Every finding on record at Artesia Christian Home Inc.

Based on observation, interview, and record review, the facility failed to ensure the storage of food was done under sanitary conditions affecting 46 out of 46 residents by not labeling a salad with the date it was prepared and by not labeling raw meats with the date it was placed in the refrigerator.These deficient practices placed residents at risk for food-borne illnesses (any illness resulting from eating contaminated/spoiled foods) had the potential to cause nausea, vomiting and diarrhea .Findings:During a concurrent observation and interview on 1/20/2026 at 8:16 a.m., with [NAME] (CK)1, a tray of opened bag of raw chicken was observed without a date in the facility kitchen refrigerator. CK 1 stated the tray of raw chicken should have a date on it.During a concurrent observation and interview on 1/20/2026 at 8:20 a.m., with CK 2, trays of raw ground beef, pork loin, pork, and chicken were observed unlabeled without a date in the facility kitchen refrigerator. There was an observation on another shelf, with a packaged container of green salad without a date on it. CK 1 stated the food items should have been labeled.During an interview on 1/22/2026 at 9:48 a.m. with the Registered Dietician (RD), the RD stated raw meat, and prepared foods need to be labeled with date for resident safety.During a review of the facility's P&P, titled Food Handling Guidelines , revised 1/2021, the P&P indicated thawing frozen meat and poultry under refrigeration need to be labeled with the date it was removed from the freezer, and the date by which it must be used.During a review of the facility's policy and procedure (P&P), titled Food and Supply Storage, revised 1/2021, the P&P indicated all food items shall be stored to maintain safety and wholesomeness of food for human consumption. The P&P indicated to cover, label, and date unused portions and open packages.

Based on observation, interview and record review, the facility failed to: Ensure staff performed hand hygiene prior to entering Resident 16 and Resident 30's room. Ensure Restorative Nursing Aide (RNA nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) 2 wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assisting with range of motion (ROM, full movement potential of a joint) exercises to Resident 8's both arms and both legs which required direct contact with Resident 8 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms).Ensure Certified Occupational Therapist Assistant 1 (COTA 1) used the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt after providing occupational therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) services to Resident 54. Follow their water testing policy and procedure. These failures had the potential to result in:a. Transmission of infectious microorganisms and increase the risk of infection for the residents. b. Transmission of infectious microorganisms and increase the risk of infection among the residents and staff c. Transmission of infectious microorganisms and increase the risk of infection among the residents and staff d. The spread of legionella [a type of bacteria found in water that causes Legionnaire's Disease (a severed type of pneumonia)].Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (group of thinking and social symptoms that interferes with daily functioning) (severe with agitation), Alzheimer's disease (a type of disease that affects memory, thinking, and behavior), and atherosclerotic heart disease (caused by fat buildup in arterial walls that blocks blood flow). During a review of Resident 16's History and Physical (H&P), dated 2/19/2025, the H&P indicated Resident 16 did not have the capacity to understand and make decisions. During a review of Resident 16's Minimum Data set ([MDS], A resident assessment tool), dated 10/31/2025, the MDS indicated Resident 16's cognitive (functions your brain uses to think, pay attention, process information, and remember things) skills were severely impaired. The MDS indicated Resident 16 was dependent on performing all aspects of activities of daily living (ADL: basic activities such as eating, dressing, toileting). During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was readmitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), traumatic amputation at level between left hip and knee (on 1/14/2026), and peripheral vascular disease (PVD: a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 30's MDS, dated [DATE] the MDS indicated Resident 30 was cognitively intact. The MDS indicated Resident 30 was dependent on chair/bed-to-chair transfer, required maximal assistance (provide more than half the effort) for toileting hygiene and lower body (below waist) dressing, required moderate assistance (provide less than half the effort) for upper body (above waist) dressing, sit to lying, and required set up for eating and oral hygiene. During an observation on 1/21/2026 at 8:40 a.m., with the Licensed Vocational Nurse 2 (LVN 2), LVN 2 was observed after preparing Resident 16's morning medications, entered Resident 30's room without performing hand hygiene. During a concurrent observation and interview on 1/21/2026 at 9:17 a.m., with LVN 3, LVN 3 was observed after preparing Resident 30's medication, LVN 3 did not perform hand hygiene and entered Resident 30's room. LVN 3 stated hand hygiene was performed before you enter and after you leave the resident's room, when having direct contact with the resident, before putting gloves on and when hands are visibly soiled. LVN 3 stated hand hygiene prevents cross contamination and indicated she did not do hand hygiene prior to entering Resident 30's room. During an interview on 1/22/2026 at 3:39 p.m., with the Director of Nursing (DON), the DON stated hand hygiene should be performed when the hand is visibly soiled, contaminated, or before going into a resident's room. The DON stated hand hygiene was important to prevent spread of microorganisms. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised August 2015, the P&P indicated this facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Findings: b. During a review of Resident 8's admission Record, the admission Record indicated the facility initially admitted Resident 8 on 11/6/2024 and re-admitted Resident 8 on 1/22/2025 with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), fracture of the left neck of the femur (broken hip, broken bone in the top potion of the thigh bone where it connects to the hip joint), and malignant neoplasm of the prostate (uncontrolled growth of cancerous cells in the prostate gland, a male reproductive organ). During a review of Resident 8's Physician Order Report, the Physician Order Report indicated a physician's order, dated 12/31/2024, for Resident 8 to be placed on EBP due to Resident 8's indwelling foley catheter (thin, flexible rube inserted into the bladder to drain urine). During an RNA observation on 1/21/2026 at 11:10 am, RNA 2 transported Resident 8 who was seated in a wheelchair from the dining room into Resident 8's room. RNA 2 entered Resident 8's room, positioned Resident 8's wheelchair next to the bed, and put on a pair of gloves. RNA 2 did not put on an isolation gown. RNA 2 physically assisted Resident 8 with range of motion exercises to Resident 8's both shoulders, both elbows, both hands, and both knees. When exercises were complete, RNA 2 removed both gloves, performed hand hygiene, and transported Resident 8 back to the dining room. During an interview with RNA 2 on 1/21/2026 at 11:24 am, RNA 2 confirmed she did not wear an isolation gown while assisting Resident 8 who was on EBP with ROM exercises. RNA 2 stated she should have worn an isolation gown while assisting Resident 8 with ROM exercises because she had direct contact with Resident 8 who was on EBP. RNA 2 stated it was important to follow infection control protocols to prevent the spread of infection. During a concurrent interview and record review with Assistant Director of Nursing (ADON) and Infection Preventionist Nursing (IPN) on 1/22/2026 at 4:46 pm, the ADON and IPN stated the purpose of EBP precautions was to reduce the transmission of infection for residents with wounds (injury to the body that typically involves a laceration or breaking of a membrane) and indwelling devices (medical devices inside the body) such as gastrostomy tube (G-tube- a tube placed directly into the stomach for long-term feeding) and foley catheters. The IPN stated all staff providing direct patient care which included assisting with ROM to residents on EBP must wear the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) which included an isolation gown and gloves to prevent the spread of infection. The ADON and IPN stated it was important staff wore an isolation gown and gloves when providing direct care to residents on EBP to prevent the spread of infection. During an interview with the Director of Nursing (DON) on 1/22/2026 at 5:42 pm, the DON stated staff should wear an isolation gown and gloves when providing direct care to residents on EBP according to Center for Disease Control and Prevention (CDC) guidelines. During a review of the facility's undated Policy and Procedure (P/P) titled, Enhanced Barrier Precautions, the P/P indicated it was the facility's policy to implement EBP for the prevention of transmission of multidrug resistant organisms (MRDO). The P/P indicated EBP referred to an infection control intervention designed to reduce transmission of MRDO that employed targeted gown and glove use during high contact resident care activities. The P/P indicated an order for EBP for residents with wounds, indwelling medical devices including foley catheters, and infection or colonization with MDRO. c. During a review of Resident 54's admission Record, the admission Record indicated the facility initially admitted Resident 54 on 1/8/2026 with diagnoses including cardiomyopathy (disease that causes weakening of the heart muscle) and difficulty walking. During an observation in the Therapy gym on 1/21/2026 at 2:42 pm, Resident 54 was observed seated on the therapy mat with a cloth gait belt around the waist. COTA 1 assisted Resident 54 with sit to stand exercises and marching exercises using a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking). Once the RNA session was complete, COTA removed Resident 54's cloth gait belt, rolled it up, placed the gait belt on the sink, performed hand hygiene, put on gloves, and wiped down both sides of the gait belt using disinfectant wipes. During an interview with COTA 1 on 1/21/2026 at 2:55 pm, COTA 1 stated she cleaned and disinfected the cloth gait belt with disinfectant wipes (disposable wipes used to disinfect surfaces) after working with Resident 54. COTA 1 stated cloth gait belts were made of fabric. COTA 1 stated it was important shared equipment was disinfected properly to prevent the spread of infection. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 1/21/2026 at 3:19 pm, the DOR stated all shared equipment which included cloth gait belts were disinfected using Lysol disinfectant wipes after and in between resident use. The DOR stated cloth gait belts were made of fabric, a porous (having small spaces or holes through which liquid or air may pass) material. The DOR reviewed the Lysol disinfectant wipes manufacturer instructions and confirmed the instructions indicated the disinfectant wipes were to be used on hard, non-porous surfaces only. The DOR stated Lysol disinfectant wipes were ineffective because cloth gait belts were made of porous material. The DOR stated the only way to effectively clean and disinfect cloth gait belts was to launder them after each resident use. The DOR stated it was important to properly disinfect shared equipment according to manufacturer's instructions to ensure equipment was disinfected effectively. During a concurrent interview and record review with ADON and IPN on 1/22/2026 at 4:46 pm, the ADON and IPN stated shared equipment was disinfected before and after resident use using Lysol disinfecting wipes. The ADON and IPN stated they were unaware the facility still used cloth gait belts and thought all cloth gait belts were disposed of due to infection control concerns since they were difficult to effectively disinfect because they were made of fabric. The IPN reviewed the Lysol disinfecting wipes manufacturers guidelines and confirmed disinfecting wipes were to be used on hard, non-porous surfaces only. The ADON and IPN stated cloth gait belts were made of porous material and Lysol disinfecting wipes would be an ineffective disinfectant according to manufacturer's guidelines. The ADON and IPN stated the only way to properly clean and disinfect cloth gait belts was to launder them after each resident use. The ADON and IPN stated it was important to clean and disinfect shared equipment properly to prevent the spread of infection and avoid cross contamination. During an interview with the Director of Nursing (DON) on 1/22/2026 at 5:42 pm, the DON stated it was important shared equipment was disinfected properly and according to manufacturer guidelines before and after resident use to prevent the spread of infection. During a review of the facility's P/P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, the P/P indicated resident care equipment, including reusable items and durable medical equipment would be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The P/P indicated reusable resident care equipment would be decontaminated and/or sterilized between residents according to manufacturer's instructions. During a review of the facility's undated P/P titled, Use of Lysol Disinfectant Wipes, the P/P indicated the disinfectant wipes shall be used according to manufacturer instructions to reduce the transmission of infection organisms and maintain compliance with infection prevention and control standards. The P/P indicated Lysol Disinfectant Wipes could not be used on porous surfaces. Findings: d. During a concurrent interview and record review on 1/22/2026 at 11:52 a.m., with the Disaster Coordinator (DC), the Policy and Procedure (P&P) titled Water Testing Policy and Procedure (undated) and the water temperature logs for 2025 were reviewed. The P&P indicated the facility to check the water temperatures in water heaters.temperatures should be at least 123 degrees Fahrenheit (F – a unit of measure) or higher. The DC stated there is no documentation that indicated the water heater temperatures were being checked monthly as written in the policy. The DC stated they did not know when the Water Testing P&P was last reviewed or revised. During an interview on 1/22/2026 at 4:00 p.m. with the Director of Nursing (DON), the DON stated water testing is important to prevent the residents from contracting legionnaires disease. The DON stated the Water Testing P&P should be reviewed at least annually to ensure that it reflects the current guidance.

Based on interview and record review the facility failed to ensure two of four residents' (Resident 16 and 31) oral medications were not crushed and administered together during medication pass.This deficient practice placed Resident 16 and Resident 31 at risk for dangerous chemical interactions and had the potential for altered drug effects, and incorrect dosage. Findings: 1. During a review of Resident 16's admission Record, the admission record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including dementia (group of thinking and social symptoms that interferes with daily functioning), Alzheimer's disease (a type of disease that affects memory, thinking, and behavior), and atherosclerotic heart disease (caused by fat buildup in arterial walls that blocks blood flow). During a review of Resident 16's History and Physical (H&P), dated 2/19/2025, the H&P indicated Resident 16 did not have the capacity to understand and make decisions. During a review of Resident 16's MDS ([MDS], A resident assessment tool), dated 10/31/2025, the MDS indicated Resident 16's cognitive skills (functions your brain uses to think, process information, and remember things) was severely impaired. The MDS indicated Resident 16 was dependent (helper does all the effort) on performing all aspects of activities of daily living ([ADL] basic activities such as eating, dressing, toileting). During a review of Resident 16's Physician Order Report dated 12/22/2025 to 1/22/2026, the report indicated the following orders: a) 2/20/2023: Crush all crushable medications. b) 4/20/2023: Aspirin (nonsteroidal anti-inflammatory drug (NSAID) used to treat inflammation and prevent heart attacks) [Over the Counter (OTC)] tablet, chewable, 81 milligrams (mg: unit of mass), oral once a day. c) 1/2/2025: Multivitamin (combinations of vitamins) tablet, oral once a day. During a concurrent observation and interview on 1/21/2026 at 8:30a.m. with the Licensed Vocational Nurse 2 (LVN 2), LVN 2 was observed crushing the multivitamin and aspirin together and mixing the two crushed medications with apple sauce. LVN 2 gave Resident 16 apple sauce mixed with the medications. LVN 2 stated it is acceptable to crush the medications (multivitamins and aspirin) together. LVN 2 stated crushing the medications together in one bag and administering the medications together would not affect the residents. During an interview on 1/22/2026 at 3:39p.m. with the Director of Nursing (DON), the DON stated the Medication Administration Policy, did indicate they could not crush two pills together in one bag and administer them together. The DON stated it is acceptable to crush two medications in one bag together and administer the medications, The DON stated there could be a potential outcome based on the chemical component of the medication. 2. During a review of Resident 31's admission Record, the admission record indicated Resident 31was readmitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health issue characterized by severe and excessive worry that affects daily life), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 31's MDS, dated [DATE], the MDS indicated Resident 31's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was severely impaired. The MDS indicated Resident 31 needed set up or clean up assistance with eating. During a review of Resident 31's Physician Order Report dated 12/22/2025 to 1/22/2026, the report indicated the following orders,: a) 1/15/2025, Crush all crushable medications. b) 1/15/2025, Loratadine (medication for chronic rhinitis [long term inflammation of nasal lining])10 milligrams, one tablet, oral once a day. c) 1/15/2025, Tylenol (pain medication) 325 milligrams tablet, 2 oral tablets, once a day. d) 9/17/2025, Seroquel (medication for psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality]) 25 milligrams tablet, one tablet, twice a day. During a concurrent observation and interview on 1/20/2026 at 9:07 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 placed the Loratadine, Tylenol, and Seroquel in a pill crusher pouch and crushed the pills to administer to Resident 31. LVN 1 stated I crush her pills to make it easier for Resident 31. During a concurrent interview and record review on 1/22/2026 at 4:30 p.m., with the Director of Nursing (DON) the facility pharmacy's policy and procedure titled, Crushing Medications, reviewed 5/21/2025, was reviewed. The DON stated the P&P indicated residents shall not receive crushed medications combined and given all at once orally.

Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aides (RNA, trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) were competent to provide RNA services to one of six sampled residents (Resident 8) by failing to: 1.Ensure Restorative Nursing Aide 2 (RNA 2) was competent to perform active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to Resident 8's both arms and both legs in accordance with physician orders. 2.Ensure RNA 1 and RNA 2 were competent and knowledgeable of left posterior hip precautions (specific movements and positions that must be followed after having surgery to prevent a hip dislocation [disruption of the normal position of the ends of two or more bones where they meet at the joint] or injury which includes no bending of the hip past 90 degrees, no rotation of the operated leg inwards, and no crossing of the operated leg past the midline of the body) while assisting with ROM exercises to Resident 8's left leg. These failures had the potential to cause Resident 8 to experience pain, a left hip dislocation or injury, and resulted in inefficient delivery of ROM services which could lead to ROM and functional decline for residents receiving RNA services. Findings: During a review of Resident 8's admission Record, the admission Record indicated the facility initially admitted Resident 8 on 11/6/2024 and re-admitted Resident 8 on 1/22/2025 with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), fracture of the left neck of the femur (broken hip, broken bone in the top potion of the thigh bone where it connects to the hip joint), and malignant neoplasm of the prostate (uncontrolled growth of cancerous cells in the prostate gland, a male reproductive organ). During a review of Resident 8's Physician Order Report, the Physician Order Report indicated a physician's order, dated 1/3/2025 and discontinued 4/2/2025, for Resident 8 to be weightbearing as tolerated (WBAT, a person is medically cleared to place as much weight through the affected arm or leg to the point of comfort or tolerance) to the left leg with posterior hip precautions. During a review of Resident 8's Physician Order Report, the Physician Order Report indicated an RNA order, dated 6/6/2026, for RNA to provide AAROM exercises to Resident 8's both arms and both legs for a minimum of five (5) times a week or as tolerated while observing left hip precautions. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 8 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 8 required substantial/maximal assistance (helper does more than half the effort) for eating, rolling to both sides, and was dependent (helper does all the effort) for transfers, hygiene, bathing, and dressing. During an RNA session observation on 1/21/2026 at 11:10 am, RNA 2 transported Resident 8 who was seated in a wheelchair from the dining room into Resident 8's room. RNA 2 entered Resident 8's room and positioned Resident 8's wheelchair next to the bed. RNA 1 physically raised and lowered Resident 8's both arms to shoulder height, bent and straightened Resident 8's both elbows, and bent, straightened, and spread the fingers of Resident 8's both hands, eight (8) times each. RNA 1 did not assist or cue Resident 8 to perform ROM exercises to both wrists. RNA 1 asked Resident 8 to march both legs in place while seated in the wheelchair. Resident 8 minimally raised and lowered both thighs three times and had difficulty following RNA 2's instructions. RNA 2 did not assist with ROM of Resident 8's both hips. RNA 2 physically assisted Resident 8 to bend and straighten both knees, 8 times for each leg. RNA 2 did not provide exercises or cue Resident 8 to perform ankle ROM exercises. RNA 2 stated the RNA session was complete and transported Resident 2 back to the dining room. During a concurrent interview and record review with RNA 2 on 01/21/2026 11:24 am, RNA 2 confirmed Resident 8 had an RNA order for AAROM exercises to both arms and both legs while observing left hip precautions, 5 times a week. RNA 2 stated AAROM meant that RNA 2 verbally cued and demonstrated the ROM exercises for the resident to perform independently and did not physically assist the resident with exercises. RNA 2 stated Resident 8 was unable to fully move both arms and both legs independently but did not physically assist with ROM because the order was for AAROM. RNA 2 stated she thought she was assisting with AAROM exercises to both hips because she provided verbal cueing only and did not physically assist Resident 8 through the ROM. RNA 2 stated she provided passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 8's both shoulders, both elbows, both hands, and both knees because he did not assist at all with exercises but was unsure why she did because the RNA order was for AAROM, not PROM. RNA 2 stated Resident 8 could move both arms and both legs but had difficulty with ROM due to confusion and difficulty following instructions. RNA 2 stated she forgot to provide ROM exercises to Resident 8's both wrists, both hips, and both ankles. RNA 2 stated she did not know what hip precautions meant. RNA 2 stated she had been providing RNA ROM exercises to Resident 8's both legs since the RNA order which indicated for RNA to observe left hip precautions was written but did not know what left hip precautions meant. RNA 2 stated she thought Resident 8 had a history of a hip fracture but was unsure. RNA 2 stated the Rehabilitation Department (Rehab) never instructed RNA 2 in what hip precautions were when Resident 8 transitioned to RNA and confirmed she never asked for clarification before starting Resident 8's RNA program. RNA 2 stated the facility did not assess RNA competency. RNA 2 stated it was important for RNAs to be knowledgeable of ROM exercises and precautions to prevent joint stiffness and harm. During a concurrent interview and record review with RNA 1 on 1/22/2026 at 11:29 am, RNA 1 reviewed Resident 8's RNA order and confirmed Resident 8 had an RNA order for AAROM exercises to both arms and both legs while observing left hip precautions. RNA 1 stated she did not know what left hip precautions meant in Resident 8's RNA order. RNA 1 stated therapy never instructed RNA in what hip precautions were and she did not ask for clarification. RNA 1 stated she had been providing RNA ROM exercises to Resident 8's both legs since the RNA order which indicated for RNA to observe left hip precautions was written but did not know what left hip precautions meant. RNA 1 stated Resident 8 broke his hip a long time ago but thought hip precautions meant for RNA to ensure RNA did not irritate Resident 8's left hip when doing ROM and did not know which ROM movements and positions to avoid. RNA 1 stated the facility did not assess RNA competency. RNA 1 stated it was important RNAs provided RNA services as ordered and were knowledgeable of precautions to prevent resident injury. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 1/22/2026 at 2:19 pm, the DOR who was also a Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) stated Rehab created the RNA programs and trained the RNAs in how to properly carry out the prescribed exercises before transitioning residents to an RNA program. The DOR stated RNAs were to carry out RNA exercises as ordered. The DOR stated there were three main types of ROM exercises: Active ROM which meant the resident performed the exercises independently, AAROM exercises which meant the resident performed the exercises as much as possible on his or her own and required the physical assistance of another person or equipment to move the arm or leg through the rest of the motion, and PROM which meant a person or equipment provided total physical assistance with ROM. The DOR reviewed Resident 8's RNA orders and confirmed Resident 8 had an RNA order for AAROM exercises to Resident 8's both arms and both legs while observing left hip precautions. The DOR stated AAROM exercises were typically prescribed to residents who were unable to obtain full ROM on their own and needed the assistance of RNA or equipment to help move through the rest of the motion. The DOR stated if an RNA order was written for AAROM exercises to both legs, it was expected the RNA provide AAROM to the entire leg, which included the hips, knees, and ankles. The DOR stated if an RNA order was written for AAROM exercises to both arms, it was expected the RNA provide AAROM to the entire arm, which included the shoulders, elbows, wrists, and hands. The DOR stated it was important for RNA to know the differences between the types of ROM exercises and carry out the exercises as ordered to ensure the resident maintained his or her abilities and did not have a functional decline. The DOR stated posterior hip precautions were put in place to decrease the risk of hip dislocation after surgery. The DOR stated posterior hip precautions meant no bending of the operated leg past 90 degrees, no rotation of the operated leg inwards, and no movement of the operated leg toward the middle of the body. The DOR stated it was very important for RNAs to be knowledgeable of hip precautions while providing ROM exercises because not knowing and/or not following hip precautions during RNA could lead to resident injury and hip dislocation. During an interview with the Director of Nursing (DON) on 01/22/2026 at 5:42 pm, the DON stated conducting staff competencies were important to ensure staff were up to date and competent in performing their job duties. The DON stated the facility had two primary RNAs for all the residents in the facility and were in the process of training more CNAs to have RNA certification. The DON stated the RNAs assisted residents with activities such as ROM exercises, walking exercises, sit to stand exercises and feeding to ensure the residents in the facility maintained their current level of function and did not experience a functional decline. The DON stated it was important for the RNAs to know the differences in ROM and be knowledgeable of precautions while providing RNA services to the residents in the facility to prevent injuries and functional declines. The DON stated the facility did not have a way to ensure the RNA staff were competent in their job duties since they did not conduct RNA competencies. The DON stated if RNA competencies were not completed routinely, the facility would not know the staff were up to date and competent in their job duties which could potentially lead to injury of staff and/or residents. During an interview with the Director of Staff Development (DSD) on 1/23/2026 at 10:17 am, the DSD stated the RNAs in the facility were CNAs with specialized training in RNA services. The DSD stated she was responsible for completing CNA competencies yearly but never completed any competencies for the RNAs. The DSD stated the facility did not have a way to ensure the RNA staff were competent in their job duties since they did not conduct RNA competencies. The DSD stated the CNA competency checklist did not assess staff's competency of RNA tasks such as ROM exercises. The DSD stated it was important for RNAs to know the differences in ROM and be knowledgeable of precautions while providing RNA services to ensure the appropriate treatment was being given to the residents and to prevent any injury or decline. The DSD stated it was important for the facility to have recurring competency assessments for staff to ensure the care and services provided were appropriate and safe. The DSD stated it placed the residents in the facility at risk for harm if staff were not competent in the services they were providing. During a review of the facility's Policy and Procedures (P/P), titled, Competent Nursing, revised 2001, the P/P indicated the facility provided nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The P/P indicated competency requirements and training for nursing staff were established and monitored by nursing leadership with input from the medical director to ensure programming for staff training results in nursing competency, gaps in education are identified and addressed, education topics and skills needed are determined based on the resident population, tracking or other mechanisms were in place to evaluate effectiveness of training, and training included critical thinking skills and managing care in a complex environment with multiple interruptions.

