Every finding on record at All Saints Healthcare Subacute

Based on observation, interview, and record review, the facility failed to:A. Ensure one of five sampled residents (Resident 18), who was investigated for pressure ulcers/injuries (also known as pressure sores and decubitus ulcers, localized damage to the skin and/or underlying tissue caused by prolonged pressure or friction, often over bony areas), received care consistent with professional standards of practice to prevent pressure ulcers and maintain skin integrity (the condition of the skin being intact, healthy and free from damage). Resident 18 had Moisture Associated Skin Damage (MASD - inflammation [becomes reddened, swollen or hot] or skin erosion [breakdown of outer layers of skin] caused by prolonged exposure to moisture-like urine, stool, sweat) on 10/28/2025, was assessed as at risk for developing pressure ulcers, required assistance with turning while in bed and while seated in a chair, and was incontinent of bowel and bladder (having no or insufficient voluntary control over urination or defecation) function. The facility failed to ensure that Resident 18 did not develop a pressure ulcer while in the facility and failed to provide appropriate treatment and services to maintain skin integrity by failing to:A1. Ensure licensed nurses, Licensed Vocational Nurses (LVNs), and Treatment Nurses (TNs) completed at least weekly evaluations of Resident 18's MASD skin breakdown and documented the findings, including a description of the MASD.A2. Ensure that Treatment Nurse 1 (TN 1) reported Resident 18's wounds to Medical Doctor 1 (MD 1 - Resident 1's physician) and Medical Doctor 2 (MD 2 - a wound care specialist physician), upon Resident 18's readmission on [DATE].A3. Ensure TN 1 followed up and obtained treatment orders from MD 1 and MD 2 on 10/28/2025 when MASD was identified on Resident 18's left buttock. A4. Ensure Certified Nurse Assistants (CNAs) repositioned Resident 18 every two (2) hours (hrs - a unit of measurement for time) and as needed.A5. Implement the facility's policy and procedure (P&P) titled, Decubitus Ulcer Prevention, last reviewed on 1/21/2025, which indicates the implementation of preventative measures and regular assessments to identify the presence of any pressure ulcers.These deficient practices resulted in the development of one facility-acquired pressure ulcer (a new, preventable skin injury that develops after a resident is admitted or readmitted , typically caused by unrelieved pressure or friction) for Resident 18, as identified by MD 2 on 1/20/2026. On 1/23/2026, MD 2 identified a stage 2 (partial thickness loss of skin, presenting as a shallow open sore or wound) pressure ulcer on Resident 18's left buttock.B. Provide care consistent with professional standards of practice to prevent pressure ulcers for four of five sampled residents (Resident 11, Resident 39, Resident 81, and Resident 72), who were at risk for pressure ulcer/injury, required assistance with turning while in bed and chair, were incontinent of bowel and bladder, by failing to:B1. Ensure pressure ulcer wound care treatment was administered and documented on 9/10/2025 and 9/11/2025 for Resident 11.B2. Set Resident 39's and Resident 81's low air loss mattress (LALM - a special type of air mattress that uses a constant, gentle flow of air through microscopic holes to keep the skin dry and prevent pressure wounds) according to weight and the physician's order.B3. Apply Resident 72's bilateral (both sides) heel protectors (a boot-like device that floats the heel off the mattress or other surface to entirely relieve pressure and prevent painful bedsores or pressure ulcers) while off of Ankle-Foot Orthosis (AFOs - a support intended to control the position and motion of the ankle and compensate for weakness or correct deformities).These deficient practices had the potential for development and worsening of pressure ulcers/injuries to Resident 11, Resident 39, Resident 81, and Resident 72.Findings: A. During a review of Resident 18's admission Record (AR), the AR indicated that the facility originally admitted Resident 18 on 12/7/2023 with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery) in hemisphere (sides of the cerebrum [area that controls movement, sensation, language, and thinking]), dysphagia (difficulty swallowing) following cerebral infarction (also known as stroke, loss of blood flow to a part of the brain), and hydrocephalus (the buildup of fluid in cavities deep within the brain called ventricles). During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 18 had the ability to understand others sometimes and rarely or never makes self understood. The MDS indicated Resident 18 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 18 was dependent on staff for bed mobility including rolling to the left and right. The MDS indicated Resident 18 had no unhealed pressure ulcer but was identified as being at risk for developing pressure ulcers. During a review of Resident 18's Clinical admission Screener (CAS – a pre-admission document used to evaluate a prospective resident's medical and physical needs to ensure the facility can provide appropriate care) form, dated 10/28/2025, the CAS form indicated Resident 18 had left buttock MASD. During a review of Resident 18's admission Progress Notes (APN - a comprehensive, written, or electronic document created by a provider upon a resident's entry into an inpatient facility that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 10/29/2025, the APN indicated Resident 18 did not have the capacity to understand and make decisions. The APN indicated that Resident 18's skin had no erythema (superficial reddening of the skin as a result of injury or irritation). During a review of Resident 18's Assessment of Decubitus Ulcer Potential (ADUP - a scoring tool used to predict a resident's risk of developing pressure ulcer, the higher the score, the greater the potential to develop decubitus ulcers), dated 12/24/2025, the ADUP indicated residents with a score above 12 should be considered at risk for developing pressure ulcers. The ADUP indicated Resident 18 scored 23. During a review of Resident 18's ADUP, dated 12/26/2025, the ADUP indicated Resident 18 scored 25. During a review of Resident 18's Physician Order, dated 1/19/2026, the Physician Order indicated the following treatment : Cleanse the Left Buttock open blister (bubble on the skin filled with clear, watery liquid or blood, usually caused by friction, rubbing, or burns) with normal saline (NS - sterile water used to cleanse and moisten wounds), apply moist gauze (a wound care product designed to absorb wound drainage and protect the wound), pat dry with dry gauze, apply xeroform (a moist yellow dressing that covers the wound and promotes wound healing) and cover with a foam dressing every day shift for one (1) Day, with the Wound Doctor to reassess on 1/20/2026. During a review of Resident 18's wound care Progress Note Details (PND), dated 1/20/2026, the wound care PND indicated that Resident 18 had the following wound: Left buttock open blister, measuring 1.6 centimeters (cm- a unit of measure) in length x (by) 1.5 cm in width x 0.1 cm in depth, with a small amount of serous (clear, thin, watery fluid that's typically pale yellow in color) drainage noted. During a review of Resident 18's Physician Order, dated 1/20/2026, the Physician Order indicated the following treatment: Cleanse the Left Buttock open blister with NS, apply moist gauze, pat dry with dry gauze, apply xeroform and cover with a foam dressing every day shift for 14 Days. During a review of Resident 18's wound care PND, dated 1/27/2026, the wound care PND indicated that Resident 18 had the following wound: Left buttock stage 2 pressure ulcer, measuring 1.2 cm in length x 0.8 cm in width x 0.2 cm in depth, with a moderate amount of serous drainage, and a wound bed (exposed tissue surface within a wound) 76 to 100 percent (%). During a review of Resident 18's Physician Order, dated 1/27/2026, the Physician Order indicated the following treatment: Cleanse the Left Buttock Stage 2 Pressure Ulcer with NS, apply moist gauze, pat dry, apply xeroform and cover with a foam dressing every day and as needed for 30 days. During a concurrent interview and record review on 1/27/2026 at 1:08 p.m., with TN 1, Resident 18's Physician Orders and Nursing Progress Notes from 10/28/2025 to 1/27/2026 were reviewed. TN 1 stated that there were no treatment orders and no monitoring for Resident 18's MASD on the left buttock during this period (10/28/2025 to 1/27/2026). TN 1 stated that Resident 18's progress notes indicated Resident 18's open blister on the left buttock was first identified on 1/19/2026 during perineal care (peri-care – gently washing the genitals [male or female reproductive organ] and anal [opening at the end of the digestive tract, where stool leaves the body] area to maintain hygiene, comfort, and prevent infection or skin irritation) provided by the CNAs. TN 1 stated a one-time wound treatment order was placed on 1/19/2026. TN 1 also stated that Resident 18 had an order to be evaluated by MD 2, a wound specialist physician, on 1/20/2026. TN 1 further stated that the open blister was classified as a stage 2 pressure ulcer. During a concurrent interview and record review on 1/27/2026 at 1:41 p.m., with TN 1, Resident 18's care plans in effect as of 1/27/2026 were reviewed. TN 1 stated there was no care plan developed for Resident 18's MASD on the left buttock identified on 10/28/2025. TN 1 further stated that the care plan titled Wound Management, last revised on 1/20/2026, did not include Resident 18's stage 2 pressure ulcer on the left buttock. TN 1 stated that she (TN 1) forgot to add the pressure ulcer to the care plan and should have been added on the day it was identified. TN 1 stated repositioning and turning the resident every 2 hours and as needed should be included in the care plan. TN 1 stated the purpose of the care plan is to manage the wound and ensure the resident does not develop an infection. TN 1 further stated that she (TN 1), along with the LVNs, and Registered Nurses (RNs) taking care of Resident 18, review the care plan interventions. During an interview on 1/27/2026 at 1:49 p.m. with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated she (CNA 2) is the assigned CNA for Resident 18 today, 1/27/2026. CNA 2 stated she (CNA 2) and another CNA (did not specify) reposition Resident 18. CNA 2 stated Resident 18 does not have any wounds on her (Resident 18) buttocks. CNA 2 stated she (CNA 2) usually repositions Resident 18 every two hours. CNA 2 stated she (CNA 2) sometimes does not reposition Resident 18 every two hours. CNA 2 stated it sometimes takes more than two hours to reposition Resident 18 because it is not possible. CNA 2 stated turning residents requires two people. During a concurrent interview and record review on 1/27/2026 at 2:10 p.m., with Registered Nurse 8 (RN 8), Resident 18's Physician Orders and Care Plans from 10/28/2025 to 1/27/2026 were reviewed. RN 8 stated that upon Resident 18's readmission on [DATE], she (RN 8), Treatment Nurse 2 (TN 2), and Licensed Vocational Nurse 4 (LVN 4) assessed Resident 18's skin. RN 8 stated TN 2 is responsible for measuring wounds, developing care plans related to skin and wound issues, contacting the wound care physician (referring to MD 2), and initiating wound treatment orders, if indicated. RN 8 further stated TN 2 should have developed a care plan for Resident 18's MASD on the left buttock and initiated the appropriate treatment orders. During a concurrent interview and record review on 1/27/2026 at 4:56 p.m., with TN 2, Resident 18's Physician Orders, Care Plans, and Nursing Progress Notes from 10/28/2025 to 1/27/2026 were reviewed. TN 2 stated that when she (TN 2) identifies wounds, redness, skin discoloration (any change in your natural skin tone) on residents, the charge nurse (RN) and the primary nurse (LVN), document the findings in the admission Notes, and the charge nurse enters orders for any identified skin issues. TN 2 stated she (TN 2) is not responsible for documenting findings in the admission Notes and that only the primary nurse and the charge nurse complete admission documentation. TN 2 stated she (TN 2) assists with wound measurements and wound treatments, depending on the Physician's Orders. TN 2 further stated that the charge nurse or whoever enters the order, is responsible for developing the care plan. TN 2 stated that only charge nurses are allowed to enter physician orders and that the charge nurse would contact the resident's primary physician or the wound care physician, who visits weekly. TN 2 stated when Resident 18 was readmitted on [DATE], she (TN 2) worked with the primary nurse (LVN 4), and the charge nurse (RN 8). TN 2 stated she (TN 2) did not document her (TN 2) findings because RN 8 and LVN 4 documented in their (RN 8 and LVN 4) notes. TN 2 stated she (TN 2) provided RN 8 and LVN 4 with the wound measurements and related details. TN 2 stated she (TN 2) did not call the wound care physician (MD 2) on 10/28/2025 for Resident 18. During a concurrent observation and interview on 1/28/2026 at 10:08 a.m., with TN 2, at Resident 18's bedside, observed TN 2 measured Resident 18's wounds. TN 2 stated Resident 18's stage 2 pressure ulcer on the left buttock measured at 1.5 cm in length x 1.2 cm in width x 0.2 cm in depth with a small amount of yellow drainage and granulation (the formation of new connective tissue and blood vessels [a network of hollow, elastic tubes that circulate blood throughout the body] that fill in a wound bed during the proliferative [rapid growth] phase of healing) with pinkish red wound edges. During a concurrent interview and record review on 1/28/2026 at 3:51 p.m., with TN 1, Resident 18's Wound Assessments and Nursing Progress Notes from 10/28/2025 to 1/28/2026 were reviewed. TN 1 stated there were no weekly skin assessments done prior to 1/20/2026. TN 1 stated weekly skin assessments should have been performed to monitor the left buttock's wound progress, determine whether it was improving or worsening, and because assessments are part of the facility's monitoring process. During a concurrent interview and record review on 1/29/2026 at 8:27 a.m., with LVN 4, Resident 18's admission summary, dated [DATE], timed at 3:10 p.m. was reviewed. The admission Summary indicated [MD 1] went to assess [Resident 18], new order of labs in [morning] and to continue previous orders and treatment. Orders noted and carried out. [Responsible party] . at bed side. LVN 4 stated she (LVN 4) did not communicate with MD 1 regarding Resident 18's admission orders. LVN 4 stated that RN 8 was the one who communicated with MD 1 regarding Resident 18's admission orders. During an interview on 1/28/2026 at 10:35 a.m., with MD 2, MD 2 stated that during rounds on 1/20/2026, he (MD 2) was notified of Resident 18's wounds. MD 2 stated he (MD 2) did not have any documentation or notes for Resident 18 prior to 1/20/2026. MD 2 stated Resident 18 is contracted (a condition in which a joint or body part becomes fixed in a bent or twisted position and cannot move through its full, normal range of motion). MD 2 stated that blisters located over pressure points that do not heal can progress to stage 2 pressure ulcers. MD 2 further stated treatments he (MD 2) would have recommended for Resident 18 included turning and repositioning while in bed. MD 2 stated residents should not remain on one side for prolonged periods and that regular turning is good clinical practice. During an interview on 1/29/2026 at 11:57 a.m., with RN 8, RN 8 stated she (RN 8) communicated with MD 1 regarding Resident 18's admission, on 10/28/2025, and wounds at that time (unable to recall specific date and time). RN 8 stated notifying the wound care physician (MD 2), should have been done by TN 2. RN 8 stated she did not call MD 2 to inform him (MD 2) of Resident 18's left buttock wounds. During an interview on 1/29/2026 at 12:26 p.m., with MD 1, MD 1 stated that he (MD 1) may have been in the facility and seen Resident 18 on 10/28/2025, but he (MD 1) does not have progress notes on 10/28/2025. MD 1 stated MD 3, the covering physician, saw Resident 18 the following day, on 10/29/2025. MD 1 stated the charge nurse would notify him (MD 1) when a resident is in the facility and requests orders. MD 1 stated MD 2, the wound doctor, would follow the resident and see the residents for wound evaluation. MD 1 stated the wound treatment nurses are usually on top of reporting wounds and they would tell him (MD 1) and MD 2 about the residents' wounds. During an interview on 1/29/2026 at 3:07 p.m. with the Director of Nursing (DON), the DON stated when a resident is admitted or readmitted to the facility, the licensed nurses complete a full body assessment, and if there are skin issues identified, the licensed nurses are responsible for notifying the wound (treatment) nurse. The DON stated the communication goes from the primary nurse (LVN) to the treatment nurse, and the TN communicates to the charge nurse (RN). The DON stated the charge nurses are usually the ones directly communicating to the physician, but all of them RN 8, LVN 4, and TN 2, did not do anything about Resident 18's wound, there was a communication gap, and the wound was not documented. The DON stated it was a miscommunication on the facility's part. The DON stated the facility did not document the communication between RN 8, LVN 4, TN 2, MD 1, and MD 2; therefore, the communication was not done. The DON stated TNs should be responsible for communicating and informing the wound care physician, as TNs conduct weekly wound rounds (visits). The DON stated the wound care physician rounds weekly and should have been notified of Resident 18's left buttock MASD. The DON stated that the swelling and redness on Resident 18's left buttock should have been measured and assessed weekly to monitor if the MASD is healing and to track the progress. The DON stated measuring and checking are part of the facility's decubitus ulcer prevention practices. The DON stated that upon admission, the facility also takes photographs of wounds at the discretion of the TNs. The DON stated the primary nurses also document wounds during daily skin assessments or in their nursing progress notes. During a concurrent interview and record review on 1/29/2026 at 3:25 p.m., with the DON, the facility's P&P titled, Decubitus Ulcer Prevention, last reviewed on 1/21/2025, was reviewed. The DON stated the TN is responsible for developing the care plan upon identification of a wound including pressure ulcer. The DON stated she (DON) was not aware of Resident 18's left buttock stage 2 pressure ulcer or the left buttock MASD on readmission. The DON stated TN 2 should have communicated with RN 8 that the wound care physician needs to be notified and that she (TN 2) should have documented the communication for Resident 18's left buttock MASD. The DON further stated TN 2 should have developed the care plan for Resident 18's MASD immediately and followed through with interventions. The DON stated that because TN 2 did not develop the care plan, MD 2 was not notified, and there was no follow-through for Resident 18's wounds. The DON stated that the care plan should have been updated to reflect the current approaches to wound care. The DON stated wound treatment care plan interventions are usually updated every 2 weeks, and skin and wounds are assessed weekly by the TN. The DON stated if a resident has a wound, the wound care physician follows up weekly. The DON stated that without a care plan developed, a resident's wounds can worsen. The DON stated Resident 18's left buttock MASD had not been noted, and the wound care physician had not been called. The DON stated Resident 18's stage 2 pressure ulcer on the left buttock was avoidable and that this was the first time Resident 18 had a pressure ulcer of this type. The DON stated that the facility's P&P titled, Decubitus Ulcer Prevention, was not followed for Resident 18. During a concurrent interview and record review on 1/29/2026 at 3:29 p.m., with the DON, Resident 18's Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) task for position (Follow Up Question Report for Position), for the month of 1/2026, was reviewed. The DON stated resident turning and repositioning are interventions that must be included in the care plan. The DON stated that on multiple days including 1/1/2026, 1/2/2026, 1/3/2026, 1/4/2026, 1/5/2026, 1/6/2026, 1/7/2026, 1/8/2026, 1/9/2026, 1/10/2026, 1/11/2026, 1/12/2026, 1/13/2026, 1/14/2026, 1/15/2026, 1/16/2026, 1/17/2026, 1/18/2026, 1/19/2026, 1/20/2026, and 1/21/2026, Resident 18 was positioned on her (Resident 18) left side or back for more than two hours. The DON stated repositioning residents is a key intervention to prevent skin breakdown and provide comfort for the resident. The DON stated that remaining in one position such as laying on one side for too long can cause discomfort for the resident. During a review of Resident 18's Follow Up Question Report for Position, from 1/1/2026 to 1/29/2026, the Follow Up Question Report indicated the date, time, and resident's position as follows: 1/1/2026 at 6 a.m. – Left 1/1/2026 at 8 a.m. – Left 1/1/2026 at 10 a.m. – Left 1/1/2026 at 2 p.m. – Left 1/1/2026 at 4 p.m. – Left 1/1/2026 at 6 p.m. – Left 1/1/2026 at 8 p.m. – Left 1/2/2026 at 4 a.m. – Left 1/2/2026 at 6 a.m. – Left 1/2/2026 at 8 a.m. – Left 1/2/2026 at 2 p.m. – Left 1/2/2026 at 4 p.m. – Left 1/3/2026 at 10 p.m. – Left 1/4/2026 at 12 a.m. – Left 1/4/2026 at 2 a.m. – Left 1/4/2026 at 4 a.m. – Left 1/5/2026 at 4 a.m. – Left 1/5/2026 at 6 a.m. – Left 1/5/2026 at 8 a.m. – Left 1/5/2026 at 2 p.m. – Left 1/5/2026 at 4 p.m. – Left 1/5/2026 at 6 p.m. – Right 1/5/2026 at 10 p.m. – Right 1/6/2026 at 8 a.m. – Left 1/6/2026 at 10 a.m. – Left 1/6/2026 at 2 p.m. – Left 1/6/2026 at 4 p.m. – Left 1/6/2026 at 10 p.m. – Left 1/7/2026 at 12 a.m. – Left 1/7/2026 at 4 a.m. – Back 1/7/2026 at 6 a.m. – Back 1/7/2026 at 2 p.m. – Left 1/7/2026 at 4 p.m. – Left 1/7/2026 at 8 p.m. – Left 1/7/2026 at 10 p.m. – Left 1/8/2026 at 8 p.m. – Left 1/8/2026 at 10 p.m. – Left 1/9/2026 at 10 a.m. – Back 1/9/2026 at 12 p.m. – Back 1/9/2026 at 6 p.m. – Left 1/9/2026 at 8 p.m. – Left 1/9/2026 at 10 p.m. – Left 1/10/2026 at 12 a.m. – Left 1/10/2026 at 2 p.m. – Left 1/10/2026 at 4 p.m. – Left 1/10/2026 at 6 p.m. – Left 1/11/2026 at 2 p.m. – Left 1/11/2026 at 4 p.m. – Left 1/11/2026 at 6 p.m. – Left 1/11/2026 at 8 p.m. – Right 1/11/2026 at 10 p.m. – Right 1/12/2026 at 6 a.m. – Left 1/12/2026 at 8 a.m. – Left 1/12/2026 at 2 p.m. – Left 1/12/2026 at 4 p.m. – Left 1/12/2026 at 6 p.m. – Back 1/12/2026 at 8 p.m. – Back 1/13/2026 at 6 a.m. – Left 1/13/2026 at 8 a.m. – Left 1/13/2026 at 2 p.m. – Left 1/13/2026 at 4 p.m. – Left 1/13/2026 at 6 p.m. – Left 1/13/2026 at 8 p.m. – Left 1/14/2026 at 4 p.m. – Left 1/14/2026 at 6 p.m. – Left 1/14/2026 at 10 p.m. – Left 1/15/2026 at 12 a.m. – Left 1/15/2026 at 4 a.m. – Back 1/15/2026 at 6 a.m. – Back 1/16/2026 at 12 a.m. – Left 1/16/2026 at 2 a.m. – Left 1/16/2026 at 2 p.m. – Left 1/16/2026 at 4 p.m. – Left 1/16/2026 at 10 p.m. – Right 1/17/2026 at 12 a.m. – Right 1/17/2026 at 8 a.m. – Left 1/17/2026 at 10 a.m. – Left 1/17/2026 at 2 p.m. – Left 1/17/2026 at 4 p.m. – Left 1/17/2026 at 8 p.m. – Left 1/17/2026 at 10 p.m. – Left 1/18/2026 at 12 a.m. – Left 1/18/2026 at 4 a.m. – Back 1/18/2026 at 6 a.m. – Back 1/18/2026 at 6 p.m. – Back 1/18/2026 at 8 p.m. – Back 1/19/2026 at 4 a.m. – Back 1/19/2026 at 6 a.m. – Back 1/19/2026 at 2 p.m. – Left 1/19/2026 at 4 p.m. – Left 1/20/2026 at 6 a.m. – Left 1/20/2026 at 8 a.m. – Left 1/20/2026 at 2 p.m. – Left 1/20/2026 at 4 p.m. – Left 1/20/2026 at 6 p.m. – Left 1/20/2026 at 8 p.m. – Left 1/20/2026 at 10 p.m. – Left 1/21/2026 at 12 a.m. – Left 1/21/2026 at 2 a.m. – Right 1/21/2026 at 4 a.m. – Right During a review of the facility's P&P titled, Decubitus Ulcer Prevention, last reviewed on 1/21/2025, The P&P indicated: Policy: 1. The Registered Nurse will evaluate the Residents/ Patients on admission and then on a daily basis to establish the presence of any pressure sores. Preventive Measures:1. Bed Residents/Patients will be repositioned every two hours and PRN (as needed). There will be charting substantiating the repositioning and direction of the body turn.2. Charge Nurses will make rounds at least four times daily.3. Immediate measures will be taken to eliminate pressure to this particular area. As necessary treatment orders will be obtained from the attending physician (mattress, air mattress, gel mattress, etc.).4. Nurses will chart a description and evaluation of the skin breakdown or the ulceration at least weekly.5. Any Resident/Patient admitted with a pressure sore will have immediate and appropriate action to treat the problem. Proper documentation of the presence, location, size and description of the pressure sore will be recorded in the Resident/Patient health record.6. Proper documentation of the treatment performed via the Physician Orders will be in the treatment book.7. Should a Resident/Patient or responsible party refuse procedures by the Nursing Staff to prevent or treat a pressure sore, adequate documentation will be noted in the Resident/Patient health records. Risks and benefits will be explained to Resident/Patient and/or Responsible Party by MD or Registered Nurse. Special Observations: All pressure points, especially bony prominences, should be assessed for redness, irritated or lacerated (a jagged, torn or ripped wound affecting the skin and underlying tissues) skin:. Buttocks, Sacrum. Include: Back of head, shoulder blades, various skin folds, any ischemic skin (refers to tissue damage, discoloration, or death caused by severely reduced blood flow) area or any area subject to pressure or abrasion (superficial injury where skin is scraped or rubbed off). Residents/Patients Most Vulnerable:1. Residents/Patients required to lie in one position due to immobilization (the act of stopping movement or restricting motion) or restrictive appliances (devices or items attached to or adjacent to a person's body that limit freedom of movement or access to their own body and cannot be easily removed by them). 2. Residents/Patients incapable of voluntary movement. 3. Residents/Patients who are abnormally thin, elderly, debilitated (severely weakened or impaired in strength), incontinent.4. Residents/Patients with poor circulation or peripheral vascular disease (slow, progressive circulation disorder characterized by the narrowing, blockage or spasms of blood vessels). During a review of the facility's P&P titled, Pressure Ulcer, last reviewed on 1/21/2025, the P&P indicated the following: Purpose: Assessment and documentation is an ongoing process. Accurate documentation provides for timely preventative interventions. These interventions may minimize the frequency and the severity of pressure ulcers. Policy: All wounds will be assessed and documented in the Patient's permanent record. Documentation of the pressure ulcer will include location, stage, size, depth, exudate, odor, eschar, pain and peri wound (the skin immediately surrounding a wound) skin condition. Effective January 1, 2022, all wounds will be evaluated by the wound M.D. for proper treatment. Equipment: Skin Assessment/Documentation Tool Pen Procedures: At least weekly or as changes are noted (or as State requirements dictate), chart the following in the permanent record: 1. Location of wound2. Stage of wound3. Size of wound (use a measuring guide)a. Length (cm)b. Width (cm)4. Depth of wounda. Insert sterile (germ-free), flexible six inch cotton-tipped applicator gently into the deepest part of the wound.b. Grasp with thumb and forefinger at skin surface and withdraw.c. Measure distance from the tip to fingers in centimeters.5. Exudate (fluid that leaks out of blood vessels into the wound bed during the healing process), describe type6. Odor, if present, describe.7. Eschar (a thick, dry black or brown layer of dead tissue that forms over severe wounds, burns or infections)/necrotic (dead) tissuea. Color b. Consistencyc. Location in wound or edgesd. Pain (presence or absence)e. Peri wound skin condition B1. During a review of Resident 11's AR, the AR indicated the facility admitted the resident on 1/7/2022 and most recently admitted the resident on 2/25/2025 with diagnoses including chronic respiratory failure with hypoxia (low oxygen in the tissues), tracheostomy (trach - opening surgically created through the front of the neck and into the trachea [windpipe]), dependence of respirator (ventilator - a medical device to help support or replace breathing), and Huntington's disease (inherited condition that affects movement, thinking and behavior). During a review of Resident 11's H&P, dated 2/26/2025, the H&P indicated that the resident had a history of multiple pressure injuries on the lower extremities and osteomyelitis (a bone infection). During a review of Resident 11's MDS, dated [DATE], the MDS indicated the resident rarely/never was able to understand others and rarely/never was able to make herself understood. The MDS further indicated that the resident was dependent on staff for bathing, dressing, oral and personal hygiene, toileting, and mobility. During a review of Resident 11's Order Summary Report (OSR), the OSR indicated the following orders:- Dated 9/10/2025, left distal (away from the center of the body) plantar (sole of the foot) stage four (4) (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure injury, cleanse with NS moist gauze, pat dry, apply calcium alginate (a specialized dressings to treat wounds), cover with foam dressing every shift for 30 days. - Dated 9/10/2025, left dorsal (the top, upper surface) foot stage 4, cleanse with NS moist gauze, pat dry, apply calcium alginate, cover with foam dressing, every day shift for 30 days.- Dated 9/1

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for three of three sampled residents (Residents 42, 43, and 3) reviewed for urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure: 1. Resident 42 and 43's suprapubic catheter (a urinary catheter that is inserted into the bladder from a small cut in the tummy, just above the pubic bone) had a leg strap (a common and simple medical device used to securely hold the catheter tubing or a urine collection bag (leg bag) against the patient's leg) or a securement device in place. 2. Resident 3's suprapubic catheter had a leg strap or a securement device in place and the suprapubic catheter tubing was free of loops or kinks. The deficient practice had the potential for residents to develop catheter associated urinary tract infection (CAUTI, a type of infection that occurs when germs (usually bacteria) enter the urinary system via a urinary catheter) and dislodgement of the suprapubic catheter. Findings: 1a. During a review of Resident 42's admission Record (AR), the AR indicated the facility admitted the resident on 9/11/2023, and readmitted the resident on 2/20/2025, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (is a surgically created hole in the front of the neck that goes into the windpipe (trachea)), and dependence on respirator status (if a patient is unable to wean off a ventilator and breathe independently). During a review of Resident 42's History and Physical (H&P), dated 2/20/2025, the H&P indicated the resident was on a ventilator (a medical device to help support or replace breathing), alert, with eyes open intermittently (stopping and starting repeatedly rather than continuously), looking around and smiled to provider voice, with no acute distress. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 12/14/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person has extreme difficulty with fundamental mental tasks like thinking, learning, remembering, and making decisions, to the point where they are unable to live independently). The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 42's Order Summary Report (OSR), the OSR indicated an order of: 12/18/2025 Bolster suprapubic catheter at all times every 12 hours for catheter maintenance. 2/20/2025 Suprapubic Catheter: Change catheter #16 French size (FR, is a universal system used to measure the outer thickness, or diameter, of the catheter tube) every 2 weeks and as needed out or plugged. During a review of Resident 42's Care Plan (CP) Report titled, At Risk for UTI related to resident has suprapubic catheter in place, last revised on 6/16/2025, the CP indicated a goal of the resident will not exhibit any signs and symptoms of UTI e.g. elevated temperature, elevated white blood cells (WBC, a key part of the body's immune system), dark yellow or tea colored urine and presence of sediments with an intervention to keep suprapubic catheter tubing free from coils and dignity bag for suprapubic catheter in place at all times, monitor every (q) shift. During a concurrent observation and interview on 1/26/2026 at 11:34 a.m., with Registered Nurse (RN) 3, inside Resident 42's room, observed Resident 42's suprapubic catheter without a leg strap or securement device in place. RN 3 stated the resident's suprapubic catheter should have a securement device in place to prevent dislodgment of the tubing and to prevent tugging and pulling on the tube causing skin tears that can be a portal of infection to set in. During an interview on 1/29/2026, at 7:49 a.m., with the Manager of Pediatrics (MP), the MP stated that Resident 42's suprapubic catheter should have a leg strap or securement device to preventer tugging and dislodgement of the tubing causing trauma to the insertion site of the resident. The MP also stated the licensed staff should also be checking for loops or kinks, and to make sure the bag is lower than the bladder of the resident to prevent backflow of urine causing UTI. The MP also added that the drainage bag should not be touching the floor due to ascending infection (an infection that starts in a lower part of the body's system (like the lower urinary or biliary tract) and then travels or spreads upward to affect higher organs). During an interview on 1/29/2026, at 8: 37 a.m., with the Director of Nursing (DON), the DON stated the licensed staff should always be checking Resident 42's suprapubic catheter to make sure the catheter has a securement device, the tube should have no loops or kinks, and the bag is below the level of the bladder of the resident to prevent backflow of urine that can cause UTI. The DON stated the failure of the staff to place a securement device had predisposed the resident to tugging and pulling of the suprapubic catheter tubing that can cause trauma to the insertion site that can open a portal of entry to infection and potential dislodgement of the tubing. During a review of the facility's recent policy and procedure (P&P) titled, Catheterization, Suprapubic, last reviewed on 1/21/2025, the P&P indicated to drain the bladder via a tube placed in the bladder from the supra pubic area. To divert the flow of urine from the urethra. General Instructions: 1. Physician's order Procedure: 2. An obstructed flow must be maintained on indwelling catheters a. Keep the catheter and drainage system free of kinks and the drainage bag below the level of the bladder. Completion of indwelling catheterization: 4. Secure catheter to prevent movement and urethral traction. 6. Maintain tubing in a position that facilitates gravity drainage bag must be lower than bladder. During a review of the facility's recent P&P titled, Catheter-Associated Urinary Tract Infection (CAUTI), last reviewed on 1/21/2025, the P&P indicated the purpose of this policy is to prevent and manage Catheter Associated Urinary Tract Infections (CAUTI). Procedure: Proper Insertion - Properly secure catheters after insertion to prevent movement and urethral traction, do not attach to movable parts in bed. Proper Maintenance/Prevention of UTI - Check for kinks and dependent loops in catheter tubing. 1b. During a review of Resident 43's AR, the AR indicated the facility admitted the resident on 9/11/2023, with diagnoses including neuromuscular dysfunction of bladder (is a condition where a person lacks proper bladder control because of a problem with the nerves that connect the brain and spinal cord to the bladder), chronic kidney disease stage three (the kidney's function has been cut by half, and most patients experience ancillary problems like high blood pressure or bone difficulties), and UTI. During a review of Resident 43's H&P, dated 10/29/2025, the H&P indicated the resident was well nourished, with global disability (the experience of a physical or mental condition that limits a person's ability to participate fully in society, largely due to societal barriers like inaccessible environments, discrimination, and lack of support), no distress, and awake. The resident was not interactive, no purposeful response, opens eye spontaneously but no tracking. During a review of Resident 43's MDS, dated [DATE], the MDS indicated the resident had rarely to never had the ability to make self-understood and understand others and had severely impaired cognition. The MDS indicated the resident was dependent on mobility and ADLs. During a review of Resident 43's OSR, the OSR indicated an order for: 12/18/2025 Bolster suprapubic catheter at all times every 12 hours for catheter maintenance. 12/1/2025 Suprapubic Catheter: Change catheter #14 FR every two weeks and prn out or plugged as needed out or plugged. During a review of Resident 43's CP Report titled, At Risk for UTI related to resident has suprapubic catheter in place, last revised on 6/14/2025, the CP indicated a goal of the resident will not exhibit any signs and symptoms of UTI e.g. elevated temperature, elevated WBC, dark yellow or tea colored urine and presence of sediments with an intervention to keep suprapubic catheter tubing free from coils and dignity bag for suprapubic catheter in place at all times, monitor q shift. During a concurrent observation and interview on 1/26/2026, at 11:37 a.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 43's room, observed Resident 43's suprapubic catheter without a leg strap or securement device in place. LVN 1 stated the resident's suprapubic catheter should have a securement device in place to prevent dislodgment of the tubing and to prevent tugging and pulling on the tube causing skin tears that can be a portal of infection to set in. During an interview on 1/29/2026, at 7:49 a.m., with the MP, the MP stated that Resident 43's suprapubic catheter should have a leg strap or securement device to preventer tugging and dislodgement of the tubing causing trauma to the insertion site of the resident. The MP also stated the licensed staff should also be checking for loops or kinks, and to make sure the bag is lower than the bladder of the resident to prevent backflow of urine causing UTI. The MP also added the drainage bag should not be touching the floor due to ascending infection. During an interview on 1/29/2026, at 8:37 a.m., with the DON, the DON stated the licensed staff should always be checking Resident 43's suprapubic catheter to make sure the catheter has a securement device, the tube should have no loops or kinks, and the bag is below the level of the bladder of the resident to prevent backflow of urine that can cause UTI. The DON stated the failure of the staff to place a securement device had predisposed the resident to tugging and pulling of the suprapubic catheter tubing that can cause trauma to the insertion site that can open a portal of entry to infection and potential dislodgement of the tubing. During a review of the facility's recent P&P titled, Catheterization, Suprapubic, last reviewed on 1/21/2025, the P&P indicated to drain the bladder via a tube placed in the bladder from the supra pubic area. To divert the flow of urine from the urethra. General Instructions: 1. Physician's order Procedure: 2. An obstructed flow must be maintained on indwelling catheters a. Keep the catheter and drainage system free of kinks and the drainage bag below the level of the bladder. Completion of indwelling catheterization: 4. Secure catheter to prevent movement and urethral traction. 6. Maintain tubing in a position that facilitates gravity drainage bag must be lower than bladder. During a review of the facility's recent P&P titled, Catheter-Associated Urinary Tract Infection (CAUTI), last reviewed on 1/21/2025, the P&P indicated the purpose of this policy is to prevent and manage Catheter Associated Urinary Tract Infections (CAUTI). Procedure: Proper Insertion - Properly secure catheters after insertion to prevent movement and urethral traction, do not attach to movable parts in bed. Proper Maintenance/Prevention of UTI - Check for kinks and dependent loops in catheter tubing. 2. During a review of Resident 3's AR, the AR indicated the facility admitted the resident on 8/3/2022, and readmitted the resident on 3/12/2024, with diagnoses including retention of urine (the inability to fully empty your bladder, or in severe cases, to urinate at all), presence of urogenital implants (medical devices that are surgically placed inside the body to restore or support the function of the urinary and reproductive organs), and UTI. During a review of Resident 3's H&P, dated 10/3/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident was dependent on mobility and ADLs. The MDS indicated the resident had a catheter (indwelling). During a review of Resident 3's OSR, dated 10/31/2025, the OSR indicated an order of suprapubic catheter FR #16 X 10 cubic centimeters (cc, a metric unit for measuring volume): Change q monthly and PRN when out or plugged (urinary retention) as needed. During a review of Resident 3's CP Report titled, At Risk for UTI related to suprapubic catheter, last revised on 8/20/2025, the CP indicated a goal of the resident will not exhibit any signs and symptoms of UTI e.g. elevated temperature, elevated WBC, dark yellow or tea colored urine and presence of sediments with an intervention to keep suprapubic catheter tubing free from coils and bag below the waist and provide suprapubic catheter care q shift and PRN. During a concurrent observation and interview on 1/26/2026 at 11:45 a.m., with RN 4, inside Resident 3's room, observed Resident 3's suprapubic catheter without a leg strap or securement device in place and the tubing was looped. RN 4 stated the resident's suprapubic catheter should have a securement device in place to prevent dislodgment of the tubing and to prevent tugging and pulling on the tube causing skin tears that can be a portal of infection to set in. RN 4 also stated there should be no loops on the suprapubic catheter tubing to prevent backflowing of the urine to the bladder that can cause UTI to residents. During an interview on 1/29/2026, at 7:49 a.m., with the MP, the MP stated that Resident 3's suprapubic catheter should have a leg strap or securement device to prevent tugging and dislodgement of the tubing causing trauma to the insertion site of the resident. The MP also stated the licensed staff should also be checking for loops or kinks, and to make sure the bag is lower than the bladder of the resident to prevent backflow of urine causing UTI. The MP also added the drainage bag should not be touching the floor due to ascending infection. During an interview on 1/29/2026, at 8: 37 a.m., with the DON, the DON stated the licensed staff should always be checking Resident 3's suprapubic catheter to make sure the catheter has a securement device, the tube should have no loops or kinks, and the bag is below the level of the bladder of the resident to prevent backflow of urine that can cause UTI. The DON stated the failure of the staff to place a securement device had predisposed the resident to tugging and pulling of the suprapubic catheter tubing that can cause trauma to the insertion site that can open a portal of entry to infection and potential dislodgement of the tubing. During a review of the facility's recent P&P titled, Catheterization, Suprapubic, last reviewed on 1/21/2025, the P&P indicated to drain the bladder via a tube placed in the bladder from the supra pubic area. To divert the flow of urine from the urethra. General Instructions: 1. Physician's order Procedure: 2. An obstructed flow must be maintained on indwelling catheters a. Keep the catheter and drainage system free of kinks and the drainage bag below the level of the bladder. Completion of indwelling catheterization: 4. Secure catheter to prevent movement and urethral traction. 6. Maintain tubing in a position that facilitates gravity drainage bag must be lower than bladder. During a review of the facility's recent P&P titled, Catheter-Associated Urinary Tract Infection (CAUTI), last reviewed on 1/21/2025, the P&P indicated the purpose of this policy is to prevent and manage Catheter Associated Urinary Tract Infections (CAUTI). Procedure: Proper Insertion - Properly secure catheters after insertion to prevent movement and urethral traction, do not attach to movable parts in bed. Proper Maintenance/Prevention of UTI - Check for kinks and dependent loops in catheter tubing.

