Social Services Designee (SSD) stated Resident 1 was not given a bath because Resident 1 was . resistive. SSD stated Resident 1's RP should be notified when Resident 1 refused the shower.During a concurrent interview and record review on 12/23/25 at 11:41 a.m., with the Director of Staff Development (DSD) Resident 1's Nurse Progress Notes were reviewed. The DSD stated when Resident 1 was not given the shower, Resident 1's RP should have been notified. DSD stated she was unable to find documentation that Resident 1's RP was notified. DSD further added if Resident 1 was not given a shower Resident 1 would feel dirty. 2. During a review of the admission Record indicated the facility admitted Resident 2 on 11/10/25 with diagnoses including dementia, dysphagia and muscle weakness.During a review of the MDS dated [DATE], indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent on staff for oral hygiene, toileting hygiene, shower/bathe, upper/lower body dressing, putting on/taking off footwear and personal hygiene. Resident 2 needed substantial assistance with eating. During observation on 12/23/25 at 7:25 a.m. Resident 2's breakfast tray was observed on top of Resident 2's bedside table located at the foot of her bed.During an interview on 12/23/25 at 7:48 a.m., CNA 2 stated she has three residents to feed including Resident 2. CNA 2 stated she has two other residents to feed before Resident 2's turn. During an interview on 12/23/25 at 8:02 a.m., the restorative nursing assistant (RNA) stated breakfast trays were delivered from the kitchen at around 7 a.m., and the trays are passed to the residents as soon as the trays arrived. RNA stated Resident 2 was a feeder (physical assistance with feeding). RNA stated Resident 2 should be fed as soon as the breakfast tray was taken to Resident 2. RNA stated if the tray is left too long on the bedside table, the food can get cold.During observation, CNA 2 was observed feeding Resident 2. During an interview on 12/23/25 at 8:11 a.m., CNA 3 stated three residents to feed during mealtimes would be too much. CNA 3 stated the three residents had to wait a bit longer to be fed. During an interview on 12/23/25 at 9:56 a.m., the ADON stated Resident 2 was a feeder. ADON stated if the food is left on the table too long, the food can get cold.During a review of the facility's policy and procedure (P&P) titled, Resident Showers, revised on 5/2/25 indicated, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. The same Policy indicated residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. During a review of the facility P&P titled Documentation in Medical Record revised on 5/2/25 indicated each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. During a review of the facility's P&P titled Resident Rights revised on 5/2/25 indicated the resident has a right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living.

Based on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to:1. Ensure staff labeled laundry bins indicating if they were for clean or dirty items in the facility's laundry room.2. Discard and remove from the facility's storage room expired N95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) masks and expired Covid-19 (a respiratory illness that can spread from person to person) testing kits. These failures had the potential to place residents at increased risk of infection and cross-contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).Findings:During a concurrent observation and interview on [DATE] at 9:55AM, with the Maintenance Worker (MW) in the laundry room, light gray fabrics were observed in a yellow unlabeled laundry bin next to the. A gray bin was observed next to the washing machine labeled laundry, the bin did not specify clean or dirty. Yellow shiny reusable washable gowns were observed in plastic drawers, not labeled clean or dirty. The MW stated the yellow bin with light gray fabrics next to the dryer was for clean clothes, and the grey bin was for dirty clothes next to the washing machine. The MW stated the laundry bins should have been labeled clean or dirty, and if not labeled, no one would be able to identify if they were clean or not. The MW stated the yellow gowns were personal protective equipment (PPE - garments designed to protect the wearer from injury or infection) isolation (keeping a person who is sick with a contagious disease away from people who are healthy) gowns and should have been labeled clean or dirty. The MW stated if items were not labeled correctly, it could cause cross-contamination. During a concurrent observation and interview on [DATE] at 10:40 AM, with Central Supply Personnel (CSP) in the facility's basement medical supply storage, 1 box of N95 masks were observed with an expiration date of [DATE] and 68 boxes of N95 masks with an expiration date of [DATE] were observed. The CSP stated it was everyone's responsibility to check expiration dates. The CSP stated the elastic band on the N95 mask could break and the seal would not be tight. The CSP stated residents could get sick if expired masks were used. During an interview on [DATE] at 10:58 AM, Registered Nurse (RN) 2 stated if expired N95 masks were used the masks could rip and that could cause a break in infection control (stopping germs from spreading by interrupting their [chain of infection]). During an observation on [DATE] at 11:05 AM, in the facility's hallway storage closet a total 90 boxes of N95 masks with expiration date of [DATE] were observed. During an observation on [DATE] at11:55 AM in the facility's storage closet between resident's room [ROOM NUMBER] and 3, 18 expired COVID-19 antigen test kits were observed in an opened box with expiration date of [DATE], and two closed boxes of COVID-19 antigen test kits with the expiration date of [DATE] were observed. During an interview on [DATE] at 12:28PM, the Infection Preventionist Nurse (IPN) stated using expired N95 masks would not have provided any protection against infection. During an interview on[DATE] at 1:48 PM, the IPN stated using expired covid tests could have given an inaccurate reading, and all staff should have checked for expiration dates. The IPN stated expired COVID-19 antigen tests kits could result in a false positive. During an interview on [DATE] at 2:33 PM, the Director of Nursing (DON) stated expired covid tests could have given false positive readings. The DON stated using expired N95 masks had the potential for residents to get sick, and the masks would not have functioned to prevent any respiratory illness (infections of parts of the body involved in breathing, such as the sinuses, throat, airways or lungs). During an interview on [DATE] at 3:06 PM, with the Director of Nursing (DON), the DON stated all laundry bins had to be labeled clean or dirty to identify the difference, so that everybody would know. The DON stated laundry bins could cause cross contamination if not labeled properly. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program dated [DATE], the P&P indicated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary. and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The P&P indicated, .supplies are routinely checked for expiration dates and are replaced as necessary. The P&P indicated, Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection.

Based on observation, interview, and record review, the facility failed to respect the residents' rights to dignity and respect for one of one sampled residents (Resident 110). By failing to utilize privacy curtains or closing the door while the resident was undressed from the waist down. This deficient practice left Resident 110 exposed to facility staff, residents, and visitors, leaving Resident 110 vulnerable to exploitation, humiliation, and safety concerns.Findings: During a review of Resident 110's admission Record, the admission Record indicated the facility admitted the resident on 6/2/2025 and readmitted the resident on 8/2/2025 with diagnoses including other sequelae(after effects) of cerebral infarction (a stroke caused by a blocked blood vessel in the brain), immunodeficiency(the decreased ability of the body to fight infections and other diseases) due to conditions classified elsewhere, dysphagia(difficulty swallowing) following cerebral infarction, anxiety disorder( excessive worry, fear, and nervousness) unspecified, vascular dementia (a progressive state of decline in mental abilities caused by reduced blood flow to the brain), unspecified severity(degree of illness) without behavioral disturbance(acting in ways that are disruptive), contracture (a stiffening/shortening at any joint, that reduces joint's range of motion) right knee, contracture left knee, and lack of coordination(uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movement). During a review of Resident 's 110 History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 6/14/2025, the H&P indicated Resident 110 had fluctuating (varying irregularly) capacity (ability) to understand and make decisions. During a review of Resident 110's Minimum Data Set (MDS- a resident assessment tool), dated 9/9/2025, the MDS indicated Resident 110 had severe cognitive(ability to think, understand, learn, and remember) impairment and required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs and provides less than half the effort) from facility staff for rolling left and right, sit to lying to sitting on side of bed, chair/bed to chair transfer, toileting hygiene, bathing, lower body dressing, putting on/taking off footwear. During an observation on 12/3/2025 at 12:49PM in the facility's hallway outside of Resident 110's room, the room door was observed wide open with an open privacy curtain. Resident 110 was observed unclothed and exposed from the waist down. Resident 110's pants were observed down by her ankles while lying down on her back in her bed. Resident 110's stomach, pelvis (bony structure at the base of the spine connecting the torso to the legs), pubic (above sexual organs) area, and legs were exposed, and visible from the facility hallway outside of Resident 110's room. During a concurrent observation and interview on 12/3/2025 at 12:52 PM in Resident 110's room with Licensed Vocational Nurse (LVN) 2, LVN 2 confirmed Resident 110 was on her back in the bed unclothed, exposed from the waist down, with her pants around her ankles. The privacy curtain and room door were open, and Resident 110 was visible from the facility hallway. LVN 2 pulled Resident 110's privacy curtain closed and stated facility staff needed to provide privacy and protect Resident 110 since she was confused and not aware that she was exposed. LVN2 stated leaving the resident exposed would be undignified (behaviors or actions lacking respect and are beneath a person's usual standards). LVN 2 stated other residents passing by could have seen Resident 110 and may not have understood why the resident was exposed. LVN 2 stated Resident 110 would have probably felt embarrassed. During an interview on 12/3/2025 at 3:40PM with Registered Nurse (RN) 2 stated facility staff needed to have provided care to help residents maintain their privacy and dignity when they were not able to or if they were confused. RN 2 stated if a resident was exposed and visible to others, the resident would have probably feel embarrassed. During an interview on 12/4/2025 at 2:33 PM with the Director of Nursing (DON), the DON stated it was not appropriate for facility staff to have left a resident exposed, visible to others. The DON stated residents had to be provided with dignity and privacy, especially if they were confused. During a review of the facility's policy and procedure (P&P) titled, Promoting/Maintaining Resident Dignity, dated 5/2/2025, the P&P indicated It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life . The P&P indicated, All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The P&P indicated, Maintain resident privacy. The P&P indicated, Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source.

Based on interview and record review, the facility failed to ensure resident's medical records were updated to show documentation that advance directives (a legal document indicating resident preference on End-of-life treatment decisions) were discussed and written information were provided to the residents and/or responsible parties for one (1) of 1 sampled residents (Resident 84).This deficient practice had the potential to result in resident's healthcare wishes not being known or followed, placing the resident at risk of receiving unwanted or inappropriate treatment. Findings:During a review of Resident 84's admission Records, the admission Records indicated Resident 84 was admitted on [DATE] to the facility with a diagnosis of aftercare following joint replacement; presence of right artificial knee joint; type 2 diabetes mellitus without complications (a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 84's History and Physical (H&P) dated 11/21/25, the H&P indicated patient has the capacity to understand and make decisions.During a concurrent interview and record review for Resident 84 on 12/02/25 at 11:41 am with Admissions (AD), stated that the Advance Directive Acknowledgement Form was not completed for Resident 84. AD hasn't reviewed the Advance Directive Acknowledgement Form with resident/family because resident was recently admitted . AD stated he still has to perform and ask resident/family regarding Advance Directives. AD also mentioned that he normally reviews the advance directive acknowledgment form with the resident and/or family when the resident is first admitted , if they do not have an advance directive and they would like more information regarding an advance directive then he would let social services know. During an interview with Resident 84 on 12/04/2025 at 9:23 am, used phone translator number 402497, Resident 84 stated she does not know anything about paperwork because her daughter signed and took care of papers when she was admitted to facility. During an interview on 12/04/25 at 11:15 am with Director of Nursing (DON), he stated that the advance directive is done prior to admission or on admission. He also mentioned that it's important to have an advance directive to assist the resident with their wishes and if they have an assigned designee to make decisions.During a review of the facility's policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directives, dated 5/02/25, the P&P indicated, on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. The P&P indicated, provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medial or surgical treatment and formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicate with staff.

Based on observation, interview and record review, the facility failed to appropriately destroy or remove identifiable information on discarded medications for two (2) out of 2 sampled residents (Resident 87, 91). This deficient practice has the potential for unauthorized release of resident's personal information. Findings: During a review of Resident 87's admission Records, the admission Records indicated Resident 87 has original admission date on 6/02/23 and re-admission on [DATE] to the facility with diagnoses of dysphagia following cerebral infarction (difficulty swallowing after a stroke); gout, unspecified (type of arthritis that causes painful, swollen joints due to too much uric acid a natural waste product); muscle weakness(Generalized)(weakness in many muscles throughout the body.During a review of Resident 87's Minimum Data Set (MDS- a resident assessment tool), dated 09/17/25, the MDS indicated that the resident has the capacity to make herself understood and to understand others. During a review of Resident 91's admission Records, the admission Records indicated Resident 91 was admitted on [DATE] to the facility with diagnoses of traumatic subdural hemorrhage without loss of consciousness, subsequent encounter( bleeding around the brain caused by an injury without fainting); pulmonary fibrosis, unspecified ( is a lung disease where the lung tissue gets thick, scarred, and stiff, making it hard to breathe and get enough oxygen); emphysema (is a condition where the lungs are damaged and don't work well making it hard to breath).During a review of Resident 91's MDS dated [DATE], the MDS indicated that the resident has the ability to make herself understood and to understand others. During an observation and interview on 12/03/25 at 11:31AM, with Registered Nurse 1 (RN 1) in medication room, two (2) medication bottles with Resident 87's and Resident 91's information label attached to it, were found in blue disposal bin. RN 1 stated that they place all the non-narcotic medications that are discontinued or waste inside the bin including the medication bottle with Resident's name on it. RN 1 stated that they do not take the label off, as everything goes back to the pharmacy for proper disposal. During an Interview with Director of Nursing (DON) on 12/4/25 at 10:55 AM, the DON stated that when disposing of medication bottles there should not be a resident's name on it. DON added that License Nurses should blacken it out or peel off labels with personal information. During a review of the facility's policy and procedure (P&P) titled, Confidentiality of Personal and Medical Records, dated 05/02/25, the P&P indicated, facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record.