Based on interview and record review, the facility failed to provide documented evidence of COVID-19 (contagious infectious disease) education and vaccination (medications used to prevent diseases) status for four of four sampled employee records (Certified Nursing Assistant (CNA1, CNA2), Food Service Worker (FSW) and Laundry Staff (LS).This failure had the potential to place staff and residents at risk for Covid 19.During an interview and record review on 1/22/2026 at 11:03 a.m., with the Assistant Director of Nursing (ADON), the facility's employee records of COVID-19 status were reviewed, four of four sampled facility employee records of COVID-19 immunization, the ADON stated status was unknown.During an interview and record review on 1/22/2026 at 11:03 a.m., with the Infection Prevention Nurse (IPN), the County of Los Angeles Department of Public Health order of the Health Officer, Annual Influenza and Covid-19 immunization or Masking Requirement for Healthcare Personnel during Respiratory Virus Season, issued 8/26/2024, was reviewed. The order indicated healthcare provider who declined either or both an influenza or COVID-19 vaccination. must provide their employer, on a form provided by their employer, a written declaration for each vaccine that they have declined. The ADON stated most of the staff have not replied whether they accept or decline vaccinations.During an interview on 1/22/2026 at 3:34 p.m. with the Director of Nursing (DON), the DON stated the facility needed employees' Covid vaccination status updated.During a review of the facility's policy and procedure (P&P) titled, COVID-19 Vaccination, undated, the P&P indicated, compliance guidelines indicated the person receiving the immunization, his/her legal representative, will be provided with copy of current vaccine information statement relative to COVID-19 vaccination.

Based on observation, interview, and record review, the facility failed to ensure medical records for two of six sampled residents (Residents 2 and 8) were accurate by failing to: Ensure Restorative Nursing Aides (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) accurately documented RNA services provided for Resident 2 in December 2025 and January 2026.Ensure Resident 8's left posterior (toward the back) hip precautions (specific movements and positions that must be followed after having hip surgery to prevent a hip dislocation [disruption of the normal position of the ends of two or more bones where they meet at the joint] or injury which includes no bending of the hip past 90 degrees, no rotation of the operated leg inwards, and no crossing of the operated leg past the midline of the body) were discontinued on the RNA order when Resident 8's left hip precautions were discontinued by the physician.These deficient practices had the potential to negatively impact the provision of necessary care and services, cause miscommunication among staff, and cause a decline in range of motion (ROM, full movement potential of a joint), mobility, and overall function. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 8/27/2025 and re-admitted Resident 2 on 10/2/2025 with diagnoses including rheumatoid arthritis (painful swelling and stiffness of the joints caused by the body attacking its own healthy tissues and joints by mistake), gastrointestinal hemorrhage (bleeding that occurs in the digestive track), and muscle weakness. During a review of Resident 2's Physician Order Report, the Physician Order Report indicated a physician's order, dated 12/15/2025, for RNA to assist Resident 2 with ambulation (walking) exercises using a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) a minimum of 5 times a week. During a review of Resident 2's December 2025 RNA History Report (daily record of RNA services provided for each month), the RNA History Report indicated for RNA to assist Resident 2 with walking exercises. The RNA History Report indicated missing care records for the following days: 12/16/2025, 12/21/2025, 12/24/2025, 12/26/2025, 12/28/2025, 12/29/2025, and 12/31/2025. During a review of Resident 2's January 2026 RNA History Report, the RNA History Report indicated for RNA to assist Resident 2 with walking exercises. The RNA History Report indicated missing care records for the following days: 1/1/2026, 1/2/2026, 1/7/2026, 1/14/2026, and 1/21/2026. During a review of Resident 2's minimum data set (MDS a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2 was cognitively (mental action or process of acquiring knowledge and understanding) intact. The MDS indicated Resident 2 required set up or clean up assistance (helper sets up or cleans up) for eating and oral hygiene, partial/moderate assistance (helper does less than half the effort) for rolling to both sides and walking, substantial/maximal assistance (helper does more than half the effort) for upper body dressing, personal hygiene, and transfers and was dependent (helper does all the effort) for toileting hygiene, lower body dressing, and bathing. The MDS indicated Resident 2 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation and interview with Resident 2 in Resident 2's room on 1/20/2026 at 3:27 pm, Resident 2 was lying in bed. Resident 2 was unable to straighten her right knee and minimally moved her ankle upwards and downwards. Resident 2 stated she has had right knee pain for awhile because of rheumatoid arthritis which interfered with her ability to walk. Resident 2 stated she required assistance with walking because she was unable to walk by herself. Resident 2 stated RNA assisted with walking exercises every now and then but did not feel they came enough during the week. Resident 2 stated she wished RNA came more often to walk her back and forth to the dining room since she was unable to walk on her own. During an interview with Restorative Nursing Aide 2 (RNA 2) on 1/20/2026 at 11:41 am, RNA 2 stated the facility had one RNA on the floor during the day shift providing RNA exercises, seven days a week. RNA 2 stated RNA provided services which included ROM exercises, walking exercises, transfers, applying splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint), and feeding. RNA 2 stated RNA tried but did not always get to all the residents on the RNA caseload daily because of occasional staffing shortages. RNA 2 stated RNA was supposed to document the exercises provided to each resident on the RNA program in the electronic health record after every RNA session. RNA 2 stated if she was unable to provide RNA exercises to a resident as scheduled, she would not document in the electronic health record at all. During an interview with Restorative Nursing Aide 1 (RNA 1) on 1/22/2026 at 9:56 am, RNA 1 stated the RNAs were supposed to document the services provided to the residents after every RNA session. RNA 1 stated she was supposed to document services provided after every RNA session but usually tried to ensure all documentation was in the electronic record by the end of the shift. RNA 1 stated she tried to ensure all documentation was done timely but could possibly forget at times if very busy. During a concurrent record review and interview with the Director of Staff Development (DSD) on 1/23/2026 at 2:12 pm, the DSD stated she supervised the RNAs. The DSD stated the purpose of the RNA program was to ensure the residents in the facility received exercises to maintain their current level of function and to prevent joint stiffness and contractures. The DSD stated RNAs were supposed to document RNA services provided after every RNA session. The DSD reviewed Resident 8's December 2025 RNA History Report and confirmed missing care records on the following days: 12/16/2025, 12/21/2025, 12/24/2025, 12/26/2025, 12/28/2025, 12/29/2025, and 12/31/2025. The DSD reviewed Resident 8's January 2026 RNA History Report and confirmed missing care records on the following days: 1/1/2026, 1/2/2026, 1/7/2026, 1/14/2026, and 1/21/2026. The DSD stated missing care records on the RNA History Reports indicated RNA did not document the RNA session for the day or RNA treatment was not provided. The DSD stated if RNAs forgot to document the RNA exercises provided, it meant the RNA service was not provided due to lack of documented evidence. The DSD stated it was important that RNAs documented accurately to ensure the facility could correctly monitor a resident's progress and tolerance to the RNA program and to ensure all residents on the RNA program were seen as ordered to prevent any functional declines. 2. During a review of Resident 8's admission Record, the admission Record indicated the facility initially admitted Resident 8 on 11/6/2024 and re-admitted Resident 8 on 1/22/2025 with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), fracture of the left neck of the femur (broken hip, broken bone in the top potion of the thigh bone where it connects to the hip joint), and malignant neoplasm of the prostate (uncontrolled growth of cancerous cells in the prostate gland, a male reproductive organ). During a review of Resident 8's Physician Order Report, the Physician Order Report indicated a physician's order, dated 1/3/2025 and discontinued 4/2/2025, for Resident 8 to be weightbearing as tolerated (WBAT, a person is medically cleared to place as much weight through the affected arm or leg to the point of comfort or tolerance) to the left leg with posterior hip precautions. During a review of Resident 8's Physician Order Report, the Physician Order Report indicated an RNA order, dated 6/6/2026, for RNA to provide active assistive ROM (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to Resident 8's both arms and both legs for a minimum of five times a week or as tolerated while observing left hip precautions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had severely impaired cognition. The MDS indicated Resident 8 required substantial/maximal assistance for eating, rolling to both sides, and was dependent for transfers, hygiene, bathing, and dressing. During an RNA session observation on 1/21/2026 at 11:10 am, RNA 2 transported Resident 8 who was seated in a wheelchair from the dining room into Resident 8's room. RNA 2 entered Resident 8's room and positioned Resident 8's wheelchair next to the bed. After arm ROM exercises, RNA 1 asked Resident 8 to march both legs in place while seated in the wheelchair. Resident 8 minimally raised and lowered both thighs three times and had difficulty following RNA 2's instructions. RNA 2 did not assist with ROM of Resident 8's both hips. RNA 2 physically assisted Resident 8 to bend and straighten both knees, eight times for each leg. RNA 2 did not provide exercises or cue Resident 8 to perform ankle ROM exercises. RNA 2 stated the RNA session was complete and transported Resident 2 back to the dining room.During an interview with the Director of Nursing (DON) on 1/22/2026 at 5:42 pm, the DON stated the purpose of the RNA program was to ensure the residents in the facility maintained their level of function and to prevent any functional declines. The DON stated it was important RNA documentation and RNA orders were accurate to ensure the facility was providing the appropriate care and meeting the current needs of the residents. During a concurrent record review and interview with the Director of Rehabilitation on 1/22/2026 at 2:19 pm, the DOR who was also a Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) stated Rehab created the RNA programs and trained the RNAs in how to properly carry out the prescribed exercises before transitioning residents to an RNA program. The DOR stated RNAs were to carry out RNA exercises and necessary precautions as ordered. The DOR reviewed Resident 8's RNA orders and confirmed Resident 8 had an RNA order for AAROM exercises to Resident 8's both arms and both legs while observing left hip precautions. The DOR stated posterior hip precautions were put in place to decrease the risk of hip dislocation after surgery. The DOR stated posterior hip precautions meant no bending of the operated leg past 90 degrees, no rotation of the operated leg inwards, and no movement of the operated leg toward the middle of the body. The DOR stated the RNA order was inaccurate because Resident 8's left hip precautions were discontinued by the physician on 4/2/2025. The DOR stated staff should have discontinued Resident 8's left hip precautions on the RNA order when the physician discontinued the precautions on 4/2/2025. The DOR stated if RNA was ordered to observe hip precautions on a resident who no longer had active orders to maintain hip precautions, it could result in a decline in ROM and function due to avoidance of ROM and positions that did not need to be avoided. During a concurrent record review and interview with the DSD on 1/23/2026 at 2:12 pm, the DSD stated RNAs were to carry out the RNA program as ordered. The DSD stated it was important that RNA orders were accurate to ensure the RNAs were providing the appropriate care and services based on the resident's needs. The DSD stated inaccurate RNA orders could result in harm, injury, inappropriate delivery of services, and functional decline. During a review of the facility's Policy and Procedure (P/P), titled Charting and Documentation, revised 7/2017, the P/P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the medical record. The P/P indicated treatment or services performed was to be documented in the medical record. The P/P indicated documentation in the medical record would be objective, completed, and accurate.

