Every finding on record at Angels Nursing Health Center

Based on observation, interview, and record review the facility failed to implement fall prevention interventions for one of four sampled residents (Resident 1).This failure resulted in Resident 1 falling a second time on 7/6/26 where the resident sustained a lip laceration and bump on her head.During a review of Resident 1's admission Record dated 7/8/26 indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dysphagia (difficulty swallowing), hypertension (HTN - high blood pressure), muscle weakness, difficulty in walking, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells). A review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 6/26/26 indicated Resident 1 had severe cognitive (ability to think, understand and make daily decisions) impairment. Further review of the same MDS indicated Resident 1 required supervision or touching assistance to substantial/maximal assistance from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility. During a review of Resident 1's History and Physical (H&P) dated 6/20/26 indicated the resident lacks the capacity to make and understand decisions. During a review of Resident 1's Fall risk assessment dated 6/20/26 indicated the resident was a Moderate risk for falls. During a review of Resident 1's Post Fall Assessment dated 7/5/26 indicated the resident had an unwitnessed fall that morning with no injury. During a review of Resident 1's Fall risk assessment dated 7/5/26 indicated the resident was a high fall risk. During a review of Resident 1's Post Fall Assessment dated 7/6/26 indicated the resident had a second unwitnessed fall that morning with and was assessed with a left forehead contusion (medical term for bruise), and skin tear (wound where the top layers of skin separate from the underlying tissue) on the left lower extremity and superficial laceration (cut) to the lower lip and was sent to the hospital for further treatment. During a review of Resident 1's Actual fall: Unwitnessed fall care plan revised on 7/6/26 indicated interventions including; place non-skid mats on floor at the bedside, and place the resident in an area where they can be observed visually. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1 on 7/8/26 at 1:25 pm the area around Resident 1's bed was noted not to have any non-skid mats at the bedside. CNA 1 verified there were no mats and states the nurses are the ones that put them. During an interview with Registered Nurse (RN) 1 on 7/8/26 at 1:43 pm, RN 1 verified Resident 1 had a fall the morning of 7/5/26, and the nurse supervisor was a registry nurse (not regular staff), and she did not update the care plan. RN 1 Stated she updated the care plan with new interventions after the second fall the morning of 7/6/26, further stating the fall may have been prevented had they implemented new interventions like landing pads or moving the resident closer to nursing station. During a review of the facility's policy and procedures titled Fall Management Program revised 5/1/26, the P&P indicated Purpose. To prevent resident falls and minimize complications associated with falls. Care planning. The Nursing Staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls. post fall, interventions will be implemented or changed based on the resident's condition and response.

Based on observation, interview, and record review, the facility failed to implement infection control practices to provide a safe, sanitary, and comfortable environment for one of two sampled medication carts (Medication cart 2) and for two of five sampled residents (Resident 34 and Resident 59) by failing to ensure:-Licensed nurses (in general) cleaned the pill cutter (safely and accurately cut medication tablets in half) in Medication Cart 2 and ensured the pill cutter did not have medication residuals inside the pill cutter.-Licensed Nurses (in general) labeled Resident 34's breathing treatment (a nebulizer machine that turns liquid medicine into a mist for inhalation) tubing and mask with date and ensure the tubing and mask were not on the floor.-Licensed Vocational Nurse 2 (LVN 2) wore a gown and gloves when checking Resident 59's blood pressure.These failures resulted in inadequate infection prevention practices. Findings: During a concurrent observation and interview on 6/9/2026 at 1:22 PM with LVN 3, observed a pill cutter in Medication Cart 2 with white particles and a piece of an unknown tablet left inside the pill cutter. LVN 3 stated that they (licensed nurses in general) were supposed to clean after each use and discard the remaining tablet per facility policy. LVN 3 stated there was a risk of infection and the possibility of medication interactions when the pill cutter was not properly cleaned after each use. During an interview on 6/11/2026 at 12:17 PM with the Director of Nursing (DON), the DON stated that the pill cutter should be cleaned between use and the remaining tablet should be disposed per facility policy due to possible cross contamination (the process by which a harmful or dirty substance spreads from one area to another) and not safe for the residents. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program, reviewed on 12/30/2025, the P&P indicated that the facility must establish an Infection Prevention and Control Program under which it – A. Identifies, investigates, control, and prevents infections in the Facility. During a review of the facility's P&P titled, Preparation and General Guidelines: Medication Administration-General Guidelines, reviewed on 12/30/2025, the P&P indicated that when using only one-half of the tablets from a unit-dose package, the remainder is disposed per facility policy. During a review of Resident 34's admission Record, the admission Record indicated the facility admitted Resident 34 on 4/24/2026 with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should). During a review of Resident 34's Medication Administration Record (MAR-facility report detailing the drugs administered to a resident by a licensed nurse) dated 4/24/2026, the MAR indicated an order for Ipratropium Bromide (breathing treatment medication that stops mucus and opens up airway) 0.02 percent (%) one unit via inhalation every four hours as needed for wheezing (whistling sound or coarse rattle sound when airway is partially blocked during inhalation) or shortness of breath. The MAR indicated that Ipratropium Bromide was administered on 5/29/2026 at 8:15 PM. During a review of Resident 34's Minimum Data Set (MDS- a resident assessment tool), dated 4/30/2026, the MDS indicated Resident 34 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from moderate (helper does less than half the effort) to Supervision (helper provides verbal cues, touching and/or contact guard assistance as resident completes activity) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent observation and interview on 6/8/2026 at 9:47 AM with LVN 1, breathing treatment mask and tubing were found on the floor unlabeled with date. LVN 1 stated breathing treatment mask and tubing were supposed to be inside a bag and with labeled date when it was opened. LVN 1 also stated that the set up for the breathing treatment was supposed to be changed once a week due to infection control. During an interview on 6/11/2026 at 8:34 AM with the DON, the DON stated that breathing treatment mask and tubing were not supposed to be on the floor. DON also stated breathing treatment mask and tubing were supposed to be inside respiratory bag and dated due to possible infection control issues. During a review of the facility's P&P titled, Oxygen Administration, reviewed on 12/30/2025, the P&P indicated under infection control that all oxygen tubing, humidifiers, masks and cannulas will be changed weekly and when visibly soiled. The P&P also indicated that oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. During a review of Resident 59's admission Record, the admission Record indicated the facility originally admitted Resident 59 on 11/6/2025 and re-admitted on [DATE] with diagnoses including end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that filters waste and excess fluid from the blood] stop functioning on a permanent basis) and dependence on Hemodialysis (HD-a life-sustaining treatment for kidney failure that acts as an artificial kidney, filtering waste, toxins and excess water from the person's body using a machine) During a review of Resident 59's Order Summary Report dated 5/27/2026, the Order Summary Report indicated Resident 59 was on enhanced barrier precautions (EBP-infection control strategy for nursing home, requiring gowns and gloves to be used during high-contact care for residents with or at high risk for multidrug-resistant organisms [MDRO,microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents)]). The Order Summary Report indicated that providers and staff must wear gloves and gown with high-contact care activities. During a review of Resident 59's History and Physical (H&P), dated 5/28/2026, the H&P indicated Resident 59 had the capacity to make decisions. During a review of Resident 59's MDS dated [DATE], the MDS indicated Resident 59 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and mostly needing moderate (helper does less than half the effort) assistance from staff for ADLs. During a concurrent medication observation and interview on 6/10/2026 at 8:36 AM with LVN 2, LVN 2 checked Resident 59's blood pressure without wearing a gown and gloves. LVN 2 stated and validated that Resident 59 needed to be in EBP. LVN 2 also stated that she (LVN 2) was supposed to wear gown and gloves when checking Resident 59's blood pressure. During an interview on 6/10/2026 at 11:55 AM with Registered Nurse 1 (RN 1), RN 1 stated that when checking Resident 59's blood pressure, the nurse was supposed to wear both gown and gloves due to possible risk of infection. During a review of the facility's policy and procedure (P&P), titled, Standard and Enhanced Precautions, reviewed on 12/30/2025, the P&P indicated for residents whom EBP were indicated, EBP should be used when performing high-contact resident care activities. During a review of the facility's P&P titled, Infection Prevention and Control Program reviewed on 12/30/2025, the P&P indicated that the facility established and maintained an infection control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements.

Based on observation, interview, and record review, the facility failed to maintain the housekeeping standards by failing to:-Ensure a clean and sanitary dumpster area outside the facility's kitchenThis failure had the potential to cause contamination, poor sanitation in the facility and safety risks among its residents and staff. Findings:During a concurrent observation and interview on 6/10/2026 at 8:26 AM with the Maintenance Supervisor, in the dumpster area outside the facility's kitchen, the dumpster area had loose trash present on the ground with significant odor and the concrete pad around the dumpsters was visibly soiled with stains and debris. The Maintenance Supervisor stated that the loose trash should not be sitting on the ground and the area should be kept clean.During an interview on 6/10/2026 at 8:40 AM, with the Infection Preventionist (IP), the IP stated that the facility had an infection control program that included monitoring of adherence to infection prevention standards, with a focus on safety and sanitation practices.During an interview on 6/11/2026 at 10:02 AM with the Maintenance Supervisor and the Housekeeping and Laundry (H&L) Supervisor, the Maintenance Supervisor and the H&L Supervisor stated that the facility had a schedule for housekeeping and sanitation of areas in the facility. The H&L Supervisor stated that housekeeping was very important, especially in areas close to the kitchen, because dirty conditions could potentially affect the health of the residents and staff (in general).During an interview on 6/11/2026 at 10:32 AM, with the Administrator, the Administrator stated the dumpster area outside the kitchen needed sanitation and attention to meet oversight expectations. The Administrator stated that improving the housekeeping process could prevent environmental issues that could potentially harm the residents and staff.During a review of the facility's policy and procedure (P&P) titled, Housekeeping-general, dated 2/9/2024, the P&P indicated that housekeeping ensures the facility is clean, sanitary and in good repair at all times so as to promote the health and safety of residents, staff, and visitors. The Housekeeping Department uses a safe and proper method for cleaning, disinfecting and sterilizing all areas. All infectious wastes are disposed of in a proper and safe manner in accordance with the policies contained in the Infection Control Manual.

Based on observation, interview, and record review, the facility failed to ensure to safeguard the personal belongings for one of two sampled residents (Resident 2) by failing to: -Ensure Resident 2's clothing (in general) was labeled in accordance with the facility's policy and procedure titled Laundry-Resident clothing. This failure resulted in Resident 2's clothing to be unidentifiable, lost, and the potential to negatively affect Resident 2's dignity and right to keep personal property.Findings:During review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 6/24/2022 and readmitted the resident on 1/8/2025 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), and functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 2's History and Physical Examination(H&P) dated 1/6/2026, the H&P indicated Resident 2 had the diagnosis but not limited to dementia (a significant decline in memory, thinking, problem-solving and other cognitive skills that interferes with daily life). During a review of Resident 2's Minimum Data Set (a resident assessment tool) dated 6/3/2026, the MDS indicated Resident 2 could not recall and report correct day of the week. The MDS indicated Resident 2 was dependent (helper does all of the effort) for eating, oral hygiene, toileting, shower, toileting hygiene, lower and upper body dressing. During an interview on 6/9/2026 at 7:55 AM with Resident 2's family member, family member stated that they had brought in some clothing (unidentified) for Resident 2 which the facility was aware of and the items had gone missing.During a concurrent observation and interview on 6/9 /2026 at 10:31 AM with Housekeeping and Laundry (H&L) Supervisor inside the residents' room, Resident 2's closet had some hanging clothing inside and a black, long-sleeve, folded shirt not being labeled. H& L Supervisor stated Resident 2's clothing should be labeled by the facility staff with the resident's name to ensure identification and properly maintained to prevent loss. During an interview on 6/11/2026 at 10:41 AM with Certified Nursing Assistant 1 (CNA1), CNA 1 stated that all residents' clothing should be labeled (in general) with their names and when Resident 2's clothing (unidentified) was missing the Social Services Director was informed about it. During an interview on 6/11/2026 at 10:52 AM with the Social Services Director (SSD), the SSD stated that all staff were trained and informed about labeling the residents' (in general) belongings. The SSD stated that when belongings were lost, it could create emotional distress for families and residents, potentially affecting their overall quality of life and health. During an interview on 6/29/2026 at 10:57 AM with the Director of Nursing (DON), the DON stated that staff were educated to inventory and properly label residents' belongings to avoid frustration to both residents and families. During a review of the facility's policy and procedure (P&P) titled, Laundry-Resident Clothing, dated 2/9/2024, the P&P indicated that laundering of residents' personal clothing includes resident clothing is labeled in accordance with facility procedure and resident clothing should be clearly labeled with the resident's name. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2/9/2024, the P&P indicated that the resident's have the rights to retain and use personal possessions to the maximum extent that space and safety permit.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs of one of 15 sampled residents (Resident 34) by failing to:- Develop a care plan for Resident 34's breathing treatment (a nebulizer machine that turns liquid medicine into a mist for inhalation).This failure had the potential to result negative impact on Resident 34's health, as well as the quality of care and services received.Findings:During a review of Resident 34's admission Record, the admission Record indicated the facility admitted Resident 34 on 4/24/2026 with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should).During a review of Resident 34's Order Summary Report, dated 4/24/2026, the Order Summary Report indicated Resident 34 had a physician order for Ipratropium Bromide (breathing treatment medication that stops mucus and opens up airway) 0.02 percent (%) one unit via inhalation (breathing in) every four hours as needed for wheezing (whistling sound or coarse rattle sound when airway is partially blocked during inhalation) or shortness of breath (SOB).During a review of Resident 34's Minimum Data Set (MDS- a resident assessment tool), dated 4/30/2026, the MDS indicated Resident 34 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from moderate (helper does less than half the effort) to Supervision (helper provides verbal cues, touching and/or contact guard assistance as resident completes activity) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 34's COVID-19 (a respiratory illness that can spread from person to person) vaccine was not up to date.During a concurrent interview and record review on 6/8/2026 at 9:47 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 34's Medication Administration Record (MAR-facility report detailing the drugs administered to a resident by a licensed nurse) was reviewed from 5/1/2026 to 6/8/2026. The MAR indicated Ipratropium Bromide was administered on 5/29/2026 at 8:15 PM.During an interview with Registered Nurse 1 (RN 1) on 6/10/2026 at 10:25 AM, RN 1 stated and validated missing breathing treatment care plan for Resident 34. RN 1 stated the importance of having the breathing treatment care plan so facility could provide individualized care to Resident 34 such as monitoring for any issues such as wheezing, SOB and/or adverse reaction (harmful) after providing breathing treatment to Resident 34.During an interview on 6/11/2026 at 8:34 AM with the Director of Nursing (DON), the DON stated that breathing treatment should be care planned to guide them on how to properly care for Resident 34's respiratory needs.During a review of facility's policy and procedures (P&P) titled Care Planning reviewed on12/30/2025, the P&P indicated that a comprehensive care plan would be developed for each resident including measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. P&P also indicated that each comprehensive care plan will describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on interview, and record review, the facility failed to meet professional standards of care and practice for one of two sampled residents (Resident 37) by failing to ensure diet order was checked prior to serving Resident 37's lunch tray.This failure had the potential to negatively impact on the delivery of care service provided to Resident 37.Findings:During a review of Resident 37's admission Record, the admission Record indicated the facility admitted Resident 37 on 6/9/2024 with diagnoses including hypothyroidism (a condition in which the thyroid gland [a gland that controls hormones in the body] doesn't produce enough thyroid hormone), dysphagia (difficulty swallowing food or liquid), and generalized muscle weakness. During a review of Resident 37's History and Physical (H&P) dated 6/26/2025, the H&P indicated Resident 37 had the capacity to make decisions. During a review of Resident 37's Order Summary Report dated 12/1/2025, the Order Summary Report indicated Resident 37 had a physician order of no added salt level 6 (soft and bite-sized) texture and thin liquids consistency diet.During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 5/13/2026, the MDS indicated Resident 37 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from moderate (helper does less than half the effort) to setup assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).During a concurrent dining observation and interview on 6/8/2026 at 12:17 PM with Registered Nurse 1 (RN 1), the Director of Staff Development (DSD) and Certified Nursing Assistant 2 (CNA 2), observed CNA 2 provided lunch tray to Resident 37. CNA 2 stated that licensed nurses were supposed to check the trays first before handing them to the residents. Both the DSD and RN 1 stated both were supposed to check the food trays using the residents diet order list and comparing it to the tray and the meal prior to serving to the residents. The DSD stated the importance of checking the right diet order to ensure facility was providing the right diet order for the safety of the residents.During an interview on 6/8/2026 at 12:23 PM with the Director of Nursing (DON), the DON stated that it was best practice to check residents' tray with the updated diet list prior to providing meal tray to the residents.During a review of the facility's policy and procedure (P&P), titled, Meal Distribution, reviewed on 12/30/2025, the P&P indicated that nursing staff will be responsible for verifying meal accuracy to residents/patients.

Based on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for one of five sampled residents (Resident 34) reviewed for immunizations, by failing to:- Ensure to offer Resident 34 the pneumococcal (Pneumonia [PNA]-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccine, in accordance with facility policy and procedures (P&P) titled Pneumococcal Disease Prevention reviewed by the facility on 12/30/2025 and current standards of practice.This failure placed Resident 34 at a higher risk of acquiring pneumonia as well as other residents, visitors and staff within the facility.Findings:During a review of Resident 34's admission Record, the admission Record indicated the facility admitted Resident 34 on 4/24/2026 with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) During a review of Resident 34's Minimum Data Set (MDS- a resident assessment tool), dated 4/30/2026, the MDS indicated Resident 34 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from moderate (helper does less than half the effort) to Supervision (helper provides verbal cues, touching and/or contact guard assistance as resident completes activity) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). MDS also indicated PNA vaccine was not offered to Resident 34.During an interview on 6/10/2026 at 9:02 AM with Resident 34, Resident 34 stated he (Resident 34) did not remember if the PNA vaccine was offered to him upon admission.During a concurrent interview and record review on 6/11/2026 at 9:40 AM with Registered Nurse 1 (RN 1), Resident 34's immunization record was reviewed via CAIR (California Immunization Registry: secure web-based system that stores immunization records for children and adults in California) as of 6/10/2026. Resident 34's immunization record indicated last PNA vaccine was received on 10/4/2011 with recommendation for a second dose of PNA vaccine. Resident 34's medical record was reviewed, indicated no documentation that PNA vaccine was offered to Resident 34 prior to 6/11/2026. RN 1 stated that the previous infection preventionist nurse (unidentified) resigned and she (RN 1) recently started updating the resident vaccine log. RN1 stated she (RN1) did not have the time to offer the PNA vaccine to Resident 34. RN 1 stated that the facility was supposed to assess and offer PNA vaccine to all residents upon admission. RN 1 stated the importance of offering PNA vaccine since Resident 34 recently had PNA infection and was at risk for respiratory infection.During a review of facility's P&P, titled, Pneumococcal Disease Prevention reviewed by the facility on 12/30/2025, the P&P indicated that facility would provide education and offer the PNA vaccine to residents to prevent and control the spread of PNA disease in the facility.