Based on observation, interview, and record review the facility failed ensure the Minimum Data Set (MDS, a standardized resident assessment tool) assessment for the Restorative Nursing Program (RNP, nursing interventions that aim to promote, maintain, and support a resident's ability to perform at their highest level) was accurately performed for two of three sampled residents (Resident 79 and Resident 86). These failures had the potential to result in adequate care for Resident 79 and Resident 86.Findings: During a review of Resident 79's admission record, the admission record indicated the facility admitted the resident on 12/27/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or the inability to move on one side of the body), cerebral infarction (stroke, loss of blood flow to part of the brain), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities). During a review of Resident 79's Care Plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) Report initiated 4/4/2025, the Care Plan Report indicated the resident was on the RNP for walking due to the resident's potential for a decline in walking skills related to a cerebrovascular accident (stroke). The Care Plan Report indicated a goal for Resident 79 was to maintain the resident's ability to ambulate (walk) with an assistive device and to facilitate the ease of transfers. The Care Plan Report indicated an intervention (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to ambulate Resident 79 up to 90 feet with minimal assistance (when an individual is able to perform the majority of an activity but requires some assistance from another person) and a front wheeled walker every day five times a week as tolerated. During a review of Resident 79's Documentation Survey Report dated 9/1/2025 - 9/30/2025, the Documentation Survey Report indicated the resident was on the RNP for walking. The report indicated Resident 79 was to be ambulated up to 90 feet with minimal assistance and a front wheeled walker every day five times a week as tolerated. The report indicated Resident 79 was ambulated on 9/23/2025, and 9/24/2025. During a review of Resident 79's Minimum Data Set (MDS, a resident assessment tool) dated 9/29/2025, the MDS indicated Resident 79 did not receive at least 15 minutes a day of the RNP in the prior 7 calendar days (9/21/2025 - 9/28/2025). During a review of Resident 86's admission Record, the admission Record indicated the facility re-admitted the resident on 1/7/2025 with diagnoses that included peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), hyperlipidemia (high levels of cholesterol in the blood), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), lack of coordination (lack of muscle control that causes awkward, clumsy movements that affect how you walk, use your arms, speak, or move your eyes), and acquired absence of the left leg above the knee (a condition where an individual has lost a part of their leg through the section above the knee). During a review of Resident 86's Documentation Survey Report dated 9/1/2025 - 9/30/2025, the report indicated the resident was on the RNP for Active Assisted Range of Motion (AAROM: a type of physical therapy exercise where a person uses their own muscles to move a joint but gets help from a therapist) of the bilateral (both) upper extremities (arms) using 2 pound weights every day five times a week as tolerated and for AAROM of the right lower extremity (leg) and left hip every day five times a week as tolerated. The report indicated there was documentation that Resident 86 received AAROM of the bilateral upper extremities, right lower extremity, and left hip on 9/17/2025. During a review of Resident 86's MDS dated [DATE], the MDS indicated Resident 86 did not receive at least 15 minutes a day of the RNP during the prior seven calendar days (9/12/2025 - 9/18/2025). During a review of Resident 86's Care Plan Report revised 9/30/2025, the Care Plan Report indicated the resident was on the RNP for AAROM due to the resident's potential for decline in ROM related to a left above the knee amputation (absence of the left leg above the knee). The Care Plan Report indicated Resident 86 was to receive AAROM of the lower right extremity (right leg), left hip, and bilateral upper extremities (both arms). The Care Plan Report indicated goals for Resident 86 were to be able to adapt and adjust to living as independently and safely as possible, enable good hygiene, promote functional mobility, and decrease the risk for skin breakdown. The Care Plan Report indicated interventions included having AAROM on the right and left upper extremity using a two-pound (lbs., a unit of mass) weights daily five times a week as tolerated, and AAROM on the right lower extremity and left hip daily five times a week as tolerated. During an observation on 12/03/2025 at 10:34 AM, in Resident 86's Room, Restorative Nursing Assistant 1 (RNA 1) observed assisting Resident 86 to perform RNA exercises on the resident's bilateral upper extremities with 2 lbs. weights; and ARROM exercises with right lower extremity and left hip. Resident 86 was observed tolerating the RNA exercises well. RNA 1 was observed to finish performing RNA exercises with Resident 86 at 10:50 AM. During an interview on 12/03/2025 at 11:00 AM with RNA 1, RNA 1 stated the exercises for an RNP usually lasted 10 - 15 minutes to complete per resident depending on how the resident tolerated the exercise. RNA 1 stated the goal for an RNP was 15 minutes per resident. During an interview on 12/4/2025 at 10:11 AM with RNA 2, RNA 2 stated each RNP took 15 minutes to complete per resident. During a concurrent interview and record review on 12/4/2025 at 10:52 AM with the MDS Coordinator (MDSC), Resident 79's MDS dated [DATE] and Resident 86's MDS dated [DATE] were reviewed. The MDSC stated the MDS for Resident 79 and Resident 86 did not indicate the residents were on a RNP because the intervention did not indicate how many minutes Resident 79 and Resident 86 were receiving RNP exercises a day. During a concurrent interview and record review on 12/4/2025 at 2:06 PM with the Director of Nursing (DON), Resident 79's MDS dated [DATE] and Resident 86's MDS dated [DATE] were reviewed. The DON stated each RNA tried to spend at least 15 minutes with each resident on the RNP when doing exercises if the resident tolerated the exercises. The DON stated the intervention for the RNP for Resident 79 and Resident 86 did not indicate the number of minutes the RNA exercises were to take place. The DON stated Resident 79's and Resident 86's RNP was not reflected on the residents' MDS because the residents' intervention for RNA did not include the number of minutes the RNP was to take place. The DON stated the MDS for Resident 79 and Resident 86 was not accurate because it did not indicate the residents were on the RNP. The DON stated the MDS assessment should have been accurate to ensure Resident 79, and Resident 86 received appropriate care. During a review of the facility's Policy and Procedure (P&P) titled Restorative Nursing Program dated 5/2/2025, the P&P indicated Potential candidates for restorative nursing services may be identified though one or more of the following processes: physical assessments, MDS assessments, Specialized rehabilitation assessments, in-house referrals due to unusual occurrence/event.A resident's Restorative Nursing plan will include: the problem, need, or strength the restorative tasks are to address, the type of activities to be performed, frequency of activities, duration of activities, measurable goal and target date. During a review of the facility's P&P titled Resident Assessment -RAI dated 5/2/2025, the P&P indicated This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS.The current version of the RAI (MDS 3.0) will be utilized when conducting a comprehensive assessment of each resident in accordance with the instructions found in the RAI Manual.The assessment will include at least.special treatments and procedures.The assessment process will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. During a review of the Centers for Medicare & Medicaid Services user manual titled Long-erm Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2025, the user manual indicated Steps for Assessments: 1. Review the restorative nursing program notes and/or flow sheets in the medical record.2. For the 7-day look-back period, enter the number of days on which the technique, training or skill practice was performed for a total of at least 15 minutes during the 24-hour period.3. The following criteria for restorative nursing programs must be met in order to code O0500: Measurable objectives and interventions must be documented in the care plan and in the medical record. If a restorative nursing program is in place when a care plan is being revised, it is appropriate to reassess progress, goals, and duration/frequency as part of the care planning process. Good clinical practice would indicate that the results of this reassessment should be documented in the resident's medical record. Evidence of periodic evaluation by the licensed nurse must be present in the resident's medical record. When not contraindicated by state practice act provisions, a progress note written by the restorative aide and countersigned by a licensed nurse is sufficient to document the restorative nursing program once the purpose and objectives of treatment have been established. Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity. A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program. Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents.

Based on interview and record review the facility failed to provide treatments and services to maintain or improve mobility (ability to move) and Range of Motion (ROM, full movement potential of a joint) for two of three sampled residents (Resident 79 and Resident 86). By failing to:1. Implement Resident 79's Restorative Nursing Program (RNP, nursing interventions that aim to promote, maintain, and support a resident's ability to perform at their highest level) for walking as indicated Resident 79's Care Plan (a plan of care that summarizes a resident's health conditions and the specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) Report initiated 4/4/2025.2. Implement Resident 86's RNP for Active Assisted ROM (AAROM, when the resident uses the muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment) as indicated in Resident 86's Care Plan Report revised 9/30/2025. These failures had the potential for Resident 79 and Resident 86 to develop a decline (to gradually become less, worse, or lower) in mobility and ROM.Findings: During a review of Resident 79's admission Record, the admission Record indicated the facility admitted the resident on 12/27/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness or the inability to move on one side of the body), cerebral infarction (stroke, loss of blood flow to part of the brain), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities). During a review of Resident 79's Care Plan Report initiated 4/4/2025, the Care Plan Report indicated the resident was on a RNP for walking due to the resident's potential for a decline in walking skills related to a cerebrovascular accident (stroke). The Care Plan Report indicated a goal to maintain Resident 79's ability to ambulate (walk) with an assistive device and to facilitate the ease of transfers. The Care Plan Report indicated an intervention (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to ambulate Resident 79 up to 90 feet with minimal assistance (when an individual is able to perform the majority of an activity but requires some assistance from another person) and a front wheeled walker every day five times a week as tolerated. During a review of Resident 79's Minimum Data Set (MDS, a standardized resident assessment tool) dated 9/29/2025, the MDS indicated the resident had severely impaired cognition (having impairment with the ability to think, understand, and reason). The MDS indicated Resident 79 required partial/moderate assistance (helper does less than half the effort) for walking 50 feet with two turns. The MDS indicated Resident 79 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with walking 10 feet. During a review of Resident 79's Documentation Survey Report dated 11/1/2025 - 11/30/2025, the Documentation Survey Report indicated the resident was on a RNP for walking. The Documentation Survey Report indicated Resident 79 was to be ambulated up to 90 feet with minimal assistance and a front wheeled walker every day five times a week as tolerated. The Documentation Survey Report indicated documentation that Resident 79 was ambulated on 11/4/25, 11/5/25, 11/10/25, 11/11/25, 11/14/25, 11/17/25, 11/20/25, 11/21/2025, 11/26/2025, 11/27/2025, and 11/28/2025. The Documentation Survey Report indicated there was no documentation of the resident being ambulated on 11/3/2025, 11/6/2025, 11/7/2025, 11/12/2025, 11/13/2025, 11/18/2025, 11/19/2025, 11/24/2025, and 11/25/2025. During a review of Resident 86's admission Record, the admission Record indicated the facility re-admitted the resident on 1/7/2025 with diagnoses that included peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), hyperlipidemia (high levels of cholesterol in the blood), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), lack of coordination (lack of muscle control that causes awkward, clumsy movements that affect how you walk, use your arms, speak, or move your eyes), and acquired absence of the left leg above the knee (a condition where an individual has lost a part of their leg through the section above the knee). During a review of Resident 86's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition (some problems with the ability to think, understand, and reason). The MDS indicated Resident 86 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering/bathing self, lower body dressing, putting on footwear, and taking off footwear. The MDS indicated Resident 86 required partial/moderate assistance (helper does less than half the effort) for upper body dressing. The MDS indicated Resident 86 required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity) for personal hygiene. The MDS indicated Resident 86 required set up or clean up assistance (helper sets up or cleans up and the resident does the activity) for eating and oral hygiene. During a review of Resident 86's Care Plan Report revised 9/30/2025, the Care Plan Report indicated the resident was on a RNP for AAROM due to the resident's potential for decline in ROM related to a left above knee amputation (absence of the left leg above the knee). The Care Plan Report indicated Resident 86 was to receive AAROM to the right lower extremity (right leg), left hip, and bilateral upper extremities (both arms). The Care Plan Report indicated goals for Resident 86 were to be able to adapt and adjust to living as independently and safely as possible, enable good hygiene, promote functional mobility, and decrease the risk for skin breakdown. The Care Plan Report indicated interventions for Resident 86 to have AAROM on the right and left upper extremity using a two-pound (lbs., a unit of mass) weights daily five times a week as tolerated, and AAROM on the right lower extremity and left hip daily five times a week as tolerated. During a review of Resident 86's Documentation Survey Report dated 11/1/2025 - 11/30/2025, the Documentation Survey Report indicated the resident was on a RNP for AAROM of the bilateral upper extremities using 2 lbs. weights every day five times a week as tolerated and for AAROM of the right lower extremity and left hip every day five times a week as tolerated. The Documentation Survey Report indicated there was documentation that Resident 86 received AAROM of the bilateral upper extremities, right lower extremity, and left hip on 11/4/2025, 11/5/2025, 11/10/2025, 11/11/2025, 11/14/2025, 11/17/2025, 11/20/2025, 11/21/2025, 11/26/2025, 11/27/2025, and 11/28/2025. The Documentation Survey Report indicated there was no documentation of the resident receiving RNA services on 11/3/2025, 11/6/2025, 11/7/2025, 11/12/2025, 11/13/2025, 11/18/2025, 11/19/2025, 11/24/2025, and 11/25/2025. During a concurrent interview and record review on 12/03/2025 at 11:00 AM, Restorative Nursing Assistant 1 (RNA 1) reviewed Resident 79's Documentation Survey Report dated 11/1/2025 - 11/31/2025 and Resident 86's Documentation Survey Report dated 11/1/2025 - 11/31/2025. RNA 1 stated he (RNA 1) was familiar with both Resident 79 and Resident 86 because he (RNA 1) was assigned to help both residents with RNP exercises. RNA 1 stated Resident 79 was assisted with ambulating 90 feet everyday five times a week as tolerated. RNA 1 stated Resident 86 was receiving AAROM for his bilateral upper extremities using two lbs. weights and AAROM for his right lower extremity and left hip every day five times a week as tolerated. RNA 1 stated the RNP exercises were scheduled to take place Monday - Friday and sometimes on the weekends if needed. RNA 1 stated the documentation for the RNP exercises was done under tasks on the Documentation Survey Report. RNA 1 confirmed there was no documentation on Resident 79's Documentation Survey Report on 11/3/2025, 11/7/2025, 11/12/2025, 11/13/2025, 11/18/2025, 11/19/2025, 11/24/2025, and 11/25/2025. RNA 1 stated there was no documentation on Resident 86's Documentation Survey Report on 11/3/2025, 11/6/2025, 11/7/2025, 11/12/2025, 11/13/2025, 11/18/2025, 11/19/2025, 11/24/2025, and 11/25/2025. RNA 1 stated the days that had no documentation indicated RNP exercises were not performed for Resident 79 and Resident 86. RNA 1 stated there was no documentation that Resident 76 or Resident 86 refused RNP exercises on the days that had no documentation on the Documentation Survey Reports. RNA 1 stated the interventions for Resident 76 and Resident 86 indicated the residents were both supposed to receive RNP exercises five times a week. RNA 1 stated the Documentation Survey Report for Resident 79 and Resident 86 did not indicate the residents received RNP exercises five times a week. RNA 1 was not sure why Resident 76 and Resident 86 did not receive RNP exercises five times a week. RNA 1 stated there wasn't shortage of RNAs at the facility. During an interview on 12/3/2025 at 11:10 AM with Resident 86, Resident 86 stated he liked to do exercises with the RNA. Resident 86 stated he would like to do RNP exercises every day because the exercises made him stronger. Resident 86 stated he did not do exercises every day because the RNAs had a schedule they had to follow. Resident 86 stated he had RNP exercises maybe three times a week. During a concurrent interview and record review on 12/4/2025 at 2:06 PM, the Director of Nursing (DON) reviewed Resident 79's Documentation Survey Report dated 11/1/2025 - 11/31/2025 and Resident 86's Documentation Survey Report dated 11/1/2025 - 11/31/2025. The DON stated there was no documentation that RNP exercises for Resident 79 were performed on 11/3/2025, 11/7/2025, 11/12/2025, 11/13/2025, 11/18/2025, 11/19/2025, 11/24/2025, and 11/25/2025. The DON stated there was no documentation that RNP exercises for Resident 86 were performed on 11/3/2025, 11/6/2025, 11/7/2025, 11/12/2025, 11/13/2025, 11/18/2025, 11/19/2025, 11/24/2025, and 11/25/2025. The DON stated there was no documentation that Resident 76 or Resident 86 refused RNP exercises on the days that were blank on the Documentation Survey Reports. The DON stated the purpose of the RNP was to maintain the resident's current level of mobility and ROM. The DON stated there was a potential for Resident 79 and Resident 86 to have a decline in their level of mobility and ROM. During a review of the facility's Policy and Procedure (P&P) titled Restorative Nursing Programs dated 5/2/2025, the P&P indicated It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services.Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the electronic health record.