Based on interview and record review, the facility failed to administer psychotropic medications (chemical substance that treat mental illnesses that affect the brain that modifies mood, thought, emotions, and behavior) in a timely manner for one of four sampled residents (Resident 39). This deficient practice had the potential to cause delay in treatment and exacerbate Resident 39's condition. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted on [DATE] and was readmitted to the facility on [DATE] with diagnoses including unspecified dementia (group of thinking and social symptoms that interferes with daily functioning) with agitation and psychotic (seeing, hearing and believing that is not based on reality) disturbance, anxiety disorder, and Parkinsonism (group of movement disorders that includes symptoms such as tremors, stiffness, slow movements, and balance problems). During a review of Resident 39's History and Physical (H&P), dated 12/17/2025, the H&P indicated Resident 39 did not have the capacity to understand or make decisions. During a review of Resident 39's Minimum Data set ([MDS], a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 39's cognitive (ability to think, learn and remember) skills was severely impaired. The MDS indicated Resident 39 was dependent on staff for performing all aspects of activities of daily living (ADL: basic activities such as eating, dressing, toileting).During a review of Resident 39's Physician Order Report dated 12/22/2025 to 1/22/2026, the report indicated the following orders:Order dated 11/18/2024: Seroquel (Quetiapine: antipsychotic medication used to manage symptoms of mental disorder) tablet 100 milligram (mg: unit of mass) oral for dementia with psychosis manifested by (m/b) resisting care and continuous yelling out that interferes with care and safety twice a day 9:00a.m., 5:00p.m.Order dated 8/2/2025: Sertraline (antidepressant used to treat anxiety and other conditions) tablet 50mg for anxiety m/b yelling behavior once a day 9:00a.m.During a review of Resident 39's Psychotropic medication Administration History dated 1/1/2026 - 1/22/2026, the Psychotropic Administration History indicated the following: Seroquel (Quetiapine) tablet 100mg twice a day Scheduled date and time: 1/13/2026 at 9:00a.m. Administration time: 1/13/2026 at 10:41a.m. Comment: Administered LateScheduled date and time: 1/14/2026 at 9:00a.m. Administration time: 1/14/2026 11:59a.m. Comment: Administered LateScheduled date and time: 1/16/2026 at 9:00a.m. Administration time: 1/16/2026 at 10:29a.m. Comment: Administered LateScheduled date and time: 1/17/2026 at 9:00a.m. Administration time: 1/7/2026 at 11:06a.m. Comment: Administered LateSertraline tablet 50mg once a dayScheduled date and time: 1/13/2026 at 9:00a.m. Administration time: 1/13/2026 at 10:41a.m. Comment: Administered LateScheduled date and time: 1/14/2026 at 9:00a.m. Administration time: 1/14/2026 11:59a.m. Comment: Administered LateScheduled date and time: 1/16/2026 at 9:00a.m. Administration time: 1/16/2026 at 10:29a.m. Comment: Administered LateScheduled date and time: 1/17/2026 at 9:00a.m. Administration time: 1/7/2026 at 11:06a.m. Comment: Administered LateDuring a concurrent interview and record review of Resident 39's Psychotropic Administration History dated 1/1/2026 - 1/22/2026 on 1/22/2026 at 12:44p.m. with the Licensed Vocational Nurse 4 (LVN 4), the LVN 4 stated medication is administered one hour (hr.) before and after the scheduled medication administration time. The LVN 4 stated the Seroquel and Sertraline given on 1/16/2026 at 10:29a.m. was late and indicated she cannot get to the resident on time all the time, however stated if Resident 39 was starting to yell, she will give Resident 39 her medication sooner. The LVN 4 stated that administering a late medication will not impact the residents and indicated realistically, medications should be given on time. During a concurrent interview and review of Resident 39's Psychotropic Administration History dated 1/1/2026 - 1/22/2026 on 1/22/2026 at 3:50 p.m. with the Director of Nursing (DON), the DON stated the Seroquel and Sertraline medications were administered late and indicated medications should not be given two hours later than scheduled time. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised December 2012, the P&P indicated medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for three (3) of six sampled residents (Residents 1, 2, and 8) with ROM concerns by failing to: 1.Objectively measure and identify the location of Resident 1's ROM limitations of both legs during the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 12/23/2025. 2.Objectively measure Resident 2's ROM limitations of both shoulders and both hands during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 10/3/2025. 3.Provide ROM exercises to Resident 8's both arms and both legs during a Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) session in accordance with physician's orders. 4.Ensure RNA assisted Resident 2 with walking exercises five (5) times a week in accordance with physician's orders. These failures had the potential for Residents 1, 2, and 8 to experience a further decline in ROM resulting in contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints [where two bones meet]) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting).Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 9/1/2025 and re-admitted Resident 1 on 12/22/2025 with diagnoses including cellulitis (skin infection) of both legs, muscle weakness, and sepsis (illness caused by the body's response to an infection). During a review of Resident 1's PT Evaluation, dated 12/23/2025, the PT Evaluation indicated Resident 1's right leg and left leg ROM were impaired. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/11/2026, the MDS indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 required set up or clean up assistance (helper sets up or cleans up) for eating and oral hygiene, partial/moderate (helper does less than half the effort) assistance with upper body dressing, substantial/maximal assistance (helper does more than half the effort) for lower body dressing and rolling to both sides, and was dependent (helper does all the effort) for transfers and bathing. During an observation and interview with Resident 1 in Resident 1's room on 1/20/2026 at 11:26 am, Resident 1 was sitting in a wheelchair. Resident 1 minimally bent both hips, was unable to straighten both knees, and minimally bent and straightened both ankles. Resident 1 stated she was weak and had limited ROM in both legs. During a concurrent record review and interview with the Director of Rehabilitation (DOR) on 1/22/2026 at 2:19 pm, the DOR who was a PT stated PTs and Occupational Therapists (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) used goniometers (instrument used for the precise measurement of angles) to measure joint mobility to objectively (unbiased, based on facts) determine a resident's baseline ROM and detect changes in joint ROM. The DOR reviewed Resident 1's PT Evaluation dated 12/23/2025, and confirmed Resident 1's ROM of both legs were impaired. The DOR confirmed PT did not use a goniometer to measure the joints of both leg limitations and did not indicate the location of ROM impairment in both legs. The DOR stated she was unsure of the location and severity of the ROM impairments in both legs because the PT Evaluation did not indicate which joints were limited and did not have objective measurements to indicate the severity of ROM impairments. The DOR stated Resident 1's baseline ROM of both legs were not determined because the ROM limitations were not measured with a goniometer. The DOR stated the Rehab Screens (brief assessment of a resident's ROM of both arms and both legs and current level of function) performed upon admission, quarterly, and as needed by Rehab did not provide precise measurements of each joint since the therapist only indicated a range of impairment (minimal, moderate, severe) which could vary significantly and did not detect subtle changes in the joints. The DOR stated lack of objective ROM measurements and identification of joint limitations had the potential to negatively impact the staff's ability to detect changes such as improvements or declines in Resident 1's ROM. The DOR stated it was important to provide objective measurements and identify which joints were limited in the PT evaluation to ensure subtle changes of ROM could be detected which would in turn guided the treatments and services provided. During an interview with the Director of Nursing (DON) on 1/22/2026 at 5:42 pm, the DON stated the facility monitored for changes in ROM by staff report and Rehab Screens performed upon admission, quarterly, and as needed by Rehab. The DON stated it was important to accurately monitor changes in joint ROM to ensure the residents received the appropriate services to prevent ROM decline and contractures. 2. During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 8/27/2025 and re-admitted Resident 2 on 10/2/2025 with diagnoses including rheumatoid arthritis (painful swelling and stiffness of the joints caused by the body attacking its own healthy tissues and joints by mistake), gastrointestinal hemorrhage (bleeding that occurs in the digestive track), and muscle weakness. During a review of Resident 2's OT Evaluation, dated 10/3/2025, the OT Evaluation indicated the ROM of Resident 2's both shoulders and both hands were impaired. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required set up or clean up assistance for eating and oral hygiene, partial/moderate assistance for rolling to both sides and walking, substantial/maximal assistance for upper body dressing, personal hygiene, and transfers and was dependent for toileting hygiene, lower body dressing, and bathing. The MDS indicated Resident 2 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation and interview with Resident 2 in Resident 2's room on 1/20/2026 at 3:27 pm, Resident 2 was lying in bed. The knuckles of both of Resident 2's hands appeared swollen with all fingers bent downwards and sideways toward the small finger (outer side) of each hand. Resident 2 was unable to straighten the index fingers (pointer fingers), middle fingers, ring fingers, and small fingers of both hands. Resident 2 moved the thumbs of both hands up and down and grabbed a cup by hooking her left thumb into the cup handle and took a sip of water. During a concurrent record review and interview with the Director of Rehabilitation (DOR) on 1/22/2026 at 2:19 pm, the DOR stated PTs and OTs used goniometers to measure joint mobility to objectively determine a resident's baseline ROM and detect changes in joint ROM. The DOR reviewed Resident 2's OT Evaluation, 10/3/2025, and confirmed Resident 2's ROM of both shoulders and both hands were impaired. The DOR confirmed OT did not use a goniometer to measure the joints of both shoulder and both hand ROM limitations. The DOR stated she was unsure of the severity of the ROM impairments in both shoulders and both hands because the OT Evaluation did not have objective measurements to indicate the severity of ROM impairments. The DOR stated Resident 2's baseline ROM of both shoulders and both hands were not determined because the ROM limitations were not measured with a goniometer. The DOR stated the Rehab Screens performed upon admission, quarterly, and as needed by Rehab did not provide precise measurements of each joint since the therapist only indicated a range of impairment (minimal, moderate, severe) which could vary significantly and did not detect subtle changes in the joints. The DOR stated lack of objective ROM measurements and identification of joint limitations had the potential to negatively impact the staff's ability to detect changes such as improvements or declines in Resident 2's ROM. The DOR stated it was important to provide objective measurements in the OT evaluation to ensure subtle changes of ROM could be detected which would in turn guided the treatments and services provided. During a concurrent record review and interview with Occupational Therapist 1 (OT 1) on 1/22/2026 at 3:23 pm, OT 1 stated OTs used goniometers to measure joint mobility to objectively determine a resident's baseline ROM. OT 1 reviewed Resident 2's OT Evaluation, 10/3/2025, and confirmed Resident 2's ROM of both shoulders and both hands were limited. OT 1 confirmed she did not use a goniometer to measure the joints of both hands and both shoulders but should have because Resident 2 had ROM limitations. OT 1 stated Resident 2's baseline ROM of both shoulders and both hands were not determined because the ROM limitations were not measured with a goniometer. OT 1 stated lack of objective ROM measurements of impaired joints could result in missed opportunities to detect ROM changes and determine if the treatment and services provided were effective. OT 1 stated it was important to provide objective measurements of a limited joint in the OT evaluation to ensure changes such as improvements or declines in ROM could be detected. During an interview with the Director of Nursing (DON) on 1/22/2026 at 5:42 pm, the DON stated the facility monitored for changes in ROM by staff report and Rehab Screens performed upon admission, quarterly, and as needed by Rehab. The DON stated it was important to accurately monitor changes in joint ROM to ensure the residents received the appropriate services to prevent ROM decline and contractures. 3. During a review of Resident 8's admission Record, the admission Record indicated the facility initially admitted Resident 8 on 11/6/2024 and re-admitted Resident 8 on 1/22/2025 with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), fracture of the left neck of the femur (broken hip, broken bone in the top potion of the thigh bone where it connects to the hip joint), and malignant neoplasm of the prostate (uncontrolled growth of cancerous cells in the prostate gland, a male reproductive organ). During a review of Resident 8's Physician Order Report, the Physician Order Report indicated an RNA order, dated 6/6/2026, for RNA to provide active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to Resident 8's both arms and both legs for a minimum of 5 times a week or as tolerated while observing left hip precautions (specific movements and positions that must be followed after having surgery to prevent a hip dislocation [disruption of the normal position of the ends of two or more bones where they meet at the joint] or injury which includes no bending of the hip past 90 degrees, no rotation of the operated leg inwards, and no crossing of the operated leg past the midline of the body). During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had severely impaired cognition. The MDS indicated Resident 8 required substantial/maximal assistance for eating, rolling to both sides, and was dependent for transfers, hygiene, bathing, and dressing. During an RNA session observation on 1/21/2026 at 11:10 am, Restorative Nursing Aide 2 (RNA 2) 2 transported Resident 8 who was seated in a wheelchair from the dining room into Resident 8's room. RNA 2 entered Resident 8's room and positioned Resident 8's wheelchair next to the bed. RNA 1 physically raised and lowered Resident 8's both arms to shoulder height, bent and straightened Resident 8's both elbows, and bent, straightened, and spread the fingers of Resident 8's both hands, eight (8) times each. RNA 1 did not assist or cue Resident 8 to perform ROM exercises to both wrists. RNA 1 asked Resident 8 to march both legs in place while seated in the wheelchair. Resident 8 minimally raised and lowered both thighs 3 times and had difficulty following RNA 2's instructions. RNA 2 did not assist with ROM of Resident 8's both hips. RNA 2 physically assisted Resident 8 to bend and straighten both knees, 8 times for each leg. RNA 2 did not provide exercises or cue Resident 8 to perform ankle ROM exercises. RNA 2 stated the RNA session was complete and transported Resident 2 back to the dining room. During a concurrent interview and record review with RNA 2 on 01/21/2026 11:24 am, RNA 2 confirmed Resident 8 had an RNA order for AAROM exercises to both arms and both legs while observing left hip precautions, 5 times a week. RNA 2 stated AAROM meant that RNA 2 verbally cued and demonstrated the ROM exercises for the resident to perform independently and did not physically assist the resident with exercises. RNA 2 stated Resident 8 was unable to fully move both arms and both legs independently but did not physically assist with ROM because the order was for AAROM. RNA 2 stated she thought she was assisting with AAROM exercises to both hips because she provided verbal cueing only and did not physically assist Resident 8 through the ROM. RNA 2 stated she provided passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 8's both shoulders, both elbows, both hands, and both knees because he did not assist at all with exercises but was unsure why she did because the RNA order was for AAROM, not PROM. RNA 2 stated Resident 8 could move both arms and both legs but had difficulty with ROM due to confusion and difficulty following instructions. RNA 2 stated she forgot to provide ROM exercises to Resident 8's both wrists, both hips, and both ankles as ordered. RNA 2 stated it was important to provide RNA exercises as ordered to prevent joint stiffness and harm. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 1/22/2026 at 2:19 pm, the DOR who was a PT stated Rehab created the RNA programs and trained the RNAs in how to properly carry out the prescribed exercises before transitioning residents to an RNA program. The DOR stated RNAs were to carry out RNA exercises as ordered. The DOR stated there were 3 main types of ROM exercises: Active ROM which meant the resident performed the exercises independently, AAROM exercises which meant the resident performed the exercises as much as possible on his or her own and required the physical assistance of another person or equipment to move the arm or leg through the rest of the motion, and passive ROM which meant a person or equipment provided total physical assistance with ROM. The DOR reviewed Resident 8's RNA orders and confirmed Resident 8 had an RNA order for AAROM exercises to Resident 8's both arms and both legs. The DOR stated AAROM exercises were typically prescribed to residents who were unable to obtain full ROM on their own and needed the assistance of RNA or equipment to help move through the rest of the motion. The DOR stated if an RNA order was written for AAROM exercises to both legs, it was expected the RNA provide AAROM to the entire leg, which included the hips, knees, and ankles. The DOR stated if an RNA order was written for AAROM exercises to both arms, it was expected the RNA provide AAROM to the entire arm, which included the shoulders, elbows, wrists, and hands. The DOR stated it was important for RNA to carry out the exercises as ordered to ensure the resident maintained his or her abilities and did not have a functional decline. During an interview with the DON on 1/22/2026 at 5:42 pm, the DON stated it was important for RNA to provide exercises as ordered to prevent contracture development and functional declines. 4. During a review of Resident 2's admission Order, the admission Order indicated the facility initially admitted Resident 2 on 8/27/2025 and re-admitted Resident 2 on 10/2/2025 with diagnoses including rheumatoid arthritis, gastrointestinal hemorrhage, and muscle weakness.During a review of Resident 2's Physician Order Report, the Physician Order Report indicated a physician's order, dated 12/15/2025, for RNA to assist Resident 2 with ambulation (walking) exercises using a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) a minimum of 5 times a week. During a review of Resident 2's December 2025 RNA History Report (daily record of RNA services provided for each month), the RNA History Report indicated for RNA to assist Resident 2 with walking exercises. The RNA History Report indicated missing care records for the following days: 12/16/2025, 12/21/2025, 12/24/2025, 12/26/2025, 12/28/2025, 12/29/2025, and 12/31/2025. During a review of Resident 2's January 2026 RNA History Report, the RNA History Report indicated for RNA to assist Resident 2 with walking exercises. The RNA History Report indicated missing care records for the following days: 1/1/2026, 1/2/2026, 1/7/2026, 1/14/2026, and 1/21/2026. The RNA History Report indicated the RNA task was not performed on the following days: 1/11/2026, 1/12/2026, and 1/20/2026. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required set up or clean up assistance for eating and oral hygiene, partial/moderate assistance for rolling to both sides and walking, substantial/maximal assistance for upper body dressing, personal hygiene, and transfers and was dependent for toileting hygiene, lower body dressing, and bathing. The MDS indicated Resident 2 had functional limitations in ROM in both arms and both legs. During an observation and interview with Resident 2 in Resident 2's room on 1/20/2026 at 3:27 pm, Resident 2 was lying in bed. Resident 2 was unable to straighten her right knee and minimally moved her ankle upwards and downwards. Resident 2 stated she has had right knee pain for awhile because of rheumatoid arthritis which interfered with her ability to walk. Resident 2 stated she required assistance with walking because she was unable to walk by herself. Resident 2 stated RNA assisted with walking exercises every now and then but did not feel they came enough during the week. Resident 2 stated she wished RNA came more often to walk her back and forth to the dining room since she was unable to walk on her own. During an interview with RNA 2 on 1/20/2026 at 11:41 am, RNA 2 stated the facility had one RNA on the floor during the day shift providing RNA exercises, seven days a week. RNA 2 stated RNA exercises provided included ROM exercises, walking exercises, transfers, applying splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint), and feeding. RNA 2 stated RNA tried but did not always get to all the residents on the RNA caseload daily because of occasional staffing shortages. RNA 2 stated RNA was supposed to document the exercises provided to each resident on the RNA program in the electronic health record after every RNA session. RNA 2 stated if she was unable to provide RNA exercises to a resident as scheduled, she would not document in the electronic health record at all. During an interview with the DON on 1/22/2026 at 5:42 pm, the DON stated the purpose of the RNA program was to ensure the residents in the facility maintained their level of function and to prevent any functional declines. The DON stated missed RNA treatments could potentially cause a resident to have a functional decline and develop contractures. During a concurrent record review and interview with the Director of Staff Development (DSD) on 1/23/2026 at 2:12 pm, the DSD stated she supervised the RNAs. The DSD stated the purpose of the RNA program was to ensure the residents in the facility received exercises to maintain their current level of function and to prevent joint stiffness and contractures. The DSD reviewed Resident 2's December 2025 and January 2026 RNA History Reports and physician's orders. The DSD confirmed Resident 2 had physician's orders for RNA to assist Resident 2 with ambulation exercises using a FWW a minimum of 5 times a week. The DSD stated missing dates on the RNA History Reports indicated RNA did not document the RNA session which meant RNA services were not provided that day. The DSD confirmed Resident 8 missed one RNA session the week of 12/14/2025 to 12/20/2025, 3 RNA sessions the week of 12/21/2025 to 12/27/2025, 5 RNA sessions the week of 12/28/2025 to 1/3/2026, one RNA session the week of 1/4/2026 to 1/10/2026, and 3 RNA sessions the week of 1/11/2026 to 1/17/2026, totaling 13 missed RNA sessions from 12/1/2025 to 1/23/2026. The DSD stated RNA did not provide Resident 8 with RNA services, 5 times a week as ordered by the physician. The DSD stated it was important for RNA to provide services as prescribed by the physician because missed treatments could place residents at risk for a functional decline in ROM, ADLs, and contracture development. During a review of the facility's Policy and Procedure (P/P) titled, Resident Mobility and ROM, revised 7/2017, the P/P indicated the facility would ensure residents would not experience an avoidable reduction in ROM, residents with limited ROM would receive treatment and services to increase and/or prevent a further decrease in ROM, and residents with limited mobility would receive appropriate services, equipment, and assistance to maintain mobility unless unavoidable. The P/P indicated the nurse would identify the current ROM of his or her joints, limitations in movement or mobility, opportunities for improvement, and previous treatment and services for mobility. The P/P indicated the care plan would include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. The P/P indicated the care plan would include the type, frequency, and direction of interventions as well as measurable goals and objectives. During a review of the facility's P/P titled, Restorative Nursing Services, the P/P indicated residents would receive restorative nursing care as needed to help promote optimal safety and independence.

Based on interview and record review, the facility failed to verify the dose of Vitamin B-12 (supplement) order for one of two sample residents (Resident 35). This deficient practice had the potential to result in medication errors. Findings: During a review of Resident 35's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteopenia (condition characterized by lower-than-normal bone mineral density).During a review of Resident 35's Minimum Data set ([MDS] A resident assessment tool), dated 10/16/2025, the MDS indicated Resident 35's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was intact. During a review of Resident 35's View Prescription Order, starting 7/7/2023, the prescription ordered indicated to give Vitamin B-12 1,000 microgram (mcg) tablet once a day.During a concurrent interview and record review on 1/21/2026 at 8:36 a.m. with the Assistant Director of Nursing (ADON) Resident 35's physician order for vitamin B-12 was reviewed. The ADON stated the order needed to be clarified because the tablet was 1,000 milligrams (mg) and the order indicated to administer 1000 mcg. The ADON stated it was important to administer the correct dosage for resident safety. During an interview on 1/22/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated medication orders need to have the correct dosage. During a review of the facility's policy and procedure (P&P) titled, Administering Medication, revised 12/2012, the P&P indicated medications shall be administered in a safe manner as described with the right the right dose. During a review of the facility pharmacy's policy and procedure (P&P) titled, Medication Orders, reviewed 5/21/2025, the P&P indicated all medications orders must be complete and clear and the order must include the dose.

Based on interview and record review, the facility failed to ensure the Physical Therapy (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 12/23/2025, and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 12/23/2025, were completed under the written order of a physician for one of six sampled residents (Resident 1). These deficient practices had the potential to result in inaccurate care planning, harm, inaccurate provision of care and services, and lack of physician verification and coordination of skilled needs and care.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 9/1/2025 and re-admitted Resident 1 on 12/22/2025 with diagnoses including cellulitis (skin infection) of both legs, muscle weakness, and sepsis (illness caused by the body's response to an infection). During a review of Resident 1's PT Evaluation and Plan of Treatment (PT Eval), dated 12/23/2025, the PT Evaluation indicated Resident 1's reason for PT Eval was for decrease in functional mobility, decrease in range of motion (ROM, full movement potential of a joint), decreased strength, decreased postural alignment, decreased ambulation (walking), increased need for assistance from others, limited and painful movement, decreased balance, and decreased activities of daily living (ADL, basic activities such as eating, dressing, toileting). The PT Eval indicated Resident 1 would receive PT services five times a week for 30 days. During a review of Resident 1's OT Evaluation and Plan of Treatment (OT Eval), dated 12/23/2025, the OT Evaluation indicated Resident 1 the reason for the OT Eval was for edema exacerbation (sudden, significant increase in fluid retention), decreased strength, decreased ROM, wounds, and increased need for assistance from others. The OT Eval indicated Resident 1 would receive OT services five times a week for 30 days. During a review of Resident 1's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 1 was discharged from PT services on 1/9/2026. During a review of Resident 1's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 1 was discharged from OT services on 1/9/2026. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/11/2026, the MDS indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 required set up or clean up assistance (helper sets up or cleans up) for eating and oral hygiene, partial/moderate (helper does less than half the effort) assistance with upper body dressing, substantial/maximal assistance (helper does more than half the effort) for lower body dressing and rolling to both sides, and was dependent (helper does all the effort) for transfers and bathing. During a concurrent record review and interview with the Director of Rehabilitation (DOR) on 1/22/2026 at 2:19 pm, the DOR who was a PT stated PT and OT required physician orders to evaluate and treat residents in the facility. The DOR reviewed Resident 1's physician's orders and confirmed PT and OT did not have physician orders to evaluate and treat Resident 1. The DOR reviewed Resident 1's therapy and clinical records and confirmed PT and OT evaluated Resident 1 for skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant) on 12/23/2025 and provided therapy treatment five times a week until the time of discharge on [DATE] without a physician's order. The DOR stated PT and OT required physician's orders to evaluate and treat residents in the facility to ensure the resident was medically stable and appropriate to participate in therapy and to ensure the plan of care was developed in conjunction with the physician. During an interview with the Director of Nursing (DON) on 1/22/2026 at 5:42 pm, the DON stated PT and OT required physician orders to evaluate and provide therapy to residents in the facility. The DON stated PT and OT required physician orders to evaluate and treat residents in the facility to ensure the physician was aware of the resident's plan of care and the residents were appropriate to participate in a therapy program. During a review of the facility's Policy and Procedures (P/P), titled, Scheduling Therapy Services/Screenings, revised July 2013, the P/P indicated the therapist shall interview and consult with the Attending Physician as to the type of treatment to be administered. During a review of the facility's Job Description, titled, Occupational Therapist, revised 12/2018, the Job Description indicated the OT performed appropriate assessment(s) and reassessment(s) of patient's functional abilities, including physical, emotional, cognitive, and sensory components to evaluate the necessity of skilled OT intervention, identify and initiate clinically appropriate therapeutic intervention that is evidence based and comprehensive to the needs of the individual patient and/or as directed by physician orders in accordance with the standards set by American Occupational Therapy Association, the state of employment and the company. During a review of the facility's Job Description, titled, Physical Therapist, revised 12/2018, the Job Description indicated the OT performed appropriate assessment(s) and reassessment(s) of patient's functional abilities, including physical, emotional, cognitive, and sensory components to evaluate the necessity of skilled PT intervention, identify and initiate clinically appropriate therapeutic intervention that is evidence based and comprehensive to the needs of the individual patient and/or as directed by physician orders in accordance with the standards for professional PT practice, the state of employment and the company.