Based on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for one of five sampled residents (Resident 34) reviewed for immunizations, by failing to:-Ensure to offer Resident 34 the COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) vaccine, in accordance with facility policy and procedures (P&P) titled COVID-19 Vaccination reviewed by the facility on 12/30/2025 and current standards of practice.This failure placed Resident 34 at a higher risk of acquiring COVID-19 as well as other residents, visitors, and staff within the facility.Findings:During a review of Resident 34's admission Record, the admission Record indicated the facility admitted Resident 34 on 4/24/2026 with diagnoses including chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should).During a review of Resident 34's Minimum Data Set (MDS- a resident assessment tool), dated 4/30/2026, the MDS indicated Resident 34 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from moderate (helper does less than half the effort) to Supervision (helper provides verbal cues, touching and/or contact guard assistance as resident completes activity) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). MDS also indicated Resident 34's COVID-19 vaccine was not up to date.During an interview on 6/10/2026 at 9:02 AM with Resident 34, Resident 34 stated he (Resident 34) did not remember if the COVID-19 vaccine was offered to him upon admission.During a concurrent interview and record review on 6/11/2026 at 9:40 AM with Registered Nurse 1 (RN 1), Resident 34's immunization record was reviewed via CAIR (California Immunization Registry: secure web-based system that stores immunization records for children and adults in California) as of 6/10/2026. Resident 34's immunization record indicated last COVID-19 vaccine was received on 7/12/2024 with recommendation for a seasonal dose of COVID-19 vaccine. Resident 34's medical record was reviewed, indicated no documentation that COVID-19 vaccine was offered to Resident 34 prior to 6/11/2026. RN 1 stated that the previous infection preventionist nurse (unidentified) resigned and she (RN 1) recently started updating the resident vaccine log. RN1 stated she (RN1) did not have time to offer the COVID-19 vaccine to Resident 34. RN 1 stated that the facility was supposed to assess and offer COVID-19 vaccine to all residents upon admission. RN 1 stated importance of offering COVID-19 vaccine since Resident 34 was at risk for respiratory infection.During a review of facility's P&P, titled, COVID-19 Vaccination reviewed by the facility on 12/30/2025, the P&P indicated that facility would provide education and offer the COVID-19 vaccinations to residents to reduce transmission of COVID-19.

Based on observation, interview, and record review, the facility failed to maintain accountability for 17 Percocet (an opioid pain medication used to relieve severe pain) tablets, schedule II Medications (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) for one of three sampled residents (Resident 1). This failure had the potential to result in a drug diversion (when a medication is taken for use by someone other than whom it is prescribed), opioid abuse (excessive use of a drug in a way that is detrimental to self, society, or both), and accidental overdose (unintentional intake or administration of a substance in doses higher than what is considered safe or recommended) for Resident 1 and or other residents. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 3/18/2025 with diagnoses including muscle weakness and spina bifida (a condition that affects the spine). During a review of Resident 1 ' s History and Physical Examination dated 3/19/2025, the History and Physical Examination indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Medication Administration Record (MAR) dated for 5/1/2025 to 5/31/2025, the MAR indicated an order for the resident to receive Percocet 10-325 milligrams (mg, a unit of measurement) one tablet by mouth every six hours as needed for severe pain. The MAR indicated the order was discontinued on 5/31/2025 at 3:59 pm. The inventory account indicated 17 Percocet tablets were not administered at the time of discontinuation and were unaccounted for. During a review of the facility ' s pharmacy Manifest form (document that records) dated 5/20/2025 indicated the facility ' s contracted pharmacy delivered 24 tablets of Percocet prescribed for Resident 1 on 5/20/2024. During a review of Resident 1 ' s Skilled Nursing Pharmacy Antibiotic or Controlled Drug Record between 5/20/2025 to 5/28/2025, the Skilled Nursing Pharmacy Antibiotic or Controlled Drug Record indicated the last Percocet administered to Resident 1 was on 5/28/2025 at 6:45pm. During a review of the facility ' s Narcotic Inventory list (a detailed document used to track the movement and management of drugs like opioids) dated 5/1/2025 to 5/31/2025 and 6/1/2025 to 6/4/2025, indicated the list was signed by outgoing (off duty) and incoming (on duty) nurses and did not indicate any discrepancies at each change of shift. The Narcotic Inventory sheet indicated Countable drugs are to be counted at each change of shift. The Last person whose name appears on the inventory sheet is responsible for the drugs. During a review of Resident 1 ' s MAR dated 6/4/2025 indicated seven Percocet 10-325 (medication dose) milligrams (mg-unit of measure) tablets were administered after 5/28/2025 at 18:45pm as follow: · 5/29/2025 at 5:00am and 7:30pm · 5/30/2025 at 2:00am, 8:14am and7:30pm · 5/31/2025 at 2:14am and 11:30 am. During an observation and interview on 6/4/2025 at 8:39 am, with Resident 1 inside Resident 1 ' s room, Resident 1 was awake and was well groomed. Resident 1 stated he (Resident 1) would receive the medications timely, and he (Resident 1) did not have any concerns. During a telephone interview on 6/4/2025 at 8:59am, with Licensed Vocational Nurse (LVN2), LVN 2 stated she (LVN2) carried out (completed) an order issued by Resident 1 ' s physician to discontinue Percocet for Resident1. LVN2 stated she (LVN2) informed LVN 3 (Resident 1 ' s medication nurse) of the discontinued Percocet order and they (LVN2 and LVN3) removed the skilled Nursing Pharmacy controlled drug record sheet wrapped it around the remaining Percocet medication ' s bubble pack (a type of packaging used to organize and dispense medications) and placed it at the back of the Narcotic box inside Med Cart 1. LVN2 indicated she did not carry out an inventory check of the remaining Percocet with LVN3 and was unable to state the number of Percocet medications left in the bubble pack. During a telephone interview on 6/4/2025 at 11:12 am, LVN 3 indicated she (LVN3) began her work shift on 5/31/2025 at 6:45am - 7:00pm and left work at approximately 8:30pm, LVN3 indicated she did not carry out an inventory check of the discontinued Percocet ' s with LVN2, LVN3 indicated the process for handling discontinued medication is to remove the medication from the med Cart, perform an inventory of remaining narcotic and to place the narcotics in a locked cabinet, LVN3 indicated she endorsed the Medication Cart 1 (Med Cart 1, a mobile storage unit used in healthcare settings to hold and transport medications) key to LVN4 at the end of her shift at 7 pm. LVN3 stated she (LVN3) did not remember carrying out an off duty narcotic inventory count with LVN4 on 6/1/2025 at the end of her shift at 7 pm. During a review of Cart 1 ' s Narcotic Inventory sheet dated 5/2025 indicated LVN3 signed off on the Narcotic inventory sheet on 5/31/2025 with on duty LVN4. The Narcotic Inventory sheet indicated there were no discrepancies were reported. During a telephone interview on 6/4/2025 at 11:42am with LVN4, LVN 4 stated she (LVN4) began her work shift on 5/31/2025 7pm to 6/1/2025 7 am, LVN4 stated she (LVN4) carried out a narcotic inventory count with LVN3 at the beginning of her shift on 5/31/2025 at 7pm. LVN4 stated there were no narcotic discrepancies. LVN4 stated she (LVN4) noticed there was a bubble pack of Percocet wrapped in a narcotic count sheet during the narcotic count. LVN4 stated she (LVN4) asked LVN3 about the Percocet tablet. LVN 4 stated LVN3 stated the Percocet medication had been discontinued. LVN4 stated on 6/1/2025 LVN6 arrived late for the 7am-3pm shift. LVN4 stated she (LVN4) left the Med Cart 1 key inside a drawer at the nursing station and clocked out at 7:13 am. LVN4 stated she (LVN4) did not do a narcotic inventory with LVN6. LVN4 stated she (LVN4) left the facility and assumed the incoming desk nurse Registered Nurse (RN1) who was also late for his shift would carry out the narcotic count with LVN6. During a telephone interview on 6/4/2025 at 12:40pm with RN, RN1 stated on 6/1/2025 he (RN1) worked the 7am to 3pm shift. RN1 stated he (RN1) arrived at work between 7:20 and 7:30am. RN1 stated when he (RN1) arrived at the facility LVN6 was on Med Cart 1 passing medications. RN1 stated LVN6 completed her (LVN6) shift and left at the end of her shift at 3 pm. RN1 stated LVN6 did not report any concerns and/or narcotic discrepancies to RN1. During a telephone interview on 6/4/2025 at 12:24pm with LVN6, LVN6 stated she (LVN6) arrived at the facility on 6/1/2024 at 7:07am for her 7am-3pm work shift. LVN6 stated she (LVN6) asked the charge nurses (LVN3 and LVN5) about her work assignment, and they (LVN3 and LVN5) told LVN6 she (LVN6) was assigned to Med Cart 1. LVN6 stated LVN3 had the key to Med Cart 1 and proceeded to carry out a narcotic count with LVN6. LVN 6 stated there were no discrepancies and LVN3 gave LVN6 the Med Cart 1 key after the Narcotic inventory count. LVN6 stated there was no narcotic sheet wrapped with discontinued bubble pack during the Narcotic Inventory count with LVN3. During a follow-up telephone interview on 6/5/2025 at 10:32 am with LVN3, LVN3 stated on the morning of 6/1/2025 she (LVN3) carried out a narcotic count with LVN 6 and handed over Med Cart 1 key to LVN6. LVN3 stated she (LVN3) did not mention to LVN6 that there was a narcotic sheet wrapped with discontinued Percocet bubble pack in the narcotic box. LVN3 stated she (LVN3) did not check if the Narcotic count sheet wrapped in discontinued Percocet Bubble Pack was still in the narcotic box. During an interview on 6/5/2025 at 12:15 pm Director of Nursing (DON), the DON stated a Licensed Nurse (in general) should only hand it (Medication Cart keys) over to another licensed nurse and/or supervisor when going on break or leaving the facility. The DON stated Medication Cart keys should never leave be left in a drawer unattended, because drawers were not secure and were accessible to anyone. The DON stated an unattended med cart key gave unaccounted access to all medications in the Medication Cart including narcotics. The DON stated an unauthorized person with access key could take narcotics lead to diversion, drug abuse and/or drug overdose. During a review of facility Policy and Procedure (P&P) titled Medication Storage in the facility dated 1/2025, the P&P indicated Schedule II-V medications and other medications subject to abuse are stored in a separate area under double lock. Medications nurse on duty maintains possession of the key to controlled medications storage areas. At each shift changed, a physical inventory of all controlled medications, including the emergency supply is conducted by tow licensed nurses and is documented on the controlled medications accountability record. Any discrepancy in controlled substance medication count is reported to the director of nursing immediately. Current controlled medication accountability records are kept at nursing station. When completed, accountability records are kept on file for 1 year at the facility. During a review of facility policy and procedure (P&P) titled Drug Diversion dated 01/2025 indicated, only authorized personnel may have access to controlled substances. The designated staff member(s) will be responsible for maintaining the controlled substance inventory, storage, and disposal. During a review of Licensed Vocational Nurse (LVN) job description, undated, indicated essential LVN responsibilities and job functions as: -Monitoring and removing any discontinued . medications from the medication carts. -Maintaining a current, accurate listing of all resident medications.

Based on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 5/20/2025 when: 1.Fortified Diets (Diet enriched to increase caloric content of the foods commonly consumed by the resident. The amount of calorie increase should be 300-400 per day) were not prepared and were not served to seven residents who were on a fortified diet. 2.The facility failed to ensure cooks followed the spreadsheet (food portions and serving guide) 14 residents on regular diet did not receive the seasoned peas (vegetable dish) on their plate per menu and residents who were on the renal diet (a diet intended for residents with decreased kidney function. This diet regulates the dietary intake of sodium, potassium, and protein to lighten the work of the diseased kidney.) received the three-bean salad instead of wheat roll with margarine per menu. These failures had the potential to result in meal dissatisfaction, decreased nutritional intake, and weight loss. Findings: During the tray line observation on 5/20/2025 at 11:45AM, residents who were on a fortified diet, Dietary Aide (DA1) did not communicate the fortified diet orders written on the meal tickets during tray line service for lunch. A review of resident's tray or meal tickets that were placed on the carts indicated the orders for fortified diets. DA1 did not read out loud the fortified diet and Cook1 who was serving the food did not add any additional food items per fortified menu. During a concurrent observation and interview with Cook1 and DA1 on 5/20/2025 at 12:45PM regarding diet fortification process, Cook1 stated when there was a fortified diet, melted butter or margarine was added to the vegetables. [NAME] 1 stated he did not hear any fortified diet and did fortify the meal. DA1 stated he forgot to read the fortified diet orders, forgot to read resident food likes and dislikes and the different diets such as renal or carbohydrate control (diet for residents with high blood sugar). DA1 stated this resulted in some residents being served food they (residents) did not like and not serving the ordered additional calories for the residents who were on a fortified diet. DA1 stated this could result in residents being unhappy with the food and weight loss. 2.According to the facility lunch menu for the regular diet on 5/20/2025, the following items would be served on the regular diet: Roast turkey 3 ounces (oz.-unit of measure); cranberry ginger citrus sauce; bread dressing 1/3 cup; seasoned peas ½ cup; three bean salad ½ cup; vanilla mousse chocolate chip garnish 1/3 cup; milk. Renal Diet: Roast Turkey with cranberry ginger citrus sauce; bread dressing 1/3 cup; seasoned peas ½ cup; Wheat Roll and margarine; applesauce for dessert ½ cup; beverage. During an observation of tray line service for lunch on 5/20/2025 at 11:45AM, residents who were on regular diet did not receive the seasoned peas and the residents who were on renal diet received the three-bean salad instead of the wheat roll and margarine. During a concurrent observation and interview on 5/20/2025 at 11:45AM with cook 1 and DA1, Cook1 stated the menu for 5/20/2025 was roast turkey with bread dressing. Residents on mechanical soft (food is chopped into smaller pieces and served soft) receive seasoned peas and the resident on a regular diet received the three-bean salad instead of the peas. During the same interview on 5/20/2025 at 11:45AM with DA1, DA1 stated he was not familiar with the menu and did not know if residents on regular diet should receive the seasoned peas along with the three-bean salad. DA1 stated every tray received the three-bean salad including the residents on renal diet. During a concurrent review of the spreadsheet and interview with Cook1 on 5/20/2025 at 12:45PM, Cook1 stated the residents on regular diet should receive the seasoned peas for their vegetable choice and they did not. Cook1 stated the residents on renal diet should have received the whole wheat roll with margarine and not the three bean salad. [NAME] 1 stated he did not review the spreadsheet and made mistakes during serving lunch. Cook1 stated residents on a regular diet received less food. During an interview on 5/202/2025 at 12:45PM with the DS and District manager (DM), the DS stated there were multiple mistakes during lunch service. The DS stated the residents on renal diet should have received the whole wheat bread with margarine instead of three bean salad. The DS stated the Renal diet should not have beans. The DS stated the plate looked empty for the resident (unidentified) on the regular diet who did not receive vegetables. During the same interview on 5/202/2025 at 12:45PM with the DM, the DM stated cooks (in general) should always review and follow the menu. The DM stated the staff (in general) should read all the notes and orders that were on the resident's meal ticket. During a dining observation in the residents dining room adjacent to the kitchen on 5/20/2025 at 1:15PM residents on a regular diet, their plate consisted of two items the roast turkey and bread dressing no vegetables. During a review of the facility's policy titled Menu (revised 10/2022) the policy indicated, Menus will be served as written, unless a substation is provided in response to preference, unavailability of an item. .

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food and preparation practices in the kitchen by failing to: 1. Ensure Dietary Staff Dietary Aide1 (DA1) washed his hands after changing gloves and when removing the clean and sanitized dishes from the dish machine when working in the kitchen. 2. Ensure to maintain a clean kitchen when the floor and shelving in the dry storage area were dirty, one package of dried pasta was open. The Coffee machine glass gauge pipe was stained with dark brown color residue. Resident dishes were not clean and had dried white and yellow stains on them. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 35 out of 36 residents who received food from the facility. Findings: 1.During an observation in the dishwashing area on 5/20/2025 at 9:45AM, DA1 was rinsing soiled dishes and loading the dirty dishes in the dish machine. DA1 had gloves on, and after the dish machine stopped DA1 removed soiled gloves and proceeded to remove the clean and sanitized dishes from the dish machine without washing hands. During a concurrent observation and interview with DA1 on 5/20/2025 at 9:55AM, DA1 stated he (DA1)did not wash his hands after removing gloves and before touching the clean dishes. DA1 stated he (DA1) needed to go to the handwashing sink to wash then return to pick up the clean dishes. DA1 stated that not washing hands could contaminate clean dishes. During a concurrent interview on 5/20/2025 at 9:55AM, with dietary supervisor (DS), the DS stated two staff members (unidentified) worked in the dishwashing area. The DS stated one staff member was responsible for dirty dishes and the other would remove the clean and sanitized dishes to avoid cross contamination. The DS stated the second staff was late assisting the dishwasher in removing the clean dishes. During a review of the facility's policy titled, Food: Preparation (Revised 2/2023), the policy indicated, All staff will practice proper hand washing techniques and glove use. During a review of the facility's policy titled, Ware washing (revised 2/2023), the policy indicated, All dishware, service ware, and utensils will be cleaned and sanitized after each use, all dishes will be air dried and properly stored. During a review of the 2022 U.S. Food and Drug Administration Food Code, Code 2-301.14 titled When to wash. The Code indicated, Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and E) After handling soiled equipment or utensils. 2. During an observation in the kitchen on 5/20/2025 at 10 AM, observed the coffee maker machine had glass gauge pipe in front of the machine. The pipes were half filled with coffee and there were dark brown stains inside the pipe. During a concurrent interview on 5/20/2025 at 10 AM with the DS, the DS stated the coffee machine was cleaned every week and the glass gauge/pipes should be cleaned with a special thin pipe brush. The DS looked at the coffee machine and stated the glass pipe was dirty. The DS did not find the special thin brush that was used to clean the glass pipe. The DS stated the stained and dirty coffee maker could contaminate the coffee and change the quality of the coffee. During an interview on 5/20/2025 at 10:05AM with Cook2 (Cook2), Cook2 stated he had never seen the brush and he had not tried to clean the coffee machine glass gauge/pipes. Cook2 stated he did not know how to access the inside of the coffee machine glass gauge for cleaning. During a review of the facility's policy titled, Equipment (revised 9/2017) the policy indicated, All equipment will be routinely cleaned and maintained in accordance with manufacture's direction and training materials. All staff members will be properly trained in the cleaning and maintenance of all equipment. During a review of facility's daily cleaning schedule log, the schedule indicated cleaning the coffee container, coffee pots and machine once a week and did not indicate cleaning the gauge and pipe. During an observation in the dry storage area on 5/20/2025 at 10:10AM, the floor behind the shelf was dirty with food particles, there was one bag of pasta with a date of 5/16/2025 stored on the shelf and the bag was open not sealed. During a concurrent observation and interview 5/20/2025 at 10:10AM, with the DS, the DS stated the dry storage room is cleaned and the floors are swept every day. The DS stated all items in the dry storage area should be labeled and packages sealed to prevent contaminants from going inside the food. The DS stated the pasta in the open bag would be discarded because it had been open and exposed to the environment. The DS looked under the shelf and stated there were food debris on the floor.The DS stated the floor behind the shelves had not been swept. The DS stated it was important to keep the floors and the food area clean to prevent attracting pests and harborage of pests. During a review of facility's policy titled Food Storage: Dry Goods (revised 2/2023) the policy indicated, All packaged and canned food items will be kept clean, dry and properly sealed. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. During an observation of the tray line service for lunch (a system of food preparation, in which trays move along an assembly line) on 5/20/2025, at 11:30AM, observed three serving plates were dirty with dried white and yellow food stains on them. During a concurrent interview on 5/20/2025, at 11:30AM, with Cook1, Cook1 stated he did not notice the dirt on the plates while waiting for service. Cook1 stated food should not be served on dirty plates. Plates were expected to be cleaned and sanitized. During an interview on 5/20/2025 at 11:35AM with the DS, the DS stated the plates were not clean and there was dried food debris stuck on them. The DS stated dishes should be scrubbed, rinsed and then loaded in the dish machine. The DS removed the dishes and instructed DA1 to rewash and scrub before loading in the dishwashing machine. The DS stated dirty dishes could contaminate food served on the plates. During a review of the 2002 U.S. Food and Drug Administration Food Code, code 3-304.11 titled Food Contact with Equipment and Utensils code indicated, Food shall only contact surfaces of: (A) Equipment and utensils that are cleaned and sanitized .Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized.