Based on observation, interview, and record review the facility failed to meet the requirement for no more than four residents per room for one of 63 resident residential rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents in room eight.Findings: During multiple room observations conducted in room eight from 12/1/2025 to 12/4/2025, nursing staff were observed with adequate space to provide care to the residents in room [ROOM NUMBER]. Each resident in room [ROOM NUMBER] was observed to have privacy curtains for privacy, working call-lights, a dresser and a bedside table. During review of the facility's room waiver request letter dated 12/4/2025, the room waiver request letter indicated room [ROOM NUMBER] did not meet the 4 bed per room regulation. The letter indicated room [ROOM NUMBER]was in accordance with the special needs of residents and would not have an adverse effect on the residents' health and safety or impede the ability of any resident in the room to attain his/her highest practicable well-being. The letter indicated room [ROOM NUMBER] had 5 resident beds and was measured at 377 square feet (75.4 square feet per resident). During an interview on 12/4/2025 at 10:51 AM with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated she was assigned to room [ROOM NUMBER]. CNA 4 stated room [ROOM NUMBER] had five beds. CNA 4 stated there were no issues with the space in the room. CNA 4 stated there was space in room [ROOM NUMBER] to place wheelchairs. CNA 4 stated no one had complained about feeling overcrowded in room [ROOM NUMBER]. A review of the facility's policy and procedures (P&P) titled Resident Rooms revised on 5/2/2025, the policy indicated resident bedrooms must be designed and equipped for adequate nursing care, comfort and privacy of resident and will measure at least 80 square feet per resident in multiple resident bedrooms. The Department is recommending continuation of the room waiver request.

Based on observation, interview, and record review the facility failed to ensure 24 out of 63 rooms (room [ROOM NUMBER], 6, 8, 12,19, 24, 26, 30, 32, 37, 39, 40, 41, 45, 46, 48, 50, 54, 56, 58, 59, 61, 62, and 63) met the required 80 square feet per resident regulation. This failure had the potential to result in the inadequate space necessary to provide safe nursing care and privacy for residents.Findings: During multiple room observations conducted from 12/1/2025 to 12/4/2025, nursing staff were observed with adequate space to provide care to the residents in each facility resident room. Each resident was observed to have privacy curtains for privacy, working call-lights, a dresser, and a bedside table. During a review of the facility's room wavier letter dated 12/4/2025, the letter indicated the facility was requesting a room variance (room size different from required amount) for 24 resident rooms (room [ROOM NUMBER], 6, 8, 12,19, 24, 26, 30, 32, 37, 39, 40, 41, 45, 46, 48, 50, 54, 56, 58, 59, 61, 62, and 63). The room waiver letter indicated the following rooms had less than 80 square feet per bed:Room NumberFloor AreaCapacityroom [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER] The room waiver request letter indicated the rooms were in accordance with the special needs of the residents and would not have adverse effect on the residents' health and safety; and would not impede the ability of any resident in the rooms to attain his/her highest practicable well-being. The room wavier letter indicated resident, staff, and visitor safety would not be compromised by the facility's exiting room square footage. The room wavier letter indicated the room sizes were addressed with the resident council (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life) who did not feel the room size negatively impacted their care or safety. During an interview on 12/4/2025 at 10:29 AM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she was assigned to room [ROOM NUMBER]. CNA 3 stated there was enough room to move around and have resident walkers and wheelchairs in the room. CNA 3 stated there were no issues with bumping into things or each other in room [ROOM NUMBER]. CNA 3 stated the residents in room [ROOM NUMBER] had not stated they felt crowded in the room. During an interview on 12/4/2025 at 10:35 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated she was assigned to room [ROOM NUMBER]. LVN 4 stated she did not have any issues with not having enough space or feeling crowded in room [ROOM NUMBER]. LVN 4 stated she could place her medication cart in room [ROOM NUMBER] if she needed to. During an interview on 12/4/2025 at 10:39 AM with Resident 31, in room [ROOM NUMBER], Resident 31 reported having enough space in the room for belongings and to move around. During an interview on 12/4/2025 at 11:02 AM with LVN 5, LVN 5 stated she was assigned to room four. LVN 5 stated residents in room four had not stated anything about the room being too small or having enough room to move around. During an interview on 12/4/2025 at 11:06 AM with Resident 78, in room [ROOM NUMBER], Resident 78 had no complaints about the space in the room. Resident 78 reported having plenty of room to move around in room [ROOM NUMBER]. A review of the facility's policy and procedures (P&P) titled Resident Rooms revised on 5/2/2025, the policy indicated resident bedrooms must be designed and equipped for adequate nursing care, comfort and privacy of resident and will measure at least 80 square feet per resident in multiple resident bedrooms. The Department is recommending continuation of the room waiver request.

Based on observation, interview, and record review the facility failed to ensure three of eight sampled staff (the Environmental Services Director [EVSD], Certified Nursing Assistant 2 [CNA 2] and Dietary Aide 1 [DA 1], maintained infection control practices (refers to policies and procedures used to minimize the risk of spreading infections) during a COVID-19 (a respiratory illness that can spread from person to person) outbreak (a rise in the number of cases of a disease) in the facility by failing to: 1.Ensure the EVSD performed hand hygiene (a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub) after throwing a cup in the trash for a resident (unidentified) in room A. 2. Ensure CNA 2 and DA 1 wore an N95 mask (highly effective air filter for your face designed to block a very high percentage of tiny particles, including those that can carry viruses like COVID-19 from being breathed in or exhaled). These deficient practices had the potential to spread infection and illnesses to residents, staff, and visitors. Findings: During a concurrent observation and interview on 5/14/2025 at 12:30 PM with the Infection Preventionist (IP - a healthcare professional who works to prevent the spread of infections among patients, staff, and visitors by making sure everyone follows proper guidelines for cleaning, handwashing, and other measures to keep everyone healthy) outside of room A, the EVSD came out of room [ROOM NUMBER] and walked down the hallway and did not sanitize his hands after exiting the room. The EVSD stated he (EVSD) went inside the room to throw away a cup for a resident (unidentified) inside the room. The EVSD stated if he (EVSD) did not sanitize his hands, he (EVSD) could spread infections. The IP nurse stated the EVSD did not sanitize his hands and stated the EVSD could spread infection. During an observation and interview on 5/14/2025 at 1:23 PM with the Director of Nursing (DON) and DA 1 in the kitchen, DA 1 was observed wearing a surgical mask (do not form a tight seal around the face, meaning they may not be as effective at filtering out very small airborne particles [aerosols] that can also carry the virus). DA 1 was then observed changing the surgical mask for an N95 respirator mask once DA 1 noticed the DON and surveyor made rounds in the kitchen. The DON stated DA 1 should have been wearing an N95 respirator mask and not a surgical mask. During an observation on 5/14/2025 at 1:26 PM at the facility entrance, CNA2 was observed wearing a surgical mask and sitting at a table screening employees and visitors for possible signs and symptoms of infection such as COVID. During an interview on 5/14/2025 at 1:31 PM with the IP, the IP stated the facility was considered to be in an outbreak status and all staff needed to wear N95 respirator masks. The IP stated the facility ' s COVID outbreak could be prolonged if the staff did not wear the N95 respirators. During an interview on 5/14/2025 at 1:39 PM with the DON and the Administrator (ADM), the DON stated if the staff (in general) did not wear the N95 respirator during the COVID outbreak, it would be an infection control issue. The DON stated CNA 2 who was the designated to screen at the front of the facility, CNA 2 would not be protected from COVID and could spread the infection if CNA2 did not wear the N95 respirator while screening visitors to the facility. During a review of the undated facility ' s flu and COVID vaccination records, the vaccination records indicated the EVSD declined the COVID vaccine on 11/20/2025, CNA 2 declined the COVID vaccine on 3/21/2025, and DA 1 declined the COVID vaccine on 11/20/2025. During a review of the facility ' s policy and procedure (P&P) titled Hand Hygiene, dated 3/7/2025, the P&P indicated hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The P&P indicated all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The P&P indicated staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The P&P indicated hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The hand hygiene table indicated staff would need to either use soap and water or (ABHR) between resident contact, after handing contaminated objects, before and after handing clean or soiled dressings, linens, etc., after handing items potentially contaminated with blood, body fluids, secretions (the process by which an animal produces and releases a liquid such as saliva) or excretions ( he process of eliminating waste products from the body) and when in doubt. During a review of the facility ' s P&P titled Infection Outbreak Response and Investigation, dated3/7/2025, the P&P indicated outbreak generally refers to the occurrence of more cases of a communicable disease (a disease that is spread from one person to another through a variety of ways that include: contact with blood and bodily fluids) than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. The P&P indicated symptomatic (having symptoms) employees will be screened by the Infection Preventionist, or designee, and referred to appropriate medical provider. The P&P indicated standard precautions (basic hygiene practices and precautions that healthcare workers and patients use to prevent the spread of infections) will be emphasized. Transmission-based precautions (used in addition to standard precautions for patients with known or suspected infection) will be implemented (put in place) as indicated for the particular organism (any living thing). The P&P indicated will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures. This includes special environmental infection control measures that are warranted based on the organism and current CDC (Center for Disease control is the nation ' s health protection agency that protects America from preventable diseases and health threats) guidelines. The P&P indicated surveillance (monitoring) activities will increase to daily for the duration of the outbreak. During a review of the facility ' s P&P titled Transmission (how a disease spreads)-Based (Isolation - special steps taken to keep a sick person separate from healthy people to prevent the spread of germs or infections) Precautions, dated 3/7/2025, the P&P indicated it was the facility ' s policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens ' modes of transmission. For training and quick referencing purposes, a summary of precautions is contained at the end of this policy. The P&P indicated the following definitions: Airborne precautions refer to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air. Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment. Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Transmission-based precautions (a.k.a. Isolation Precautions) refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact and droplet) in order to prevent or control infections. The P&P indicated the facility will use standard approaches, as defined by the CDC or local public health, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. The P&P indicated staff will wear a fit-tested (the method for finding the respirator that fits your face and making sure it provides a tight seal to help keep you protected) N95 or higher-level respirator and other appropriate PPE while delivering care to the resident. During a review of the CDC Infection Control Guidance: SARS-CoV-2 (https://www.cdc.gov/covid/hcp/infection-control/index.html), dated 6/24/2024, indicated when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. During a review of an email provided by the IP, dated 5/12/2025, indicated the Los Angeles County Public Health Outbreak Investigator ([NAME]), recommended surgical masks for visitors readily available at the entrance and N95 masks readily available at the entrance for staff. The email indicated all staff to wear a mask (N95) at all times during the outbreak and should be masked if more than one person in the room, such as offices.