Based on observation, interview and record review, the facility failed to ensure an opened Tuberculin, Purified Protein Derivative ([PPD] medication used to do a skin test to help detect tuberculosis serious lung infection) for one of two medication rooms was labeled with the date opened. These deficient practices had the potential to result in the loss of viability (ability to work) of the PPD if used beyond recommended date. Findings: During a concurrent observation and interview on 1/20/2026 at 8:41 a.m. with Registered Nurse Supervisor (RNS) 1, in the North station medication room, the PPD vial was previously opened, and the vial was not labeled with the date it was opened. RNS 1 stated the vial should have had the open date on it. During a concurrent interview and record review on 1/20/2026 at 8:41 a.m. with RNS 1, the PPD vial carton was reviewed. RNS 1 stated the package indicated once opened vial should be discarded after 30 days. During an interview on 1/22/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated PPD vials should be discarded in 30 days once they are opened. During a review of the facility pharmacy's policy and procedure (P&P) titled, Medication Labeling and Proper Storage, reviewed 5/21/2025, the P&P indicated Tuberculin PPD opened vial should be discarded after one month of use because of oxidation (chemical reaction) and degradation (process by which a drug deteriorates) may reduce potency.During a review of the facility's P&P titled, Administering Medication, revised 12/2024, the P&P indicated when opening a multidose container, the date opened shall be recorded in the container.

Based on interview and record review, the facility failed to notify the physician when one of three sampled residents (Resident 45's) wound progressed from a pressure injury (PI- localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) to a PI Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound). This failure had the potential to delay care in treating and preventing Resident 45's PI from getting worse.Findings: During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), benign prostatic hyperplasia (BPH - an enlargement of the prostate gland causing difficult urination and incomplete bladder emptying), and a urinary device-supra pubic catheter (a hollow tube inserted through the lower abdomen skin into the bladder to drain or collect urine). During a review of Resident 45's History and Physical (H&P), dated 10/3/2025, the H&P indicated Resident 45 did not have the capacity to understand and make decisions. During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool), dated 10/21/2025, the MDS indicated Resident 45 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, and was dependent (helper does all the effort) when eating, oral hygiene, toileting hygiene, bathing, and dressing. During a concurrent interview and record review on 1/22/2026 at 1:22 p.m., with the Treatment Nurse (TXN), Resident 45's medical record was reviewed. Resident 45's nursing note dated 1/16/2026 indicated Resident 45 had a stage 1 PI on the sacrum. Resident 45's nursing note dated 1/17/2026 indicated Resident 45 had a stage 2 PI on the sacrum. The TXN stated there was no documentation that the RN notified the physician that the wound progressed from a PI stage 1 to a PI stage 2. The TXN stated the physician should have been notified the had worsened on 1/17/2026. During an interview on 1/22/2026 at 4:00 p.m., with the Director of Nursing (DON), the DON stated the nurse should notify the physician when there is a change of condition and document it as a progress note. The DON stated if the physician was not notified, three was a risk that the resident's wound, would not being treated appropriately to promote healing. During a review of the facility's policy and procedure (P&P), titled Change in a Resident's Condition or Status, dated December 2016, the P&P indicated the facility shall promptly notify the resident, his or her attending physician, and resident's medical/mental condition and/or status.The nurse will notify the resident's Attending Physician or physician on call when there has been a(an):.significant change in the resident's physical/emotional/mental condition.a significant change of condition is major decline or decline or improvement in the resident's status.

Based on interview and record review, the facility failed to ensure an Advance Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was formulated for one (1) out of the four (4) sampled residents (Resident 26).This deficient practice had the potential to cause conflict with Resident 26's wishes regarding health care and end of life wishes.Findings:During a review of Resident 26's admission record, the admission record indicated Resident 26 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (group of thinking and social symptoms that interfere with daily functioning), hypertension (high blood pressure), and hypertrophic lichen planus (chronic inflammatory condition).During a review of Resident 26's History and Physical (H&P), dated 3/3/2025, the H&P indicated Resident 26 does not have the capacity to make healthcare decisions.During a review of Resident 26's Minimum Data Set ([MDS] a resident assessment tool), dated 12/12/2025, the MDS indicated Resident 26's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were severely impaired. The MDS indicated Resident 26 is dependent (helper does all the effort) of activities of daily living (ADLs: routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an interview on 1/21/2026 at 3:28p.m. with the Social Services Designee 1 (SSD 1), the SSD 1 stated an AD helps residents who could not make decisions and identify what kind of decisions or wishes they would like to have for their medical care. The SSD 1 stated an AD is offered upon admission and indicated Resident 26 did not have an AD. The SSD 1 stated an AD was important to ensure the family is aware of what kind of decision, or who the resident would want to make their health care decisions.During an interview on 1/22/2026 at 3:43p.m. with the Director of Nursing (DON), the DON stated an AD is a document that reflects the resident's decisions regarding the care they wish to receive or decline. The DON stated it was important to ask Resident 26 if he would like to formulate an advanced directive and provide education and information to the residents.During a review of the facility's policy and procedure (P&P) titled, Advanced Directives, revised December 2016, the P&P indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 45) was treated with respect and dignity when the trash bag was placed on Resident 45's bed during a treatment. This failure had the potential affect resident's sense of dignity and self-worth.Findings:During an observation on 1/22/2026 at 9:33 a.m., the Treatment Nurse (TXN) was observed placing a clear bag on Resident 45's bed. The TXN was observed disposing gauze, gloves, and a medicine cup into the clear plastic bag during Resident 45's wound treatment.During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities, benign prostatic hyperplasia (BPH - an enlargement of the prostate gland causing difficult urination and incomplete bladder emptying), and a urinary device-supra pubic catheter (a hollow tube inserted through the lower abdomen skin into the bladder to drain or collect urine).During a review of Resident 45's History and Physical (H&P), dated 10/3/2025, the H&P indicated Resident 45 did not have the capacity to understand and make decisions.During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool), dated 10/21/2025, the MDS indicated Resident 45 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, and was dependent (helper does all the effort) when eating, oral hygiene, toileting hygiene, bathing, and dressing. During an interview on 1/22/2026 at 9:33 a.m. with the TXN, the TXN stated they placed the trash bag on the bed because there is no trash can in the room. The TXN stated they cannot place it on the bedside table because that is where the resident eats and cannot place it on the floor or the bathroom.During an interview on 1/22/2026 at 6:21 p.m. with the Director of Nursing (DON), the DON stated residents have a right to be treated with respect and dignity. The DON stated trash bags should not be placed on residents' beds during treatment, it can be put on the bedside table. The DON stated it a trash bag was placed on a resident's bed, it could potentially make the resident feel not respected or cared for in a respectful way.During a review of the facility's policy and procedure (P&P), titled Quality of Life - Dignity, dated August 2009, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The P&P indicated treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on observation, interview and record review, the facility failed to ensure bedrooms measure at least 80 square (sq) foot (ft) per resident for six of twelve resident rooms.This failure had the potential to result in compromised resident safety due to limited bedroom space.During an interview with the Administrator (ADMIN) on 1/23/2026 at 2:49 p.m., the ADMIN stated the residents in the affected rooms were not negatively impacted. The ADMIN stated there was sufficient room for the provision of nursing services for these group of residents, the rooms were approved during ( Office of Statewide Health Planning and Development (OSHPD) inspection.During a review of the letter provided by the ADMIN dated 1/20/2026 , the ADMIN requested a room waiver for the residents' room sizes less than 80 sq ft per resident for six of 18 rooms.The following resident rooms measured as follows:Room, Number of beds, and Square Footageroom [ROOM NUMBER] 4 beds 305.5 sq ftroom [ROOM NUMBER] 4 beds 305.5 sq ftroom [ROOM NUMBER] 2 beds 151 sq ftroom [ROOM NUMBER] 2 beds 152 sq ftroom [ROOM NUMBER] 2 beds 152 sq ftroom [ROOM NUMBER] 2 beds 151 sq ftDuring observations in these rooms during the survey period from 1/20/2026 through 1/23/2026, there were no quality of care issues observed with the residents having access in and out of the rooms, the space fortheir furniture, and no problems with staff being able to administer or assist with care.

Based on interview and record review, the facility failed to ensure they reported a suspected scabies (a contagious skin condition caused by tiny insects called microscopic mites which infest and irritate the skin causing intense itching, red patches and inflammation outbreak (two or more clinically suspect or confirmed cases identified in patients/residents, healthcare workers, volunteers and/ or visitors) to the California Department of Public Health (CDPH) for three of fourteen sampled residents (Resident 1, Resident 2 and Resident 3). This deficient practice resulted in CDPH being unaware that a possible scabies outbreak existed and a delay in their investigation, placing placed residents, staff and visitors at risk of acquiring and spreading scabies. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] with a diagnosis of an anxiety disorder (mental health condition characterized by excessive worrying). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 10/16/2025, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding ability) was severely impaired and Resident 1 was dependent (helper does all) on staff for hygiene, and to shower/bath. During a review of Resident 1's Order History (Physician's Orders) dated 8/14/2025 the Physician's Orders indicated to apply Permethrin 5% cream (a topical cream used to treat an infestation like scabies) to Resident 1's neck down to the sole of his feet times 1, shower in eight to 14 hours, then repeat in one week for prophylaxis (action taken to prevent disease). During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of an anxiety disorder. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired, and she was dependent on staff to shower/bathe. During a review of Resident 2's Physicians Order Report dated 10/22/2025, the Physician's Orders indicated to apply Permethrin 5% cream to Resident 2, from the neck down to the toes, leave it on for eight to 12 hours then rinse or give a shower in the a.m. Apply second dose due to suspicious rashes. Give Ivermectin (oral medication used to treat scabies) 3 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) 4 tablets to equal 12 mg then repeat in two weeks for suspicious scabies. During a review of Resident 3's admission Record (Face Sheet) the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of an anxiety disorder. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 1 was dependent on staff to shower/bathe. During a review of Resident 3's Physician's Order dated 10/20/2025 the Physician's Order indicated to give Resident 3 Ivermectin 3 mg, 4 tablets to equal 12 mg once a day on Sunday at 9 a.m., for scattered rashes and repeat in two weeks for suspected scabies. During an interview on 10/28/2025 at 1:08 p.m., the Infection Prevention Nurse (IPN) stated she was not aware that she had to report a suspected scabies outbreak to (CDPH). During an interview on 10/28/2025 at 1:45 p.m., the Director of Nursing (DON) stated the IP nurse reported to the DON that the PHN told her she would call CDPH, that was why she did not report the suspected scabies outbreak to CDPH. During a review of the facilities' undated Policies and Procedure (P&P) titled Unusual Occurrence Reporting the P&P indicated the facility would report the following events to the appropriate agency: An outbreak of any communicable disease: Other occurrences that interfere with the facility operations and affect the welfare, safety or health of residents, employees or visitors. Unusual occurrences shall be reported via telephone to the appropriate agency as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.

Based on observation, interview, and record review, the facility failed to serve requested menu items to one of three sampled residents (Resident 1).This deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (how we think, learn and remember). The MDS indicated Resident 1 needed set-up assistance when eating.During a review of Resident 1's General Order, dated 9/18/2023, the order indicated a diet order for Regular Diet, ground meat only with thin liquids.During a concurrent observation and interview on 11/26/2025 at 12:16 p.m., in the Dining Room, with the Director of Staff Development (DSD), there were no coleslaw and roasted vegetables observed on Resident 1's plate. The DSD stated there was no coleslaw and roasted vegetables on Residents 1's plate. During an interview and record review on 11/26/2025 at 12:16 p.m., with the DSD, Resident 1's Diet Ticket, dated 11/26/2025 printed at 11:51 a.m., was reviewed and the ticket indicated Resident 1 ordered Jicama Coleslaw and Balsamic Oregano roasted Vegetables. The DSD stated the staff ask the residents what they want to eat, and the resident preferences were indicated in the diet tickets, so they need to be served as requested. The DSD stated Resident 1 should have been served coleslaw and roasted vegetables.During a telephone interview on 11/26/2025 at 1:01 p.m., with the Registered Dietician (RD), the RD stated food items on the Diet Ticket reflect resident preferences and need to be served to the residents.During a review of the facility's policy titled, Resident Meal Service, revised 01/2025, the policy indicated residents will be offered menu choices for all meals, beverages, and snacks and are based on their prescribed diet and food preferences. The policy indicated menu served will be honoring residents' rights.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) belongings were safe.This deficient practice resulted in Resident 1 jewelry being lost.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (how we think, learn and remember). The MDS indicated Resident 1 needed set-up assistance when eating.During a concurrent interview and record review on 11/26/2025 at 1:17 p.m., with the Associate Director of Social Services (ADSS), Resident 1's Resident Inventory List, signed and dated 6/20/2023, was reviewed. The ADSS stated, the list indicated Resident 1 had a necklace with a heart [NAME]. The ADSS stated Resident 1's necklace listed in the inventory list was lost. The ADSS stated it was of sentimental value because Resident 1 has had it since she graduated from high school.During an interview on 11/26/2025 at 2:27 p.m., with the ADSS, the ADSS stated residents should not lose their personal belongings in the facility. During a review of the facility's policy titled, Theft and Loss, revised 01/2025, the policy indicated the following: a) It was the policy of the facility to protect and safeguard the belongings of its residents. b) Upon admission all valuables of the resident will be labeled and will be listed on the resident personal property and inventory list. c) Items of value brought to or removed from the facility shall be added or deleted from the inventory list by facility representatives at the time item is brought in or taken. Facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory.During a review of the facility's policy titled, Resident Rights, revised 12/2016, the policy indicated residents have the right to retain and use personal possessions to the maximum extent that space and safety permit.

Based on observation, interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 1) left arm bruise was assessed and reported as a change of condition after being reported to a licensed nurse. This deficient practice resulted in a delay of care for Resident 1 and had the potential to cause pain, infection and lead to hospitalization. Findings: During a review of Resident 1’s admission Record, the admission Record indicated Resident was 1 admitted to the facility to the facility on 6/2/2025 with a diagnosis including unspecified dementia (decline in mental ability severe enough to interfere in daily life) , unspecified severity, without behavioral disturbance, hypertension (high blood pressure) and anxiety (having constant worry and fear). During a review of Resident 1’s MDS a resident assessment tool) dated 6/12/2025, the MDS indicated Resident 1’s cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) were severely impaired. The MDS indicated Resident 1 was dependent (resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) on eating, oral hygiene, sit to lying, chair/bed to chair transfer, toilet hygiene, tub/ shower transfer, oral hygiene and upper body dressing (arms/shoulders). During a review of Resident 1’s admission Body/ Skin Assessment (BSA) dated 6/2/2024, the BSA indicated Resident 1 had a purple/red discoloration measuring 8. 5 X 10 cm (centimeters- unit of measure) to left arm. During review of Resident 1’s untitled Care Plan (CP) dated 6/2/2025. The CP indicated Resident 1was admitted with purplish skin discoloration on left arm about 8.5x 10 cm. monitor and report any signs of localized infection ( swelling, redness, pain or tenderness, heat at the affected area, purulent drainage, or bruises and report any significant changes. During a review of Resident 1’s Event Report (ER) dated 6/28/2025 at 7:13 p.m., the ER indicated a skin discoloration to left arm and elbow measuring 25 cm x 17 cm (increased in size from admission). During a review of Resident 1’s ER dated 6/28/2025 at 9:46 p.m., the ER indicated Certified Nurse Assistant 2 (CNA 2) reported to Licensed Vocational Nurse 2 (LVN 2) Resident 1 had discoloration to the left arm. During a review of Resident 1’ s Radiology report dated 6/29/2025 the report indicated there was an acute fracture (a sudden break in the bone) involving the neck of the left humerus (the long bone located in the upper arm extending from the shoulder to the elbow), with mild displacement. During an interview on 7/ 9/2025 at 1:45 p.m., with CNA 1, CNA 1stated she took care of Resident 1 on 6/28/2025 for 7 a.m. to 3 p.m. shift and saw Resident 1 trying to protect her left arm. CNA1 stated upon observing the left arm there was a large purplish bruise present. CNA 1 stated she reported her findings to her LVN 1. CNA 1 stated LVN 1 told her she would let the treatment nurse know about the bruise. During an interview on 7/9/2025 at 4:00 p.m., with LVN 1, LVN 1 stated he worked 6/28/2025 from 7 a.m. to 3:00 p.m. shift when CNA 1 reported Resident 1’ s bruise on the left arm to him. LVN 1 stated he looked in the chart and saw charting that Resident 1 had a bruise on the left arm on admission but did not go to assess the resident. LVN 1stated he told CNA 1 to report it to the treatment nurse. LVN1 stated it was important to assess Resident 1’s arm because there could be changes and the arm can get worse. During a telephone interview on 7/10/2025 at 2:30 p.m. with the Registered Nurse (RN) 1, RN 1 stated on 6/28/2025 she worked as a treatment nurse from 7 a.m. to 3 p.m. shift when LVN 1 told her Resident 1 has a purplish bruise to the left arm. RN stated she checked the charting in the computer and stated the bruise was already charted . RN stated she never went to assess Resident 1’s arm because she didn’t consider it a change in condition. RN 1 stated when someone reports a bruise it is her job to go and assess the bruise, she stated she should have looked at Resident 1’s arm when it was reported to her. RN 1 stated part of her assessment is to measure the size of the bruise, the color, if there is pain , appearance of the resident’s skin and chart her findings. RN 1 stated it is important to do an assessment to identify if there were any changes to the skin. RN 1 stated because the left arm went unnoticed the injury could have gotten worse. RN 1 stated this was a change of condition. During an interview on 7/11/2025 at 11 :15 a.m. with the Director of Nursing (DON), the DON stated the LVN can look at the resident’s arm chart and notify the doctor and the RN does a more thorough assessment document and notify the doctor. The DON stated the nurses chose to look at the documentation in the chart instead of looking at the resident’s arm. The DON stated it is important to do an assessment to confirm what is going on or if there are any changes, then the nurse must start a change of condition form (COC). The DON stated she knew the day shift did not assess the resident and this was a learning experience for the staff. A review of the facility's policies and procedures (P&P) titled, “Change in a Residents Condition or Status, revised December 2016, indicated, our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident’s medical/ mental condition and/or status (e.g., changes in the level of care, billing/payments, resident’s rights, etc.). The nurse will notify the resident’s Attending Physician or Physician on call when there has been a(an): accident or incident involving the resident. A significant change is a major decline or involvement in the residents’ status that will not normally resolve itself without intervention by staff or implementing standard disease- related clinical interventions (is not “self- limiting”). The P&P indicated the nurse will record in the resident’s medical record information relative to changes in the resident’s medical/ mental condition or status. A review of the facility's P&P titled, “Charge Nurse (RN/LVN), “job description undated, indicated the purpose of this position is to supervise, provide and coordinate nursing care in compliance with the facility policies and procedures, assess residents’ care needs, and take appropriate action.