c.During a review of Resident 28's admission Record, the admission Record indicated the facility readmitted the resident on 1/8/2025 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's History and Physical (H&P) dated 1/9/2025, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 28's ADA dated 1/17/2025, the ADA indicated section 2 was not completed. During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 had the ability to understand others however missed some part/intent of the message but comprehended most of the conversation. During an interview on 5/20/2025 at 12:52 PM with Registered Nurse (RN) 1, RN 1 stated the social worker was supposed to follow up on the advance directives and that sometimes the licensed staff (in general) also would follow up. RN 1 stated the resident would need an advance directive upon admission and a new advance directive if readmitted . RN 1 stated the ADA form was not official if not signed by the resident or their representative. During an interview on 5/20/2025 at 12:53 PM with the SSD, the SSD stated that upon admission the advance directive must be signed, including upon readmission. The SSD stated Resident 28's advance directive was incomplete. During a concurrent interview and record review on 5/20/2025 at 12:55 PM with the SSD, the facility's policy and procedures (P&P) titled, Advance Directives dated 2/9/2024 was reviewed. The SSD stated the P&P indicated the admission staff or designee would obtain a [NAME] of a resident's advance directive.The SSD stated the P&P indicated a copy of the resident's advance directive would be included in the resident's medical record. The P&P indicated upon admission, the admissions staff or designee will provide written information to the residents concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. The SSD stated that the policy indicated the advance directive for Resident 28 should be done on admission and readmission. During an interview on 5/20/2025 at 1 PM with the ADM, the ADM stated that if the ADA form was incomplete, the facility would not know what the resident's wishes were. b.During a review of Resident 26's admission Record indicated the facility admitted the resident on 3/11/2021 with diagnoses that included vascular dementia (reduced blood flow to the brain leading to damage and death of brain cells) and metabolic encephalopathy (a dysfunction that disrupts the body's chemical processes and affect brain function). During a review of Resident 26's History and Physical dated 7/15/2024, the History and Physical indicated Resident 26 could make needs known but could not make medical decisions. During a review of Resident 26's Minimum Data Set (MDS, a resident assessment tool) dated 3/22/2025, the MDS indicated the resident was not oriented to year, month, or day and had poor recall. During an interview on 5/20/2025 at 11:19 AM with the Social Services Director (SSD), the SSD stated Resident 26 did not have an advance directive. The SSD stated Resident 26 did not have family or friends to be a representative. The SSD stated the Interdisciplinary Team (IDT, group of diverse health care professionals from different fields) could make decisions for Resident 26 per their policy. The SSD stated she (SSD) applied for a conservator for Resident 26 dated 5/2/2025. The SSD stated she (SSD) went back and forth with the public guardian department to determine if Resident 26 would be assigned a conservator. The SSD stated she (SSD) applied to the conservatorship due to the IDT team being Resident 26's only decision maker. During an interview on 5/21/2025 at 9:58 with the SSD, the SSD stated if a resident (in general) did not have the capacity to make decisions, the Bioethics Committee, which was made up of the members of the IDT team, could meet and determine Resident 26 was a full treatment and resuscitation. During an interview on 5/21/2025 at 10:28 AM with the Director of Nursing (DON), the DON stated if Resident 26 did not have an advance directive, then the resident would be considered a full code (a patient who chooses to be resuscitated if he or she stops breathing of if the heart stops beating). The DON stated it was difficult for the facility to determine what to do for the resident. The DON stated without an advance directive the facility did not know the wishes of Resident 26. During a review of the facility's policy and procedures (P&P) titled, Advance Directives dated 2/9/2024, the P&P indicated the admission staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. Upon admission, the admissions staff or designee will provide written information to the residents concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. Based on interview and record review the facility failed to ensure three of nine sampled residents (Resident 18, Resident 26, and Resident 28) had a documented advance directive (written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This failure had the potential for the facility not to know the wishes of Resident 18, Resident 26, and Resident 28. Findings: a. During a review of Resident 18's admission Record, the admission Record indicated the facility originally admitted the resident on 4/13/2018 and readmitted him on 7/13/2023 with diagnoses that included metabolic encephalopathy (change in how your brain works due to an underlying condition), dementia (a progressive state of decline in mental abilities) and a history of mental and behavioral disorders (conditions that affect how a person thinks, feels, and behaves). The admission Record indicated Resident 18 had a responsible party (a person who is named in as someone who the facility could reach for questions and to help make decisions for the resident) identified as Family Member 1 (FAM1). During a review of Resident 18's social worker progress note dated 11/9/2023, the social worker progress note indicated Resident 18's FAM1 was the resident's responsible party. During a review of Resident 18's History and Physical (H&P) dated 12/11/2024, the H&P indicated Resident 18 did not have the capacity to understand (ability to understand the meaning of something) and make decisions. During a review of resident 18's Advance Directive Acknowledgement (ADA, a form given to a resident that indicates the resident understands their options for an advanced directive [a legal document indicating resident preference on end-of-life treatment decisions]) dated 12/11/2024, indicated the resident, or their representative did not sign the form. The ADA indicated only the physician signed the form. The ADA indicated the initials on the following sections were blank: -The resident/representative had been given materials about their right to accept or refuse medical treatments. -The resident/representative had been informed of their rights to formulate (create) an advanced directive. -The resident/representative understood they were not required to have an advanced directive in order to receive medical treatment at the facility. -The resident/representative understood the terms of any advanced directive that they have executed (put into place) will be followed by the health care facility and the resident's caregivers to the extent permitted by law. During a review of Resident 18's Minimum Data Set (MDS, a resident assessment tool) dated 2/9/2025, the MDS indicated Resident 18's temporal orientation (ability to tell the year, month, and week) was impaired. The MDS indicated Resident 18 could not answer what day, month or year it was. The MDS indicated Resident 18 could not recall (remember) the words sock, blue, and bed when asked to repeat those words. The MDS indicated Resident 18's memory, orientation, and judgment were severely impaired. During a concurrent interview and record review on 5/20/2025 at 12:52 PM with Registered Nurse 1 (RN 1), Resident 18's ADA dated 12/11/2025 was reviewed. RN 1 stated the facility's social worker was supposed to follow up with the resident/resident representative for advanced directives. RN 1 stated the ADA was not signed by the resident or their representative. RN 1 stated the ADA form was not official if it was not signed by the resident or their representative. During a concurrent interview and record review on 5/20/2025 at 12:55 PM with the Social Services Director (SSD) the facility's policy and procedure (P&P) titled Advanced Directives, dated 2/9/2024 and the ADA dated 12/11/2024 was reviewed. The SSD stated the P&P indicated the facility would obtain (get) a copy of a resident's advanced directive upon admission and place it into the resident's medical record. The SSD stated the P&P indicated if a resident did not have an advanced directive, the facility would provide the resident and/or next of kin (is the closest living relative to someone who would step in if the person is unable to make decisions for themselves) with information about advanced directive upon admission. The SSD stated the ADA is not complete. The SSD stated the facility should have fille out Resident 18 ' s ADA when he was readmitted per the facility's policy. During an interview on 5/20/2025 at 1pm with the facility's Administrator (ADM), the ADM stated if Resident 18 ' s advanced directive was not completed the facility would not know what his end-of-life wishes were.

b. During a review of Resident 28's admission Record, the admission Record indicated the facility readmitted the resident on 1/8/2025 with diagnoses that included contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) on both knees, both ankles, both hands and right elbow, type 2 diabetes mellitus, quadriplegia 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 28's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 1/9/2025, for the resident to have a LALM for wound care and management. The order indicated for staff to check the LALM placement and function every shift. During a review of Resident 28's care plan titled, The resident has pressure relieving device: LAL mattress, dated 1/21/2025, the care plan indicated to Set device to appropriate setting related to resident ' s weight. During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 had the ability to understand others however Resident 28 missed some part/intent of the message but comprehends most of the conversation. The MDS indicated Resident 28 was dependent on others for going from sitting to lying position, lying to sitting on the side of the bed, and transferring from chair/bed to chair, toilet, and tub/shower. During a review of the facility's vitals for Resident 28 dated 5/2/2025, the vitals indicated Resident 28 weighed 153 lbs. During an observation on 5/19/2025 at 9:30 AM in Resident 28's room, Resident 28's LALM pump located at the food of her bed was observed to be set to 230 lbs. A sticker to the left of the pump indicated the LALM should be set to 150-180 lbs. During an interview on 5/19/2025 at 9:35 AM with the Certified Nurse Assistant (CNA) 1, CNA 1 stated they (CNAs in general) were not allowed to touch the buttons on the LALM pump. During an interview on 5/19/2025 at 9:37 AM with the Infection Control Nurse(IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), the IP stated the LALM must have been disconnected by the maintenance personnel (unidentified) while on break because before going on break, the bed was at the correct setting. During an interview on 5/19/2025 at 9:41 AM with the IP, the IP stated the LALM was used to prevent sores on the buttocks, elbows, and other body parts with bony prominences. The IP stated if the LALM was not within the proper range, it could not achieve their goal. The IP stated the LALM was set to 230 lbs., and it should have been lower since Resident 28 weighed 153 lbs. The IP stated the bed could be too hard for Resident 28, which could cause pressure sores. During an interview on 5/19/2025 at 9:45 AM with the Maintenance Director (MD), the MD stated the LALM was never unplugged because he (MD) was working on finding a solution for the feeding machines cords to reach the outlet. During an interview on 5/20/2025 at 8:59 AM with the TX, the TX stated the LALM should be set based on the resident's weight. The TX stated the LALM settings were evaluated daily to ensure it was functioning properly and to ensure the LALM had the correct setting. During an interview on 5/20/2025 at 9:08 AM with the TX, the TX stated she (TX) was not sure what the facility's LALM policy and stated the licensed nurses (in general) set the pump setting based on the resident ' s weight and make sure that it was working properly. The TX stated if there were any issues with the LALM the facility would call the manufacturer. During an interview on 5/20/2025 at 9:25 AM with the Director of Nursing (DON), the DON stated that if the LALM is too hard, it could cause a wound ulcer, slow wound healing or make a wound ulcer worse. During a review of the LALM manufacturer guidelines titled, Proactive medical products Operation Manual for Proteckt® Aire 6000, dated 10/25/2023, the manufacturer guidelines indicated the LALM was selected by patients weight guide listed on the panel providing pressure change options. The manufacturer guideline indicted users can adjust the air mattress to a desired firmness according to the patient ' s weight and comfort. Based on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure injuries [localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device]) settings for two of six sampled residents (Resident 6 and Resident 28). This failure had the potential to place Resident 6 and Resident 28 at risk for discomfort and worsening of wounds and pressure ulcers/injuries Findings: a. During a review of Resident 6's admission Record, the admission Record indicated the facility readmitted the resident on 2/28/2025 with diagnoses that included right buttock (butt) pressure ulcer stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), left hip pressure ulcer stage 3 (a deep wound that has broken through all layers of the skin and into the fat tissue underneath, but not yet to the muscle, bone, or tendon), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 6's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 2/28/2025, for the resident to have a LALM for skin management. The Order Summary Report indicated for staff to check the LALM placement and function every shift. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool) dated 3/5/2025, the MDS indicated Resident 6 had the ability to understand others and had the ability to make herself understood. The MDS indicated Resident 6 was dependent on others for toileting (going to the bathroom), dressing, putting on/taking off footwear, showering, rolling left and right, going from sitting to lying position, and transferring from chair to chair. During an review of the facility's SBAR (a simple communication tool, often used in healthcare, that breaks down a message into four key parts: Situation, Background, Assessment, and Recommendation) Communication dated 3/19/2025, the SBAR Communication indicated Resident 6's right ischium (one of the three bones that make up each hip bone, forming the lower and back part) stage 4 pressure ulcer depth had increased in size. Previous measurements: 1.5 x 1.4 x 3.9 (the length, width, and depth of a wound/ulcer measured in inches). Most recent measurements: 1.4 x 1.2 x 6.9). During a review of Resident 6's care plan titled, the resident has pressure relieving device: LAL mattress, dated 3/28/2025, the care plan indicated to set device to appropriate setting related to residents' weight. During a review of the facility's vitals (group of measurements) record for Resident 6 dated 5/2/2025, the vitals record indicated Resident 6 weighed 135 pounds (lbs.). During an observation on 5/20/2025 at 8:35 AM in Resident 6's room, Resident 6's LALM pump located at the foot of her bed was observed to be set to 230 lbs. A sticker to the left of the pump indicated the LALM should be set to 130 lbs. During an interview on 5/20/2025 at 8:59 AM with the treatment nurse (TX), the TX stated Resident 6's LALM should be set based on Resident 6's weight. TX stated she (TX) evaluated Resident 6's LALM settings daily to ensure it was functioning properly and to ensure the LALM had the correct setting. The TX nurse stated she (TX) did not know what Resident 6's LALM was set to and would need to go to Resident 6's room to check. During an interview on 5/20/2025 at 9:06 AM with the TX, the TX stated Resident 6's LALM was set to 180 and stated Resident 6 weight 135 lbs. The TX stated Resident 6's LALM should have been set to 130. The TX stated she (TX) was not sure what the facility's LALM policy stated and stated the licensed nurses (in general) were responsible to check the LALM function and settings. The TX stated if there were any issues with the LALM the facility would call the manufacturer.