Based on observation, interview, and record review the facility failed to implement its policies and procedure on infection control to prevent the spread of coronavirus disease 2019 (COVID-19, a highly contagious infection affecting the respiratory system caused by a virus that can spread from person to person). By failing to: 1. Ensure all personnel wear N95 mask (disposable face mask that covers the user's nose and mouth which offers protection form small solid or liquid droplets found in the air) during the COVID-19 outbreak. 2. All staff perform COVID-19 test at beginning of their shift. 3. Pause resident activity during the COVID-19 outbreak. 4. Use dedicated shower room for COVID-19 positive residents only. 5. Place portable air purifiers with High Efficiency Particulate Air (HEPA, can help reduce airborne contaminants including viruses in a building or small space) in all hallways. These deficient practices had the potential to continue to spread the COVID-19 to all residents, staff, and visitors. Findings: During a review of the local health department Viral Respiratory Illness Outbreak Notification dated 10/17/24 and sent by email to the facility on [DATE] at 3:48 p.m., indicated the local health department .will review site-specific control measures that you (facility) are required to implement to help control the outbreak and protect residents, personnel and/or other individuals at your site. Measures included all staff to test for the COVID-19 before each shift, to pause resident dining/activities, all staff to wear N95 mask during the COVID19 outbreak and to place air purifiers in all hallways. During an observation on 11/4/24 at 8:25 a.m., Certified Nursing Assistant 1 (CNA 1) was observed wearing a surgical mask (a loose fitting, disposable device that creates barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment). CNA 1 stated she removes the surgical mask and replace with the N95 mask when she is directly taking care of the COVID-19 positive resident. CNA 1 stated she tests for the COVID-19 two times a week only. During an interview on 11/4/24 at 8:27 a.m., CNA 2 stated she does not test for the COVID19 at the start of her shift. During an interview on 11/4/24 at 8:34 a.m., CNA 3 stated she does not test daily for the COVID-19. During an observation and interview on 11/4/24 at 8:52 a.m. with the Director of Staff Developer (DSD) CNA 4 was observed wearing a surgical mask. CNA 4 was observed inside the shower room giving a bath to Resident 1. The shower room had a sign posted on the door reserved for covid patients only. DSD stated CNA 4 was giving shower to Resident 1 who was not COVID19 positive. During an observation and interview on 11/4/24 at 9:03 am., 13 residents were observed sitting in wheelchairs in the activity/dining room, sitting close to each other. Activity Assistant (AA) stated there are 13 residents attending activity. AA further stated she tests for COVID19 every week. During observation and interview on 11/4/24 at 10 a.m., Infection Preventionist (IP) stated, there is one air purifier in the west nursing station and in the activity room. No other air purifier was observed in the hallways. During an interview on 11/4/24 at 12:38 p.m., the IP stated, it is important for staff to test for the COVID19 before the start of their shift so that if they are positive, staff do not bring the COVID19 in the facility. IP stated further, it is important to have dedicated shower room for residents who are COVID19 positive to prevent exposure and prevent spread of the COVID19 in the facility. During the exit conference with the administrator (ADM), director of nursing (DON) and the IP on 11/4/24 at 1:22 p.m., the ADM stated some of the facility staff were wearing surgical masks. IP stated, it is important to wear the N95 as barrier and as droplet precautions (a set of infection control measures used to prevent the spread of illnesses through air droplets). The ADM stated the facility did not pause activities but limited the number of participants (including residents). During a review of the facility's Policy and Procedures (P&P) reviewed on 3/27/24 titled Infection Prevention and Control Program reviewed on 3/27/24, indicated, the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. During a review of the facility's P&P titled Coronavirus Prevention and Response reviewed on 3/27/24, indicated, the facility will respond promptly upon suspicion of illness associated with COVID-19 infection in efforts to identify, treat, and prevent the spread of the virus. The same P&P indicated, source control options for health care workers include respirator with N95 filters or higher. When the COVID19 community transmission levels are not high, the facility may choose not to require universal source control. However, even if source control is not universally required, it is recommended for individuals in the facility who have otherwise had source control recommended by public health authorities. The facility will explore options to improve ventilation delivery and indoor quality in resident rooms and all shared areas. The facility will take measures to limit crowding in communal areas. The same P&P indicated, the facility will perform viral testing as per (Centers for Disease Control and Prevention (CDC, federal agency that conducts and supports health promotion and prevention) guidance and facility policy. Local health jurisdictions may continue to implement additional requirements that are stricter than federal CDC and state recommendations. Ensure to follow the local county health public health guidelines.

Based on observation, interview, and record review, the facility failed to implement and maintain infection control procedures when the facility did not screen family members and visitors for three day on signs and symptoms of Coronavirus (COVID-19, a contagious and infectious disease that is characterized by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) during a COVID-19 outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in the facility. This deficient practice had the potential to result in the spread of COVID 19 to residents and staff. Findings: During an observation on 10/17/2024 at 11:50 AM, Family Member (FM) 1 was observed entering the facility unmasked. Upon entering the facility, FM 1 was observed entering Resident 15's room. FM 1 did not screen themselves for sign and symptoms of COVID-19. During an interview on 10/17/2024 at 12 PM, FM 1 stated they did not sign in on the visitor screening log and stated she was not screened for COVID-19. FM 1 stated they were not informed of the screening process and stated she just walked into the facility. During an observation on 10/17/2024 at 12:45 PM, the facility's visitor screening log was observed on a table at the entrance of the facility. There was no designated staff observed to screen visitors upon entrance. During a concurrent review of the facility's visitor screening log dated 10/15 to 10/17/2024, the facility had 26 visitors on 10/15/2024, 26 visitors on 10/16/2024, and 23 visitors on 10/17/2024. The visitor screening log indicated the visitors who signed the log on 10/15/2024 to 10/17/2024 did not indicate if they had any signs and symptoms of COVID 19. During a concurrent interview and record review on 10/17/2024 at 1:03 PM, the Infection Preventionist (IP) stated the outbreak of COVID-19 in the facility started on 10/15/2024. The IP stated there were two residents who were positive for COVID-19 and no staff were positive for COVID-19. The IP stated the facility had a log for visitors to sign in prior to entering the facility and visitors were supposed to fill out the log before entering the facility. The IP stated the log had visitors sign their name, indicate the resident they were visiting, the room number, the visitors COVID-19 test results, and asked if the visitors had any signs and symptoms of COVID-19. The IP stated the facility did not have a designated staff to screen visitors coming into the facility. The IP reviewed the visitor screening log for 10/15 - 10/17/2024 and confirmed visitors did not indicate whether the visitors had signs and symptoms of COVID-19 on the visitor screening log. The IP stated visitors were supposed to be screened for signs and symptoms of COVID-19. The IP stated there was a potential for COVID-19 to be spread to more residents and staff if visitors were not screened prior to entering the facility. A review of an e-mail from the Department of Public Health (DPH) to the IP titled, Department of Public Health - COVID-19 Outbreak, dated 10/17/2024, indicated the following recommendations: Please complete symptom check for all visitors before entering the facility. Masking is required at all times during visitation. During a concurrent interview and record review with the Director of Nursing (DON) on 10/18/2024 at 1:06 PM, the facility's visitor screening log was reviewed. The DON stated and confirmed visitors were not being screened for signs and symptoms of COVID-19. The DON stated the facility currently had an outbreak of COVID-19 and the residents at the facility were long term care residents and did not really leave the facility, so there was a possibility the residents may have gotten COVID-19 from the visitors. The DON stated there were no facility staff who were positive of COVID-19 and there was a potential for COVID-19 to spread amongst residents if visitors were not screened prior to entering the facility. A review of the facility's policy and procedures titled, Infection Prevention and Control Program, Reviewed 3/27/2024 indicated resident/Family/Visitor Education and Screening: Residents, family members, and visitors were provided information relative to the rationale for the isolation, behaviors required of them in observing there precautions, and conditions for which to notify the nursing staff. More active screening, such as the completion of screening tools or questionnaires that elicits information related to recent exposures or current symptoms may be used as per facility policy.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one of five sampled residents (Resident 51) when Certified Nursing Assistant (CNA) 3 was observed standing over Resident 51 while feeding the resident lunch. This deficient practice had the potential to cause psychosocial harm to the Resident 51 and violated the resident's right to be treated with dignity. Findings: A review of Resident 51's face sheet (admission record), indicated the facility readmitted the resident on 9/25/2024 with diagnoses including dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's daily life and activities), lack of coordination (a condition that affects muscle control), muscle weakness (lack of muscle strength), and dysphagia (difficulty swallowing). A review of Resident 51's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/30/2024, indicated the resident had severely impaired cognition (lack of the ability to think, remember, and make decisions). The MDS indicated Resident 51 required partial / moderate assistance with eating and would hold food in their mouth / checks after meals. During an observation on 10/15/2024 at 12:52 PM. CNA 3 was observed feeding Resident 51 lunch. CNA 3 was observed standing up on the right side of Resident 51 next to the resident's bed feeding the resident. CNA 3 was observed looking down at Resident 51 while the resident was looking up at CNA 3. During a concurrent interview, CNA 3 stated Resident 51 was a feeder and required assistance with meals. CNA 3 stated she was supposed to be sitting down while feeding Resident 51, that she usually would sit in a chair. CNA 3 stated she was supposed to be at eye level with the resident. During an interview on 10/27/2024 at 1:06 PM, the Director of Nursing (DON) stated when a staff member was feeding a resident they should be sitting and maintaining themselves at eye level with the resident. The DON stated this was done to protect resident dignity and there was a potential for the resident to not feel respected if staff stood up while feeding the resident. A review of the facility's policy and procedure titled, Promoting / Maintaining resident Dignity During Mealtimes, reviewed 3/27/2024, indicated to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. Staff members involved in providing feeding assistance to resident promote and maintain resident dignity during mealtimes. All staff will be seated, if possible, while feeding a resident.

Based on observation, interview, and record review, the facility failed to update the person-centered care plan for one of three sampled residents (Resident 43), who suffered from depression. Resident 43's care plan did not include the resident's preferred activities. This deficient practice caused an increased risk of Resident 43 having meaningful activity to promote and enhance the resident's quality of life. Findings: A review of the Admission Record indicated Resident 43 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living]), dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), muscle wasting and atrophy (decrease in size and thinning of muscle tissue). A review of the Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 7/17/2024, indicated Resident 43 had severe cognitive impairment (problems with a person's ability to think, remember, use judgement, and make decisions) and was totally dependent with bed mobility, transfer, dressing, feeding, toileting, personal hygiene, and bathing. A review of Resident 43's care plan for alteration in activity related to hearing impairment, cognitive impairment, self-care, and mobility deficits, revised on 7/17/2024 indicated the goal was for Resident 43 to participate in activities of resident's choice 3-4 times a week. The care plan interventions included praise efforts for attendance and participation in church service. During an observation on 10/17/2024 at 9:13 AM, Resident 43 was lying in bed awake, was nonverbal and unable to make needs known. While observing Resident 43, church service could be heard from the activities room. There was no attempt from facility staff observed to assist Resident 43 to church service. During an observation on 10/17/2024 at 10:18 AM, Resident 43 was lying in bed watching television and the Rehabilitation Nursing Assistant (RNA 1) was outside of Resident 43's room. During a concurrent interview, RNA 1 was asked if Resident 43 would be going to Church Service and RNA 1 stated that Resident 43 did not like going. RNA 1 stated Resident 43 would become agitated while at Church Service and the family comes and takes Resident 43 out daily. RNA 1 stated Resident 43 enjoyed spending time with family. During an interview on 10/17/2024 at 12:05 PM, the Activities Director (AD) stated Resident 43 used to attend Church Service but no longer enjoyed going. The AD stated Resident 43 preferred to spend time with their family. During a concurrent review of Resident 43's activities care plan, the AD stated the care plan for Resident 43 should have been updated to reflect their current interests of enjoying time with family. On 10/17/2024 at 2:45 PM, the family member was called regarding Resident 43's activity preference for attending church service. There was no answer and the family member did not return the message. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, revised 3/27/2024, indicated to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment.