Based on interview and record review the facility failed to ensure Resident was assessed and evaluated after an unwitnessed fall on 12/7/2024 for one out of 2 high risks for falls (Resident 1). This deficient practice resulted in Resident 1 falling in bed sustaining multiple skin tears to the left forearm. Findings: During a review of Resident 1's Face Sheet dated 12/30/24, the face sheet indicated Resident 1 was admitted to facility with diagnoses including mild cognitive impairment (changes in thinking and memory), Atrial Fibrillation (irregular heart rate), foley catheter use(thin flexible tube that drains urine from the bladder into a collection bag), glaucoma (chronic eye disease), muscle wasting and atrophy (loss of muscle mass) and difficulty walking, history of falls. During a review of Resident 1's History and Physical (H&P) dated 11/8/24 indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ({MDS}- a resident assessment tool) dated 11/18/24 the MDS indicated Resident 1 has severe cognitive impairment. The MDS also indicated Resident 1 was dependent (helper does all the work) with activities of daily living ({ADL's}- activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1's Physicians Order Report dated 11/30/24-12/30/24 indicated, Resident1 has orders for Dulcolax suppository 10mg give once a day as needed. The physician orders report also indicated Resident1 has orders for pressure pad alarm at all times in bed to monitor getting out of bed without assistance. During a review of the Medication Administration History dated 11/30/24-12/30/24 indicated Resident 1 was given a Dulcolax suppository on 12/24/24 at 6:23 a.m. During a review of Resident 1's Progress Note dated 12/24/24 the progress note indicated Resident 1 was transferred to a general acute care hospital (GACH) on 12/24/24 at 12:22 p.m. During an interview on 12/30/24 at 6:26 am with Certified Nursing Assistant (CNA) 1, CNA 1 stated that Resident 1 is impulsive and sometimes he doesn't use the call light. CNA 1 stated Resident 1 had been given a suppository at 5:30 a.m. and the last time she saw the resident was at 6:00 a.m. and at 7:00 a.m. CNA 1 stated that it is important to check on residents after they have been given a suppository, for safety reasons the resident could fall trying to get up to go to the bathroom. During an interview on 12/31/24 at 7:30 am with CNA 2, CNA 2 stated he was given report at 6:30 a.m. on 12/24/24 that Resident 1 was given a suppository. CNA 2 stated the last time he saw Resident 1 was around 6:45 a.m. and that Resident 1 was asleep. CNA 2 stated that at around 7:00 a.m. he heard the alarm and he found Resident 1 on the floor and his diaper was full of bowel movement (BM). During an interview on 12/30/24 at 7:25 a.m. with Licensed Vocational Nurse (LVN), LVN1 stated that Resident 1 was confused and did not really use his call light LVN 1 stated Resident 1 was given a suppository around 5:30 a.m LVN 1 stated that she did not check to see if Resident 1 had a BM she asked CNA 1 at 6:00 a.m. LVN 1 stated that around 7:00 am she was called to Resident 1's room, and he was on the floor with BM in his diaper. LVN 1 stated that when a resident is given a suppository the CNA needs to check on the residents every 30 min until resident has a bowel movement because resident could try to get up get up and fall During an interview on 12/30/24 at 11:17 a.m. with Assistant Director of nurses (ADON), The ADON stated Resident 1 has poor safety awareness and is very impulsive ADON added that Resident 1 had fallen from the wheelchair 3 times, 2 times trying to go to the bathroom and one time in the hallway. ADON stated that when a resident falls the nurses need to do a change of condition (COC), a fall risk evaluation, care plan and Director of Nurses (DON) does the post fall assessment. ADON stated that when residents are given a suppository the CNA's and the charge nurses need to check the resident every 30min to one hour after suppository is given if resident are not checked they can get skin break down or residents could fall trying to go to bathroom. During a concurrent interview and record review on 12/30/24 at 11:17 a.m. with, the ADON indicated Resident 1 did not have a fall risk evaluation done after his unwitnessed fall on 12/7/24 and that the fall risk evaluations are important because they asses for changes in the resident that might be contributing to the fall. During an interview on 12/31/24 at 9:00 a.m. with, the Director of Nurses (DON), the DON stated she was aware that Resident 1 had fallen multiple times in the last month and that no fall risk evaluation was done after the fall on 12/7/24, and that she must have missed it. The DON stated that fall risk evaluations are important because you can see if there are any functional changes you could miss some type of visual cue, DON also said it can show you that you may need to change your plan of care. DON stated that after every fall a Fall risk evaluation must be done. DON stated that she expects her nursing staff to check on a resident every 30 min after a suppository is given. DON stated there is a safety concern when given a suppository because it stimulates you makes you want to go to the bathroom. DON stated there is a potentially for the resident to fall and have an injury needing to go to the bathroom. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing dated 12/2007, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try and minimize complications.

Based on interview and record review the facility failed to ensure the facility's consulting pharmacist (PH) conducted monthly and as needed Drug Regiment Reviews ([DRR]thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) of psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) and made recommendations for gradual dose reduction ([GDR] - tapering mediation dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) or medication dosage adjustments to control behavioral symptoms for two of two residents with dementia (a progressive state of decline in mental abilities) for 2 of 25 sampled residents (Resident 17 and Resident 51) and for 23 residents (Residents 1, 2, 4, 9, 10, 13, 14, 19, 20, 22, 23, 26, 27, 29, 31, 32, 35, 38, 44, 45, 47, 53, 60) receiving psychotropic medications to ensure the residents were not receiving duplicate therapy (multiple medications for the one diagnosis) and unnecessary medications. The facility failed to: 1. Ensure Resident 17 had DRR and GDR assessments of psychotropic medication by the facility's PH or documentation by the physician that a dose reduction was not recommended as the benefits of the current dose outweighed the risk for side effects. Resident 17 was admitted on [DATE], and has been on the following psychotropic medications: Cymbalta (drug used to treat depression - a mood disorder that causes a persistent feeling of sadness and loss of interest) 30 milligrams ([mg] unit of weight measurement), started 11/1/2024, once a day, Ativan (drug that is used to treat anxiety [feeling of fear, dread, and uneasiness]) 0.5 mg, started 9/14/2022, twice a day for anxiety manifested by periods of restlessness or agitation that interferes with care, Seroquel, an antipsychotic (a class of drugs used to treat symptoms of psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality]) 50 mg, started on 6/2/2023, every 12 hours for bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and Depakote (a medication used to treat manic episodes [emotional highs- associated with bipolar disorder]) 250 mg, started 11/2/2024, twice a day for bipolar disorder. 2. Ensure Resident 51 had a DRR and GDR assessment by the facility PH for psychotropic medication or documentation by the physician that the dose reduction was not recommended as the benefits of the current dose outweigh the risk for side effects. Resident 51 was admitted to the facility on [DATE] and has been on the following psychotropic medications: Donepezil (medication to treat dementia), oral, 5 mg once a day started on 12/19/2023. Seroquel 50 mg, oral, twice a day for dementia with agitation starting on 7/17/2024. Ativan 0.5 milligrams oral, every 12 hours as needed for anxiety manifested by constantly yelling that interfere with self and other residents. The order was started on 7/20/2024. 3. Ensure staff followed the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use indicating antipsychotic, a class of drugs that treat symptoms of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), medication will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Residents 1, 2, 4, 9, 10, 13, 14, 17, 19, 20, 22, 23, 26, 27, 29, 31, 32, 35, 38, 44, 45, 47, 51, 53, and 60 will only receive antipsychotics medications when necessary to treat specific conditions for which they are indicated and effective. These deficient practices placed Residents 17, 51 and Residents 1, 2, 4, 9, 10, 13, 14, 17, 19, 20, 22, 23, 26, 27, 29, 31, 32, 35, 38, 44, 45, 47, 51, 53, and 60 who were receiving psychotropic medication at high risk for receiving unnecessary psychotropic medication, potential side effects associated with the use of these medication, and not to have behavioral symptoms under control. Potential side effects of psychotropic medications including the following: a. Ativan: drowsiness and confusion b. Haloperidol (drug used to treat mental illness such as psychosis): difficulty speaking/swallowing, loss of balance, muscle spasms, and extrapyramidal symptoms (EPS - motor problems that include Parkinsonian-like symptoms (stiffness, tremor, shuffling gait [walking without lifting feet completely off the gound]), acute dystonia (abrupt spasms of head and neck), and akathisia (physical restlessness) c. Seroquel: increased mortality (death) in elderly patients with dementia, chills, confusion, and dizziness. d. Depakote: confusion, crying, delusions (altered reality that is persistently held despite evidence or agreement to the contrary) of persecution, mistrust, and combativeness. e. Cymbalta: body aches, cough, constipation (a common condition that involves infrequent or difficult bowel movements), and dry mouth. f. Donepezil: diarrhea, loss of appetite, and trouble sleeping On 11/14/2024, at 5:42 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure the facility's consulting PH conducted monthly DRR's and GDR's monthly and as needed and made recommendations for psychotropic medications to control behavioral symptoms for 25 residents (Residents 1, 2, 4, 9, 10, 13, 14, 17, 19, 20, 22, 23, 26, 27, 29, 31, 32, 35, 38, 44, 45, 47, 51, 53, and 60) receiving psychotropic medications to ensure the residents were not receiving duplicate therapy and unnecessary medications. On 11/16/2024 at 6:48 p.m., the facility submitted an acceptable IJ removal Plan ([IJRP] - interventions to correct the immediacy of the deficient practices) and after onsite verification through observation, record review and interviews, the IJ was removed in the presence of the DON. The IJRP included the following immediate actions: 1. The facility contacted the consulting PH on 11/14/2024, to conduct a drug regimen review for Residents 17 & 51 who were on psychotropic medications for irregularities, appropriateness and make recommendations on GDR's by 11/15/2024. Additionally, the licensed pharmacist will complete psychotropic drug regimen reviews for the remaining 24 residents on psychotropic medications to assess for irregularities, appropriateness and make recommendations on GDR's by 11/15/24. 2. On 11/14/2024, all licensed nurses working on 3-11 shift were in- serviced (educated, trained) immediately on the need for a licensed pharmacist to review the resident's drug regimen and review duplicate therapy. The Director of Staff Development (DSD) will do another in service on 11/15/24 for those licensed nurses that were not at the facility on 11/14/2024. The DSD has a list of those on leave, vacation or who were not able to attend and when they are back on schedule will be in serviced as well. 3. This facility will ensure the admission of residents whose needs we can meet according to our Facility Assessment (a review of the facility's resources and capabilities to provide care for its residents) dated, 11/14/2024 through the utilization of the facility consulting pharmacist to conduct DRR for residents on psychotropic medications for irregularities, appropriate and make recommendations on GDR's. The facility's consulting pharmacist will conduct this monthly for all current and future residents. 4. The DON will monitor monthly that the consulting PH has conducted a drug regimen review for residents who are on psychotropic medications for irregularities, appropriateness and make recommendations on GDR's. The DON will report any recommendations made to the resident's physician. The DON will use the audit form to track all GDR recommendations and keep copies of the GDR recommendations in the audit binder with the audit form. The DON will monitor that 100% of the residents on psychotropic medications were reviewed by the consulting pharmacist and will report the findings to the facility's Quality Assurance Performance Improvement quarterly monitoring meetings with a threshold of 100% through November 2025. Findings: A. During a review of Resident 17's Admission Record, the Admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance, bipolar disorder, generalized anxiety disorder (mental health condition that causes people to experience excessive and uncontrollable worry about everyday events or activities), major depressive disorder, abnormalities of gait and mobility. During a review of Resident 17's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/3/2024, the MDS indicated Resident 17's cognition (the mental process of thinking, understanding, and processing information) was severely impaired. The MDS indicated the resident was independent when eating, needed set up assist with oral hygiene, needed moderate assist (helper does less than half the effort) with personal hygiene, needed maximal assistance (helper does more than half the effort) with showering, and was dependent on staff with toileting hygiene. The MDS indicated Resident 17 was on antipsychotic medications since admission. Resident 17 was on the following psychotropic medications: Cymbalta 30 milligrams started 11/1/2024, once a day for depression, Ativan 0.5 mg, started 9/14/2022, twice a day for anxiety, Seroquel 50 mg, every 12 hours for bipolar disorder and Depakote 250 mg, started 11/2/2024, twice a day for bipolar disorder. The MDS also indicated a GDR had not been attempted and the physician had not documented a GDR was clinically contraindicated (a reason for a person to not receive a particular treatment or procedure because it may be harmful). During a review of Resident 17's Physician's Order Report dated 11/1/2024 - 11/10/2024, the Physician's Order Report indicated the following orders: a. Starting, 6/2/2023, Seroquel 50 mg oral, every 12 hours, for bipolar disorder, depressive type manifested by easily getting irritated or angry and suspicious at anything you say that interferes with care. b. Starting 11/1/2024, Cymbalta capsule delayed release (medication designed to release in the body over time) 30 mg, oral once a day. c. Starting 11/1/2024, Depakote delayed release tablet 250 mg, oral, twice a day, for bipolar disorder, depressive type manifested by easily getting irritated or getting angry and suspicious of anything you say, that interferes with care. During an observation of Resident 17, on 11/8/2024 at 7:18 p.m., in Resident 17's room, Resident 17 was observed falling asleep while brushing her teeth. During an observation of Resident 17 on 11/9/2024 at 9:25 a.m., in the hallway in front of Resident 17's room, Resident 17 was observed sleeping in her wheelchair. During an observation of a medication pass on 11/10/2024 at 8:51 a.m., Resident 17 stated to Licensed Vocational Nurse (LVN 3) that it was too much medication pills, LVN 3 was giving her to take. LVN 3 responded by instructing Resident 17 to drink more water and take the medication. During an interview and record review on 11/12/2024 at 9:15 a.m., with the Assistant Director of Nursing (ADON), Resident 17's Physician Progress note, dated 11/1/2024 and timed at 3:40 p.m., was reviewed. The Physician Progress note indicated Resident 17's psychotropic medications were adjusted over the last several months due to Resident 17's complaint of feeling low in energy and drooling (saliva flowing out of your mouth unintentionally). The Physician Progress note indicated that the psychotropic medications made it difficult for Resident 17 to think. The ADON stated primary physician 2 (MD 2) managed Resident 17 psychotropic medications. The ADON stated Resident 17 was diagnosed with bipolar disorder and major depression, but the last psychiatric consultation Resident 17 had was on 11/29/2021. During an observation and interview on 11/12/2024 at 2:54 p.m., with Certified Nurse Assistant (CNA) 3, by the door of Resident 17's room, Resident 17 was observed sleeping in her wheelchair. CNA 3 looked at Resident 17 and stated Resident 17 usually dozed off and fell asleep in her wheelchair, so the staff would put her back in bed. During a phone interview on 11/13/2024 at 7:49 a.m., the facility's consulting PH stated that drooling or excessive salivation can be a side effect of psychotropic medication use. The PH stated psychotropic medication use was worse for elderly and even worse for dementia residents. The PH stated inappropriate psychotropic medication use can cause residents to be drowsy or sedated (falling asleep as a side effect of a drug). During an interview and record review on 11/13/2024 at 9 a.m., with the Assistant Director of Nursing (ADON), Resident 17's Behavior Quarterly Management Follow up, dated 7/3/2024, was reviewed. The ADON confirmed and stated Resident 17 was on Ativan 0.5 mg twice a day for anxiety manifested by episodes of restlessness or agitation that interferes with care. The Behavior Quarterly Management Follow up indicated for the month of January 2024, Resident 17 had zero episodes of restlessness and one episode of agitation. For the month of February 2024, Resident 17 had 4 episodes of restlessness and 3 episodes of agitation. For the months of March and April 2024 Resident 17 had no episodes of agitation and restlessness. The ADON stated Resident 17 was on Seroquel 50 mg every 12 hours for bipolar disorder, depressive type manifested by Resident 17 gets easily irritated or gets angry and suspicious of anything you say, that interferes with care. The ADON stated during the months of January, February and March 2024 Resident 17 had behaviors of easily getting irritated and paranoia (extreme unjustified fear and mistrust of others), and in the month of April 2024 the resident had zero behaviors manifested. The ADON stated, Seroquel was last increased to every 12 hours on 6/2/2023, last year, and the Interdisciplinary Team (IDT -the residents health care team consisting of various specialties) team decided to continue the current psychotropic regimen because the benefits outweighed the risks for reduction. The ADON stated the physician was not contacted because the IDT team had decided there were no pharmacological (medication) adjustments required. The form indicated no physician's signature showing a physician or a psychiatrist was not consulted about IDT's decision not to complete a GDR. The ADON stated they don't factor in how the length of time the residents have been on psychotropics. The ADON stated the IDT only considers the behavior summary when discussing a possible GDR for the resident. B. During a review of Resident 51's Admission Record, the Admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic (set of symptoms that indicate a loss of touch of reality) disturbance, and anxiety disorder. During a review of Resident 51's MDS, dated [DATE], the MDS indicated the resident's cognition was severely impaired. The MDS indicated Resident 51 was dependent on staff with bathing, toileting hygiene, dressing, personal hygiene, oral hygiene, and transfer to and from the bed to a chair. The MDS indicated Resident 51 was routinely on antipsychotic medications since admission. Resident 51 was admitted to the facility on [DATE] and has been on the following psychotropic medications: Donepezil (medication to treat dementia), oral, 5 mg once a day started on 12/19/2023. Seroquel 50 mg, oral, twice a day for dementia with agitation starting on 7/17/2024. Ativan 0.5 milligrams oral, every 12 hours as needed for anxiety manifested by constantly yelling that interfere with self and other residents starting on 7/20/2024. The MDS also indicated a GDR had not been attempted. The MDS indicated that the physician had not documented that a GDR was clinically contraindicated. During a review of Resident 51's Physician's order Report (active orders) dated 10/12/2024 - 11/12/2024, the Physician's order Report indicated the following orders: a. Starting on 12/19/2023, Donepezil (medication to treat dementia), oral, 5 mg, once a day. b. Starting on 7/17/2024, Seroquel 50 mg, oral, twice a day for dementia with agitation. c. Starting on 7/20/2024, Ativan 0.5 milligrams oral, every 12 hours as needed for anxiety manifested by constantly yelling that interfere with self and other residents. The order was discontinued on 9/23/2024. During a review of Resident 51's Progress Notes, the Progress Notes indicated: a. On 6/25/2024 at 11:04 a.m., Resident 51 was noted with behaviors of agitation, yelling out, and constantly moving. The Progress Note indicated that the Assistant Director of Social Services (ADSS) provided the resident with increased opportunity to socialize and engage in activities. b. On 6/29/2024 at 4:05 p.m. Resident 51's family (FM 1) reported that Resident 51 was frequently moving her lips from front to back and side to side and her eyes stayed wide open without blinking much, as the resident did in the hospital. The Progress Note indicated the MD was made aware, and Resident 51 was to be monitored for frequently moving her lips from front to back and side to side, and for her eyes staying wide open without blinking. c. On 7/11/2024 at 3:15 p.m., the Progress Notes indicated that Resident 51 displayed uncontrollable disruptive behavior, yelling out, hello for no apparent reason. The Progress Notes indicated that Resident 51's Primary Care Physician (PCP), who is not a psychiatrist ordered Seroquel 12.5 mg oral, twice a day ordered for dementia with agitation manifested by resisting care and yelling out that interferes with care and safety. d. On 7/17/2024 at 10:42 a.m., the PCP increased the dosage of Seroquel to 50 mg for dementia with agitation manifested by resisting care and yelling out that interferes with care and safety. The Progress Notes indicated that a neurologist (medical doctor who diagnoses, treats, and manages disorders of the brain and nervous system -brain, spinal cord and nerves) evaluation was pending. During a review of Resident 51's Physician's order Report (active orders) dated 10/12/2024 - 11/12/2024, the Physician's order Report indicated the following orders: a. Starting on 12/19/2023, Donepezil (medication to treat dementia), oral, 5 mg, once a day. b. Starting on 7/17/2024, Seroquel 50 mg, oral, twice a day for dementia with agitation. c. Starting on 7/20/2024, Ativan 0.5 milligrams oral, every 12 hours as needed for anxiety manifested by constantly yelling that interfere with self and other residents. The order was discontinued on 9/23/2024. During a review of Resident 51's Progress notes, the Progress Notes indicated the following: a. On 7/23/2024 at 12:46 p.m., order received for psychiatric consultation due to continuous yelling out. b. On 7/29/2024 at 11:12 a.m., Resident 51 continued the constant disruptive yelling for 18-20 hours a day, causing multiple other residents (unidentified) to have agitative disruptive behaviors as well. Resident 51 was yelling so much Resident 51 would not eat, or drink fluids and this distressing behavior was attributing to her continued weight loss. Resident 51 was inconsolable and not redirectable. c. On 7/29/2024 the Progress Notes indicated a new order from MD 1 for Haloperidol 2.5mg oral every 12 hours for dementia with psychosis. During a review of Resident 51's Physicians Order, created on 7/29/2024 and timed at 11:09 a.m., the order indicated Haloperidol 2.5 mg oral every 12 hours for dementia with psychosis and agitation manifested by resisting care and continuous yelling out interferes with care and safety. During a review of Resident 51's Physician's order Report dated 10/12/2024 - 11/12/2024, the report indicated, the following orders: a. Starting 7/29/2024, monitor for side effects every shift of anti-psychotic use (Seroquel and Haloperidol). b. Observe closely for significant side effects: Common - sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction symptoms ([EPS] - motor problems that include Parkinsonian-like symptoms (stiffness, tremor, shuffling gait), acute dystonia (abrupt spasms of head and neck), and akathisia (physical restlessness)1, weight gain, edema (fluid buildup in the body), postural hypotension (feeling dizzy and weak upon standing), sweating, loss of appetite, urinary retention. c. Special attention for tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation (skin color changing), jaundice (yellowing of the skin or whites of eyes by buildup of waste products). During a review of Resident 51's Progress Notes, the Progress Notes indicated on 10/2/2024 at 12:35 p.m., Resident 51 was continuously yelling out nonstop and interfering with ADLs and causing social disturbance. The Progress Notes indicated Resident 51's behavior was discussed with the IDT and MD 1, and MD 1 made an order to double the dose of the Haloperidol from 2.5 mg twice a day to 5 mg twice a day and may give one additional dose of 2.5 mg. The Progress Notes indicated that MD 1 ordered a follow up with psychiatrist's consult. During a review of Resident 51's Physician's order Report dated 10/12/2024 - 11/12/2024, the report indicated, starting on 10/2/2024, Haloperidol 5 mg every 12 hours, for dementia with psychosis and agitation manifested by resisting care and continuous yelling out that interferes with care and safety. During an interview and record review on 11/12/2024 at 2:00 p.m., with the ADON, Resident 51's Progress Notes and Physician's orders were reviewed. The ADON confirmed Resident 51 was readmitted back from the General Acute Care Hospital (GACH) without any psychotropic medications on 6/11/2024. The ADON stated on 7/29/2024 Haloperidol 2.5 mg was started due to continued behaviors. On 10/2/2024 the behaviors of yelling out continued, and Haldol was increased to 5 milligrams twice a day. The ADON stated as of 11/12/2024 Resident 51 still has not had a psychiatrist consultation. During an interview and record review on 11/12/2024 at 2:35 p.m., with the ADSS, the Facility Matrix (a grid-like tool used to organize and analyze data about a healthcare facility) was reviewed and the Facility Matrix indicated 25 residents (Resident 14, 60, 17, 44, 2, 10, 29, 4, 32, 35, 53, 1, 26, 27, 51, 31, 45, 19, 22, 47, 38, 20, 23, 9, and 13) were on psychotropic medications. During an interview and record review on 11/12/2024 at 2:35 p.m., with the ADSS, Resident 17, and 51's latest Monthly Behavior Summary were reviewed and the ADSS confirmed and stated she (ADSS) did the psychotropic medications behavior summary for all the residents on psychotropic medications and documented it on the respective residents' medical records. The ADSS stated the IDT team including the DON, the ADON, dietician and MDS coordinator and her(ADSS) met quarterly to analyze the residents (in general) behaviors (see if there's an increase or decrease). The ADSS stated that the IDT team would then make pharmacological intervention recommendations to the primary care physicians of the residents. The ADSS stated she does not know what is considered an unnecessary psychotropic medication is because she is not clinician. During an observation in the dining room, on 11/12/2024 at 5:55 pm, Resident 51 was yelling while eating dinner. During a phone interview on 11/13/2024 at 7:49 a.m., with the facility consulting PH stated that she does not conduct review of residents' psychotropic drug regimens. The PH stated the IDT reviews the quarterly behavior management; the PH stated she expected a physician would be in attendance in IDT meetings. The PH stated she was unsure who attended. During a concurrent interview on 11/13/2024 at 10:15 am, with the ADON, Resident 51's Behavior Quarterly Management Follow up, dated 10/16/2024 and timed at 2:09 p.m. was reviewed. The ADON confirmed and stated during July 2024, Resident 51 had 26 episodes of resisting care and 144 episodes of constant yelling out, during August 2024, Resident 51 had 15 episode of resisting care and 101 episodes of constant yelling out, and during September 2024 Resident 51 had 16 episodes of resisting care and 103 episodes of constant yelling out. The ADON stated the IDT team called MD 1 and MD 1 put Resident 51 on Haloperidol. During an interview on 11/13/2024 at 3:55 p.m., the DON stated the IDT team comprised of the DON, the ADON, Registered Dietician, ADSS, MDS Coordinator, and sometimes the Director of Rehabilitation (DOR). The DON stated the IDT team conducted residents (in general) Quarterly Behavior Management meeting on psychotropic medication use. During IDT meetings the behaviors ,medications, and interventions were discussed and summated in the document tilted Behavior Quarterly Management Follow up for each resident. The ADSS does the monthly summary of behaviors. The DON stated the IDT team will discuss whether a pharmacological adjustment would be required depending on an increase or decrease of behaviors. After the IDT discussed the behaviors the DON or the ADON reach out to the respective physicians if the IDT deemed that a GDR was indicated. The DON stated the consulting PH did not make GDR recommendations and the PH did not look at the residents' behavior record because the IDT team reviewed the behaviors and made the recommendations. During a phone interview on 11/13/2024 at 4:49 p.m., the PH stated she had been the pharmacy consultant for the facility for two years. The PH stated there were 28 residents on psychotherapeutic medications. The PH stated she did not make recommendations for GDR of psychotropic medications based on her assessment. The PH stated the IDT team managed the residents on psychotherapeutic medication and not her. During a review of the facility's P&P titled, Behavioral Assessment, Interventions and Monitoring, revised 12/2016, the P&P indicated the facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. During a review of the facility's Job profile for the Pharmacist Consultant, dated 4/6/2021, the profile indicated the following essential job functions: a. Evaluates the drug regimen reviews of residents in the facility, assuring appropriate drug therapy. b. Monitors the compliance of the facility with Federal and State guidelines and notes any irregularities. c. Serves as an information source regarding medication and Federal and State pharmacy regulations. d. Acts as a liaison between the pharmacy and the facility when problems need to be resolved. e. Educates nurses about problem areas within the facility and is a in areas of staff interest. f. Attends necessary meetings of the facility, pharmacy, infection control, quality assurance, and interdisciplinary team conference. g. Reviews physician's orders and evaluates for appropriate action, dosage, potential drug interactions, administration, and stability. h. Produces written reports on findings and recommendations for each monthly visit to facilities and provides reports to the Administrator, DON, and where appropriate the medical director/physician. Reviews each resident's drug regimen at least monthly. The consultant pharmacist prescriber and IDT work together to determine whether prescribed medications are indicated based on: a. Need for the medication in relation to resident's documented diagnosis and condition. b. Whether the physician's indications for use have been documented for all medications. c. The medications effectiveness. d. Risk related to administration, including known incidence of adverse drug reactions and potential error know drug-drug and food interactions. 44055