Based on observation, interview, and record review, the facility failed to inform two of three sampled residents (Resident 24 and Resident 250) of the medications that were administered to them during medication pass, as per facility's policy and procedure (P&P), titled Medication Administration - General Guidelines, dated 10/2017 and nurses' education document, titled Principles of Medication Administration, dated 2/5/2025. This deficient practice failed to provide information about medications to Resident 24 and Resident 250 before administering them. Findings: a. During a review of Resident 24's admission Record (a document containing demographic and diagnostic information), dated 5/21/2025, the admission Record indicated the facility originally admitted Resident on 2/26/2021 and readmitted the resident on 3/2/2021 with diagnoses including, but not limited to, hypertensive (high blood pressure) heart disease without heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), other iron deficiency (low level of iron) anemias, hyperlipidemia (a medical condition with high level of lipids [fatty compounds] in the blood), Type 2 Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood glucose level), paranoid Schizophrenia (a mental illness that is characterized by disturbances in thought), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs type) and anxiety disorder. During a review of Resident 24's Minimum Data Set (MDS, a resident assessment tool) dated 3/9/2025, the MDS indicated Resident 24 had severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought and senses). The MDS indicated Resident 24 needed setup or clean-up assistance from the facility staff for performing activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, oral hygiene, toileting and upper body dressing, and supervision level assistance for showering, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 5/20/2025 at 8:55 AM with Licensed Vocational Nurse1 (LVN 1) in Resident 24's room, LVN 1 checked Resident 24's blood pressure. LVN 1 stated Resident 24's blood pressure reading was systolic blood pressure (SBP, the pressure caused by heart while contracting) of 122 millimeters of mercury (mmHg, a measurement of pressure) and diastolic blood pressure (DBP the pressure in the arteries when the heart rests between beats) of 70 mmHg, and heart rate was 74 beats per minute. During a concurrent observation and interview on 5/20/2025 at 8:55 AM, LVN 1 did not identify medications by their name and/or explain their purpose and indications to Resident 24 before he (Resident 24) took his medications. LVN 1 prepared and administered the following nine medications to Resident 24: 1. One tablet of benztropine (a medication used to treat extrapyramidal symptoms [movement disorders caused by use of antipsychotics]) 2 milligrams (mg, a unit of measurement for mass). 2. One tablet of docusate sodium (a medication used to treat constipation) 100 mg. 3. One capsule of fish oil (a medication used to treat high level of lipids) 1000 mg. 4. One capsule of hydrochlorothiazide (a medication used to treat high blood pressure) 12.5 mg. 5. One-half tablet of metoprolol succinate (a medication used to treat high blood pressure) extended release (ER) 25 mg (dose of 12.5 mg). 6. One tablet of multivitamin. 7. One tablet of risperidone (a medication used to treat schizoaffective disorder) 3 mg. 8. One tablet of vitamin C (a vitamin used to treat low level of vitamin C) 500 mg. 9. One tablet of vitamin D3 (a vitamin used to treat low level of vitamin D) 25 micrograms (mcg - a unit of measurement for mass). During a medication reconciliation (a process of comparing medications) review on 5/20/2025 at 11:13 AM, Resident 24's Order Summary Report (a document containing a summary of all active physician orders), dated 5/21/2025 was reviewed. The Order Summary Report indicated but not limited to the following physician orders: 1. Benztropine mesylate tablet 2 mg give one tablet by mouth two times a day for extrapyramidal and movement disorder, order date 2/26/2021, start date 02/26/2021. 2. Docusate sodium oral tablet 100 mg, give one tablet by mouth one time a day for bowel management, hold for loose stools, order date 1/6/2024, start date 1/7/2024 3. Fish oil 1000 mg soft gel, give 1000 mg by mouth one time a day for supplement, order date 5/19/2025, start date 5/20/2025 4. Hydrochlorothiazide capsule 12.5 mg, give one capsule by mouth one time a day related to hypertensive heart disease without heart failure, hold if SBP is less than 110 or pulse rate less than 60, order date 9/1/2022, start date 9/2/2022. 5. Metoprolol succinate ER oral tablet, give 12.5 mg by mouth one time a day related to hypertensive heart disease without heart failure, hold if SBP <110 or pulse rate <55, order date 1/10/2024, start date 1/11/2024. 6. Multivitamins tablet, give 1 tablet by mouth one time a day for supplement, order date 2/26/2021, start date 2/27/2021. 7. Risperidone tablet 3 mg, give one tablet by mouth two times a day for paranoia that people are out to hurt him related to paranoid schizophrenia, order date 2/26/2021, start date 2/26/2021. 8. Vitamin C tablet 500 mg, give one tablet by mouth two times a day for supplement, order date 2/26/2021, start date 2/26/2021. 9. Vitamin D3 tablet 25 mcg, give 1 tablet by mouth one time a day for supplement, order date 2/26/2021, start date 2/27/2021. b. During a review of Resident 250's admission Record, the admission Record indicated the facility admitted Resident 250 on 5/1/2025 with diagnoses including unilateral primary osteoarthritis (inflammation and pain in joints) right knee, polyneuropathy (nerve pain), essential primary hypertension and other abnormalities of gait and mobility. During a review of Resident 250's History and Physical, dated 5/3/2025, the History and Physical indicated Resident 250 had the capacity to understand and make decisions. During a concurrent observation and interview on 5/20/2025 at 9:38 AM with LVN 1 in Resident 250's room, LVN 1 checked Resident 250's blood pressure. LVN 1 stated Resident 250's blood pressure reading was SBP of 138 mmHg and DBP of 76 mmHg, and heart rate was 82 beats per minute. During a concurrent observation on 5/20/2025 at 9:38 AM LVN 1 did not identify medications by their name and/or explain their purpose and indications to Resident 250 before he took his medications. LVN 1 prepared and administered the following 13 medications to Resident 250: 1. One tablet of amlodipine (a medication used to treat high blood pressure) 10 mg. 2. One capsule of celecoxib (a medication used to manage osteoarthritis) 200 mg. 3. One capsule of docusate sodium 100 mg. 4. One tablet of ferrous sulfate (a medication used to treat low level of iron) 325 mg. 5. One capsule of fish oil 1000 mg. 6. One tablet of folic acid (a vitamin used to treat low level of B vitamin) 1 mg. 7. One tablet of metoprolol tartrate 100 mg. 8. One tablet of multivitamin with minerals. 9. One capsule of tamsulosin (a medication used to treat benign prostatic hyperplasia ([BPH] a medical condition for prostate) 0.4 mg. 10. One tablet of lisinopril (a medication used to treat high blood pressure) 40 mg. 11. One tablet of vitamin C 500 mg. 12. One tablet of vitamin D3 125 mcg (5000 international units ([IU] a measurement for dose). 13. 30 mg of enoxaparin (a medication used to prevent blood clots) sodium injection 30 mg per 0.3 milliliters ([mL] a unit of measurement for volume) injected subcutaneously (under the skin). During a medication reconciliation review on 5/20/2025 at 11:13 AM, Resident 250's order summary report, dated 5/21/2025 was reviewed. The Order Summary Report indicated the following physician orders: 1. Amlodipine besylate oral tablet 10 mg, give 1 tablet by mouth one time a day for HTN hold for SBP <110, order date 5/1/2025, start date 5/2/2025. 2. Celecoxib oral capsule 200 mg, give 1 capsule by mouth two times a day for swelling/pain for right knee arthroplasty, order date 5/1/2025, start date 5/1/2025. 3. Docusate sodium soft gel, give 100 mg by mouth two times a day for bowel management prophylaxis, order date 05/19/2025, start date 5/19/2025. 4. Enoxaparin sodium injection solution prefilled syringe 30 mg/0.3 mL, inject 30 mg subcutaneously two times a day for deep venous thrombosis (DVT, a medical condition with blood clot in extremities like legs, which can lead to stroke [loss of blood flow to a part of the brain]) alternate site, order date 5/1/2025, start date 5/1/2025. 5. Ferrous sulfate tablet 325 (65 Fe [iron]), give 1 tablet by mouth two times a day for supplement, order date 05/09/2025, start date 5/10/2025. 6. Fish oil 1000 mg soft gel, give 1000 mg by mouth one time a day for supplement, order date 5/19/2025, start date 5/20/2025. 7. Folic acid 1 mg, give 1 tablet by mouth one time a day for supplement, order date 5/5/2025, start date 5/6/2025. 8. Lisinopril oral tablet 40 mg, give 1 tablet by mouth one time a day for HTN hold for SBP<110, order date 5/1/2025, start date 5/2/2025. 9. Metoprolol tartrate oral tablet, give 1 tablet by mouth two times a day for HTN hold for SBP <110 and HR <60, order date 5/1/2025, start date 5/2/2025. 10. Multivitamin-minerals oral tablet, give 1 tablet by mouth one time a day for supplement, order date 05/15/2025, start date 5/16/2025. 11. Tamsulosin hydrochloride (HCl) oral capsule 0.4 mg, give 1 capsule by mouth one time a day for BPH, order date 05/01/2025, start date 5/2/2025. 12. Vitamin C oral tablet 500 mg, give 1 tablet by mouth one time a day for supplement, order date 05/15/2025, start date 5/16/2025. 13. Vitamin D3 tablet 125 mcg (5000 IU), give 1 tablet by mouth one time a day for supplement, order date 5/5/2025, start date 5/6/2025. During an interview on 5/20/2025 at 12:49 PM with LVN 1, LVN 1 stated while administering medications to Resident 24 and Resident 250, she (LVN1) would explain to the residents if they were receiving blood pressure medications. LVN 1 stated the facility's policy usually stated to explain if residents were getting new medications. LVN 1 stated since she had been giving medications for a long time and residents were familiar with the medications it was not necessary to explain those medications. During an interview on 05/21/2025 at 12:22 PM with the Director of Nursing (DON), the DON stated the facility nurses (in general) should have identified the name of medications, their indication and possible side effects to the residents during medication administration. The DON stated the nurse should have explained the medications (for example, risperidone), to the residents who were alert and oriented. The DON stated it was important to receive consent from residents before administering medications. The DON stated the facility staff were instructed to explain medications to residents during a recent in-service (education) conducted at the facility. The DON stated it would be a part of ensuring resident rights policy that all residents Especially who are alert and oriented were informed of the medications being administered to them. During a review of the facility's nurses' education document titled, Principles of Medication Administration, dated 2/5/2025, the document indicated, Administration Phase: involves diligent clinical judgement, decision making and full understanding of medication(s) and their side effects. Explain each procedure to the resident before performing them. During a review of the facility's P&P titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 02/09/2024, the P&P indicated, All residents have a right to a dignified existence and communication with and access to persons and services inside and outside the facility including those specified in this policy.

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. On 5/20/2025 at 10:30AM one of the two garbage dumpsters was overfilled with trash bags and uncovered. This failure had the potential for harborage and feeding of pests. Findings: During a concurrent observation and interview with the Dietary Supervisor (DS) and the Maintenance Supervisor (MS) on 5/20/2025 at 10:30AM, one large dumpster outside of the kitchen back door was not covered. The dumpster was overfilled with trash bags and not covered.There was another large trash dumpster that was behind gates and not accessible to staff. During a concurrent interview on 5/20/2025 at 10:30AM with the DS and the MS, the DS stated trash should be covered so flies did not accumulate around the trash areas. During the same interview on 5/20/2025 at 10:30AM with the MS, The MS stated trash was picked up three times a week. The MS stated the large dumpster that was behind the gate was empty and it should be accessible to staff to throw away trash instead of overfilling one dumpster with lid open. The MS stated all trash lids should be covered to prevent from attracting flies and pests in the facility. During a review of the facility's policy titled, Garbage and Trash (dated 2023) the policy indicated, Garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. A review of Food and Drug Administration (FDA) Food Code 2022, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

Based on interview and record review the facility failed to investigate and determine how a resident got out of the facility for one of three sampled residents (Resident 1). For Resident 1, who was found in the facility ' s parking lot on 4/13/25, the facility failed to determine how Resident 1 left her room unattended and was found in the facility ' s parking lot. This deficient practice had the potential for Resident 1 to leave the facility unattended again and potentially be exposed to danger. Findings: During a review of the Admission Record indicated the facility initially admitted Resident 1 on 2/25/14 and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder. During a review of Resident 1 ' s Minimum Data Set (MDS, a resident screening tool) dated 1/22/25 indicated Resident 1 had moderately impaired cognitive skills. Resident 1 needed supervision with shower/bathe self, set-up or clean-up assistance with oral hygiene/toileting hygiene, upper/lower body dressing, putting on/taking off footwear, personal hygiene and independent with eating. During a review of Resident 1 ' s Elopement Risk assessment dated [DATE] at 3:43 p.m., indicated Resident 1 had intermittent confusion, ambulatory and was at risk for elopement. During an interview on 4/24/25 at 9:04 a.m., guard 1 stated Resident 1 was found in the parking lot on 4/13/25. Guard 1 stated the facility ' s location is not in a very good neighborhood. Guard 1 stated Resident 1 can be exposed to danger when Resident 1 leaves the facility unattended. During a telephone interview, on 4/24/25 at 10:08 a.m., guard 2 stated he saw Resident 1 standing in the parking lot adjacent to the facility. Guard 2 stated he does not know how Resident 1 got to the parking lot but thinks that Resident 1 may have exited from the window of Resident 1 ' s room. Guard 2 stated he escorted Resident 1 back inside the facility. During a telephone interview on 4/24/25 at 10:30 a.m., licensed vocational nurse (LVN) 1 stated Resident 1 was found in the parking lot on 4/13/25. LVN 1 stated she does not know how long Resident 1 was in the parking lot. LVN 1 stated guard 2 found Resident 1 in the parking lot and escorted Resident 1 back inside the building. LVN 1 stated she did not document because Resident 1 was found in the facility property. LVN1 stated it is important to monitor Resident 1 ' s whereabouts because Resident 1 was a wanderer and to ensure Resident 1 is safe. During an interview on 4/24/25 at 11 a.m., the director of nursing (DON) stated LVN 1 notified the DON that Resident 1 was found in the parking lot. DON stated he does not know how Resident 1 left her room and was found in the parking lot. DON agreed there was no documentation of the incident. During an interview on 4/24/25 at 12:36 p.m., the administrator (ADM) stated the facility did not investigate how Resident 1 left her room and was found in the facility parking lot. ADM stated there was no red flag because Resident 1 was found within the facility property. During a review of the facility's policy and procedures (P&P) titled Safety and Supervision of Residents revised on 7/24, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision, and assistance to prevent accidents are facility-wide priorities. The same Policy indicated our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive devices.

Based on observation, interview, and record review the facility failed to provide protection from physical abuse for one out of three sampled residents (Resident 2), by failing to: 1. To follow facility policy and procedures (P&P) titled Behavior-Management, dated 2/9/2024, and document Resident 1's specific identified aggressive behaviors. Resident 1 had aggressive behaviors 17 out of 28 days in February 2025, the type of aggressive behaviors was not documented. 2. Update care plan and interventions to address increase in aggression and behavioral changes quarterly and with changes in condition (COCs) and after identified aggressive behaviors as per facility P&P titled Behavior-Management dated 2/9/2024, and P&P titled Care Planning dated 2/9/2024. As a result on 2/25/2025, Resident 1 hit Resident 2 on the chest, after Resident 2 refused to give Resident 1 money. This deficient practice had the potential for Resident 2 to feel unprotected and suffer physical and/or psychosocial harm (any situation or factor that can negatively impact someone's mental health, well-being, or emotional state). Findings: During a review of Resident 1's admission record, the admission record indicated the facility originally admitted the resident on 8/17/2021 and readmitted the resident on 7/22/2024, with the diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), generalized anxiety disorder (you are worrying constantly and can't control it), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 2/22/2025, the MDS indicated Resident 1 had the ability to make himself understood and had the ability to understand others. The MDS indicated Resident 1 hallucinated (when you experience something seeing, hearing, smelling, tasting, or feeling something that isn't there, but your mind believes it is real). During a review of Resident 1's history and physical (H&P) dated 7/23/2024, the H&P indicated Resident 5 was anxious, had a labile affect (someone experiences unpredictable and rapid shifts in their emotions, often seeming out of proportion to the situation), and had paranoid/persecutory delusions (fixed, false beliefs that someone is being harmed, harassed, or conspired against, despite proof or information that shows something is not true). The H&P indicated Resident 1 had a history of aggression, insomnia (trouble falling asleep or staying asleep), inadequate attention/concentration (having trouble focusing on tasks, easily getting distracted, and struggling to maintain your focus for any length of time), with impaired judgement (when someone struggles to make good decisions or understand the consequences of their actions, potentially leading to risky or inappropriate behavior) and impaired insight (when someone struggles to understand or recognize that they have a mental health problem or that their behavior is abnormal, even when it's obvious to others). The H&P indicated diagnoses of bipolar disorder and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). The H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's psychiatric progress note dated 12/5/2025, the psychiatric progress note indicated Resident 1 had intermittent (something that happens on and off) auditory (relating to or involving the sense of hearing) hallucinations, partially impaired (difficulty controlling) impulse control, insight, and judgement. The psychiatric progress note indicated Resident 1 was a high risk for decompensation (a person starts to experience a worsening of their symptoms and struggles to cope) if Resident 1's medication was lowered or discontinued. During a review of Resident 1's facility's situation, background, assessment and recommendation (SBAR) report dated 2/25/2025, the SBAR indicated Resident 2 was in his wheelchair at the doorway of the room he shared with Resident 1. The SBAR indicated Resident 1 approached Resident 2 and indicated Resident 1 told Resident 2 he was not going to let him fuck with him. The report indicated Resident 2 got up and Resident 1 hit him on the left side of his chest. The SBAR indicated Resident 1's physician ordered the facility to transfer Resident 1 to the hospital for behavior evaluation. During a review of Resident 1's physician Order Summary Report (OSR) dated 3/3/2025, the OSR indicated the facility was to give Resident 1 Haloperidol (a medication used to treat nervous, emotional, and mental conditions like schizophrenia) 5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) three times a day for schizophrenia and to monitor Resident 1 for aggressive and confrontational (behaving in an angry or unfriendly way that is likely to cause an argument) behavior toward staff. During a review of Resident 1's care plan titled, The resident has altered (changed or modified in some way) behavior problems and schizophrenia, dated 7/23/2025, the care plan indicated the staff were to focus on Resident 1's aggressive and confrontational behavior towards staff, the resident's repetitive health concerns, hearing voices, talking to self, and poor impulse control (struggling to resist urges or acting without thinking about the consequences, often leading to actions that are harmful). The care plan goal was for Resident 1 to have a decrease in aggressive behaviors. The care plan interventions included giving Resident 1 Lurasidone (used to treat symptoms of mental disorders, such as schizophrenia) 40 mg, Haloperidol 5 mg, Ativan (a medication to treat anxiety) 0.5 mg, and Depakote Delayed Release Tablet (treat manic [abnormally elevated or irritable mood, increased energy and activity, and potentially impulsive or risky behaviors] episodes (something that happens) related to bipolar disorder in adults) 500 mg. The care plan indicated the interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) were last updated 7/23/2024 During a review of Resident 1's care plan titled, the resident is on antipsychotic medication (a class of drugs used to treat symptoms of psychosis like hallucinations and delusions, primarily in conditions like schizophrenia and bipolar disorder) for episodes of delusions dated 7/2/23/2025, the care plan indicated a goal for Resident 1 to limit his aggressive behavior to zero to one episode of aggressive and confrontational behavior toward staff a day or zero to one episode a week. The care plan interventions included encouraging Resident 1 to be involved in activities, for staff to listen to Resident 1 and address concerns, for staff to refocus Resident 1's inappropriate behavior (offensive behavior), and to monitor the side effects of antipsychotic medication. The care plan also indicated the staff would monitor Resident 1's behavior and summarize it monthly for the physician to evaluate. The care plan indicated the interventions were last updated 7/23/2024. During a review of Resident 1's Medication Administration Record (MAR), date the month of February 2025, the MAR indicated Resident 1 initially had an order for Haloperidol 5 mg by mouth twice a day then Resident 1's physician increased the Haloperidol to 5 mg three times a day on 2/25/2025. The MAR indicated the facility documented Resident 1 had aggressive behavior toward staff as follows: Day shift Resident 1 had one instance of aggressive behavior on 2/1/2025, 2/2/2025, 2/4/2025, 2/5/2025, 2/11/2025, 2/12/2025, 2/13/2025, 2/14/2025, 2/15/2025, 2/17/2025, 2/20/2021, 2/21/2025, 2/22/2025, 2/23/2025, 2/24/2025, and 2/28/2025. Evening shift Resident 1 had one instance of aggressive behavior on 2/1/2025, 2/3/2025, 2/4/2025, 2/13/2025, 2/14/2025, 2/15/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/27/2025, and 2/28/2025. Night shift Resident 1 had one instance of aggressive behavior on 2/3/2025, 2/4/2025, 2/13/2025, 2/19/2025, 2/20/2025, 2/25/ 2025, 2/26/2025, and 2/27/2025. During a concurrent observation and interview on 3/3/2025 at 12:32 PM with Resident 1 in Resident 1's room, Resident 1 was observed to be irritable (easily annoyed, frustrated, or angered, and may react with a short temper or quick impatience). Resident 1 stated he was arguing with Resident 2 when Resident 2 got up from his wheelchair and Resident 1 thought Resident 2 was going to hit him. Resident 2 stated he then hit Resident 1. During a review of Resident 2's admission record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with the diagnoses of multiple rib fractures (broken bones) on the left side, pneumonia (an infection of the lungs), history of falls, and unspecified fracture of the lumbar vertebra (a break or crack in one of the bones in your lower back). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to make himself understood and had the ability to understand others. The MDS indicated Resident 2 did not have any behavior issues. The MDS indicated Resident 2 used a walker and a wheelchair. During a review of Resident 2's H&P dated 11/8/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. The H&P indicated Resident 2 had rib fractures and a history of falls. During a review of Resident 2's care plan titled, resident to resident altercation, dated 2/25/2025 indicated the goal of the care plan was for Resident 2 to feel safe. The care plan interventions included anticipating Resident 2's needs, getting a psychiatric consultation (evaluation), intervening (to become involved in a situation to try and change it, often to help or improve it, or to stop something from happening) to protect resident rights and safety, and monitoring/modifying (changing) behaviors. During a review of Resident 2's SBAR dated 2/25/2025, the SBAR indicated Resident 2 was sitting in his wheelchair at the doorway in the room he shared with Resident 1. The SBAR indicated Resident 1 approached Resident 2 and stated, you want to fuck with me but I'm not going to let you. The SBAR indicated Resident 2 stood up and Resident 1 raised his hand and struck Resident 2 on the left side of his chest. The SBAR indicated Resident 2 lost his balance and sat on the trash can behind him. The SBAR indicated the RN supervisor placed herself between the residents. The SBAR indicated both residents were moved to different rooms. The SBAR indicated Resident 2's physician was notified, and an order was received for a psychiatric evaluation. During a review of Resident 2's psychiatric evaluation dated 2/25/2025, the psychiatric evaluation indicated Resident 1 had an altercation with another resident. The psychiatric evaluation indicated Resident 2 was frequently approached by a resident (Resident 1) asking Resident 2 for money and when the resident said no, the other resident (Resident 1) became angry. The psychiatric evaluation indicated Resident 2 had no previous psychiatric history. During a concurrent observation interview on 3/3/2025 at 12:23 PM with Resident 2 in front of Resident 2's room, Resident 2 stated Resident 1 asked him for money for soda and Resident 2 refused to give Resident 1 money. Resident 2 stated Resident 1 left and then came back and stated Resident 1 was upset so Resident 2 stool up from his seat and was immediately hit in the chest by Resident 1. Resident 2 stated he did not sustain any injuries. An observation of Resident 2's chest did not show and bruising, redness, or visual signs or injury. During a review of the facility's Follow-Up Investigation Report dated 3/2/2025, the report indicated Registered Nurse Supervisor 1 (RNS 1) witness Resident 1 struck Resident 2 in the chest causing Resident 2 to lose his balance and then sat himself on the trash can behind him. The report indicated Resident 2 usually gave Resident 1 a dollar when Resident 1 asked him for money. The report indicated on 2/25/2025 Resident 1 asked Resident 2 for money but Resident 2 refused and Resident 1 became upset. The report indicated Resident 2 was moved to a different room. The report indicated the facility transferred Resident 1 to the hospital for psychiatric evaluation and treatment. During an interview on 3/3/2025 at 12:47 PM with the Director of Rehabilitation (DR), the DR stated she saw Resident 1 on the day of the incident (2/25/2025), come out of his room and was upset and rambling (talking in a way that is long-winded, confused, and often wanders off the main topic). She stated Resident 1 went back to the room Resident 1 and Resident 2 shared. She stated she saw Resident 2 stand up and saw Resident 1 take a swing at Resident 2. During an interview on 3/3/2025 at 3:42 PM with the Director of Nursing (DON), the DON stated the facility staff had been documenting Resident 1's behavior on the MAR, Resident 1's Haloperidol was increased from 5 mg twice a day to 5 mg three times a day on 2/26/25, the day after Resident 1 hit Resident 2. The DON stated the facility did not call the doctor right away because the facility would report it to the doctor at the end of the month. The DON stated Resident 1's behavior was normal for the resident. During an interview on 3/4/2025 at 8:21 AM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated if a resident had been aggressive, the facility staff should have called the resident's physician about the behavior. LVN 2 stated the doctor usually reviewed the resident's medication at the end of the month. LVN 2 stated the facility updated a resident's care plan monthly, quarterly (every 3 months), and for a change in condition. LVN 2 stated Resident 1's care plan was not revised until Resident 1 hit Resident 2. LVN 2 stated if the care plan was not updated or revised, the staff would not be able to tell if the care plan interventions were effective or if the care plan was still appropriate for the resident. LVN 2 stated the facility's care plan for Resident 1 was not effective in managing his behavior. During a concurrent interview and record review on 3/4/2025 at 8:36 AM with the DON, Resident 1's care plan titled The resident is on anti-psychotic medication for episodes of delusions aeb verbalization of chest pain and needing to go to the hospital, hearing voices & talking to self-related, confrontational and verbally aggressive to staff related to schizophrenia with an intervention indicating The resident will manifested behavior will be limited to 0-1 episodes per day 0-1 times a week dated 7/23/2024, was reviewed. The DON reviewed Resident 1's MAR for February 2025 indicating Resident 1 had multiple episodes of being aggressive with staff. The DON stated the facility should have been updating Resident 1's care plans every 3 months and for a change in condition. The DON stated the facility staff had not been documenting Resident's care plan interventions and it would be difficulty for the facility staff to assess the effectiveness of the interventions if the staff did not document them. During an interview on 3/4/2025 at 10:16 A M with Resident 1's PGC, the PGC stated Resident 1 had enough funds for soda and the facility should have been directing Resident 1 to the facility's social worker or other staff when he approached other residents for money. During a review of the facility's P&P titled Abuse Prevention and Prohibition Program dated 2/9/2024, the P&P indicated each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property (to take possession of something that belongs to someone else without the right to do so). The P&P indicated the facility would train staff regarding appropriate interventions to deal with aggressive and/or catastrophic reactions (an over-the-top, sudden, and often disruptive emotional or behavioral outburst that someone experiences when feeling overwhelmed or unable to cope with a situation, even if it seems minor to others) of residents. The P&P indicated residents identified by staff as being self-injurious or exhibiting abusive behavior that requires professional services not provided in the Facility (e.g., mental health services), will be reviewed by the IDT (Interdisciplinary Team is a group of professionals with different skills and backgrounds who work together to provide comprehensive care for a patient, focusing on the patient's needs and goals) and/or physician. The P&P indicated Resident assessments (a process by which nursing home staff identifies your health care needs, daily schedules and habits, and likes and dislikes) and care planning are performed to monitor resident needs and address behaviors that may lead to conflict (serious disagreement and argument about something). During a review of the facility's P&P titled Care Planning dated 2/9/2024, the P&P indicated the care plan purpose was to ensure that a comprehensive person-centered (prioritizing the individual's needs, preferences, and values in all aspects of care, support, and treatment, ensuring a holistic and personalized experience) Care Plan is developed for each resident based on their individual assessed (evaluated) needs. The P&P indicated 'the Baseline (starting point) Care Plan will be updated to reflect changes in the resident's condition or needs occurring prior to the development of the Comprehensive Care Plan (a detailed roadmap outlining all aspects of a patient's care, including medical, nursing, and other health-related activities, to ensure their needs are met). The P&P indicated The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive Admission Assessment (a thorough examination of a patient's health history, physical condition, and psychosocial factors, conducted upon admission to gain a complete understanding of their needs), and must be periodically (from time to time) reviewed and revised (something has been changed or updated) by a team of qualified persons after each assessment, including the comprehensive and quarterly (something that happens or is done every three months, or four times a year) review assessments. During a review of the facility P&P titled Behavior-Management, dated 2/9/2024, the P&P indicated the purpose of the P&P was to ensure facility staff performs an appropriate assessment of the resident's behavioral symptoms and implement (to put a plan, idea, or policy into action) appropriate interventions before and after the resident begins taking psychotherapeutic (medicines used to treat mental health conditions) medications. The P&P indicated When a resident exhibits (shows) adverse behavioral symptom (yelling, hitting, resisting care, etc.), Licensed Nursing Staff will document the behaviors in the medical record, noting the time the behavior(s) occur, antecedent events (something that happens before a behavior or action, and can potentially trigger or influence it), possible causal (causes) factors and interventions attempted. The P&P indicated when the resident exhibits behaviors, the Licensed Nurse will document the resident's medical record and include the following as indicated: i. Any precipitating factors (triggers or events that directly lead to or worsen a problem, illness, or behavior) ii. Interventions used to redirect behavior iii. The resident's response to the intervention iv. Notification of Attending Physician (a medical doctor who is responsible for the overall care of a patient) and responsible party (the person who is financially responsible for paying the patient's medical bills, often the patient themselves, but sometimes a parent, guardian, or other designated individual) as indicated. v. Update the plan of care as indicated.

Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) on 2/13/2025 to the facility after hospitalization to a General Acute Care Hospital (GACH), as indicated in the facility's policy titled Readmission. As a result, Resident 1 remained in the GACH with discharge orders written on 2/12/2025 to return to the facility. Denying the resident the right to return to their home in the facility and placing Resident 1 at risk for psychosocial harm. Findings: During a review of Resident 1's Admission Records dated 2/26/2025, the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including quadriplegia (paralysis below the neck that affects all a person's limbs), type two diabetes (A long-term condition in which the body has trouble controlling blood sugar and using it for energy). During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 12/11/2024 the MDS indicted Resident 1 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) to make daily decisions on self-care activities. The MDS indicated the resident was dependent on staff for position changes such as sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer. During a review of Resident 1 ' s History and physical (H&P) dated 6/6/2024, the H&P indicated Resident 1 had a cervical 3 to cervical 5 spinal injury, functional quadriplegic (paralysis below the neck that affects all a person's limbs), type two diabetes (A long-term condition in which the body has trouble controlling blood sugar and using it for energy). The H&P indicated resident has the capacity to understand and make decisions. During a review of Resident 1 ' s General Acute Care Hospital (GACH) Patient Orders dated 2/12/2025 indicated, Resident 1 was to be discharged from GACH back to the Skilled Nursing Facility (SNF) on 2/12/2025. During a revie of Resident 1 ' s GACH Patient Orders dated 2/12/2025 indicated, Discharge to NF (Nursing Facility) today, continue IV (Intravenous) Vancomycin (an antibiotics medication used to treat and prevent various bacterial infections) 1250 milligram IVPB (Intravenous Piggy Bag) daily times 2 more weeks, and Ceftriaxone (an antibiotics medication used to treat bacterial infections in many different parts of the body) 2 milligram IVPB daily times one more week. During a review of the facility census ' from 2/12/2025 to 2/18/2025, the census ' indicated the following: 2/11/2025 total census 48, one female bed open. New female resident admitted on [DATE] into room with the bed hold. 2/12/2025 total census 47, no female bed open. 2/13/2025 total census 48, one female bed open. 2/14/2025 total census 47, one female bed open. 2/15/2025 total census 47, one female bed open. 2/16/2025 total census 48, one female bed open. 2/17/2025 total census 47, one female bed open. 2/18/2025 total census 49. One open female bed given to a different bed hold resident returning from GACH. During an interview on 2/20/2025 at 10:48 AM with facility case manager (CM), the CM stated, CM had communicated with GACH case manager on 2/12/2025 and received an email indicating the resident was ready to be discharged back to the facility. During a telephone interview on 2/20/2025 at 11:00 AM with GACH Discharge Coordinator (DC), the DC stated, Resident 1 had a discharge plan since 1/23/2025. The DC stated the facility had denied readmission on 1/23/2025 because the resident was on three intravenous (IV: medication administered directing into a vein) antibiotics and the facility would not provide a Registered Nurse (RN) 24/7. The DC stated on 2/12/2025 the facility was informed the resident ' s IV antibiotics had been reduced from three to just one IV antibiotic. The facility CM informed the DC the facility did not have a female bed available. During an interview on 2/20/2025 at 11:15 AM with the Director of Nursing (DON), the DON confirmed having been informed by the GACH DC the resident was ready for discharge on 1/23/2025 and the facility informed the DC the resident could not be readmitted with three IV antibiotics because the facility would only staff one RN 8 hours per day. The DON stated from 2/12/2025 to the date of interview (2/20/2025) there was one female bed available, but the bed was on hold for a resident who was expected to come back within the bed hold time frame. The DON could not produce documentation of a discharge order from the GACH for the resident the facility was holding the bed for. During a review of the facility ' s Policy and Procedure (P&P) titled Readmission, implemented on 2/9/2024, the P&P indicated An individual is a readmit if he or she was readmitted to the Facility form a hospital to which he/she was transferred for the purpose of receiving care or was discharged to a lower-level care and directly returned to the facility. A resident who exercised his/her bed hold rights prior to transfer from the Facility is not considered readmitted if the resident returns within the bed hold period. When a bed hold is not exercised or expires will be permitted to return to their previous room, if available or the next available bed in a semi-private room, assuming the resident still requires services offered by the facility.

Based on interview and record review, the facility failed to revise a bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) care plan on a quarterly basis for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of care and services for Resident 1. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including bipolar disorder, anxiety (feelings of worry), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/22/2024, indicated Resident 1 had moderate cognitive impairment (difficulty with complex tasks and occasional confusion) but was able to make her needs known. The MDS further indicated Resident 1 had delusions (false belief) and was taking antipsychotic medication. A review of the altered behavior pattern care plan for Resident 1, revised 5/25/2024, indicated Resident 1 had altered behavior related to bipolar disorder with a goal to reduce the episodes of behaviors. The care plan interventions included to approach the resident in a calm and friendly manner and to administer lithium carbonate (a medication that is used to treat bipolar disorder) as ordered. During an interview with the Director of Nursing (DON) on 12/17/2024 at 1:30 PM, the DON stated that resident care plans should be updated when there was a change of condition, quarterly, and as needed. The DON further stated it was important to have an updated plan of care for a resident so that the interventions and goals were appropriate. A review of the facility ' s policy and procedure titled, Care Planning, dated 2/9/2024, indicated the comprehensive care plan must be periodically reviewed and revised by a team of qualified persons after each assessment, including the quarterly review assessments.

Based on interview, and record review the facility failed to implement policies and procures to prevent and control the transmission of COVID-19 (coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and it spread during close contact and through the air from person to person) infection. By failing to ensure Licensed Vocational Nurse 3 (LVN 3) immediately left the facility upon testing positive for COVID-19. LVN 3 tested positive on 7/27/2024 at 7 PM and continued to work until 8 PM, charting and preparing medications for approximately 20 residents. This deficient practices had the potential to transmit infectious disease microorganisms and increase the risk of infection to all 43 residents and staff. Findings: A review of the facility ' s Nursing Staffing Assignment and Sign-In Sheet dated 7/27/2024, indicated LVN 3 was assigned to work on 7/27/2024 from 4pm to 12am and was assigned medication administration. During an interview on 7/31/2024 at 9:34 AM, the Infection Preventionist (IP) stated on 7/27/2024, LVN 3 tested positive while at work in the facility. The IP stated LVN 3 stayed for a period in the facility to assist the registered nurse supervisor, who was to take over for LVN 3, by preparing medications for LVN 3 ' s assigned residents (approximately 20). The IP stated the current guidelines in place were for positive staff to go home, isolate for 5 days and return to work once symptoms were improving and had a negative test. The IP stated the guidelines were in place to ensure the safety of the facility ' s residents. The IP stated the spread of COVID in the facility could have been stopped if positive staff was removed from the facility. During an interview on 7/31/2024 at 12:14 PM, Resident 2 stated he has COVID-19. Resident 2 stated he had COVID-19 and was moved to this room when he tested positive. During a phone interview on 8/1/2024 at 9:32 AM, Licensed Vocational Nurse 3 (LVN 3) stated around 7 PM on 7/27/2024 while working the 3-11 PM shift at the facility she started feeling symptoms of COVID-19 that included headache and a runny nose. LVN 3 stated she tested positive at the facility then stayed at the nurse ' s station for about an hour to complete her charting and prepared the resident ' s medications (approximately 20) for the registered nurse supervisor to give. LVN 3 stated it was the facility ' s policy for staff to go home once testing positive. LVN 3 also stated staff had leave the facility due to residents being at high risk for becoming infected with COVID-19 and it was a very serious condition. During a phone interview on 8/1/2024 at 10:08 AM, the facility ' s Public Health Nurse (PHN) stated once a staff member tested positive, they were required to leave the facility because they were no longer able to work. During an interview on 8/1/2024 at 10:36 AM, the Director of Staff Development (DSD) stated LVN 3 tested positive on 7/27/24 while working at the facility. The DSD stated once the LVN 3 tested positive she should have left facility immediately. The DSD repeated LVN 3 she should not have stayed in the facility after testing positive. The DSD stated LVN 3 exposed the residents receiving the medication LVN 3 prepared to COVID-19. During an interview on 8/1/2024 at 3:01 PM, the Director of Nursing (DON) stated if staff who have tested positive for COVID-19 were not allowed to work. The DON stated positive staff were required to stay away from the facility for 5 days. The DON stated contact tracing should have been initiated right away to find out patient zero (first COVID-10 positive) and to know if it was staff, a visitor, or a resident. The DON stated not conducting contact tracing right away could lead to further spread of COVID in the building. A review of the facility ' s policy and procedures (P&P) titled, Infection Prevention and Control Program dated February 9, 2024, indicated The Facility must establish an Infection Prevention and Control Program under which it- A. Identifies, investigates, controls, and prevents infections in the Facility; B. Decides what procedures, such as isolation, should be applied to an individual resident; and C. Maintains a record of incidents and corrective actions related to infections. During an interview on 8/1/2024 at 8:53 AM, the IP stated the facility used their COVID-19 Mitigation plan as the facility ' s policy because the current policy and procedures were being reviewed and revised to meet current guidelines.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls and was assessed as high risk for falls, received the care and services necessary to prevent accidents and falls as evidenced by failing to provide the resident with assistance and supervision when ambulating (walking) to the bathroom. As a result, on 7/5/2024 (three days after admission), Resident 1 was found on the floor bleeding, and with a four-centimeter laceration (deep cut or tear in the skin or flesh) on the occipital posterior area of the head (back of the head). Resident 1 was transferred to General Acute Care Hospital (GACH) 2 where Resident 1 was diagnosed with subdural hematomas (pools of blood between the brain and its outermost covering caused by a head injury strong enough to burst blood vessels). Findings: A review of Resident 1's General Acute Care Hospital (GACH) 1 History and Physical (H&P) dated 6/3/2024 at 11:34 PM, indicated the resident was brought in by ambulance from their home to GACH 1 after having a fall. The H&P indicated Resident 1 fell while attempting to get out of the bed. The H&P indicated Resident 1 also fell when attempting to use the restroom in the Emergency Department (ED) at GACH 1. A review of Resident 1's Admission Record indicated the resident was admitted on [DATE] from GACH 1 with diagnoses including subarachnoid hemorrhage (bleeding in the space between the brain and surrounding membrane), hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (also known as a stroke; refers to damage to tissues in the brain due to a loss of oxygen to the area), abnormalities of gait and mobility (when the pattern in which you walk and move is not normal), lack of coordination (impaired balance), repeated falls, and history of falls. A review of Resident 1's Fall Risk assessment dated [DATE] at 9:50 AM, indicated the resident was a high risk for falls with a score of 80 (a score of 45 or more indicated a resident was a high risk for falling). The Fall Risk Assessment indicated Resident 1 had fallen before, had more than one diagnosis, used crutches, a cane, or a walker as an ambulatory (walking) aid; had a weak gait (stooped [having the head and shoulders bent forward] but able to lift head without losing balance, steps were short, resident may shuffle [to walk by pulling your feet slowly along the ground rather than lifting them]); and forgets limits or overestimated. A review of Resident 1's At Risk for Falls Care Plan related to a cerebral vascular accident (CVA, also known as a stroke; refers to damage to tissues in the brain due to a loss of oxygen to the area), lack of safety awareness, poor safety awareness, weakness, and a recent fall incident at home was initiated on 7/2/2024. The care plan indicated a goal to reduce the risk of falls and/or injury for Resident 1 through appropriate interventions. The care plan interventions included to assist Resident 1 with all ambulation or transfers as needed. A review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment dated 7/3/2024, indicated the resident was referred to PT due to exacerbation (increase in the worsening of a disease or symptoms) of decrease in functional mobility (a person's ability to move independently and safely), decrease in strength, decrease coordination, reduced dynamic balance (the ability to remain standing and stable while performing movements or actions), reduced static balance (the ability to hold the body in a specific position and posture) and increased need for assistance from others. The Evaluation and Plan of Treatment indicated Resident 1 felt unsteady when standing and walking. The Evaluation and Plan of Treatment indicated Resident 1 worried about falling. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/5/2024, indicated the resident had moderately impaired cognition (reduced ability to think, understand, and reason) and previously used a walker. The MDS indicated Resident 1 required partial/moderate assistance with toileting hygiene, toilet transfers, walking 10 feet, and walking 50 feet with two turns. The MDS indicated Resident 1 was frequently incontinent (having no voluntary control over urination or defecation) of urine and bowel. The MDS further indicated Resident 1 had a fall in the last month prior to admission. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique that provides a framework for communication between members of the health care team about a patient's condition) Form and Progress Note dated 7/5/2024 at 10:37 PM indicated the resident had an unwitnessed fall. The note indicated at 8:35 PM, Resident 1 had a fall incident in the resident's bathroom and did not use the call light for assistance. The note indicated Resident 1 was found lying on the floor, on their back with blood coming out from the resident's head. The note indicated a pressure dressing was applied and the resident was transferred back to their bed assisted by four nurses. The SBAR note indicated at 8:50 PM, 911 was called for medical assistance, at 8:55 PM the paramedics arrived and per the paramedics' assessments Resident 1 was stable enough to be transferred to the hospital via regular ambulance. The SBAR note indicated Resident 1 had a four-centimeter laceration on the occipital posterior area of the head, was in stable condition, awake, alert, and could make their needs known. The note indicated Resident 1's physician was notified and gave orders to transfer the resident to the General Acute Care Hospital (GACH) 2 for evaluation of the resident's head/trauma fall. The note indicated Resident 1 left the facility at 10:05 PM. A review of the Physician's Order dated 7/5/2024, indicated to transfer Resident 1 to GACH 2 for evaluation of head trauma/fall and head laceration. A review of Resident 1's GACH 2 Face Sheet Report indicated the resident was admitted to the GACH on 7/5/2024 at 10:16 PM. A review of Resident 1's GACH 2 Patient Results, indicated the resident had a Computed Tomography (CT - diagnostic imaging procedure that uses a computer linked x-ray machine to create detailed images of the inside of the body) of the head on 7/5/2024 at 11:15 PM, with an acute on chronic subdural hematomas (refers to a second episode of sudden bleeding that occurs in same area where bleeding in the brain had already existed) which measured 7 millimeters (mm) on the right and 4 mm on the left. The CT results further indicated Resident 1 had a moderate left parietal scalp hematoma (a collection of blood that collects in the skin and muscle on the upper back of the head, not affecting the brain). A review of Resident 1's Emergency Department (ED) Note from GACH 2 dated 7/6/2024 at 1:04 AM, indicated the resident presented to the ED after a fall two hours prior to arrival. The note indicated Resident 1 stated he did not hit his head or lose consciousness (to no longer be awake and aware of what is happening around you). The note indicated Resident 1 stated he had a headache that was mild. According to a review of Resident 1's Patient Results from GACH 2, the resident had a second CT of the head on 7/6/2024 at 5:18 AM, which indicated Resident 1 had stapling of their left parietal scalp laceration (deep cut of the upper back of the head). A review of Resident 1's Post Fall Interdisciplinary Team (IDT) note dated 7/8/2024, indicated on 7/5/2024 at around 8:35 PM, the resident had a fall incident outside their bathroom. Resident 1 was found lying on the floor, on his back with blood coming out from the head. The Post Fall IDT note indicated Resident 1 can ambulate with supervision using the front wheel walker (FWW). Per nursing, the call light was not on at the time of incident, it was assumed that the resident did not use the call light or ask for assistance to go to the bathroom. The resident was continent of bowel and bladder and used a urinal when in bed. The resident goes to the toilet for bowel movements with assistance of the nursing aide. The IDT documentation further indicated Resident 1's periods of confusion may have contributed to the resident's poor safety judgment by not asking for assistance or using the call light to go to the bathroom. During a telephone interview on 7/16/2024 at 12:54 PM, Certified Nursing Assistant (CNA) 1 stated they were assigned to take care of Resident 1 on 7/5/2024, and did not see Resident 1 fall. CNA 1 stated after being called to Resident 1's room, they saw Resident 1 on the floor, bleeding from the back of their head. CNA 1 stated there was a lot of blood. CNA 1 stated Resident 1 normally used a walker when ambulating and required one-person assistance to the bathroom. During a telephone interview on 7/16/2024 at 1:45 PM, CNA 2 stated they were working on 7/5/2024 during the 3 PM - 11 PM shift and was watching the facility's front door that night. CNA 2 stated she saw Resident 1 walking to the bathroom with a walker but the resident did not use the call light to ask for assistance to the bathroom. CNA 2 stated they did not assist Resident 1 to the bathroom because the resident was walking fine. CNA 2 stated they then saw Resident 1 fall, so they called for help for the resident. During an interview on 7/16/2024 at 2:32 PM, Physical Therapist (PT) 1 stated, they had been seeing the resident after they were admitted to the facility. PT 1 stated Resident 1 required minimal to moderate assistance with bed mobility and transferring. PT 1 stated Resident 1 could walk approximately 10-20 feet. PT 1 stated Resident 1 had unsteady gait and needed to use a walker. PT 1 stated Resident 1 was not safe to ambulate independently. PT 1 stated Resident 1 needed assistance with close supervision and always needed supervision when walking. During an interview on 7/16/2024 at 3 PM, Registered Nurse Supervisor (RNS) 1 stated at about 8:35 PM on 7/5/2024 Resident 1 fell . RNS 1 stated when she entered the room, she found Resident 1 on the floor with their head towards the door of the bathroom. When the resident was asked what happened, the resident stated they fell but did not know why. RNS 1 stated they saw blood coming from Resident 1's head, as there was a laceration to the occipital area. RNS 1 stated Resident 1 did not use the call light and usually always called for assistance. RNS 1 stated Resident 1 should have assistance when going to the bathroom. RNS 1 stated any staff who sees a resident ambulating should provide assistance for safety reasons to ensure the resident did not fall. RNS 1 stated if Resident 1 had assistance to the bathroom that night the resident probably would not have fallen. During an interview on 7/16/2024 at 3:30 PM, the Director of Nursing (DON) stated Resident 1 always used the call light but was not sure what happened that night on 7/5/2024. The DON stated he had not seen Resident 1 walk or go to the bathroom in the past, but stated from what he gathered from the nurses was that the Resident 1 normally utilized a walker and needed assistance and supervision when ambulating. Furthermore, the DON stated that according to the Fall Risk Assessment, Resident 1 was at high risk for falls. The DON stated Resident 1's care plan indicated that the staff were to provide Resident 1 with assistance when ambulating as needed. The DON stated that if Resident 1 was provided with supervision and assistance when ambulating the resident might not have fallen. A review of the facility's policy and procedure titled, Fall Management Program, dated 2/9/2024, indicated the purpose was to prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program. It was the policy of this facility to provide the highest quality of care in the safest environment for the residents residing in the facility. The facility developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. The licensed nurse will assess each resident for their risk of falling upon admission, quarterly, and with a significant change in condition. Based on the information gathered from the history and assessment of the resident, the Nursing Staff, and Interdisciplinary Team (IDT), with input from the Attending Physician, will identify and implement interventions to reduce the risk of falls. The following are suggested measures that can be used in the prevention of falls. This list is not all-inclusive. Assist patient with toileting as appropriate. Encourage use of assistive devices (i.e. walker/wheeled walker and cane) as appropriate.