Based on interview and record review, the facility failed to review, update, and/or revise the care plans for two of three sampled residents (Resident 71 and Resident 75). Resident 71 did not have current wound care treatment indicated for the Stage III sacral pressure ulcer and Resident 75's care plan did not include updated interventions for pressure injury prevention. These deficient practices had the potential to affect the provision of necessary care, treatment, and services for Resident 71 and Resident 75. Findings: a. A review of Resident 71's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (impaired ability to remember, or make decisions that interferes with doing everyday activities) and pressure ulcer of sacral region Stage III. A review of the Physician's Orders dated 9/27/2024, indicated to cleanse the sacro coccyx (tail bone) pressure injury with normal saline (NS-a salt solution), pat dry, apply Santyl (medication that removes dead tissue from a wound) ointment, apply Bacitracin (topical antibiotic used to prevent infection) ointment, and apply foam dressing every day shift. A review of Resident 71's potential for pressure ulcer development related to the sacro coccyx pressure ulcer care plan dated 9/30/2024, indicated the resident's pressure ulcer would show signs of healing and remain free from infection by or through review date. The care plan indicated to administer medications and treatment as ordered. A review of Resident 71's 35's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/1/2024, indicated the resident had severe cognitive impairment and did not have the capacity to understand or make their own decisions. The MDS further indicated Resident 71 needed maximum assistance with bed mobility, transfer, and personal hygiene. During an observation on 10/17/2024 at 11:34 AM, the Treatment Nurse (TX 1) performed wound care treatment on Resident 71's sacral pressure ulcer. During a concurrent interview, TX 1 stated Resident 71's wound was healing and had gotten smaller since the resident was first admitted . TX 1 stated if there was a change in the resident's wound status or if a treatment was changed it should be updated in the care plan to ensure continuity of care. TX 1 stated they forgot to revise and update the care plan for Resident 71. During an interview on 10/17/24 12:41 PM, the Minimum Data Set Coordinator (MDS) stated that treatment orders for pressure ulcers should be indicated in the care plan because it was important to know what the recent treatment for the resident was and if the interventions were effective. The MDS also stated the stage of the pressure ulcer should also be indicated in the care plan. A review of the facility's policy and procedures (P&P) titled, Comprehensive Care Plans, revised on 3/27/2024, indicated to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 49881 b. A Review of Resident 75's Admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including Type II diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and vascular dementia (a progressive state of decline in mental abilities). A review of Resident 75'S Braden Scale Assessment (a tool used for predicting pressure ulcer/sore risk) dated 5/17/2024 indicated a total score of 14 which placed the resident at moderate risk for developing pressure ulcer. A review of Resident 75's MDS dated [DATE] indicated the resident's cognition (the ability to think and process information) was severely impaired and was at risk for developing pressure ulcers/injuries. A review of the Physician's Order dated 10/14/2024, indicated Resident 75 was to receive the APP overlay for skin and wound management. A review of Resident 75's At Risk for potential skin breakdown and development of pressure injuries care plan, revised 10/14/2024, indicated an intervention for a pressure reduction mattress in bed (low air loss mattress, LAL) and APP (alternating pressure pad) overlay for skin and wound management. During a concurrent observation and interview on 10/16/2024 at 1:25 PM with Registered Nurse 1 (RN 1), Resident 75 was observed in his room. RN 1 stated and confirmed Resident 75 had an alternating pressure pad and did not have a low air loss mattress. RN 1 stated it was important to follow the care plan interventions to prevent any skin injuries from residents who were risk for developing skin issues. During a concurrent record review and interview on 10/16/2024 at 1:45 PM with Treatment Nurse 1 (TX 1), Resident 75's At Risk for potential skin breakdown care plan was reviewed. TX 1 stated the plan was for the resident to have an APP to prevent skin breakdown and that it was confusing to have an intervention for the low loss mattress and alternating pressure pad in the same care plan. TX 1 stated Resident 75's care plan should have been revised to include the APP intervention only. During a concurrent record review and interview with the Director of Nursing (DON) on 10/18/2024 at 9:20 AM, Resident 75's care plan at risk for potential skin breakdown was reviewed. The DON stated Resident 75's care plan should have been updated to resolve the intervention for the LAL mattress because the plan was for the resident to have an APP mattress. The DON stated it was important to resolve the care plan interventions that were no longer needed to ensure the resident was getting the interventions needed. A review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, revised 3/2024, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, and include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 75), who was assessed as a moderate risk to develop pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was provided with a pillow or heel protectors (pressure relieving devices) to the left and right heels and repositioned every two hours and PRN (as needed), per the resident's care plan. This deficient practice placed Resident 75 at increased risk for developing pressure sores. Findings: A review of Resident 75's Admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including Type II diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and vascular dementia (a progressive state of decline in mental abilities). A review of Resident 75's Braden Scale assessment (a tool used for predicting pressure ulcer/sore risk) dated 5/17/2024 indicated a total score of 14 which placed the resident at moderate risk for developing pressure ulcer. A review of Resident 75's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/15/2024 indicated the resident's cognition (the ability to think and process information) was severely impaired and was at risk for developing pressure ulcers/injuries. A review of Resident 75's At Risk for potential skin breakdown and development of pressure injuries care plan revised 10/14/2024 indicated the interventions were turning and reposition Resident 75 every two hours and PRN (as needed) and reducing pressure off heel(s) with pillow(s) or heel protectors. During an interview on 10/16/2024 at 1:06 PM, Certified Nurse Assistant (CNA 2) stated and confirmed she was the nurse assistant assigned to Resident 75. CNA 2 stated she did not know if Resident 75 required heel protectors. CNA 2 stated she was repositioning the resident every two hours but was not keeping track of the repositioning because only the residents with a wound had a repositioning log. During a concurrent observation and interview on 10/16/2024 at 1:25 PM with Registered Nurse 1 (RN 1), Resident 75 was observed in his room. Resident 75 was observed laying in his bed and RN 1 stated and confirmed the resident did not have pillows or heel protectors to reduce pressure from the resident's left and right heels. RN 1 stated it was important to follow the residents care plan interventions to prevent any skin injuries from residents who were at risk for developing skin issues. During an interview with the Director of Staff Developer (DSD) on 10/16/2024 at 2:46 PM, the DSD stated there was a binder at the nurse's station with a list of residents who needed repositioning ever two hours. The DSD stated the staff have a log for each resident and log repositioning ever two hours and pressure reduction from the heels. The DSD stated Resident 75 was not on the list and there was no documentation that the resident was repositioned every two hours or that staff reduced pressure off his heels from 10/1 to 10/16/2024. The DSD stated it was important to reposition the resident every two hours and use pillows to reduce pressure off the heels to prevent skin breakdown. A review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention and Management, revised 3/2024, indicated the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional ulcers/injuries. Interventions for prevention and to promote healing included evidenced-based interventions for prevention would be implemented for all residents who are assessed at risk or who have pressure injury present. The policy indicated basic or routine care interventions could include but are not limited to redistributing pressure (such as repositioning, protecting, and/or offloading heels, etc.).

Based on interview and record review, the facility failed to provide services for one of two sampled residents (Residents 84) at risk for decline in range of motion (ROM, full movement potential of a joint) and mobility. Resident 84 did not receive Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises and left knee extension splint, per the care plan. This deficient practice had the potential to cause further decline in functional mobility, ROM, and quality of life for Residents 84. Findings: A review of Resident 84's Admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting left non-dominant side, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of left knee, and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). A review of Resident 84's care plan initiated 12/18/2023 indicated the resident was on the RNA program for PROM exercises on BLE, BUE, and bilateral knee extension splint assistance to address potential for decline in range of motion. The interventions included PROM daily five times a week as tolerated to the right and left upper extremity, PROM daily seven times a week as tolerated to the right and left lower extremity, and right and left knee extension splint to be worn two hours daily seven times a week as tolerated. A review of Resident 84's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/11/2024 indicated the resident's cognition (the ability to think and process information) was severely impaired, was dependent with toileting and shower. The MDS indicated Resident 84 had impairment on both sides of the lower extremity and no impairment on both sides of the upper extremity. A review of Resident 84's Documentation Survey Report for September 2024 indicated the resident received PROM to the right and left lower extremity nine times on the following dates: 9/5, 9/7, 9/9 - 9/12/24, 9/15, 9/26 and 9/30/2024, PROM to the right and left upper extremity seven times on the following dates: 9/5, 9/9 - 9/12/2024, 9/27, and 9/30/2024, and right and left knee extension splint assistance nine times on the following dates: 9/5, 9/7, 9/9 - 9/12/2024, 9/15, 9/27, and 9/30/2024. A review of Resident 84's Rehab Screen dated 10/10/2024 indicated the resident maintained functional task performances and bilateral upper and lower extremity ROM. The screen indicated Resident 84 would benefit from continued restorative nursing program to maintain current functional task performances. A review of Resident 84's Documentation Survey Report for October 2024 indicated the resident received PROM to the right and left lower extremity six times on the following dates: 10/3, 10/5, 10/9, 10/10, 10/14, and 10/17/2024, PROM to the right and left upper extremity five times on the following dates: 10/3, 10/9, 10/10, 10/14, and 10/17/2024, and right and left knee extension splint assistance five times on the following dates: 10/3, 10/5, 10/9, 10/10, 10/14, and 10/17/2024. During a concurrent record review and interview, on 10/18/2024 at 9 AM, Resident 84's Documentation Survey Report for September 2024 and October 2024 were reviewed with the Director of Nursing (DON). The DON stated and confirmed Resident 84 was on the RNA program for the following: PROM to the lower extremity seven times as tolerated, PROM to the upper extremity [NAME] time a week as tolerated, and bilateral knee splint assistance seven times a week for two hours as tolerated. The DON confirmed Resident 84 received RNA services to the lower extremity nine times in the month September 2024, RNA services to the upper extremity seven times in the month of September 2024, and assistance with the knee splints nine times in the month September 2024. The DON stated Resident 84 received RNA services to the lower extremity six times from October 1 to 17, 2024, RNA services to the upper extremity five times from October 1 to 17, 2024, and assistance with the knee splints six times from October 1 to 17, 2024. The DON stated based on the documentation, the staff were not following Resident 84's RNA Program. The DON stated it was important to follow the residents RNA Program to maintain mobility because there was a risk for a decline in mobility. A review of the facility's policy and procedure (P&P) titled, Restorative Nursing Program, revised 3/2024, indicated it was the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. The policy indicated restorative aides will implement the plan for a designated length of time, performing the activities, and documenting the electronic health record.

Based on interview and record review, the facility failed to provide an environment free from accident hazards to prevent avoidable accidents for one of two sampled residents (Resident 306), who was admitted to the facility with a history of falls and was at continued risk for falls, by failing to: -Accurately assess Resident 306's risk for falls dated 9/10/2024. -Evaluate and analyze fall risk hazards, implement individualized interventions to reduce risk of falling, and monitor for effectiveness of interventions. -Reevaluate and update individualized interventions to prevent recurrent falls after Resident 306 fell on ,d+[DATE] and 9/17/2024. -Ensure Resident 306 was not left without staff supervision in the facility patio. As a result, on 9/16/2024 Resident 306 stood up from the wheelchair in front of the nurse's station and fell . On 9/17/2024, Resident 306 was left alone in the wheelchair with a family member and Resident 306 fell again from the wheelchair. These deficient practices placed Resident 306 at increased risk for recurrent falls and complications related to fall injuries such as fractures, cuts, and internal bleeding. Findings: A review of Resident 306's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), history of falling, and wedge compression of the second to fourth lumbar vertebrae (a type of spinal compression fracture that occurs when the front of a vertebra collapses, giving it a wedge shape). A review of Resident 306's Fall Risk assessment dated [DATE] indicated the resident had a total score of 17 and was at risk for falls. A review of Resident 306's care plan for at risk for fall injury dated 7/13/2024, indicated intervention for facility staff included to monitor the resident for behavioral issues manifested by restlessness and agitation. A review of Resident 306's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/16/2024 indicated the resident's cognition (the ability to think and process information) was severely impaired and had a history of a fall in the month prior to admission to the facility. A review of Resident 306's Fall Risk assessment dated [DATE] indicated the resident had a total score of 17 which placed the resident at risk for falls. The assessment indicated no falls in past three months under the section titled History of Falls. A review of Resident 306's care plan regarding 9/10/2024 resident had an actual fall with no injury dated 9/10/2024 indicated to continue interventions on the at-risk plan. A review of Resident 306's Interdisciplinary Team (IDT, a team of health care professions, which include the facility's medical director, Director of Nursing (DON), social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents) Progress Note dated 9/11/2024 indicated the resident had a fall on 9/10/2024 at the nursing station. The IDT progress note indicated Resident 306 was observed standing up from the wheelchair, lost balance, and fell . The IDT Progress Note indicated a recommendation to continue rehab treatment, continue to encourage the resident to call for assistance when transferring, frequently check the resident (did not indicate the frequency) when up in the wheelchair, continue falling star program, and follow up with psychiatric doctor. A review of Resident 306's At Risk for Fall Injury care plan dated 9/11/2024 indicated interventions to continue rehab treatment, continue to encourage the resident to call for assistance when transferring, frequently check the resident when up in the wheelchair, continue falling star program, and follow up with psychiatric doctor. A review of Resident 306's Nurse Progress Note dated 9/16/2024 indicated the resident had a fall by the nurse's station. The note indicated an unidentified staff member observed Resident 306 stand from the wheelchair with an unsteady gait and fall to the floor. A review of Resident 306's Fall Risk assessment dated [DATE] indicated the resident had a total score of 21 and was at risk for falls. A review of Resident 306's Progress Note dated 9/17/2024 indicated the resident was sitting on the wheelchair in the patio with a family member. The note indicated on 9/17/2024 at about 3:30 PM, a staff member found Resident 306 sitting on the ground. The note indicated Resident 306 reported she had fallen. A review of Resident 306's IDT Progress Note dated 9/19/2024 indicated the resident had a fall incident on 9/16/024 and 9/17/2024. The IDT recommended to continue rehab treatment, continue to encourage the resident to call for assistance when transferring, frequently check the resident when she was up in the wheelchair, continue fall star program, and follow up with psychiatric doctor. A review of Resident 306's At Risk for Fall Injury care plan dated 9/19/2024 indicated interventions to continue rehab treatment, continue to encourage the resident to call for assistance when transferring, frequently check the resident when up in the wheelchair, continue falling star program, and follow up with psychiatric doctor. During an interview on 10/17/2024 at 3:40 PM, Registered Nurse (RN) 3 stated Resident 306 had a witnessed fall on 9/16/2024 in front of the nurse's station. RN 3 stated the resident had another fall on 9/17/2024. RN 3 stated on 9/17/2024, Resident 306 was calm and sitting in her wheelchair outside in the patio with a family member. RN 3 stated she did not think Resident 306 needed frequent monitoring. RN 3 stated she saw Resident 306 at 3:30 PM and at about 3:41 PM, another staff member reported Resident 306 had fallen in the patio. During a concurrent record review and interview with the Director of Nursing (DON) on 10/18/2024 at 11:01 AM, Resident 306's Fall Risk assessment dated [DATE] was reviewed. The DON stated the fall risk assessment was incorrect because the second question was answered incorrectly and should have indicated 1-2 or more falls in past 3 months and would have resulted in a higher fall risk score. The DON stated the higher number would indicate the resident had a higher risk for falls. The DON stated it was important to have an accurate fall assessment for residents to prevent falls. During a concurrent record review and interview with the DON on 10/18/2024 at 11:15 AM, Resident 306's Interdisciplinary Progress Note dated 9/11/2024 was reviewed. The DON stated the recommendation of frequently checking the resident when up in the wheelchair was included in the care plan. The DON stated frequent checking meant staff would visually check the resident when rounding or providing care. The DON stated the intervention was broad and should have indicated a frequency of how often to check the resident. The DON stated there was no documentation to show that Resident 306 was frequently checked when she was up in the wheelchair. The DON stated it was important to frequently check the resident to prevent falls and to have specific interventions that included a frequency to ensure the resident was getting the supervision needed. During a concurrent record review and interview with the DON on 10/18/2024 at 11:15 AM, Resident 306's Interdisciplinary Progress Note dated 9/19/2024 was reviewed. The DON stated the IDT met to discuss Resident 306's fall on 9/16/2024 and 9/17/2024. The DON stated during the meeting, IDT discussed more frequent visual checking of the resident while in the wheelchair. The DON stated Resident 306's falls occurred while the resident was in the wheelchair. The DON confirmed there were no new interventions from the IDT meeting on 9/19/2024 and there were no new interventions added the care plan. The DON stated it was important to determine new interventions to prevent the resident from falling. A review of the facility's policy and procedures (P&P) titled, Fall Prevention Program, revised 3/2024 indicated each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy indicated each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive care plan and the plan of care will be revised as needed. The policy indicated the at-risk protocols included additional services as directed by the resident's assessment, including but not limited to increased frequency of rounds. A review of the facility's P&P titled, Comprehensive Care Plans, revised 3/2024, indicated the comprehensive care plan will describe resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated.