44055 Based on observation, interview, and record review the facility failed to ensure the psychiatrist's (medical practitioner specializing in the diagnosis and treatment of mental illness) services were provided to residents who were receiving psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication for four out of six sampled residents (Residents 2, 17, 19, and 51). Resident 2 had a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Residents 17, 19, and 51 had diagnoses of dementia (a progressive state of decline in mental abilities), The facility failed to: 1. Ensure Residents 2, 17, 19, and 51, who were being treated with psychotropic medications including Cymbalta (a drug used to treat depression), Ativan (drug that is used to treat anxiety [feeling of fear, dread, and uneasiness]), Seroquel an antipsychotic (a class of drugs used to treat symptoms of psychosis [ a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), Depakote (a medication used to treat manic episodes - emotional highs- associated with bipolar disorder [bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]), Mirtazapine (medication to treat depression), Haloperidol (a high potency drug used to treat certain mental and neurological disorders), and Donepezil (a medication that treats symptoms of dementia like memory loss and confusion), were evaluated by a psychiatrist for the appropriateness of psychotropic medication use before starting the psychotropic medication regimen during use of psychotropic medications, and as needed. 2. Ensure Residents 2's medication regimen therapy with Cymbalta 30 milligrams ([mg] a unit of weigh measurement), that started on 4/23/2024, twice a day for depression, was evaluated by a psychiatrist to assess for appropriateness, effectiveness, and the need to increase or decrease medication dosage to ensure the resident's safety, and that Resident 2 reached the highest practicable quality of life. Resident 2 was admitted on [DATE] and has been taking psychotropic medications since admission. Resident 2 had not been evaluated by a psychiatrist since 2/28/2023. 3. Ensure Resident 17's psychotropic medication regimen was evaluated by a psychiatrist to assess the effectiveness of the psychotropic medications and the need to increase or decrease the dosage to ensure Resident 17 reached the highest practicable quality of life. Resident 17's medication regimen included: a. a. Cymbalta, 30 mg which Resident 17 started taking once a day, on 11/1/2024. b. Ativan 0.5 mg, which Resident 17 started taking twice a day on 9/14/2022. c. Seroquel 50 mg, which Resident 17 started taking every 12 hours on 6/2/2023 for bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and d. Depakote 250 mg, which Resident 17 started taking twice a day on 11/2/2024, 250 mg. 4. Ensure Resident 19's medication regimen therapy was evaluated by a psychiatrist to assess the effectiveness of the psychotropic medications and the need to increase or decrease the dosage to ensure Resident 19 reached the highest practicable quality of life. Resident 19 was admitted on [DATE] and has not been evaluated by a psychiatrist for being on psychotropics since admission. Resident 19's medication regimen included: a. Ativan 0.5 mg, which Resident 19 started taking every 12 hours on 5/14/2024. b. Mirtazapine 7.5 mg, which Resident 19 started taking every night starting on 10/17/2023. c. Seroquel 25 mg, which Resident 19 started taking every day on 12/14/2023, for dementia with agitation. 5. Ensure Resident 51's medication regimen therapy was assessed by a psychiatrist for effectiveness and the need to increase or decrease dosage so Resident 51 reached the highest practicable quality of life. Resident 51 was admitted on psychotropics since 12/19/2023 and has not been evaluated by a psychiatrist. A psychiatrist consult had been ordered on 7/23/2024 but as of 11/14/2024 Resident 51 have not been evaluated by a psychiatrist. Resident 51's was taking the following medication regimen included: a. Haloperidol 5 mg, which Resident 51 started taking every 12 hours on 10/2/2024, every 12 hours for psychosis. b. Seroquel 50 mg, which Resident 51 started taking twice a day, on 7/17/2024. c. Donepezil 5 mg which Resident 51started taking daily on 12/19/2023. 6. Ensure a psychiatrist was part of the Interdisciplinary team ([IDT] a resident's healthcare team consisting of various specialties who work together to provide care for a patient) meetings to evaluate the residents' behavior and use of psychotropic medication, and plan the care accordingly for Residents 2, 17, 19, and 51 regarding the need and appropriateness of a gradual dose reduction ([GDR] - the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) of psychotropic medications. 7. Ensure staff followed the facility's policy and procedure (P/P) titled, Dementia Care Manual indicating residents who have reoccurring behavioral disturbances should be routinely seen and reevaluated by a psychiatrist. 8. Ensure staff followed the facility's P/P titled, Antipsychotic Medication Use indicating antipsychotic medication will be prescribed at the lowest possible dosage for a short period of time and are subject to GDR and re-review. Residents will only receive antipsychotics medications when necessary to treat specific conditions for which they are indicated and effective. 9. Ensure staff followed the facility's P/P titled, Behavioral Assessment, Intervention and Monitoring dated 12/2016, that indicated the facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. 10. Ensure staff implemented the Facility Assessment (a review of the facility's needed resources and capabilities to provide care for its residents), reviewed 10/16/2024, which indicated the facility resources needed to provide competent support and care for the resident population every day and during emergencies- under Therapy services - Psychology Services and Behavioral Health Services as indicated. These deficient practices placed Residents 2, 17, 19, and 51 at high risk for receiving unnecessary psychotropic medication, experiencing the potential side effects associated with the use of these medications, and not to have behavioral symptoms under control. The potential side effect of psychotropic medications included but are not limited to the following: a. Ativan: drowsiness and confusion. b. Haloperidol: difficulty speaking/swallowing, loss of balance, muscle spasms, and extrapyramidal symptoms (EPS - motor problems that include Parkinsonian-like symptoms (stiffness, tremor, shuffling gait), acute dystonia (abrupt spasms of head and neck), and akathisia (physical restlessness). c. Seroquel: increased mortality (death) in elderly patients with dementia, chills, confusion, and dizziness. d. Depakote: confusion, crying, delusions (altered reality that is persistently held despite evidence or agreement to the contrary) of persecution, mistrust, and combativeness. e. Cymbalta: body aches, cough, constipation (bowel dysfunction that makes it difficult or infrequent to have a bowel movement), and dry mouth. f. Donepezil: diarrhea, loss of appetite, and trouble sleeping. g. Mirtazapine: dizziness and drowsiness On 11/14/2024 at 1:16 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) situation due to the facility's failure to obtain psychiatric services for Residents 2, 17, 19, and 51 was called in the presence of Administrator (ADM) and the Director of Nursing (DON). On 11/16/2024 at 6:48 p.m., the IJ was removed in the presence of the DON after the facility submitted an acceptable IJ Removal Plan ([IJRP] - interventions to correct the immediacy of the deficient practices) and the IJRP implementation was verified through observation, interview, and record review. The IJRP included the following immediate actions: 1. Residents 2, 17, 19 and 51 will be evaluated on 11/18/2024, by a psychiatrist and to be completed by end of the day on 11/21/2024. Following these evaluations, ongoing monthly psychiatric services will take place for these residents. In addition, evaluations and routine psychiatric services will be completed for residents with psychiatric diagnosis upon admission, thereafter, and as needed by a Psychiatrist. The facility will have a monthly Behavioral Intervention Treatment meeting where we will discuss and review any residents on a psychotropic medication and any recommendations will be discussed at this meeting. Those who will attend the meeting will include the Licensed Psychiatrist and the Licensed Pharmacist. Any Resident with a behavioral change in condition (increased behaviors or new behavior) will be placed on a 72-hour change of condition monitoring using the facilities matrix (a grid-like tool used to organize and analyze data about a healthcare facility) event titled Behavior Log. 2. On 11/14/2024 all licensed nurses, which included the Interdisciplinary team (IDT) members, the DON, the Assistant Director of Nursing (ADON), the Associate Director of Social Services (ADSS) and the Minimum Data Set (MDS) coordinator, working on the 7-3 & 3-11 shifts were in-serviced immediately on psychiatric diagnosis and the need for a psychologist or psychiatrist consult for residents on psychotropic medication. The Director of Staff Development (DSD) will do another in-service tomorrow morning on 11/15/2024 for those that were not here today. The DSD has a list of those on leave, vacation or who were not able to attend and when they are back on schedule will set a date for an Inservice as well. 3. The facility will ensure they will be able to meet the needs of residents who are admitted with psychiatric or behavioral needs based off the recently updated Facility Assessment (a review of the facility's needed resources and capabilities to provide care for its residents) revised on 11/14/2024. 4. The facility added Psychiatric Services to the Facility Assessment as we have obtained a psychiatric services company to evaluate those with psychiatric diagnoses and to assess the effectiveness and the need to increase or decrease medication dosage to ensure resident's safety and symptoms are under control. If the facility is unable to meet the needs of any resident, the ADSS will initiate the discharge planning process. Currently there are no residents whose needs we cannot meet. 5. The facility will ensure that a Psychiatrist/Psychiatric Nurse Practitioner participates in the monthly Behavioral Intervention Treatment meeting for those residents receiving psychotropic medications. The Psychiatrist/Psychiatric Nurse Practitioner will make routine rounding visits to assess the effectiveness and the need to increase or decrease medication dosage to ensure resident's safety and symptoms are under control. On these rounding monthly Behavioral Intervention Treatment meetings the team (Administrator, DON, ADON, ADSS, MDS Coordinator, DSD, Licensed contracted Pharmacist, and the Board-Certified Psychiatric Nurse Practitioner) will meet to discuss any recommendations and carry out any recommendations from those visits. 6. The facility's DON will monitor the current number of residents on psychotropic medications to ensure that every resident with psychotropic medications is receiving psychiatric services monthly. The Associate Director of Social Services/SSD will report the number of residents and visits to the facilities Quality Assurance Performance Improvement quarterly monitoring meetings with a threshold of 100% through November 2025. Findings: 1. During a review of Resident 17's Admission Record, the Admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance, bipolar disorder generalized anxiety disorder (mental health condition that causes people to experience excessive and uncontrollable worry about everyday events or activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), abnormalities of gait and mobility. During a review of Resident 17's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/3/2024, the MDS indicated Resident 17's cognition (the mental process of thinking, understanding, and processing information) was severely impaired. The MDS indicated the resident was independent when eating, needed set up assist with oral hygiene, needed moderate assist (helper does less than half the effort) with personal hygiene, needed maximal assistance (helper does more than half the effort) with showering, and was dependent on staff with toileting hygiene. The MDS indicated the resident was on antipsychotic medications since admission. The MDS also indicated a GDR had not been attempted and the physician had not documented a GDR was clinically contraindicated (a reason for a person to not receive a particular treatment or procedure because it may be harmful). During a review of Resident 17's Physician's Order Report dated 11/1/2024 - 11/10/2024, the Physician's Order Report indicated the following orders: a. Starting 6/27/2019, monitor for episodes of agitation that interfere with care, every shift, for use of Ativan. b. Starting 6/27/2019, monitor for restlessness that interfere with care, every shift, for use of Ativan. c. Starting 6/27/2019, monitor for side effects of anti-anxiety medication use Ativan. - Observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision (a loss of sharpness in your vision that makes it difficult to see fine details), skin rash. d. Starting 6/27/2019, monitor for side effects of antipsychotic medication use Seroquel - Edema (swelling caused by fluid building up in the body's tissues), postural hypotension (medical condition that causes a drop in blood pressure when you stand up or sit down), sweating, loss of appetite, urinary retention (a condition that makes it difficult to empty the bladder, either partially or completely). Special attention for tardive dyskinesia (a movement disorder caused by the long term use of antipsychotics that causes involuntary, jerky movements in the face and body), seizure disorder (chronic brain problem causing sudden burst of electric activity in the brain), chronic constipation (a common condition that involves infrequent or difficult bowel movements ), glaucoma (group of eye diseases that can damage the optic nerve, leading to vision loss and blindness), diabetes (group of diseases that result in too much sugar in the blood), skin pigmentation (refers to color of skin changing), jaundice (condition that causes the skin eyes, and mucous membranes to turn yellow or greenish)every shift. e. Starting 9/14/2022, Ativan. 0.5 mg twice a day, for anxiety manifested by restlessness or agitation that interferes with care, monitor for signs and symptoms of respiratory depression/sedation. f. Starting 10/7/2022, monitor behavior of being suspicious of everything that interferes with care, for Seroquel every shift. g. Starting 10/7/2022, monitor for behavior of easily getting irritated or getting angry that interferes with care, for Seroquel, every shift, h. Starting, 6/2/2023, Seroquel 50 mg oral, every 12 hours, for bipolar disorder, depressive type manifested by easily getting irritated or angry and suspicious at anything you say that interferes with care. i. Starting 7/23/2024, monitor for side effects of Anti-depressant Medication use (Cymbalta)- Observe resident closely for significant side effects: sedation (sleepiness caused by certain drugs), drowsiness, dry mouth, blurred vision, urinary retention, tachycardia (abnormally fast heartbeat), muscle tremor (an involuntary, rhythmic shaking of a body part) agitation, headache, skin rash, photosensitivity (skin becomes more sensitive to light and is more likely to burn), excessive weight gain. j. Starting 11/1/2024, Cymbalta capsule delayed release 30 mg, oral once a day. k. Starting 11/1/2024, Depakote delayed release tablet 250 mg, oral, twice a day, for bipolar disorder, depressive type manifested by easily getting irritated or getting angry and suspicious of anything you say, that interferes with care. l. Starting 11/1/2024, Monitor for side effects of Depakote observe resident closely for significant side effects: drowsiness, ataxia, nystagmus (condition that causes abnormal involuntary rhythmic eye movements), dizziness, blurred vision, nausea, rash, gum enlargement(a condition where the gums increase in size ), jaundice: Special attention in use with other Central Nervous System depressant drugs (drug that slows down the brain activity causing relaxation and calm) or if resident develops a fever (unhealthy increase in body temperature) blood dyscrasias (disorder of the blood). During an observation of Resident 17, on 11/8/2024 at 7:18 p.m., in Resident 17's room, Resident 17 was observed falling asleep while brushing her teeth. During an observation of Resident 17 on 11/9/2024 at 9:25 a.m., in the hallway in front of Resident 17's room, Resident 17 was observed sleeping in her wheelchair. During an interview and record review on 11/12/2024 at 9:15 a.m., with the ADON, Resident 17's Physician's Progress note, dated 11/1/2024 at 3:40 p.m., was reviewed. The Physician's Progress note indicated Resident 17's psychotropic medications were adjusted over the last several months due to Resident 17's complaint of feeling low in energy and drooling (saliva unintentionally flowing out of the mouth unintentionally). The Physician's Progress note indicated the psychotropic medications made it difficult for Resident 17 trust and think. The ADON stated primary physician 2 (MD 2), who is not a psychiatrist, managed Resident 17 psychotropic medications. The ADON stated Resident 17 was diagnosed with bipolar disorder and major depression, but the last psychiatric consultation Resident 17 had was on 11/29/2021. During an observation and interview on 11/12/2024 at 2:54 p.m., with Certified Nurse Assistant (CNA 3), by the door of Resident 17's room, Resident 17 was sleeping in her wheelchair. CNA 3 looked at Resident 17 and stated Resident 17 usually dozed off and falls asleep in her wheelchair, so the staff put her back in bed. During a phone interview on 11/13/2024 at 7:49 a.m., with the Licensed Pharmacist (LP), the LP stated that drooling or excessive salivation can be a side effect of psychotropic use. The LP stated psychotropic use was worse for elderly and even worse for dementia residents. The LP stated inappropriate psychotropic use can cause falls and can cause residents to be drowsy or sedated (falling asleep as a side effect of a drug). During an interview and record review on 11/13/2024 at 9 a.m., with the ADON, Resident 17's Behavior Quarterly Management Follow up, dated 7/3/2024, was reviewed. The ADON confirmed and stated Resident 17 was on Lorazepam 0.5 mg twice a day for anxiety manifested by episodes of restlessness or agitation that interferes with care. The Behavior Quarterly Management Follow up indicated for the month of January 2024, Resident 17 had zero episodes of restlessness and one episode of agitation. For the month of February 2024, Resident 17 had 4 episodes of restlessness and 3 episodes of agitation. For the months of March and April 2024 Resident 17 had no episodes of agitation and restlessness. The ADON stated Resident 17 was on Seroquel 50 mg every 12 hours for bipolar disorder, depressive type manifested by easily gets irritated or gets angry and suspicious of anything you say, that interferes with care. The ADON stated during the months of January, February and March 2024 Resident 17 had behaviors of easily getting irritated and paranoia, and in the month of April 2024 the resident had zero behaviors manifested. The ADON stated, Seroquel was increased last year to every 12 hours on 6/2/2023, the IDT team decided to continue the current psychotropic regimen because the benefits outweighed the risks for reduction. The ADON stated the physician was not contacted because the IDT team had decided there were no pharmacological (medication) adjustment required. The form indicated there was no physician signature indicating the physician or a psychiatrist was consulted with IDT decision to not complete the GDR and Resident 17 continue to receive the same medication at the same dose. 2. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including major depressive disorder, spondylolysis lumbar region (age-related change of the back bones), and history of falling. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident was understandable and was able to understand others. The MDS indicated the resident was on setup or clean up assistance for eating and oral hygiene and dependent (helper does all the effort) on the staff for bathing, toileting hygiene, and transfer to and from the bed to a chair. During a record review of Resident 2's Physician's Order for Paroxetine (medication to treat depression), the order indicated Paroxetine was ordered for management of depression manifested by crying and verbalization of loneliness since admission 2/28/2023 and discontinued on 4/16/2024. During a review of Resident 2's Physician's Order Report dated 10/12/2024 - 11/12/2024, the Physician's Order Report indicated the following orders: a. Starting 4/23/2024, monitor episodes of crying every shift for Cymbalta. b. Starting 4/23/2024, monitor verbalizing loneliness every shift for Cymbalta. c. Staring 4/23/2024, Cymbalta delayed capsule release 30 mg oral for chronic musculoskeletal (having to do with muscles, bones, tendons, ligaments, joints, and cartilage) pain and depression manifested by crying and verbalizing loneliness. During an interview and record review on 11/12/2024 at 9:30 a.m., with the ADON, Resident 2's Copy of Behavior Quarterly Management Follow up, dated 7/3/2024 and timed at 5:56 p.m., was reviewed. The Copy of Behavior Quarterly Management Follow up indicated Paroxetine was discontinued and Cymbalta was added for both pain and management of depression manifested by crying and verbalization of loneliness. The ADON stated the Paroxetine had been ordered for Resident 2 upon admission to the facility on [DATE] for major depressive disorder. The ADON stated Resident 2 has never been seen by a psychiatrist for management of Resident 2's psychiatric diagnosis of depression. The ADON stated Resident 2 has never had a psychiatric consult while in the facility for depression and while being on psychotropic medication. During an interview on 11/12/2024 at 2:35 p.m., with the ADSS, the ADSS stated the need for a medication dose adjustment was decided by the IDT team consist of the DON, the ADON, MDS coordinator, the Registered Dietician (RD), and the ADSS. After IDT makes determination, the physician then contacted to write the order. During an interview and record review on 11/13/2024 at 10:20 a.m., Resident 2's Behavior Quarterly Management Follow up, dated 9/20/2024 was reviewed and the ADON confirmed and stated the resident was doing well (not having behaviors) so the IDT team decided no pharmacologic changes in dose were needed for this quarter. The ADON stated the IDT team only called and notified the physician if the IDT team recommended a medication dose adjustment or need for more pharmacological measures. 3. During a review of Resident 19's Admission record, the Admission Record indicated Resident 19 was admitted on [DATE] with diagnoses including dementia with agitation. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognition was severely impaired. The MDS indicated Resident 19 was dependent on facility staff to complete activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated the resident was routinely on antipsychotic medications since admission. Resident 19 was on During a review of Resident 19's Physician's Order Report dated 10/11/2024 - 11/11/2024, the Physician's Order report indicated. a. Starting 10/17/2023, monitor combativeness every shift for Seroquel. b. Starting 10/17/2023, monitor for continuous screaming that interferes with care every shift for Seroquel. c. Starting 10/17/2023, monitor for side effects of antipsychotic medication use (Seroquel) - Observe closely for significant side effects: Common - sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, and urinary retention. Special attention for tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, jaundice every shift. d. Starting 10/17/2023, Mirtazapine 7.5 mg at bedtime for depression. e. Starting 12/14/2023, Seroquel 25 mg, oral, once a day, for dementia moderate agitation manifested by combativeness and continuous screaming that interferes with care. Increased mortality in elderly patients. f. Starting 5/14/2024, Ativan 0.5 mg oral, for anxiety manifested by inability to express what she wants and ending up yelling out and crying, every 12 hours. g. Starting 5/15/2024, monitor for unable to express what she wants and end up yelling out and cry, every shift, for Ativan. h. Starting 5/14/2024, monitor for side effects every shift of anti-anxiety medication use Ativan - Observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash: special attention if given with other sedatives hypnotics (a prescription medication that slows brain activity to calm a person down, relieve anxiety, or help them sleep), or alcohol. During an interview and record review on 11/12/2024 at 1:39 p.m., with the ADON, Resident 19's View Safety Alert Acknowledgement for Seroquel was reviewed. The View Safety Alert Acknowledgement Alert indicated a Black Box warning (the most serious warning that the U.S. Food and Drug Administration - [FDA] - can issue for a medication used to inform health care providers and consumers about serious adverse reactions or risks associated with a drug) indicating Seroquel should be used with extreme caution with patients with senile dementia (diseases related old age) The ADON stated Resident 19 was admitted to the facility with a diagnosis of dementia with agitation and Resident 19 had been on Seroquel. The ADON stated she overrode the Acknowledgement, and she did not select a reason for the override of the Alert. The order for Seroquel, dated 12/14/2023, was also reviewed and the warning of the View Safety Alert indicated an increased mortality in elderly residents. The ADON stated the Black Box warnings and Safety Alerts on medications were supposed to be reviewed because the Alerts indicated that there was increased risk for harm for the residents taking the medication mentioned in the Alert. During an interview and record review on 11/12/2024 at 1:39 p.m., with the ADON, Resident 19's Behavior Quarterly Management Follow Up, dated 10/31/2024 and timed at 7:51 a.m., was reviewed. The Behavior Quarterly Management Follow Up indicated Seroquel was increased on 12/14/2023, Ativan was changed from PRN (given as needed or requested) to being administerd every 12 hours on 5/14/2024, and Mirtazapine was continued. The ADON stated Resident 19 was on three psychotropics concurrently and Resident 19 had never had an assessment by a psychiatrist to evaluate the need for psychotropic medication since she has been in the facility. 4. During a review of Resident 51's Admission Record, the Admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic (set of symptoms that indicate a loss of touch of reality) disturbance, and anxiety disorder. During a review of Resident 51's MDS, dated [DATE], the MDS indicated the resident's cognition was severely impaired. The MDS indicated Resident 51 was dependent on staff with bathing, toileting hygiene, dressing, personal hygiene, oral hygiene, and transfer to and from the bed to a chair. The MDS indicated Resident 51 was routinely on antipsychotic medications since admission. The MDS also indicated a GDR had not been attempted. During a review of Resident 51's Physician's order Report (active orders) dated 10/12/2024 - 11/12/2024, the Physician's order Report indicated the following orders: a. Starting on 12/19/2023, Donepezil (medication to treat dementia), oral, 5 mg, once a day. b. Starting on 7/11/2024, monitor for behavior of continuous yelling out that interferes with care every shift. c. Starting on 7/11/2024, monitor behavior of resisting care every shift. d. Starting on 7/17/2024, Seroquel 50 mg, oral, twice a day for dementia with agitation. e. Starting on 7/20/2024, Ativan 0.5 milligrams oral, every 12 hours as needed for anxiety manifested by constantly yelling that interfere with self and other residents. The order was discontinued on 9/23/2024. During review of physician's order dated 7/23/2024, the order indicated a psychiatric consult for Resident 51. During a review of Resident 51's Progress Notes, the Progress Notes indicated the following: a. On 7/23/2024 at 12:46 p.m., order received for psychiatric consultation due to continuous yelling out. b. On 7/29/2024 at 11:12 a.m., Resident 51 continued the constant disruptive yelling for 18-20 hours a day, causing multiple other residents (unidentified) to have agitative disruptive behaviors as well. Resident 51 was yelling so much Resident 51 would not eat, or drink fluids and this distressing behavior was attributing to her continued weight loss. Resident 51 was inconsolable and not redirectable. c. On 7/29/2024 the Progress Notes indicated a new order from MD 1 for Haloperidol 2.5 mg oral every 12 hours. During a review of Resident 51's physician's order dated 7/29/2024 at 11:09 a.m., the order indicated Haloperidol 2.5 mg oral every 12 hours for dementia with psychosis and agitation manifested by resisting care and continuous yelling out interferes with care and safety. During a review of Resident 51's Physician's order Report dated 10/12/2024 - 11/12/2024, the report indicated, starting 7/29/2024, monitor the resident for side effects every shift for anti-psychotic use (Seroquel and Haloperidol) - Observe closely for significant side effects: Common - sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Special attention for tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, jaundice. During a review of Resident 51's physician's order dated on 9/23/2024 and timed at 9:39 p.m., the order indicated Ativan 0.5 mg, every 12 hours as needed for anxiety manifested by constantly yelling [TRUNCATED]