Based on interview and record review, the facility failed to identify and ensure one of three sampled residents (Resident 43), who had difficulty swallowing and was at risk for aspiration (accidentally inhaling your food or liquid into your airway), received necessary care and services in accordance with professional standards of practice by failing to: -Follow the Physician's Order dated [DATE], for Resident 43 to receive a pureed diet (food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding). - Assess for tolerance of diet, per the Alteration in Oral / Dental Status care plan dated [DATE]. - Develop comprehensive person-centered Dysphagia (difficulty swallowing) care plan, per the facility's Comprehensive Plan of Care policy. -Monitor Resident 43 for any changes in condition and inform the physician, per the Activities of Daily Living care plan dated [DATE]. -Perform assessments consistently and accurately, during each shift or Resident 43's change in condition and report to physician timely. As a result, on [DATE] at 12:38 AM, after eating a regular food brought in by the family, Resident 43 became congested, had difficulty breathing, and cyanotic (blue- indicating reduced blood oxygen levels). Resident 43 became unresponsive, required cardiopulmonary resuscitation (CPR - medical intervention used to restore circulatory and/or respiratory function that has stopped) and at 1 AM, Resident 43 was pronounced dead (nine days after his admission). On [DATE] at 8:11 PM, an Immediate Jeopardy (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) was identified in the presence of the Administrator (ADM), regarding the facility's failure to identify and ensure Resident 43, who had difficulty swallowing and was at risk for aspiration, received necessary care and services in accordance with professional standards of practice. On [DATE] at 1:12 PM, while onsite at the facility, the IJ was removed in the presence of the ADM, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: On [DATE], the Minimum Data Set (MDS) nurse reviewed the diet orders of all current residents (42) to determine if their diet texture and fluid consistency needed to be clarified with the physician. 39 residents needed clarification of their diet orders. The MDS completed the clarification of diet orders on the same day. Starting [DATE], the Nurse Consultant provided an in-service to 6 Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) members to inform the resident's family, during the initia1 IDT meeting and subsequent IDT meetings as needed, about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The resident's family will be asked to sign a form acknowledging that they have received this information. The DON was the remaining IDT member who will be provided with an in-service by the Nurse Consultant upon their return to work. Starting [DATE], the IDT reviewed 36 current residents who were on a therapeutic diet and informed their family members via telephone conversation about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The information was provided using the family members' native language. The IDT members documented in the resident's chart that the family has been informed. The consultant provided an in-service to RNs, Licensed Vocational Nurses, Certified Nursing Assistants and Restorative Nurse Aides (60% of staff) regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility. The in-service emphasized the following: o Diet orders will be printed daily by the licensed nurse and will be made available as a reference at the nurses' station. o Food brought in by family from outside sources must be consistent with the resident's prescribed diet; o Food brought in by family from outside sources should be shown to the licensed nurse for evaluation if it matches the resident's prescribed diet. o The licensed nurse must be notified if the resident is observed to be eating food that does not match the diet order or when the family is observed to have brought in food for the resident that is different from the diet order. o The licensed nurse will check on residents who have food brought in by family every two hours and as needed; and, o The licensed nurse will record both the evaluation of the food brought from outside and the q2 hour visual checks in a log that will be submitted to the DON or designee for further review. Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service. In-services will be completed for all the active nursing staff by the Nurse Consultant on or before [DATE]. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work. Starting [DATE], the Nurse Consultant checked competencies of two RNs, eight LVNs, and 16 CNAs in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies. Competency evaluations will be performed by the Nurse Consultant and completed for all active nursing staff by [DATE]. Staff who were currently on vacation or on leave will have their competencies evaluated upon their return to work. On [DATE], the Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources, emphasizing the importance of reporting to the licensed nurse when the resident was observed to be eating food that was different from the diet order. At the end of the in-service, the CNA was asked questions to evaluate his knowledge about the information provided to him and was able to answer questions correctly. On [DATE], the Nurse Consultant provided an in-service to 15 CNAs and two RNAs (50%) regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources. The Nurse Consultant would complete the in-service for all the active CNAs and RNAs by [DATE]. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work. Starting [DATE], the Nurse Consultant provided an in-service to 2 RNs and 8 LVNs (60%) regarding the facility's policy on Change of Condition. The in-service addressed the importance of identifying significant changes in condition, performing a timely assessment, providing appropriate interventions, and immediately notifying the physician of a resident's change in condition. The in-service also addressed notifying the alternate physician or the medical director of the changes in condition within a two -hour timeframe if unable to contact the primary physician, except during medical emergencies. A post-test was given to evaluate the staff's knowledge about the information they received. Passing score was three out of three Licensed nurses who did not pass will be asked to attend the in-service and take the posttest again. The Nurse Consultant will complete the in-service and post-test for all of active licensed nurses by [DATE]. Staff who were currently on vacation or on leave will be provided the in-service and post-test upon their return to work. Starting [DATE], the Medical Records staff will conduct changes in condition audits daily Monday through Friday, five times a week to identify changes in condition, determine completeness of documentation, and determine if physician notification had occurred. On Mondays, the audit will cover changes in condition that occurred during the weekend. The DON or RN designee will review the audits daily five times a week to review the timeliness and appropriateness of the assessment and interventions in response to the change in condition. RN 2 was dismissed from facility and no longer an employee of the facility since [DATE]. Starting [DATE], the Director of Nursing (DON) or Director of Staff Development (DSD) would evaluate licensed nurses' competencies related to identifying, managing, and notifying the physician, alternate physician, or medical director of any changes in condition upon hire and annually. On [DATE], the Nurse Consultant provided a one-to-one in-service with the Administrator regarding the statute on Reporting Unusual Occurrences, emphasizing the definition of an unusual occurrence and the requirement to report unusual occurrences to the state survey agency within 24 hours of the incident. Starting [DATE], the Nurse Consultant provided in-service to 48 facility staff (60%) regarding the statute on Reporting Unusual Occurrences, emphasizing the definition of an unusual occurrence, the importance of reporting unusual occurrences to the Administrator, the requirement to report unusual occurrences to the state survey agency within 24 hours of the incident, and to report to the state survey agency unusual occurrences that constitute abuse within 2 hours of the incident. The Administrator will review changes of condition during the stand-up meeting daily five times a week to identify abuse, suspicious deaths, major injuries, and other types of unusual occurrences and ensure that they are reported timely. The outcome of the review will be recorded in the stand-up meeting minutes. Findings: A review of Resident 43's Admission Record indicated the facility admitted the resident on [DATE], with diagnoses including but not limited to history of stroke, adult failure to thrive, repeated falls and presence of cardiac pacemaker. A review of Resident 43's Admission Assessment, dated [DATE], indicated the resident was admitted with a regular heartbeat and a strong pulse. The Admission Assessment indicated Resident 43 did not have a cough, breath sounds were clear, and was not receiving respiratory therapy. A review of Resident 43's Nursing Progress Notes, dated [DATE], indicated Resident 43 was awake, alert and oriented to name. Resident 43 was able to make his needs known, responsive to all stimuli, had no complaints of pain or discomfort and his breathing was even and unlabored. According to a review of the Physician's Order Summary Report, dated [DATE], Resident 43 was to receive a pureed diet, speech therapy (ST), physical therapy (PT) and occupational therapy (OT) evaluations. A review of Resident 43's Alteration in Oral / Dental Status care plan initiated [DATE], indicated the resident did not have teeth and the goal was for Resident 43 to not have unrecognized signs and symptoms of oral or dental problems daily. The care plan interventions indicated to provide the diet as ordered and monitor percentage of intake, ensure good oral hygiene and for staff to assess for tolerance of prescribed diet. A review of the Activities of Daily Living (ADLs -essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) care plan, dated [DATE], indicated Resident 43 required limited assistance with eating and the interventions included to monitor the resident for any changes in condition and inform physician. A review of the Nursing Progress notes, dated [DATE], indicated Resident 43 was able to make his needs known, responsive to all stimuli, there were no significant changes, was calm and compliant, denied pain or discomfort, and the resident's breathing was even and unlabored. A review of Resident 43's Admission Interdisciplinary Team (IDT) conference record dated [DATE], indicated Resident 43's diagnoses, physical therapy and the resident's pain were discussed. The IDT conference record indicated Resident 43's diet and diet texture was not mentioned. According to a review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated [DATE], Resident 43 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement) and required setup or clean up assistance with eating. The MDS indicated the resident had a mechanically altered diet (required change in texture of food or liquids [pureed food, thickened liquids]) and did not have a problem with vomiting. The MDS indicated Resident 43 had complaints of difficulty or pain with swallowing and had no natural teeth or tooth fragments. A review of the Speech-Language Pathologist (SLP) Evaluation and Plan of Treatment, dated [DATE], indicated Resident 43's oral motor (movements of the muscles in the mouth, jaw, tongue, lips and cheeks) structure and function was impaired. The SLP evaluation indicated a recommendation for Resident 43 to receive pureed food. A review of the Physician's Order, dated [DATE], indicated Resident 43 was to receive Speech Therapy (ST) three times a week for dysphagia (difficulty swallowing) and the treatment included diet assessment, compensation strategies (learning new ways to perform tasks in an alternative manner) and resident / caregiver education. A review of the Skilled ST care plan dated [DATE], indicated the goals for Resident 43 included to demonstrate improved oral motor strength for functional swallowing, the progression of his diet and for Resident 43 to tolerate his diet without signs and symptoms of aspiration. The care plan interventions included safe swallowing strategies, ongoing assessment of swallow efficiency and skilled ST evaluation and treatment. A review of the Nutritional Assessment, dated [DATE], indicated Resident 43's current diet order was a mechanically altered diet, pureed with regular consistency liquids due to dysphagia. A review of the Nutritional Assessment, dated [DATE], indicated Resident 43's current diet order was a mechanically altered diet (foods that can be safely and successfully swallowed) pureed with regular consistency liquids (no chewing required) due to dysphagia. According to a review of the Situation, Background, Assessment, Recommendation (SBAR - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident) dated [DATE] at 11:21 PM, it was reported by the prior shift (,d+[DATE] PM staff) that Resident 43 vomited a large amount of undigested food (around 5PM). At 12:38 AM, on [DATE], Resident 43 had congestion which worsened, manifested by an acute change in the resident's level of consciousness (LOC), shallow and labored breathing with cyanotic nail beds and cold, clammy skin. The SBAR indicated code blue (a person is in need of immediate medical attention) was announced, 911 (a telephone number used to reach emergency medical, fire, and police services) was called and pulmonary resuscitation CPRP with high flow oxygen support through ambu bag (a device used to provide respiratory support to patients in emergency situations) was initiated, while active chest compression were performed by a trained support staff. At 12:55 AM, paramedics arrived and assumed care. A review of Resident 43's Certificate of Death indicated the resident expired on [DATE] at 1 AM, with the cause of death as acute cardiopulmonary arrest (the heart and lungs suddenly and unexpectedly stop working), with acute myocardial infarction (heart attack). The Certificate of Death indicated Resident 43 passed away at the facility. During an interview on [DATE] at 10:21 AM, Registered Nurse 1 (RN 1) stated on [DATE], RN 1 worked the 11 PM to 7 AM shift, and the prior shift nurse, Registered Nurse (RN) 2, told RN 1 that during the 3PM to 11 PM shift, Resident 43 had eaten foods with a regular texture including a tortilla, and subsequently vomited a large amount of undigested food. RN 1 stated Resident 43 later became congested with difficulty breathing. After review of Resident 43's electronic chart, RN 1 stated RN 2 had not documented any progress notes, had not completed an SBAR and had not notified the primary physician regarding any of these changes of condition for the resident (eating regular textured food, vomiting). RN 1 stated he left a message for the primary physician due to Resident 43's congestion and difficulty breathing, the resident became more congested and then was unresponsive around 12:38 AM, on [DATE]. RN 1 stated he started CPR, called emergency services and the paramedics took over the CPR upon their arrival. Resident 43 was pronounced dead several minutes later. RN 1 further stated Resident 43's congestion may have resulted from the resident ingesting regular textured foods. During an interview on [DATE] at 12:06 PM, the Registered Dietician (RD) 1 stated Resident 43 was on a pureed diet and if Resident 43 received a regular texture while prescribed a puree diet, this would make the resident at risk for aspiration or choking. During an interview on [DATE] at 12:53 PM, the Dietary Supervisor (DS) stated a pureed diet was to be creamy soft, as it was placed in a food processor to have a smooth texture with no pieces inside of it. The primary physician did not respond to requests for interview. RN 2 did not respond to voicemail requests for interview. During a phone interview on [DATE] at 4:35 PM, Certified Nursing Assistant 1 (CNA) 1 stated he saw from outside the room that the family brought in food for Resident 43. CNA 1 stated he saw Resident 43 eating the food and did not attempt to stop the resident. CNA 1 stated he did not enter the room because he was busy. CNA 1 further stated Resident 43 then vomited about 30 minutes later and that was when he notified RN 2 that Resident 43 had eaten the wrong texture food. During an interview on [DATE] at 11:03 AM, the Director of Staff Development (DSD) stated the facility policy indicated that food brought in by family should be shown to the charge nurse or RD prior to giving it to the resident. The DSD stated when CNA 1 knew Resident 43 was eating the wrong diet, he should have gone in and reminded the resident and his family that the resident was eating the wrong food. Resident 43 had difficulty swallowing, choking could be very imminent, and the food could go to the lungs. The DSD stated RN 2 should have assessed the resident once Resident 43 vomited and should have notified the physician. The DSD stated if the resident's doctor was not responding, staff can contact the physician's alternate physician or the medical director. The DSD also stated there was a delay in care after the resident was found to have eaten the wrong type of food, after the resident vomited, and also when the resident was found to be congested. During an interview on [DATE] at 12:29 PM, the Medical Director (MD) stated she was not aware of Resident 43's death in the facility and the primary physician should be notified of all changes in condition. The MD further stated she was always available if staff were unable to contact the primary physician. During a phone interview on [DATE] at 12:26 PM, Family Member (FM) 1 stated he called the facility and received permission to bring in food for Resident 43. FM 1 stated he brought in chicken quesadillas for Resident 43, and no one educated him on any special diet or texture that Resident 43 was to receive. A review of the facility's Certified Nursing Assistant (CNA) Job Description, undated indicated essential responsibilities and job functions were to ensure that any change in resident condition or unusual circumstances was reported immediately to the charge nurse. A review of the facility's Registered Nurse (RN) Job Description, undated, indicated the RN was under the general supervision of the Director of Nursing. The Registered Nurse performs a variety of resident care functions and closely observes residents for changes in medical status. Consistently and accurately performs reassessments during each shift and when the resident condition changes and reports all abnormal test results to physician in a timely manner; triages activities based on borderline and/or abnormal and/or unusual findings. A review of the facility's policy and procedure (P&P) titled, Change of Condition, reviewed [DATE], indicated to promptly notify the resident, his or her Attending Physician, and representative (sponsor), of changes in the resident's medical/mental condition and/or status. Under 'Procedure,' the P&P indicated acute medical changes or any sudden or serious change in condition manifested by a marked change in physical, mental and psychosocial status: -a Licensed Nurse will notify the physician, -If unable to contact attending physician or alternate physician, notify the Medical Director, -Notify and inform legal surrogate for any change of condition. -Using the Interact Tool SBAR - notify physician for all signs and symptoms manifested by the patient. The form will be used to initiate change of condition documentation for any decline or improvement. The P&P also indicated nurses notes would record information relative to changes in the resident's medical/mental condition or status. A review of the facility's P&P titled, Comprehensive Plan of Care, reviewed [DATE], indicated to provide each resident with comprehensive plan of care that includes goals, measurable objectives, and timetables to meet their medical, nursing, psychosocial needs identified during comprehensive assessment. The comprehensive care plan would address resident's needs, strengths, and preferences, would include treatment goals with measurable objectives, interventions to prevent avoidable decline in function or functional level and would be periodically reviewed and revised by the IDT team as changes in the resident's care and treatment occur. The comprehensive care plan was required to be maintained in the resident's current chart.