Based on observation, interview, and record review, the facility failed to ensure the staff providing care and services to residents who had feeding tubes (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) were aware of, competent in, and utilized facility protocols regarding feeding tube nutrition and care for four of five sampled residents (Residents 42, 3,105 and 41) reviewed for tube feeding by failing to ensure: 1. Resident 42's tube feeding bag was labeled with the complete name of the resident, the rate of infusion, and the initials of the licensed nurse who hung the tube feeding bag. 2. Resident 3's water flush bag was labeled with the complete name of the resident, the rate of infusion, and the initials of the licensed nurse who hung the water flush bag. 3. Resident 105's EF bag indicated the resident's name, room number, start date and time, and administration rate. 4. Residents 105's and 41's medication syringes were properly rinsed after use. The deficient practices had the potential to result in altered nutritional status that can lead to over or under hydration, gastrointestinal (GI, relating to stomach and intestines) infection to the resident. Findings: 1. During a review of Resident 42's admission Record (AR), the AR indicated the facility admitted the resident on 9/11/2023, and readmitted the resident on 2/20/2025, with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), gastro-esophageal reflux disease (GERD, a chronic (long-lasting) condition where stomach contents, including harsh stomach acid, frequently flow back up into the esophagus (food pipe)), and constipation (a problem with passing stool). During a review of Resident 42's History and Physical (H&P), dated 2/20/2025, the H&P indicated the resident was on a ventilator (a medical device to help support or replace breathing), alert, with eyes open intermittently (stopping and starting repeatedly rather than continuously), looking around, smiled to provider voice, with no acute distress, responded appropriately to exam, face symmetric (both sides of the body are identical), and moved all extremities equally. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 12/14/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person has extreme difficulty with fundamental mental tasks like thinking, learning, remembering, and making decisions, to the point where they can no longer live independently). The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was on a feeding tube while a resident at the facility. During a review of Resident 42's Order Summary Report (OSR), dated 5/19/2025, the OSR indicated an order of enteral feed (a way of providing nutrition to the body using the natural digestive system (the gut) when a person cannot eat or swallow enough food by mouth to meet their nutritional needs) order five times a day gastrostomy tube (GT, a soft, flexible tube inserted through the belly wall directly into the stomach) feeding: Fibersource HN (a nutritionally complete liquid formula used for tube feeding) 1.2 at 140 cubic centimeters per hour (cc/hr, it is a unit of measurement that describes a rate of flow, or how much of something is moving over a specific period of time) via pump five times a day to provide 700 cubic centimeters (cc, a measurement of volume—the amount of three-dimensional space an object or a substance occupies)/840 kilocalorie (kcal, a measurement of volume—the amount of three-dimensional space an object or a substance occupies) every (q) 24 hours a day. During a review of Resident 42's Care Plan (CP) Report titled, Alteration in nutrition and hydration, last revised on 8/19/2025, the CP indicated a goal of patient will not have any significant weight changes q month till next review, and an intervention to provide tube feeding as ordered. During a concurrent observation and interview on 1/26/2026, at 11:13 a.m., with Registered Nurse (RN) 3, observed Resident 42's feeding bag not labeled with the complete name of the resident, the rate of infusion, and the initials of the licensed nurse who hung the feeding bag. RN 3 stated the licensed nurse should have labeled the feeding bag of Resident 42 with the resident's complete name, the rate of infusion of the feeding formula and the licensed nurse who hung the feeding bag to ensure its safe use and to ensure they are giving the right nutrition to the resident. During an interview on 1/29/2026, at 7:49 a.m., with the Manager of Pediatrics (MP), the MP stated the licensed nurse should have labeled the feeding bag of Resident 42 with the complete name of the resident, the name of the formula, the date and time it was hung, the rate of infusion, and the initial of the licensed nurse who hung the feeding bag to ensure they were providing the right nutrition to the resident and can be used as a cross reference when endorsing to incoming nurse during shift changes to catch errors in the orders. The MP stated that labeling the feeding bag accurately and completely is what a prudent nurse should be doing. During an interview on 1/29/2026, at 8:37 a.m., with the Director of Nursing (DON), the DON stated the feeding bag of Resident 42 should have been completely labeled with the name of the resident, the name of the formula, the date and time it was hung, the rate of infusion, and the bag should be initialed by the nurse who hung the bag to ensure they are providing the right nutrition to the right resident. The DON stated the failure of the staff to label the bag completely can cause errors in the infusion of the formula causing nutritional deficits to the resident. During a review of the facility's recent policy and procedure (P&P) titled, Labeling Tube Feeding/Water Flush, last reviewed on 1/21/2025, the P&P indicated to ensure patient safety by establishing standardized labeling requirements for all tube feeding formulas, and water flushes. All tube feeding formulas and water flush sets must be labeled with the name of the patient, room and bed number, time started and the rate. During a review of the facility's recent P&P titled, Enteral Feeding- General Policy, last reviewed on 1/21/2025, the P&P indicated enteral nutrition is provided for those Resident who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. Storage of Formula: 3. Label formula with time, date, Resident's name and nurse's initials when hung. 2. During a review of Resident 3's AR, the AR indicated the facility admitted the resident on 8/3/2022, and readmitted the resident on 3/12/2024, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), gastrostomy, and anoxic brain damage (happens when the brain is completely deprived of oxygen, usually for four minutes or longer, causing brain cells to die rapidly and leading to severe damage, disability, coma, or even death). During a review of Resident 3's H&P, dated 10/3/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident was dependent on mobility and ADLs. The MDS indicated the resident had a feeding tube while a resident in the facility. During a review of Resident 3's OSR, dated 11/21/2025, the OSR indicated an order of enteral feed order every shift: Continuous water flush feeding tube with 30 cc of water x 22 hr. During a review of Resident 3's CP Report titled, Presence of Nasogastric (NG, nose to stomach) /jejunostomy (JT, a soft, flexible tube that a doctor places directly into the small intestine through the skin of the abdomen)/ gastrostomy tube (GT, a soft tube inserted through the belly wall directly into the stomach, acting as a shortcut for delivering food, fluids, and medicine when someone cannot eat or drink enough by mouth, or to help decompress the stomach) at risk for potential or actual malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients) and dehydration (a condition where the body loses more fluid than what is taken in, and does not have enough water to function properly) related to long term use of artificial nutrition, last revised on 11/7/2025, the CP indicated an intervention to administer feeding formula and water flushes as ordered. During a concurrent observation and interview on 1/26/2026, at 11:40 a.m., with RN 4, inside Resident 3's room, observed Resident 3's water flush bag not labeled with the complete name of the resident, the rate of infusion, and the initials of the nurse who hung the water flush bag. RN 4 stated the licensed staff who hung the water flush bag of Resident 3 should have placed the complete name of the resident, the name of the solution being infused, the date and the time it was hung, the rate of infusion, and the initials of the licensed nurse who hung the bag. RN 4 stated it was important to label the water flush bag accurately and completely to ensure they are providing the right hydration to the right patient. RN 4 stated the failure of the licensed staff to label the water flush bag completely could result to improper infusion of the solution causing dehydration to the resident and had the potential for errors in administration. During an interview on 1/29/2026, at 7:49 a.m., with the MP, the MP stated the licensed nurse should have labeled the water flush bag of Resident 3 with the complete name of the resident, the name of the formula/solution, the date and time it was hung, the rate of infusion, and the initial of the licensed nurse who hung the feeding bag to ensure they were providing the right hydration to the resident and can be used as a cross reference when endorsing to incoming nurse during shift changes to catch errors in the orders. The MP stated that labeling the feeding/water flush bag accurately and completely is what a prudent nurse should be doing. During an interview on 1/29/2026, at 8:37 a.m., with the DON, the DON stated the water flush bag of Resident 3 should have been completely labeled with the name of the resident, the name of the formula/solution, the date and time it was hung, the rate of infusion, and the bag should be initialed by the nurse who hung the bag to ensure they are providing the right hydration to the right resident. The DON stated the failure of the staff to label the bag completely can cause errors in the infusion of the formula causing nutritional deficits and dehydration to the resident. During a review of the facility's recent P&P titled, Labeling Tube Feeding/Water Flush, last reviewed on 1/21/2025, the P&P indicated to ensure patient safety by establishing standardized labeling requirements for all tube feeding formulas, and water flushes. All tube feeding formulas and water flush sets must be labeled with the name of the patient, room and bed number, time started and the rate. During a review of the facility's recent P&P titled, Enteral Feeding- General Policy, last reviewed on 1/21/2025, the P&P indicated enteral nutrition is provided for those Resident who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. Storage of Formula: 3. Label formula with time, date, Resident's name and nurse's initials when hung. 3. During a review of Resident 105's admission Record, the admission Record indicated the facility originally admitted Resident 105 on 10/10/2017, and readmitted in the facility on 4/19/2019, with diagnoses including cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture caused by damage that occurs to the developing brain, most often before birth), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 105's History and Physical (H&P) dated 10/3/2025, the H&P indicated Resident 105 did not have the capacity to understand and make decisions. During a review of Resident 105's Minimum Data Set (MDS, a resident assessment tool), dated 12/18/2025, the MDS indicated Resident 105 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was not able to understand and make his needs known. The MDS further indicated Resident 105 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 105 received tube feeding while a resident in the facility. During a review of Resident 105's Order Summary Report dated 1/29/2026, the Order Summary Report indicated the following physician's orders: - 5/8/2025: every four (4) hours GT feeding: Enteral Feeding (EF) 1 at 230 milliliters (ml – a unit of measurement) bolus (refers to administration of a single relatively large amount of a substance such as GT feeding) six (6) times per day to provide 1380 mi per 1656 kilocalories (kcals – a unit of measurement for calories) every 24 hours. - 9/17/2025: every four hours enteral: Flush feeding tube with 120 ml of water six times per day, to provide 720 ml per day. During a review of Resident 105's care plan (CP) titled, The resident requires tube feeding, initiated on 4/18/2025, and last revised on 8/19/2025, the CP indicated to administer feeding formula and water flushes as ordered, monitor for signs and symptoms of malnutrition and dehydration, weigh resident every month, monitor and report for any signs and symptoms of infection as a few of the interventions to maintain nutritional and hydration status, and will remain free of side effects or complications related to tube feeding. During an observation on 1/26/2026 at 9:35 a.m. inside Resident 105's room, observed Resident 105's EF 1 bag was hanging from the EF pole and the EF 1 bag did indicate Resident 105's name, room number, start date and time, and administration rate and that the medication syringe was not rinsed properly and had some medication residuals left on the tip of the medication syringe. During a concurrent observation and interview on 1/26/2026 at 10:06 a.m., a photograph of Resident 105's EF bag and medication syringe was reviewed with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 105's EF bag did not indicate the resident's name, room number, start date and time, and administration rate and that the medication syringe was not rinsed properly and had some medication residuals left on the tip of syringe. LVN 1 stated that during medication administration thru the GT, the GT should be flushed with 50 ml of water before and after each medication administration to ensure all the medications were administered to the resident. LVN 1 stated the medication syringe is supposed to be rinsed properly after each use. LVN 1 stated that when an EF bag is changed, the bag should be labeled with the resident's name, room number, start date and time, and administration rate. LVN 1 stated Resident 105's EF bag label should have indicated the resident's name, room number, start date and time, and administration rate so the staff would be aware if Resident 105 was receiving the correct amount of feeding to prevent malnutrition or dehydration. LVN 1 stated he should have rinsed the medication syringe properly to ensure there were no residuals left at the tip as it is an infection control issue and that Resident 105 received the full dose of the medication. During a concurrent interview and record review on 1/27/2026 at 1:52 p.m. a photograph of Resident 105's EF bag and medication syringe were reviewed with Registered Nurse (RN) 7. RN 7 stated Resident 105's EF bag did not indicate the resident's name, room number, start date and time, and administration rate and that the medication syringe was not rinsed properly and had some medication residuals left on the tip of syringe. RN 7 stated that EF bags are changed by the night shift nurse usually at 6 a.m. and should be labeled with the resident's name, room number, start date and time, and administration rate. RN 7 stated that after each medication administration, the medication syringe should be properly rinsed to ensure there were no residuals left on the tip. RN 7 stated that Resident 105's EF bag should have been labeled with the resident's name, room number, start date and time, and administration rate at the time it was hung by the nurse so the staff would be aware that the EF bag hanging was the correct EF and amount to be received and that the EF bag was not expired. RN 7 stated that the nurse should have properly rinsed Resident 105's medication syringe after medication administration to ensure there were no medication residuals left on the tip as the tip can be contaminated and placed Resident 105 at risk for complications such as infection. During a concurrent interview and record review on 1/29/2026 at 8:37 a.m., a photograph of Resident 105's EF bag and medication syringe and the original plastic packaging of the medication syringe were reviewed with the Director of Nursing (DON). The DON stated the photograph of the EF bag did not indicate the resident's name, room number, start date and time, and administration rate and that the medication syringe was not rinsed properly and had some medication residuals left on the tip of syringe. The DON stated the original plastic packaging of the medication syringe indicated to rinse the container and syringe thoroughly with hot water after each use and must be replaced every 24 hours. The DON stated that EF bottles should be labeled with the resident's name, room number, start date and time, and administration rate when a new bag is hung and that the medication syringe should be properly rinsed after each use to ensure there were no residuals left. The DON stated Resident 105's EF bag should have indicated the resident's name, room number, start date and time, and administration rate when a new bag is hung and that the medication syringe should be properly rinsed after each use to ensure there were no residuals left as indicated in the original plastic packaging. The DON stated if Resident 105 was not receiving the correct bolus feeding, it would place the resident at risk for malnutrition or dehydration. The DON stated that if the medication syringe was not rinsed properly to ensure there were no residuals left on the tip, it placed Resident 105 at risk for health complications such as infection due to a contaminated medication syringe. During a review of the facility provided original plastic packaging for the medication syringe, undated, the original plastic packaging indicated to rinse the container and syringe thoroughly with hot water after each use and must be replaced every 24 hours. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding – General Policy, last reviewed on 1/21/2025, the P&P indicated enteral nutrition is provided for those residents who cannot or will not take necessary nutrients by mouth due to disease process or physical disorders and who have a functioning gastrointestinal tract. The P&P further indicated: - Label the formula with time, date, resident's name and nurse's initials when hung. - Administration bag and/or tubing shall be labeled with date and time and nurse's initials when changed. During a review of the facility's P&P titled, Labeling Tube Feeding/Water Flush, last reviewed on 1/21/2025, the P&P indicated a purpose to ensure patient safety by establishing standardized labeling requirements for all tube feeding formulas, and water flushes. The P&P further indicated all tube feeding and water flush sets must be labeled with: - Patient last name - Room number and bed number of patient - Date and time prepared or opened - Rate of the tube feeding 4. During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was originally admitted in the facility on 5/25/2017, and readmitted in the facility on 6/17/2025, with diagnoses including respiratory failure (a condition that occurs when the lungs cannot remove all of the carbon dioxide [a colorless, odorless gas that the body breathes out] the body produces), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture caused by damage that occurs to the developing brain, most often before birth). During a review of Resident 41's History and Physical (H&P) dated 6/18/2025, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a review of Resident 41's MDS, the MDS assessment indicated Resident 41 had severely impaired cognition (mental action or process of acquiring knowledge and understanding), required total assistance from staff with all activities of daily living. The MDS indicated Resident 41 required suctioning (mechanical removal of a patient's secretions with artificial airway such as tracheostomy). During a review of Resident 41's Order Summary Report dated 1/29/2026, the Order Summary Report indicated the following physician's orders: - 6/17/2025: every four hours GT feeding: EF 2 at 240 ml bolus every four hours to provide 1440 ml per 2160 kcals. - 6/17/2025: every shift enteral: flush 50 ml water thru the GT before and after medication administration and 5-10 ml in between medications. - 6/17/2025: flush feeding tube with 150 ml of water manual bolus every two hours to provide 1800 ml per day. During a review of Resident 41's care plan (CP) titled, The resident requires tube feeding, initiated on 4/24/2025 and last revised on 8/21/2025, the CP indicated to monitor for signs of malnutrition and dehydration and notify the physician, weigh resident every month or as needed, and monitor and report for any signs and symptoms of infection as a few of the interventions to maintain nutritional and hydration status, and will remain free of side effects or complications related to tube feeding. During an observation on 1/26/2026 at 9:46 a.m., inside Resident 41's room, observed Resident 41's medication syringe was not rinsed properly and had some residuals left on the tip. During a concurrent observation and interview on 1/26/2026 at 10:06 a.m., a photograph of Resident 41's medication syringe was reviewed with LVN 1. LVN 1 stated Resident 41's medication syringe was not rinsed properly and had some medication residuals left on the tip of syringe. LVN 1 stated that during medication administration thru the GT, the GT should be flushed with 50 ml of water before and after each medication administration to ensure all the medications were administered to the resident. LVN 1 stated the medication syringe is supposed to be rinsed properly after each use. LVN 1 stated he should have rinsed the medication syringe properly to ensure there were no residuals left at the tip as it is an infection control issue and that Resident 41 received the full dose of the medication. During a concurrent interview and record review on 1/27/2026 at 1:52 p.m. a photograph of Resident 41's medication syringe was reviewed with RN 7. RN 7 stated Resident 41's medication syringe was not rinsed properly and had some medication residuals left on the tip of syringe. RN 7 stated that after each medication administration, the medication syringe should be properly rinsed to ensure there were no residuals left on the tip. RN 7 stated that LVN 1 should have properly rinsed Resident 41's medication syringe after medication administration to ensure there were no medication residuals left on the tip as the tip can be contaminated and placed Resident 41 at risk for complications such as infection. During a concurrent interview and record review on 1/29/2026 at 8:37 a.m., a photograph of Resident 41's original plastic packaging of the medication syringe was reviewed with the DON. The DON stated the photograph indicated the medication syringe was not rinsed properly and had some medication residuals left on the tip of syringe. The DON stated the original plastic packaging of the medication syringe indicated to rinse the container and syringe thoroughly with hot water after each use and must be replaced every 24 hours. The DON stated that the medication syringe should be properly rinsed after each use to ensure there were no residuals left. The DON stated Resident 41's medication syringe should have been properly rinsed after each use to ensure there were no residuals left as indicated in the original plastic packaging. The DON stated that if the medication syringe was not rinsed properly to ensure there were no residuals left on the tip, it placed Resident 41 at risk for health complications such as infection due to a contaminated medication syringe. During a review of the facility provided original plastic packaging for the medication syringe, undated, the original plastic packaging indicated to rinse the container and syringe thoroughly with hot water after each use and must be replaced every 24 hours. During a review of the facility's P&P titled, Infection Control Program, last reviewed on 1/21/2025, the P&P indicated that the facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for respiratory care by failing to: 1. Ensure Respiratory Therapist (RT) 4 provided tracheostomy (trach - opening surgically created through the front of the neck and into the trachea [windpipe] that is held open by a specialized tube [cannula]) care per the physician's orders by cleaning the resident's stoma (actual physical opening in the skin at the front of the neck) with hydrogen peroxide (H2O2 -a liquid chemical used to clean wounds and reduce risk of infection from a wide variety of microorganisms) for one of five sampled residents (Resident 93) reviewed for respiratory care. 2. Ensure RT 4 performed hand hygiene (process of cleaning one's hands to prevent the spread of infectious diseases) before and after glove use during tracheostomy care for one of five sampled residents (Resident 93) reviewed for respiratory care. 3. Ensure RT 4 performed tracheostomy care per the facility policy and procedure (P&P) by cleaning the neck and stoma prior to inserting the sterile inner cannula (a smaller, removable tube that fits inside the main outer tracheostomy tube) for one of five sampled residents (Resident 93) reviewed for respiratory care. 4. Ensure the suction catheter (SC) indicated the date they were last changed for three residents (Residents 41, 94, and 13) reviewed for respiratory care. 5. Ensure a resident`s Hand Held Nebulization (HHN, deliver medicines in the form of aerosols to add moisture and help control your respiratory symptoms) setup was changed per physician`s order for one of five sampled residents (Resident 57) reviewed for respiratory care. These deficient practices placed residents at risk for respiratory infections resulting in hospitalization and death. Findings: 1. During a review of Resident 93's admission Record (AR), the AR indicated the facility admitted the resident on 9/20/2022, and most recently admitted the resident on 10/8/2024, with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood), tracheostomy, dependence of respirator (ventilator - a medical device to help support or replace breathing), unspecified intracranial brain injury (a brain injury that is caused by an outside force) with loss of consciousness of unspecified duration, and sepsis (a life-threatening blood infection). During a review of Resident 93's Minimum Data Set (MDS – resident assessment tool) dated 12/16/2025, the MDS indicated the resident rarely/never was able to understand others and rarely/never was able to make himself understood. The MDS further indicated that the resident was dependent on staff for bathing, toileting, dressing, oral and personal hygiene, and mobility. The MDS indicated while in the facility the resident was on an invasive mechanical ventilator and received tracheostomy care. During a review of Resident 93's Order Summary Report, the Order Summary Report indicated the following orders: -Tracheostomy care every shift and as needed (PRN): cleanse stoma with H202. Rinse with normal saline (NS – a sterile solution), dated 2/18/2025. - Ventilator dependent resident: change inner cannula daily and PRN, every day shift, dated 2/18/2025. - Suction tracheostomy secretions every two hours and PRN, dated 10/21/2025. During a review of Resident 93's Care Plan (CP) titled, Presence of tracheostomy: ineffective airway clearance related to inability to expel excess secretions.potential for infection., initiated 4/13/2025, the CP indicated a goal that the resident would remain free from signs and symptoms of infection at all times. The CP indicated interventions that included suction tracheal secretions every two hours and render trach care every shift. During a review of Resident 93's CP titled, Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities)., initiated 7/30/2025, the CP indicated a goal that the resident would remain free from infections. The CP indicated interventions that included to observe good hand washing before and after contact with residents or resident equipment. During a tracheostomy care observation on 1/28/2026 at 11:15 a.m. with RT 4 and Licensed Vocational Nurse (LVN) 2, observed RT 4 and LVN 2 entered Resident 93's room and performed HH. RT 4 donned (put on) clean (non-sterile) blue gloves. RT 4 then suctioned Resident 93's mouth with a yankauer (disposable medical tool used to suction), doffed (took off) the blue gloves, and donned a new pair of blue gloves. Observed RT 4 did not perform HH between glove changes. RT 4 then opened a pair of sterile gloves and placed a sterile glove over the top of the left-hand blue glove. LVN 2 stated do not double glove (practice of wearing two pairs of gloves simultaneously). RT 4 then removed both sets of gloves, opened a new sterile glove package, and donned the sterile gloves. Observed RT 4 did not perform HH between changing gloves. RT 4 then suctioned Resident 93's trach and inserted the sterile inner cannula wearing sterile gloves, doffed the sterile gloves, and donned blue gloves. Observed RT 4 did not perform HH between glove changes. RT 4 then used NS to clean Resident 93's neck around the stoma, changed gloves, and then applied a new dressing at the stoma. Observed RT 4 did not use H2O2 to clean around the stoma, did not perform HH between glove changes, and performed the insertion of the sterile inner cannula before cleaning the area around the stoma. RT 4 exited the resident's room and performed HH. During an immediate follow-up interview with RT 4, RT 4 stated she (RT 4) usually double gloves to perform the sterile procedure of suctioning and placing a sterile inner cannula. RT 4 stated LVN 2 told her not to double glove, so she stopped and removed all the gloves. RT 4 then stated she (RT 4) changed gloves multiple times during Resident 93's trach care and did not perform HH between glove changes. RT 4 stated she (RT 4) only performs HH before and after resident care and not between glove changes. RT 4 further stated RT 4 did not use H2O2 to cleanse around Resident 93's stoma. RT 4 proceeded to review Resident 93's physician's orders and stated the order indicated to use H2O2 and rinse with NS. RT 4 stated the RT Manager (RTM) told her (RT 4) to use only NS to clean around the stoma, so she only used NS and not H2O2. During a concurrent interview and record review on 1/28/2026 at 12:02 p.m., with the RTM and RT 4, the RTM reviewed Resident 93's physician orders. The RTM stated it was important to clean around the stoma during tracheostomy care to prevent infection. The RTM stated that tracheostomy care should be provided per the physician's orders. The RTM stated Resident 93's order indicates to use H2O2 to cleanse around the stoma, and RT 4 should have used H2O2 during trach care for Resident 93. RT 4 stated she was nervous and did not use H2O2 for Resident 93's trach care. The RTM then stated HH should be performed between glove changes and the RT should not double glove. The RTM stated HH between glove changes prevents contamination from any bacteria from the used gloves transferring to the new gloves. The RTM stated RT 4 should have performed HH between glove changes and she did not. The RTM stated when RT 4 did not perform HH between glove changes and did not use H2O2 per the physician's orders, there was the potential to result in a respiratory infection in Resident 93. During a follow-up interview and record review on 1/28/2026 at 1:03 p.m. with the RTM, the RTM reviewed the P&P regarding trach care. The RTM stated the facility P&P for trach care indicates to first provide cleaning of the area around the stoma, then change to sterile gloves and insert the sterile inner cannula. The RTM stated cleaning first and then inserting the sterile cannula prevents infection. The RTM stated RT 4 did not follow the P&P when RT 4 replaced the sterile cannula before cleaning the area around the stoma. During a concurrent interview and record review on 1/29/2026 at 9:20 a.m. with the Director of Nursing (DON), the DON reviewed the facility P&P regarding hand hygiene and trach care. The DON stated proper technique during trach care is very important because bad practices could introduce infections to residents. The DON stated sterile procedures are completed after clean procedures because everything has to be removed and cleaned per physician's orders with H2O2 before inserting the inner cannula during a sterile procedure. The DON stated this process prevents the growth of microorganisms at the stoma site from entering the airway. The DON stated double gloving during trach care is a bad practice and only protects the staff performing trach care and not the resident. The DON stated when RT 4 attempted to double glove and did not perform HH between glove changes, there was the potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). The DON stated RT 4 did not demonstrate professional standards of practice for trach care and did not follow the facility P&Ps potentially leading to pneumonia and other respiratory infections resulting in hospitalization and death in the resident. During a review of the facility P&P titled, Hand Washing and Sanitizing, last reviewed 1/21/2025, the P&P indicated, Purpose: . The purpose of this policy and procedure is to minimize transmission of microorganisms in the healthcare setting. Compliance with this policy also provides a clean, healthy environment for patients and staff. Hand washing and the use of alcohol-based hand rub are the most effective techniques for preventing spread of infection. Hand washing or the use of alcohol-based hand rub should be done before and after resident contact, and between clean and dirty procedures. Hand washing or alcohol-based hand rub will be done at any time when hands are visibly soiled or contaminated. Hand washing will be done even when staff has donned gloves during a procedure. (Rationale: hands may become contaminated even with glove use and may transfer organisms to a fresh set of gloves). During a review of the facility P&P titled, Tracheostomy Care / Routine Daily Care / Inner Cannula Care, last reviewed 1/21/2025, the P&P indicated, Standard of Care: . Tracheostomies will be kept clean and the airway clear of mucus. Tracheostomy care will be done daily and PRN. Purpose. I. To maintain an adequate airway and to clear excessive secretion. 2. To prevent encrustation of the tracheostomy tube inner cannula (if used). 3. To prevent breakdown or irritation of the surrounding skin. 4. To maintain patency, placement, and security of the tracheostomy. Equipment Needed: . 1. NS . 2. Hydrogen peroxide. 3. Gauze. 6. Inner cannula if applies. 7. Plastic bag for waste. Procedure Steps: . 1. Remove old gauze and place in waste bag. 2. Remove trach tie. 3. Clean around stoma with NS and Hydrogen Peroxide moist gauze. 4. Clean around neck with NS moist gauze. 5. Pat dry neck and stoma with dry gauze. 6. Place new trach tie to secure trach tube. 7. Place new 4x4 around stoma. 8. If applies remove old inner cannula. 9. Change gloves to sterile and insert new inner cannula. 2. During a review of Resident 41's AR, the AR indicated Resident 41 was originally admitted in the facility on 5/25/2017, and readmitted in the facility on 6/17/2025, with diagnoses including respiratory failure (a condition that occurs when the lungs cannot remove all of the carbon dioxide [a colorless, odorless gas that the body breathes out] the body produces), tracheostomy, and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture caused by damage that occurs to the developing brain, most often before birth). During a review of Resident 41's History and Physical (H&P) dated 6/18/2025, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a review of Resident 41's MDS dated [DATE], the MDS assessment indicated Resident 41 had severely impaired cognition (mental action or process of acquiring knowledge and understanding), required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities. The MDS indicated Resident 41 required suctioning (mechanical removal of a patient's secretions with artificial airway such as tracheostomy). During a review of Resident 41's CP on impaired breathing due to risk respiratory failure initiated on 4/24/2025, and last revised on 11/4/2025, the CP indicated to suction secretions as necessary as one of the interventions to achieve Resident 41's airway patent at all times. During a concurrent observation and interview on 1/26/2026 at 9:46 a.m. inside Resident 41's room with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 41's SC was placed inside the plastic storage bag, not in the original packaging and did not indicate the date it was last changed. During a concurrent observation and interview on 1/26/2025 at 10:08 a.m. inside Resident 41's room with RT 2, RT 2 stated Resident 41's SC did not indicate the date it was last changed. RT 2 stated SC are supposed to be changed every week and as needed if soiled, placed inside a plastic storage bag, and should indicate the date it was last changed. RT 2 stated night shift RT assigned is supposed to change the SC. RT 2 stated Resident 41's SC should have indicated the date it was last changed so the staff would know that the SC was changed and clean as it placed Resident 41 at risk for getting infection from a contaminated or old SC. During an interview on 1/29/2026 at 7:58 a.m. with the RTM, the RTM stated the facility practice for SC changes is daily during the night shift and as needed if soiled and should indicate the date of when it was last changed. RTM stated Resident 41's SC should have indicated the date it was last changed so the staff would it was actually changed and it was clean. RTM stated the staff would not know if Resident 41's SC was contaminated which placed the resident at risk for acquiring infection. During a review of the facility's P&P titled, Respiratory Equipment Maintenance, last reviewed on 1/21/2025. The P&P indicated to maximize the prevention of infections and control communicable disease to patients and personnel associated with respiratory care equipment and procedures within patient care areas, suction canister and tubing are changed twice per week and as needed. During a review of the facility's P&P titled, Infection Control Program, last reviewed on 1/21/2025, the P&P indicated that the facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. 3. During a review of Resident 94's AR, the AR indicated Resident 94 was originally admitted in the facility on 5/2/2019 and readmitted in the facility on 6/9/2019, with diagnoses including respiratory failure, tracheostomy, and dependence on respirator status. During a review of Resident 94's H&P dated 10/3/2025, the H&P indicated Resident 94 did not have the capacity to understand and make decisions. During a review of Resident 94's MDS dated [DATE], the MDS assessment indicated Resident 94 had severely impaired cognition (mental action or process of acquiring knowledge and understanding), required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities. The MDS indicated Resident 94 required suctioning (mechanical removal of a patient's secretions with artificial airway such as tracheostomy). During a review of Resident 94's CP on excessive secretions initiated on 6/16/2025 and last revised on 11/5/2025, the CP indicated frequent visual monitoring and suction secretions as needed as one of the interventions to keep Resident 94 free from infection at all times. During an observation on 1/26/2026 at 10:15 a.m. inside Resident 94's room observed Resident 94's SC was placed inside the plastic storage bag, not in the original packaging and did not indicate the date it was last changed. During a concurrent observation and interview on 1/26/2025 at 10:09 a.m. inside Resident 94's room with RT 2, RT 2 stated Resident 94's SC did not indicate the date it was last changed. RT 2 stated SC are supposed to be changed every week and as needed if soiled, placed inside a plastic storage bag, and should indicate the date it was last changed. RT 2 stated night shift RT assigned is supposed to change the SC. RT 2 stated Resident 94's SC should have indicated the date it was last changed so the staff would know that the SC was changed and clean as it placed Resident 94 at risk for getting infection from a contaminated or old SC. During an interview on 1/29/2026 at 7:58 a.m. with the RTM, the RTM stated the facility practice for SC changes is daily during the night shift and as needed if soiled and should indicate the date of when it was last changed. RTM stated Resident 94's SC should have indicated the date it was last changed so the staff would it was actually changed and it was clean. RTM stated the staff would not know if Resident 94's SC was contaminated which placed the resident at risk for acquiring infection. During a review of the facility's P&P titled, Respiratory Equipment Maintenance, last reviewed on 1/21/2025. The P&P indicated to maximize the prevention of infections and control communicable disease to patients and personnel associated with respiratory care equipment and procedures within patient care areas, suction canister and tubing are changed twice per week and as needed. During a review of the facility's P&P titled, Infection Control Program, last reviewed on 1/21/2025, the P&P indicated that the facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. 4. During a review of Resident 13's AR, the AR indicated Resident 13 was originally admitted in the facility on 9/9/2025 and readmitted in the facility on 10/20/2025, with diagnoses including respiratory failure, tracheostomy, and dependence on respirator status. During a review of Resident 13's H&P dated 10/22/2025, the H&P indicated Resident 13 did not have the capacity to understand and make decisions. During a review of Resident 13's MDS dated [DATE], the MDS assessment indicated Resident 13 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities. The MDS indicated Resident 13 required suctioning. During a review of Resident 13's CP titled, The resident has a tracheostomy related to respiratory failure, initiated on 10/21/2025 and last revised on 1/19/2026, the CP indicated to suction secretions as needed as one of the interventions to keep Resident 13 free from signs and symptoms of infection. During an observation on 1/27/2026 at 8:50 a.m. inside Resident 13's room observed Resident 13's SC was placed inside the plastic storage bag and inside the opened original packaging but did not indicate the date it was last changed. During a concurrent observation and interview on 1/27/2025 at 8:54 a.m. inside Resident 13's room with RT 3, RT 3 stated Resident 13's SC did not indicate the date it was last changed. RT 3 stated SC are supposed to be changed every week and as needed if soiled, placed inside a plastic storage bag, and should indicate the date it was last changed. RT 3 stated night shift RT assigned change the SC and he ensures that the SC for his patients are changed during hand off report. RT 3 stated Resident 13's SC should have indicated the date it was last changed so the staff would know that the SC was changed and clean as it placed Resident 13 at risk for getting infection from a contaminated or old SC. During an interview on 1/29/2026 at 7:58 a.m. with the RTM, the RTM stated the facility practice for SC changes is daily during the night shift and as needed if soiled and should indicate the date of when it was last changed. RTM stated Resident 13's SC should have indicated the date it was last changed so the staff would it was actually changed and it was clean. RTM stated the staff would not know if Resident 13's SC was contaminated which placed the resident at risk for acquiring infection. During a review of the facility's P&P titled, Respiratory Equipment Maintenance, last reviewed on 1/21/2025. The P&P indicated to maximize the prevention of infections and control communicable disease to patients and personnel associated with respiratory care equipment and procedures within patient care areas, suction canister and tubing are changed twice per week and as needed. During a review of the facility's P&P titled, Infection Control Program, last reviewed on 1/21/2025, the P&P indicated that the facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. 5. During a review of Resident 57's admission Record (AR), the AR indicated the facility admitted the resident on 9/20/2011, and readmitted the resident on 5/27/2025, with diagnoses including hypercapnia (a condition where there is too much carbon dioxide (CO2) in the bloodstream), tracheostomy (a surgical procedure that creates a small opening in the front of the neck, leading directly into the windpipe (trachea)), and dependence on respirator status (means a person cannot breathe adequately on their own and requires a machine to push air into their lungs to sustain life). During a review of Resident 57's H&P dated 5/27/2025, the H&P indicated the resident was on a ventilator (a medical device to help support or replace breathing), nonverbal and did not follow commands at baseline. During a review of Resident 57's MDS dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person has a serious loss of mental abilities—like thinking, remembering, and reasoning—that makes it impossible for them to live independently and manage basic daily tasks without complete dependence on others). The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was on oxygen therapy (a medical treatment that provides extra oxygen to people who cannot get enough on their own from breathing normal air). During a review of Resident 57's Order Summary Report (OSR), dated 5/27/2025, the OSR indicated an order of: - Change HHN setup every Wednesday and if needed (PRN) every night shift every Wed. - Budesonide 0.5 microgram (mcg, a very small unit of weight used for measuring tiny amounts of substances like vitamins, minerals, and medications)/2 milliliters (ml, a unit of volume) susp 0.5 mg via trach two times a day for chronic lung disease. - Ipratropium bromide 0.02%-sol 250 mcg via trach two times a day for anti-secretory. During a review of Resident 57's Care Plan (CP) Report titled, The resident is ventilator dependent related to head injury, respiratory failure, last revised on 5/5/2025, the CP indicated a goal of the resident will be free from ventilator associated pneumonia ([NAME], a term used to describe pneumonia (lung infection) that develops in a patient who has been on mechanical ventilation for more than 48 hours) through the review date and an intervention to administer aerosol treatments using an in-line nebulizer. During a concurrent observation and interview on 1/26/2026, at 10:53 a.m., with Registered Nurse (RN) 3, inside Resident 57's room, observed Resident 57's HHN set up dated 10/6/2025 on the medication instillation barrel and on the plastic bag it indicated 1/3/2026. RN 3 stated the HHN set up should have been changed every Wednesdays and PRN. RN 3 stated the failure of the licensed staff to change the HHN set up per MD order predisposed the resident to [NAME]. During a concurrent interview and record review on 1/27/2026 at 9:35 a.m., with RN 2, reviewed Resident 57's Medical Diagnosis, OSR, and CP. RN 2 stated there was an order for Resident 57 to change HHN setup every Wednesday and PRN. RN 2 stated the staff should have changed the HHN set up per physician's order to prevent the resident from respiratory infections. During an interview on 1/29/2026, at 7:49 a.m., with the Manager of Pediatrics (MP), the MP stated the Respiratory Therapist (RT) is responsible for changing the HHN setup. The MP stated the failure of the RT to change the HHN set can lead to [NAME] on Resident 57. The MP also stated the licensed staff should also be checking for the dates of respiratory contraptions on the resident and report for overdue contraptions to be changed by RT. During an interview on 1/29/2026, at 8:37 a.m., with the Director of Nursing (DON), the DON stated the RT should have changed Resident 57's HHN setup as ordered by the physician. The DON stated that all licensed staff are also responsible to ensure that the respiratory contraptions attached to the residents are up to date. The DON stated the licensed staff should report to the RT the contraptions that needed to be changed to prevent respiratory infections to residents. During a review of the facility's recent policy and procedure (P&P) titled, Respiratory Equipment Maintenance, last reviewed on 1/21/2025, the P&P indicated to maximize the prevention of infections and control communicable diseases to patients and personnel associated with respiratory care equipment and procedures within patient care areas. Guidelines: 2. Equipment will be discarded in appropriate waste receptacles (standard vs. isolation) by RCP, Respiratory Care Aide and/or Nursing. a. For Pediatrics: i. Nebulizers, tubing, disposable masks, trach collars, nasal cannulas, adapters, and tubing is changed Q week and PRN. ii. Ventilator circuit tubing is changed Q month and PRN. iii. Suction Canister and tubing changed twice per week and PRN.