Based on interview and record review, the facility failed to implement its policy and procedures (P&P) titled, Scabies Identification, Treatment and Environmental Cleaning, and Infection Control Program, for five of 23 residents (Residents 5, 18, 19, 21, and 31) who had a suspicious skin rashes ( the skin that has changes in texture or color and may be inflamed or irritated) by failing to: 1.Ensure Residents 5, 18, 19, 21 and 21, who had red scattered inflamed red spots with bumps and itching, were placed on isolation (separation of residents with an infection from residents without an infection). 2.Initiate and conduct infection surveillance (close observation or monitoring) by completing a line listing (a table that contains key information about each case in an outbreak) of residents with a suspicious rash in the Dementia (a progressive state of decline in mental abilities) Unit (a secure environment that provides specialized care for people with dementia). 3.Ensure precautionary measures were implemented to ensure suspicious rashes were contained for Residents, 5, 18, 19, 21, 31 and other residents in the secured unit 4.Coordinate with the local Department of Public Health to obtain guidance on how to handle the suspicious rashes. These deficient practices had the potential to spread a suspicious rash infection to all residents, staff, vendors, and visitors of the facility. On 11/10/2024 at 8:11 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider'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 called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to establish and maintain an for five residents (Resident 19, 31, 5, 18, and 21) with suspicious skin rashes. The facility had 23 total residents in the dementia unit. On 11/11/2024 the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 11/11/2024 at 5:56 p.m., in the presence of the facility's DON and ADM. The facility's IJRP included the following immediate actions: 1. The facility conducted body skin assessments on the five residents listed on the IJ document. Resident 19, Resident 5, Resident 18, and resident 31 had rashes. Resident 21 did not have rashes but had scratches on her skin. All five residents were placed on contact isolation (precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the person or the person's environment) with no stop date as of now. Additionally, the facility conducted body skin assessments on the remaining 18 residents in the Covenant Care Unit- the dementia unit referenced in the IJ document the facility was provided (CCU), no rashes were found on the remaining 18 residents. A line list was created for all 23 CCU residents. The facility also created a CCU Line List for Skin Rashes for staff that work in CCU. The facility staff were contacted, or messages were left for those staff assigned in CCU, to inquire if they had any rashes. 25 staff were called and 16 said they have no rashes. The facility staff will follow up with the other staff in the morning on 11/11/2024. On 11/11/2024 facility staff followed up with the remaining staff and they reported no rashes. All 25 CCU staff denied having rashes. 2a. On 11/10/2024 at 8:51p.m., the facility notified the Medical Director (MD 1) of all the interventions that are being implemented. MD 1 agreed to the dermatologist consult order for Resident 21, who did not have rashes but had scratches on her skin. 2b. The facility notified the Primary Care Physician (PCP) 1 on 11/10/2024 at 9:10 p.m., of this said IJ. PCP 1 is the Physician for 3 of the residents (Residents 5, 18 and 31). PCP 1 did order dermatology consults for the 3 residents. PCP 1 also gave a new order for Hydroxyzine (medication that treats the symptoms of allergies and allergic reactions) as needed for Resident 18. 2c. PCP 2 was notified on 11/10/2024 at 9:20 p.m., of this said IJ. PCP 2 is the physician for resident 19. PCO 2 ordered a dermatology consult for Resident 19. 2d. On 11/11/2024, The Director of Social Services Department (DSSD) was able to schedule the dermatology appointments for the 5 residents (Residents 19, 5, 18, 21, 2 3) whose families agreed to dermatology consults. Two residents will go to the dermatology appointment on Tuesday 11/12/2024 (Residents 19 and 31). The other three residents will go to their dermatology appointments on Thursday 11/14/2024 (Residents 5, 18, and 21). 3. The facility also notified the CDPH (non-licensing division) on 11/10/2024 at 10 p.m. The DON spoke to county operator #10. Then operator #10 transferred DON to the on-call MD. The DON spoke to the on-call MD from 10:01 p.m. to 10:15 p.m. The DON reported the IJ and the current skin issues for said residents. The DON also reported all interventions the facility has done and implemented. The on-call MD said the case will be referred to the local regional Public Health Nursing (PHN) team and the PHN team will connect with the facility. 4. On 11/10/2024 all Licensed Nurses and Certified Nursing Assistants (CNAs) working on the 3 p.m.-11 p.m. shift were in serviced immediately on skin issues, infection control, use of PPE (personal protective equipment refers to protective clothing, gloves and facemasks or other equipment designed to protect the wearers from injury or the spread of infection or illness) and isolation precautions (precautions used to reduce transmission of microorganisms in healthcare). Upon arrival today, 11/10/2024, the 11 a.m.- 7 p.m., shift licensed nurses and CNAs were also in-serviced on the same topics. The Director of Staff Development (DSD) would complete another in-service on 11/11/2024 for those staff that were not in the facility today. On Monday 11/11/2024 the DSD did an in-service again for those staff who were not at the facility yesterday (11/10/2024). The DSD has a list of those on leave, vacation or who were not able to attend and when they are back on schedule will set a date for an in-service as well. The facility also implemented the precautionary measures listed in paragraph 1, 2 and 3. 5. The facilities Infection Preventionist (IP) or designee would monitor and track any residents with suspicious rashes and maintain an infection control program by ensuring they are added to line listings for surveillance purposes, placed on isolation, ensure precautionary measures were done and implemented and reach out to DPH when facility staff suspect an outbreak has occurred for additional guidance on how to handle the situation. A root cause analysis would be done for those residents with suspicious rashes. The facilities IP or designee would report the findings to the facilities quarterly QAPI (Quality Assurance and Performance Improvement- a data driven proactive approach to improvement used to ensure services are meeting quality standards) monitoring meeting with a threshold of 100% compliance through November 2025 for all current and future residents have the potential to be affected by this deficient practice. Findings: 1a. During a review of Resident 5's Admission Record (AR), the AR indicated Resident 5 was admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 10/3/2024, the MDS indicated Resident 5's cognition (ability to process and understand information) was severely impaired. The MDS indicated Resident 5 was dependent (helper does all the effort) on facility staff to complete activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 5's Progress Notes dated 10/25/2024, the Progress Notes indicated Resident 5's physician was notified regarding Resident 5's generalized rashes which appeared like red lesions (an area of abnormal or damaged tissue caused by injury, infection, or disease) with bumps, dry and rough in texture, and occasionally itching by Resident 5. The Progress Note indicated Resident 5's physician ordered permethrin cream (medication used to treat scabies, a condition caused by tiny insects called mites that infest and irritate the skin) 5% to treat the rashes. During a review of Resident 5's Physician Order (PO), dated 10/25/2024, the PO indicated permethrin 5% to be applied to Resident 5's body from the neck to sole of the feet overnight for 8 hours and wash off in the morning for generalized rashes once a day on Friday for 2 weeks. During a review of Resident 5's Treatment Administration Record (TAR) for 10/2024 and 11/2024, the TAR indicated permethrin cream 5% was administered/applied to Resident 5 on 10/25/2024 and 11/1/2024. 1b. During a review of Resident 18's AR, the AR indicated Resident 18 was admitted on [DATE] with hospice care (a comprehensive, holistic program of care and support for terminally ill patients and their families) and diagnoses including dementia. During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18's cognition was severely impaired. The MDS indicated Resident 18 was dependent on facility staff to complete ADLs. During a review of Resident 18's POs, dated from 10/24/2024 to 11/7/2024, the POs indicated: On 10/24/2024, an order for scattered rashes on upper back: cleanse with soap and water, pat dry and apply hydrocortisone cream (cream to reduce swelling, itchiness, and redness in skin conditions) 1 percent (%), twice a day for 14 days. On 11/7/2024, an order for scattered rashes on the chest: cleanse with soap and water, pat dry and apply hydrocortisone cream 1%, twice a day for 14 days. On 11/7/2024, an order for scattered rashes on upper back: cleanse with soap and water, pat dry and apply hydrocortisone cream 1%, twice a day for 14 days. During a review of Resident 18's Progress Notes (PN), dated 10/24/2024, the PN indicated Resident 18 was experiencing scattered rashes on the chest and upper back which appeared to be red spots with bumps and appeared inflamed (red, sore, and often swollen). The PN indicated PCP 1 ordered hydrocortisone cream 1%, twice a day for a duration of 14 days. During a review of Resident 18's PN, dated 11/7/2024, the PN indicated a new order was received from the Hospice Nurse (HN) to continue to cleanse the rashes on the upper back and chest with soap and water, pat dry and apply hydrocortisone cream 1% for a duration of 14 days. During a review of Resident 18's untitled Care Plan (CP), dated 10/24/2024 related to Resident 18's rashes on the chest and upper back, the CP indicated a goal for the rashes to heal without complication. The CP interventions indicated treating the rashes per physician's order. During a review of Resident 18's Medication Administration Records (MARs) dated 10/2024 and 11/2024, the MARs indicated that 10/24/2024 -11/10/2024, Resident 18 received hydrocortisone cream 1% to the scattered rashes on the chest and upper back. 1c. During a review of Resident 19's AR, the AR indicated the facility admitted Resident 19 on 10/16/2023 with diagnoses including dementia. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognition was severely impaired. The MDS indicated Resident 19 was dependent on facility staff to complete ADLs. During a review of Resident 19's POs, dated 10/12/2024, the POs indicated: An order for a dermatology consult for generalized rashes. An order for Permethrin cream 5 % apply to whole body with special instructions to apply from the neck down to sole of the feet overnight for 8 hours and wash off in morning for generalized rashes, once a week on Tuesday for 2 weeks. During a review of Resident 19's PN, dated 10/22/2024 at 4:19 p.m., the PN indicated an order from PCP 1 to obtain a dermatologist consult when available for generalized rashes. During a review of Resident 19's PN, dated 10/22/2024 at 4:55 p.m., the PN indicated PCP 1 was contacted to inform PCP 1 of Resident 19's rashes starting in the mid chest, spreading to the left upper arm, posterior back, right upper chest, left hip, and right posterior thigh. The PN indicated the rashes appeared as small, scattered scabs (the crusty patch of skin that forms when a scrape or cut is healing) with reddened surrounding areas. The PN indicated Resident 19 was reporting occasional itching, and PCP 1 ordered Permethrin cream 5%. During a review of Resident 19's untitled CP, dated 10/4/2024, the CP indicated Resident 19 experienced rashes on the mid chest and left upper arm. The CP indicated a goal for Resident 19's rashes to heal without complication with the interventions of discouraging resident from scratching and treating the rashes per physician's order. During a review of Resident 19's MAR for 10/2024, the MAR indicated Resident 19 received a dose of Permethrin cream 5%, applied to the whole body on 10/22/2024. 1e. During a review of Resident 21's AR, the AR indicated Resident 21 was admitted on [DATE] with diagnoses including dementia. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21's cognition was moderately impaired. The MDS indicated Resident 21 was dependent on facility staff to complete ADLs. During a review of Resident 21's PO, dated 11/6/2024, the PO indicated for the scattered rashes on the chest: cleanse with soap and water, pat dry and apply a thin layer of hydrocortisone cream 1% and leave open to air twice a day for a duration of 14 days. During a review of Resident 21's Skin Integrity Events- Rash/Lesions document, dated 11/6/2024, the Skin Integrity Events- Rash/Lesions document indicated Resident 21 had scattered redness on the chest. During a review of Resident 21's TAR for 11/2024, the TAR indicated from 11/6/2024 through 11/9/2024, Resident 21 had scattered rashes to the chest which were cleansed with soap and water, patted dry and a thin layer of hydrocortisone cream 1% was applied. 1f. During a review of Resident 31's AR, the AR indicated Resident 31 was admitted on [DATE] with diagnoses including dementia. During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31's cognition was severely impaired. The MDS indicated Resident 31 was dependent on facility staff to complete ADLs. During a review of Resident 31's PO, dated 10/1/2024, the PO indicated an order for the scattered rashes on abdomen: cleanse with soap and water, pat dry, and apply Hydrocortisone cream 1 %, twice a day for a duration of 14 days. During a review of Resident 31's PN, dated 11/8/2024, the PN indicated Resident 31 was experiencing rashes that spread throughout the chest and hip. The PN indicated the rashes appeared pink and raised, and mild itchiness was observed. The PN indicated PCP 1 was notified and PCP 1 ordered to continue the current treatment of hydrocortisone cream. During a review of Resident 31's PN, dated 11/8/2024, the PO indicated an order for generalized rashes: cleanse with soap and water, pat dry, and apply Hydrocortisone cream 1% twice a day for a duration of 14 days. During a review of Resident 31's untitled CP, dated 11/1/2024, the CP indicated Resident 31 experienced scattered rashes on Resident 31's abdomen. The CP indicated a goal for the scattered rashes healing without complication. The CP interventions included a dermatology consult. During a review of Resident 31's TAR for 11/2024, the TAR indicated Resident 31 received hydrocortisone cream 1% twice a day for scattered rashes on the abdomen from 11/1/2024 -11/10/2024. During a review of the facility's Housekeeping Checklist for 11/2024, the SNF Housekeeping Checklist indicated privacy curtains were changed every quarter (January, April, July, and October) beds, closets, lamps, and furniture are cleaned every month. During an interview on 11/9/2024 at 1:05 p.m., with the Housekeeper (HK), the HK stated she has not performed any deep cleaning (a thorough cleaning that eliminates visible dirt, bacteria, and germs; is a lot more extensive than standard weekly cleaning) of any room recently in the dementia care unit. During an interview on 11/10/2024 at 6:32 a.m., with Treatment nurse (TN 1), TN 1 stated that Resident 18 was scratching and has rashes. TN 1 stated Resident 18's rash has not improved while being treated by hydrocortisone cream for 14 days starting on 10/25/2024 so the PCP 1re-ordered the hydrocortisone for another 14 days starting on 11/7/2024. During an interview on 11/10/2024 at 6:41 a.m., with Certified Nursing Assistant 1 (CNA1) regarding the rashes on Residents 18, 19 and 21, CNA 1 stated Resident 18 has a rash around Resident 18's neck, Resident 19 scratches around Resident 19's upper chest and has rashes, and Resident 21 scratches on Resident 21's upper chest and has rashes. During an interview on 11/10/2024 at 6:59 a.m., with Licensed Vocational Nurse 1 (LVN 1) regarding Resident 5, 18, 19 and 21's rashes, LVN 1 stated she has seen Resident 18 scratching Resident 18's neck; Resident 5 has a generalized rashes on Resident 19's body, Resident 19 has redness and rashes on her chest and is scratching around her upper chest; and Resident 21 has redness and scratches on Resident 21'schest area. During an interview on 11/10/2024 at 9:15 a.m., and 3:32 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Residents 5 and 9 were ordered permethrin cream to treat rashes prophylactically (to prevent or protect against disease or infection). The DON stated there was no skin scraping (a common procedure used to obtain the superficial dead layers of the skin used to diagnose skin infections) ordered. The DON stated the residents (Resident 5 and 9) were placed in isolation when the cream was applied (duration of 8 hours), and the residents' clothing was sent to the laundry. The ADON stated no precautionary measures, to prevent the spread of the rashes were done for the roommates of Resident 5 and 19. The ADON stated there were a total of five residents who are experiencing rashes. The ADON stated there was no line listing for skin surveillance after Residents 5 and 19 were treated with permethrin cream for other residents and staff. The ADON stated in the past, the facility had experienced residents with suspicious rashes, then they administered the permethrin cream, deep cleaned the rooms, provided precautionary measures such as contact isolation for the residents, and did skin surveillance for other residents and staff at risk. During an interview on 11/10/2024 at 6:33 p.m., with the DON, the DON stated she was aware Residents 5 and 9 were treated with permethrin for generalized rashes. The DON stated Residents 5 and 9 were treated with permethrin as an off label use (used for a disease or medical condition that the medication is not approved to treat) for generalized rashes. The DON stated Resident 5 had not been assessed by dermatology for the rashes. The DON stated Resident 9 was awaiting authorization for a dermatology consult. The DON stated she was aware other residents (Residents 31, 18 and 21) were experiencing rashes, but she was unsure if a line listing for skin surveillance for residents and staff was completed. The DON stated the suspicious rashes was not reported to the Department of Public Health. The DON stated the housekeeping staff have their daily, weekly, monthly, and quarterly cleaning routines and have not completed a deep clean in the secured unit to prevent the rashes from spreading. During an interview on 11/13/2024 at 7:49 a.m., with the Facility Pharmacy Consultant (PC), the PC stated permethrin can be prescribed for prophylaxis but there is no indication it can be used off-label to treat generalized rashes. During a review of the facility's P&P) titled, Scabies Identification, Treatment and Environmental Cleaning, dated 8/2016, the P&P indicated when scabies is treated with Permethrin cream, the resident should be placed on contact precautions during treatment period and 24 hours after application of permethrin cream. The P&P indicated the resident's bed linens, towels, and clothing used during the four days prior to initiation of treatment should be placed in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for 10-20 minutes. During a review of the facility undated P&P titled, Infection Control Program, the P&P indicated the facility residents would be provided screening for infectious diseases, physical exams and health histories, infection monitoring and treatment for infectious disease. The P&P indicated surveillance (close observation) of residents would include maintenance of an infectious disease log and reporting individual incidents of infection documented in the log.