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 43), who had difficulty swallowing and was at risk for aspiration (accidentally inhaling your food or liquid into your airway), received care and monitoring of the resident's food consumption within the guidelines of the diet order by failing to: - Implement the facility's policy and procedure (P&P) titled, Food for Residents from Outside Sources, that food brought in from outside the facility for a resident would be first shown to the Charge Nurse for approval that the food was within the diet order (therapeutic and texture). - Implement the facility's P&P titled, Food for Residents from Outside Sources, by providing the family of Resident 43 with the information sheet, Bringing in Food for A Resident. - Ensure facility staff had ongoing communication and coordination to support the nutritional well-being and safety of Resident 43, when Family Member (FM) 1 brought food into the facility. -Report to charge nurse when Certified Nursing Assistant (CNA) 1 observed Resident 43 eating regular textured food brought by FM 1. As a result, on [DATE] at 12:38 AM, after eating a regular textured food brought in by the family, around six hours prior, Resident 43 became congested, had difficulty breathing, and cyanotic (blue- indicating reduced blood oxygen levels). Resident 43 soon became unresponsive, required cardiopulmonary resuscitation (CPR - medical intervention used to restore circulatory and/or respiratory function that has stopped) and at 1 AM on [DATE], Resident 43 was pronounced dead (nine days after his admission). On [DATE] at 8:11 PM, an Immediate Jeopardy (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) was identified in the presence of the Administrator (ADM), regarding the facility's failure to identify and ensure Resident 43, who had difficulty swallowing and was at risk for aspiration, received necessary care and services in accordance with professional standards of practice. On [DATE] at 1:12 PM, while onsite at the facility, the IJ was removed in the presence of the ADM, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: -On [DATE], the Minimum Data Set (MDS - a standardized assessment and care screening tool) Nurse reviewed the diet orders of all current residents (42) to determine if their diet texture (qualities of a food that can be felt with the fingers, tongue, palate, or teeth) and fluid consistency (refers to the thickness of the liquid) needed to be clarified with the physician. Thirty-nine residents needed clarification of their diet orders. The MDS Nurse completed the clarification of diet orders on the same day. -Starting [DATE], the Nurse Consultant provided an in-service to six Interdisciplinary Team (IDT members Activities Director, MDS Nurse, Director of Rehab, Dietary Supervisor, Administrator, Social Services Director, and Director of Staff Development) to inform the resident's family, during the initial IDT meeting and subsequent IDT meetings as needed, about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The resident's family would be asked to sign a form acknowledging they received this information. The DON was the only remaining IDT member who would be provided with an in-service by the Nurse Consultant upon their return to work. -Starting [DATE], the IDT reviewed 36 current residents who were on a therapeutic diet (meal plan that controls the intake of certain foods or nutrients in the treatment or management of certain diseases, illnesses, or medical conditions) and informed their family members via telephone conversation about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The information was provided using the family members' native language. The IDT members documented in the resident's chart that the family has been informed. -Consultant provided an in-service to Registered Nurses (RNs), Licensed Vocational Nurses (LVN), Certified Nursing Assistants (CNA) and Restorative Nurse Aides (RNA), 60% of staff, regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility. The in-service emphasized the following: -Diet orders will be printed daily by the licensed nurse and will be made available as a reference at the nurses' station. -Food brought in by family from outside sources must be consistent with the resident's prescribed diet; -Food brought in by family from outside sources should be shown to the licensed nurse for evaluation if it matches the resident's prescribed diet. -The licensed nurse must be notified if the resident is observed to be eating food that does not match the diet order or when the family is observed to have brought in food for the resident that is different from the diet order. -The licensed nurse will check on residents who have food brought in by family every 2 hours and as needed; and, -The licensed nurse will record both the evaluation of the food brought from outside and every two-hour visual checks in a log that would be submitted to the DON or designee for further review. -Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service. In-services would be completed for all the active nursing staff by the Nurse Consultant on or before [DATE]. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work. -Starting [DATE], the Nurse Consultant checked competencies of two RNs, eight LVNs and 16 CNAs, as in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies. Competency evaluations would be performed by the Nurse Consultant and completed for all active nursing staff by [DATE]. Staff who were currently on vacation or on leave would have their competencies evaluated upon their return to work. -On [DATE], the Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources, emphasizing the importance of reporting to the licensed nurse when the resident was observed to be eating food that was different from the diet order. At the end of the in-service, the CNA was asked questions to evaluate his knowledge about the information provided to him and was able to answer questions correctly. -On [DATE], the Nurse Consultant provided an in-service to 15 CNAs and 2 RNAs (50%) regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources. The Nurse Consultant would complete the in-service for all the active CNAs and RNAs by [DATE]. Staff who were currently on vacation or on leave would be provided the in-service upon their return to work. -The RD would review diet orders once a week to ensure diet orders were clear and correct. She would conduct rounds once a week to ensure that residents were provided the correct diet texture and fluid consistency. Findings would be reported to the Director of Nursing (DON) and Administrator weekly for follow-up. Findings: A review of Resident 43's Admission Record indicated the facility admitted the resident, on [DATE], with diagnoses including but not limited to history of stroke, adult failure to thrive, and presence of cardiac pacemaker. A review of Resident 43's Admission Assessment, dated [DATE], indicated the resident was alert and oriented x 1, had a regular heartbeat with a strong pulse, he did not have a cough and breath sounds were clear. A review of the Physician's Order Summary Report, dated [DATE], indicated Resident 43 was to receive a pureed diet texture. regular consistency. According to a review of Resident 43's Nursing Progress Notes, dated [DATE], the resident was able to make his needs known, responsive to all stimuli, and had no complaints of pain or discomfort. A review of Resident 43's Alteration in Oral / Dental Status care plan initiated [DATE], indicated the resident did not have teeth and the goal was for Resident 43 to not have unrecognized signs and symptoms of oral or dental problems daily. The care plan interventions indicated to provide the diet as ordered and monitor percentage of intake, ensure good oral hygiene and for staff to assess for tolerance of prescribed diet. A review of the Activities of Daily Living care plan, dated [DATE], indicated Resident 43 required limited assistance with eating and the interventions included to monitor the resident for any changes in condition and inform the physician. A review of the Nursing Progress notes, dated [DATE], indicated Resident 43 was able to make his needs known, responsive to all stimuli, there were no significant changes, was calm and compliant, denied pain or discomfort, and the resident's breathing was even and unlabored. A review of Resident 43's Admission Interdisciplinary Team (IDT) conference record dated [DATE], indicated Resident 43's diagnoses, physical therapy and the resident's pain were discussed. The IDT conference record indicated Resident 43's diet and diet texture was not mentioned. A review of Resident 43's Minimum Data Set (MDS, standardized assessment and care-planning tool) dated [DATE], indicated Resident 43 had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement), required setup or clean up assistance with eating and had a mechanically altered diet (required change in texture of food or liquids [pureed food, thickened liquids]). The MDS indicated the resident did not have a problem with vomiting, had complaints of difficulty or pain with swallowing and the resident had no natural teeth or tooth fragment(s). A review of the Physician's Order, dated [DATE], indicated Resident 43 was to receive Speech Therapy (ST) three times a week for dysphagia (difficulty swallowing) and the treatment included diet assessment, compensation strategies (learning new ways to perform tasks in an alternative manner) and resident / caregiver education. According to a review of the Speech-language pathologist (SLP) Evaluation and Plan of Treatment, dated [DATE], Resident 43's oral motor structure (movements of the muscles in the mouth, jaw, tongue, lips and cheeks) and function was impaired and the recommendation was for Resident 43 to receive pureed food. A review of the Skilled Speech Therapy care plan dated [DATE], indicated the goals for Resident 43 included to demonstrate improved oral motor strength for functional swallowing, the progression of his diet and for Resident 43 to tolerate his diet without signs and symptoms of aspiration. The care plan interventions included safe swallowing strategies, ongoing assessment of swallow efficiency and skilled ST evaluation and treatment. A review of the Nutritional Assessment, dated [DATE], indicated Resident 43's current diet order was a mechanically altered diet (foods that can be safely and successfully swallowed) pureed with regular consistency liquids due to dysphagia. According to a review of the Situation, Background, Assessment, Recommendation (SBAR - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident) dated [DATE] at 11:21 PM, it was reported by the prior shift (3 -11 PM staff) that Resident 43 vomited a large amount of undigested food (around 5pm). At 12:38 AM, on [DATE], Resident 43's had congestion which worsened manifested by an acute change in the resident's level of consciousness (LOC), shallow and labored breathing with cyanotic nail beds and cold / clammy skin. The SBAR indicated code blue was announced, 911 (a telephone number used to reach emergency medical, fire, and police services) was called and pulmonary resuscitation (CPR) with high flow oxygen support through ambu bag (type of device known as a bag valve mask, which is used to provide respiratory support to patients) was initiated, while active chest compression was performed by a trained support staff. At 12:55 AM, paramedics arrived and assumed care. A review of Resident 43's Certificate of Death indicated the resident expired on [DATE] at 1 AM, with the cause of death as acute cardiopulmonary arrest (the heart and lungs suddenly and unexpectedly stop working), with acute myocardial infarction (heart attack). The Certificate of Death indicated Resident 43 passed away at the facility. During an interview on [DATE] at 10:21 AM, Registered Nurse 1 (RN 1) stated on [DATE], RN 1 worked the 11 PM to 7 AM shift, and the prior shift nurse, Registered Nurse (RN) 2, told RN 1 that during the 3PM to 11 PM shift, Resident 43 had eaten foods with a regular texture including a tortilla, and subsequently vomited a large amount of undigested food. RN 1 stated Resident 43 later became congested with difficulty breathing. After review of Resident 43's electronic chart, RN 1 stated RN 2 had not documented any progress notes, had not completed an SBAR and had not notified the primary physician regarding any of these changes of condition for the resident (eating regular textured food, vomiting). RN 1 stated he left a message for the primary physician due to Resident 43's congestion and difficulty breathing, the resident became more congested and then was unresponsive around 12:38 AM, on [DATE]. RN 1 stated he started CPR, called emergency services and the paramedics took over the CPR upon their arrival. Resident 43 was pronounced dead several minutes later. RN 1 stated Resident 43's congestion may have resulted from the resident ingesting regular textured foods. During an interview on [DATE] at 12:06 PM, the Registered Dietician (RD) 1 stated Resident 43 was on a pureed diet and if Resident 43 received a regular texture while prescribed a puree diet, this would make the resident at risk for aspiration or choking. During an interview on [DATE] at 12:53 PM, the Dietary Supervisor (DS) stated a pureed diet was to be creamy soft, as it was placed in a food processor to have a smooth texture with no pieces inside of it. RN 2 did not respond to voicemail requests for interview. During a phone interview on [DATE] at 4:35 PM, Certified Nursing Assistant 1 (CNA) 1 stated he saw from outside the room that the family brought in food for Resident 43. CNA 1 stated he saw Resident 43 eating the food and did not attempt to stop the resident. CNA 1 stated he did not enter the room because he was busy. CNA 1 further stated Resident 43 then vomited about 30 minutes later and that was when he notified RN 2 that Resident 43 had eaten the wrong texture food. On [DATE] at 11:03 AM, during an interview, the DSD stated the facility policy indicated that food brought in by family should be shown to the charge nurse or RD prior to giving it to the resident. The DSD stated when CNA 1 knew Resident 43 was eating the wrong diet, he should have gone in and reminded the resident and his family that the resident was eating the wrong food. Resident 43 had difficulty swallowing, choking could be very imminent, and the food could go to the lungs. During a phone interview on [DATE] at 12:26 PM, Family Member (FM) 1 stated he called the facility and received permission to bring in food for Resident 43. FM 1 stated he brought in chicken quesadillas for Resident 43, and no one educated him on any special diet or texture that Resident 43 was to receive. A review of the facility's policy and procedure (P&P) titled, Food for Residents from Outside Sources, reviewed [DATE], indicated food brought in from outside the facility kitchen for residents' consumption would be monitored. This was done to measure the effectiveness of this intervention in residents with low food intake, to be sure the food was within the guidelines of the diet order, and to better assess nutrient intake. Nursing and/or Admissions would provide the family of new admits with the information sheet, Bringing in Food for A Resident (Section 6, page 6.24). The P&P indicated the following was to be done to ensure the above was accomplished: -Food brought in from outside the facility for a resident would be first shown to the Charge Nurse for approval that the food was within the diet order (therapeutic and texture). If there were any questions, the Nurse would consult with the FNS Director or the Facility Registered Dietitian. -The Nurse would alert the resident's CNA to the food brought in. The CNA would be responsible for recording the food and the amount consumed, in accordance with the facility meal percentage documentation standard.