Based on interview and record review, the facility failed to assure that all nursing staff possess the competencies, and skill sets to safely provide nursing and related services to meet the resident's needs for two of five sampled staff, reviewed for sufficient and competent nurse staffing by failing to ensure: 1. Registered Nurse (RN) 1 was competent in documenting and monitoring for adverse effects (an unwanted, harmful, or unpleasant result of a medical treatment, drug, or other intervention) on the use of antibiotics (a medicine used to treat infections caused by bacteria) as prophylaxis (any action taken to prevent a disease or stop it from spreading). 2. RN 2 recognized the gastrostomy tube (g-tube, a soft tube placed through the skin and abdominal wall directly into the stomach, acting as a shortcut for delivering food, fluids, and medicine when someone cannot eat or drink enough by mouth) venting had back flowed with feeding formula during her shift. The deficient practices had the potential for unrecognized adverse effects on the use of antibiotics that can lead to antibiotic resistance (bacteria have changed and become superbugs that can fight off the medicines (antibiotics) designed to kill them, making infections harder or impossible to cure and posing a major health threat) for Residents 39 and 71 and development of gastric infection due to contaminated feeding formula administered via open system for Resident 71. Findings: 1. During a review of Resident 39's admission Record (AR), the AR indicated the facility admitted the resident on 12/3/2015, and readmitted the resident on 3/15/2023, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), acute tracheitis (an inflammation and infection of the windpipe (trachea), usually caused by bacteria after a common viral cold or the flu), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 39's History and Physical (H&P), dated 1/27/2025, the H&P indicated the resident was delayed (a child who has not gained the developmental skills expected of him or her, compared to others of the same age), spastic (muscles that are stiff, tight, and hard to control, leading to jerky, involuntary movements or spasms, often due to brain or nerve damage) with upper extremity flexion contracture (a condition where a joint, like a knee or elbow, becomes stuck in a bent position and cannot be fully straightened, either by the person themselves or with assistance), and non-verbal. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 11/10/2025, the MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 39's Order Summary Report (OSR), dated 11/24/2025, the OSR indicated an order of Erythromycin Ethyl succinate Oral Suspension Reconstituted 200 milligrams (mg, a unit of weight)/5 milliliters (ml, a unit of volume) (Erythromycin Ethyl succinate). Give 70 mg via g-tube every six hours due to (d/t) delayed gastric emptying for six months. Give 70 mg via g-tube every six hours for gastric motility (the movement of the stomach muscles that helps to mix, grind, and move food through the digestive system). During a review of Resident 39's Care Plan (CP) Report titled, At risk for adverse effects due to long term use of antibiotic therapy, last revised on 8/12/2025, the P&P indicated an intervention to monitor for signs and symptoms (s/s) of side effects and adverse reactions to antibiotics and intervene appropriately. During a concurrent interview and record review on 1/27/2026, at 9:49 a.m., with RN 2, reviewed Resident 39's Medical Diagnosis, OSR, Progress Notes, and Nursing Assessments. RN 2 stated there was no order from the physician to monitor for adverse effects on the use of Erythromycin Ethyl succinate. RN 2 stated the Progress Notes and Nursing Assessments from 12/2025 to 1/2026 did not indicate specific monitoring for adverse effects on the use of the antibiotic. However, RN 2 stated documenting no change of condition means that the adverse effects of all medications including the antibiotics were monitored for adverse effect already. RN 2 stated it is okay to be vague in documenting the monitoring for adverse effects of the antibiotics. RN 2 stated she (RN 2) learned her practice from the previous educator but cannot remember his/her name. RN 2 also stated she (RN 2) learned them from nursing school that documenting no change in condition as assessing and monitoring for adverse effects of antibiotics. During an interview on 1/28/2026, at 6:57 a.m., with RN 9, RN 9 stated when she (RN 9) administers antibiotics to residents, she (RN 2) makes sure that the indication is correct for the medication, there is an end date, and the monitoring for adverse effect is specified in the order. RN 9 stated they are supposed to document the antibiotic administered and document if the resident had tolerated the medication or had an adverse effect on the resident. RN 9 stated the licensed nurse who received the order should have clarified with the physician what adverse effects should the nurse be monitoring for Resident 39. RN 9 stated it was important to monitor for the adverse effect of administering antibiotics to resident and document specific reactions so the primary physician can intervene appropriately and to keep resident free from undue harm of the medication. During an interview on 1/28/2029, at 7:05 a.m., with the Manager of Pediatrics (MP), the MP stated when they have residents with antibiotic used as prophylaxis, they monitor for laboratory results and monitor for its adverse effects on the resident. The MP stated the licensed staff should have documented every shift on the progress notes or Nursing Assessment every shift to indicate what antibiotic is given and to monitor for resident's tolerance to the medication or if the resident had an adverse effect on the resident. The MP stated they were not asking the physicians what adverse effect to monitor on the use of the antibiotic, and he (MP) would have to start educating the staff and the physicians to indicate in their orders what specific adverse effects to report and watch for. The MP stated antibiotics are significant medications that needed to be monitored for adverse effects and should be documented every shift. The MP stated the failure of the licensed staff to monitor for specific adverse effect on the use of antibiotics increases the risk of antibiotic resistance on Resident 39. The MP stated the Adult/Pediatrics Subacute RN and Licensed Vocational Nurse (LVN) Annual Skills List includes medication administration; however, it does not cover specific antibiotic monitoring and documentation of adverse effects. During an interview on 1/29/2026, at 8:37 a.m., with the Director of Nursing (DON), the DON stated the staff should check if antibiotics were prescribed to residents if they have the proper indication, the correct duration, and to ensure the MD provided what adverse effects to monitor and report to ensure its safe use. The DON stated not monitoring for specific adverse effects of the antibiotics could lead to antibiotic resistance on Resident 39. During a concurrent interview and record review on 1/29/2026, at 9:29 a.m., with the Director of Staff Development (DSD), reviewed RN 2's Adult/Pediatrics Subacute RN and LVN Annual Skills List, dated 10/16/2025. The DSD stated RN 2's Adult/Pediatrics Subacute RN and LVN Annual Skills List did not indicate specific competency done for antibiotic administration and adverse effects monitoring. During an interview on 1/29/2026, at 12:17 p.m., with the Infection Preventionist (IP), the IP stated the licensed staff should monitor for the adverse effect of the antibiotic medication even though it is used as a prophylaxis and it needed to be documented in the narrative the specific antibiotic given and the adverse reaction observed or no reactions noted because they need the information during the interdisciplinary team meeting (IDT, is a group of healthcare professionals from various fields who work together to assess the resident's needs, develop a single, coordinated plan of care, and ensure all needs are being met). The antibiotic for prophylaxis is not a routine medication it has an end date of 60 days. The IP stated the staff should have monitored for specific adverse effects on the use of Erythromycin Ethyl Succinate on Resident 39 and document to prevent antibiotic resistance. During a review of the facility's recent policy and procedure (P&P) titled, Employee Performance and Skills Evaluation, last reviewed 1/21/2025, the P&P indicated, Purpose: . The purpose of this policy is to provide guidelines to perform employee performances and skills evaluation. Policy: Annual performance and skills evaluations will be done for all clinical employees. Procedures: . 1. All clinical employees will receive annual skills and performance evaluations. 2. The evaluations will be done by the unit or department manager. 4. Each EMPLOYEE PERFORMANCE AND SKILLS EVALUATION will be based on the individual employee's license and job description. 5. The Performance Evaluation form will include the following: . e. Job Performance. m. Job Knowledge. Safety. 6. The Performance Evaluation will be used as a tool for employee development. During a review of the facility-provided, Job Duty Statement (JDS), for Registered Nurse/Licensed Vocational Nurse Adult and Pediatric Units, undated, the JDS indicated under Duties and Responsibilities: 9. Chart nurses' notes in an informative and descriptive manner that reflects the care provided, as well as the Resident's/patient's response to the care. During a review of the facility's recent P&P titled, Antibiotic Stewardship Program, last reviewed on 1/21/2025, the P&P indicated this policy, and procedure promotes reduction in unnecessary use of Antibiotics while optimizing pertinent infection treatment, which in turn will help reduce potential adverse reaction risk. During a review of the facility-provided Pharmacy Services Consultant (PSC) 1 Service Job Description, revised on 10/2018, indicated the pharmacist will present a quality assurance report and work with the I.D. (interdisciplinary) Team to identify medications that require special study based on (but not limited to): 6. Adverse drug reactions and medication errors. During a review of the facility-provided Erythromycin (Systemic) (Children's Hospital of LA) Information, undated, the Information indicated: Adverse Reactions Gastrointestinal: Abdominal pain, anorexia, diarrhea, nausea, vomiting Hypersensitivity: Hypersensitivity reaction (including anaphylaxis) Cardiovascular: Cardiac arrhythmia (including torsade's de pointes, ventricular arrhythmia, ventricular tachycardia), prolonged QT interval ECG 2. During a review of Resident 71's AR, the AR indicated the facility admitted the resident on 3/9/2017, and readmitted the resident on 3/21/2017, with diagnoses including acute upper respiratory tract infection (a short-term, contagious bug (usually a virus, like a cold or flu) that hits your nose, sinuses, and throat, causing classic symptoms like a runny nose, sore throat, sneezing, and cough, and typically resolves on its own with rest and fluids within a few days to a couple of weeks), gastrostomy, and otitis media (is a common medical term for an ear infection in the middle ear). During a review of Resident 71's H&P, dated 1/27/2025, the H&P indicated the resident was well nourished, no acute distress, and opens his eyes without tracking. The H&P also indicated the resident was non-verbal, with spasticity (a condition in which muscles become stiff, tight, or rigid, preventing normal, fluid movement), hypertonicity with (w/) clonus bilat (a person has abnormally high muscle tension or stiffness (hypertonicity) accompanied by involuntary, rhythmic, and rapid muscle jerking (clonus) in both sides of the body (bilat). During a review of Resident 71's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person has a serious loss of mental abilities-like thinking, remembering, and making decisions-so significant that they are unable to live an independent life and require substantial assistance with daily activities). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 71's OSR, dated 11/24/2025, the OSR indicated an order for Metronidazole 18.7 milligrams (mg, a unit of weight)/milliliters (ml, a unit of volume) susp. Give 187 mg via g-tube every eight hours for ethylmalonic encephalopathy (a rare, severe, inherited metabolic disorder that causes brain damage and affects multiple body systems from a very young age) for six months. During a review of Resident 71's CP Report titled, At risk for adverse effects due to long term use of antibiotic therapy, initiated on 6/3/2025, the CP indicated an intervention to assess for s/s of adverse reactions and report to MD. During a concurrent interview and record review on 1/27/2026, at 9:49 a.m., with RN 2, reviewed Resident 71's Medical Diagnosis, OSR, Progress Notes, and Nursing Assessments. RN 2 stated there was no order from the physician to monitor for adverse effects on the use of Metronidazole. RN 2 stated the Progress Notes and Nursing Assessments from 12/2025 to 1/2026 did not indicate specific monitoring for adverse effects on the use of the antibiotic. However, RN 2 stated documenting no change of condition means that the adverse effects of all medications including the antibiotics were monitored for adverse effect already. RN 2 stated it is okay to be vague in documenting the monitoring for adverse effects of the antibiotics. RN 2 stated she (RN 2) learned her practice from the previous educator but cannot remember his/her name. RN 2 also stated she (RN 2) learned them from nursing school that documenting no change in condition as assessing and monitoring for adverse effects of antibiotics. During an interview on 1/28/2026, at 6:57 a.m., with RN 9, RN 9 stated when she (RN 9) administers antibiotics to residents, she (RN 9) makes sure that the indication is correct for the medication, there is an end date, and the monitoring for adverse effect is specified in the order. RN 9 stated they are supposed to document the antibiotic administered and document if the resident had tolerated the medication or had an adverse effect on the resident. RN 9 stated the licensed nurse who received the order should have clarified with the physician what adverse effects should the nurse be monitoring for. RN 9 stated it was important to monitor for the adverse effect of administering antibiotics to Resident 71 and document specific reactions so the primary MD can intervene appropriately and to keep resident free from undue harm of the medication. During an interview on 1/28/2029, at 7:05 a.m., with the MP, the MP stated when they have residents with antibiotic used as prophylaxis, they monitor for laboratory results and monitor for its adverse effects on the resident. The MP stated the licensed staff should have documented every shift on the progress notes or Nursing Assessment every shift to indicate what antibiotic was given and to monitor for resident's tolerance to the medication or if the resident had an adverse effect on the resident. The MP stated they were not asking the physicians what adverse effect to monitor on the use of the antibiotic, and he (MP) would have to start educating the staff and the physicians to indicate in their orders what specific adverse effects to report and watch for. The MP stated antibiotics are significant medications that needed to be monitored for adverse effects and should be documented every shift. The MP stated the failure of the licensed staff to monitor for specific adverse effect on the use of antibiotics increases the risk of antibiotic resistance on Resident 71. The MP stated the Adult/Pediatrics Subacute RN and LVN Annual Skills List includes medication administration, however it does not cover specific antibiotic monitoring and documentation of adverse effects. During an interview on 1/29/2026, at 8:37 a.m., with the DON, the DON stated the staff should check if antibiotics were prescribed to residents if they have the proper indication, the correct duration, and to ensure the MD provided what adverse effects to monitor and report to ensure its safe use. The DON stated not monitoring for specific adverse effects of the antibiotics could lead to antibiotic resistance on Resident 71. During an interview and record review on 1/29/2026, at 9:29 a.m., with the DSD, reviewed RN 2's Adult/Pediatrics Subacute RN and LVN Annual Skills List, dated 10/16/2025. The DSD stated RN 2's Adult/Pediatrics Subacute RN and LVN Annual Skills List did not indicate specific competency done for antibiotic administration and adverse effects monitoring. During an interview on 1/29/2026, at 12:17 p.m., with the IP, the IP stated the licensed staff should monitor for adverse effect of the antibiotic medication even though it is used as a prophylaxis and it needed to be documented in the narrative the specific antibiotic given and the adverse reaction observed or no reactions noted because they need the information during IDT. The antibiotic for prophylaxis is not a routine medication it has an end date of 60 days. The IP stated the staff should have monitored for specific adverse effects on the use of Metronidazole on Resident 71 and document to prevent antibiotic resistance. During a review of the facility P&P titled, Employee Performance and Skills Evaluation, last reviewed 1/21/2025, the P&P indicated, Purpose: . The purpose of this policy is to provide guidelines to perform employee performances and skills evaluation. Policy: Annual performance and skills evaluations will be done for all clinical employees. Procedures: . 1. All clinical employees will receive annual skills and performance evaluations. 2. The evaluations will be done by the unit or department manager. 4. Each EMPLOYEE PERFORMANCE AND SKILLS EVALUATION will be based on the individual employee's license and job description. 5. The Performance Evaluation form will include the following: . e. Job Performance. m. Job Knowledge. Safety. 6. The Performance Evaluation will be used as a tool for employee development. During a review of the facility-provided, Job Duty Statement (JDS), for Registered Nurse/Licensed Vocational Nurse Adult and Pediatric Units, undated, the JDS indicated under Duties and Responsibilities: 9. Chart nurses' notes in an informative and descriptive manner that reflects the care provided, as well as the Resident's/patient's response to the care. During a review of the facility's recent P&P titled, Antibiotic Stewardship Program, last reviewed on 1/21/2025, the P&P indicated this policy, and procedure promotes reduction in unnecessary use of Antibiotics while optimizing pertinent infection treatment, which in turn will help reduce potential adverse reaction risk. During a review of the facility-provided PSC 1 Service Job Description, revised on 10/2018, indicated the pharmacist will present a quality assurance report and work with the I.D. (interdisciplinary) Team to identify medications that require special study based on (but not limited to): 6. Adverse drug reactions and medication errors. During a review of the facility-provided Metronidazole (Flagyl, Likmez)- Uses, Side Effects, and More Information, dated 10/23/20214, the Information indicated while less common, the most serious side effects of metronidazole are described below, along with what to do if they happen. - Severe Allergic Reactions - Breathing problems or wheezing - Racing heart - Fever or general ill feeling - Swollen lymph nodes - Swelling of the face lips, mouth, tongue, or throat Etc 3. During a review of Resident 71's admission Record (AR), the AR indicated the facility admitted the resident on 3/9/2017, and readmitted the resident on 3/21/2017, with diagnoses including gastrostomy, abdominal hernia (when an internal body part, like fatty tissue or a piece of the intestine, pushes through a weak spot or a small hole in the strong muscle wall that's supposed to hold it in, creating a bulge, often in the belly or groin area, that can be painful when straining or lifting), constipation (a problem with passing stool). During a review of Resident 71's History and Physical (H&P), dated 1/27/2025, the H&P indicated the resident was well nourished, no acute distress, and opens his eyes without tracking. The H&P also indicated the resident was non-verbal, with spasticity, hypertonicity w/ clonus bilat. During a review of Resident 71's Minimum Data Set (MDS, a resident assessment tool), dated 11/30/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition. The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs). The MDS indicated the resident had a feeding tube. During a review of Resident 71's Order Summary Report (OSR), dated 3/31/2018, the OSR indicated an order may vent g-tube continuously every shift. During a review of Resident 71's Care Plan (CP) Report titled, Presence of NG/JT/g-tube. At risk for potential or actual: Infection related to aspiration and or g-tube/JT opening or stoma, initiated on 6/2/2025, the CP indicated a goal of resident will not have any irritation or infection on NGT/JT/g-tube site at all times and an intervention to render NGT/g-tube/JT care as ordered every shift and if needed (PRN). During an observation on 1/26/2026, at 10:05 a.m., observed Resident 71, with 60-cubic centimeters (cc, a basic unit for measuring volume, essentially the space inside a tiny cube that's one centimeter long, one centimeter wide, and one centimeter high) syringe (a small tube with a plunger, like a tiny pump, used to push liquids in or pull liquids out of something, often a person's body for medicines or blood tests) hanging at the resident's head board without a plunger (the rod you push or pull to move liquid in or out of the syringe) open to air with 60-cc of formula. The syringe was labeled vent syringe with the resident's name and room number. During a concurrent observation and interview on 1/26/2026, at 10:14 a.m., with RN 1, inside Resident 71's room, observed Resident 71's vent syringe with 60-cc of formula without a plunger open to air, hanging at the resident's headboard. RN 1 stated the feeding should be on a closed system and leaving the syringe open to air can lead to gastric infection to the resident. RN 1 stated it was the night shift nurse who hang the syringe with the feeding formula open to air and she was not able to catch them on shift change. During a concurrent interview and record review on 1/27/2026, at 9:58 a.m., with RN 2, reviewed Resident 71's Medical Diagnoses, OSR, and CP. RN 2 stated there was an order for may vent g-tube continuously every shift. RN 2 stated the 60-cc syringe hanging at the headboard of the resident with feeding formula is meant for g-tube venting. RN 2 stated the presence of feeding formula on the 60-cc syringe open to air can result to GI infection when introduced to the g-tube of the resident. RN 2 stated RN 1 should have ensured there were no backflow of feeding formula on the 60-cc syringe to prevent infection to set in on the resident. RN 2 stated the purpose of g-tube venting is to release the gas from the gut of the resident and not for feeding. During an interview on 1/29/2026, at 7:49 a.m., with the MP, the MP stated RN 1 should have caught the issue on change of shift report with another licensed nurse. The MP stated the purpose of the manual g-tube venting was to decompress the gut with air not for feeding. RN 1 stated the failure of RN 1 to ensure there were no feeding formula that back flowed to the 60-cc syringe can lead to gastric infection when introduced to the stomach. The MP stated the formula back flowed to the syringe probably due to incorrect clamping on the Y connection site (Y-port for feeding is a small, Y-shaped access point on a feeding tube or the attached tubing that allows for a second connection without interrupting the main flow of nutrition). The MP stated that the Adult/Pediatrics Subacute RN and LVN Annual Skills List had g-tube, but it does not discuss in full details the process for gastric venting. The MP also stated he does not have any lesson plan to show regarding what topics was discussed during the Adult/Pediatrics Subacute RN and LVN Annual Skills List on g-tube. During an interview on 1/29/2026, at 8:37 a.m., with the DON, the DON stated the 60-cc syringe that was hanging on Resident 71's headboard was for manual g-tube venting and was not intended for feeding. The DON stated the failure of the staff to intervene during shift change when a 60-cc syringe for g-tube venting had a feeding formula that back flow to the 60-cc syringe can cause infection to the resident as the formula was open to air and exposed to environmental contaminants. During a concurrent interview and record review on 1/29/2026, at 9:45 a.m., with the DSD, reviewed RN 1's Adult/Pediatrics Subacute RN and LVN Annual Skills Checklist, dated 10/16/2025. The DSD stated there was no specific training or in-service offered regarding gastric venting, the staff learns them on the floor. During a review of the facility P&P titled, Employee Performance and Skills Evaluation, last reviewed 1/21/2025, the P&P indicated, Purpose: . The purpose of this policy is to provide guidelines to perform employee performances and skills evaluation. Policy: Annual performance and skills evaluations will be done for all clinical employees. Procedures: . 1. All clinical employees will receive annual skills and performance evaluations. 2. The evaluations will be done by the unit or department manager. 4. Each EMPLOYEE PERFORMANCE AND SKILLS EVALUATION will be based on the individual employee's license and job description. 5. The Performance Evaluation form will include the following: . e. Job Performance. m. Job Knowledge. Safety. 6. The Performance Evaluation will be used as a tool for employee development. During a review of the facility-provided, Job Duty Statement (JDS), for Registered Nurse/Licensed Vocational Nurse Adult and Pediatric Units, undated, the JDS indicated under Duties and Responsibilities: 14. Administer professional service such as: .tube feedings. 16. Assure that established infection control and aseptic techniques are followed as per facility policies. During a review of the facility's recent P&P titled, Gastrostomy Tube Venting, last reviewed on 1/21/2025, the P&P indicated the purpose of this policy is to provide a guideline on the venting of gastrostomy tubes (GT) to alleviate abdominal distention and bloating in tube feeding residents. Bolus feeding with venting: 2. Once the bolus feeding is completed, clamp GT (see Physician's orders for duration of clamping) to allow feeding and medications to absorb. During a review of the facility's recent P&P titled, Infection Control Program, last reviewed on 1/21/2025, the P&P indicated the facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for Residents and staff to help prevent the development and transmission of disease and infection.

Based on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication emergency kit ([eKIT] - kit containing medications needed to be used during emergencies) containing narcotics (medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Medication [CM] or Controlled Drug [CD]) for January 2026, in one (1) of two (2) inspected medication storage areas (Medication storage Nursing Station 1.) 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled Drug Record accountability logs for two (2) of two (2) narcotics awaiting disposal (removal, destroying) in the CD locked cabinet. As a result, control and accountability of CDs, and medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CD diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and increased the risk that residents in the facility could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm, and hospitalization. Findings: During an observation and concurrent interview on 1/26/2026 at 12:21 p.m., with Registered Nurse (RN) 10, in Medication storage Nursing Station 1 there was: 1. One (1) medication eKIT stored in the refrigerator and labeled 13503 containing narcotics without an accountability log for the reconciliation of narcotic inventory at every shift change for January 2026. During a concurrent interview, RN 10 stated that all narcotics, including medication eKITs containing narcotics should be reconciled at every shift. RN 10 stated the eKIT labeled 13503 containing narcotics in Medication storage Nursing Station 1 was not reconciled at every shift in January 2026, and it was important to account for all narcotics to ensure accountability and prevent narcotic diversion. During an observation and record review in the Director of Nursing (DON) office, on 1/26/2025 at 2 p.m., in the presence of the DON, there were two (2) Controlled Drug Record accountability logs for narcotics awaiting final disposition/destruction in a locked cabinet without containing verifying signatures of either the DON or an RN along with a Licensed Vocational Nurse (LVN). During a concurrent interview, the DON acknowledged the two (2) Controlled Drug Record accountability logs for narcotics awaiting final disposition did not contain verifying signatures. The DON stated the DON was unable to locate the verifying signatures of RN/DON and LVN. The DON stated the DON and the LVNs failed to sign the accountability logs upon receipt of the narcotics from the LVNs. The DON stated the DON counts the narcotics with the LVN upon receipt of the accountability log; however, they overlooked to sign and date the two (2) logs. The DON stated the DON understood the importance of narcotic accountability to ensure each narcotic dose was accounted for until disposed. The DON stated it was important to verify and sign these logs to prevent narcotic diversions and accidental exposure of harmful substances to residents. During an interview on 1/28/2026 at 11 a.m., with the DON, the DON stated that medication eKITs containing narcotics needed to be counted and reconciled at every shift change to ensure accountability and prevent narcotic diversion. The DON stated the eKIT labeled 13503 containing narcotics in Medication storage Nursing Station 1 was not reconciled at every shift in January 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing narcotics. During a review of the Policy and Procedures (P&P,) titled Narcotics, last reviewed 1/21/2025, the P&P indicated the purpose of the policy: To ensure narcotics are accurately accounted for and administered safely. 1. A licensed nurse will perform all change of shift narcotic counts with another licensed nurse (RN or LVN.) During a review of the P&P titled Disposal of Narcotics, last reviewed 1/21/2025, the P&P indicated: For controlled medications submitted to the DON or appointed designee to store pending destruction with pharmacist and DON, a separate log is recommended to be used for the accountability and auditing purposes. During a review of the log titled Narcotic Disposal log, last revised October 2018, the log indicated a column for DON and Licensed Nurse signatures.

Based on interview and record review, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs (medication that is not needed for the current medical condition) for one (1) of two (2) sampled residents (Resident 97) reviewed for anticoagulant use by failing to monitor the resident for signs and symptoms of bleeding for the use of Eliquis (also known as apixaban, an AC used to treat and prevent blood clots). This deficient practice had the potential for Resident 97 to receive suboptimal (less than the highest standard or quality) care leading to the use of unnecessary medications causing potential side effects and negatively impacting their physical, mental, and psychosocial well-being. Cross-reference F656.Findings: During a review of Resident 97's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 4/30/2025, and readmitted in the facility on 6/16/2025, with diagnoses including gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN-high blood pressure). During a review of Resident 97's History and Physical (H&P) dated 6/18/2025, the H&P indicated Resident 97 did not have the capacity to understand and make decisions. During a review of Resident 97's Minimum Data Set (MDS, a resident assessment tool), dated 11/5/2025, the MDS indicated Resident 97 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated Resident 97 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 97 received anticoagulant. During a review of Resident 97's Order Summary Report dated 1/29/2026, the Order Summary Report indicated a physician's order dated 7/5/2025 for Eliquis oral tablet 2.5 milligrams (mg - a unit of measurement) give 2.5 mg via GT every 12 hours for deep vein thrombosis (DVT - a blood clot that forms in the veins located deep within a limb, usually the lower leg or thigh) prophylaxis (a measure taken to maintain health and prevent the spread of disease). The Order Summary Report did not indicate a monitoring for signs and symptoms of bleeding for the use of Eliquis. During a review of Resident 97's care plan (CP) titled, Potential for injury or bleeding, initiated on 12/10/2025, the CP did not indicate monitoring for signs and symptoms of bleeding as one of the interventions for the use of Eliquis. During a concurrent interview and record review on 1/27/2026 at 2:25 p.m., Resident 97's physician's orders, CP, and medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 11/2025, 12/2025, and 1/2026 were reviewed with Registered Nurse (RN) 7. RN 7 stated that Resident 97 had a physician's order for Eliquis but there was no physician's order to monitor Resident 97 for signs and symptoms of bleeding. RN 7 stated that monitoring for signs and symptoms of bleeding is every shift and documented in the MAR. RN 7 stated that the MAR did not contain documentation for monitoring for signs and symptoms of bleeding and bruising with the use of Eliquis. RN 7 stated a CP was initiated on 12/10/2025 but did not indicate monitoring signs and symptoms of bleeding as one of the interventions for the use of Eliquis. RN 7 stated there should have been a physician's order to monitor Resident 97 for signs and symptoms of bleeding for the use of Eliquis so the nurses would check the resident for any signs of bleeding and report to the physician immediately. RN 7 stated if Resident 97 was not monitored routinely for signs and symptoms of bleeding, Resident 97 could have signs of bleeding not seen by staff, delaying notification of the physician, leading to a delay in the necessary care the resident need. During a concurrent interview and record review on 1/28/2026 at 3:39 p.m. Resident 97's physician's orders, CP, and MAR for 11/2025, 12/2025, and 1/2026 were reviewed with the MDS Coordinator (MDSC). The MDSC had a physician's order for Eliquis but there was no order to monitor Resident 97 for signs and symptoms of bleeding every shift. The MDSC stated that monitoring for signs and symptoms of bleeding is done by the nurses every shift and documented in the MAR and notify the physician right away if there are signs present. The MDSC stated that there should have been a physician's order to monitor Resident 97 for signs and symptoms of bleeding. The MDSC stated if there was no monitoring for signs and symptoms of bleeding in place for the use of Eliquis for Resident 97, there is no way for the nurses to notice any symptoms which can delay notification of the physician and placed Resident 97 at risk for a delay in receiving the care needed. During a review of the facility's policy and procedure (P&P) titled, Monitoring of Anticoagulant Therapy, last reviewed on 1/21/2025, the P&P indicated that patients receiving anticoagulation therapy should be assessed for bruising, swelling, and/or redness every shift and as needed. The P&P further indicated that the physician should be notified immediately for any abnormalities. During a review of the facility's P&P titled, Anticoagulant Therapy, last reviewed on 1/21/2025, the P&P indicated that patients shall be assessed for signs and symptoms of adverse effects including unusual bruising or bleeding, hematuria (blood in the urine), bleeding gums, sudden headache, dizziness, or weakness, shortness of breath or chest pain, and swelling at the injection site.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%.) Three (3) medication errors out of 30 total opportunities contributed to an overall medication error rate of 10% affecting one (1) of two (2) residents observed for medication administration (Resident 61.) The medication errors were as follows: 1. Licensed Vocational Nurse (LVN) 5 failed to wait at least five (5) minutes in between administration of brimonidine tartrate (a medication used for glaucoma [a condition of increased pressure in the eyeball,]) dorzolamide hydrochloride (a medication used for glaucoma,) and refresh tears (a medication used to moisturize dry eyes) ophthalmic (eye) drops to Resident 61. These failures had the potential to result in Resident 61 not absorbing the full medication dose resulting in Residents 61's health and well-being to be negatively impacted. Findings: During an observation on 1/26/2026 at 10 a.m., in Medication Cart 9, LVN 5 was observed administering brimonidine one (1) drop to both eyes, immediately followed by administering dorzolamide one (1) drop to left eye, immediately followed by administering refresh tears to both eyes to Resident 61. During an interview on 1/26/2026 at 10:15 a.m., with LVN 5, LVN 5 acknowledged LVN 5 administered brimonidine one (1) drop to both eyes, immediately followed by administering dorzolamide one (1) drop to the left eye, immediately followed by administering refresh tears to both eyes to Resident 61, during the morning medication administration that day (1/26/2026) at 10 a.m. LVN 5 stated according to the directions on the brimonidine ophthalmic prescription label, the label indicated to wait three (3) to five (5) minutes between drops to same eye. LVN 5 stated the reason for waiting three (3) to five (5) minutes between drops to same eye was to ensure each drop of medication had enough time to be fully absorbed before another drop was administered, that could flush out both drops. LVN 5 stated LVN 5 failed to wait three (3) to five (5) minutes between administering brimonidine, dorzolamide and refresh tears to Resident 61 likely flushing out each drop and not allowing full absorption of each medication potentially worsening Resident 61's glaucoma and dry eyes. LVN 5 stated these were considered medication administration errors. During an interview on 1/28/2026 at 11 a.m., with the Director of Nursing (DON,) the DON stated according to manufacturer guidelines and facility policy and procedures (P&P,) when administering eye drops there needs to be a three (3) to five (5) minutes lapse between administrations of more than one (1) drop or more than one (1) medication to each eye to allow the medication to be fully absorbed and not flushed out. The DON stated LVN 5 failed to wait three (3) to five (5) minutes between administration of brimonidine, dorzolamide and refresh tear eye drops to Resident 61 on 1/26/2026 at 10 a.m. The DON stated these were considered medication administration errors. During a review of Resident 61's admission Record (a document containing demographic and diagnostic information,) dated 1/28/2026, the record indicated that Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including hypertension (high blood pressure.) During a review of Resident 61's Medication Administration Record ([MAR] - a record of mediations administered to residents), for January 2026, the MAR indicated Resident 61 was prescribed: 1. brimonidine tartrate one (1) drop in both eyes three (3) times a day for Glaucoma, to be administered at 9 a.m., 1 p.m. and 5 p.m. 2. dorzolamide one (1) drop in left eye three (3) times a day for Glaucoma, to be administered at 9 a.m., 1 p.m. and 5 p.m. 23. refresh tears one (1) drop in both eyes two (2) times a day for dry eyes, to be administered at 9 a.m. and 5 p.m. During a review of the facility's P&P titled Medication Error Policy and Record Completion, last reviewed 1/21/2025, the P&P indicated that A Medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm or no harm while the medication is in control of the health care professional. During a review of the facility's P&P, titled Medication Administration Techniques, last reviewed 1/21/2025, the P&P indicated: 6. Observe 10 Medication Rights: 5. Right Time 4. Verify direction on the Med Sheet with the directions on the prescription label. During a review of the facility's P&P, titled Eye Medication Administration, last reviewed 1/21/2025, the P&P indicated: 8. Wait 3-5 minutes between more than 1 drop or more than one medication. This will allow the medication time to be absorbed. During a review of manufacturer's guidelines titled Highlights of Prescribing Information for brimonidine tartrate, last revised May 2025, the document indicated: Brimonidine tartrate ophthalmic solution may be used concomitantly with other topical ophthalmic drug products to lower intraocular pressure. If more than one topical ophthalmic product is to be used, the different products should be instilled at least 5 minutes apart. During a review of manufacturer's guidelines titled Highlights of Prescribing Information for dorzolamide hydrochloride, last revised December 2024, the document indicated: Dorzolamide hydrochloride ophthalmic solution may be used concomitantly with other topical ophthalmic drug products to lower intraocular Sections or subsections omitted from the full prescribing information are not listed. pressure. If more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (meaning the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one (1) of one (1) sampled resident (Resident 6) reviewed for anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) heparin (an anticoagulant) administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of heparin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: During a review of Resident 6's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 1/21/2025, and readmitted in the facility on 5/31/2025, with diagnoses including dependence on respirator (also known as ventilator - a machine used to help a person breath when they are unable to do so on their own) status , tracheostomy (an opening a surgeon makes through the neck and into the trachea [also known as windpipe] to help a patient breathe), and type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 6's History and Physical (H&P) dated 5/31/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 6 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated Resident 6 had impairment of both upper and lower extremities and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 6's Order Summary Report dated 1/29/2026, the Order Summary Report indicated a physician's order dated 5/31/2025 for: - Heparin sodium injection solution 5000 unit per milliliter (unit/ml - a unit of measurement) inject one ml subcutaneously every 12 hours for deep vein thrombosis (DVT - a blood clot that forms in the veins located deep within a limb, usually the lower leg or thigh) prophylaxis (a measure taken to maintain health and prevent the spread of disease). During a review of Resident 6's Location of Administration Report for heparin sodium for the months of 12/2025 and 1/2026, the Location of Administration Report indicated the heparin sodium was administered on the following dates, times, and sites: - 12/09/25 9 p.m. 12/09/25 8:45 p.m. subcutaneously abdomen - right lower quadrant (RLQ) - 12/10/25 9:00 a.m.12/10/25 8:53 a.m. subcutaneously abdomen - RLQ - 1/22/26 9:00 p.m. 1/22/26 9:51 p.m. subcutaneously abdomen - left lower quadrant (LLQ) - 1/23/26 9:00 a.m. 1/23/26 9:38 a.m. subcutaneously abdomen - LLQ - 1/24/26 9:00 p.m. 1/24/26 8:21 p.m. subcutaneously arm - left - 01/25/26 9:00 a.m.1/25/26 8:09 a.m. subcutaneously arm - left During a concurrent interview and record review on 1/27/2026 at 4:47 p.m., Resident 6's physician's order, medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), and Location of Administration Reports for 12/2025 and 1/2026 were reviewed with Registered Nurse (RN) 7. RN 7 stated there were multiple instances the licensed nurses did not rotate the subcutaneous injection sites of heparin on 12/9/2026, 12/10/2026, 1/22/2026, 1/23/2026, 1/24/2026, and 1/25/2026. RN 7 stated administration sites for subcutaneous injection should be rotated per standards of practice and according to the manufacturer's guideline to prevent excessive bruising and lipodystrophy on the injection site. During an interview on 1/28/2026 at 3 p.m. with the Director of Nursing (DON), the DON stated she was made aware of multiple instances of not rotating the subcutaneous injection sites for heparin for Resident 6. The DON stated the staff are able to see in the MAR the previous administration sites for the heparin and are supposed to rotate according to professional standards of practice and the manufacturer's guideline. The DON stated there should be no reason for the licensed staff to repeat the administration sites for all subcutaneous injections, not just heparin. The DON stated Resident 6's injection site for heparin should have been rotated as it can place Resident 6 at risk for discomfort or irritation at the injection site, excessive bruising, or lipodystrophy which can affect the absorption of the medication. The DON stated that not following the professional standards of practice and manufacturer's guideline to rotate heparin injection sites can be considered a medication error. During a review of the facility provided Highlights of Prescribing Information on the use of heparin sodium injection, last revised on 9/2019, the Highlights of Prescribing Information indicated that a few of the adverse reactions for heparin included but not limited to hemorrhage (any type of internal or external loss of blood from a damaged blood vessel [tubes that carry blood throughout the body]), and injection site irritation. The Highlights of Prescribing Information further indicated that for therapeutic anticoagulant effect a different site should be used for each injection to prevent the development of massive hematoma (a localized collection of blood outside of blood vessels and should be administered as a deep subcutaneous injection. During a review of the facility's policy and procedure (P&P) titled, Subcutaneous Medication Administration, last reviewed on 1/21/2025, the P&P indicated a purpose to ensure safe and effective administration of medications via the subcutaneous route, reducing the risk of infection, and tissue injury. The P&P further indicated: - Site Selection: approved sites include abdomen, upper outer arms, rotate injection sites to prevent tissue damage, avoid areas with bruising, scars, inflammation, edema or infection. - Post administration: observe the patient for adverse reactions. - Documentation: document medication name, dose, route, time, and site of administration; note site rotation as required. During a review of the facility's P&P titled, Adverse Drug Reactions, last reviewed on 1/21/2025, the P&P indicated that the purpose of the policy is to establish written standards for monitoring, reporting, and analyzing real or potential adverse drug reactions. The P&P further indicated an adverse drug reaction is defined as any unexpected, unintended, undesired, or excessive response to a drug that results in temporary or permanent harm, disability, or death. During a review of the facility's P&P titled, Medication Error Policy and Record Completion, last reviewed on 1/21/2025, the P&P indicated a medication error is any preventable event that may cause or [NAME] to inappropriate medication use or patient harm or no harm while the medication is in the control of the healthcare professional.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for two (2) of two (2) sampled residents (Resident 26 and 39) reviewed for physical restraints by failing to: 1. Complete a restraint assessment prior to application of the hand mitten (a large, soft glove that covers a patient's hands and prevent them from pulling out any lines or tubes) for Resident 26. 2.Ensure Resident 39's restraint bed placed against the wall had a/an: a)Physician's order b)Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident and/or representative c)Physical restraint assessment for its safe use. d)Comprehensive Care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments). These deficient practices had the potential to result in the restriction of resident's freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (an occurrence involving a patient who is caught, trapped, or entangled in a hospital bed system), and death of residents. Findings: a. During a review of Resident 26's admission Record (AR front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility originally admitted Resident 26 on 6/1/2025 and readmitted in the facility on 1/6/2026, with diagnoses including congenital malformation (also known as birth defect, physical abnormalities which can affect various parts of the body that occurs before a baby is born), tracheostomy (an opening a surgeon makes through the neck and into the trachea [also known as windpipe] to help a patient breathe), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 26's History and Physical (H&P) dated 1/6/2026, the H&P indicated Resident 26 did not have the capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set (MDS, a resident assessment tool), dated 11/2/2025, the MDS indicated Resident 26 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was not able to understand and make his needs known. The MDS further indicated Resident 26 required substantial or maximal assistance to total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 26's Order Summary Report dated 1/29/2026, the Order Summary Report indicated a physician's order dated 1/8/2026 for both hand mittens as needed to prevent self-inflicted injury, release every two (2) hours for 15 minutes for circulation check while in use as needed. The Order Summary Report indicated that informed consent was verified with the physician. During a review of Resident 26's informed consent form dated 1/8/2026, the form indicated that an informed consent was obtained from the responsible party thru the phone for the use of both hand mittens as needed. During a review of Resident 26's care plan (CP) on use of restraints both hand mittens initiated on 1/20/2026, the CP indicated to apply safety device as ordered, continue to implement less restrictive measures such as talking to the resident in a calm, firm manner, explaining procedures and nursing care, and release restraint every two (2) hours or when providing care and/or when resident is closely supervised as a few of the interventions to maintain resident without any episode of falls and injury at all times. During a review of Resident 26's restraint assessment dated [DATE], the restraint assessment did not mention the application of both hand mittens as needed to prevent self-inflicted injury and any least restrictive measures attempted by the facility prior to use of both hand mittens. During a concurrent observation and interview on 1/26/2026 at 9:45 a.m. inside Resident 262's room with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 26 had mitten on the right hand, and she releases the hand mitten every two hours to check the skin for circulation, breakdown, or bruising and report to the nurse if she finds anything. During a concurrent interview and record review on 1/28/2026 at 2:14 p.m., Resident 26's physician's orders, informed consent, CP, and restraint assessment were reviewed with the MDS Coordinator (MDSC). The MDSC stated that Resident 26 had a physician's order for both hand mittens as needed to prevent self-inflicted injury. The MDSC stated that Resident 26's restraint assessment did not indicate any least restrictive measures attempted prior to application of both hand mittens. The MDSC stated that Resident 26's restraint assessment did not indicate application of both hand mitten as a recommendation by the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) to prevent self-inflicted injury. The MDSC stated least restrictive measures should have been attempted first by the IDT and documented prior to application of both hand mitten. The MDSC stated that Resident 26's restraint assessment should have been completed to reflect the IDT recommendation to apply both hand mittens as needed to prevent self-inflicted injury to ensure that the use of the restraint is appropriate and it placed Resident 26 at risk for restriction of his freedom of movement of his hand and fingers which could lead to a decline in physical functioning of the hands and fingers. During an interview on 1/28/2026 at 2:45 p.m. with the Director of Nursing (DON), the DON stated restraint assessments are completed prior to application of restraints or any device. The DON stated the IDT should try least restrictive measures prior to application of restraints and document in the restraint assessment to ensure the use of the restraint or device is appropriate to prevent unnecessary use of physical restraints. The DON stated Resident 26's restraint assessment should have been completed prior to application of both hand mittens to reflect that the least restrictive measures attempted by the IDT or staff were not effective and should also reflect the recommendation to use the hand mitten. The DON stated it was important to complete Resident 26's restraint assessment prior to application of both hand mitten as it placed Resident 26 at risk for restriction of his freedom to move his hands and fingers. The DON stated if Resident 26 cannot use his fingers freely it could lead to a decline of his physical functioning on the hands and fingers. During a review of the facility's policy and procedure (P&P) titled, Hand Mittens for Resident Safety, last reviewed on 1/21/2025, the P&P indicated that residents who have the potential for self-injury such as scratching, placing objects into their mouth, pulling monitor's lines, self-decannulation of tracheostomy tubes) may use hand mitten to prevent such injury. During a review of the facility's P&P titled, Protective Devices and Restraints, last reviewed on 1/21/2025, the P&P indicated that protective devices or restraints should be used only under explicit circumstances, for the resident's benefit. Whenever possible, alternatives to these devices should be tried first. With rare exception, a physician's authorization is required initially for their use. When protective devices or restraints are used, the staff should make observations and take precautions to attempt to prevent problems and complications related to their use. The P&P further indicated that periodically the attending physician and nursing staff will consider whether an individual still needs the device(s), or if their use could be reduced or eliminated. Whenever possible the nursing staff will discontinue the device(s) for a trial period and observe and report the results. b. During a review of Resident 39's AR, the AR indicated the facility admitted the resident on 12/3/2015, and readmitted the resident on 3/15/2023, with diagnoses including convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body), cortical blindness (is the total or partial loss of vision in a normal-appearing eye caused by damage to the brain's occipital cortex), and fracture of femur (is a break or crack in the thighbone). During a review of Resident 39's H&P, dated 1/27/2025, the H&P indicated the resident was delayed (a child who has not gained the developmental skills expected of him or her, compared to others of the same age), spastic (born with a disability which makes it difficult for them to control their muscles, especially in their arms and legs) with upper extremity flexion contracture (a bent (flexed) joint that cannot be straightened actively or passively), and non-verbal. During a review of Resident 39's MDS, dated [DATE], the MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 39's Resident at Risk for Falls Assessment (RFA), dated 2/11/2025, the RFA indicated the resident was at risk for falls. During a concurrent observation, interview, and record review on 1/26/2026, at 9:15 a.m., with the Manager of Pediatrics (MP), observed Resident 39's bed was placed against the wall on the right side of the bed with all 4 side rails up. The MP stated placing the bed against the wall is a restraint and requires a physician's order, informed consent, restraint assessment, and a care plan. The MP reviewed Resident 39's Diagnoses, Informed Consents, Order Summary Report (OSR), Restraint Assessments, and Care Plans. The MP stated he (MP) did not find any physician's order, informed consent, restraint assessment, and care plan on the use of bed placed against the wall on Resident 39's chart. The MP stated they did not do any of the requisites prior to application of the restraint bed against the wall on Resident 39 because it is not appropriate for the resident. The MP stated placing the bed against the wall had the potential to violate the resident's right to freedom of movement and can result to deconditioning (the loss of physical fitness and strength that happens when a person is inactive for a prolonged period) on the resident. The MP also stated the resident was also predisposed to accidents such as bed entrapment. During an interview on 1/29/2026, at 8:37 a.m., with the DON, the DON stated the licensed staff should have obtained a physician's order, informed consent from the resident or the representative, performed a restraint assessment, and developed and implemented a care plan on the use of restraint bed placed against the wall to ensure its safe use. The DON stated the failure of the licensed staff to obtain a physician's order, informed consent from the resident or the representative, perform a restraint assessment, and developed and implemented a care plan on the use of restraint bed placed against the wall had predisposed the resident to accidents such as bed entrapment and major injuries such as fractures. During a review of the facility's recent policy and procedure (P&P) titled, Protective Devices and Restraints, last reviewed on 1/21/2025, the P&P indicated protective devices or restraints should be used only under explicit circumstances, for resident's benefit. Wherever possible, alternatives to these devices should be tried first. With rare exception, a physician's authorization is required initially for their use. When protective devices or restraints are used, the staff should make observations and take precautions to attempt to prevent problems and complications related to their use. Procedure: 2. The physician's order will contain the specific type of protective device(s) to be used (for example, wrist restraints, pelvic device, waist device, or padded mittens)/ Also, the physician's orders or progress notes should reflect the reason for ordering the device(s). Periodically, the attending physician and nursing staff will consider whether an individual still needs the device(s), or if their use could be reduced or eliminated. Wherever possible, the nursing staff will discontinue the device(s) for a trial period and observe and report the results.

Based on observation, interview, and record review, the facility failed to ensure to store, prepare, and serve food in accordance with professional standards for food service safety for 19 out of 109 residents by failing to ensure: 1. The facility discarded the bag of deli bread and an unopened bag of deli hot dog buns with the best by date of 1/20/2026. 2. The facility did not hang a spoodle (is a hybrid kitchen utensil that combines the features of a spoon and a ladle) with butter residues on the clean rack near the steam table. These deficient practices had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 1/26/2026, at 8:09 a.m., with Dietary Supervisor/Registered Dietician (DS/RD), during Kitchen Facility Task, observed the following inside the facility's walk-in refrigerator: 1. A bag of opened deli bread with best by date of 1/20/2026, no open date. 2. A bag of unopened deli hot dog buns with best by date of 1/20/2026. Observed a spoodle hanging on the clean rack near the steam table with butter residues on them. The DS/RD stated it was the responsibility of all the kitchen staff to ensure the food products in the facility were not used after its best by date to ensure food quality and palatability is maintained. The DS/RD stated the staff should ensure the food products has their delivery date, and open date to make sure they are not going past the expiration date of the food products. The DS/RD also stated there is a potential for food-borne illnesses on residents served with food past their best by dates. The DS/RD also stated the spoodle should not have any butter residues in them because it is contaminated and when used to stir/prepare food, it can cause food-borne illnesses. During an interview on 1/29/2026, at 8:37 a.m., with the Director of Nursing (DON), the DON stated the kitchen staff should have discarded the deli buns without the open date, with best by date of 1/20/2026 and the deli hot dog buns with the best by date of 1/20/2026 because it is past due of their best by dates. The DON stated serving the buns to resident can affect the food palatability and worse can cause food-borne illnesses on residents. The DON stated the kitchen staff should inspect and ensure kitchen utensils such as the spoodle should be free from food residues as it can contaminate the food and can cause gastrointestinal (GI, having to do with the gastrointestinal (GI) tract or GI system) infections to residents. During a review of the facility's recent policy and procedure (P&P) titled, Food and Formula Storage, last reviewed on 1/21/2025, the P&P indicated proper food and formula storage procedure are followed to allow for effective, safe, and sanitary kitchen operations. During a review of the facility's recent P&P titled, Labeling and Dating of Foods, last reviewed on 1/21/2025, the P&P indicated newly opened food items will need to be closed and labeled with an open date and use by date that follow manufacturer's guideline.