Based on observation, interview, and record review, the facility failed to ensure one opened vial of Novolin R (a medication used to control blood sugar) was labeled with an open date per the manufacturer's requirements in one of two inspected medication carts (West Medication Cart.) The deficient practices of failing to store or label medications per the manufacturers' requirements increased the risk that residents could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation on [DATE] at 11:06 AM of [NAME] Medication Cart, with the Licensed Vocational Nurse (LVN 1), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: -One opened vial of Novolin R was found stored at room temperature and not labeled with an open date. According to the manufacturer's product labeling, once stored at room temperature, vials of Humulin R were to be used or discarded within 42 days. During a concurrent interview, LVN 1 stated the Novolin R was opened, but not labeled with an open date. LVN 1 stated without an open date, there was no way to know when the product would expire because the expiration date could not be determined, nor exactly how long the Novolin R had been stored at room temperature. LVN 1 stated if expired insulin was administered to a resident, expired insulin could cause medical complications due to poor blood sugar control. A review of the facility's policy titled, Medication Storage, revised [DATE], indicated to ensure all medications housed on our premises will be stored in the pharmacy and / or medication rooms according to the manufacturer's recommendations. A review of the facility's policy titled, Labeling of Medications and Biologicals, revised [DATE], indicated labels for multi-use vials must include the date the vial was initially opened or accessed (needle punctured). All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Based on observations, interviews, and record reviews, the facility failed to provide supervision to one of three sampled residents (Resident 1), who had history of falls, diagnosis of fractured thigh bone, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), received the care, treatment and services to prevent falls. The facility failed to: -Provide the correct level of assistance (two or more while eating) per the comprehensive assessment and the fluid imbalance care plan. - Implement a comprehensive person-centered fall care plan to include supervision of Resident 1 to prevent falls. As a result, on 1/7/2024, at 7 PM, Resident 1 fell from her bed and sustained a second acute fracture of the right radius (the thicker and shorter of the two long bones in the forearm) and a fracture of the ulna (the other of the two bones which make up the lower forearm). Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including displaced fracture of the base of neck of right femur (a break in the uppermost part of thighbone, next to hip joint), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), difficulty in walking, age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases), and history of falling. A review of Resident 1's Risk for Injury Care Plan initiated on 11/2/2023, indicated this risk was related to poor body control secondary to right displaced femoral neck fracture, poor safety awareness secondary to impaired cognition, unsteady gait, advanced dementia, unclear speech and trying to get out of bed without assist. The care plan indicated the goals for Resident 1 were to provide preventive intervention to minimize injury potential. The care plan interventions indicated to assist with transfer and ambulation, to be sure the resident's call light was within reach, to keep area clutter free and well-lit and to encourage the resident to use call light for assistance as needed. The care plan interventions indicated to apply floor bed, to apply blue pad on both sides of the bed and provide meal tray table during mealtime. The care plan did not indicate supervision was required for Resident 1. A review of Resident 1's Risk for Fall Care Plan initiated on 11/3/2023, indicated this risk was related to trying to get out of bed without assistance. The goal for Resident 1 was to provide preventive intervention to minimize potential injury. The care plan interventions indicated to apply floor bed, blue pads on both sides of the bed, and to provide a meal tray table during mealtime. The care plan did not indicate supervision was required for Resident 1. A review of the Fall Risk assessment dated [DATE], indicated Resident 1 had was at risk for fall. The Fall Risk Assessment indicated Resident 1 was disoriented x3 at all the times, had no falls in the past three months, was chair bound -required assist with elimination, had a decreased muscular coordination, unsteady gait, required the use of an assistive device, took three or more medications currently and/or within the last seven days, and had three or more predisposing disease present (advanced dementia, osteoporosis, fractures). The Fall Risk Assessment did not indicate whether Resident 1 was low or moderate risk for falls. According to a review of the History and Physical (H&P) dated 11/4/2023, Resident 1 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/6/2023, indicated Resident 1 had severely impaired cognition (decisions poor; cues/supervision required). The MDS indicated Resident 1 was dependent on assistance of two or more for eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, personal hygiene and on chair-to-bed transfer. A review of the Fluid Imbalance Care Plan (potential for dehydration), initiated on 11/3/2023, indicated Resident 1 was at risk related to displaced femoral neck fracture, dementia and osteoporosis. The care plan indicated Resident 1 was total dependent for all meals due to mental status and the care plan interventions indicated to provide assistance with meals. A review of Situation Background Assessment Resolution Communication Form (SBAR) dated 1/7/2024 indicated Resident 1 was found on the floor in supine position (on her back, face upward) near her bed at 7 PM. The SBAR form indicated there was no change in level of consciousness (LOC), no complaints of pain, no swelling on affected site. The SBAR indicated there was slight purplish color on right forearm, no skin tear or active bleeding observed. According to a review of the Progress Note dated 1/7/2024 at 7 PM, the Certified Nursing Assistant (CNA 1) reported to the Licensed Nurse (LN 1) that Resident 1 was found on the floor in her room. The Progress Note indicated LN 1 went to Resident 1's room and found the resident in the middle of the floor in supine position and performed head-to-toe body assessment. The Progress Note indicated there was slight purplish discoloration noted on right forearm, ice pack applied. The Progress Note indicated Resident 2 witnessed when Resident 1 was eating dinner on the bed and suddenly Resident 1 tried get out of the bed, lost her balance, and started crawling toward Resident 2. The Progress Note did not indicate Resident 1 had assistance while eating dinner. A review of Progress Note dated 1/8/2024, indicated Resident 1 was on monitoring for observed on floor. The nursing note indicated at 4:30 AM the resident had swelling with slight skin discoloration on right forearm, Resident 1 complained of pain on the affected area, and a stat X-ray was ordered at 4:50 AM. A review of Radiology Report dated 1/8/2024, Resident 1's findings indicated: There is a fracture of the distal radius with minimal impaction. There is minimally separated of the styloid ulna fracture. Fractures appears to be acute or subacute. A review of the Physician's Order dated 1/8/2024 at 9:24 AM, indicated to transfer Resident 1 to the General Acute Care Hospital (GACH) for fracture of the distal radius and distal ulna. A review of the Physician's Progress notes, dated 1/11/2024, indicated Resident 1 had a fracture of the right distal radius and to continue using the current splint. On 1/18/2023 at 3:15 AM, during a phone interview, CNA 1 stated she was walking past Resident 1's room when the call light went on and she saw Resident 1 on the floor in supine position. CNA 1 stated Resident 1 was confused and was not able to say what happened. CNA 1 stated she called the charge nurse to report what she saw. CNA 1 stated during dinner time Resident 1's bed was raised to serve the dinner on the bedside table. During an observation on 1/18/2023 at 12:50 PM, Resident 1 was observed in her room with the bed in the lowest position with floor mats to the left and right side of the bed. Resident was observed with splint on her right forearm. During an observation on 1/18/2023 at 12:55 PM, Resident 2 was observed sitting in wheelchair next to her bed. During a concurrent interview Resident 2 stated that a few days ago she saw Resident 1 was eating dinner on the bed and suddenly Resident 1 tried get out of the bed, lost her balance, and started crawling toward Resident 2. Resident 2 stated that she pushed call light for assistance when she noticed Resident 1 on the floor. On 1/18/2024 at 3:20 PM, during a phone interview, CNA 1 stated she was taking care of Resident 1 on 1/7/2024 and that during mealtime CNA 1 would raise Resident 1's bed to set up the dinner tray on the bedside table. CNA 1 stated that she was providing frequent visual checks on Resident 1, but she was not aware that Resident 1 needed constant supervision during her mealtime. CNA 1 stated she was walking past Resident 1's room when the call light went on and she saw Resident 1 on the floor in a supine position. CNA 1 stated Resident 1 was confused and was not able to say what had happened. CNA 1 stated she called the charge nurse to report what she saw. On 1/18/204 at 3:59 PM, during concurrent interview and record review with Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 1's MDS dated [DATE]. The MDSC stated that section GG of the MDS indicated Resident 1 was dependent on assistance of two or more helpers for eating. During an observation on 1/18/2023 at 4:30 PM, with the DON, Resident 1 was observed in her room on the floor bed with floor mats to the left and right side of the bed. Resident 1 was observed eating dinner served on a new bedside table without raising the floor bed and eating dinner without any assistance. During a concurrent interview, the DON stated they were not raising the floor bed for Resident 1 during mealtime anymore and that the resident can eat dinner without assistance, even with a splint on. A review of the facility's policy and procedure titled, Fall Risk Assessment, reviewed 12/19/2023, indicated to provide an environment that was free from accident hazards, provide supervision and assistive devices to each resident to prevent avoidable accidents. A review of the facility's policy and procedure titled, Fall Prevention Program, reviewed 12/19/2023, indicated to provide intervention that addresses unique risk factors measured by the risk assessment tool: medications, psychosocial, cognitive status, or recent changes in functional status. Provide additional intervention as directed by the resident's assessment, including but not limited to assistive devices, increased frequency of rounds, sitter if indicated. A review of the facility's policy and procedure titled, Comprehensive Care Plans, dated 12/19/2022 indicated to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing and psychosocial needs that are identified in the resident's comprehensive assessment. The policy indicated the comprehensive care plan would describe at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The policy indicated qualifies staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out the interventions initially and when changes are made.