Based on interview and record review, the facility failed to ensure three of four sampled residents (Residents 13, 29, and 36) received care and services necessary to prevent accidents and falls by failing to: -Assess Resident 13 accurately for a high fall risk on 11/3/2023. - Identify measures and interventions for risk for falls prior to Resident 13's fall on 1/20/2024. -Complete the Fall Risk Assessments quarterly for Residents 29 and 36, per facility policy. As a result, Resident 13 had a witnessed fall on 1/20/2024, was transferred to the General Acute Care Hospital (GACH) 1 and sustained an acute (new) left femoral neck fracture (hip fracture) and placed Resident 29 and 36 at increased risk for recurrent falls. Findings: A review of Resident 13's Admission Record (face sheet) indicated the facility admitted the resident on 9/16/2014, with diagnoses including fracture of left femur (thigh bone), personal history of traumatic healed fracture (occurs when significant or extreme force is applied to a bone), pain in left hip, chronic pain syndrome (occurs when pain remains long after an illness or injury has healed), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and lack of coordination (not able to move different parts of the body together well or easily) and muscle weakness. A review of Resident 13's History and Physical (H&P) dated 2/26/2020, indicated the resident could make needs known but could not make medical decisions. The H&P indicated Resident 13 required Physical Therapy (PT- certain exercises, massages, and treatments that relieve pain and help you move better), and Occupational Therapy (OT-therapy that focuses on helping people do all the things that they want and need to do in their daily lives) due to potential for falls. A review of Resident 13's Physical Therapy (PT) Evaluation and Plan of Treatment dated 3/5/2023, indicated the resident exhibited knee instability which was associated with the underlying causes of muscle weakness and reduced functional activity tolerance. The PT evaluation indicated Resident 13 had reduced quad (a group of muscles in our front thigh that support activities such as standing, walking, climbing, and running) strength and felt unsteady when walking. A review of Resident 13's Pain assessment dated [DATE], indicated the resident had pain to his bilateral (both) knees and he thought the chronic pain syndrome and osteoarthritis (a joint disease, in which the tissues in the joint break down over time) were the causes of his pain. The pain assessment further indicated Resident 13 was feeling sharp pain to his knees. A review of Resident 13's Minimum Data Set (MDS- standardized assessment and care planning tool) dated 11/3/2023, indicated the resident had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement), required facility staff set up or clean up assistance with putting on taking off footwear and toilet transfer. The MDS indicated Resident 13 required partial assistance for mobility and ambulation (walking from room to room). According to a review of the Fall Risk assessment dated [DATE], Resident 13 had never fallen, had more than one diagnoses, was not using ambulatory aids (wheelchairs, walkers, canes, and crutches), and exhibited normal gait (the pattern that you walk). The fall risk assessment indicated Resident 13 had a score of 15 and a score from 1 - 24 indicated a low risk for falls. A review of Resident 13's Situation Background Assessment and Recommendation Form (SBAR - a form that was a documentation of a complete assessment in response to a change in condition) dated 1/20/2024, indicated Resident 13 had pain to his left leg due to a witnessed fall while ambulating in the hallway, near the nurse's station. The SBAR form indicated Resident 13 fell on his left side. A review of Resident 13's left hip X-Ray result dated 1/20/2024, indicated there was no acute fracture or dislocation of Resident 13's left hip. According to review of the Post Fall assessment dated [DATE], Resident 13 went to smoke in the patio and while returning back to his room, he attempted to ambulate independently, tripped while wearing slippers, and fell on the floor on 1/20/2024. Resident 13 was found on the floor in the hallway next to the nurse's station. A review of Resident) Post Event / Fall Assessment Form dated 1/22/2024, indicated the following factors contributed to Resident 13's current fall: improper use or failure to use assistive device, mobility issues, taking psychoactive (medications that affect the brain) anti-hypertensive medications (used to treat high blood pressure), and diagnoses of schizophrenia and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 13's Fall Event / Interdisciplinary Team (IDT, health care professionals who work together to establish plans of care for residents) Progress Note dated 1/22/2024, indicated the root/cause analysis (technique that helps people answer the question of why the problem occurred in the first place) of the resident's fall on 1/20/2024, was improper use of footwear, impulsiveness, and unsteady gait. The IDT progress note indicated that on 1/24/2024, during rounds, Resident 13 reported to Social Service Director (SSD) and Activity Director (AD) that he had pain to his left leg rating 6-7 out of 10 (using pain rating scale of zero being no pain and 10 being the worst pain possible) when trying to get up. The IDT progress note indicated a registered nurse on duty notified Resident 13's physician and received an order for left pelvis (lower part of the trunk, between the abdomen and the thighs) X-Ray. A review of Resident 13's left hip X-Ray result dated 1/24/2024, indicated an acute left femoral neck fracture. A review of Resident 13's SBAR Communication Form dated 1/24/2024, indicated the resident complained of left hip pain 8/10, and the staff noted a swelling (an abnormal enlargement of a part of the body) to Resident 13 left hip. The SBAR communication form indicated Resident 13's physician ordered to transfer the resident to GACH 1 for further evaluation and treatment of acute left femoral neck fracture. According to a review of GACH 1 Physician Progress Notes dated 2/1/2024, Resident 13 underwent left hip hemiarthroplasty surgery (a surgery to replace half of a hip joint). A review of Resident 13's active care plans on 4/27/2024, indicated the licensed staff did not develop a care plan with person-centered interventions for Resident 13's risk for fall. During a concurrent interview and record review, on 4/27/2024 at 4:40 PM, with the MDS Coordinator (MDSN), Resident 13's care plans were reviewed. The MDSN stated licensed nurses did not develop a care plan for Resident 13's risk for fall. The MDSN stated on 1/20/2024, Resident 13 was wearing slippers while he was walking towards the nurse's station and fell on the floor. During a concurrent interview and record review, on 4/27/2024 at 4:48 PM, with Registered Nurse Supervisor 1 (RN 1), Resident 13's medical record was reviewed. RN 1 stated Resident 13 was taking anti-depressant, anti-psychotic medications and anti-hypertensive medications. There is a risk for fall if a resident is taking these types of medications. RN 1 stated, Seems like there is no care plan with specific goals and person-centered interventions for Resident 13's risk for fall in his medical chart. During a concurrent interview and record review, on 4/27/2024 at 5:05 PM, with the Director of Staff Development (DSD), Resident 13's Fall Risk Assessments were reviewed. The DSD stated Resident 13's fall risk assessments dated 11/3/2023, indicated he was considered a low risk for potential falls and the licensed nurses documented Resident 13 had normal gait. The DSD stated Resident 13's gait was not normal. The DSD stated, Resident 13 had a history of surgery and pain to his left leg and both knees. Resident 13 was limping. The DSD further stated licensed staff should have documented weak gait instead of normal gait when completing Resident 13's fall risk assessments dated 11/3/2023. The DSD stated Resident 13 was not considered a high risk for fall based on the incorrect fall risk assessments. Therefore, appropriate interventions were not implemented to prevent his fall. The DSD stated, Resident 13 was wearing an open toe slipper and that is why he tripped and fell . During an interview on 4/30/2024 at 11:35 AM, Licensed Vocational Nurse (LVN) 3 stated Resident 13 was a risk for falls because of his abnormal gait because of his knee pain. The resident was bowlegged (having legs that curve outward at the knee) and was walking fast. LVN 3 stated Resident 13 was wearing a pair of open-toe slippers and he fell because he tripped on his open toe slippers. Those slippers were not safe for the resident and Resident 13 was insisting to wear them. LVN 3 further stated, We could have prevented Resident 13's fall on 1/20/2024, by not letting him wear those slippers. LVN 3 stated licensed staff did not develop a care plan for Resident 13's non-compliance (not obeying a rule) of wearing inappropriate footwear. b. A review of Resident 29's admission record indicated the facility readmitted the resident, on 5/25/2021, with diagnoses including atrial fibrillation (an irregular and often very fast heartbeat that can lead to blood clots, stroke and heart failure), liver failure and dementia (is a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality). A review of the High Risk for Falls care plan, initiated 6/1/2022, indicated Resident 29 was at high risk for falls due to psychoactive drug use, unaware of safety needs and his gait/balance problems. The care plan interventions included to follow the facility's fall protocol and for staff to review information on past falls and attempt to determine cause of falls, to record possible root causes and educate family/resident/caregivers as to the causes of his falls. A review of the SBAR Communication Form dated 6/24/2023, indicated Resident 29 had an unwitnessed fall with a skin tear on the left forearm. A review of the IDT meeting, dated 9/12/2023, indicated Resident 29 required limited to extensive assistance with activities of daily living (ADLs -essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) and supervision to limited assist with eating. According to a review of the Fall Risk Assessments, the most recent was dated 12/8/2023 with a score of 55, indicating a high risk for falls. There was no quarterly fall assessment for March 2023. A review of the Quarterly MDS dated [DATE], indicated Resident 29 had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement. A review of the April 2024 Medication Administration Record (MAR) indicated Resident 29 was administered Seroquel (a psychoactive medication-any medication capable of affecting the mind, emotions, and behavior) 25 milligrams (mg) by mouth at bedtime for behavioral or psychological symptoms of dementia at 9 PM for from 4/1/2024 to 4/25/2024. A review of National Library of Medicine (NLM)'s DailyMed a searchable database provides the most recent labeling submitted to the Food and Drug Administration (FDA), revised date of 1/27/2022, manufacturer's labeling for Seroquel indicated, the medication could cause low blood pressure and sleepiness which may lead to falls. During an observation on 4/26/2024 at 6:55 PM, a star on a red piece of paper was located on Resident 29's nameplate. Resident 29 was sleeping and lying in a low bed. During an interview on 4/27/2024 at 1:19 PM, CNA 2 stated the red star next to Resident 29's name indicated the resident was on fall precautions. CNA 2 stated at times, Resident 29 tried to get out of bed and go to the restroom on his own. CNA 2 stated Resident 29 was in a low bed to prevent falls. During an interview on 4/27/2024 at 1:45 PM, Licensed Vocational Nurse 3 (LVN 3) stated Resident 29 had a fall during the 3 PM to 11 PM shift on 6/24/2023. LVN 3 stated Resident 29's last fall risk assessment was completed in December 2023 and the resident should have one completed in March 2024. c. A review of Resident 36's Admission Record indicated the facility admitted the resident on 3/7/2023, with diagnoses including difficulty in walking, lack of coordination, and repeated falls. A review of the Fall Risk assessment dated [DATE], indicated Resident 36 had fallen before, had more than one diagnoses, was using ambulatory aids, exhibited impaired gait and forgets his limits. The assessment indicated Resident 36 had a score of 90 and that a total score was 45 and higher, the resident was considered a high risk for potential falls. A review of Resident 36's Fall Risk assessment dated [DATE], indicated 36 had fallen before, had more than one diagnoses in his chart, was using ambulatory aids (tools like wheelchairs, walkers, canes, and crutches to help in walking), exhibited impaired gait and knows his limit. The assessment indicated Resident 36 had a score of 75 and was a high risk for fall. A review of Resident 36's MDS dated [DATE], indicated the resident had severely impaired cognition, required partial/moderate staff assistance with personal hygiene, required staff supervision or touching with oral hygiene, toileting hygiene, showering and upper and lower body dressing. During a concurrent interview and record review on 4/27/2024 at 1:31 PM, with RN 1, Resident 36's fall risk assessments were reviewed. RN 1 stated licensed staff did not develop any fall risk assessment for Resident 36 after 12/15/2023 and the fall risk assessments were completed by licensed staff quarterly, and after each incident of fall. RN 1 stated the potential outcome of not developing a fall risk assessment quarterly was the inability to deliver required care and services and consequently repeated falls and injuries. During an interview on 4/27/2024 at 1:40 PM, the MDSN stated, I am in charge of completing assessments for the residents and I am behind. The MDSN stated no fall risk assessment was initiated and documented for Resident 36 after 12/15/2023. A review of the facility's policy and procedures (P&P) titled, Fall Prevention Program, revised 1/18/2024, indicated all residents will be assessed for risk for fall in order to facilitate fall prevention and reduction program. If a resident is at risk for falls, it will be identified on the care plan. A review of the facility's P&P titled Fall Risk Assessment, revised 1/18/2024, indicated the facility will complete a fall risk assessment on admission, and update after any falls or change of condition and with quarterly and annual MDS assessment. All residents will be assessed for risk for fall in order to facilitate fall prevention and reduction program. A review of the facility's policy and procedure titled, Post Fall Management Program, dated 12/2016, indicated all residents will be assessed for risk of fall in order to facilitate fall prevention and reduction program. To ensure that all residents are assessed following an incident of fall. It also indicated Seroquel was a prescription medication that increases the risk for fall for patients 65 and older.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dementia (loss of memory, thinking and reasoning), was a high risk for falls and was diagnosed with [CONDITION(S)] (serious mental disorder in which people interpret reality abnormally, may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior), was provided a low bed and floor mats, per facility's Fall Prevention Program policy and failed to notify the physician of Resident 1's altered behavior / change in condition. As a result, on 11/27/2021, at 8:20 a.m., Resident 1 sustained an injury, complained of left leg pain, moaned with facial grimacing when trying to stand, and had bilateral (both) hip bruises with pain on movement. Resident 1 was transferred to the general acute hospital (GACH 1) where Resident 1 was found to have a left hip fracture (complete or partial break in the bone) and required surgery. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including [CONDITION(S)], major depressive disorder (a common and serious medical illness of severe low mood, sadness or despair) and dementia (loss of memory, thinking and reasoning). A review of Resident 1's Fall Risk assessment dated [DATE], indicated Resident 1 had intermittent confusion, was chair bound and had a balance problem while standing. The fall risk assessment indicated Resident 1 had a total score of 10 and 10 or greater indicated the resident should be considered a high risk for potential falls. The fall risk assessment indicated the prevention protocol should be initiated and immediately documented on the care plan. A review of the Care Plan for Falls dated 11/15/2021, indicated Resident 1 was at risk for falls due to wandering, constant pacing, poor safety awareness, restlessness / frequent position changes, and use of medication with potential adverse side effects. The Care Plan goal indicated Resident 1 would have no falls or injuries daily for the next three months. The interventions indicated to provide adequate lighting, monitor resident's whereabouts / location with visual checks at least every two hours, keep call light within reach and answer promptly, monitor for sedation, dizziness, unsteady standing / sitting balance and inform the physician. The interventions did not include placing Resident 1's bed in the lowest position and applying bilateral floor mats. A review of Resident 1's Behavior Care Plan dated 11/15/2021, and updated on 11/26/2021, indicated Resident 1 had altered behavior patterns related to [CONDITION(S)] manifested by persistent wandering from room to room, episodes of cleaning the floor, lying and sleeping on the floor. The care plan goal was to reduce the episodes of behavior daily and minimize the risk of decline daily for 90 days. The interventions included provide reality awareness, assess what may cause and trigger behavior, attempt to reduce / eliminate those triggers if possible, notify the physician of the refusal and psychiatrist follow up as indicated. According to a review of Resident 1's Behavioral Pattern Care Plan dated 11/15/2021 and updated on 11/26/2021, Resident 1 had behavior of wandering, moving without rational purpose oblivious to needs or safety, constant pacing and episodes of cleaning the floor for no apparent reason. Interventions included redirect behavior to something positive, psychology and psychiatrist consult, monitor side effects of medications and notify the physician. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/23/2021, indicated Resident 1's cognitive skills of daily decision making were moderately impaired and was disoriented to year, month and day (unable to make decisions). The MDS indicated Resident 1 needed one-person physical assistance with activities of daily living (ADLs, includes bed mobility, transfer, dressing, eating). A review of Resident 1's Nursing Daily Notes dated 11/26/2021, indicated Resident 1's skin was assessed, with no bruises or discoloration. Resident 1 denied pain or discomfort. The daily notes indicated Resident 1 was assisted back to bed, explained to resident to use the call light, provided reality orientation and redirection. The daily notes did not indicate Resident 1 was restless, pacing back and forth in the hall, lying down on the floor inside her room or cleaning the floor using her hands. A review of Resident 1's Nurses Progress Notes dated 11/27/2021, at 8:20 a.m., indicated Resident 1 was sitting on her bed and complained of pain on the left leg. Resident 1 was unable to get up. Resident 1 was moaning and with facial grimacing when assisted to stand up. Resident 1 was placed back to her bed. The nurse's notes indicated during assessment there were bruises on bilateral hips. Resident 1 was given acetaminophen (pain medication) 650 milligrams (mg.). A review of Resident 1's Physician and Telephone Orders dated 11/27/2021, at 9:15 a.m., indicated Resident 1's primary physician gave an order to transfer Resident 1 to GACH 1 due to pain on bilateral hips. A review of Resident 1's the GACH 1 Urgent Care Physician's Note dated 11/27/2021, at 7:02 p.m. indicated Resident 1 had bruises on bilateral hips. Resident 1 had increased pain and decreased range of motion (ROM, full movement potential of a joint,) in the left hip. A review of Resident 1's History and Physical dated 11/28/2021 at 4:35 p.m., indicated x-rays of the hip indicated a displaced left sub capital hip fracture (broken bones have moved out of their normal position). The history and physical form indicated Resident 1 was unable to explain the circumstances of how this happened due to confusion. A large hematoma (collection of blood outside of blood vessels caused by an injury) was noted on bilateral hips. The history and physical form indicated Resident 1 was unable to move the left leg without visible pain and discomfort. According to a review of Resident 1's GACH 1 Operative Report dated 12/3/2021, Resident 1 presented to GACH 1 after a fall and suffered a left hip injury. This GACH 1 report indicated Resident 1 had left hip hemiarthroplasty (surgical procedure that involves replacing half of the hip joint). A review of Resident 1's Nurses Progress Notes dated 12/8/2021 at 10:55 p.m., indicated Resident 1 was readmitted to the facility with 24 staples (used to close incisions after surgery) on the surgical site in the left hip measuring 16 centimeters (cm.) by 0.5 cm. The surgical site had no evidence of infection with wound dressing. Leg abduction pillow (device used to prevent the hip from moving out of the joint) was in place to prevent hip adduction (movement of the leg away from the midline of the body) or internal rotation (twisting motion that creates inward rotation of the thigh at the hip joint). On 12/15/2021, at 10:03 a.m., during an interview the director of nursing (DON) stated Resident 1 may have had an unwitnessed fall on 11/26/2021 between the hours of 9 p.m. to 7 a.m. The DON stated on 11/26/2021, at 9 p.m., Resident 1 was found on the floor in her room and was cleaning the floor with her hands. Resident 1 was assessed and had no injury. At 10 p.m., Resident 1 was found on the floor again, assessed and had no injury. Resident 1 was assisted back to bed. At 12:30 a.m., Resident 1 was found lying on the floor with pillow and blanket. Resident 1 was assisted back to bed. At 2 a.m. Resident 1 was found lying on the floor with pillow insisting that her sister wants her to sleep on the floor. Resident 1 was assisted back to bed. At 4 a.m., Resident 1 wants to sleep on the floor and tried to slide down from her bed. Resident 1 was assisted back to bed. At 5:20 a.m. Resident 1 was trying to slide down from her bed and assisted back to bed. At 7 a.m. Resident 1 was sliding down from the bed and crawled towards the closet. On 12/15/2021, at 10:57 a.m., during an interview registered nurse supervisor (RNS) 1 stated on 11/27/2021, at about 8 a.m., he received report that Resident 1 had bruises on bilateral hips. RNS 1 stated Resident 1 complained of pain in the left hip and gave her pain medication. Resident 1's primary physician was notified and gave an order to transfer Resident 1 to GACH 1 for further evaluation. On 12/17/2021, at 4:20 p.m., during a telephone interview, licensed vocational nurse (LVN) 1 stated on 11/26/2021, at about 9 p.m., Resident 1 was found on the floor on her knees cleaning the floor with her hands. LVN 1 stated he assisted Resident 1 to get up from the floor and Resident 1 was able to stand up easily. Resident 1 had no complaints of pain. LVN 1 stated he did not document his assessment in the medical records. LVN 1 stated at 10 p.m. Resident 1 was found on the floor again and cleaning the floor. During a telephone interview, on 12/17/2021, at 4:35 p.m., RNS 2 stated Resident 1 was found sitting on the floor two different times on 11/26/2021, both times cleaning the floor with her hands. RNS 2 agreed that when Resident 1 was found on the floor, Resident 1 may have had an unwitnessed fall. RNS 2 stated he did not notify the physician. During an interview on 12/22/2021, at 10:36 a.m., the certified occupational therapist assistant (COTA) stated prior to the fall, Resident 1 was ambulatory and independent when walking. After the fall, Resident 1 had to use the wheelchair and can only walk for a distance of three feet. On 12/22/2021, at 9:26 a.m., during an interview and a review of Resident 1's Care Plan for fall and the facility Policy for Fall Management with the DON, the DON was unable to find documentation indicating Resident 1 was placed on low bed and floor mats as stipulated in the facility's Policy and procedures. The DON stated the low bed would lessen the impact of injury in case of falls. The DON further stated when Resident 1 was exhibiting behavior of restlessness, inability to sleep, sliding and crawling out of bed, cleaning and wiping the floor, he would have called the physician. The DON was unable to find documentation that the physician was notified. During a telephone interview on 12/22/2021, at 4:29 p.m., LVN 2 stated during the night shift on 11/27/2021, Resident 1 was restless and crawling out of bed. LVN 2 stated she found Resident 1 on the floor four different times, cleaning the floor. LVN 2 stated Resident 1 would crawl out of bed or slide herself off the bed, she assessed Resident 1 for injury and there was no injury. LVN 2 stated she did not document her assessments or interventions each time Resident 1 was found on the floor and stated she did not notify the physician. During a telephone interview on 12/30/2021 at 4:22 p.m., the psychiatrist nurse practitioner (NP) stated when Resident 1 was exhibiting behavior of restlessness, inability to sleep, sliding out of bed and found on the floor, the facility staff should have notified her. The NP stated she could have given an order for laboratory tests to rule out infection, [CONDITION(S)] or dehydration. The NP stated she may prescribe new medication. A review of the facility's policy and procedures titled, Fall Prevention Program, date 12/2016, indicated the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. All residents will be assessed following incident of fall. The policy indicated a fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The policy indicated if upon admission, a risk for fall is identified, initiate use of fall prevention and reduction program according to fall risk score. If a resident is at risk for falls, it will be identified on the care plan. All precautions will be implemented to protect the resident according to the fall prevention and reduction program. Direct staff will re-assess resident with every episode of fall. The Policy indicated consider the use of the following equipment: -bed and/or chair alarms -alarms at exit -nonskid floor mat -raised edge mattress -nurses call systems and communication systems -beds for residents at risk for fall - low bed, bed in lowest position. The policy indicated to keep the beds in lowest position when feasible. Use height adjustable hi-low beds or fixed low-deck height beds where applicable. Consider providing a bed footboard to assist patients and residents use in transferring in and out of bed or in ambulating about the bedroom. Mattresses should be firm enough to support safe bed transfer. Landing mattress may be used for fall prevention next to bed to decrease injuries. A review of the facility's policy and procedures titled, Change of Condition, dated 8/2017, indicated to promptly notify the resident, his or her attending physician and representative of changes in the residents' medical/mental condition and/or status. Acute medical changes or serious change in condition manifested by a marked change in physical, mental or psychosocial status licensed nurse will notify the physician. Nurses will record in the resident's medical record information relative to changes in the resident's medical or mental condition or status.