Based on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB, a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for two of three sampled residents (Residents 39 and 71) reviewed for antibiotic use by failing to ensure: 1. Resident 39's Erythromycin Ethyl succinate Oral Suspension Reconstituted (a common antibiotic medication used to treat a wide variety of bacterial infections) 200 milligrams (mg, a unit of weight)/5 milliliters (ml, a unit of volume) (Erythromycin Ethyl succinate) via gastrostomy tube (g-tube, a soft, flexible tube that a doctor places directly into the stomach through a small, surgically created opening in the skin of the belly) every six (6) hours due to (d/t) delayed gastric emptying for 6 months had monitoring for its adverse effects (an undesired, harmful, or unexpected result caused by a medical treatment, such as a drug, surgery, or intervention). 2. Resident 71's Metronidazole (a prescription antibiotic that kills certain bacteria and parasites, especially those that do not need oxygen) 18.7 mg/ml susp for ethylmalonic encephalopathy (a severe, rare, inherited disorder that causes damage to several body systems, particularly the brain, nerves, and blood vessels) for 6 months had monitoring for its adverse effects. The deficient practices had placed the residents at risk for adverse effects and multidrug resistant organisms (MDRO) resistance (means that a germ, like a bacteria or fungus, has evolved to a point where multiple drugs that once killed it are no longer effective) to antibiotics. Findings: 1. During a review of Resident 39's admission Record (AR), the AR indicated the facility admitted the resident on 12/3/2015, and readmitted the resident on 3/15/2023, with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), acute tracheitis (an inflammation or, more commonly, a serious bacterial infection of the windpipe [trachea]), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 39's History and Physical (H&P), dated 1/27/2025, the H&P indicated the resident was delayed (a general term used when a child does not reach common age-appropriate skills, known as developmental milestones, at the expected time), spastic (muscles that are stiff, tight, and hard to control, leading to jerky, involuntary movements or spasms, often due to brain or nerve damage) with upper extremity flexion contracture (a condition where a joint, like a knee, hip, or finger, gets stuck in a bent (flexed) position and cannot be fully straightened, either by the person themselves or with help from another person), and non-verbal. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 11/10/2025, the MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 39's Order Summary Report (OSR), dated 11/24/2025, the OSR indicated an order of Erythromycin Ethyl succinate Oral Suspension Reconstituted 200 mg/5 ml (Erythromycin Ethyl succinate). Give 70 mg via g-tube every 6 hours d/t delayed gastric emptying for 6 months. Give 70 mg via g-tube every 6 hours for gastric motility (the automatic muscle movements of the stomach that mix, break down, and move food through the digestive system). During a review of Resident 39's Care Plan (CP) Report titled, At risk for adverse effects due to long term use of antibiotic therapy, last revised on 8/12/2025, the P&P indicated an intervention to monitor for signs and symptoms (s/s) of side effects and adverse reactions to antibiotics and intervene appropriately. During a concurrent interview and record review on 1/27/2026, at 9:49 a.m., with Registered Nurse (RN) 2, Resident 39's Medical Diagnosis, OSR, Progress Notes, and Nursing Assessments were reviewed. RN 2 stated there was no order from the physician to monitor for adverse effects on the use of Erythromycin Ethyl succinate. RN 2 stated the Progress Notes and Nursing Assessments from 12/2025 to 1/2026 did not indicate specific monitoring for adverse effects on the use of the antibiotic however, RN 2 stated documenting no change of condition means that the adverse effects of all medications including the antibiotics were monitored for adverse effect already. RN 2 stated it is okay to be vague in documenting the monitoring for adverse effects of the antibiotics. During an interview on 1/28/2026 at 6:57 a.m. with RN 9, RN 9 stated when she (RN 9) administers antibiotics to residents, she (RN 9) makes sure that the indication is correct for the medication, there is an end date, and the monitoring for adverse effect is specified in the order. RN 9 stated they are supposed to document the antibiotic administered and document if the resident had tolerated the medication or had an adverse effect on the resident. RN 9 stated the licensed nurse who received the order should have clarified with the physician what adverse effects should the nurse be monitoring for Resident 39. RN 9 stated it was important to monitor for the adverse effect of administering antibiotics to resident and document specific reactions so the primary MD can intervene appropriately and to keep resident free from undue harm of the medication. During an interview on 1/28/2026 at 7:05 a.m. with the Manager of Pediatrics (MP), the MP stated that when the facility has residents with antibiotic used as prophylaxis (any action taken to prevent a disease or illness before it happens), the facility monitor for laboratory results and monitor for its adverse effects on the resident. The MP stated the licensed staff should have documented every shift on the progress notes or Nursing Assessment every shift to indicate what antibiotic is given and to monitor for resident's tolerance to the medication or if the resident had an adverse effect. The MP stated the facility was not asking the physicians what adverse effect to monitor on the use of the antibiotic. The MP stated antibiotics are significant medications that needed to be monitored for adverse effects and should be documented every shift. The MP stated the failure of the licensed staff to monitor for specific adverse effect on the use of antibiotics increases the risk of antibiotic resistance (occurs when bacteria develop defenses against the antibiotics designed to kill them) on residents. During an interview on 1/29/2026 at 8:37 a.m. with the Director of Nursing (DON), the DON stated the staff should check if antibiotics were prescribed to residents if the orders have the proper indication, the correct duration, and to ensure the MD provided what adverse effects to monitor and report to ensure its safe use. The DON stated not monitoring for specific adverse effects of the antibiotics could lead to antibiotic resistance on Resident 39. During an interview on 1/29/2026 at 12:17 p.m. with the Infection Preventionist (IP), the IP stated the licensed staff should monitor for the adverse effect of the antibiotic medication even though it is used as a prophylaxis and it needed to be documented in the narrative the specific antibiotic given and the adverse reaction observed or no reactions noted because the facility needs the information during the interdisciplinary team meeting (IDT, a group of healthcare professionals and staff who work together to create, implement, and review the care plan for each resident). The antibiotic for prophylaxis is not a routine medication and has an end date of 60 days. The IP stated the staff should have monitored for specific adverse effects on the use of Erythromycin Ethyl Succinate on Resident 39 and document to prevent antibiotic resistance. During a review of the facility's recent policy and procedure (P&P) titled, Antibiotic Stewardship Program, last reviewed on 1/21/2025, the P&P indicated this policy and procedure promotes reduction in unnecessary use of Antibiotics while optimizing pertinent infection treatment, which in turn will help reduce potential adverse reaction risk. During a review of the facility provided Pharmacy Services Consultant (PSC) 1 Service Job Description, revised on 10/2018, indicated the pharmacist will present a quality assurance report and work with the I.D. (interdisciplinary) Team to identify medications that require special study based on (but not limited to): 6. Adverse drug reactions and medication errors. During a review of the facility provided Erythromycin (Systemic) Information, undated, the Information indicated: Adverse Reactions Gastrointestinal: Abdominal pain, anorexia (a type of eating disorder), diarrhea, nausea, vomiting Hypersensitivity: Hypersensitivity reaction (including anaphylaxis [a severe, potentially life-threatening, and fast-acting allergic reaction]) Cardiovascular: Cardiac arrhythmia (an abnormal heart rhythm), prolonged QT interval (an abnormal heart rhythm) ECG (electrocardiogram - a test to the electrical signals traveling through the heart) 2. During a review of Resident 71's AR, the AR indicated the facility admitted the resident on 3/9/2017, and readmitted the resident on 3/21/2017, with diagnoses including acute upper respiratory tract infection (viruses and bacteria that infect the respiratory tract above the vocal cords), gastrostomy, and otitis media (a middle ear infection or inflammation). During a review of Resident 71's H&P, dated 1/27/2025, the H&P indicated the resident was well nourished, no acute distress, and opens his eyes without tracking. The H&P also indicated the resident was non-verbal, with spasticity, hypertonicity with (w/) clonus bilat (a condition involving abnormally tight or stiff muscles that also experience rapid, involuntary, rhythmic jerking movements, occurring on both sides of the body). During a review of Resident 71's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person has a serious loss of mental abilities-like thinking, remembering, and making decisions-that is significant enough to prevent them from living independently and managing their daily life). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 71's OSR, dated 11/24/2025, the OSR indicated an order for Metronidazole 18.7 mg/ml susp. Give 187 mg via g-tube every 8 hours for ethylmalonic encephalopathy for 6 months. During a review of Resident 71's CP Report titled, At risk for adverse effects due to long term use of antibiotic therapy, initiated on 6/3/2025, the CP indicated an intervention to assess for s/s of adverse reactions and report to MD. During a concurrent interview and record review on 1/27/2026 at 9:49 a.m. with RN 2, Resident 71's Medical Diagnosis, OSR, Progress Notes, and Nursing Assessments were reviewed. RN 2 stated there was no order from the physician to monitor for adverse effects on the use of Metronidazole. RN 2 stated the Progress Notes and Nursing Assessments from 12/2025 to 1/2026 did not indicate specific monitoring for adverse effects on the use of the antibiotic however, RN 2 stated documenting no change of condition means that the adverse effects of all medications including the antibiotics were monitored for adverse effect already. RN stated it is okay to be vague in documenting the monitoring for adverse effects of the antibiotics. During an interview on 1/28/2026, at 6:57 a.m., with RN 9, RN 9 stated when she administers antibiotics to residents, she makes sure that the indication is correct for the medication, there is an end date, and the monitoring for adverse effect is specified in the order. RN 9 stated staff are supposed to document the antibiotic administered and document if the resident had tolerated the medication or had an adverse effect on the resident. RN 9 stated the licensed nurse who received the order should have clarified with the physician what adverse effects should the nurse be monitoring for Resident 71. RN 9 stated it was important to monitor for the adverse effect of administering antibiotics to Resident 71 and document specific reactions so the primary MD can intervene appropriately and to keep resident free from undue harm of the medication. During an interview on 1/28/2026 at 7:05 a.m. with the MP, the MP stated that when the facility has residents with antibiotic used as prophylaxis, the facility monitors for laboratory results and monitor for its adverse effects on the resident. The MP stated the licensed staff should have documented every shift on the Progress Notes or Nursing Assessment every shift to indicate what antibiotic is given and to monitor for resident's tolerance to the medication or if the resident had an adverse effect. The MP stated they were not asking the physicians what adverse effect to monitor on the use of the antibiotic and he (MP) would have to start educating the staff and the physicians to indicate in their orders what specific adverse effects to report and watch for. The MP stated antibiotics are significant medications that needed to be monitored for adverse effects and should be documented every shift. The MP stated the failure of the licensed staff to monitor for specific adverse effect on the use of antibiotics increases the risk of antibiotic resistance on Resident 71. During an interview on 1/29/2026 at 8:37 a.m. with the DON, the DON stated the staff should check if antibiotics were prescribed to residents if the orders have the proper indication, the correct duration, and to ensure the MD provided what adverse effects to monitor and report to ensure its safe use. The DON stated not monitoring for specific adverse effects of the antibiotics could lead to antibiotic resistance on Resident 71. During an interview on 1/29/2026 at 12:17 p.m. with the IP, the IP stated the licensed staff should monitor for adverse effect of the antibiotic medication even though it is used as a prophylaxis and it needed to be documented in the narrative the specific antibiotic given and the adverse reaction observed or no reactions noted because the facility needs the information during the IDT. The antibiotic for prophylaxis is not a routine medication it has an end date of 60 days. The IP stated the staff should have monitored for specific adverse effects on the use of Metronidazole on Resident 71 and document to prevent antibiotic resistance. During a review of the facility's recent P&P titled, Antibiotic Stewardship Program, last reviewed on 1/21/2025, the P&P indicated this policy and procedure promotes reduction in unnecessary use of antibiotics while optimizing pertinent infection treatment, which in turn will help reduce potential adverse reaction risk. During a review of the facility provided PSC 1 Service Job Description, revised on 10/2018, indicated the pharmacist will present a quality assurance report and work with the I.D. (interdisciplinary) Team to identify medications that require special study based on (but not limited to): 6. Adverse drug reactions and medication errors. During a review of the facility provided Metronidazole (Flagyl, Likmez) - Uses, Side Effects, and More Information, dated 10/23/2024, the Information indicated while less common, the most serious side effects of metronidazole are described below, along with what to do if they happen. - Severe Allergic Reactions - Breathing problems or wheezing - Racing heart - Fever or general ill feeling - Swollen lymph nodes (body parts that filter fluid in the body for harmful substances or cells) - Swelling of the face lips, mouth, tongue, or throat Etc

Based on observation, interview, and record review the facility failed to ensure garbage and refuse in the facility were disposed of properly. The deficient practice had the potential to attract pests that can bring diseases to the residents. Findings: During an observation on 1/26/2026, at 7:30 a.m., near the facility's trash bin area, observed a racoon lurking around the trash bins. During a concurrent observation and interview on 1/26/2026 at 8:09 a.m. with the Dietary Supervisor/ Registered Dietician (DS/RD), observed multiple black and blue trash bins opened and overflowing with trash and cannot be shut closed. The DS/RD stated the trash bins were not totally shut. The DS/RD stated they were already aware of the issue because they dispose more trash and the bins were not enough to store them without overflowing. The DS/RD stated they had requested for an extra bin and they were awaiting for the delivery. The DS/RD stated that it was not appropriate to leave the trash bins open as it attracts pests such as rats and rodents that can carry diseases to the facility causing the residents to get sick. During a concurrent interview and record review on 1/29/2026 at 8:37 a.m. with the Director of Nursing (DON), reviewed the pictures of the trash bins taken on 1/26/2026 at 7:09 a.m., with the DON. The DON stated the bins on the pictures were showing their trash bins were not closed and overflowing. The DON stated it was not acceptable to have trash bins left open because it can attract pests, rodents, rats that carry diseases causing the residents to get sick. During a review of the facility's recent policy and procedure (P&P) titled, Grounds, last reviewed on 1/21/2025, the P&P indicated facility grounds shall be maintained in a safe and attractive manner. Policy Interpretation and Implementation 4. Facility outdoor trash bins will remain covered at all times, unless during times when being emptied or filled.

Based on observation, interview, and record review the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures by failing to: 1. Monitor and record medication storage area room temperature on a temperature monitoring log for January 2026, for one (1) of two (2) inspected medication storage areas (Medication storage Nursing Station 1.) 2. Label and store one (1) levalbuterol (a generic name for medication used to treat and prevent shortness of breath) inhalation solution foil pouch (a package made of foil protecting the inhalation solution from light and degradation) for Resident 79 at room temperature in accordance with the manufacturer's requirements in one (1) of ten (10) inspected Medication Carts (Medication Cart room [ROOM NUMBER].) 3. Ensure nasal sprays were stored separately from orally administered medications, in one (1) of ten (10) inspected Medication Carts (Medication Cart 3.) 4. Ensure eye drops and nasal sprays were stored separately from orally administered medications, in one (1) of ten (10) inspected Medication Carts (Medication Cart 2.) These deficient practices increased the risk for Resident 79 and others to receive medication that had become ineffective or toxic due to improper storage or labeling and increase the risk of contamination and receiving medications via the wrong route (internal versus external routes,) possibly leading to adverse health consequences resulting in in the negative impact to their health and well-being, hospitalization or death. Findings: During an observation and concurrent interview on 1/26/2026 at 12:21 p.m., with Registered Nurse (RN) 10, the medication storage cabinets in Nursing Station 1 contained medication bottles for facility stock and residents. The room temperature monitoring log for the storage of medications in Nursing Station 1 for January 2026 was not available. RN 10 stated the room temperature log for the storage of medications in Nursing Station 1 for January 2026 was not available, and without a log containing documentation for room temperatures, it was implied that the room temperature for medication storage area in Nursing Station 1 was not monitored. RN 10 stated the room temperature should be monitored and documented every day during all shifts to ensure medications are properly maintained at an acceptable temperature range, and their potency (the strength of medication required to produce an effect) not affected. RN 10 stated if the room temperature was not monitored it was unknown if the temperatures were maintained within the acceptable range and if the medications were affected negatively. RN 10 stated using improperly stored medications can harm the residents and not help in treating their condition. During an observation on 1/27/2026 at 10:27 a.m., in Medication Cart room [ROOM NUMBER] with Licensed Vocational Nurse (LVN) 7, the following medication was found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One (1) open levalbuterol inhalation solution foil pouch containing several unused solutions/vials for Resident 79, was found stored at room temperature and not labeled with a date indicating when the foil pouch was opened. According to the manufacturer's product storage and labeling, opened foil pouch of levalbuterol inhalation solutions should be stored between 68 to 77 degrees Fahrenheit and once the foil pouch is opened to be used within two (2) weeks. During a concurrent interview, LVN 7 stated the levalbuterol inhalation solution foil pouch for Resident 79 in Medication Cart room [ROOM NUMBER] was not labeled with a date indicating when the foil pouch was opened. LVN 7 stated that per facility policy multi-dose (containing more than one dose) products such as inhalation solutions should be labeled with the date when first opened to know when they expire. LVN 7 stated that expired medications have lost potency and will not be effective in treating residents' condition. LVN 7 stated according to the manufacturer guidelines, the inhalation solutions should be used within two (2) weeks of opening the pouch. LVN 7 stated failing to record the date of first use could lead to Resident 79 receiving potentially expired and ineffective levalbuterol. LVN 7 stated this could cause Resident 79 harm by not treating or preventing the shortness of breath, making breathing more difficult, requiring immediate treatment and potential hospitalization. During an observation on 1/27/2026 at 11:05 a.m., in Medication Cart 3, with RN 11, the following medications were stored in a manner contrary to the facility's P&P: 1. One (1) fluticasone (a medication used for allergies) nasal spray, and one (1) azelastine (a medication used for allergies) nasal spray was stored with one (1) melatonin (a medication used to regulate sleep cycles) oral tablet bottle, in the same bin/compartment of the medication cart. During a concurrent interview, RN 11 stated that internally administered medications, such as oral tablets, and externally administered medications, such as nasal sprays, should be stored separately in their own sections/bins and not together, to prevent errors in wrong route administration and possible infections/contaminations. RN 11 acknowledged one (1) medication bin contained one (1) fluticasone nasal spray, one (1) azelastine nasal spray and one (1) melatonin oral tablet bottle. RN 11 stated the facility failed not to separate and store fluticasone and azelastine nasal sprays from melatonin oral tablets. During an observation on 1/27/2026 at 11:45 a.m., in Medication Cart 2, with LVN 8, the following medications were stored in a manner contrary to the facility's P&P: 1. One (1) fluticasone (a medication used for allergies) nasal spray, and one (1) refresh tears (a medication used for dry eyes) eye drop was stored with one (1) Tylenol (a medication used for fever and/or pain) oral tablet bottle, in the same bin of the medication cart. During a concurrent interview, LVN 8 stated that nasal sprays and eye drops should be stored separately from oral medications, to prevent errors in wrong route administration and possible infections/contaminations. LVN 8 acknowledged one (1) medication bin contained one (1) fluticasone nasal spray, one (1) refresh tears eye drops and one (1) Tylenol oral tablet bottle. LVN 8 stated the facility failed not to separate and store nasal spray and eye drops from oral tablets. During an interview, on 1/28/2026 at 11 a.m., with the Director of Nursing (DON,) the DON stated that the temperature of medication storage areas should be monitored and documented twice daily. The DON stated not knowing the temperature of the medication storage areas from lack of monitoring, may result in medications being stored in unacceptable temperature ranges and lose efficacy, and when used they will not be effective in treating the residents' conditions. The DON acknowledged that the medication storage area in Nursing Station 1 contained several medication bottles for facility stock and residents and did not have a temperature monitoring log for January 2026. During the same interview the DON stated that breathing inhalation solutions stored in foil pouches should be labeled with a date when removed from pouch to know when the solutions expire, otherwise would be unable to determine the expiration date. The DON stated levalbuterol inhalation solutions expire within two (2) weeks of opening the foil pouch. The DON stated that expired inhalation solutions have lost effectiveness and when administered in error will not treat the shortness of breath further causing respiratory (related to breathing) distress (discomfort) and stoppage of breathing for Resident 79 requiring immediate treatment and hospitalization. The DON stated the facility failed to label the levalbuterol inhalation solution pouch with the date when first opened for Resident 79. During the same interview the DON stated internally (such as oral) and externally (such as eyes, ears, nose, skin) administered medications should be stored separately to prevent wrong route administration, infections and contaminations. The DON stated the facility failed to store nasal sprays in Medication Cart 3 separate from oral medications and failed to store nasal and eye drops in Medication Cart 2 separate from oral medications. During a review of facility's Policy and Procedures (P&P) titled, Multiple-Use Medications, last reviewed on 1/21/2025, the P&P indicated that Multiple-Use medications maybe used for individual patients only and must be handled in a manner that prevents contamination, medication errors, and infection transmission. 1. LABELING a. All multiple-use medications must be labeled with iii. Date opened b. Unlabeled medications must be discarded immediately. 2. STORAGE a. Medications must be stored according to manufacturer recommendations. During a review of facility's P&P titled, Medication Storage for Internal and External Medications, last reviewed on 1/21/2025, the P&P indicated To prevent cross contamination by ensuring that medications intended for external use are stored separately from medications intended for internal use. All medications intended for external use will be stored separately from medications intended for internal use at all times to minimize the risk of medication errors. Definitions: Internal Medications: Medications intended for administration inside the body, including oral, sublingual, injectable, inhaled, rectal, and vaginal medications. External Medications: Medications intended for external use only, including topical creams, ointments, lotions, patches, eye drops, ear drops, nasal sprays, and medicated shampoos. Procedures: Medication carts must have separate compartments for internal and external medications. During a review of facility's P&P titled, Temperature of Medications, last reviewed on 1/21/2025, the P&P indicated Drugs shall be stored in appropriate temperatures. A. Drugs required to be stored at room temperature shall be stored at a temperature between 59 degrees Fahrenheit (F) and 86 degrees F. 1)Recommend a temperature log for daily documentation, saving records for a minimum of 1 year. During a review of facility's P&P titled, Medication Room Temperature and Monitoring, last reviewed on 1/21/2025, the P&P indicated Room temperature shall be monitored and documented at least twice daily. Temperature readings shall be recorded on a designated Medication room Temperature Log. During a review of facility's P&P titled, Expiration Dates after Opening, last reviewed on 1/21/2025, the P&P indicated: Xopenex (brand name for levalbuterol) foil pouch inhalation solution - expiration 14 days at room temperature. a. Be sure to document Date when opened on . multi-dose medications with a shortened shelf life once seal is broken. During a review of manufacturer's guide Highlights of Prescribing Information for levalbuterol inhalation dated July 2019, the guide indicated 'Store Levalbuterol Inhalation Solution, USP in the protective foil pouch at 20 - 25 C (68 - 77 F). Protect from light and excessive heat. Keep unopened vials in the foil pouch. Once the foil pouch is opened, the vials should be used within 2 weeks.

Based on observation, interview, and record review, the facility failed to notify the primary physician and responsible party of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one (1) of one (1) sampled resident (Resident 13) reviewed for change of condition by failing to notify the responsible party when the resident was transferred to the hospital. This deficient practice had violated the resident's responsible party's right to be informed of the care services provided. Findings: During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was originally admitted in the facility on 9/9/2025 and readmitted in the facility on 10/20/2025, with diagnoses including respiratory failure (a condition that occurs when the lungs cannot remove all of the carbon dioxide [a colorless, odorless gas that the body breathes out] the body produces), tracheostomy (a surgical opening in the neck into the windpipe when a person is unable to breathe thru the nose or mouth), and dependence on respirator (also known as ventilator - a machine used to help a person breath when they are unable to do so on their own) status. During a review of Resident 13's History and Physical (H&P) dated 10/22/2025, the H&P indicated Resident 13 did not have the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 12/30/2025, the MDS assessment indicated Resident 13 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs- routine tasks/activities. The MDS indicated Resident 13 required suctioning (mechanical removal of a patient's secretions with artificial airway such as tracheostomy). During a review of Resident 13's Discharge Summary notes dated 9/10/2025, the Discharge Summary notes indicated that during routine patient care, a large amount of blood was noticed by the Certified Nursing Assistants (CNAs) from the rectum (end part of the large intestine that connects to the anus [opening at a person's bottom] where the stools accumulate) and bleeding in the trachea during suctioning of secretions (process of removing fluids or mucus from a person's body using a suction device) by the respiratory therapist. The discharge summary notes further indicated the nurse practitioner was notified and ordered to transfer Resident 13 to the nearest emergency room (ER) via paramedics (healthcare professionals trained to respond in emergency calls for medical help outside the hospital). The discharge summary notes did not indicate that Resident 13's representative was notified of the change in condition. During a review of Resident 13's eINTERACT SBAR Summary form (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 9/10/2025, the eINTERACT SBAR Summary form indicated Resident 13 had bleeding in the rectum and trachea during routine patient care. The eINTERACT SBAR Summary form further indicated the nurse practitioner was notified and ordered to transfer Resident 13 to the nearest emergency room via paramedics. The eINTERACT SBAR Summary form did not indicate that Resident 13's representative was notified of the change in condition. During a concurrent interview and record review on 1/29/2026 at 8:39 a.m., Resident 13's physician's order, eINTERACT SBAR Summary form, and discharge summary notes were reviewed with the Minimum Data Set Coordinator (MDSC). The MDSC stated that Resident 13 was transferred to the ER for bleeding on the rectum and trachea on 9/10/2025. The MDSC stated the discharge summary notes and eINTERACT SBAR Summary form did not indicate Resident 13's family was notified of the transfer to the nearest ER via paramedics. The MDSC stated the eINTERACT SBAR Summary form entails identifying the changes in a resident's health status, obtaining vital signs, assessment for mental status or behavior, documentation of skin changes, immediate action taken, and the notification of the primary physician and the resident representative of the change in condition of the resident. The MDSC stated it was important to complete Resident 13's eINTERACT SBAR Summary form to have a complete account of what happened that day including notification of the resident's representative to honor the resident representative's right for informed care of their family member and be aware of Resident 13's plan of care. During an interview on 1/29/2026 at 10:06 a.m., with the Director of Nursing (DON), the DON stated the licensed staff are supposed to complete the eINTERACT SBAR Summary form to include the notification of the resident's representative of any changes in condition of the resident and what are the plans to address the resident's change in condition. The DON stated resident representatives have the right to be notified of any change in condition. The DON stated if a resident was transferred to the ER via paramedics, the family can be notified at the soonest time possible or after the resident had left the facility for them to be aware of what had happened to the resident. The DON stated Resident 13's representative should have been notified by the nurses of Resident 13's transfer to the hospital via paramedics to respect their right to be aware of the informed care. During a review of the facility's policy and procedure (P&P) titled, Reporting Changes in Condition, last reviewed on 1/21/2025, the P&P indicated that the facility shall notify the family or responsible party and physician or nurse practitioner of resident's change in condition. The P&P further indicated: - The nursing staff will report changes in a resident's condition or status to the resident's family/responsible party in a timely manner. - The licensed nurse who reported change of condition to the physician or nurse practitioner and family/responsible party will document it in the nurse's notes.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a patient when in need) was within reach for one (1) of one (1) sampled resident (Resident 6) reviewed under the environment task. This deficient practice had the potential to result in a delay of care and services and possible injury to Resident 6 when the resident was unable to call for assistance. Findings: During a review of Resident 6's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 1/21/2025, and readmitted in the facility on 5/31/2025, with diagnoses including dependence on respirator (also known as ventilator - a machine used to help a person breath when they are unable to do so on their own) status , tracheostomy (an opening a surgeon makes through the neck and into the trachea [also known as windpipe] to help a patient breathe), and type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 6's History and Physical (H&P) dated 5/31/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 6 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated Resident 6 had impairment of both upper and lower extremities and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 6's fall risk assessment dated [DATE], the fall risk assessment indicated Resident 6 was at a high risk for falls. During a review of Resident 6's care plan (CP) on potential for falls and injury initiated on 4/28/2025, and last revised on 6/6/2025, the CP indicated to place call light within reach as one of the interventions to keep the resident free from falls and injury at all times. During a concurrent observation and interview on 1/26/2025 at 11:48 a.m. inside Resident 6's room with Registered Nurse (RN) 6, Resident 6 was observed lying in bed and asleep. RN 6 stated Resident 6's call light was at the foot of the bed on the left side. RN 6 stated that the staff should ensure that the call light was within the residents' reach prior to leaving the room so they can call for assistance. RN 6 stated that Resident 6's pad call light should have been within reach at least next to the hand as Resident 6 was able to slightly move the hands and touch the pad call light for assistance. RN 6 stated if the call light was not within Resident 6's reach, it placed the resident at risk for a delay in providing the care and services the resident needed. During a concurrent interview and record review on 1/28/2026 at 1:40 p.m. Resident 6's fall risk assessment, and CP were reviewed with RN 7. RN 7 stated that the fall risk assessment indicated that Resident 6 is at a risk for falls. RN 7 stated Resident 6`s CP on potential for falls indicated to place call light within reach as one of the interventions to keep Resident 6 free from falls and injury. RN 7 stated that staff are supposed to ensure that the call lights are placed within the residents' reach after providing care and prior to leaving the room. RN 7 stated Resident 6's call light should have been placed within reach and not by the foot of the bed as the resident was unable to move both lower extremities and it placed Resident 6 at risk for a delay in receiving the care he needed. RN 7 stated Resident 6 can slightly move both hands and if the call light was placed near the hands, he would be able to call for assistance when needed. During a review of the facility's policy and procedure (P&P) titled, Call Lights, last reviewed on 1/21/2025, the P&P indicated a purpose to enable residents to call for assistance and to enable staff to respond to call lights in a timely and efficient manner. The P&P further indicated: - All residents on the adult unit have a working call light to enable them to call for assistance. - Procedure: - All residents will be given a call light. - The call light will be placed within their reach. - Patients who are unable to use the standard call light will be given an adaptive call light to enable them to call for assistance. - Call lights will be answered timely and efficiently. - Call lights will be monitored for positioning by licensed nurses and Certified Nursing Assistance (CNA) during rounds and after treatments.

Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity and respect for one of one sampled resident (Resident 23) reviewed under dignity care area by failing to ensure that Housekeeping (HSK) 1 moved Resident 23's wheelchair to create adequate space when bringing the large gray bin (storage bin container used to store used reusable gowns [a personal protective equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses]) into the room, which resulted in the bin colliding with the foot of Resident 23's bed and bedside table, as observed on 1/28/2026. This deficient practice had the potential to affect Resident 23's self-esteem and self-worth. Findings: During a review of Resident 23's admission Record (AR), the AR indicated that the facility originally admitted Resident 23 on 4/14/2016 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), convulsions (n abnormal violent and involuntary contraction or series of contractions of the muscles), and cerebral palsy (a group of conditions that affect movement and posture). During a review of Resident 23's History and Physical (H&P), dated 10/16/2025, the H&P indicated that Resident 23 had assay to understand and make a decision. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 1/21/2026, the MDS indicated Resident 23 had clear speech and adequate vision, makes self-understood, and had the ability to understand others. The MDS indicated Resident 23 was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). During a review of Resident 23's Care Plan (CP) focused on potential for hypotension (low blood pressure), dated 5/20/2025, the CP indicated the resident with goal of blood pressure will be within range. The care plan with intervention was to provide resident with an environment conductive to rest and free from obnoxious stimuli. During an interview on 1/26/2026 at 9:46 a.m. with Resident 23, Resident 23 stated HSK 1 comes in the morning and wakes her (Resident 23) due to the banging the bed with the broom, the mop while cleaning her (Resident 23) room. Resident 23 stated she (Resident 23) has lost sleep in the morning. During an observation on 1/28/2026 at 8:51 a.m., Resident 23 was asleep in bed. During an observation on 1/28/2026 at 8:56 a.m., in front of Resident 23's room, HSK 1 entered Resident 23's room and brought in a gray bin, with lid and wheels, to the restroom. Resident 23's foot of the bed was in front of the restroom door. HSK 1 opened the restroom door and crashed gray bin into Resident 23's foot of the bed and overbed table. HSK 1 placed the gray bin inside the restroom, closed the restroom door, and exited the room. During an interview on 1/28/2026 at 9:03 a.m. with HSK 1, HSK 1 stated she (HSK 1) picked up the gray bin from the restroom, and she (HSK 1) did not have enough space to move because Resident 23's wheelchair was in the way. HSK 1 stated her (HSK 1) gloves were dirty and she (HSK 1) was touching the barrel, so she (HSK 1) did not move the wheelchair. HSK 1 stated she (HSK 1) should have used alcohol sanitizer and put on new gloves and moved Resident 23's wheelchair. HSK 1 stated when the gray bin collided with Resident 23's bed, the resident was alert and became upset. During an interview on 1/29/2026 at 2:54 p.m. with the Director of Nursing (DON), the DON stated HSK 1 should be told to be careful and to apologize to the resident for the incident. The DON stated she (DON) will make sure her (Resident 23) concerns are addressed and what she (Resident 23) wants is addressed. The DON stated she (DON) can change the assignment to avoid this issue. The DON stated if it continues, it will cause friction and would cause a problem. The DON stated she (DON) will talk to Resident 23 for her concern and will address it. The DON stated HSK 1 should not have done that because this is the resident's home, they need to give their respect. The DON stated the residents are to be treated with respect because it is their residents' rights. During a review of the facility's policy and procedures (P&P) titled, Resident Rights, last reviewed on 1/21/2025, the P&P indicated that the purpose of this policy is to ensure that residents rights and dignity are ensured. Policy: Employees shall treat all residents with kindness, respect, and dignity. Procedure: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity.