Based on interview and record review, for one of three residents (Resident 1), the facility failed to protect Resident 1's right to be free from physical abuse by a Certified Nursing Attendant (CNA) in accordance with the facility's policy and procedures (P&P) titled Abuse, Neglect and Exploitation dated 12/19/2022. As a result, Resident 1 suffered a right femur (bone in the thigh) fracture (cracking or breaking of a bone) on 10/15/2023 and was transferred to a general acute care hospital (GACH) for further evaluation and management on 10/15/2023 at GACH at 5:15 PM. On 10/16/2023 Resident 1 had open reduction internal fixation (ORIF-surgical procedure that puts pieces of a broken bone into place using screws, plates, or rods that are used to hold the broken bone together) to repair the right femur fracture. Findings: A review of Resident 1's admission record, indicated Resident 1 was admitted to the facility (skilled nursing facility [SNF]) initially on 11/5/2021 with a readmission to the facility on [DATE] with diagnoses that included cerebral infarction (lack of blood supply to the brain causing damage to the brain) with left sided weakness, bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs and lows), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), restlessness (the inability to rest or relax as a result), agitation and contracture (a condition of shortening and hardening of muscles or other tissue, often leading to deformity [disfigurement or distortion ]) of the left knee. The admission record did not indicate Resident 1 had osteoporosis (brittle/fragile bones). A review of Resident 1's history and physical dated 11/29/2022, indicated Resident 1 did not have the capacity to understand and make decisions on her own. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/11/2023, indicated Resident 1's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) is severely impaired. Resident 1 required one person physical assist with bed mobility, transfer, eating, toilet use and personal hygiene. A review of Resident 1's care plans did not reveal Resident 1 had kicking or thrashing behavior. A review of Resident 1's Change of Condition (COC- a deterioration in health, mental status, or psychosocial [mental, emotional, social, and spiritual health] status) form, dated 10/15/2023, indicated that on 10/15/2023 at 4:20 PM, Resident 1 was noted to have a misaligned (having an incorrect position or alignment) right thigh with a fracture was suspected. Resident 1 unable to move the right leg. Resident 1 complained of moderate pain, 4 out of 10 (4/10) pain level, using the numeric pain scale (numeric pain scale of 0 to 10 pain level with 0 as no pain, and score of 10, the highest level of pain). Resident 1 was administered Tylenol (medication given for pain). Resident 1's medical doctor (MD) ordered to transfer Resident 1 to a General Acute Care Hospital (GACH) for higher level of care (further evaluation and management). A review of Resident 1's Transfer Form (facility initiated form to inform the GACH of resident current condition) dated 10/15/2023 at 5:15 PM, indicated Resident 1 transferred to GACH via Emergency Medical Services (EMS-ambulance emergency services or paramedic services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) due to suspected fracture of the right thigh. A review of Resident 1's emergency room (ER - department/unit of the GACH for initial assessment and treatment) Physician note, dated 10/15/2023, indicated Resident 1 presented with right leg swelling with significantly deformed right distal femur fracture. The ER notes indicated the mechanism of the fracture was unclear and a concern for possible neglect/elder abuse. The ED notes indicated x-ray (a specialized image of a body part) of the right femur showed Resident 1 had displaced femur fracture, considering this traumatic (caused by various forces from outside of the body, which can either be blunt or penetrating [sharp]) injury, will do board imaging (expanded pictures of the body) to evaluate for any other traumatic injuries Consultation with orthopedic physician (a doctor who specializes in part of the human body that includes your bones, cartilage, ligaments, tendons and connective tissues injuries), x-ray results impression showed moderate to severely displaced comminuted (bone that is broken in at least two places) fracture of the midshaft of the right femur for [Resident 1]. A review of Resident 1's GACH Xray report dated 10/15/2023 at 8:24 PM, indicated Resident 1 had a moderate to severely displaced comminuted extra-articular (outside of the joint) fracture of the mid shaft of the right femur. A review of Resident 1's GACH Operative Report dated 10/16/2023, indicated Resident 1 had a right femur ORIF completed under general anesthesia (a method of medically inducing loss of consciousness that renders a patient unarousable even with painful stimuli) to repair the right femur fracture. A review of Resident 1's GACH Discharge Summary dated 10/20/2023, indicated Resident 1 had right femur ORIF completed on 10/16/2023 and was tolerated well. Complicated with metabolic encephalopathy (commonly defined as an alteration in consciousness caused due to brain dysfunction) after surgery .Day of discharge had no significant complaints and agreeable to plan of discharge. [Resident 1] was discharged back to the facility [SNF] on 10/20/2023 . During an interview on 10/24/2023 at 1:45 PM with Resident 1's responsible party (RP) 1, RP 1 stated that she was very involved in her Resident 1's care. RP 1 stated that she visits Resident 1 at the SNF twice a day on most days. RP 1 stated that on 10/15/2023 at 2 PM, she arrived at the facility to be with Resident 1. RP 1 stated she left the faciity on [DATE] at around 3 PM. RP 1 stated that on 10/15/2023 at around 4 PM, she received a call from the SNF informing her that Resident 1 was being transferred to GACH following an injury to the right leg. RP 1 stated that she went directly to the GACH ED on 10/15/2023 and met with Resident 1. RP 1 stated that she observed that Resident 1's right thigh had a deformity. RP 1 stated that when she last saw Resident 1 at the SNF on 10/15/2023 at around 3 PM, Resident 1 did not have a deformity of the right thigh. RP 1 stated that she asked Resident 1 what happened to Resident 1's right leg to which Resident 1 said, the big lady referring to Certified Nurse Assistant 1 (CNA 1), hit my leg while demonstrating a hitting motion with her [Resident 1's] hand. During an interview on 10/24/2023 at 3:15 PM with CNA 2, CNA 2 stated that she was working the day shift (7AM to 3PM) on 10/15/2023 and was assigned to provide care to Resident 1. CNA 2 stated that on 10/15/2023 at around 10:20 AM, she placed Resident 1 in a wheelchair (WC) and then wheeled Resident 1 to the patio area. CNA 2 stated stayed with Resident 1 while Resident 1 drank coffee and ate a cookie. CNA 2 stated that she placed Resident 1 back into bed around 10:45 AM. CNA 2 stated that RP 1 arrived at the SNF at around 2 PM on 10/15/2023 and that RP 1 stayed with Resident 1 until 2:40 PM on the same day. CNA 2 stated she checked on Resident 1 at 2:45 PM to see if Resident 1 needed to be cleaned/provided care prior to CNA 2 ending her shift at 3 PM. CNA 2 stated that she did not observe Resident 1's right leg deformity at any time during her the 7AM to 3PM shift. During an interview on 10/24/2023 at 3:32 PM with LVN 1, LVN 1 stated he worked on 10/15/2023 on 3PM to 11PM shift. LVN 1 stated he was the charge nurse for Resident 1. LVN 1 stated that on 10/15/2023 around 4 PM, he was sitting at the nursing station far from Resident 1's room. LVN 1 stated CNA 1 came and told him that Resident 1 had a loose leg (not firmly or tightly fixed in place). LVN 1 stated that he went to Resident 1's room right away and found Resident 1 lying on her back with her head slightly elevated and her right foot was rotated in towards her left leg. LVN 1 stated Resident 1's right thigh, was curved. Not normal appearing and called the Registered Nurse Supervisor (RNS). LVN 1 stated he observed a new (clean and unused) incontinent brief (a product designed to help manage urinary or bowel output) at the foot of Resident 1's bed. LVN 1 stated Resident 1 was yelling in pain. LVN 1 stated Resident 1's skin was intact, no bleeding or redness observed. LVN 1 stated RNS came to the bedside of Resident 1. LVN 1 stated that CNA 1 stated that Resident 1 was like that when she entered the room. LVN 1 stated that he asked Resident 1 what happened but Resident 1 said she was in pain. LVN 1 stated that RNS called a medical doctor (MD). LVN 1 stated that he administered Tylenol (medication for pain) to Resident 1 for pain control for 7 out of 10 pain level. LVN 1 stated that EMS arrived and transferred Resident 1 to the GACH. During an interview translated by RP 1 on 10/25/2023 at 11:23 AM, Resident 1 stated the big lady, referring to CNA 1, came into her room, placed her leg onto the bedrail on the right side of the bed and hit her leg. Resident 1 stated that she asked CNA 1 why she was doing this to her. Resident 1 stated that she [Resident 1] did not do anything to CNA 1. During an interview on 10/26/2023 at 3:15 PM with RNS, RNS stated that on 10/15/2023, she was working the afternoon (3 PM to 11 PM) shift as the RNS. RNS stated that on 10/15/2023 at around 4:10 PM, she received a call from LVN 1 that something was wrong with Resident 1's right leg. RNS stated she went quickly to Resident 1's room and found LVN 1 and CNA 1 in Resident 1's room. RNS stated that she observed Resident 1 lying on her back with the head of the bed slightly elevated. RNS stated Resident 1 had a right leg deformity. RNS stated Resident 1 stated Resident 1 was in pain at a pain level of 4 /10. RNS 1 stated she contact the MD who ordered for Resident 1 to be transferred to GACH. During an interview on 10/26/2023 at 3:35 PM with CNA 1, CNA 1 stated she was assigned to work on the evening shift (3 PM to 11 PM). CNA 1 stated she arrived late at work on 10/15/2023 at 3:45 PM. CNA 1 stated she her assignment included Resident 1. CNA 1 stated she went to provide care to Resident 1 around 4 PM and when she entered Resident 1's room, she observed Resident 1 lying on her bed without clothes on and had removed her incontinent brief. CNA 1 stated that initially she did not notice any deformity on Resident 1's right leg or if Resident 1 was in pain. CNA 1 stated Resident 1 did not complain of any pain when CNA 1 entered Resident 1's room. CNA 1 stated she went to Resident 1's left side of the bed, turned Resident 1 onto the left side and noticed Resident 1's right leg was loose. CNA 1 stated that once she noticed Resident 1's right leg was loose, she went and informed LVN 1. CNA 1 stated she did not remember how long she was in Resident 1's room for. CNA 1 stated that she did not turn Resident 1 to Resident 1 left side. During an interview on 10/26/2023 at 4:05 PM with the Director of Nursing (DON), the DON stated that on 10/15/2023 at around 4 PM, RNS informed him that Resident 1 had an injury of unknown origin to the right leg. The DON stated he right away informed the Administrator (ADM) and Social Services Director (SSD). The DON stated the RNS told him that she received MD's order to transfer Resident 1 to GACH. The DON stated CNA 1 and LVN 1 were suspended until the investigation on how Resident 1 sustained a fracture of the right femur was completed. The DON stated during facility's investigation interview, CNA 1 explained that when she entered the room on 10/15/2023, CNA 1 noticed Resident 1's right leg was misaligned. The DON stated he could not remember if CNA 1 informed him that CNA 1 had attempted to turn Resident 1. The DON stated that the facility was unable to determine how Resident 1 sustained a right femur fracture. During an interview on 10/26/2023 at 4:35 PM with the ADM, the ADM stated that on 10/15/2023 at around 4 PM (unsure of the exact time), the DON informed her that Resident 1 had an injury of unknown origin to the right leg. The ADM stated during facility's investigation all staff involved (CNA 1, CNA 2 and LVN 1) were interviewed. The ADM stated CNA 1 said that when she [CNA 1] entered Resident 1's room, CNA 1 noticed Resident 1's right leg was misaligned (incorrect position). The ADM stated that the ADM and the DON reviewed the facility's inhouse video footage, and that CNA 1 was observed entering room and exiting Resident 1's room on 10/15/2023 at around 4 PM. CNA 1 was observed exiting Resident 1's two to three minutes after entering the Resident 1's room. The ADM stated the facility was unable to determine how Resident 1 sustained a right femur fracture. The ADM stated, [CNA 1] will no longer be assigned to provide care for [Resident 1]. A review of the facility's P&P titled, Abuse, Neglect and Exploitation dated 12/19/2022, indicated, It is the policy of this facility protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written .Establishing a safe environment .The facility will have written procedure to assist staff in identifying the different types of abuse .Possible indicators of abuse include .Physical injury of a resident, of unknown source .Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received immediate basic life-saving support, including cardiopulmonary resuscitation (CPR, any medical intervention used to restart a person's heartbeat and breathing after one or both have stopped), as per the resident's representative wishes and not by the Physician Orders for Life Sustaining Treatment (POLST - is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) form the Social Services Director (SSD) asked Resident 1 to sign on [DATE] despite Resident 1 being confused, unable to make decisions, and having Family Member 2 (FM 2) as the resident's representative. The POLST indicated do no attempt resuscitation (DNR) and comfort focused treatment (refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort). As a result, on [DATE] at 11:40 a.m., when Resident 1 had no blood pressure reading, CPR was not attempted. Resident 1 was pronounced dead on [DATE], at 11:46 a.m. Because of the seriousness related to Resident 1's signing a POLST when impaired and against the Resident 1's representative wishes and not providing the necessary care and treatments, on [DATE], at 4:48 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) under the 42 Code of Regulation (CRF) S483.24 Quality of Life (F678) with the scope and severity of J (isolated) in the presence of the facility's Administrator, Company's lead DSD, Company's Chief Nursing Officer, and the Director of Nursing (DON). On [DATE], at 6:32 p.m., after the facility provided an acceptable IJ Removal Plan (interventions to correct the deficient practice), while onsite, the team confirmed the implementation of the immediate corrective actions through observation, interview, and record review. The SSA removed the IJ situation in the presence of the Administrator and the DON on [DATE], at 6:45 p.m. The IJ Removal Plan included the following summarized actions: a. On [DATE], the facility's Medical Director (FMD) was notified of the complaint visit and that an intent to cite was issued to the facility. b. On [DATE], the FMD was notified of the IJ situation. The DON, DSD, Lead DSD or designee completed a chart audit on every resident and compared the advance directives, including POLST/Advance Directive to the physician order for accuracy as well as resident's capacity to make decision. Six residents had the POLST signed by family member and not the responsible party. 1l residents with the capacity had the POLST signed by responsible party. The facility reached out to the responsible parties or spoke with residents respectively on [DATE]. c. Residents with change of condition for the past 24 hours were audited to ensure that responsible party and primary physicians were notified as indicated and that medical emergency response were implemented were indicated. d. On [DATE], the Resource Nurse Consultant provided one on one (ASS) on how to complete the POLST focusing on a resident's mental capacity to understand and make decision. Residents must be competent (have the mental capacity) to make medical decision. The SSD and ASS were inserviced on the facility's policy and procedures (P&P) and on notifying a resident's family member regarding any resident's POLST status whether Full Code, No Code or Comfort-Focused Treatment or Selective Treatment. e. The Resource Nurse Consultant and Lead DSD re-educated licensed nurses on the facility's P&P regarding the immediate notification of the attending physicians when a residents develops a significant change of condition (COC - a significant change) and how to complete the POLST/ Advance Directive focusing on a resident's mental capacity to understand and make decisions. A resident's family member must be notified of any resident's POLST status. f. By [DATE], the Resource Nurse Consultant and Lead DSD educated licensed nurses on the facility's P&P for medical emergency response including transfer to a General Acute Care Hospital respecting residents' wishes. g. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented on [DATE]. The DON or a designee to monitor for code status, resident's capacity to make decisions, COC timely notification of responsible party and primary physician and medical emergency response including transfer to a general acute care hospital (GACH) compliance for at least five resident's chart during their scheduled care conference meeting starting on [DATE]. h. The Medical Records Director (MRD) or designee to audit new admissions (residents) and to compare the resident's POLST, advance directives with resident's capacity to make decisions to the physician orders for accuracy. The audit trends will be reported and reviewed at the monthly QAA Committee meeting for three months or until substantial compliance is sustained. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on [DATE] with diagnoses including Alzheimer dementia (A progressive disease that destroys memory and other important mental functions), diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]), chronic kidney disease (CKD - a condition in which the kidneys are damaged and cannot filter blood as well as they should), and gastroenteritis (intestinal infection that includes symptoms such as watery diarrhea, stomach cramps, nausea or vomiting), and dysphagia (difficulty or abnormality of swallowing) oropharyngeal phase (characterized by difficulty initiating a swallow - occurring in the mouth and/or the throat). The Admission Record indicated FM 2 was Resident 1's representative. A review of Resident 1's Standard Admission Agreement, dated [DATE], indicated that on [DATE], FM 2 electronically signed the standard admission agreement as the legal representative for Resident 1. The standard admission agreement further indicated, The resident consents to routine nursing care ., as well as emergency care that is required. A review of Resident 1's POLST prepared on [DATE] indicated: - Section A Cardiopulmonary Resuscitation (CPR): Do not attempt resuscitation/DNR (allow natural death). - Section B Medical intervention: Comfort focused treatment - Section C Artificially Administered Nutrition: No artificially means of nutrition including feeding tubes (flexible tubes inserted in the nose or through the stomach for nutrition, medication, and hydration). - Section D Information and Signatures: discussed with patient (patient has capacity); Patient has no advance directives (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury). Resident 1 signed with a date of [DATE] overwritten on the date of [DATE]. However, the physician signed on [DATE]. The signature box indicated, I am aware that this form is voluntary. By signing this form, the person legally recognized acknowledges that this form regarding resuscitative measures is consistent with the known desires of. and with the best interest of. the individual who is the subject of this form. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated Resident 1 had moderately impaired cognition (a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 1 required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of the Physician's Order for Resident 1, dated [DATE], indicated DNR and comfort focused treatment. A review of the Physician's Order for Resident 1 dated [DATE], indicated to give intravenous fluid (IVF - administer into a vein) Dextrose (sugar) 5% with Sodium Chloride (salt) 0.9% solution (D5w/NS) at 50 milliliters (ml - unit of measurement) per hour (ml/hr) every shift for poor oral intake for five days. A review of Resident 1's nursing Progress Notes, dated [DATE] and timed at 8 a.m., indicated Resident 1 was in sleeping state, able to arouse, receiving IVF, and Resident 1's grandkids were at bedside. There was no documentation the licensed nurse called Resident 1's attending physician about the resident being in a sleeping state (asleep). A review of Resident 1's nursing Progress Notes, dated [DATE] and timed at 10:45 a.m., indicated Resident 1 was sleeping, able to open eyes, answer yes / no questions, and did not eat her breakfast. At 11 a.m., Resident 1 was noted with labored (difficult) breathing, her Oxygen (O2) Sat was 85%. Resident 1 was administered oxygen (O2) at 2 liters per minute (2L/min) through a nasal cannula (device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils). At 11:30 a.m., Resident 1's O2 Sat increased to 92%, the resident was still in a lethargic state (condition that involves deep and lasting drowsiness from which the person can be aroused only with difficulty), with a weak pulse, the heart rate was 67 beats per minute (bpm, normal rate ,d+[DATE] bpm), the breathing rate was 16 breath per minute (normal range 16 to 20 breaths/min), the blood pressure was ,d+[DATE] millimeters of mercury (mmHg - unit of measurement [normal blood pressure less than ,d+[DATE] mmHg), the body temp 97.8 degrees Fahrenheit ( F, normal range 97 F to 99 F), and the O2 Sat was 82%. FM 2 arrived and requested to transfer Resident 1 to hospital. Called 911 (telephone number for emergencies to request emergency medical services [EMS, paramedics - are healthcare professionals who respond to emergency calls for medical help outside of a hospital]) and came. At 11:40 a.m., the paramedics were unable to obtain Resident 1's blood pressure. At 11:52 a.m. unable to check apical pulse (taken in the left center of the chest, just below the nipple) and the resident was not breathing. Family at bedside. At 12 p.m., the paramedics called the police who arrived at 12:30 p.m. The police called and spoke to Resident 1's attending physician. Family called the mortuary and cleaned Resident 1's body. At 2:40 p.m., the mortuary picked up Resident 1's body. A review of Resident 1's SSD notes dated [DATE], a late entry for [DATE], indicated SSD communicated with FM 2 on [DATE] during a care conference and SSD informed FM 2 that Resident 1 clearly did not want to be full code (do CPR). SSD explained that if CPR was checked on the POLST, then a resident would receive full treatment, with the option of intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe) and advance respiratory interventions. FM 2 stated he would speak with Resident 1 and would get back to SSD. On [DATE], at 9:30 a.m., during a telephone interview, FM 1 stated that on [DATE], at 10:56 a.m., she was at Resident 1's bedside since earlier in the day. FM 1 stated Licensed Vocational Nurse 2 (LVN 2) checked on Resident 1 and told FM 1 that Resident 1 did not look well. LVN 2 checked Resident 1's vital signs (include blood pressure, heart and respiratory rate, body temperature). LVN 2 placed Resident 1 on oxygen and the bed in Trendelenburg position (the patient lays flat on the back on a ,d+[DATE]-degree incline with the feet elevated above the head). LVN 2 told FM 1 to call the rest of family members. FM 1 stated FM 2 arrived at the facility at 11:25 a.m. and asked the nurses if they had called 911 and Registered Nurse 2 (RN 2) provided FM 2 with Resident 1's POLST and asked FM 2 if he still wanted RN 2 to call 911. FM1 stated FM 2 questioned RN 2 about the validity of Resident 1's POLST document because FM 2 was Resident 1's legal representative. FM 1 stated FM 2 told RN 2 to call 911. FM 1 stated that when paramedics arrived, the paramedics told FM 2 that Resident 1 was pulseless (no heart beat) and unresponsive (not reacting when touched, spoken to, etc.) and asked if FM 2 wanted them to initiate CPR and FM 2 said no. FM 1 stated that FM 1, FM 2, and other family members visited Resident 1 every day and the staff did not inform any of them that Resident 1 had signed a POLST and was a DNR with comfort focused care. On [DATE], at 12:55 p.m., during an interview with RN 1 and concurrent review of Resident 1's POLST, RN 1 stated she was familiar with the care of Resident 1 and was aware the family was very involved in Resident 1's care, visited and checked on Resident 1 every day. RN 1 stated Resident 1 was deemed by the attending physician as unable to make decisions and could not sign a POLST (date not provided). On [DATE], at 1:25 p.m., during an interview, the SSD stated that on [DATE] the facility conducted interdisciplinary team (IDT - a group of health care professionals from various disciplines who work together on the care of the resident) care conference and she (SSD) informed FM 2 about the POLST Resident 1 signed. FM 2 stated he wanted CPR done for Resident 1 and he would discuss the signed POLST with Resident 1 and get back to SSD, but FM 2 did not get back to her (SSD). On [DATE], at 3:10 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 did not have the mental capacity to make decisions or consent to a POLST. On [DATE], at 10:34am, during an interview, RN 2 stated she was the supervisor on [DATE], when Resident 1 experienced a change of condition and subsequently died . RN 2 stated Resident 1 has a signed POLST for DNR and comfort measures and that was the reason they did not call the physician or paramedics. RN 2 stated that when the paramedics arrived, Resident 1 had no heartbeats and was not breathing. Paramedics asked FM 2, if he wanted the paramedics to initiate CPR but FM 2 declined. On [DATE], at 11:30 a.m., during an interview, LVN 2 stated that on [DATE], when she returned from her break at 10:59 a.m., she went to check Resident 1's blood sugar Resident 1 responded sluggishly to her compared to how Resident 1 was at 8 a.m. when LVN 2 last spoke to Resident 1. LVN 2 stated Resident 1's blood sugar was 441 milligrams per deciliters (mg/dl), and she administered Resident 1 a dose of 12 units of insulin (medication to decrease the blood sugar) as ordered and notified RN 2. LVN 2 stated when FM 2 arrived at the facility and yelled out loudly, why is no one doing anything? Did you call 911? On [DATE], at 10 a.m., during an interview, the SSD stated she and the assistant SS (ASS) interviewed Resident 1 regarding the POLST. The SSD stated the ASS spoke Resident 1's native language and also interpreted for the SSD. The SSD stated that during Resident 1's assessment interview, Resident 1 was able to state her name. The SSD stated Resident 1 said had a weak heart and knew that she was in a hospital but could not know which hospital. The SSD stated that based on Resident 1's response, she determined Resident 1 was capable of understanding and making decisions and SSD had Resident 1 sign the POLST. The SSD stated Resident 1 agreed to a DNR status with comfort measures only (refers to medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort). The SSD stated she did not review Resident 1's medical record to check if Resident 1 had the capacity to understand and make decisions. On [DATE], at 10:30 a.m., during an interview, the DON stated Resident 1 expired unexpectedly in the facility and paramedics pronounced (declared) Resident 1 dead on [DATE], at 11:46 a.m. On [DATE], at 11:15 a.m., during an interview, FM 2 stated on [DATE], the facility conducted an IDT meeting with him and discussed Resident 1's treatment plan, care plan plans and goals. FM 2 stated during the IDT meeting he expressed his desired goal for Resident 1 to eat more, get stronger, and return to the Assisted living Facility (AFL, housing and services for people who need some help with daily care) the resident lived before going to the hospital. FM 2 stated FM 1 called him on [DATE], at 11 a.m., to inform him Resident 2 did not look well and the nurses were asking for him (FM 2) to come to the facility. FM 2 stated he arrived at the facility at about 11:25 a.m. and asked the nurses if they had called 911 and RN 2 gave him Resident 1's POLST form. FM 2 stated RN 2 refused to answer when he questioned the validity of the POLST why no one had discussed Resident 1's POLST with him as the resident's legal representative and he was the signatory of all the other documents pertaining to Resident 1's admission to the facility. FM 2 stated when the paramedics arrived, Resident 1 was already dead and that is the reason he declined when paramedics asked him if he wanted them to initiate CPR. On [DATE], at 3:47 p.m., during an interview, the facility's Medical Director (FMD) stated a medical assessment is required to determine a resident's capability to understand and make decisions. The FMD stated it was important to involve the resident's family members in the care of the resident. The FMD stated if medical interventions have been attempted and a resident does not respond positively to the treatment/interventions, the resident should be transferred to a hospital for further evaluation and diagnostic tests to rule out any medical problems. A review of the paramedics Patient Care Report dated [DATE], indicated dispatch was notified at 11:30 a.m., paramedics arrived at Resident 1's bedside at 11:46 a.m., to find an [AGE] year-old female on bed supine (face up) unresponsive, apneic (not breathing), pale, pupils dilated (when the black/dark center of the eyes are larger than normal), non-responsive, pulseless, asystole (no heartbeat) on monitor. A review of facility's policy and procedures (P&P) titled, Informed Consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) dated [DATE] indicated, it is the responsibility of the healthcare professional who proposes any medical interventions or treatment that requires informed consent to provide information to the resident/resident representative regarding the resident's condition and circumstances that are pertinent to a decision to accept or refuse the proposed intervention or treatment. A review of the facility's P&P titled, Residents' Rights Regarding Treatment and Advanced Directives dated [DATE] indicated, In the event the resident is unable to formulate an Advance Directive (AD) due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and education to the resident representative. A review of facility's P&P titled, Residents' Rights Regarding Treatment and advanced Directives, dated [DATE], indicated, Policy Explanation and Compliance Guidelines: 1. a. In the event the resident is unable to formulate an Advance Directive (AD) due to cognitive impairment or deemed by the medical doctor that the resident is incapable of making decisions on his or her own, the facility will provide information and education to the resident representative.