Based on interview, and record review, the facility failed to develop and implement a baseline care plan (an initial, temporary care document that is developed within 48 hours of a resident's admission, providing essential, person-centered care instructions to staff to ensure safety and continuity of care while a more comprehensive plan is developed) for one (1) of five (5) sampled resident (Resident 6) reviewed for unnecessary medications review when Resident 6 was readmitted to the facility on [DATE]. This deficient practice placed Resident 6 at risk of not receiving the appropriate care and treatment specific to the residents' needs. Findings: During a review of Resident 6's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 1/21/2025 and readmitted in the facility on 5/31/2025, with diagnoses including dependence on respirator (also known as ventilator - a machine used to help a person breath when they are unable to do so on their own) status , tracheostomy (an opening a surgeon makes through the neck and into the trachea [also known as windpipe] to help a patient breathe), and type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 6's History and Physical (H&P) dated 5/31/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 6 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated Resident 6 had impairment of both upper and lower extremities and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 6's baseline care plans (CP), the baseline CP indicated the following baseline CP were initiated on 6/3/2025: - Physical Therapy (PT - a therapy that is used to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability) Care Plan - Resident has arteriovenous fistula (AV fistula - created by directly connecting a person's artery and vein to provide a good blood flow during dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed]) on left upper arm. - Potential for falls and injury related to impaired cognition and balance - Potential for hypoglycemia (low blood sugar) or hyperglycemia (increased blood sugar) related to DM 2 - The resident has DM 2 - The resident is on anticoagulant therapy - The resident is on oxygen therapy. During a concurrent interview and record review on 1/28/2026 at 1:50 p.m., Resident 6's admission Record, physician orders, and baseline care plans (CP) were reviewed with Registered Nurse (RN) 7. RN 7 stated Resident 6 was readmitted in the facility on 5/31/2025 and the resident`s baseline CPs were initiated on 6/3/2025. RN 7 stated that the charge RNs are supposed to initiate the baseline CP upon admission or within 48 hours of the admission. RN 7 stated Resident 6's baseline CP was not initiated and implemented timely. RN 7 stated Resident 6's baseline CP should have been initiated between 5/31/2025 to 6/2/2025 so the staff would know how to provide the immediate care and prevent delay in providing the care Resident 6 need. During a concurrent interview and record review on 1/29/2026 at 9:01 a.m., Resident 6's admission Record, physician orders, and baseline care plans (CP) with the MDS Coordinator (MDSC). The MDSC stated Resident 6 was readmitted in the facility on 5/31/2025 and that the baseline CPs were initiated on 6/3/2025. The MDSC stated that the charge RNs or admitting nurse are supposed to develop a baseline CP upon admission or within 48 hours of admission and then comprehensive care plan will be developed by the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) seven (7) days after completion of the comprehensive assessment or 21 days after admission or readmission date. The MDSC stated Resident 6's baseline CP was not initiated and implemented timely. The MDSC stated Resident 6's baseline CP should have been initiated on 5/31/2025 or 6/2/2025 so the staff would be aware of the care the resident needed upon admission so the care would not be delayed. During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plans, last reviewed on 1/21/2025, the P&P indicated that the IDT shall develop and implement a baseline CP for each resident that includes instructions needed to provide effective and person-centered care of the resident within 48 hours of admission. The P&P further indicated the baseline CP include the minimum healthcare information necessary to properly care for a resident immediately upon admission which is to address resident-specific health and safety concerns to prevent decline or injury, such as elopement (refers to a situation where a patient leaves a facility without permission or the proper level of supervision) or fall risk, and to identify needs for supervision, behavioral interventions, and assistance with ADLs, as necessary.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs) by failing to: 1. Develop and implement a CP for the resident's use of Eliquis (also known as apixaban - an anticoagulant [AC] medication used to treat and prevent blood clots) included measurable goals and outcomes for monitoring signs and symptoms of bleeding for one of two sampled residents (Resident 97) reviewed for AC medications. 2. Develop and implement a CP for a resident who was identified with a Moisture-Associated Skin Damage (MASD - inflammation [becomes reddened, swollen or hot] or skin erosion [breakdown of outer layers of skin] caused by prolonged exposure to moisture-like urine, stool, sweat) and at risk for pressure ulcer/injuries (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) for one of four sampled residents (Resident 18) reviewed for pressure ulcer. These deficient practices had the potential to result in miscommunication among interdisciplinary (a group of health care professionals with various areas of expertise who work together toward the goals of their clients) staff, residents, and resident representatives resulting in a delay of necessary care and services. Findings: a. During a review of Resident 97's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 4/30/2025 and readmitted in the facility on 6/16/2025, with diagnoses including gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN-high blood pressure). During a review of Resident 97's History and Physical (H&P) dated 6/18/2025, the H&P indicated Resident 97 did not have the capacity to understand and make decisions. During a review of Resident 97's Minimum Data Set (MDS, a resident assessment tool), dated 11/5/2025, the MDS indicated Resident 97 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated Resident 97 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 97 received anticoagulant. During a review of Resident 97's Order Summary Report dated 1/29/2026, the Order Summary Report indicated a physician's order dated 7/5/2025 for Eliquis oral tablet 2.5 milligrams (mg – a unit of measurement) give 2.5 mg via GT every 12 hours for deep vein thrombosis (DVT - a blood clot that forms in the veins located deep within a limb, usually the lower leg or thigh) prophylaxis (a measure taken to maintain health and prevent the spread of disease). During a review of Resident 97's care plan (CP) titled, Potential for injury or bleeding, initiated on 12/10/2025, the CP did not indicate monitoring for signs and symptoms of bleeding as one of the interventions for the use of Eliquis. During a concurrent interview and record review on 1/27/2026 at 2:25 p.m., Resident 97's physician's orders, CP, and medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 11/2025, 12/2025, and 1/2026 were reviewed with Registered Nurse (RN) 7. RN 7 stated that Resident 97 had a physician's order for Eliquis and a CP was initiated on 12/10/2025. However, the CP did not indicate to monitor for signs and symptoms of bleeding as one of the interventions for the use of Eliquis. RN 7 stated monitoring for signs and symptoms should be included in the care plan as one of the interventions. RN 7 stated Resident 97's care plan for the use of Eliquis should have included monitoring for signs and symptoms of bleeding as one of the interventions to ensure staff are aware of what is in Resident 97's plan of care so they would know how to properly care for the resident. RN 7 stated if the proper interventions are not in place such as monitoring for signs and symptoms of bleeding, it placed Resident 97 at risk unmonitored bleeding which may lead to a delay in receiving the necessary care and services needed. During a concurrent interview and record review on 1/28/2026 at 3:39 p.m. Resident 97's physician's orders, CP, and MAR for 11/2025, 12/2025, and 1/2026 were reviewed with the MDS Coordinator (MDSC). The MDSC stated that there is a physician's order for Eliquis, and the CP for the use of Eliquis did not indicate monitoring signs and symptoms of bleeding as one of the interventions. the MDSC stated CP should be comprehensive and person-centered and must include complete interventions to properly car for the residents. The MDSC stated Resident 97's CP for the use of Eliquis should have included monitoring signs and symptoms of bleeding as one of the interventions so the staff would be aware what are the interventions in place to properly care for the resident, especially monitor for signs and symptoms of bleeding to prevent delay in providing the care the resident needs. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, last reviewed on 1/21/2025, the P&P indicated a comprehensive person-centered care plan for each resident must be developed and implemented for each resident consistent with the resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The P&P further indicated that the care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. b. During a review of Resident 18's AR, the AR indicated that the facility originally admitted the resident on 12/7/2023 and readmitted on [DATE], with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery) in hemisphere (sides of the cerebrum- area that controls movement, sensation, language, and thinking), dysphagia (difficulty swallowing) following cerebral infarction (stroke- loss of blood flow to a part of the brain), and hydrocephalus (the buildup of fluid in cavities called ventricles deep within the brain). During a review of Resident 18's Clinical admission Screener (CAS), dated 10/28/2025, the CAS indicated Resident 18 had left buttock MASD. During a review of Resident 18's admission Progress Notes (APN- a comprehensive, written, or electronic document created by a provider upon a resident's entry into an inpatient facility that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern) dated 10/29/2025, the APN indicated Resident 18 did not have the capacity to understand and make decisions. The APN indicated that Resident 18's skin had no erythema (redness of skin). During a review of Resident 18's MDS, dated [DATE], the MDS indicated that Resident 18 had the ability to understand others sometimes and rarely or never makes self-understood. The MDS indicated Resident 18 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 18 was dependent on staff for bed mobility including rolling to the left and right. The MDS indicated Resident 18 had no unhealed pressure ulcer but was identified as being risk for developing pressure ulcers. During a review of Resident 18's Assessment of Decubitus Ulcer Potential (ADUP- a scoring tool used to predict resident's risk of developing pressure ulcer, the higher the score, the greater is the potential to develop decubitus ulcers), the ADUP indicated the resident with a score above 12 should be considered at risk: - Score of 23, dated 12/24/2024. - Score of 25, dated 12/26/2025. During a concurrent interview and record review on 1/27/2026 at 1:41 p.m., with TN 1, reviewed Resident 18's care plans. TN 1 stated there was no care plan developed for Resident 18's MASD on the left buttock on 10/28/2025. TN 1 stated that she (TN 1) forgot to add it and should have been added on the day it was identified. TN 1 stated she (TN 1) will include in the interventions the treatment orders because they evaluate the wound every 14 or 30 days depending on the order if it is working or not. TN 1 stated she (TN 1) would also include repositioning and turning the resident every two hours and as needed. LVN stated the purpose of care plan is to manage the wound and ensure the resident does not develop infection. TN 1 stated that she (TN 1) reviews the care plan interventions (approaches) and so do the LVNs and Registered Nurses (RNs) taking care of Resident 18. During a concurrent interview and record review on 1/27/2026 at 2:10 p.m., with RN 8, reviewed Resident 18's physician orders and care plans. RN 8 stated that when Resident 18 was readmitted on [DATE], she (RN 8) assessed the resident, TN 2 and LVN 4 checked the skin, and she (RN 8) checked the skin as well. RN 8 stated TN 2 measures the wounds, develops care plans related to skin and wounds, reaches out to the wound doctor, MD 2, and places wound treatment orders, if there is any. RN 8 stated TN 2 should have developed a care plan addressing Resident 18's MASD on the left buttock and placed Resident 18's treatment orders. During a concurrent interview and record review on 1/27/2026 at 4:56 p.m., with TN 2, reviewed Resident 18's physician orders, care plans, and nursing progress notes. TN 2 stated that when she (TN 2) finds wounds, redness, skin discoloration on the resident, the charge nurse (RN) and the primary nurse (LVN), documents it in the admission Notes, and the charge nurse places the orders for any skin issue. TN 2 stated she (TN 2) does not have to document, only the primary nurse and the charge nurse, does the documentation for the admission. TN 2 stated she (TN 2) helps with wound measurement, wound treatment, and depends on the order. TN 2 stated the charge nurse or whoever enters the order would also develop the care plan. TN 2 stated she (TN 2) does not have any documentation because RN 4 and LVN 4 document on their notes and she (TN 2) provides them with the wound measurements and details. TN 2 stated she (TN 2) did not call the wound doctor on 10/28/2025 for Resident 18. During a concurrent interview and record review on 1/29/2026 at 3:25 p.m., with the Director of Nursing (DON), reviewed the facility's P&P titled, Decubitus Ulcer Prevention. The DON stated that the TN is responsible for developing the care plan upon identification of any skin issues. The DON stated she (DON) was not aware of Resident 18's left buttock open blister and stage two (2) pressure ulcer, and the MASD on admission. The DON stated TN 2 should have communicated to RN 4 regarding a need for calling the wound doctor and she (TN 2) should have documented. The DON stated TN 2 should have developed the care plan right away and followed through. The DON stated because TN 2 did not develop a care plan, MD 2 was not notified, and Resident 18's wounds were not followed through. The DON stated the care plan should have been updated to reflect the current approaches and wound treatments are usually every two weeks and skin/wound is assessed weekly. The DON stated if there is no care plan developed, the resident's wounds will become worse, it has not been noted, and the wound doctor has not been called. During a review of the facility's P&P titled, Decubitus Ulcer Prevention, last reviewed on 1/21/2025 that indicated that: Policy: 1. The Registered Nurse will evaluate the Residents/Patients on admission and then on a daily basis to establish the presence of any pressure sores. Preventive Measures:. 5. Any Resident/Patient admitted with a pressure sore will have immediate and appropriate action to treat the problem. Proper documentation of the presence, location, size and description of the pressure sore will be recorded in the Resident/Patient health record. 6. Proper documentation of the treatment performed via the Physician Orders will be in the treatment book. Special Observations: All pressure points, especially bony prominences, should be assessed for redness, irritated or lacerated skin:. Buttocks, Sacrum. Residents/Patients Most Vulnerable: 1. Residents/Patients required to lie in one position due to immobilization or restrictive appliances (cast, traction, infusion board, etc.) 2. Residents/Patients incapable of voluntary movement (comatose, stuporous, paralyzed, heavily sedated). 3. Residents/Patients who are abnormally thin, elderly, debilitated, incontinent. 4. Diabetics and Residents/Patients with poor circulation or peripheral vascular disease. During a review of the facility's P&P titled, Comprehensive Care Plans, last reviewed on 1/21/2025, the P&P indicated that a comprehensive person-centered care plan for each resident must be developed and implemented for each resident consistent with he resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The P&P further indicated that the care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on interview and record review, the facility failed to revise one of four sampled residents (Resident 18) care plan when Resident 18's care plan was not updated to reflect current left buttock stage 2 pressure ulcer interventions addressing Resident 18's risk for worsening PU. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: During a review of Resident 18's admission Record (AR), the AR indicated that the facility originally admitted Resident 18 on 12/7/2023 with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery) in hemisphere (sides of the cerebrum [area that controls movement, sensation, language, and thinking]), dysphagia (difficulty swallowing) following cerebral infarction (also known as stroke, loss of blood flow to a part of the brain), and hydrocephalus (the buildup of fluid in cavities deep within the brain called ventricles). During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 18 had the ability to understand others sometimes and rarely or never makes self understood. The MDS indicated Resident 18 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 18 was dependent on staff for bed mobility including rolling to the left and right. The MDS indicated Resident 18 had no unhealed pressure ulcer but was identified as being at risk for developing pressure ulcers. During a review of Resident 18's Clinical admission Screener (CAS - a pre-admission document used to evaluate a prospective resident's medical and physical needs to ensure the facility can provide appropriate care) form, dated 10/28/2025, the CAS form indicated Resident 18 had left buttock MASD. During a review of Resident 18's admission Progress Notes (APN - a comprehensive, written, or electronic document created by a provider upon a resident's entry into an inpatient facility that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 10/29/2025, the APN indicated Resident 18 did not have the capacity to understand and make decisions. The APN indicated that Resident 18's skin had no erythema (superficial reddening of the skin as a result of injury or irritation). During a review of Resident 18's Assessment of Decubitus Ulcer Potential (ADUP - a scoring tool used to predict a resident's risk of developing pressure ulcer, the higher the score, the greater the potential to develop decubitus ulcers), dated 12/24/2025, the ADUP indicated residents with a score above 12 should be considered at risk for developing pressure ulcers. The ADUP indicated Resident 18 scored 23. During a review of Resident 18's ADUP, dated 12/26/2025, the ADUP indicated Resident 18 scored 25. During a review of Resident 18's Physician Order, dated 1/19/2026, the Physician Order indicated the following treatment : Cleanse the Left Buttock open blister (bubble on the skin filled with clear, watery liquid or blood, usually caused by friction, rubbing, or burns) with normal saline (NS - sterile water used to cleanse and moisten wounds), apply moist gauze (a wound care product designed to absorb wound drainage and protect the wound), pat dry with dry gauze, apply xeroform (a moist yellow dressing that covers the wound and promotes wound healing) and cover with a foam dressing every day shift for one (1) Day, with the Wound Doctor to reassess on 1/20/2026. During a review of Resident 18's wound care Progress Note Details (PND), dated 1/20/2026, the wound care PND indicated that Resident 18 had the following wound: Left buttock open blister, measuring 1.6 centimeters (cm- a unit of measure) in length x (by) 1.5 cm in width x 0.1 cm in depth, with a small amount of serous (clear, thin, watery fluid that's typically pale yellow in color) drainage noted. During a review of Resident 18's Physician Order, dated 1/20/2026, the Physician Order indicated the following treatment: Cleanse the Left Buttock open blister with NS, apply moist gauze, pat dry with dry gauze, apply xeroform and cover with a foam dressing every day shift for 14 Days. During a review of Resident 18's wound care PND, dated 1/27/2026, the wound care PND indicated that Resident 18 had the following wound: Left buttock stage 2 pressure ulcer, measuring 1.2 cm in length x 0.8 cm in width x 0.2 cm in depth, with a moderate amount of serous drainage, and a wound bed (exposed tissue surface within a wound) 76 to 100 percent (%). During a review of Resident 18's Physician Order, dated 1/27/2026, the Physician Order indicated the following treatment: Cleanse the Left Buttock Stage 2 Pressure Ulcer with NS, apply moist gauze, pat dry, apply xeroform and cover with a foam dressing every day and as needed for 30 days. During a concurrent interview and record review on 1/27/2026 at 1:41 p.m., with Treatment Nurse (TN) 1, Resident 18's care plans were reviewed. TN 1 stated the care plan focused on Wound Management, revised on 1/20/2026, did not include Resident 18's stage two (2) pressure ulcer on the left buttock. TN 1 stated that she (TN 1) forgot to add it and should have been added on the day it was identified. TN 1 stated the purpose of the care plan is to manage the wound and make sure there are no infections for the resident. TN 1 stated that she (TN 1), the licensed vocational nurses (LVNs), and Registered Nurses (RNs) taking care of Resident 18 reviews the care plan interventions (approaches). During a concurrent interview and record review on 1/29/2026 at 3:25 p.m. with the DON, the facility's policy and procedure (P&P) titled, Decubitus Ulcer Prevention, last reviewed 1/21/2025, was reviewed. The DON stated the TN is responsible for developing the care plan upon identification. The DON stated the care plan should have been updated to reflect the current approaches and wound treatments are usually every two weeks and skin/wound is assessed weekly. The DON stated if there is no care plan developed, the resident's wounds will become worse, it has not been noted, and the wound doctor has not been called. During a review of the facility's policy and procedure (P&P) titled, Decubitus Ulcer Prevention, last reviewed on 1/21/2025 that indicated that: Policy: 1. The Registered Nurse will evaluate the Residents/Patients on admission and then on a daily basis to establish the presence of any pressure sores. Preventive Measures:. 5. Any Resident/Patient admitted with a pressure sore will have immediate and appropriate action to treat the problem. Proper documentation of the presence, location, size and description of the pressure sore will be recorded in the Resident/Patient health record. 6. Proper documentation of the treatment performed via the Physician Orders will be in the treatment book. Residents/Patients Most Vulnerable: 1. Residents/Patients required to lie in one position due to immobilization or restrictive appliances (cast, traction, infusion board, etc.) 2. Residents/Patients incapable of voluntary movement (comatose, stuporous, paralyzed, heavily sedated). 3. Residents/Patients who are abnormally thin, elderly, debilitated, incontinent. 4. Diabetics and Residents/Patients with poor circulation or peripheral vascular disease. During a review of the facility's P&P titled, Long Term and Short Term Care Plans, last reviewed on 1/21/2025, the P&P indicated that the purpose of this policy is To have a written plan of nursing care for the resident/patient from admission to discharge. Policy. 1. All Diagnoses or Diagnosis that cannot be resolved within one month will be considered long term and will be included in the Long Term Care Plan. 2. All Diagnoses or Diagnosis that cannot be resolved within one month or less will be considered short term and included in the Short Term Care Plan. Care Plans will be updated and revised throughout the resident/patient stay. Dependent on progress, change in condition, or as new Diagnosis arises and are identified. Long Term Care Plans will be re-evaluated quarterly, annually, and as needed. Short Term Care Plans will be re-evaluated if the goals are not met within the target date.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), a two-year old, with severely impaired cognition (mental action or process of acquiring knowledge and understanding) and dependent on staff for activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily), remained free from accident. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not turn her back on Resident 1, leaving Resident 1 unattended on a shower bed which had two gaps (open space) on each side of the side rails measuring eight inches (unit of measurement) in height and 22.5 inches in width, after CNA 1 transferred Resident 1 from his crib (a small bed for a baby or young child, with high bars to prevent the child from falling) to the shower bed. 2.Complete an assessment to determine the safety of using an adult-sized shower bed for Resident 1, who was a pediatric resident. 3. Use a pediatric-sized shower bed for Resident 1, instead of an adult-sized shower bed. 4. Ensure Resident 1's Fall Risk Assessment was updated following Resident 1's fall on 10/24/2025, to reflect changes needed in Resident 1's care. 5. Include the use of size-appropriate shower beds for pediatric residents to ensure safety and prevent accidents in the facility-provided document titled, Facility Assessment 2025, reviewed on 4/17/2025, which only indicated the use of Shower chairs. 6. Follow its policy and procedure (P&P) titled, Facility Assessment Patient Population, which indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. The facility assessment also includes a detailed review of the resources available to meet the needs of the residents' population. This part of the assessment includes: . b. Equipment and supplies (medical and non-medical). 7. Follow its P&P titled, Accident Prevention, which indicated, Our facility strives to make the environment as free from accident hazards (a source of danger or an unsafe condition that has the potential to cause an accident, injury, or damage) as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. 8. Follow its P&P titled, Resident Transfers, which indicated, Clinical staff may use additional clinical staff members for assistance as needed. 9. Follow the facility-provided manual titled, Healthcare Equipment Owner's Manual, which indicated, Caregiver should be present and alert at all times while the equipment is in use. Equipment may not be appropriate for all individuals. Assessment should be conducted by a skilled caregiver for proper suitability for the individual using the equipment. As a result, on 10/24/2025 at 8:15 a.m., Resident 1 fell from the shower bed to the floor (28 inches high), on his right side and sustained a one-centimeter (cm-unit of measurement) discoloration (a change in the natural color of something) on his right cheek. Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation and care. On 11/6/2025, at 12 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON) due to the facility's failure under S483.25(d) Accidents by not providing sufficient supervision to ensure Resident 1 remained free from accident when Resident 1 slipped through a gap in the bed rail and fell to the floor on 10/24/2025 at 8:15 a.m. On 11/8/2025, at 3:33 p.m., the ADM submitted an acceptable IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/8/2025, at 4:30 p.m., the IJ situation was removed, after verifying its implementation through observations, interviews and record reviews, in the presence of the ADM, the DON, the Medical Records Manager (MRM), the Pediatric Nurse Manager (PNM), the Staff Development Coordinator (SDC), the Respiratory Therapist Director (RTD), the Dietary Manager (DM), and Registered Nurse 2 (RN 2). The IJ Removal Plan included the following immediate actions: 1. On 10/24/2025, at 8:15 a.m., RN 3 assessed Resident 1 for any injuries and transferred to the GACH for further evaluation at 9:35 a.m. (10/24/2025) and was readmitted back at the facility at 1 p.m. (10/24/2025). 2. On 10/24/2025, the PNM and RN 2 provided an in-service (refers to staff training) to CNA 1 regarding Patient Safety Prevention of Falls During Shower and Bathing Procedures. 3. On 10/26/2025, the IP revised the P&P titled, Status Post Falls/ Accident, reviewed on 3/2025, to require an immediate post-fall IDT meeting and a care plan/risk assessment revision within 24 hours of any fall. 3a. On 10/30/2025, at 7 a.m., the PNM and SDC started an in-service regarding Shower Beds/ Flexi Bath (foldable baby bathtubs)/ Bed Baths/ Grooming/ Falls/ Infection Control Reminders to all pediatric clinical staff including CNA 1 to not leave residents unattended and ensure residents remain in line of sight (refers to the physical visibility of residents by staff for safety and supervision especially for residents at risk of falls) when providing bath/shower. 3b. Use of size-appropriate pediatric shower bed for pediatric resident with weight of less than 50 pounds (lbs.-unit of measurement). The PNM and the Infection Preventionist (IP) approved the new pediatric shower bed (ordered on 11/3/2025) to ensure appropriateness for pediatric use. 4. On 10/30/2025 to 11/6/2025, the SDC provided in-services regarding Shower Beds/Flexi Bath/ Bed Baths/ Grooming/Falls/Infection Control Reminders for pediatric licensed nurses and CNAs. The in-services required that all pediatric residents must never be left unattended/out of line of sight during bathing/showering or while on assistive devices (pediatric shower beds). The in-services included the updated P&P titled, Use of Shower Bed, and hands-on competency validation (to be completed when pediatric shower bed arrives approximately on 11/20/25) for pediatric transfers and the proper use of the new pediatric shower beds. The PNM, RN 1 and RN 2 will perform the quality and safety checks when the new pediatric shower beds arrive. Any new pediatric staff and pediatric staff on leave will receive the in-services and policies regarding pediatric equipment and bathing safety prior to giving shift baths/showers. 5. On 10/31/2025, the facility stopped the use of standard-sized shower beds for pediatric residents under 50 lbs. 6. On 11/3/2025, the facility purchased size-appropriate pediatric shower beds to be used for all pediatric residents. 7. On 11/6/2025, at 10:30 a.m., RN 1 and RN 2 provided a mandatory re-education regarding the topic Bathing Safety and Demonstration and P&Ps titled, Falls Prevention, Precautions, and Assessment, reviewed on 3/2025, and Use of Shower Bed, revised on 11/6/2025, on proper bathing and safety. 8. On 11/6/2025, RN 1 and RN 2 verbally notified staff (nursing staff) during the beginning of each shift (7 a.m. to 7 p.m. and 7 p.m. to 7 a.m.) huddles (are short, frequent meetings where staff from different departments meet to discuss resident care, identify safety concerns, and improve team communication and collaboration) that no pediatric residents under 50 lbs. were bathed on the standard (adult) sized shower beds. 9. On of 11/6/2025 at 1 p.m., the IP updated the P&P titled, Use of Shower Bed, to ensure residents below 50 lbs. are not bathed/showered in standard (adult) shower bed. Residents under 50 lbs. will be showered in the pediatric-sized shower beds when they arrive with anticipated arrival date of 11/20/2025. Before the arrival of the pediatric-sized shower beds, all pediatric residents less than 50 lbs. are to be given bed baths in their respective beds. 10. On 11/6/2025, at 5 p.m., the facility's leadership team, that included the ADM, the DON, and the Medical Director (MD) conducted a Root Cause Analysis (RCA-a systematic process for identifying the underlying, fundamental causes of a problem to prevent it from happening again) to determine the cause of the deficient practice (a failure to meet a required standard, regulation, or rule). 10a. The RCA indicated CNA 1 did not adhere to established P&Ps for safety while bathing a pediatric resident (Resident 1). 10b. The RCA indicated there was a Process Failure. On 11/6/2025, the IP updated the P&P titled, Use of Shower Bed to include Resident is to always stay in line of sight of the CNA performing bath/shower. If at any moment the CNA needs to leave the resident's side during bath/shower, the CNA is to ensure there is coverage by a clinical staff member. The RCA indicated CNA 1 failed to adhere to bathing safety as per P&P titled, Use of Shower Bed by having a resident (Resident 1) out of her (CNA 1) line of sight when turning to put bedsheet on a resident's (Resident 1) mattress. 10c. The RCA indicated there was Staff Practice Failure because of lack of adherence to the facility's P&P titled, Fall Prevention, Precautions and Assessment, reviewed on 3/2025, for safe bathing of pediatric residents. 11. On 11/8/2025, the SDC, the PNM, and RN 2 in-serviced CNA 2 regarding Bathing Safety Demonstration with a return demonstration. 12. On 11/8/2025, at 9 a.m., the Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together) reviewed and revised Resident 1's comprehensive care plan and Fall Risk Assessment. The updated plan of care included: 13. On 11/8/2025, from 9 a.m. to 2 p.m., the DON and RN 2 evaluated all 33 pediatric residents for potential risk for falls from the adult size shower bed. Seven (Residents 1, 3, 4, 5, 6, 7, and 8) out of 33 residents were identified at risk for falls during bathing. 14. On 11/8/2025, at 2 p.m., the DON and RN 2 completed evaluations for potential risk for falls from a shower bed for all 33 pediatric residents that included: 14a. A review of each resident's current Fall Risk Assessment and comprehensive care plan to ensure bathing procedures are followed, supervision needs are met, and the required bathing equipment is used. 14b. The PNM and IP performing a physical inspection and assessment of all bathing equipment used for each pediatric resident to ensure proper sizing and safety. 14c. RN 1 and RN 2 completing care plan updates for any pediatric resident (names not indicated) requiring changes to bathing procedures and bathing equipment. 15. Starting 11/8/2025, the SDC, the PNM, RN 1 and RN 2 will be responsible for daily unit supervision and monitoring effectiveness. The SDC or Unit Charge Nurses will conduct random observational audits to ensure: 15a. Only size-appropriate equipment is used for pediatric residents. 15b. Care-planned bathing procedures and supervision levels are consistently followed. 15c. No pediatric resident is left unattended on any assistive device. 15d. Staff can verbalize understanding of the new and revised policies. 16. The SDC will report audit findings to the DON weekly and to the Quality Assurance and Performance Improvement (QAPI -a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee monthly. The QAPI committee will review the data, analyze trends, and make recommendations for further action as needed. The QAPI committee will monitor on an ongoing basis until sustained compliance is achieved for three consecutive months.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/11/2025, with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period, leading to low oxygen levels and/or high carbon dioxide levels in the blood) with tracheostomy and dependent on a ventilator (a machine or device used medically to support or replace the breathing of a person who is ill or injured), and liver transplant status (a life-saving surgery is performed when a person's liver fails) with gastrostomy. During a review of Resident 1's History and Physical (H&P), dated 9/11/2025, the H&P indicated Resident 1 was a medically complex ( individuals who have chronic [persistent for a long time] health conditions that require significant and ongoing medical care) two-year-old with a history of extreme prematurity (born before 28 weeks, which is less than seven months of pregnancy) and who had a liver transplant on 1/2024. During a review of Resident 1's Order Summary Report, dated 9/11/2025, the Order Summary Report indicated the use of side rails (a bar attached to the side of a bed to prevent falls and assist with repositioning) for safety. During a review of Resident 1's Child Life Development Assessment, dated 9/12/2025, the Child Life Development Assessment indicated Resident 1 could not communicate and was not able to verbalize his needs. During a review of Resident 1's Fall Risk Assessment, dated 9/12/2025, the Fall Risk Assessment indicated Resident 1 had a score of eight. The Fall Risk Assessment indicated residents who rate greater than eight should have a care plan for potential for falls. During a review of Resident 1's Bed Rail form dated 9/12/2025, the form indicated the IDT recommended the bed rail for safety and prevention of falls and injuries due to balance deficit and impaired cognition and possibility of rolling out of bed. During a review of Resident 1's Care Plan titled Potential for Injury, dated 9/15/2025 the Care Plan's interventions indicated the staff will perform frequent visuals checks and will not leave Resident 1 unattended with side rails down or seat belts unstrapped. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 9/22/2025, the MDS indicated Resident 1's cognitive skills (thought process) for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for ADLs. The MDS indicated Resident 1 had a bed rail and used an invasive mechanical ventilator. The MDS indicated Resident 1 was 33 inches in height and 26 lbs. in weight. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR-technique that provides a framework for communication between members of the health care team about a resident's condition) Communication Form, dated 10/24/2025, the SBAR indicated Resident 1 fell and sustained a right buccal (side of cheek) 1 cm purple discoloration. The SBAR indicated RN 2 did a full body and neurological assessment (a series of questions and physical tests used by doctors to check how well a person's nervous system is working) and noted Resident 1 had no changes in level of consciousness (describes their degree of awareness and responsiveness) and behaviors. The SBAR indicated an ice pack was applied to Resident 1's right cheek for five minutes. The SBAR indicated Resident 1's physician was notified 8:30 a.m., and the physician gave an order for Resident 1 to be transferred to GACH for further evaluation and care. During a review of Resident 1's Progress Notes, dated 10/24/2025, timed at 8:15 a.m., the Progress Notes indicated at 8:15 a.m., CNA 1 bathed Resident 1 and turned to put a sheet on the bed when Resident 1 fell. The Progress Notes indicated Resident 1 cried and RN 2 noticed a pea-sized right cheek discoloration. During an interview on 10/31/2025, at 9:10 a.m., with RN 3, RN 3 stated on 10/24/2025, at 8:15 a.m., she was in Resident 1's room in front of a medication cart calculating a medication dose beside Resident 1's crib and facing a window. RN 3 stated Resident 1 was off the ventilator, and she (RN 3) had disconnected him from the oxygen saturation sensor (a device that estimates the amount of oxygen in blood) so CNA 1 could shower Resident 1. RN 3 stated CNA 1 brought the shower bed inside Resident 1's room and transferred Resident 1 from the crib to the shower bed. RN 3 stated when she turned her head to the left she (RN 3) observed Resident 1 on the floor on his right side and CNA 1 was standing in between the crib and the shower bed. RN 3 stated though the shower bed had both side rails up, there was a huge gap in between. RN 3 stated Resident 1 fitted in the side rail gap and fell on the floor. RN 3 stated when she (RN 3) picked Resident 1 up from the floor, she noticed Resident 1 had a discoloration on the right cheek. RN 3 stated CNA 1 did not inform her (RN 3) that she (CNA 1) was to turn around to put a sheet on Resident 1's crib. RN 3 stated if she knew, she could have supervised Resident 1 to prevent the resident from falling. During an interview on 10/31/2025, at 9:32 a.m., with CNA 1, CNA 1 stated Resident 1 was an active resident, who could sit and crawl on his (Resident 1) own. CNA 1 stated the facility had only adult-sized shower beds. CNA 1 stated on 10/24/2025, at 8:15 a.m., she (CNA 1) placed the shower bed between Resident 1 and Resident 2's cribs and then she stood in the middle of Resident 1's crib and the shower bed. CNA 1 stated she carried Resident 1 from the crib and placed him (Resident 1) on the shower bed. CNA 1 stated she raised both side rails up and turned to get a bed sheet from the crib to cover Resident 1 before transferring Resident 1 from Resident 1's room to the shower room. CNA 1 stated as she (CNA 1) turned around, Resident 1 slipped in between the shower bed rails and fell to the floor. CNA 1 stated she (CNA 1) could not catch Resident 1. CNA 1 stated she (CNA 1) did not ask for the assistance from RN 3 who was present beside Resident 1's crib. CNA 1 stated as she (CNA 1) picked up Resident 1 from the floor, Resident 1 was crying, and CNA 1 noticed a small discoloration in Resident 1's right cheek. CNA 1 stated if she had asked RN 1's assistance, to watch Resident 1 while she (CNA 1) turned to get the bed sheet from the crib, Resident 1 would not have fallen. During an interview on 10/31/2025, at 9:45 a.m., with RN 2, RN 2 stated on 10/24/2025, she (RN 2) was the assigned charge nurse in the pediatric subacute unit (a specialized care unit for children who are medically complex and require a higher level of skilled nursing care). RN 2 stated RN 3 informed her (RN 2) that Resident 1 fell. RN 2 stated when she (RN 2) went to Resident 1's room, Resident 1 was already back in the crib, crying. RN 2 stated she (RN 2) did a full body and neurological assessment on Resident 1 to check for physical injury. RN 2 stated Resident 1 had a right cheek discoloration. RN 2 stated after consoling (to comfort) Resident 1, Resident 1 stopped crying. RN 2 stated CNA 1 should not have turned her (CNA 1) back if Resident 1 was on the shower bed. RN 2 stated CNA 1 should have notified RN 3 or the RT to monitor Resident 1, while she gathered needed supplies for the resident's care. During an interview on 10/31/2025, at 10:01 a.m., with RN 2, RN 2 stated the shower bed used by the pediatric subacute unit for shower was the adult-sized shower bed that was too big for the pediatric residents. During a concurrent interview and record review on 10/31/2025, at 10:07 a.m., with the PNM, Resident 1's Fall Risk Assessment, dated 9/12/2025 was reviewed. The PNM stated Resident 1 was active and moved a lot. The PNM stated Resident 1 was at risk for falls. The PNM stated on 10/24/2025, at 8:15 a.m., LVN 3 informed him (PNM) that Resident 1 slipped through the bottom gap of the shower bed rail and fell on the floor. The PNM stated the facility needed to provide a safe equipment for Resident 1's use. The PNM stated CNA 1 should have never turned her (CNA 1) back from Resident 1. The PNM stated CNA 1 was new at the facility and had no prior experience with pediatric residents. The PNM stated Resident 1's fall was avoidable and unacceptable. The PNM stated CNA 1 should have focused on Resident 1 and not the task. The PNM stated if CNA 1 did not turn her (CNA 1) back from Resident 1, Resident 1 would not have fallen. The PNM stated CNA 1 should have always kept a hand at Resident 1 when turning her (CNA 1) back. The PNM stated Resident 1 had a 1 cm round bruising (when small blood vessels under the skin tear or rupture, most often from a bump or fall) on his (Resident 1) right cheek from the fall. During a concurrent observation and interview on 10/31/2025, at 10:43 a.m., with the Maintenance Supervisor (MS), the MS measured the shower bed. The MS stated the shower bed had two gaps measuring eight inches in height and 22.5 inches in width on both sides. The MS stated the height of the shower bed from the floor was 28 inches. The MS stated the gap between the top of the shower bed to the top of the shower rail was 14 inches high and from the bottom of the shower bed to the bottom of the shower rail was 11 inches high. The MS stated the facility had four total standard (adult size) shower beds. The MS stated two shower beds were used for each unit (adult and pediatric subacute). During an interview on 10/31/2025, at 10:56 a.m., with the SDC, the SDC stated the shower bed used by the adult and the pediatric sub-acute residents were all adult-sized shower beds. The SDC stated the facility had modified the shower bed and applied a green net in the shower bed gaps to prevent pediatric residents from slipping through. The SDC stated the application of the net was still not safe to prevent a fall. The SDC stated Resident 1's fall was avoidable and preventable. The SDC stated Resident 1 could have broken bones and sustained a concussion from the fall. During an interview on 10/31/2025, at 11:04 a.m., with the DON, the DON stated Resident 1's Fall Risk Assessment should have been updated after the fall on 10/24/2025. The DON stated the facility had to assess Resident 1 for safety. The DON stated since Resident 1's Fall Risk Assessment was not done on 10/24/2025, Resident 1 could have a recurrent (repeated) fall. The DON stated CNA 1 should have either called for assistance or ensured one of her hands was on Resident 1 while she grabbed the sheet from the crib. The DON stated because of Resident 1's fall, Resident 1 had a discoloration on his (Resident 1) right cheek. During an interview on 11/4/2025, at 9:28 a.m., with CNA 1, CNA 1 stated she (CNA 1) did not hear any sounds that Resident 1 was moving on the shower bed when she (CNA 1) turned her (CNA 1) back. CNA 1 stated when she (CNA 1) turned back around Resident 1 had already slipped in between the shower bed rail and was already falling. CNA 1 stated she (CNA 1) could not catch Resident 1's fall. CNA 1 stated RN 3 was inside the room but was busy and RN 3's back was against the shower bed. CNA 1 stated her (CNA 1) mistake was not asking for assistance. During an interview on 11/4/2025, at 10:39 a.m., with the PNM, the PNM stated the combination of size-appropriate shower bed and CNA 1 not being attentive while providing care to Resident 1, caused Resident 1's fall. During an interview on 11/4/2025, at 11:15 a.m., with the DON, the DON stated the facility failed to use size-appropriate shower bed for pediatric resident. The DON stated the adult size shower bed used for Resident 1 was too big for a 2-year-old. The DON stated the facility failed to prevent Resident 1's fall when CNA 1 turned her back on Resident 1. The DON stated CNA 1 should always have her (CNA 1) hands on Resident 1, during care to prevent falls and in juries. The DON stated the facility could have provided a smaller shower bed free from gaps or have two staff provide showers to Resident 1 to prevent Resident 1's fall. The DON stated Resident 1 could have had fracture (break in bone) and developed a brain injury or skin breakdown from the fall. During an interview on 11/4/2025, at 1:41 p.m., with the PNM, the PNM stated Resident 1 was not assessed for safety for the use of adult-sized shower bed. The PNM stated all pediatric residents were not assessed for safety for the use of adult size shower beds. The PNM stated the facility only assesses Fall Risk Assessment. The PNM stated the facility also failed to assess Resident 1's Fall Risk Assessment after the 10/24/2025 fall. The PNM stated the importance of Fall Risk Assessment was to prevent Resident 1's fall from happening again. During a concurrent interview and record review on 11/4/2025, at 2:02 p.m., with the ADM, the Facility Assessment 2025, reviewed on 4/17/2025 was reviewed. The assessment indicated, Nursing facilities will conduct, document and annually review a facility-wide assessment which includes both their resident population and the resources the facility needs to care for their residents. The intent of the facility assessment is for the facility to evaluate its resident's population and identify the resources needed to provide the necessary person-centered care and services the residents require. Supplies and equipment are maintained to protect and promote the health and safety of the residents. The ADM stated the Facility Assessment 2025 only indicated shower chairs. The ADM stated the purpose of facility assessment was to review all aspects of care related to facility's population annually and full verification of equipment needed. The ADM stated the facility had 42 pediatric residents' beds and currently had 33 pediatric residents in the facility. The ADM stated the pediatric shower bed was not included in the Facility Assessment 2025. The ADM stated the Facility Assessment 2025 was updated on 11/3/2025, to include the pediatric gurney shower (a mobile, water-resistant bed with wheels, specifically designed to transport and bathed children who are immobile or have difficulty bathing independently). The ADM stated the Facility Assessment 2025 was again updated on 11/4/2025, after Resident 1's fall, to include pediatric bathing bassinets. The ADM stated he did not receive a request for a pediatric shower bed before Resident 1's fall. The ADM stated on 11/3/2025, the pediatric staff requested a small shower bed, so the facility had decided to place an order for a pediatric-sized shower bed. During an interview on 11/4/2025, at 2:53 p.m. with the DON, the DON stated the facility should have a pediatric shower-sized bed because the facility had pediatric residents. The DON stated the Facility Assessment 2025 reviewed on 4/17/2025, only indicated shower chair. The DON stated the facility only had shower beds, with same standard adult-sized shower bed used for both adult and pediatric residents. During an interview on 11/5/2025, at 9:48 a.m., with the DON, the DON stated the facility did not assess pediatric residents if it was safe to use the adult-sized shower beds. During a concurrent interview, and record review on 11/5/2025, at 12:36 p.m., the facility's P&P titled, Accident Prevention, reviewed on 5/2025, was reviewed with the DON. The P&P indicated, Our facility strives to make the environment as free from accident hazards (a source of danger or an unsafe condition that has the potential to cause an accident, injury, or damage) as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes and a facility-wide commitment to safety at all levels of the organization. Employees are to report potential accident hazards and try to prevent avoidable accidents. The interdisciplinary care team shall review information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The DON stated adult-sized shower bed with wide gaps on the bed rails is an environmental hazard. The DON stated the P&P was not followed. During a concurrent interview and record review on 11/5/2025, at 12:40 p.m., the facility's P&P titled, Resident Transfers (shower bed, gurney, wheelchair, geri-chair [a supportive recliner on wheels designed for individuals with limited mobility]), reviewed on 1/2025, was reviewed with the DON. The P&P indicated, The purpose of the policy is to provide a guideline for the transfer of a resident from bed to shower bed, gurney, wheelchair, and geri-chair. Procedure:. 3. Clinical staff may use additional clinical staff members for assistance as needed. The DON stated CNA 1 should have asked for assistance. The DON stated the P&P was not followed. During a concurrent interview and record review on 11/5/2025, at 12:44 p.m., the facility's P&P, titled, Falls Prevention, Precautions and Assessment, reviewed on 1/10/2024, was reviewed with the DON. The P&P indicated, Nursing will assess and identify falls risk upon admission and as needed for all residents. A Care Plan and appropriate safety measures will be implemented immediately after a resident is identified to be at risk for falls. Assess the patient on admission and as needed to identify falls risk for the resident. The assessment will include age, gender, diagnosis, cognitive impairments, environmental factors, falls history, bed placement, equipment, furniture, medication, and activity level. The DON stated Fall Risks Assessment should be done after Resident 1's fall incident on 10/24/2025. The DON stated the P&P was not followed. During a concurrent interview, and record review on 11/5/2025, at 12:50 p.m., the facility's P&P titled, Facility Assessment Patient Population, reviewed on 3/2025, was reviewed by the DON. The P&P indicated, Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. The facility assessment also includes a detailed review of the resources available to meet the needs of the residents' population. This part of the assessment includes. b. Equipment and supplies (medical and non-medical) . The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed. It is separate from the Quality Assurance and Performance improvement evaluation. The DON stated the facility assessment was not complete. The DON stated the facility assessment did not indicate about a shower bed. The DON stated the facility assessment should include pediatric-sized shower beds since the facility currently had 33 pediatric residents. During an interview on 11/6/2025, at 9:31 a.m., with the PNM, the PNM stated the pediatric subacute unit had residents ages from one- to [AGE] year-old. The PNM stated Resident 1 was admitted on [DATE]. The PNM stated since the facility admitted Resident 1, the facility should have made sure that all equipment needed by Resident 1 will be size-appropriate for safety and that includes pediatric shower bed. The PNM stated the Facility Assessment 2025 should also include shower bed. During an interview on 11/8/2025, at 3:15 p.m., with the ADM, the ADM stated the facility assessment should be updated with current equipment used by the facility including shower bed. During a concurrent interview and record review on 11/8/2025, at 3:21 p.m., with the DON, the facility-provided manual for the shower bed that CNA 1 used for Resident 1 titled, Healthcare Equipment Owner's Manual, revised on 1/2008 was reviewed. The Healthcare Equipment Owner's Manual indicated the following warnings: - Individuals should never be left unattended in shower chair, walker (a device designed to assist individuals with balance and mobility issues), geri-chair, low bed, recreational chair, shower gurney, crib, or therapy car.- Caregiver should be present and alert at all times while the equipment is in use.- Equipment may not be appropriate for all individuals. Assessment should be conducted by a skilled caregiver for proper suitability for the individual using the equipment.- The improper use of this equipm[TRUNC

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent (%). Eleven (11) medication errors out of 26 total opportunities contributed to an overall medication error rate of 42.3% affecting 3 of 5 sample residents (Residents 22, 43, and 68) observed for medication administration performed by 3 of 5 Licensed Vocational Nurses (LVNs 1, 2, and 3). The facility failed to: 1. Ensure LVN 1 did not mix three of eight medications for administration through Resident 22's gastrostomy tube (GT, a soft tube inserted during surgery into the stomach through the belly to deliver food and medications on a person unable to swallow) and followed the facility's policy and procedure (P&P) on Medication Pass to give medications one at a time. 2. Ensure LVN 2 flushed with 50 milliliters (ml, unit of measurement) of water the GT before administering medications and with 5 ml to 10 ml of water after each of the five medications administered to Resident 43, as ordered by the physician, and as indicated in the facility's P&P on Medication Pass via (through) GT. In addition, LVN 2 did not allow the medications to go through the GT by gravity as per facility's P&P. 3. Ensure LVN 3 administered Resident 68 the complete dose of three of six crushed medications via GT and did not leave significant residues of undissolved medications in the medication cup (plastic translucent cup suitable for dispensing both liquid and dry medications, calibrated from 2.5 ml to 30 ml) in accordance with the physician's orders and professional standard of practice. These deficient practices of failing to administer Resident 22's medications separately, one at a time, in accordance with P&Ps and professional standards of practice including significant medications, an antiseizure medication (to decrease the number, severity, and / or duration of seizures [sudden, uncontrolled burst of electrical activity in the brain]) and a mineral to help the heart muscle work well, placed Resident 22 at high risk for increased seizure frequency, duration, or intensity, irregular heartbeats, and to experience adverse drug interactions (two or more drugs taken concurrently may influence one another in a manner that results in either an enhanced or diminished intensity of effect produced by any of the drugs taken alone), which may lead to hospitalization or death. Failing to flush Resident 43's GT with water before and between medications which included a blood thinner, and failing to administer medications via gravity as per physician's order and P&P, placed Resident 43 at risk to have GT complications such as tube blockage, and to experience adverse drug interactions, and aspiration pneumonia (swelling and infection of the lungs or large airways that occurs when food or liquid is breathed into the airways or lungs) and pulmonary embolism (a life-threatening blood clot in the lungs). Failing to give the complete dose of Resident 68's needed anticholinergic medication (inhibits saliva production and respiratory secretions) in accordance with the physician's orders and professional standard of practice, increased the risk of Resident 68 to develop shortness of breath and airway obstruction, that may lead to hospitalization or death. On 10/18/2023 at 5:39 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 Code of Federal Regulation (CFR) S483.45(f), for the facility's failure to ensure the medication error rate was less than 5%, which threatened the health and safety of Residents 22, 43, and 68. The IJ situation was announced in the presence of the Administrator (ADM) and the Director of Nursing (DON). On 10/20/2023 at 7:51 p.m. (two days after calling the IJ) and while onsite, the IJ was removed after the SSA verified through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan. The removal of the IJ was conducted in the presence of the ADM, the DON, the [NAME] President of Operations (VPO), the Director of Respiratory Therapy, the Director of Staff Development (DSD), and the Social Services Director (SSD). The IJ Removal Plan included the following summarized actions: a. LVNs 1, 2 and 3 would be educated on proper medication administration techniques, safety, and documentation with return demonstration. The education would be completed by the DON and the DSD. b. LVNs 1, 2 and 3 would return to duty when education for medication administration is completed and return demonstration is accepted. c. Residents 22, 43 and 68 continued to receive their medications via GT by Licensed Nurses (LVNs or Registered Nurses [RNs]) that had achieved their competency by return demonstration. d. Residents 22, 43 and 68 correctly received their physician's ordered medications by the next shift (after the IJ was called) as per physicians' orders and facility's P&Ps. The next shift Licensed Nurses (LNs) were signed off for competency using the Medication Administration Tool specifically designed for evaluating competency in GT medication administration. e. The attending physicians of Residents 22, 43 and 68 were notified of the medication error and did not give new orders. Each resident's responsible party was notified of the medication error. f. All residents who received medications from LVNs 1, 2 and 3 for the past seven days were assessed for any signs (objective findings that can be seen or measured) and symptoms (subjective manifestation that can be perceived only by the person affected) of adverse medication effects. g. All Licensed Nurses administering physician ordered medications on 10/18/2023 received immediate medication administration supervision and education one on one (1:1, one person supervising one nurse) by the DON, the DSD, and the Pharmacy Consultant. h. All Licensed Nurses are being re-educated on GT medication administration for residents to include safety and technique per physician orders and facility policies and procedures. This education was initiated on 10/18/2023. Cross reference F658, F755, and F760 Findings: 1. A review of Resident 22's Admission Record indicated the facility admitted the resident on 11/6/2008 with a readmitted d 5/23/2014. Resident 22's diagnoses included seizure (convulsions) disorder, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [waste gas made in the body's cells]). Other diagnoses were dependence on respirator (or ventilator, a machine that helps persons that cannot breathe on their own), tracheostomy (a medical procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and GT. A review of Resident 22's History and Physical (H&P) exam, dated 5/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 8/29/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks such as eating, walking, dressing, bathing, moving in bed, toilet use, and personal hygiene). A review of the Physician's Orders for Resident 22 indicated the following medications: - Keppra (antiseizure medication) 1500 milligrams (mg - a unit of measurement) via GT every 12 hours for seizure disorder ordered on 7/22/2018. - Dilantin (antiseizure medication) 250 mg via GT every 12 hours for seizure disorder, hold GT feeding one hour before and after medication administration, ordered on 10/4/2023. - Potassium chloride (KCl, medicine used to prevent or treat low potassium levels in the body; potassium is a mineral the body needs for proper functioning of several organs including the heart) 20 milliequivalent (mEq - a unit of measurement) 15 ml via GT, dilute with 200 ml water, give daily as supplement, ordered on 7/5/2023. A review of Resident 22's Care Plan developed on 5/15/2023 and last reviewed on 8/2023, indicated Resident 1 was at risk for irregular heart rate related to low blood level of potassium. The interventions included to give medication as ordered. A review of Resident 22's Care Plan developed on 5/15/2023 and last reviewed on 8/2023, indicated Resident 1 was at risk for seizure activity. The interventions included to give medications as ordered. On 10/18/2023 at 8:11 a.m., during a medication administration observation outside Resident 22, LVN 1 prepared eight medications for Resident 22 including the following: - 15 ml (1500 ml) of Keppra and placed it in a medicine cup. - 10 ml (250 mg) of Dilantin and placed it in another medicine cup. - 15 ml of KCL 20 MEQ diluted with 200 ml water in a Styrofoam cup. During a concurrent observation at bedside and interview on 10/18/2023 at 9:05 a.m., LVN 1 added to the Styrofoam cup (with the KCl), the Keppra and the Dilantin and administered to Resident 22 through the GT. When asked, LVN 1 stated and verified that she poured the Dilantin and Keppra into the Styrofoam cup with the KCl diluted in 200 ml of water and administered them together via the GT. LVN 1 stated that she was trained this way on administration of medications to residents with GT but said she should have administered each medication one at a time. LVN 1 stated the medications may not be compatible and mixing them may result on adverse drug reaction placing Resident 22 at risk for serious medical complications. During an interview on 10/18/2023 at 3:00 p.m., LVN 1 stated she failed to follow the facility's P&P and standard of practice by mixing medications instead of giving Resident 22 one medication at a time. LVN 1 stated that she was nervous, and it was her first time a surveyor followed her during medication administration. On 10/19/2023 at 9:21 a.m., during an interview, the DSD stated that newly hired LVNs without experience were trained on administering medications and GT administration for seven 12-hour shifts under the guidance of an experienced LN and LVN 1 was signed off as competent on 4/13/2023. The DSD stated the medication administration part on the Competency Orientation Training Checklist and RN/LVN Annual Skills Checklist did not specify competency for medication administration through GT. The DSD stated the DON conducts the LNs annual performance evaluations on the anniversary of the LN date of hire. During an interview on 10/20/2023 at 8:00 a.m., the DON stated medications for GT administration should be given one at a time, to ensure there were no physical or chemical incompatibilities between medications and avoid placing the residents at risk for serious medical complications that may lead to hospitalization or death. The DON stated liquid medications should be administered directly into the GT unless there was a physician's order to dilute with water. On 10/20/2023 at 4:55 p.m., during an interview, the Medical Director (MD) stated antiseizure medications such as Keppra and Dilantin that are not administered properly, place the resident at risk for increased seizures. A review of the facility's P&P on Medication Pass via GT /Jejunostomy tube (JT, a soft tube inserted during surgery into the small intestine [bowel] through the belly to deliver food and medications), last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to pass medications through the GT / JT. The policy indicated to give medication as ordered one at a time. A review of the facility's P&P titled, Medication Pass, last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to properly complete medication pass. The policy indicated to give medications one at a time. 43418 2. A review of Resident 43's Admission Record indicated the facility originally admitted the resident on 9/7/2016 with diagnoses including chronic respiratory failure, GT, anoxic brain damage (injuries caused by a complete lack of oxygen to the brain, which results in the death of brain cells), acute embolism (obstruction of an artery [type of blood vessel], typically by a clot of blood or an air bubble), and thrombosis (local clotting of the blood in a part of the circulatory system [system that circulates blood through the body: the heart, blood vessels, and blood]). A review of Resident 43's MDS, dated [DATE], indicated Resident 43 rarely or never understood, was unable to make decisions, and required total staff assistance with ADLs. A review of the Physician's Order for Resident 43, indicated the following: - Flush 50 ml of water via GT before and after medication administration and 5 ml to 10 ml in between medications, ordered on 9/9/2016. - Vitamin D 1000 international units (IU - a unit of measurement) via GT every day for supplement, ordered on 1/19/2018. - Tums (medication used to relieve heartburn) 750 mg per tablet, one tablet via GT every 12 hours, ordered on 8/14/2018. - Multivitamins with minerals one tablet via GT every day for supplement, ordered on 4/15/2019. - Vitamin C 500 mg via GT every 12 hours for supplement, ordered on 7/25/2019. - Xarelto (rivaroxaban, blood thinner to treat and prevent blood clots) 10 mg via GT every day to prevent for deep vein thrombosis (DVT - a blood clot in a deep vein, usually in the legs), dated 9/23/2019. On 10/18/2023, at 9:04 a.m. during a medication administration observation and concurrent interview, LVN 2 was outside Resident 43's room reviewing Resident 43's medication administration record (MAR). LVN 2 stated Resident 43 was going to receive the following medications through the GT: - Tums 750 mg - Vitamin D 1000 IU - Multivitamins with minerals one tab - Vitamin C 500 mg - Xarelto 10 mg LVN 2 placed each medication in a medication cup, then proceeded to transfer each medication into separate clear packets and crushed each one using a pill grinder. Then, placed the crushed contents of each packet into separate medicine cups. At 9:20 a.m., at bedside, LVN 2 used a piston syringe (a medical device that consists of a calibrated hollow barrel and a movable plunger) poured approximately 5 ml to 10 ml of water into five small clear plastic cups containing crushed medications and mixed the contents of each cup separately. LVN 2 drew up the mixture from one of the five cups using the piston syringe, connected the piston syringe barrel to the GT, and slowly pushed the medication using the syringe plunger. Prior to the first medication administration, LVN 2 did not administer 50 ml of water through Resident 43's GT as ordered by the physician. LVN 2 repeated the same process for the remaining four medications. LVN 2 did not administer 5 ml to 10 ml of water into Resident 43's GT between each medication administered as per physician's order. On 10/18/2023, at 9:26 a.m., after completing the medication pass, a concurrent interview with LVN 2 and a review of Resident 43's MAR which indicated to flush 50 ml of water via GT before and after medication administration and 5 ml to 10 ml in between medications. LVN 2 stated she forgot to flush Resident 43's GT with 50 ml of water before administering the medications and confirmed not flushing the GT with 5 ml to 10 ml between the five medications. LVN 2 stated it was important to flush a GT prior to administering medications to check for patency (open or unobstructed) and to prevent clogging. LVN 2 explained that since she had a lot of medications to administer, she did not want to take time in flushing water between each medication. LVN 2 stated she sometimes administers water between each medication, but only if the medication is sticky. LVN 2 stated it is important to administer water between each medication to prevent the medications from clogging the GT. Further review of Resident 43's MAR did not indicate Resident 43 had an order for gentle pushes to administer medications and was confirmed by LVN 2. LVN 2 stated she did not administer Resident 43's medication by gravity. During an interview, on 10/20/2023, at 12:05 p.m., the DON stated that prior to medication administration, the nurses needed to review the resident's MAR for instructions on which medications needed to be administered and how the medications were to be administered. The DON stated the GT needed to be flushed with 50 ml of water prior to medication administration and medications needed to be administered one at a time, by gravity. The DON stated it was not appropriate to push medications into the GT with the piston syringe because it could result on erupting (spilled) if the GT the syringe dislodged, or the resident may aspirate (liquid go into the airway) if the medication was pushed fast. The DON stated 5 ml to 10 ml of water is needed to be flushed between each medication to make sure there were no drug interactions and to prevent the GT from clogging. On 10/20/2023, at 4:55 p.m., during an interview, the MD stated flushing the GT with water before, between, and after medication administration was a standard practice. The MD stated administering water is done to make sure the medication is distributed properly, if water is not flushed between each medication, it was possible residual medication (in the tubing) would not reach its destination. A review of the facility's P&P titled, Gastrostomy Tube Water Flush, reviewed 1/26/2023, indicated the procedure for water flush: - Insert syringe into the end of the GT - Pour water into syringe - Allow water to flow by gravity into stomach - Hold about 12-18 inches (unit of measurement) above the opening - Flush 50 ml prior to medication administration, then flush 5 ml to 10 ml between each medication or per physician's order. A review of the facility's P&P on Medication Pass Via GT / JT, reviewed on 1/26/2023, indicated to flush the tube as ordered before and after medication administration. The P&P further indicated adults are given medications as ordered one at a time with 5 ml to 10 ml in between each medication or as per physician's orders. 38552 3. A review of Resident 68's Admission Record indicated the facility admitted the resident on 10/28/2019 with diagnoses including anoxic brain damage, tracheostomy, and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 68's H&P exam, dated 3/1/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 68's MDS, dated [DATE], indicated the resident had severely impaired cognition, had a GT for feeding, and was dependent on staff for all ADLs. A review of the Physician's Orders for Resident 68 indicated the following medications: - Colace (stool softener) 100 mg via GT, every 12 hours for bowel management, hold for loose stool, ordered on 4/26/2023. - Glycopyrrolate (Robinul, anticholinergic medication) 2 mg via GT, every 8 hours for secretions, ordered on 3/1/2023. - Magnesium oxide (mineral supplement used to prevent and treat low amounts of magnesium in the blood) 400 mg via GT every day, ordered on 3/1/2023. - Vitamin D 2000 IU via GT every day for supplement ordered on 3/1/2023. - Clonidine (to treat hypertension) 0.2 mg via GT twice a day ordered on 3/1/2023. - Tizanidine (Zanaflex, muscle relaxant) 2 mg via GT three times a day ordered on 3/1/2023. A review of Resident 68's Care Plan developed on 4/17/2023 for the resident's excessive (respiratory) secretions requiring Robinul every 8 hours, had a goal for the resident to always have patent (unobstructed) airway. The interventions included to give medications as ordered. On 10/18/2023, at 8:14 a.m. during a medication administration observation outside Resident 68's room, LVN 3 prepared Resident 68's morning medications, as follows: - Colace 100 mg, 1 tablet - Robinul 2 mg, 1 tablet - Magnesium oxide 400 mg, 1 tablet - Vitamin D3 1000 IU, 1 tablet - Clonidine 0.2 mg, 1 tablet - Zanaflex 2mg 1 tablet At 8:18 a.m., LVN 3 crushed each tablet in a separate plastic packet and placed each crushed medication into separate medicine cups. The following was observed at Resident 68's bedside: At 8:23 a.m., LVN 3 placed the medicine tray with the six medication cups on top of overbed side table and poured about 10 ml of water inside each medicine cup. At 8:27 a.m., LVN 3 attached the piston syringe hollow barrel to the GT and removed the syringe plunger before administering the medications. LVN 3 shook each medicine cup before pouring each content in the syringe barrel allowing the content to go through the GT by gravity. At 8:36 a.m., during an interview, LVN 3 stated she completed medication pass for Resident 68. There were three medicine cups with residual crushed medications. LVN 3 stated the cups contained Vitamin D, magnesium oxide, and Robinul. LVN 3 stated some of the crushed tablets stuck to the bottom of the cup. LVN 3 stated she did not know how much of the medicine was left in the three medicine cups, but it seemed a lot. LVN 3 stated she was going to dispose of them. At 8:38 a.m., LVN 3 proceeded to sign Resident 68's MAR indicating the six medications were given. During an interview on 10/20/2023 at 4:06 p.m., the DON stated that after administering medication, the LNs must check the medicine cup to ensure there is no medication remaining and the residents receive the ordered dose. The DON stated LNs may use apple sauce so the crushed medications would not stick on the bottom of the medicine cup and may use a spoon or a coffee stirrer to stir the medication. The DON stated Resident 68 did not receive the ordered dose of Robinul and it was possible for Resident 68 to have increased respiratory secretions, which may lead to respiratory distress, coughing, or aspiration. On 10/20/2023 at 4:55 p.m., during an interview, the MD stated sometimes anticholinergic medications are given due to the excess secretion or for bradycardia (slow heart rate). The MD stated when anticholinergics are not administered correctly the resident may need to be suctioned (removal of secretions from the airway using a suction machine). A review of the facility's policy and procedure titled, Medication Rights, reviewed and approved 1/26/2023, indicated it is the facility's policy to make sure that licensed nurses follow the updated guidelines for the Patient Medication Rights. The procedure indicated: 3. Right Dose - compare the dose of the medication to the MAR. 6. Right Documentation - the documentation of the medication must be done at the time that you give the medications. A review of the facility's policy and procedure on Medication Pass via GT / JT, reviewed on 1/26/2023, indicated it was the facility's policy to make sure that nursing would follow the policy of giving medications. The procedures indicated to ensure all medication is given and not remaining in the cup.

Based on observation, interview, and record review, the facility failed to ensure 3 of 5 sample residents (Residents 22, 43, and 68) observed for medication administration performed by 3 of 5 Licensed Vocational Nurses (LVNs 1, 2, and 3) on 10/18/2023, were free from significant medication errors (one or more observed or identified preparation or administration of medications ordered by a physician causing the resident discomfort or jeopardizes his or her health and safety). The facility failed to: 1. Ensure LVN 1 did not mix three medications for administration through Resident 22's gastrostomy tube (GT, a soft tube inserted during surgery into the stomach through the belly to deliver food and medications on a person unable to swallow) and followed the facility's policy and procedure (P&P) on Medication Pass to give medications one at a time. LVN 1 mixed Keppra and Dilantin, both used for prevention and control of seizures (sudden, uncontrolled burst of electrical activity in the brain), and potassium chloride [KCl, medicine used to prevent or treat low potassium levels in the body; potassium is a mineral the body needs for proper functioning of several organs including the heart). 2. Ensure LVN 2 flushed (put in) with 5 milliliters (ml, unit of measurement) to 10 ml of water Resident 43's GT before and after the administration of Xarelto (rivaroxaban, a blood thinner used to treat and prevent blood clots) as ordered by the physician, and as indicated in the facility's P&P on Medication Pass via (through) GT. 3. Ensure LVN 3 administered Resident 68 the complete dose of the anticholinergic medication (inhibits saliva production and respiratory secretions) Robinul (glycopyrrolate) through Resident 68's GT and did not leave significant residues of undissolved medications in the medication cup (plastic translucent cup suitable for dispensing both liquid and dry medications, calibrated from 2.5 ml to 30 ml) as indicated in the physician's order and professional standard of practice. These deficient practices of failing to administer Resident 22's medications separately, one at a time, in accordance with P&Ps and professional standards of practice increased Resident 22's risk for seizure frequency, duration, or intensity, irregular heartbeats, and to experience adverse drug interactions (two or more drugs taken concurrently may influence one another in a manner that results in either an enhanced or diminished intensity of effect produced by any of the drugs taken alone), which may lead to hospitalization or death; failing to flush Resident 43's GT with 5 ml to 10 ml of after the administration of Xarelto as per physician's order, P&P, and professional standards of practice, placed Resident 43 at risk to experience adverse drug interactions; and failing to give the complete dose of Resident 68's Robinul through the GT in accordance with the physician's orders and professional standard of practice, increased Resident 68's risk to develop shortness of breath and airway obstruction. All these complications may result in hospitalization and even death for Residents 22, 43 and 68. On 10/18/2023 at 5:39 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.4545(f)(2), for the facility's failure to ensure Residents 22, 43, and 68 were free from significant medication errors, which threatened the health and safety of the residents. The IJ situation was announced in the presence of the Administrator (ADM) and the Director of Nursing (DON). On 10/20/2023 at 7:51 p.m. (two days after calling the IJ) and while onsite, the IJ was removed after the SSA verified through observation, interview, and record review, the implementation of the facility's submitted and accepted IJ Removal Plan. The removal of the IJ was conducted in the presence of the ADM, the DON, the [NAME] President of Operations (VPO), the Director of Respiratory Therapy, the Director of Staff Development (DSD), and the Social Services Director (SSD). The IJ Removal Plan included the following summarized actions: a. LVNs 1, 2 and 3 would be educated on proper medication administration techniques, safety, and documentation with return demonstration. The education would be completed by the DON and the DSD. b. LVNs 1, 2 and 3 would return to duty when education for medication administration is completed and return demonstration is accepted. c. Residents 22, 43 and 68 continued to receive their medications via GT by Licensed Nurses (LVNs or Registered Nurses [RNs]) that had achieved their competency by return demonstration. d. Residents 22, 43 and 68 correctly received their physician's ordered medications by the next shift (after the IJ was called) as per physicians' orders and facility's P&Ps. The next shift Licensed Nurses (LNs) were signed off for competency using the Medication Administration Tool specifically designed for evaluating competency in GT medication administration. e. The attending physicians of Residents 22, 43 and 68 were notified of the medication error and did not give new orders. Each resident's responsible party was notified of the medication error. f. All residents who received medications from LVNs 1, 2 and 3 for the past seven days were assessed for any signs (objective findings that can be seen or measured) and symptoms (subjective manifestation that can be perceived only by the person affected) of adverse medication effects. g. All Licensed Nurses administering physician ordered medications on 10/18/2023 received immediate medication administration supervision and education one on one (1:1, one person supervising one nurse) by the DON, the DSD, and the Pharmacy Consultant. h. All Licensed Nurses are being re-educated on GT medication administration for residents to include safety and technique per physician orders and facility policies and procedures. This education was initiated on 10/18/2023. Cross reference F658, F755, and F759 Findings: 1. A review of Resident 22's Admission Record indicated the facility admitted the resident on 11/6/2008 with a readmitted d 5/23/2014. Resident 22's diagnoses included seizure (convulsions) disorder, chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [waste gas made in the body's cells]), dependence on respirator (or ventilator, a machine that helps persons that cannot breathe on their own), tracheostomy (a medical procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and GT. A review of Resident 22's History and Physical (H&P) exam, dated 5/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 8/29/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks such as eating, walking, dressing, bathing, moving in bed, toilet use, and personal hygiene). A review of the Physician's Orders for Resident 22 indicated the following medications: - Keppra (antiseizure medication) 1500 milligrams (mg - a unit of measurement) via GT every 12 hours for seizure disorder ordered on 7/22/2018. - Dilantin (antiseizure medication) 250 mg via GT every 12 hours for seizure disorder, hold the feeding (food) given through the GT one hour before and after medication administration, ordered on 10/4/2023. - KCl 20 milliequivalent (mEq - a unit of measurement) 15 ml via GT, dilute with 200 ml water, give daily as supplement, ordered on 7/5/2023. A review of Resident 22's Care Plan developed on 5/15/2023 and last reviewed on 8/2023, indicated Resident 1 was at risk for irregular heart rate related to low blood level of potassium. The interventions included to give medication as ordered. A review of Resident 22's Care Plan developed on 5/15/2023 and last reviewed on 8/2023, indicated Resident 1 was at risk for seizure activity. The interventions included to give medications as ordered. On 10/18/2023 at 8:11 a.m., during a medication administration observation outside Resident 22's room, LVN 1 prepared the following medications for Resident 22: - 15 ml (1500 mg) of Keppra and placed it in a medicine cup. - 10 ml (250 mg) of Dilantin and placed it in another medicine cup. - 15 ml of KCL 20 MEQ diluted with 200 ml water in a Styrofoam cup. During a concurrent observation and interview on 10/18/2023 at 9:05 a.m., LVN 1 added to the Styrofoam cup (with the KCl), the Keppra and the Dilantin and administered to Resident 22 through the GT. When asked, LVN 1 stated and verified that she poured the Dilantin and Keppra into the Styrofoam cup with the KCl diluted in 200 ml of water and administered them together via the GT. LVN 1 stated that she was trained this way on administration of medications to residents with GT but said she should have administered each medication one at a time. LVN 1 stated the medications may not be compatible and mixing them may result on adverse drug reaction placing Resident 22 at risk for serious medical complications. During an interview on 10/18/2023 at 3:00 p.m., LVN 1 stated she failed to follow the facility's P&P and standard of practice by mixing medications instead of giving Resident 22 one medication at a time. LVN 1 stated that she was nervous, and it was her first time a surveyor followed her during medication administration. During an interview on 10/20/2023 at 8:00 a.m., the DON stated medications for GT administration should be given one at a time, to ensure there were no physical or chemical incompatibilities between medications and avoid placing the residents at risk for serious medical complications that may lead to hospitalization or death. The DON stated liquid medications should be administered directly into the GT unless there was a physician's order to dilute with water. On 10/20/2023 at 4:55 p.m., during an interview, the Medical Director (MD) stated antiseizure medications such as Keppra and Dilantin that are not administered properly, place the resident at risk for increased seizures. A review of the facility's P&P on Medication Pass via GT /Jejunostomy tube (JT, a soft tube inserted during surgery into the small intestine [bowel] through the belly to deliver food and medications), last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to pass medications through the GT / JT. The policy indicated to give medication as ordered one at a time. A review of the facility's P&P titled, Medication Pass, last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to properly complete medication pass. The policy indicated to give medications one at a time. 43418 2. A review of Resident 43's Admission Record indicated the facility originally admitted the resident on 9/7/2016 with diagnoses including chronic respiratory failure, GT, anoxic brain damage (injuries caused by a complete lack of oxygen to the brain, which results in the death of brain cells), acute embolism (obstruction of an artery [type of blood vessel], typically by a clot of blood or an air bubble), and thrombosis (local clotting of the blood in a part of the circulatory system [system that circulates blood through the body: the heart, blood vessels, and blood]). A review of Resident 43's MDS, dated [DATE], indicated Resident 43 rarely or never understood, was unable to make decisions, and required total staff assistance with ADLs. A review of the Physician's Order for Resident 43, indicated the following: - Flush 50 ml of water via GT before and after medication administration and 5 ml to 10 ml in between medications, ordered on 9/9/2016. - Xarelto 10 mg via GT every day to prevent for deep vein thrombosis (DVT - a blood clot in a deep vein, usually in the legs), ordered on 9/23/2019. On 10/18/2023, at 9:04 a.m. during a medication administration observation and concurrent interview, LVN 2 was outside Resident 43's room reviewing Resident 43's medication administration record (MAR). LVN 2 stated Resident 43 was going to receive five medications through the GT including Xarelto. LVN 2 placed each medication in a medication cup, then proceeded to transfer each medication into separate clear packets and crushed each one using a pill grinder. Then, placed the crushed contents of each packet into separate medicine cups. At 9:20 a.m., at bedside, LVN 2 used a piston syringe (a medical device that consists of a calibrated hollow barrel and a movable plunger) poured approximately 5 ml to 10 ml of water into five small clear plastic cups containing crushed medications and mixed the contents of each cup separately. LVN 2 drew up the mixture from one of the five cups using the piston syringe, connected the piston syringe barrel to the GT, and slowly pushed the medication using the syringe plunger. LVN 2 did not administer 5 ml to 10 ml of water into Resident 43's GT between each medication administration as per physician's order. On 10/18/2023, at 9:26 a.m., after completing the medication pass, a concurrent interview with LVN 2 and a review of Resident 43's MAR, LVN 2 confirmed not flushing the GT with 5 ml to 10 ml between the five medications, not before or after the administration of Xarelto. LVN 2 explained that since she had a lot of medications to administer, she did not want to take time in flushing water between each medication. LVN 2 stated she sometimes administers water between each medication, but only if the medication is sticky. LVN 2 stated it is important to administer water between each medication to prevent the medications from clogging the GT. During an interview, on 10/20/2023, at 12:05 p.m., the DON stated the GT needed to be flushed with 5 ml to 10 ml of water between each medication to make sure there are no drug interactions than could negative affect Resident 22 and to prevent the GT from clogging. On 10/20/2023, at 4:55 p.m., during an interview, the MD stated flushing the GT with water between and after medication administration was a standard practice. The MD stated administering water is done to make sure the medication is distributed properly, if water is not flushed between each medication, it was possible residual medication (in the tubing) would not reach its destination. A review of the facility's P&P titled, Gastrostomy Tube Water Flush, reviewed 1/26/2023, indicated to flush 5 ml to 10 ml between each medication or per physician's order. A review of the facility's P&P on Medication Pass Via GT / JT, reviewed on 1/26/2023, indicated to flush the tube as ordered before and after medication administration. The P&P further indicated adults are given medications as ordered one at a time with 5 ml to 10 ml in between each medication or as per physician's orders. 38552 3. A review of Resident 68's Admission Record indicated the facility admitted the resident on 10/28/2019 with diagnoses including anoxic brain damage, tracheostomy, and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 68's H&P exam, dated 3/1/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 68's MDS, dated [DATE], indicated the resident had severely impaired cognition, had a GT for feeding, and was dependent on staff with all ALDs. A review of the Physician's Orders for Resident 68, ordered on 3/1/2023, indicated to administer Robinul 2 mg via GT, every 8 hours for secretions. A review of Resident 68's Care Plan developed on 4/17/2023 for the resident's excessive (respiratory) secretions requiring Robinul every 8 hours, had a goal for the resident to always have patent (unobstructed) airway. The interventions included to give medications as ordered. On 10/18/2023, at 8:14 a.m. during a medication administration observation LVN 3 prepared for Resident 68 a total of six medications in tablet form including Robinul. At 8:18 a.m., LVN 3 crushed each tablet in a separate plastic packet and placed each crushed medication into separate medicine cups. At 8:23 a.m., LVN 3 placed medicine tray with the six medication cups on top of overbed side table and poured about 10 ml of water inside each medicine cup. At 8:27 a.m., LVN 3 attached the piston syringe hollow barrel to the GT and removed the syringe plunger before administering the medications. LVN 3 shook each medicine cup before pouring the content in the syringe barrel. At 8:36 a.m., during an interview, LVN 3 stated she completed the medication administration for Resident 68. There were three medicine cups with residual crushed medications. LVN 3 stated one of the cups contained the Robinul. LVN 3 stated some of the crushed tablets stuck to the bottom of the cup. LVN 3 stated she did not know how much of the Robinul was left in the medicine cup, but it seemed a lot. LVN 3 stated she was going to dispose of it. At 8:38 a.m., LVN 3 proceeded to sign Resident 68's MAR indicating the six medications were given. During an interview on 10/20/2023 at 4:06 p.m., the DON stated that after administering medication, LNs must check the medicine cup to ensure there is no medication remaining and the residents receive the ordered dose. The DON stated LNs may use apple sauce so the crushed medications would not stick on the bottom of the medicine cup and may use a spoon or a coffee stirrer to stir the medication. The DON stated Resident 68 did not receive the ordered dose of Robinul and it was possible for Resident 68 to have increased respiratory secretions, which may lead to respiratory distress, coughing, or aspiration. On 10/20/2023 at 4:55 p.m., during an interview, the MD stated sometimes anticholinergic medications are given due to the excess secretion or for bradycardia (slow heart rate). The MD stated when anticholinergics are not administered correctly the resident may need to be suctioned (removal of secretions from the airway using a suction machine). A review of the facility's policy and procedure titled, Medication Rights, reviewed and approved 1/26/2023, indicated it is the facility's policy to make sure that licensed nurses follow the updated guidelines for the Patient Medication Rights. The procedure indicated: 3. Right Dose - compare the dose of the medication to the MAR. 6. Right Documentation - the documentation of the medication must be done at the time that you give the medications. A review of the facility's policy and procedure on Medication Pass via GT / JT, reviewed on 1/26/2023, indicated it was the facility's policy to make sure that nursing would follow the policy of giving medications. The procedures indicated to ensure all medication is given and not remaining in the cup.

Based on interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 1), who was in a vegetative (a coma-like state characterized by open eyes and the appearance of wakefulness) state and was totally dependent on staff for activities of daily living (ADL) was kept free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) when Resident 1 was left with no supervision and monitoring in place while undergoing a hemodialysis (HD-a process of purifying the blood of a person whose kidneys are not working normally through a machine that removes blood from your body, filters it through a dialyzer [artificial kidney] and returns cleaned blood back to the body) treatment . On [DATE], [CONDITION(S)] Technician 1 (DT 1) left Resident 1, who was in Bed A at 5:05 p.m., with no supervision and monitoring. DT 1 went to Resident 2 in Bed C (same room) to clean and disinfect Resident 2's hemodialysis machine as the resident had completed their treatment at approximately 5:05 p.m. On [DATE] at 5:22 p.m., DT 1 returned to Resident 1 beside after cleaning Resident 2's hemodialysis machine and observed Resident 1 with a dislodged venous needle (when the needle slips out and returning blood is pumped onto the bed or floor instead of back to the patient's bloodstream) with a pool of Resident 1's blood on the mattress and on the floor. These deficient practices resulted in a delay in care and interventions as Resident 1 continued to lose a large amount of blood leading to Resident 1's death on [DATE] at 5:59 p.m. On [DATE] at 5:05 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) situation for the facility's negligent action of leaving Resident 1 unattended while undergoing HD treatment in the presences of the Administrator (ADM) and the Director of Nursing (DON). On [DATE] at 5:20 p.m., the SSA notified the ADM, DON, Vice President for Operations, Infection Preventionist Nurse (IPN), and Director of Staff Development (DSD) that the IJ situation was not removed, while onsite, after the facility submitted an IJ Removal Plan that was not accepted. On [DATE] at 2:56 p.m., after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy while onsite, in the presence of ADM and DON. The acceptable IJ Removal Plan for F600 included the following: [CONDITION(S)] RN and PCT who were responsible for the care of Resident 1 and were made Do not send to ASHC permanently. The contracted [CONDITION(S)] company immediately replaced both disciplines with new staff. The new [CONDITION(S)] staff were in serviced on abuse prevention and neglect of ASHC [CONDITION(S)] residents on [DATE], by the Director of Staff Development. All residents were assessed for the proper delivery of services on [DATE] by the Director of Nurses. Additional structural changes have been implemented which will make [CONDITION(S)] delivery safe as ordered by the physician. Abuse prevention, neglect, and mandated reporting in-service began [DATE] by the Director of Staff Development and will conclude on [DATE]. Staff who are unable to attend these in-services will be in-serviced upon their return to work. The following actions were implemented for resident [CONDITION(S)] safety and abuse prevention and neglect: HD RN will perform the following tasks: o All walkie talkies/cellphones are fully charged and tested every morning prior to [CONDITION(S)] of the residents. o The walkie talkie/cellphones will be assigned to each PCT and [CONDITION(S)] RN. The PCT will remain at the bedside of the [CONDITION(S)] resident at all times to visually monitor the resident's [CONDITION(S)] and access site. PCT will troubleshoot the [CONDITION(S)] machine within their scope of practice, monitor the resident's response to treatment, and alert the [CONDITION(S)] RN of any change of condition. The PCT will not leave the [CONDITION(S)] resident's bedside unless cleared to do so by the [CONDITION(S)] RN. [CONDITION(S)] RN will complete a pre-treatment line-of-sight checklist to ensure all equipment is properly arranged, and PCT is stationed in such a way that proper lines of sight and monitoring are ensured. Line of Sight protocols have been installed by the [CONDITION(S)] Provider to include the requirement to call for assistance whenever PCT or personnel activities during an active treatment momentarily prevent the assigned personnel from maintaining direct line of sight with the [CONDITION(S)] access of any actively treating patient. PCT may also request such assistance from available ASHC staff who have been adequately in-serviced for basic safety and coordination of care of [CONDITION(S)] patients. The PCT/RN began in-servicing on [DATE], by the Director of Staff Development to alert all staff shouting Code RT in the event of an emergency. Findings: a. A review of Resident 1's Admission Record indicated the facility admitted the resident on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool), dated [DATE], indicated the resident was in a persistent vegetative state and was totally dependent on staff with activities of daily living (ADL) such as bed mobility, dressing, toilet use, personal hygiene, and bathing. A review of Resident 1's Physician`s Order summary indicated an order dated [DATE] for Hemodialysis by CDP 1 every Monday, Wednesday, and Friday. A review of Resident 1's [CONDITION(S)] Order dated [DATE], indicated the following: o Order type: Home Hemodialysis (HHD) o Dialyzer (artificial kidney): F200NR (a type of dialyzer used for hemodialysis) o - Duration: 3 hours and fifteen minutes o Blood flow rate: 400 milliliters per minute (ml/min- unit of measure) o [MEDICATION(S)] flow rate: 500 ml/min o Access: primary AV fistula (left upper arm) o Needle gauge (refers to the inner measurement or opening of the needle) arterial (removes blood from the body to the machine): 15 o Needle gauge venous (returns blood from the machine to the body): 15 o Code status: Full Code (if a person's heart stopped beating and/or they stopped breathing, all procedures will be provided to keep them alive ) A review of Resident 1's HHD Treatment Flowsheet, dated [DATE], indicated the following: o [CONDITION(S)] treatment ended on [DATE] at 5:25 p.m. with BP reading of ,d+[DATE] mmHg and PR of 41 bpm with notes indicating [CONDITION(S)] RN documented that venous needle was noticed out (venous needle dislodgment) with no alarms triggered , blood was noted on bed, and blood was reinfused (returned) with 500 ml of NS. o [CONDITION(S)] treatment ended on [DATE] at 5:25 p.m. with BP reading of ,d+[DATE] mmHg and PR of 41 bpm with notes indicating [CONDITION(S)] RN documented that venous needle was noticed out (venous needle dislodgment) with no alarms triggered , blood was noted on bed, and blood was reinfused (returned) with 500 ml of NS. o On [DATE] at 5:29 p.m., a code (code blue - there is a medical emergency occurring) was called and the paramedics (a person trained to give emergency care to individuals who are injured or ill) were called through 911. Cardiopulmonary resuscitation (CPR - is an emergency lifesaving procedure performed when the heart stops beating through manual application of chest compressions and ventilations) was performed. o On [DATE] at 5:29 p.m., the treatment note indicated there was venous needle dislodgment, blood noted on the bed and floor. The note further indicated that staff was unable to give NS because the arterial needle dislodged. Paramedics arrived and took over the CPR, and Resident 1 expired on [DATE] at 5:29 p.m. A review of Resident 1's Nursing Progress Notes (Evaluation), dated [DATE], indicated the following: o On [DATE] at 5:30 p.m., [CONDITION(S)] RN 1 approached RN 3 and relayed that Resident 1 was bleeding and there is a need to call the paramedics through 911. Charge Nurse and Medical Doctor 1 (MD 1) immediately went and assessed Resident 1 who was noted with significant bleeding and [CONDITION(S)] (low blood pressure). BP was ,d+[DATE] mmHg and heart rate greater than 120 bpm. MD 1 immediately gave an order to call 911. Charge Nurse called 911 right away. o On [DATE] at 5:31p.m., a code (code blue) was called on Resident 1, vital signs (clinical measurements, specifically blood pressure, pulse rate, respiration rate, and temperature, that indicate the state of a patient's essential body functions) were not appreciated (measured), Primary Nurse and Respiratory Therapist 1 (RT 1) began chest compressions and manually bagging (giving ventilations to the patient during CPR) while waiting for the paramedics to arrive. o On [DATE] at 5:35 p.m., the paramedics arrived at the scene and took over the care of Resident 1. o On [DATE] at 5:59 p.m., the paramedics pronounced Resident 1 had expired (died ). Time of death was 5:59 p.m. b. A review of Resident 2's Admission Record indicated the facility admitted the resident on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding for daily decision-making) were moderately impaired, and the resident was totally dependent on staff with ADLs like bed mobility, dressing, toilet use, personal hygiene, and bathing. A review of Resident 2's physician`s order summary dated [DATE] indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's HHD Treatment Flowsheet, dated [DATE], indicated the following: o [CONDITION(S)] treatment started on [DATE] at 2:35 p.m. o [CONDITION(S)] treatment ended on [DATE] at 5:05 p.m. On [DATE] at 1:58 p.m., during an interview, DT 1 stated there were four [CONDITION(S)] technicians and one [CONDITION(S)] RN on [DATE] for the entire building. [CONDITION(S)] Technician stated her job description included preparing the [CONDITION(S)] machine, testing if the alarms were working, staying in the room with the residents the whole time while [CONDITION(S)] is on-going, and monitoring their BP and PR. DT 1 stated she was assigned to dialyze Resident 1 in bed A and Resident 2 in bed C in the same room, with an empty bed B (no resident). DT 1 stated Resident 1 had an AV Fistula on the left upper arm and was positioned next to the door while the machine was on the other side of the bed, and the [CONDITION(S)] machine lines placed on top of the resident`s body. DT 1 stated she was cleaning and disinfecting the machine of Resident 2 in bed C, took out the dialyzer and discarded them into the biohazard trash, and cleaned the blood pressure cuff. DT 1 stated that after cleaning the machine in Bed C, she then went back to check on Resident 1, and that is when she saw Resident 1 bleeding. DT 1 stated she first texted [CONDITION(S)] RN 1, then applied pressure on the venous access after removing the venous needle because a small part was still inside the venous access. DT 1 stated [CONDITION(S)] RN 1 came into the room and gave 500 ml of NS to Resident 1. DT 1 stated she should have monitored Resident 1 throughout the treatment time and should not have left Resident 1 to clean the [CONDITION(S)] machine of Resident 2. DT 1 stated she could have alerted [CONDITION(S)] RN 1 sooner upon the dislodgement of the HD access site for Resident 1, before the resident had lost significant amount of blood if she had only focused on Resident 1. On [DATE] at 2:50 p.m., during an interview, RN 3 stated that on [DATE], around 5:30 p.m., [CONDITION(S)] RN 1 told him to call 911 immediately. RN3 stated he and MD 1 went to Resident 1's room to assess the resident and observed blood on Resident 1's gown. RN 3 stated that Resident 1 was noted with BP reading of ,d+[DATE] mmHg. RN 3 stated that he immediately went back to the nursing station to call 911 per MD 1 order. RN 3 stated there was no call light activated during this emergency. On [DATE] at 3:14 p.m., during an interview, [CONDITION(S)] RN 1 stated he was in the [CONDITION(S)] storage room (approximately 245 feet from Resident 1's room) charting when DT 1 texted him at 5:22 p.m. saying emergency come (meaning there was an emergency and to come to the room). [CONDITION(S)] RN 1 stated that when he got to Resident 1's room in around two minutes, he observed the resident's [CONDITION(S)] machine alarming, [CONDITION(S)] RN 1 stated that Resident 1's blood was observed on the bed and on the floor with DT 1 applying pressure on Resident 1's left upper arm AV fistula site with a gauze (thin fabric). On [DATE] at 11:21 a.m., during an interview, RT 1 stated that on [DATE] sometime around 5:20 p.m., she entered the Resident 1's room. RT 1 stated that she observed Resident 1in bed A with [CONDITION(S)] staff ([CONDITION(S)] RN 1 and [CONDITION(S)] Technician 1) working on the left side of Resident 1. RT 1 stated she saw blood on the side where the [CONDITION(S)] staff were working. RT 1 stated she then called RT (this is the facility's version of Code Blue), visually assessed Resident 1, grabbed gloves, and started CPR until the paramedics arrived. On [DATE] at 8:17 a.m., during an interview, [CONDITION(S)] RN 1 stated the last time he was in Resident 1's room was at 5:05 p.m. [CONDITION(S)] RN 1 stated that he remembered the time specifically because that was the time Resident 1's roommate (Resident 2) finished the hemodialysis treatment. [CONDITION(S)] RN 1 stated he then went to check on the other residents with ongoing [CONDITION(S)] at that time, however, was unable to identify the residents he checked on. [CONDITION(S)] RN 1 stated that after checking on the other residents, he returned to the [CONDITION(S)] storage room to complete his documentation. [CONDITION(S)] RN 1 stated he did not know what time Resident 1's venous needle dislodgment occurred. [CONDITION(S)] RN 1 stated that Resident 1 was okay when he left the room at 5:05 p.m. [CONDITION(S)] RN 1 stated that when he was called into Resident 1's room due to an emergency, he was able to infuse 500 ml of NS to Resident 1 using the arterial needle. [CONDITION(S)] RN 1 then stated that he went out of Resident 1's room to inform facility staff to call 911. [CONDITION(S)] RN 1 stated that he then went back and tried giving one liter of NS to Resident 1 but could not anymore give the NS because the arterial line had clotted (when blood turns from a liquid form to a thickened mass allowing flow of NS to the body). [CONDITION(S)] RN stated that at 5:59 p.m. (on [DATE]), he told DT 1 to stop holding pressure on Resident's left upper arm AV fistula access, which was not anymore taped, because there was no more blood coming out. On [DATE] at 2:07 p.m., during an interview, RN 3 stated it was a horrifying incident because there was so much blood loss from Resident 1 that a puddle of blood began to form on the floor next to the resident. RN 3 stated that facility staff were informed late regarding Resident 1 bleeding out by the [CONDITION(S)] staff (DT 1 and [CONDITION(S)] RN 1). RN 3 stated that had [CONDITION(S)] staff informed the facility sooner, they could have reacted sooner and possibly made a difference. On [DATE] at 3:03 p.m., during an interview, the DON stated that it will be best if the staffing ratio was one [CONDITION(S)] technician to one resident and the [CONDITION(S)] staff should only focus on one resident. The DON stated that the [CONDITION(S)] staff (DT 1 and [CONDITION(S)] RN) failed to call the facility staff for help immediately upon discovering Resident 1 bleeding out from the HD access site dislodgement. DON stated that had facility staff been informed sooner, it could have meant the difference between life and death for Resident 1. The DON stated there was a failure in the communication system between the [CONDITION(S)] staff and the facility staff in addressing this [CONDITION(S)] emergency. On [DATE] at 4:05 p.m., during an interview, MD 1 stated that he was the primary physician of Resident 1, and he was informed on [DATE] at around 5:30 p.m. about Resident 1 needing emergency care. MD 1 stated he went inside Resident 1's room and gave an order to call 911 because there was already so much blood loss. MD 1 stated residents on hemodialysis needed to be observed at all times. On [DATE] at 4:52 p.m., during an interview, DT 1 stated when she was cleaning and disinfecting the [CONDITION(S)] machine of Resident 2 in bed C, [CONDITION(S)] RN 1 was not anymore inside the room, and nobody was looking at Resident 1 with an on-going hemodialysis treatment. DT 1 stated she did not know at what time the venous needle dislodgment happened because there were instances when she was not looking at Resident 1. DT 1 stated she did not call help from any facility staff and did not use the call light button. DT 1 stated had [CONDITION(S)] RN 1 or another [CONDITION(S)] technician been there inside the room, this incident could have been prevented. DT 1 stated it was her mistake and that she should have waited for Resident 1's hemodialysis treatment to finish before cleaning Resident 2's [CONDITION(S)] machine. DT 1 stated she panicked. On [DATE] at 11:07 a.m., during an interview, the DON stated that at the time this incident happened, DT 1 could have called the code RT to alert every staff of the emergency. The DON stated she did not know if [CONDITION(S)] Technician 1 was aware of the facility's emergency protocol which was to shout RT. The DON stated the facility did not provide in-service trainings to these [CONDITION(S)] technicians and presumed [CONDITION(S)] RN 1, as the supervisor for all of the [CONDITION(S)] technicians, should have in-serviced them. The DON stated it was neglect because DT 1 did not attend to Resident 1. A review of the facility's current policy and procedure titled, Reporting of Alleged Abuse, Neglect and Involuntary Seclusion, reviewed on ,d+[DATE], indicated, Neglect means: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The DSD was unable to provide any additional policy and procedures related to abuse.