Based on observation, interview, and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor / modify interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who had an amputation (removal of a limb) to right leg above the knee, the facility failed to provide a mattress or a blue floor pad on the floor to minimize injury from fall, per the care plan and failed to develop a fall policy. The facility also failed to identify environmental hazards of uneven floor for the residents. These deficient practices resulted in Resident 1 falling from her bed and sustaining a [MEDICAL CONDITION]. Cross reference F838 Findings: a. A review of Resident 1's Record of Admission indicated the resident was admitted to the facility, on 4/5/12. The admitting [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/10/19, indicated Resident 1 had cognitive impairment (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 1 required extensive assistance with bed mobility, transfers between surfaces (bed to wheelchair), and dressing. A review of the facility's incidents of falls, dated from 6/1/19 to 8/31/19, indicated the facility had a total of 70 falls with 44 of the falls occurring in resident's room (62.9%). The list indicated the following: -Falls for 6/19, there was a total of 18 falls, with 13 falls occurring in resident rooms (72%). -Falls for 7/19, there were 23 falls with 12 falls occurring in resident rooms (52%). -Falls for 8/19, there were 29 falls with 19 falls occurring in resident rooms (65.5%). On 9/3/19, at 9:02 a.m., during an interview and concurrent record review with the DON, she stated out of the 70 falls in the last three months, Resident 1's fall on 8/12/19 at 4:10 a.m., was with a major injury. A review of the care plan, dated 4/5/12, indicated Resident 1 was at risk for fall/injury related to poor body control secondary to poor safety awareness due to impaired cognition. The interventions indicated to provide Resident 1 with a mattress on the floor to minimize injury from fall. On 4/1/19, the care plan was revised to indicate Resident 1 was observed on the floor by the bed in a lying position. The revised interventions included to continue with the blue floor pad. The most recent evaluation of the care plan was on 7/23/19. A review of the Interdisciplinary (ID/group of facility staff from different areas of care) Resident Safety Investigation and Intervention form, dated 8/12/19 at 4:10 a.m., indicated Resident 1 was observed on the floor. The form indicated Resident 1 had the same incident five months prior, on 3/30/19. The form included eight sections for possible contributing factors for the incident. Under Section VIII: Review for current interventions, there was no documentation the current interventions were reviewed for implementation and effectiveness. On the back page of the form, not part of the preprint form format, included a hand written note that indicated Resident 1 was sometimes provided the mattress on the floor so resident can crawl on the mattress on floor mat. A review of the physician's order, dated 8/12/19, indicated Resident 1 received an X-ray for both hips stat (right away) after fall and to transfer Resident 1 to General Acute Care Hospital (GACH) for further evaluation. A review of the GACH note, dated 8/13/19, indicated Resident 1 was found on the floor with no witness and resident could not recall how it happen. On 8/16/19, Resident 1 underwent a surgery for [REDACTED]. On 10/15/19, at 4:52 p.m., during an electronic communication with the administrator, the administrator stated and verified the facility did not have a fall policy. The administrator stated the facility had an accident/incident policy. A review of the facility policy titled, Accident and Incident-Investigation and Reporting, dated 4/2016, included the policy on reporting, assisting during an accident/incident, medical attention, investigation action and documentation. Under the area for investigation, the policy indicated the Interdisciplinary Resident Safety Investigation and Intervention form should be completed. The Interdisciplinary Resident Safety Investigation and Intervention form failed to include the evaluation of the current intervention to prevent future incidents/accidents. On 10/17/19, at 6:45 a.m., during an interview with Certified Nursing Assistant 1 (CNA 1), she stated she found Resident 1 lying on the floor. CNA 1 stated there was no floor mat next to Resident 1's bed. CNA 1 stated she was not the regular staff assigned to Resident 1 and was not aware of Resident 1's behavior of getting out of bed unassisted. On 10/17/19, at 3:24 p.m., during an interview with the Director Of Nursing, she stated and verified Resident 1's care plan was not implemented for the floor mat on 8/12/19. The DON stated and verified the facility had no policy and procedure for falls to prevent future falls by evaluating the current interventions for effectiveness. b. On 9/3/18, at 7:18 a.m. to 8:40 a.m., during the inspection of the facility environment for hazards, the following was observed: -The West Station emergency exit had uneven floor before the ramp. -The doors across the Admission Office were labeled emergency exit and had uneven floor before the ramp. -Certified Nurse Assistant 1 (CNA 1) stated and verified the floor in room [ROOM NUMBER] was uneven due to the drain cover. On 9/3/19, at 11:30 a.m., during an interview with the Director of Nursing (DON), she verified the uneven floor at the exits and room [ROOM NUMBER], and stated it was a hazard to the residents. A review of the facility's policy and procedure titled, Accident and Incident Prevention revised 9/2007, indicated staff would perform safety inspection rounds to assess and correct safety risk factors.