Based on interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 1), who required hemodialysis (HD or [CONDITION(S)]- a process of purifying the blood of a person whose kidneys are not working normally through a machine that removes blood from your body, filters it through a dialyzer [artificial kidney] and returns cleaned blood back to the body) treatment, received care in accordance with standards of practice by: 1. Failing to ensure Resident 1 was monitored and supervised with visual observation of their Arteriovenous Fistula (AV fistula - connection between an artery [blood vessel that carries blood from the heart to tissues and organs] and a vein [blood vessel that carries blood to the heart] used as an access point for hemodialysis on the left upper arm while having an on-going hemodialysis treatment. On [DATE], [CONDITION(S)] Technician 1 (DT 1) left Resident 1, who was in Bed A at 5:05 p.m., with no supervision and monitoring, DT 1 went to Resident 2 in Bed C (same room) to clean and disinfect Resident 2's hemodialysis machine as the resident had completed their treatment at approximately 5:05 p.m. On [DATE] at 5:22 p.m., DT 1 returned to Resident 1's beside after cleaning Resident 2's hemodialysis machine and observed Resident 1 with a dislodged venous needle (when the needle slips out and returning blood is pumped onto the bed or floor instead of back to the patient's bloodstream) with a pool of Resident 1's blood on the mattress and on the floor. 2. Failing to ensure DT 1 called out for help and informed facility staff regarding Resident 1's condition after DT 1 saw Resident 1's venous needle dislodgment. On [DATE] at 5:22 p.m., DT 1, after seeing Resident 1's blood dripping on the mattress and on the floor, did not call or use the call light button to ask for help and inform any facility staff. Instead, DT 1 texted the [CONDITION(S)] Registered Nurse 1 ([CONDITION(S)] RN 1), who was at the [CONDITION(S)] Storage Room doing his documentation, to come because there was an emergency. On [DATE] at 5:25 p.m., the [CONDITION(S)] RN 1 came and infused 500 milliliters (ml - unit of measurement for fluids) of Normal Saline (NS - fluid infused into a vein to increase fluid volume inside the body). [CONDITION(S)] RN 1 then went out of the room to the nurses' station and informed Registered Nurse 3 (RN 3-facility's RN) on [DATE] at 5:30 p.m. RN 3 went to Resident 1's room and upon seeing the large amount of blood, called the paramedics (a person trained to give emergency care to individuals who are injured or ill) through 911 on [DATE] at 5:30 p.m. The paramedics arrived on [DATE] at 5:35 p.m. 3. Failing to ensure there was a communication system in place between the [CONDITION(S)] staff and facility staff when Resident 1 had a venous needle dislodgement so that immediate actions can be undertaken to save Resident 1's life. 4. Failing to ensure the facility's contracted [CONDITION(S)] provider (CDP 1) conducted in-service trainings to the facility staff regarding HD as indicated in the facility's contract agreement with CDP 1. In an interview, on [DATE] at 2:07 p.m., RN 3 stated that this incident (so much blood loss on the mattress and on the floor) was horrifying, and he was never given an in-service training on how to handle this kind of situation. 5. Failing to give in-service trainings to the [CONDITION(S)] technicians with the facility's emergency protocols. These deficient practices resulted in a delay in care and interventions as Resident 1 continued to lose a large amount of blood leading to Resident 1's death on [DATE] at 5:59 p.m. On [DATE] at 5:05 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) situation for the facility's failure to provide safe [CONDITION(S)] treatment that met professional standards of practice in the presences of the Administrator (ADM) and the Director of Nursing (DON). On [DATE] at 5:20 p.m., the SSA notified the ADM, DON, Vice President for Operations, Infection Preventionist Nurse (IPN), and Director of Staff Development (DSD) that the IJ situation was not removed, while onsite, after the facility submitted an IJ Removal Plan that was not accepted. On [DATE] at 2:56 p.m., after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy while onsite, in the presence of ADM and DON. The acceptable IJ Removal Plan for F698 included the following: [CONDITION(S)] RN and PCT who were responsible for the care of Resident 1 were made a Do Not Send to ASHC permanently. The contracted [CONDITION(S)] company immediately replaced both disciplines HD RN and PCT with new staff. The new [CONDITION(S)] staff were in-serviced on the expectations and responsibilities to ASHC [CONDITION(S)] residents. The HD RN and HD PCT job responsibilities are appended to this IJ removal plan. The contracted hemodialysis provider RN in-serviced the ASHC licensed staff on [DATE], on the following [CONDITION(S)] protocols: Hemodialysis equipment, Communication, Infection Control, Vascular access including external catheters and internal grafts and fistulas, Emergencies, including access bleeding and catheter dislodgment, Central Line access in service trainings were conducted by the hemodialysis RN and concluded on [DATE]. On [DATE], and [DATE], the Staff Developer initiated the following training in services: Emergency Procedures, Cardiopulmonary arrest, Blood loss, [CONDITION(S)], Hemo-[CONDITION(S)] dressing assessment and removal, Assess bruit and thrill of AV Fistula of [CONDITION(S)] patients, no AV fistula resident as of [DATE]. In-services were provided to the [CONDITION(S)] RNs and HD PCTs on the care, responsibilities, and expectations of [CONDITION(S)] residents during treatment. This includes line-of-sight policies during [CONDITION(S)]. The in-services were completed [DATE]. ASHC primary licensed RN's and LVN's round on their assigned residents who are receiving [CONDITION(S)] treatment during their shift, assisting in communication with the PCT, [CONDITION(S)] RN, Primary Nurse, Charge Nurse, and DON. The HD RN remains at all times in the HD treatment room of the resident during their [CONDITION(S)] treatment session. All licensed Nurses and Respiratory Therapists assigned to the adult unit are required to maintain ACLS certification as a condition of employment. ASHC licensed nurse will document on a pre [CONDITION(S)] check tool the following: 1. All walkie talkies are fully charged and tested every morning prior to [CONDITION(S)] of the residents. 2. The walkie talkie will be assigned to each PCT and [CONDITION(S)] RN. This will be documented on the pre-[CONDITION(S)] Check List tool. The in-room treatment HD RN will ensure the HD PCT remains with his/her assigned residents. The HD RN is immediately available to the HD resident along with the HD PCT since the HD RN is in room with the HD PCT at all times. [CONDITION(S)] residents in the same room receiving [CONDITION(S)] at the same time will be placed next to each other in a three resident room to provide a clear line of site for observation by the PCT, [CONDITION(S)] RN. The PCT will remain at the bedside of the [CONDITION(S)] resident at all times to visually monitor the resident's [CONDITION(S)] and access site. The PCT will not leave the [CONDITION(S)] resident's bedside unless cleared to do so by the [CONDITION(S)] RN. [CONDITION(S)] RN will complete a pre-treatment line-of-sight checklist to ensure all equipment is properly arranged, and PCT is stationed in such a way that proper lines of sight and monitoring are ensured. Line of Sight protocols have been installed by the [CONDITION(S)] Provider to include the requirement to call for assistance whenever HD PCT or personnel activities during an active treatment momentarily prevent the assigned HD personnel from maintaining direct line of sight with the [CONDITION(S)] access of any actively treating patient. HD PCT notifies HD RN for assistance when needed. HD RN continues the Line-of-Sight protocol. Available ASHC staff who have been adequately in-serviced for basic safety and coordination of the care of [CONDITION(S)] with Line-of-Sight assistance. The PCT/HD RN will alert all staff shouting Code RT in the event of an emergency. Effective [DATE] the facility ensures the residents undergoing hemodialysis are monitored and supervised at all times by the HD RN with good visual observation of the hemodialysis access by the HD RN who supervises the HD PCT in the treatment room. ASHC licensed primary nurse rounds on their assignments in their designated area and observes that the HD RN is in the treatment room. 1 [CONDITION(S)] Registered Nurse (RN) per treatment room, and 1 Patient Care Technician (PCT) per patient being treated at any time. The contracted hemodialysis provider is committed to maintaining care for these residents. In the event the contracted hemodialysis provider is unable to provide services the remaining [CONDITION(S)] residents will safely accommodated at alternate providers the transfer plan is appended herein. Each Resident receiving hemodialysis will have a dedicated PCT at bedside supervised by a hemodialysis RN, who shall be present in the treatment room where the residents are receiving [CONDITION(S)] and will be available to respond to concerns or emergencies that may occur during the residents' hemodialysis treatment. Additionally, the facility charge nurse and primary nurse are immediately available to assist the hemodialysis staff. No more than 4 bedrooms will have actively treating [CONDITION(S)] patients at any given time, and no more than 2 [CONDITION(S)] patients treated in a single bedroom at a time. Patients may only be treated in their bedrooms, with service being provided at their bedside, to prevent unnecessary transportation of the resident. When non-[CONDITION(S)]-related care is performed by ASHC staff for a patient who is actively being dialyzed, the PCT and HD RN must monitor the patients closely observe the patient's [CONDITION(S)] access site and condition until the non-[CONDITION(S)]-related care is complete. [CONDITION(S)] provider will ensure that blood leak detection devices are used for all AV Fistula patients as an extra safety precaution to audibly alert personnel who are monitoring in the room. HD residents are assigned to rooms that will have a maximum of two (2) HD residents per room in a 3 bedroom. The HD residents will be assigned to beds that are immediately adjacent to each other. (Beds A & B or Beds B & C). The HD residents remain in their assigned room during [CONDITION(S)] treatment. Mock codes will be performed quarterly to assess the staff understanding and competency during emergencies. Findings: a. A review of Resident 1's Admission Record indicated the facility admitted the resident on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool), dated [DATE], indicated the resident was in a persistent vegetative (a coma-like state characterized by open eyes and the appearance of wakefulness) state and was totally dependent on staff with activities of daily living (ADL) such as bed mobility, dressing, toilet use, personal hygiene, and bathing. A review of Resident 1's Physician`s Order summary indicated an order dated [DATE] for Hemodialysis by CDP 1 every Monday, Wednesday, and Friday. A review of Resident 1's [CONDITION(S)] Order dated [DATE], indicated the following: o Order type: Home Hemodialysis (HHD) o Dialyzer (artificial kidney): F200NR (a type of dialyzer used for hemodialysis) o - Duration: 3 hours and fifteen minutes o Blood flow rate: 400 milliliters per minute (ml/min- unit of measure) o [MEDICATION(S)] flow rate: 500 ml/min o Access: primary AV fistula (left upper arm) o Needle gauge (refers to the inner measurement or opening of the needle) arterial (removes blood from the body to the machine): 15 o Needle gauge venous (returns blood from the machine to the body): 15 o Code status: Full Code (if a person's heart stopped beating and/or they stopped breathing, all procedures will be provided to keep them alive ) A review of Resident 1's HHD Treatment Flowsheet, dated [DATE], indicated the following: o [CONDITION(S)] treatment started on [DATE] at 2:01 p.m. with blood pressure (BP- normal BP is ,d+[DATE] mmHg)) reading of ,d+[DATE] milliliter of mercury (mmHg - a unit of pressure used in measuring blood pressure) and pulse rate (PR - normal PR ,d+[DATE] beats per minute [bpm]) of 89 bpm. o [CONDITION(S)] treatment ended on [DATE] at 5:25 p.m. with BP reading of ,d+[DATE] mmHg and PR of 41 bpm with notes indicating [CONDITION(S)] RN documented that venous needle was noticed out (venous needle dislodgment) with no alarms triggered , blood was noted on bed, and blood was reinfused (returned) with 500 ml of NS. o On [DATE] at 5:29 p.m., a code (code blue - there is a medical emergency occurring) was called and the paramedics were called through 911. Cardiopulmonary resuscitation (CPR - is an emergency lifesaving procedure performed when the heart stops beating through manual application of chest compressions and ventilations) was performed. o On [DATE] at 5:29 p.m., the treatment note indicated there was venous needle dislodgment, blood noted on the bed and floor. The note further indicated that staff was unable to give NS because the arterial needle dislodged. Paramedics arrived and took over the CPR, and Resident 1 expired on [DATE] at 5:29 p.m. A review of Resident 1's Nursing Progress Notes (Evaluation), dated [DATE], indicated the following: o On [DATE] at 5:30 p.m., [CONDITION(S)] RN 1 approached RN 3 and relayed that Resident 1 was bleeding and there is a need to call the paramedics through 911. Charge Nurse and Medical Doctor 1 (MD 1) immediately went and assessed Resident 1 who was noted with significant bleeding and [CONDITION(S)] (low blood pressure). BP was ,d+[DATE] mmHg and heart rate greater than 120 bpm. MD 1 immediately gave an order to call 911. Charge Nurse called 911 right away. o On [DATE] at 5:31p.m., a code (code blue) was called on Resident 1, vital signs (clinical measurements, specifically blood pressure, pulse rate, respiration rate, and temperature, that indicate the state of a patient's essential body functions) were not appreciated (measured), Primary Nurse and Respiratory Therapist 1 (RT 1) began chest compressions and manually bagging (giving ventilations to the patient during CPR) while waiting for the paramedics to arrive. o On [DATE] at 5:35 p.m., the paramedics arrived at the scene and took over the care of Resident 1. o On [DATE] at 5:59 p.m., the paramedics pronounced Resident 1 had expired (died ). Time of death was 5:59 p.m. b. A review of Resident 2's Admission Record indicated the facility admitted the resident on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding for daily decision-making) were moderately impaired, and the resident was totally dependent on staff with ADLs like bed mobility, dressing, toilet use, personal hygiene, and bathing. A review of Resident 2's physician`s order summary dated [DATE] indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's HHD Treatment Flowsheet, dated [DATE], indicated the following: o [CONDITION(S)] treatment started on [DATE] at 2:35 p.m. o [CONDITION(S)] treatment ended on [DATE] at 5:05 p.m. On [DATE] at 1:58 p.m., during an interview, DT 1 stated there were four [CONDITION(S)] technicians and one [CONDITION(S)] RN on [DATE] for the entire building. [CONDITION(S)] Technician stated her job description included preparing the [CONDITION(S)] machine, testing if the alarms were working, staying in the room with the residents the whole time while [CONDITION(S)] is on-going, and monitoring their BP and PR. DT 1 stated she was assigned to dialyze Resident 1 in bed A and Resident 2 in bed C in the same room, with an empty bed B (no resident). DT 1 stated Resident 1 had an AV Fistula on the left upper arm and was positioned next to the door while the machine was on the other side of the bed, and the [CONDITION(S)] machine lines placed on top of the resident`s body. DT 1 stated she was cleaning and disinfecting the machine of Resident 2 in bed C, took out the dialyzer and discarded them into the biohazard trash, and cleaned the blood pressure cuff. DT 1 stated that after cleaning the machine in Bed C, she then went back to check on Resident 1, and that is when she saw Resident 1 bleeding. DT 1 stated she first texted [CONDITION(S)] RN 1, then applied pressure on the venous access after removing the venous needle because a small part was still inside the venous access. DT 1 stated [CONDITION(S)] RN 1 came into the room and gave 500 ml of NS to Resident 1. DT 1 stated she should have monitored Resident 1 throughout the treatment time and should not have left Resident 1 to clean the [CONDITION(S)] machine of Resident 2. DT 1 stated she could have alerted [CONDITION(S)] RN 1 sooner upon the dislodgement of the HD access site for Resident 1, before the resident had lost significant amount of blood, if she had only focused on Resident 1. On [DATE] at 2:50 p.m., during an interview, RN 3 stated that on [DATE], around 5:30 p.m., [CONDITION(S)] RN 1 told him to call 911 immediately. RN3 stated he and MD 1 went to Resident 1's room to assess the resident and observed blood on Resident 1's gown. RN 3 stated that Resident 1 was noted with BP reading of ,d+[DATE] mmHg. RN 3 stated that he immediately went back to the nursing station to call 911 per MD 1 order. RN 3 stated there was no call light activated during this emergency. On [DATE] at 3:14 p.m., during an interview, [CONDITION(S)] RN 1 stated he was in the [CONDITION(S)] storage room (approximately 245 feet from Resident 1's room) charting when DT 1 texted him at 5:22 p.m. saying emergency come (meaning there was an emergency and to come to the room). [CONDITION(S)] RN 1 stated that when he got to Resident 1's room in around two minutes, he observed the resident's [CONDITION(S)] machine alarming, [CONDITION(S)] RN 1 stated that Resident 1's blood was observed on the bed and on the floor with DT 1 applying pressure on Resident 1's left upper arm AV fistula site with a gauze (a thin translucent fabric of silk, linen or cotton). On [DATE] at 11:21 a.m., during an interview, RT 1 stated that on [DATE], sometime around 5:20 p.m. she entered Resident 1's room. RT 1 stated that she observed Resident 1 in bed A with [CONDITION(S)] staff ([CONDITION(S)] RN 1 and DT 1) working on the left side of Resident 1. RT 1 stated she saw blood on the side where the [CONDITION(S)] staff were working. RT 1 stated she then called RT (this is the facility's version of Code Blue), visually assessed Resident 1, grabbed gloves, and started CPR until the paramedics arrived. On [DATE] at 8:17 a.m., during an interview, [CONDITION(S)] RN 1 stated the last time he was in Resident 1's room was at 5:05 p.m. [CONDITION(S)] RN 1 stated that he remembered the time specifically because that was the time Resident 1's roommate (Resident 2) finished the hemodialysis treatment. [CONDITION(S)] RN 1 stated he then went to check on four other residents with ongoing [CONDITION(S)] at that time, however, was unable to identify the residents he checked on. [CONDITION(S)] RN 1 stated that after checking on the other residents, he returned to the [CONDITION(S)] storage room to complete his documentation. [CONDITION(S)] RN 1 stated he did not know what time Resident 1's venous needle dislodgment occurred. [CONDITION(S)] RN 1 stated that Resident 1 was okay when he left the room at 5:05 p.m. [CONDITION(S)] RN 1 stated that when he was called into Resident 1's room due to an emergency, he was able to infuse 500 ml of NS to Resident 1 using the arterial needle. [CONDITION(S)] RN 1 then stated that he went out of Resident 1's room to inform facility staff to call 911. [CONDITION(S)] RN 1 stated that he then went back and tried giving one liter of NS to Resident 1 but could not anymore give the NS because the arterial line had clotted (when blood turns from a liquid form to a thickened mass allowing flow of NS to the body). [CONDITION(S)] RN 1 stated that at 5:59 p.m. (on [DATE]), he told DT 1 to stop holding pressure on Resident's left upper arm AV fistula access, which was not anymore taped, because there was no more blood coming out. On [DATE] at 2:07 p.m., during an interview, RN 3 stated it was a horrifying incident because there was so much blood loss from Resident 1 that a puddle of blood began to form on the floor next to the resident. RN 3 stated that facility staff were informed late regarding Resident 1 bleeding out by the [CONDITION(S)] staff (DT 1 and [CONDITION(S)] RN 1). RN 3 stated that had [CONDITION(S)] staff informed the facility sooner, they could have reacted sooner and possibly made a difference. RN 3 stated he did not receive any in-service trainings regarding complications during hemodialysis treatments and how to respond to hemodialysis emergencies. On [DATE] at 3:03 p.m., during an interview, the DON stated that it will be best if the staffing ratio was one [CONDITION(S)] technician to one resident and the [CONDITION(S)] staff should only focus on one resident. The DON stated that the [CONDITION(S)] staff (DT 1 and [CONDITION(S)] RN) failed to call the facility staff for help immediately upon discovering Resident 1 bleeding out from the HD access site dislodgement. DON stated that had facility staff been informed sooner, it could have meant the difference between life and death for Resident 1. The DON stated there was a failure in the communication system between the [CONDITION(S)] staff and the facility staff in addressing this [CONDITION(S)] emergency. In a concurrent record review of the Home [CONDITION(S)] Care Coordination and Services Agreement, dated [DATE], the DON stated the facility did not ensure CDP 1 provided the in-service trainings annually or as needed regarding hemodialysis to the facility staff. On [DATE] at 4:05 p.m., during an interview, MD 1 stated that he was the primary physician of Resident 1, and he was informed on [DATE] at around 5:30 p.m. about Resident 1 needing emergency care. MD 1 stated he went inside Resident 1's room and gave an order to call 911 because there was already so much blood loss. MD 1 stated residents on hemodialysis needed to be observed at all times. On [DATE] at 4:52 p.m., during an interview, DT 1 stated when she was cleaning and disinfecting the [CONDITION(S)] machine of Resident 2 in bed C, [CONDITION(S)] RN 1 was not anymore inside the room, and nobody was looking at Resident 1 with an on-going hemodialysis treatment. DT 1 stated she did not know at what time the venous needle dislodgment happened because there were instances when she was not looking at Resident 1. DT 1 stated she did not call help from any facility staff and did not use the call light button. DT 1 stated had [CONDITION(S)] RN 1 or another [CONDITION(S)] technician been there inside the room, this incident could have been prevented. DT 1 stated it was her mistake and that she should have waited for Resident 1's hemodialysis treatment to finish before cleaning Resident 2's [CONDITION(S)] machine. DT 1 stated she panicked. On [DATE] at 11:07 a.m., during an interview, the DON stated that at the time this incident happened, DT 1 could have called the code RT to alert every staff of the emergency. The DON stated she does not know if the [CONDITION(S)] Technicians were aware of the facility's emergency protocol which was to shout RT. The DON stated the facility did not provide in-service trainings to these [CONDITION(S)] technicians and presumed [CONDITION(S)] RN 1, as the supervisor for the [CONDITION(S)] technicians, should have in-serviced them. A review of the facility's current contract with CDP 1 titled, Home [CONDITION(S)] Care Coordination and Services Agreement, dated [DATE], indicated that CDP 1 shall provide in-service training annually and as needed to the staff of Facility with respect to the nursing . needs of the Home [CONDITION(S)] Patients. This training will include: . emergency response procedures to include bleeding A review of the facility`s current policy and procedure titled, Responsibility of [CONDITION(S)] Service, dated [DATE], indicated that the delivery of supplies, services, equipment, provision of care, and the continuity and coordination of care will be clearly delineated and agreed by the Facility and [CONDITION(S)] Service Company. The DON was asked for any additional policy's related to [CONDITION(S)] services, the facility was unable to provide any additional policy and procedures.

Based on interview and record review, the facility failed to provide the necessary care and services in accordance with its policy and procedure, and professional standards of practice for one of six sampled residents (Resident 1) by: 1.) Failing to ensure that facility staff verified the pharmacy label against the dispensed bottle of [MEDICATION(S)] (medication to lower blood pressure) to ensure the correct dosage of medication was being administered to Resident 1. 2.) Failing to ensure staff reported a change of condition to the physician when Resident 1 experienced six episodes of low blood pressure resulting with the residents [MEDICATION(S)] (medication to lower blood pressure) being held as indicated in the plan of care. These deficient practices resulted in Resident 1 receiving twelve (12) doses of the medication [MEDICATION(S)], that was ten (10) times the intended prescribed dose between the days 3/22/2021 to 3/26/2021, which could have resulted in severe health complications possibly leading to hospitalization and/or death. The failure of not notifying the physician of a change of condition with Resident 1 had the potential to delay necessary care and services and could have resulted in a decline in the resident's medical condition. On 5/11/2021 at 6:43 p.m., the State Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), the Director of Nursing (DON), and the Pediatric Unit Manager (PM) with regards to administering the incorrect dose of medication to Resident 1. On 5/14/2021 at 4:01 p.m., the ADM provided a Plan of Action (POA) for the health and safety of Resident 1, which included the following summarized actions: 1.) Staff checked the pharmacy label against the bottle label and performed drug calculations for administering the correct dose of [MEDICATION(S)] 40 micrograms (mcg-unit of measure) to ensure the right dose would be given to Resident 1. A Change of direction label was obtained, and staff verified that the physician's order, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility staff notified the on-call physician of the medication error. Resident 1 had been receiving [MEDICATION(S)] 400 mcg, rather than the correct ordered dose of [MEDICATION(S)] 40 mcg. Staff informed the on-call physician of Resident 1's medication [MEDICATION(S)] 2.5 milligrams (mg-unit of measure) was held due to blood pressures being below the ordered parameters. The physician instructed the facility staff to ensure the administration of the correct dose of [MEDICATION(S)] 40 mcg, have the [MEDICATION(S)] bottle label corrected, and continue to monitor Resident 1. 2.) The assessment of Resident 1 found no changes affecting level of consciousness. The baseline of Resident 1's consciousness is a semi-comatose state (lack of consciousness, disoriented). Each assigned primary nurse monitored the vital signs of Resident 1 every two (2) hours to identify any adverse reactions to the high dose of [MEDICATION(S)], which can include increased sedation, low heartrate, low respiratory rate, and decrease in blood pressure. 3.) On 3/30/2021, an audit was done for all residents using the medication [MEDICATION(S)], with the assistance of the facility's contracted pharmacy, and in collaboration of the Pediatric Unit Manager (PM) and the Director of Nursing (DON). 4.) In-service training was provided to the nurses administering medications on the instructions of how to perform the medication administration rights by verification of Right patient, right time, right route, right dose, right medication, right documentation when new or refill medications are delivered from the pharmacy. The instructions for administration and concentration of medications are verified with the physician's order in the residents' charts, and the medication label is audited for accuracy. On 5/14/2021 at 4:34 p.m., while onsite and confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON. Findings: A record review of Resident 1's Record of Admission indicated an admitted [DATE]. List of Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 4/1/2021 indicated that Resident 1 is severely impaired with thought process and decision-making tasks. Further review of the MDS indicated that Resident 1 required total dependence from staff for bed mobility (turning side to side), transfers (moving from bed to chair), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene. A record review of the Physician's Orders for Resident 1 dated 3/22/2021 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Physician's Orders dated 3/22/2021 include [MEDICATION(S)] 2.5 mg. Resident 1's [MEDICATION(S)] 2.5 mg is to be administered every four (4) hours via J-tube with the instructions for parameters to hold when the blood pressure is below ninety over sixty (90/60) indicated for Resident 1's hypertension. On 5/11/2021 at 1:30 p.m., during interview with the Pediatric Nurse Manager (PM), PM indicated that Resident 1's correct calculated dose of [MEDICATION(S)] should have been 0.4 milliliter (ml-unit of measure) to equal the prescribed dose of [MEDICATION(S)] 40 mcg every eight hours. PM stated that instead, Resident 1 received 4 ml of [MEDICATION(S)], equaling 400 mcg, or ten (10) times the prescribed dose. Concurrent record review with PM of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/12/2021 at 6:52 a.m., during a phone interview with Registered Nurse 1 (RN 1), RN 1 stated that when the pharmacy delivers the medications to the facility, the charge nurse (nursing supervisors) should verify the received medications delivered and sign to validate that the medications received were correct. RN 1 stated that the charge nurses would hand the medications to the medication administration nurse, who should also verify the medications are correct with the physician's orders. RN 1 indicated that Resident 1's medication error started with the pharmacy incorrectly labeling the residents [MEDICATION(S)] with instructions to provide 4 ml rather than 0.4 ml of the medication to equal 40 mcg. RN 1 stated that the receiving nurse, should have validated the received pharmacy label against the bottle label to ensure accurate dosage. RN 1 stated that they failed to do the calculation before administering the [MEDICATION(S)] medication to Resident 1 to ensure accurate dosage. RN 1 stated that they normally performed the drug calculation to check dosage amount but admitted to not doing it for this instance RN 1 stated that staff should be following the physician's orders and not the pharmacy label. RN 1 stated that the five rights for medication administration include the right resident, right medication, right dose, given at the right time, and administered through the right route (whether by mouth or j-tube). On 5/12/2021 at 11:52 a.m., during an interview with Registered Nurse 2 (RN 2), RN 2 stated that high doses of blood pressure medication, such as [MEDICATION(S)] 400 mcg administered to Resident 1, can lead to a change in condition due to [CONDITION(S)] (abnormally slow heart rate), and [CONDITION(S)] (low blood pressure). Concurrent record review with RN 2 confirmed that Resident 1 is also on the blood pressure medication [MEDICATION(S)] 2.5 mg given every four hours for hypertension. RN 2 stated that Resident 1's [MEDICATION(S)] has parameters to hold medication if the blood pressure (BP) is below the range ninety over sixty (90/60). RN 2 stated, between the dates 3/23/2021 to 3/26/2021, the same dates that Resident 1 was receiving the high dose of [MEDICATION(S)] 400 mcg, Resident 1's [MEDICATION(S)] medication was held a total of six (6) times due to blood pressure being below the prescribed parameter. Concurrent record review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/2021, medication [MEDICATION(S)] 2.5 mg was not administered to Resident 1 for the 2 a.m. scheduled dose due to Resident 1's BP being 82/57. On 3/25/2021, medication [MEDICATION(S)] 2.5 mg was not administered to Resident 1 for the 6 p.m. scheduled dose due to Resident 1's BP reading at 104/55. On 3/26/2021, medication [MEDICATION(S)] 2.5 mg was not administered to Resident 1 for the 2 a.m. scheduled dose due to Resident 1's BP being 90/52, and again at 10 a.m. due to BP being at 95/56. Record review of Resident 1's nursing notes titled 24 hour Nursing Flowsheet with RN 2 indicated that on the dates 3/23/2021, 3/24/2021, 3/25/2021, and 3/26/2021, there are no nursing notes that indicated staff informed Resident 1's Physician regarding change in condition of the residents episodes of low blood pressure resulting in [MEDICATION(S)] 2.5 mg not being administered. On 5/12/2021 at 1:16 p.m., during an interview with PM, PM stated Resident 1 received [MEDICATION(S)] 400 mcg and posed a risk for low blood pressure and lethargy (a state of inactivity or unresponsiveness). PM stated that Resident 1's physician is to be notified right away for any blood pressure medications not administered due to decrease in Resident 1's blood pressure. PM stated that Resident 1 encountered six total non-administered doses of [MEDICATION(S)] 2.5 mg, and that the nurses administering the medication to Resident 1 should have notified the supervisor nurses, who would then notify Resident 1's physician of the change in condition. PM indicated that if Resident 1's physician was notified; it is possible to have identified that Resident 1 was receiving a high dose of [MEDICATION(S)] 400 mcg sooner. On 5/13/2021 at 2:02 p.m., during an interview with the Pediatric Medical Director (PMD), PMD stated that if there is a change in the residents' blood pressure, PMD should expect a call from the facility staff as soon as it happens. PMD indicated that since Resident 1 received a high dose of blood pressure medicine, PMD would worry about Resident 1's blood pressure becoming low, requiring transfer to the hospital, and requiring extra fluids to stabilize Resident 1's blood pressure. On 5/14/2021 at 1:37 p.m., during an interview with the Vice President of Operations (VP), VP confirmed that they were aware of the incident where in Resident 1 received a total of twelve doses of [MEDICATION(S)] that was ten times the intended prescribed dose. VP stated that the [MEDICATION(S)] dose administered to Resident 1 posed a risk of death due to decreased heartrate and lack of blood circulation to the brain. A review of Resident 1's record titled Resident Care Plan dated 3/22/2021 indicated the concern Potential for episode of [CONDITION(S)] (low blood pressure) related to use of antihypertensive (blood pressure medicine). The care plan indicated for nursing to Refer any abnormal findings to MD (Doctor of Medicine) immediately for possible interventions. A record review of the facility policy titled Reporting Changes In Condition with last revised date of 3/2018 states, The purpose of reporting significant changes in status of a patient is to ensure timely communication of patient/resident health status to the attending Physician. The policy also indicated Criteria for Reporting Changes in Condition to Physician which includes, Hypertension or [CONDITION(S)]. A record review of the facility policy titled Medication Pass with effective date 6/8/2015, indicated the purpose of the policy is to provide a guideline on how to pass medication through the Gastrostomy (surgical opening on abdomen allowing food or medicine directly into the stomach)/Jejunostomy tube. Procedures include 1.) Follow the 5 Rights of giving medications & 2.) Give medications as ordered. Nursing procedure indicated to Check MD order. A record review of the facility policy titled Checking Parameters Before Administering Medication with effective date of 1/10/2020 indicated the goal to, To administer medication in a safe manner taking into consideration certain types of medication requiring parameter checks prior to administration. Procedure indicated for licensed nurses to check the five (5) rights of giving medication, Right patient, right medication, right dose, right time, and right route. The policy also states, List of medications includes, but is not limited to, any blood pressure medication.

Based on interview and record review, the facility failed to administer the correct dose of [MEDICATION(S)] (medication to lower blood pressure) to one of six sampled residents, (Resident 1). Resident 1 received twelve (12) doses of medication that was ten (10) times the intended prescribed dose between the days 3/22/2021 to 3/26/2021. This deficient practice severely compromised Resident 1's health and safety, increasing the potential for the need of hospitalization , and or resultant death of Resident 1. On 5/11/2021 at 6:43 p.m., the State Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), the Director of Nursing (DON), and the Pediatric Unit Manager (PM) with regards to administering the incorrect dose of medication to Resident 1. On 5/14/2021 at 4:01 p.m., the ADM provided a Plan of Action (POA) for the health and safety of Resident 1, which included the following summarized actions: 1.) Staff checked the pharmacy label against the bottle label and performed drug calculations for administering the correct dose of [MEDICATION(S)] 40 micrograms (mcg-unit of measure) to ensure the right dose would be given to Resident 1. A Change of direction label was obtained, and staff verified that the physician's order, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility staff notified the on-call physician of the medication error. Resident 1 had been receiving [MEDICATION(S)] 400 mcg, rather than the correct ordered dose of [MEDICATION(S)] 40 mcg. Staff informed the on-call physician of Resident 1's medication [MEDICATION(S)] 2.5 milligrams (mg-unit of measure) was held due to blood pressures being below the ordered parameters. The physician instructed the facility staff to ensure the administration of the correct dose of [MEDICATION(S)] 40 mcg, have the [MEDICATION(S)] bottle label corrected, and continue to monitor Resident 1. 2.) The assessment of Resident 1 found no changes affecting level of consciousness. The baseline of Resident 1's consciousness is a semi-comatose state (lack of consciousness, disoriented). Each assigned primary nurse monitored the vital signs of Resident 1 every two (2) hours to identify any adverse reactions to the high dose of [MEDICATION(S)], which can include increased sedation, low heartrate, low respiratory rate, and decrease in blood pressure. 3.) On 3/30/2021, an audit was done for all residents using the medication [MEDICATION(S)], with the assistance of the facility's contracted pharmacy, and in collaboration of the Pediatric Unit Manager (PM) and the Director of Nursing (DON). 4.) In-service training was provided to the nurses administering medications on the instructions of how to perform the medication administration rights by verification of Right patient, right time, right route, right dose, right medication, right documentation when new or refill medications are delivered from the pharmacy. The instructions for administration and concentration of medications are verified with the physician's order in the residents' charts, and the medication label is audited for accuracy. On 5/14/2021 at 4:34 p.m., while onsite and confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON. Findings: A record review of Resident 1's Record of Admission indicates an admitted [DATE]. List of Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 1's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 4/1/2021 indicates that Resident 1 is severely impaired with thought process and decision-making tasks. Further review of the MDS indicates that Resident 1 required total dependence from staff for bed mobility (turning side to side), transfers (moving from bed to chair), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene. A record review of the Physician's Orders for Resident 1 dated 3/22/2021 indicates an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/11/2021 at 1:30 p.m., during interview with the Pediatric Nurse Manager (PM), PM indicated that Resident 1's correct calculated dose of [MEDICATION(S)] should have been 0.4 milliliter (ml-unit of measure) to equal the prescribed dose of [MEDICATION(S)] 40 mcg every eight hours. PM stated that instead, Resident 1 received 4 ml of [MEDICATION(S)], equaling 400 mcg, or ten (10) times the prescribed dose. Concurrent record review with PM of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/12/2021 at 6:52 a.m., during a phone interview with Registered Nurse 1 (RN 1), RN 1 stated that when the pharmacy delivers the medications to the facility, the charge nurse (nursing supervisors) should verify the received medications delivered and sign to validate that the medications received were correct. RN 1 stated that the charge nurses would hand the medications to the medication administration nurse, who should also verify the medications are correct with the physician's orders. RN 1 indicated that Resident 1's medication error started with the pharmacy incorrectly labeling the resident's [MEDICATION(S)] with instructions to provide 4 ml rather than 0.4 ml of the medication to equal 40 mcg. RN 1 stated that the receiving nurse, should have validated the received pharmacy label against the bottle label to ensure accurate dosage. RN 1 stated that they failed to do the drug calculation before administering the [MEDICATION(S)] medication to Resident 1 to ensure accurate dosage. RN 1 stated that they normally performed the drug calculation to check dosage amount but admitted to not doing it for this instance. RN 1 stated that staff should be following the physician's orders and not the pharmacy label. RN 1 stated that the five rights for medication administration include the right resident, right medication, right dose, given at the right time, and administered through the right route (whether by mouth or j-tube). On 5/12/2021 at 11:52 a.m., during an interview with Registered Nurse 2 (RN 2), RN 2 stated on 3/26/2021, when preparing Resident 1's medication [MEDICATION(S)] 40 mcg scheduled for 5 p.m., RN 2 indicated identifying the pharmacy label on the medication bottle being incorrectly written. RN 2 stated using the medication dose formula of D/H x Q (D= Physician's ordered dose, divided by H = available on hand, then multiplied by Q= the unit of measure) to check the dosage on the [MEDICATION(S)] bottle to ensure dose as prescribed. RN 2 indicated that the medication label delivered from the pharmacy reading Give 4 ml [MEDICATION(S)] was incorrect and had the calculation validated with another registered nurse, (RN 4). RN 2 stated that the correct dose of medication should have only been [MEDICATION(S)] 0.4 ml. RN 2 indicated that the [MEDICATION(S)] bottle received from the pharmacy was a small sized bottle, and that RN 2 questioned why the amount of medication remaining was low as the medication was newly delivered. RN 2 stated that high doses of blood pressure meds, such as [MEDICATION(S)] 400 mcg administered to Resident 1, can lead to a change in condition due to [CONDITION(S)] (abnormally slow heart rate), and [CONDITION(S)] (low blood pressure). On 5/14/2021 at 10:42 a.m., during interview with Registered Nurse 4 (RN 4), RN 4 stated that Resident 1's [MEDICATION(S)] pharmacy label to give 4 ml of [MEDICATION(S)] was incorrect. RN 4 stated that they validated alongside RN 2 that the correct dosage for [MEDICATION(S)] should have been 0.4ml to equal 40 mcg as prescribed. RN 4 indicated always reminding staff to never rely on the pharmacy label, but to always verify the physician's order so that the medication can be administered to the residents as prescribed. On 5/13/2021 at 2:02 p.m., during phone interview with the Pediatric Medical Director (PMD), PMD stated that if Resident 1 received a high dose of blood pressure medicine, PMD would worry about Resident 1's blood pressure becoming low, requiring transfer to the hospital, and requiring extra fluids to stabilize Resident 1's blood pressure. On 5/14/2021 at 1:37 p.m., during an interview with the Vice President of Operations (VP), VP confirmed that they were aware of the incident where in Resident 1 received a total of 12 doses of [MEDICATION(S)] that was 10 times the intended prescribed dose. VP stated that the [MEDICATION(S)] dose administered to Resident 1 posed a risk of death due to decreased heartrate and lack of blood circulation to the brain. A record review of the facility policy titled Medication Pass with effective date 6/8/2015, indicates the purpose of the policy is to provide a guideline on how to pass medication through the Gastrostomy (surgical opening on abdomen allowing food or medicine directly into the stomach)/Jejunostomy tube. Procedures include 1.) Follow the 5 Rights of giving medications & 2.) Give medications as ordered. Nursing procedure indicates to Check MD order. A record review of the facility policy titled Checking Parameters Before Administering Medication with effective date of 1/10/2020 indicates the goal, To administer medication in a safe manner taking into consideration certain types of medication requiring parameter checks prior to administration. Procedure indicates for licensed nurses to check the five (5) rights of giving medication, Right patient, right medication, right dose, right time, and right route. The policy also states, List of medications includes, but is not limited to, any blood pressure medication.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received care to heal and prevent the development of pressure ulcers (Injury to skin and underlying tissue due to prolonged pressure on the skin), which included but were not limited to: 1. Accurately assessed the resident's left ear wound upon admission. 2. Ensure a wound care nurse (treatment nurse) assessed immediately or as soon as possible after the resident developed a facility-acquired wound to the right ear, sacrococcyx area (below spine but above buttocks), and right and left buttocks to ensure Resident 1 receive prompt wound management including nutritional evaluation. 3. Assessing and implementing pressure-relieving device as appropriate a donut (a head positioner, which prevents pressure on the ears when the resident is turned on their side) on admission. 4. Monitoring the status of the left ear wound. 5. Developing and implementing resident-specific care plans, in accordance with Interdisciplinary Team (IDT, a team of healthcare workers from different fields who work together to care for the resident) recommendations. 6. Implementing the low air loss (LAL, special mattress used to treat, manage, or prevent PI) mattress on admission, as indicated by the Minimum Data Set (MDS), a standardized assessment and care-planning tool and initial pressure ulcer risk care plan. 7. Implementing a standardized turning and repositioning schedule consistent with professional standards. These deficient practices resulted in the development of avoidable pressure ulcers to Resident 1's right ear, sacrococcyx area stage 2 (partial-thickness loss of skin), right buttock unstageable (UTD - extent of tissue damage cannot be confirmed because it is covered by slough (dead tissue usually cream or yellow colored) or eschar (dead tissue usually black and hard)), and left buttock stage 2. On 9/28/18, Resident 1 was transferred and admitted to the General Acute Care Hospital (GACH) due to fever, received intravenous (administer in vein) antibiotics for wound infection and underwent surgical debridement (surgical removal of dead tissue in wounds) of the sacrococcyx pressure ulcer and was diagnosed with [REDACTED]. Cross-reference F580, F636, F637, F641, and F656. Findings: On 2/22/19, an unannounced visit was made to the facility to investigate a complaint regarding quality of care. The facility was alleged to have failed to notify the family of Resident 1's pressure ulcers, a change of condition, and provide appropriate pressure ulcer care. A review of Resident 1 undated Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - an assessment and care-screening tool) dated 8/20/18, indicated Resident 1 required total dependence on staff bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Assessment of Decubitus Ulcer (Pressure Ulcer) Potential, dated 8/21/18, indicated Resident 1 had a risk score of 18. The higher the score, the greater is the potential to develop decubitus ulcers. The form indicated the residents with scores above 12 should be considered high risk. A review of Resident 1's Care Plan dated 8/21/18, for potential for pressure ulcer development related to bed mobility problem, bladder and bowel incontinence (lack of voluntary control over urination or defecation), presence of [MEDICAL CONDITION] and [DEVICE]. The interventions included provide resident with adequate nutrition and hydration, turn and reposition resident every 2 hours, and use pressure-relieving device on bed. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Daily Resident Record - Progress Notes, dated 8/28/18, indicated Resident 1 was noted with sacrum (tailbone) open skin. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Daily Resident Record - Progress Notes, dated 9/3/18, indicated Resident 1's coccyx open skin is now stage 2 (involve partial thickness skin loss, lesion is superficial and presents clinically as an abrasion, blister, or shallow center) wound bed is pink, clean, surrounding area has black discoloration. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Daily Resident Record - Progress Notes, dated 9/3/18, indicated Resident 1 was noted with two (2) centimeter (cm) by three (3) cm stage 2 to the left buttock. The wound bed is pink, clean, surround area with black discoloration. The physician also ordered a low air loss mattress for skin management. A review of Resident 1's Daily Resident Record - Progress Notes, dated 9/19/18, indicated Resident 1 was noted with open skin to the right ear. On 2/25/19, at 8:52 a.m., the Assistant Director of Nursing (ADON) was interviewed. During a concurrent review of the Admission Note, dated 8/20/18, the ADON confirmed Resident 1 was noted with a left ear deep tissue injury (DTI - under intact skin, which initially looks like a bruise) stage 3 (pressure ulcer which extends into the tissues forming a crater, fat may be exposed). No other wounds were identified. The ADON stated a pressure ulcer cannot be classified as a DTI and stage 3; it is one or the other. The ADON stated the primary nurse, wound care nurse, and physician should have assessed the wounds on admission or as soon as possible. This ensures accurate prescription of treatments. The ADON confirmed there is no documented evidence a wound care nurse (treatment nurse) or physician assessed Resident 1's left ear wound. The ADON confirmed the facility does not know what the left ear wound is, as there are no wound characteristics documented (size, color, drainage, signs, and symptoms of infection, and surrounding skin). The ADON acknowledged documenting the wound characteristics is mandatory and is beneficial in identifying the wound and the associated treatments. During concurrent review with the ADON on 2/25/19, at 8:52 a.m., of Resident 1's care plan, left ear DTI Stage 3, dated 8/20/18 the goal indicated for the pressure ulcer to be resolved in 30 days. The interventions included administer treatment as ordered, monitor and assess area every shift and as needed. The ADON confirmed there is no documented evidence of treatment orders. There is no documented evidence the wound was monitored and assessed every shift. The ADON confirmed there is no documented evidence the IDT discussed the left ear wound or Resident 1's pressure ulcer risk so resident-specific interventions can be developed. A review of Resident 1's (MONTH) Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. was cleansed with normal saline moist gauze, pat dry with gauze, apply Venelex (Trademark) (treatment for [REDACTED]. The ADON stated it is possible the physician made a telephone order and the licensed staff failed to write the order. The ADON confirmed there is no documented evidence the physician was aware of left ear DTI On 2/25/19, at 10:06 a.m., the Treatment Nurse (TN 1) was interviewed in the presence of the ADON. TN 1 stated DTI and stage 3 are different pressure ulcers and have different treatments. DTIs have intact skin, while stage 3 pressure ulcers have damaged-open skin (fat may be exposed). TN 1 stated she was not aware of Resident 1's left ear wound. TN 1 stated Resident 1's left ear wound should have been assessed and treated by a treatment nurse, but there is no documented evidence this occurred; TN 1 did not have an explanation. On 2/25/19, at 10:15 a.m., the ADON was interviewed. The ADON confirmed there is no documented evidence the sacrum open wound was accurately identified. TN 1 was concurrently interviewed. TN 1 stated a treatment nurse did not assess the sacrum wound until 9/3/18, when it was determined the sacrum open skin was a stage 2 (partial-thickness loss of skin) PI to the coccyx. The ADON and TN 1 acknowledged Resident 1's sacrum wound should have been assessed by a treatment nurse on 8/28/18 when the wound was noted. This ensures accurate assessment of the wound and prescription of treatments. The ADON and TN 1 acknowledged the wound characteristics should have been documented. The sacrum open skin was likely a stage 2 pressure ulcer because they have similar presentation and the sacrum is over a bony prominence. TN 1 stated the coccyx wound should have been initially treated (8/28/18) with the hydrogel treatment ordered on [DATE] because the wound was likely a stage 2 pressure ulcers. On 2/25/19, at 10:25 a.m., the ADON was interviewed. The care plan, sacrum open skin, dated 8/25/18, and coccyx stage 2, dated 9/3/18, was concurrently reviewed. The ADON confirmed there is no documented evidence the coccyx stage 2 pressure ulcer was discussed in an IDT. There is no evidence the care plan was developed and updated with resident-specific interventions in accordance with IDT recommendations after the sacrum open skin declined to a coccyx stage 2 pressure ulcer. The ADON confirmed there is no documented evidence the facility determined the interventions remained relevant. On 2/25/19, at 10:35 a.m., the ADON was interviewed. The ADON confirmed a treatment nurse documented their initial pressure ulcer assessment on 9/10/18. The ADON stated a treatment nurse should have assessed each wound when they were noted to ensure accurate management of the wound. On 2/25/19, at 10:40 a.m., the ADON was interviewed. The ADON confirmed there is no documented evidence the facility accurately identified Resident 1's open skin to the right ear because the wound characteristics were not documented. The ADON also confirmed there is no documented evidence a treatment nurse assessed the wound. The ADON acknowledged ears are prone to PI because of pressure from the weight of the head on the pillows. The ADON stated a donut (head positioner) could relieve pressure on the ears. The physician's orders [REDACTED]. The physician ordered for Resident 1, apply ring head positioner (donut pillow) to occipital (back of head) head at all times for skin maintenance. The ADON stated the donut should have been implemented on admission because the resident was assessed to have a left ear wound. The facility should have developed a resident-specific care plan to include the donut to prevent the right ear (assessed on 9/19/18) open skin. The Daily Resident Record - Progress Notes, dated 9/25/18, was concurrently reviewed with the ADON. The note indicated Resident 1 was noted with right UTD (unstageable, extent of tissue damage cannot be confirmed because it is covered by slough (dead tissue usually cream or yellow colored) or eschar (dead tissue usually black and hard)) pressure ulcer. The ADON confirmed the wound characteristics should have been documented but was not. The ADON confirmed there is no documented evidence a treatment nurse assessed this wound but should have. The MDS, dated [DATE], was also concurrently reviewed with the ADON. The MDS indicated a pressure-reducing device for bed and turning/repositioning program were skin and ulcer treatments implemented. The ADON confirmed the LAL mattress was not implemented until 9/3/18 when the physician ordered it. The ADON stated the MDS gives an overall assessment of the resident's health status and gives recommendations on care planning and interventions. The ADON stated the LAL mattress should have been initiated on 8/21/18 as indicated by the care plan, potential for pressure ulcer development, dated 8/21/18. A review of the physician's orders [REDACTED]. A review of the GACH 1 Wound Data, dated 9/29/18, indicated Resident 1 had a pressure ulcer to the sacrococcyx ext. (sic) to bilateral buttocks. The pressure ulcer is unstageable, and measured 8 x 14 x UTD (sic). A review of the GACH 1 progress note, dated 10/1/18, indicated Resident 1 continues to have high-grade fever up to 101.8 (degrees Fahrenheit) (Normal is 98.6). The culture of the wound are growing-gram negative rods (group of bacteria identified by their shape and color when stained). The patient (Resident 1) remains on broad-spectrum antibiotics (kills or slows the growth of a variety of bacteria). Resident 1's white (cell) count was 15.6 (per microliter) (normal is 4.5 to 11.0 × 109/L) and [DIAGNOSES REDACTED]s were at 80% (normal is 45%-70%). A high temperature, white cell count, and [DIAGNOSES REDACTED]s could indicate infection. A review of the GACH 1 progress note, dated 10/7/18, indicated Resident 1's wound cultures (of the sacrum) on 9/30/18 does show [NAME]ella morganii (bacteria) and VRE ([MEDICATION NAME]-resistant [MEDICATION NAME], bacteria resistant to [MEDICATION NAME], a powerful antibiotic). A review of the GACH 1 discharge summary, dated 10/13/18 indicated Resident 1 underwent debridement (surgical removal of dead tissue in wounds) of sacrum. Resident 1's final [DIAGNOSES REDACTED]. On 2/25/19, at 12:00 p.m., the Dietitian was interviewed. The Dietitian stated her recommendations for Resident 1's diet and supplementation were partially based on the pressure ulcers communicated to her by the staff. The Dietitian stated if Resident 1 had a stage 3, left ear PI on admission, she would have recommended Vitamin C and Zinc, and probably a multivitamin. The Dietitian stated she did not recommend these supplements because she was unaware Resident 1 might have had stage 3 left ear pressure ulcer. On 2/25/19, at 12:47 p.m., the ADON and MDS Coordinator (MDSC) were interviewed. The nursing flow sheets for (MONTH) and (MONTH) were concurrently reviewed. The ADON confirmed Resident 1 did not have a turning schedule consistent with professional standards. The ADON stated Resident 1 should have been turned to the right, the back, and then the left but was not. The ADON stated Resident 1's right ear open skin, stage 2 coccyx pressure ulcer, left buttock stage 2 pressure ulcer, and right buttock UTD pressure ulcers were avoidable. A review of the policy and procedure, Pressure Sore Protocol, effective 6/21/08 and reviewed 3/15/13, indicated the purpose of the policy and procedure is to prevent the development of pressure sores, to facilitate healing of all pressure sores, and to standardize treatment modalities. Early interventions included but are not limited to, Care Plan initiated upon admission of high risk Residents, and emphasis on turning schedule by all supervisory staff. Interventions included but are not limited to, pressure relieving mattresses for Residents at high risk, nutritional supplements provided per Doctor's orders, turn q (every) two hours while in bed, and any other measures recommended for individualized treatment. A review of the policy and procedure, Decubitus Ulcer (staging, documentation, prevention), effective 1/1/10, reviewed 3/15/13, and revised (MONTH) (YEAR), indicated decubitus ulcer documentation will include the following: date and time, resident's/patient's name, size, stage, location, depth, any drainage, any odor, and photograph.

Based on observation, interview, and record review, the facility failed to ensure: 1. A one year old resident (Resident 45) with no documented history of [CONDITION(S)] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) who received two [CONDITION(S)] medications (medications that affect the mind, emotions, and behavior), [MEDICATION(S)] ([MEDICATION(S)], that included a Black Box Warning (BBW) indicating, [MEDICATION(S)] is not approved for use in pediatric patients under ten years of age), and [MEDICATION(S)] ([MEDICATION(S)], an anti-anxiety medication) without consistent indication for its use, without documented non-pharmacological interventions, documented behaviors specifically identified, in the presence of potential adverse reactions that included but not limited to sedation, tremors, respiratory depression, seizures, constipation, [CONDITION(S)] (low blood pressure), and [CONDITION(S)] (abnormally slow heart rate). 2. Resident 115 who received [MEDICATION(S)] ([CONDITION(S)] medication) was monitored for its adverse reactions that included [CONDITION(S)] (heart rate that exceeds the normal resting rate and postural [CONDITION(S)] (form of low blood pressure that happens when a person stands up from sitting or lying down) for Resident 115 These deficient practices increased the risk for unnecessary medication for two out of 25 sampled residents (Resident 45 and Resident 115). As well as duplication in therapy, medication interactions, adverse reactions, and unidentified risks associated with the use of [CONDITION(S)] medications potentially contributing to Resident 45 becoming unresponsive leading to hospitalization for [CONDITION(S)] and [CONDITION(S)] on 3/26/18. Findings: a. A review of the Admission Records indicated Resident 45 was readmitted to the facility on [DATE] with diagnoses including premature newborn, chronic respiratory failure, dependence on ventilator (respirator, a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently), pulmonary hypertension (high blood pressure in the lungs), gastrostomy tube (GT - a tube surgically inserted into the stomach through the abdominal wall to provide food and medication) and [CONDITION(S)] (a surgical hole in the front of the neck to the windpipe to allow the passage of air), restlessness, and agitation. A review of the Annual Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 6/4/18, indicated Resident 45's hearing and vision were highly impaired and was totally dependent on staff for all activities of daily living (ADLs - including transfers, dressing, and toilet use). The MDS indicated under, Special Treatments, Procedures, and Programs, Resident 45 was not provided with physical, psychological or recreational therapy in the past seven days. A review of the Physician's Orders indicated Resident 45's orders included: 1. [MEDICATION(S)] 6.25 milligrams (mg) via GT three times a day for agitation, dated 4/3/18. 2. [MEDICATION(S)] 6.25 mg via GT every six hours as needed (PRN) for agitation and irritability after PRN [MEDICATION(S)] (a sedating antihypertensive medication, side effects including drowsiness, low blood pressure, and sedation) and PRN [MEDICATION(S)] (maximum two doses per day), dated of 4/11/18. 3. [MEDICATION(S)] 2 mg/milliliter (ml) 0.3 mg (0.15 ml) via GT every four hours (six times a day) for agitation and irritability, dated 4/3/18. 4. [MEDICATION(S)] 2 mg/ml, give 0.2 mg (0.1 ml) via GT every six hours PRN for agitation and irritability with an order date of 4/3/18. A review of the Care Plan dated 4/3/18 for Resident 45's [CONDITION(S)] drug use ([MEDICATION(S)] and [MEDICATION(S)]) and risk for extrapyramidal effects (EPS - drug-induced movement disorders such tremors, slurred speech, drooling, lack of coordination), had a goal for Resident 45 not to have any adverse reactions that would outweigh the primary reason for use. The approaches included verifying condition or reason the resident was on the medication; monitoring resident's response to medication; and referring any signs that might indicate a change in sensitivity or response to the medication for possible dose changes. A review of the [CONDITION(S)] Care Plan for [MEDICATION(S)] dated 4/3/18, indicated to observe Resident 45 closely for significant side effects and report to the physician. The side effects listed on the attached sticker included sedation, drowsiness, morning hangover, ataxia (drunk walk). A review of the Care Plan dated 4/3/18, for Resident 45's potential for pain/discomfort related to medical condition. The interventions included non-medication intervention to promote comfort and evaluate effectiveness of medication given. A review of the Care Plan dated 4/3/18, for Resident 45's potential for agitation related to medical condition, included in the approaches assessing Resident 45 every shift and as needed and observing for any adverse reactions. A Care Plan dated 4/3/18, indicated Resident 45 was at risk for constipation related to decreased mobility and use of various medications. A review of the monthly Psychopharmaceutical Summary Sheets - Behavioral Data between 4/2018 and 7/2018 for Resident 45 indicated: 1. [MEDICATION(S)] 0.3 mg every 4 hours administered around the clock (ATC) for agitation and irritability. The episodes of agitation and irritability were documented as zero. 2. [MEDICATION(S)] 0.2 mg every six hours PRN for agitation or irritability indicated Resident 45 was given three times PRN [MEDICATION(S)], once in 4/2018, once in 6/2018, and once in 7/2018. The documentation indicated [MEDICATION(S)] was effective but did not indicate the behavior displayed requiring the PRN [MEDICATION(S)]. 3. [MEDICATION(S)] 6.25 mg three times a day ATC for agitation. The episodes of agitation were documented as zero. 4. [MEDICATION(S)] 6.25 mg every six hours PRN after PRN [MEDICATION(S)] and PRN [MEDICATION(S)] for agitation/irritability was given once in 7/2018. The documentation indicated the [MEDICATION(S)] was effective but did not indicate the behavior displayed requiring the PRN [MEDICATION(S)]. A review of the Medication Administration Record (MAR) from 4/1/18 to 8/9/18 indicated Resident 45 was administered: - [MEDICATION(S)]: 164 doses in 4/2018; 186 doses in 5/2018; 181 doses in 6/2018; 187 doses in 7/2018; and 51 doses from 8/1 - 8/9/18; for a total of 769 doses (766 doses of [MEDICATION(S)] 0.3 mg plus three PRN doses of [MEDICATION(S)] 0.2 mg). A total of 230 mg of [MEDICATION(S)] over 129 days. There was no documentation non-pharmacological interventions were attempted and failed. - [MEDICATION(S)]: 82 doses in 4/2018; 93 doses in 5/2018; 90 doses in 6/2018; 94 doses in 7/2018; and 26 doses from 8/1- 8/9/18; for a total of 385 doses (which included one PRN dose). A total of 2,406.25 mg of [MEDICATION(S)] over 129 days. There was no documentation non-pharmacological interventions were attempted and failed. Further review of the MAR indicated Resident 45 was administered Pediatric [MEDICATION(S)] suppositories for constipation twice on 6/9 and 6/17/18, and once on 6/22, 6/25, 6/27, 7/13, and 7/28/18. On 8/7/18 at 8:47 a.m., during a medication pass observation, Licensed Vocational Nurse 6 (LVN 6) was observed preparing Resident 45's morning medications that included [MEDICATION(S)] 2 mg/ml. LVN 6 drew up into a syringe 0.15 ml (0.3 mg) of [MEDICATION(S)] and administered Resident 45's morning medications through the GT. Resident 45 was lying in her crib awake, quiet, with her head moving slowly from side to side. On 8/7/18 at 9:16 a.m., during an interview LVN 6 stated, No agitation (for Resident 45) this morning. She was asleep when I came in today. LVN 6 stated Resident 45 gets [MEDICATION(S)] every four hours around the clock and PRN if she gets agitated. On 8/8/18 at 4:13 p.m., in the presence of the Director of Nursing (DON), Pediatric Nurse Manager (PNM), and LVN 10, Resident 45 was observed sleeping in her crib. LVN 10 stated, She (Resident 45) is sleeping right now and she sleeps a lot. No agitation now. [MEDICATION(S)] is a routine medication, so we have to give it to her every four hours around the clock. Even when she (Resident 45) is sleeping she gets the medicine. LVN 6 stated that it had been about three to four weeks since she last saw Resident 45 agitated. On 8/8/18 at 4:38 p.m., in the presence of the PNM, the DON stated the LVNs should report to the Registered Nurse (RN) Resident 45 is no longer agitated for the RN to reassess the resident. The DON stated she would not administer the [MEDICATION(S)] to the sleeping resident and would first notify Resident 45's physician to let him/her know the resident's current condition and ask the physician to re-evaluate the orders. On 8/9/18 at 8:55 a.m., during an interview LVN 10 stated Resident 45's [MEDICATION(S)] was administered at 4 p.m. the day prior (8/8/18) while Resident 45 was asleep. LVN 10 further stated, I still give the around the clock [MEDICATION(S)] when there is no heart rate change and no behavior. LVN 10 stated she does not notify the charge nurse or the physician when Resident 45 is not agitated or irritable before administering [MEDICATION(S)]. LVN 10 further stated that Resident 45 was quiet and not agitated earlier when she administered her [MEDICATION(S)] at 8 a.m. On 8/9/18 at 9:18 a.m., during an observation and interview, RN 6 was observed taking Resident 45's blood pressure. RN 6 stated Resident 45's blood pressure was 93/62 and that it was a little low. RN 6 stated she could not remember the last time she had seen Resident 45 agitated. On 8/9/2018 at 10:58 a.m., during an interview and review of Resident 45's clinical record in the presence of RN 6 and LVNs 4 and 10, LVN 4 stated Resident 45 was last seen by a neurologist on 1/10/18 and was scheduled for a follow-up appointment on 6/27/18, but the appointment was put on hold. LVN 4 could not find documentation for the reason Resident 45 was not evaluated by the neurologist. On 8/9/18 at 11:11 a.m., RN 6 after reviewing Resident 45's clinical record stated [MEDICATION(S)] PRN was given on 7/21/18 was for increased heart rate. RN 6 stated [MEDICATION(S)] was not indicated or ordered for increased heart rate. On 8/9/18 at 11:18 a.m., in the presence of RN 6, LVN 10 provided the facility's pediatric medication reference and read that [MEDICATION(S)] was indicated for [CONDITION(S)] and [CONDITION(S)] disorder and Resident 45's medical condition did not include either diagnoses. LVN 10 further stated that based on the medical reference agitation was not an indication for the use of [MEDICATION(S)]. On 8/10/18 at 7:50 a.m., LVN 10 was at Resident 45's bedside taking her blood pressure and stated Resident 45's blood pressure was 79/46 and it was low. Resident 45 was observed lying quietly in her crib with her eyes open, foam in her mouth, with tongue movement. At 7:43 a.m., LVN 10 rechecked Resident 45's blood pressure and stated it was still low at 85/52. LVN 10 was asked about Resident 45's mouth movement and stated, She (Resident 45) moves and sticks out her tongue a lot. LVN 10 stated she could not remember the last time Resident 45 was held or taken out of the room for an activity. On 8/10/18 at 8:07 a.m., in the presence of RN 3, Resident 45 was observed crying. RN 3 touched Resident 45, repositioned her and cleaned her mouth that was full of foam running down the side of her mouth. Resident 45 stopped crying immediately and her color returned to normal with normal breathing and Resident 45 appeared relaxed. LVN 10 entered the room and asked RN 3 if the activity staff should be called to hold Resident 45. RN 3 stated, She (Resident 45) is okay right now. If she cries again we can call activities and we have PRN medication we can give her. On 8/10/18 at 8:10 a.m., during a follow-up interview, LVN 10, We need activities. It would be a pleasure to hold her (Resident 45), but we are doing things and cannot hold her. Maybe she (Resident 45) wants to have people around. Everybody needs company. On 8/10/18 at 8:13 a.m., during an interview the PNM stated, Resident 45 has routine and PRN order for [MEDICATION(S)]; so, we can give the medicine when she cries. On 8/10/18 at 10:44 a.m., during a telephone interview in the presence of PNM and DON, Resident 45's physician (MD 1) stated she last saw Resident 45 on 7/20/18 and Resident 45 was sleeping during her visit. MD 1 stated Resident 45 was quite delayed with no motor or mental milestones, had major injury to the brain and was prescribed [MEDICATION(S)] ([MEDICATION(S)], medication to treat [CONDITION(S)]), [MEDICATION(S)] and [MEDICATION(S)] to be administered ATC. Resident 45 was having severe neuro-agitation with sweating, constant movement, and with the medications she is more comfortable and easier to take care of. MD 1 stated [MEDICATION(S)] should still be given when Resident 45 was asleep and if withheld the resident may have withdrawal. MD 1 stated Resident 45 had [MEDICATION(S)] because the resident needed more than one medication to control her agitation. MD 1 stated [MEDICATION(S)] was a sedating medication for agitation and was preferable than narcotics. MD 1 stated, There was no way to monitor for hallucinations (for Resident 45) and she cannot tell us if she is having any side effects. All we can do is watch for patterns and trust that the nursing staff will watch for symptoms and patterns that are not part of her baseline and notify us. On 8/10/18 at 11:30 a.m., during an interview in the presence the PNM, the DON stated Resident 45 was hospitalized in 3/26/18 for [CONDITION(S)] and [CONDITION(S)]. The DON stated Resident 45 also has muscle rigidity, drooling, and sleeps a lot. On 8/10/18 at 11:37 a.m., during a telephone interview in the presence of the PNM and the DON, the Consultant Pharmacist (CP) stated [MEDICATION(S)] was indicated for [CONDITION(S)] and agitation and irritability were not an approved indication for the use of [MEDICATION(S)]. On 8/10/18 at 3:08 p.m., during a follow-up telephone interview, the CP stated the clinical references he reviewed indicated [MEDICATION(S)] safety and efficacy was not established in pediatric patients younger than [AGE] years old and [MEDICATION(S)] was not indicated for children less than [AGE] years of age. The CP further stated, A lot of babies cry and that is the only communication they have. Picking up and holding the resident would be an intervention that could be used for a crying baby. On 8/10/18 at 3:25 p.m., during an interview, the Medical Records Manager (MR 1) stated Resident 45 was transferred to General Acute Care Hospital 1 (GACH 1) because of [CONDITION(S)] and [CONDITION(S)]. MR 1 provided Resident 45's monthly Psychopharmaceutical Summary Sheets - Behavioral Data from 10/2017 to 12/2017 for [MEDICATION(S)] and [MEDICATION(S)] which indicated the behavior of agitation was documented as zero. A review of GACH 1 Discharge Summary dated 4/3/18 indicated, It was found that (Resident 45) agitation and [CONDITION(S)] (dysfunction of the nerves that regulate non-voluntary body functions such as heart rate, blood pressure, and sweating) consistently responded to being held and gently rocked; soothing interventions (holding, bathing, rocking) calms her down .of note, venting GT helps with abdominal distension during episodes of agitation. The Activity after Discharge indicated to resume normal activity. The Hygiene Instructions indicated regular bath appropriate for age. A review of the Psychosocial Evaluation dated 4/4/18 indicated Resident 45 enjoyed being rocked to sleep. A review of the Child Life Development assessment dated [DATE] indicated Resident 45, Loves to sit in the wheelchair and bouncer .able to smile and cries in order for her needs to be met. The play and recreation needs indicated, Bedside activities, rocking and holding. A review of the facility-provided document (reference) from Pediatric Dosing Handbook and Formulary 2014-2015 indicated adverse effects of [MEDICATION(S)] included postural [CONDITION(S)], [CONDITION(S)], palpitations, sleepiness, dizziness, [CONDITION(S)], agitation, seizures, EPS, and constipation. A review of the facility's policy titled, Antipsychotic Regulation, dated 6/2012, indicated, when antipsychotics are used without monitoring, they may be considered unnecessary medications. A review of the facility's policy titled, Anxiolytic (anti-anxiety medication) Regulation, dated 6/2012, indicated, anxiolytics should only be used when evidence exists that other possible reasons for the individual's distress have been considered. According to the manufacturer's label, [MEDICATION(S)] should be prescribed for short periods only (two to four weeks), continuous long-term use of product is not recommended. The physician should periodically reassess the usefulness of the drug. [MEDICATION(S)], both used alone and in combination with other central nervous system (CNS) depressants (e.g. [MEDICATION(S)] and [MEDICATION(S)]), may lead to potentially fatal respiratory depression. Paradoxical reactions may be more likely to occur in children and the elderly. Should these occur, use of the drug should be discontinued. Paradoxical reactions, include anxiety, excitation, agitation, sleep disturbances/[CONDITION(S)], small decreases in blood pressure, and [CONDITION(S)]. b. A review of the Admission Record indicated Resident 115 was readmitted to the facility on [DATE] with diagnoses including chronic respiratory failure, [CONDITION(S)], and dependence on ventilator. A review of the Quarterly MDS dated [DATE], indicated Resident 115 had no memory problems, needed limited assistance with bed mobility, dressing and toileting, and received antidepressant (a [CONDITION(S)] for depression). A review of the Physician's Order dated 10/12/16 indicated to administer [MEDICATION(S)] 25 mg by mouth every 12 hours for herpetic neuralgia ([MEDICATION(S)] nerve pain from [CONDITION(S)] infection). A review of the Care Plan dated 10/18/17 addressing Resident 115's risk of adverse reactions related to [MEDICATION(S)] had a goal for Resident 115 not to exhibit any signs and symptoms of adverse reactions of the [CONDITION(S)] drugs. The interventions included monitoring signs and symptoms of adverse reactions (drowsiness, dry mouth, blurred vision, constipation, increased heart rate, postural [CONDITION(S)]), and refer any to the physician. A review of the Medication Administration Record (MAR) for 8/2018 indicated Resident 115 received [MEDICATION(S)] every 12 hours as ordered and did not include monitoring of adverse reactions or side effects. On 8/10/18 at 11:01 a.m., during an interview with ACN 1 and a concurrent review of the MAR, ACN 1 stated there was no documentation of adverse or side effect from [MEDICATION(S)]. A review of the facility's policy and procedures titled, [CONDITION(S)] Medication Use, dated 11/2015, indicated the purpose of the policy was to ensure residents are provided proper interventions to achieve their highest possible level of functioning and enhancement of each residents' quality of life. Resident will be monitored for any potential adverse reaction to medication and will be properly documented on the resident's record.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) with gastrostomy tube ([DEVICE] - a medical device used to provide nutrition for residents who were unable to obtain adequate nutrition by mouth) received the necessary care and services to prevent negative consequences of [DEVICE] use and complications. Resident 1, who required a two-person assist, per policy, was transferred solely by Certified Nurse Assistant 2 (CNA 2) and the [DEVICE] was dislodged. This deficient practice resulted in Resident 1 experiencing bleeding from the [DEVICE] site, being transferred to the general acute care hospital (GACH), requiring sutures to stop the bleeding, and receiving a blood transfusion with over six units of blood. Findings: A review of the admission record indicated Resident 1 was a [AGE] years of age, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the history and physical, dated August 29, 2016, indicated Resident 1 had a medical history which included no capacity to understand and make decisions due to a [MEDICAL CONDITION] ([MEDICAL CONDITION] - stroke). A review of the care plan, dated August 31, 2016, indicated Resident 1 had a concern / problem requiring maximum assistance with activities of daily living (ADLs), due to physical and mental disability. The care plan approach indicated to provide the appropriate number of support persons to assist resident in ADLs, and to turn and reposition the resident maintaining proper body alignment at all times. A review of the care plan, dated August 31, 2016, indicated Resident 1 had the potential for falls and injury related to inability to balance self when turned to the side. The care plan approach indicated to turn, reposition, and transfer the resident in and out of bed using the right technique and number of support people. A review of the care plan, dated August 31, 2016, indicated Resident 1 had an alteration in nutrition due to presence of [DEVICE] feeding. The care plan approach indicated to check placement and patency per protocol. On September 4, 2016, a laboratory test indicated Resident 1 had a low hemoglobin (HGB - a protein in red blood cells that carries oxygen throughout the body) level at 8.5 g/dL (normal range 11.0-18.0) and a low hematocrit (HCT - a protein in red blood cells that carries oxygen throughout the body) level at 26.5% (normal range 35.0 -53.7). According to PubMed Health website, ncbi.nlm.nih.gov, 2014, a very low HGB and HCT may cause shortness of breath and rapid heart rate, which can be life-threatening as it limits the delivery of oxygen to vital organs of the body. A review of the minimum data set (MDS - an assessment and care planning tool), dated September 9, 2016, indicated Resident 1 was totally dependent on two person physical assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. Resident 1 had impaired functional range of motion on both sides of the body for upper and lower extremities (unable to purposely move both arms and legs). During an interview, on December 7, 2016, the DON stated it would be a good idea to have a care plan, which included nursing interventions to prevent complications for residents with [DEVICE]s, such as and proper placement of tubing prior to moving resident. A review of the nursing assignment for September 13, 2016, indicated CNA 1, CNA 2, and licensed vocational nurse 1 (LVN 1) were assigned to Resident 1. The nursing assignment indicated Registered Nurse 1 (RN 1) was the Charge nurse and RN 2 was the RN Supervisor. A review of the nursing notes, dated September 13, 2016, indicated at 11:30 a.m., LVN 1 reported to RN 1 that Resident 1's [DEVICE] was accidentally removed during repositioning. At 12:10 p.m., LVN 1 reported to RN 1 that Resident 1's [DEVICE] site / stoma (an artificial opening made into an organ)was bleeding and the dressing was totally soaked with blood. The nursing notes indicated Resident 1's blood pressure was 146/84 (normal range 120/80), heart rate was 86 beats per minute (normal range 60-80). No other vital signs were documented in the nursing notes. The nursing notes indicated direct pressure dressing and ice pack were applied to Resident 1's [DEVICE] site / stoma, and the licensed nurse documented these interventions were ineffective. In addition, the nursing notes indicated at 12:40 p.m., Resident 1's blood pressure was 150/100 (normal range 120/80) and heart rate was 87 beats per minute. No other vital signs were documented in the nursing notes. A review of the physician's orders [REDACTED]. During an interview, on October 25, 2016, at 1:57 p.m., LVN 1 stated she replaced Resident 1's [DEVICE], per facility protocol, when CNA 2 informed her it was dislodged. LVN 1 stated the physician was notified when she could not stop the bleeding from Resident 1's [DEVICE] site. On October 25, 2016, at 2:18 p.m., during an interview, CNA 2 stated she was turning Resident 1 in order to change the diaper. CNA 2 stated she thought she could turn Resident 1 by herself due to her partner, CNA 1, was relieving another CNA. CNA 2 stated she did not ask the other CNAs or her charge nurse for assistance. CNA 2 stated the [DEVICE] was tangled with Resident 1's hand and when she turned the resident, the [DEVICE] was dislodged. A review of the facility's policy and procedure titled, Patient Lifting and Transferring Guidelines, dated August 27, 2015, indicated each resident over 50 pounds would be moved using either two persons or a mechanical lift. During an interview, on October 25, 2016, at 2:39 p.m., RN 2 stated when she went to Resident 1's room to assess the bleeding, she placed four gauze pads (4 inch by 4 inch) on the site with pressure and it was saturated with blood when the paramedics arrived approximately 10 minutes later. During an interview with the Director of Nursing (DON) and the Director of Staff Development (DSD), on October 25, 2016 at 4 p.m., they stated the CNAs were placed in pairs so they would be able to safely care for the residents. The DSD stated almost all the adult residents, including Resident 1, required two person assistance. The DSD stated CNA 2 should have asked another CNA or her Charge Nurse for assistance, if her partner was unable to help her. A review of the staff inservice form titled, G tubes, dated July 7, 2015, indicated the educational objectives included to be aware of resident tubing when turning, repositioning, and transferring residents and to be careful with resident tubing when working with the residents. The staff inservice indicated to make sure the resident was not laying on any type of tubing, and to give the tubing enough slack when turning, repositioning, and transferring. Communicate with your nurse if the [DEVICE] was dislodged. The sign-in sheet indicated CNA 2 attended this inservice. A review of the inservice titled, Lifting criteria and care plans for residents, dated September 27, 2015, indicated the educational objectives included a care plan would be initiated and individualized to address how a resident would be moved. The inservice indicated each resident over 50 pounds would be moved using either two persons or a mechanical lift. The sign-in sheet indicated CNA 2 attended this inservice. A review of the GACH 1 inter-hospital transfer summary indicated Resident 1 arrived to the Emergency Department on September 13, 2016 and received sutures to stop the bleeding at the [DEVICE] site / stoma. A review of the patient care timeline from GACH 1 indicated Resident 1 arrived with a heart rate of 125 beats per minute (normal heart beat 60-100), temperature was 99.7 degrees Fahrenheit (F, normal 98.6 degrees F), and respirations were 40 breaths per second (normal 12-16). The patient care timeline from GACH 1 indicated at 2:35 p.m., Resident 1's laboratory results were low, HGB 8.0 g/dL and HCT 25.6%. At 4:07 p.m., Resident 1's second laboratory results decreased again to HGB of 7.6 g/dL and HCT of 24.3% A review of the patient care timeline from GACH 1, dated September 13, 2016, indicated the emergency physician ordered Resident 1 to receive a blood transfusion of one unit of packed red blood cells (PRBC), administered at 4:46 p.m. Resident 1's blood pressure was elevated at 154/97, heart rate was elevated at 126 beats per second, temperature was 99.2 degrees F, and respirations 35 breaths per minute (normal range 12 -16). A review of the patient care timeline from GACH 1, on September 13, 2016, indicated at 5:30 p.m., Resident 1's blood pressure increased to 166/98, heart rate increased to 156 beats per second, and temperature increased to 102.2 degrees F. Resident 1 was transferred from the emergency department to the direct observation unit (DOU). A review of the clinical record from GACH 1 DOU indicated Resident 1 received two units of PRBCs on September 15, 2016, two days after arrival to Emergency Department, and was discharged to GACH 2, on September 16, 2016. A review of the history and physical from GACH 2, dated September 16, 2016, indicated Resident 1 was admitted with [DIAGNOSES REDACTED]. Resident 1 was discharged from GACH 2, on September 30, 2016, to another skilled facility in guarded condition.

Based on interview and record review, the facility failed to ensure a resident who had a [MEDICAL CONDITION] (a hole made in the neck and windpipe used as an opening to allow airflow and permit the removal of secretions) tube, remained in the visual field of the Sitter (person assigned to provide direct visual supervision to assigned residents) at all times as indicated in the facility's policy and procedure. As a result, staff who were in the room but were not in visual sight of Resident 17, were not immediately alerted by a flashing or sounding alarm, when the resident stopped breathing. Resident 17 was found unresponsive and was purple in color from the face to the fingertips. Cardiopulmonary resuscitation (CPR - life saving measures) was started and the resident was transferred to the general acute care hospital (GACH) where she was diagnosed with [REDACTED]. She was hospitalized for [REDACTED]. Findings: On [DATE], the Department received a complaint which alleged on [DATE], the physical therapist (PT) found the resident not breathing. The resident was transferred to the GACH where a brain scan showed no activity. The report alleged that the resident's [MEDICAL CONDITION] was not in the right place, the resident stopped breathing but the machine alarms attached to the resident did not alarm. The admission record, a one-year old, Resident 17, was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. 1. Apnea monitor (a machine that alarms when a resident stops breathing) continuously. 2. Apnea monitoring parameters as follows: low respiratory rate (RR) of 10 breaths per minute, apnea period of 15 seconds (sec), low heart rate (HR) of 60 beats per minute and high HR of 200 beats per minute. 3. Pulse oximetry (a machine that measures the percentage of oxygen in the blood) continuously. 4. Baseline FiO2 (Fractional of Inspired Oxygen) per liter flow of 28 percent (%). 5. May use an increase of supplemental oxygen to maintain saturation equal or above 95% and notify the physician if more than 28% FiO2 is required for more than 15 minutes. 6. [MEDICATION NAME] (medication to open airways to ease breathing) 0.63 milligrams via a hand held nebulizer (breathing apparatus and machine to administer medication). 7. Physical therapy (PT), therapeutic exercise three times a week times 12 weeks dated [DATE]. There was a Resident Care Plan, dated [DATE] and re-evaluated [DATE], for ineffective airway clearance, ineffective breathing pattern, and inadequate oxygenation related to medical diagnoses. The goal was to achieve adequate oxygenation by maintaining patent (open) airways and unlabored respirations as reflected by oxygen saturation (amount of oxygen in the blood) equal to or greater than 95% daily. The approaches included to assess and monitor character of respirations, assess resident's skin color, breath sounds, oxygen saturation every shift and PRN (as necessary), [MEDICAL CONDITION] midline, keep resident on monitors as ordered, and refer any abnormal findings or change in resident's baseline to the physician accordingly. The disciplines responsible for this care plan were the Respiratory Therapist (RT) and Nursing. A review of the Annual Child Life Development assessment dated [DATE], indicated Resident 17 was able to go from sitting to standing independently, maintains stance by holding onto external support and walks along/cruises with unstable gait. Eye-hand coordination had improved with excellent sustained eye contact and visually tracked objects well. Resident 17 responded to auditory (heard) stimuli 50% of the time despite [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 17's cognitive skills for daily decision-making was severely impaired. The resident needed limited assistance (one person physical assist) from staff for bed mobility, and total dependence (with one person assist) from staff members for moving on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing. The resident did not have functional limitation in movement to the upper and lower extremities (arms/legs). The staff Pediatrics Daily Assignment Sheet dated [DATE], on the 7 a.m. to 7 p.m. shift indicated the persons assigned to Resident 17 were LVN 1 and CNA 1. In an interview with CNA 1 on [DATE], at 1:45 p.m. via phone, she said that she and LVN 1 were assigned as Sitters. She stated LVN 1 was on break when the incident occurred. A review of the Therapy Treatment Flowsheet dated [DATE], at 8:10 a.m., indicated Resident 17's heart rate was 113 beats per minute before breathing treatment of [REDACTED]. A review of the Respiratory Therapy Treatment Flowsheet dated [DATE], at 10:05 a.m., indicated Respiratory Therapist 4 (RT 4) responded to RT (code) called by PT. RT 4 found Resident 17 unresponsive with dusky color and immediately grabbed the bag valve mask (BVM) to provide supplemental oxygen, along with lead RT 1. Due to low heart rate, chest compressions were started by RT 2. Resident 17 remained unresponsive. 911 (emergency) paramedics were called. [MEDICATION NAME] was given by the registered nurse (RN). Chest compressions and bagging continued by RT 2 and RT 1. A second dose of [MEDICATION NAME] was given to the resident because of low heart rate. RT 3 changed [MEDICAL CONDITION], and it was documented that no plugs found, airway was patent (clear) and secure. The paramedics arrived and took over chest compressions and bagging. According to the SNF Nursing Narrative Notes, dated [DATE], the paramedics arrive at 10:13 a.m. and took over CPR. Resident 17 was transferred to the GACH at 10:32 a.m. The paramedics' Conversion Record dated [DATE], indicated they arrived at the facility at 10:17 a.m., and was with Resident 17 by 10:18 a.m. Upon arrival, the paramedics found Resident 17 pulseless (no heart beat) and apneic (no breathing), and started CPR ((cardiopulmonary resuscitation). They got a low heartrate of 63, with no breathing, and left the facility at 10:37 a.m. A review of the Emergency Department (ED) Clinical Summary (Final Report) dated [DATE], at 11:56 a.m., indicated upon arrival to the ED, Resident 17 had some spontaneous breaths but was non-responsive. After about five to ten minutes, Resident 17 had some response to stimuli and had spontaneous movements. A review of the History and Physical Final Report from the GACH dated [DATE] at 2:46 p.m. indicated Resident 17 had [MEDICAL CONDITION] suspected dislodging; episode may have been due to dislodged trach. A review of the Neurology Progress Note dated [DATE] at 12:53 p.m., indicated Resident 17's complications included confirmed acute [DIAGNOSES REDACTED]. According to a written Declaration provided by the Physical Therapist (PT) dated [DATE], and a follow-up phone interview on [DATE], on the morning of the incident, she went to check if Resident 17 was ready to be seen for physical therapy treatment. She found Resident 17 sleeping on her stomach. She left to provide treatment to another resident. When she returned to provide treatment to Resident 17, she saw the resident was limp and lying face up, and was purple in color from the face to her arms and hands. She went to Resident 17's bed and called out RT, which meant an emergency. She stated the monitors were flashing and sounding on bed A. The pulse oximeter reading was 28%. There was a privacy curtain between bed A and bed B drawn to the foot of the bed. A staff person was working with the resident in bed C, with the privacy curtain completely drawn. The certified nursing assistant (CNA) was sitting against the closet, facing bed B, and there was a shower bed to the left of the CNA blocking the view to bed A (Resident 17). When the PT called RT, RT 4 opened bed B's curtain, and that was how the PT knew RT 4 was connecting the machines and monitors for bed B. The PT stated she did not see any LVN in the room at this time. On [DATE], at 10:15 a.m., during an interview with RT 4, he stated that the day of the incident, he was the primary respiratory therapist, and CNA 1 asked him if he would assist her to get the resident in bed B ready for the shower. Bed B had a ventilator (breathing machine) attached, which was alarming while they were working on the resident. RT 4 heard a PT shout, Oh my God, she's purple! He turned around, moved the curtain and visualized Resident 17, and she was purple. RT 4 stated he did not hear the pulse oximeter or apnea monitor alarms for Resident 17, even though they were connected. RT 4 stated the PT got his attention when she shouted, RT! On [DATE], at 1:45 p.m., during a telephone interview with CNA 1 regarding the incident on [DATE], she stated that she was the sitter for Resident 17's room on that day, and there were three active residents in the room. The primary nurse for Resident 17 was LVN 1. CNA 1 said she was in the room between Resident 17 (who was in bed A) and bed B as she was also assigned to bed B. She stated LVN 1 took a break for 15 minutes and she covered for her as a sitter. CNA 1 was with bed B, preparing the resident for a shower and called RT 4 for help. The shower bed was next to bed B with the curtain pulled for privacy, and RT 4 was inside the curtain with bed B. According to CNA 1, she did not hear any alarms for bed B or bed A (Resident 17). The facility's policy and procedure titled, Resident Sitters dated [DATE], indicated the sitter will provide support and monitoring for safety. Sitters will monitor and observe assigned residents at all times. The Sitters should interact with each resident on a continuing basis throughout the shift but all residents must remain in their field of vision at all times. Examples included talking with one or more but continuously monitoring or viewing all three. Never leave the residents unattended. Sitters may be assigned between one to three residents in a given room depending on the need.