Based on interview and record review the facility failed to: 1.Inform the physician (MD) of the abnormally low urine output (a measurement of how much urine a person produces) for one of one sampled resident (Resident 58), when Resident 58's urine output was 50 Cubic Centimeter (cc- a unit of measure of volume), (Reference Range of 280-560 cc for 8 hour) on 8/26/2024 during 7:00 a.m.- 3p.m. shift. 2. Initiate a change of condition (COC-tool used by health care professionals when a patient's condition suddenly changes) when Resident 58's urine output was observed to be 50 Cubic Centimeter on 8/26/2024 during 7:00 a.m.- 3p.m. shift. 2. Monitor Resident 58's urine output from 8/27/2024 to 9/13/2024 These deficient practices resulted in Resident 58 having signs and symptoms (S/S) of dehydration including sunken eyeballs, and dry lips was transferred to a General Acute Care Hospital (GACH) for evaluation and diagnosed with acute kidney injury likely due to prerenal azotemia (a high concentration of waste products in the blood due to dehydration). Resident 58 was admitted from 9/13/2024-9/24/2024 (a total of 11 days) for treatment. Findings: During a review of Resident 58's Admission Record, the Admission Record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease (a gradual loss of kidney function) and non-ST elevation (NSTEMI) myocardial infarction (heart attack). During a review of Resident 58's Minimum Data Set (MDS, a resident assessment tool) dated 8/26/2024, the MDS indicated the resident was able to express ideas and wants to others and usually understands others. The MDS indicated the resident was partially dependent on the staff with eating but totally dependent on staff for bathing, toileting hygiene and personal hygiene. Resident 58 needed substantial or maximal assistance with sit to lying, sit to stand, chair to bed transfer, toilet transfer and tub transfer. Resident 58 was taking diuretics during the last 7 days (of the MDS assessment look back time period) and had an indwelling catheter. During a record review of Resident 58's Physician Order report from 8/14/2024-9/30/2024, the Physician's Order Report indicated furosemide (a strong water pill that may cause dehydration and electrolyte imbalance) 20 milligram (mg- unit of measure of mass) twice daily for bilateral (both) lower extremity edema (excess fluid collecting in the tissues), black box warning (strict warning labels used when labeling medication) dehydration and electrolyte (minerals that have an electrical charge when dissolved in body fluids) depletion dated 8/14/2024. Indwelling catheter French16/10cc for diagnosis of urine retention dated 8/14/2024. During a concurrent interview and record review on 11/9/2024 at 2:56 p.m., with the Assistant Director of Nursing (ADON), Resident's 58's progress notes monthly weight, intake, and output (I &O) and COC for the month of 08/2024-09/2024 were reviewed. The ADON stated the progress notes on 8/15/2024 indicated Resident 58 was admitted with dependent (a type of swelling that occurs when fluids build up in areas of the body below the heart) edema on both legs. The ADON stated the I & O dated 8/26/2024 indicated Resident 58's urine output for the 7-3 p.m. shift was 50 cc. The ADON stated the progress notes dated 9 /13/2024 at 11:31 a.m., indicated Resident 58 returned from her primary care physician's (PCP) appointment accompanied by a family member (FM 1) who was also her emergency contact, at approximately 9:47a.m. The ADON stated according to the progress notes FM 1 informed staff that Resident 58's PCP stated Resident 58 needed to go to the emergency room (ER). The ADON stated the progress notes indicated FM and Resident 58 returned to the facility to collect the resident's belongings. During a concurrent interview and record review on 11/9/2024 at 3:35 p.m., with the ADON, Resident 58's care plan titled Dehydration/fluid maintenance related to diuretic therapy for bilateral leg edema and CHF dated 8/21/2024, the ADON stated the care plan interventions included to assess for dehydration and electrolyte imbalance signs and symptom such as dizziness on sitting/standing, change in mental status, decreased urine output, poor skin turgor (skin's inability to return to normal after pinching, which is a sign of dehydration) dry mucus membrane (moist lining of some organs and body cavities), sunken eyes, and constipation (bowel movements that are infrequent, uncomfortable or difficult to pass, which may be a sign of dehydration). The ADON stated assessing Resident 58 for dehydration was an intervention in the care plan but there was no documentation to show that licensed nurses assessed and monitored Resident 58 for dehydration during any shift. The ADON stated when nurses see these signs and symptoms of dehydration such as low urine output, they should start documenting the signs and symptoms (S/S) and notify the MD that Resident 58 was had S/S of dehydration. The ADON stated when Resident 58's urine output was 50 cc over eight hours the MD was not notified. The ADON stated it was important to notify the MD for prompt interventions and to prevent the resident's condition from worsening. During an interview on 11/10/2024 at 2:17 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated monitoring a resident's I & O is to monitor for fluid retention, especially for Resident 58 who had CHF, which can cause fluid retention. LVN 3 stated that she was the one who documented that Resident 58 had 50 cc output of urine, during her shift on 8/26/2024. LVN 3 stated she did not initiate a COC, and she did not notify Resident 58's MD of the abnormal urine output. During a record review of Resident 50's emergency room (ER) Notes dated 9/13/2024, the ER Notes indicated Resident 58 had dry mucus membranes. The ER notes also indicated Resident 58's laboratory (medical diagnostic testing using blood samples) indicated the blood urea nitrogen, (BUN- a blood test for dehydration) was 44 (reference range 7-18mg/Deciliter [a unit of measure of fluid volume]). During a record review of Resident 58's Progress Notes on 9/14/2024 the GACH progress records indicated Resident 58's admitting diagnoses included acute kidney injury likely due to prerenal azotemia (a high concentration of waste products in the blood due to dehydration). The ER Notes indicated Resident 58 was dehydrated. During an interview on 11/13/2024 at 1:12 p.m., with the Director of Nursing (DON), the DON stated LVN 3 informed her that Resident 58's MD was not notified of Resident 58's S/S of dehydration. The DON stated if a resident's urine output is less than 100 cc, for the entire 8 hour shift, the MD should be notified and a COC initiated, to closely monitor the resident's intake and output. During a record review of the facility's policy and procedure (P&P) titled comprehensive Assessments and the care delivery process dated 12/2016, the P&P indicated comprehensive assessment, care planning and the care delivery process involved collecting and analyzing information, choosing, and initiating interventions, then monitoring results and adjusting interventions. During a record review of the facility's P&P titled Change in a Resident's condition or status dated 12/2016, the P&P indicated the nurse will notify the resident's attending physician or physician on call when there has been a need to alter the resident's medical treatment significantly and need to transfer the resident to a hospital/ treatment center.

Based on observation, interview and record review, the facility failed to prevent the development of a pressure injury (skin breakdown from prolonged pressure on the skin and tissue underneath) on the inferior (lower) fold of the left buttock area for one of five sampled residents (Resident 50) by failing to: a.Ensure Resident 50 was repositioned every two hours, as indicated in the care plan titled Skin Condition, to relieve the pressure off the left buttocks area. b.Ensure the Registered Dietician (RD) assessed Resident 50's nutritional status on 6/5/2024, when Resident 50 developed a Stage 1 pressure injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness), on 6/10/2024 when the pressure injury progressed to a Stage 3, (full-thickness loss of skin, dead and black tissue may be visible), and again on 6/18/2024 when the pressure injury advanced to a stage 4 pressure injury (full thickness skin and tissue damage, where the wound exposes underlying structures including the bone). c.Ensure Resident 50's care plan titled Skin Condition was updated and interventions implemented to prevent a Stage 1 pressure injury from progressing to a Stage 4 pressure injury. d.Ensure Resident 50's Braden scale (a tool developed for early identification of patients at risk for forming pressure injuries) was updated after the resident developed a stage 1 pressure injury to the inferior fold left buttock and as it worsened to Stage 3 and then a stage 4. e.Ensure a change of condition (COC - a form used when a patient's clinical condition suddenly changes from the baseline) was completed when Resident 50 developed a Stage 1, stage 3, or stage 4 pressure injury to the inferior fold of the left buttock. f.Follow the facility's Policy and Procedure (P&P), titled Pressure Injuries/Skin Breakdown- Clinical Protocol which indicated the facility will assess and document an individual's significant risk factors for developing pressure sores. These deficient practices resulted in Resident 50 developing a stage 1 Pressure Ulcer on 6/5/2024, to the inferior fold left buttock, which progressed to a stage 4, on 6/18/2024 (13 days later) and caused Resident 50 to be in pain. Findings: During a review of Resident 50's Admission Record, the Admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty in swallowing), paroxysmal atrial fibrillation (a type of irregularly fast heartbeat, or arrhythmia), and unspecified dementia with other behavioral disturbance (progressive disease that destroys memory and other important mental functions). During a review of Resident 50's Minimum Data Set (MDS, a resident assessment tool) dated 5/23/2024, the MDS indicated the resident was unable express ideas and wants or unable to understand others. The MDS indicated the resident was dependent on the staff with bathing, toileting hygiene, dressing, personal hygiene, oral hygiene, and transfer to and from the bed to a chair. The MDS indicated Resident 50 had no pressure injuries at the time of assessment on 5/23/2024. During a record review of Resident 50's Admission Pressure and Non-Pressure Injury Risk assessment dated [DATE], the Admission, Pressure and Non-pressure Injury Risk Assessment indicated Resident 50 scored 14 which indicated a moderate risk for developing pressure injuries. During a record review of Resident 50's Progress Notes dated 6/5/2024, the Progress Notes indicated CNA (identity was not specified) reported that Resident 50 had redness in the left buttock area. The Progress Notes indicated an assessment was done, a non-blanchable (skin that doesn't fade when pressure is applied to it indicating bleeding under the skin) redness in the inferior fold of the left buttock measuring 2.5 centimeters ([cm] unit of measurement) cm x 3cm was noted, skin intact, mild erythema (abnormal redness) noted in surrounding skin. The Progress Notes indicated the Resident reported feeling pain by expressing ouch when the area was palpated (examined by touch). The Progress Notes indicated to continue monitoring for skin breakdown and adjust treatment plan as needed. During a record review of Resident 50's progress notes titled Wound Visit Progress Notes and dated 6/17/2024, the notes indicated left gluteal (buttock) tissue with slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds), moderate drainage (fluid that comes out of a wound), muscle tissue noted or visualized. During an observation on 11/9/2024 at 8:16 a.m., Resident 50 was observed in bed laying on her back. During an interview on 11/9/2024 at 9:43 a.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 50 will be staying in bed the whole day because she was expecting visitors. CNA 1 stated she did not recall when she last repositioned the resident and she did not document that she repositioned the resident. During an observation on 11/9/2024 at 11:01 a.m., Resident 50 was laying on her back, three hours and 15 minutes after Resident 50 was last observed laying on her back. During an observation on 11/10/2024 at 10:08 a.m., Resident 50 was in her bed laying on her back. During an interview on 11/11/2024 at 10:45 a.m., with Treatment Nurse 2 (TN 2). TN 2 stated she only did a Braden scale assessment when the resident is first admitted to create a baseline. TN 2 stated charge nurses did not follow up when residents of the facility developed new pressure injuries. During an interview on 11/11/2024 at 1:15 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated she performed residents' Braden scale assessment quarterly. The MDSN stated TN 2 was responsible for initiating and updating Resident 50's care plan titled Skin Condition if there were any skin changes, or the resident developed a pressure injury. The MDSN stated assessments were important for identifying if a resident was a high risk for skin breakdown, so the facility could prevent the resident from acquiring pressure injuries, by initiating a person-centered plan of care based on the assessment. The MDSN stated she did not update Resident 50's care plan titled Skin Condition when the resident's pressure injury worsened from a stage 1 to a Stage 4. During a concurrent interview and record review on 11/11/2024 at 2:00 p.m., with the Registered Dietician (RD), Resident 50's Nutritional Assessment was reviewed. The RD stated that the nutritional status and needs of residents with pressure injury should be monitored closely since nutrition helps in wound healing. The RD stated that there was no nutritional assessment done and there were no recorded weights for Resident 50 for the month of June. The RD stated there was no Interdisciplinary team meeting (IDT- resident's healthcare team consisting of various specialties) conducted regarding Resident 50's facility acquired pressure injury, and nutrition. The RD stated Resident 50's nutritional status was not monitored. The RD stated that it was important to monitor resident's nutrition to aid in wound healing. During a concurrent interview and record review on 11/11/2024 at 3:14 p.m., with TN 2, Resident 50's, progress notes dated 6/5/2024, 6/7/2024, 6/10/2024, and 6/12/2024 were reviewed. TN 2 stated according to the progress notes: a. On 6/5/2024 a CNA reported that Resident 50 developed a stage 1 pressure ulcer in the left inferior fold of the buttock measuring 2.5 cm. x 3 cm. b. On 6/7/2024 TN 2 informed the Medical Doctor (MD) that Resident 50's stage 1 pressure injury had progressed to a stage 2. c. On 6/10/2024 at 3:41 p.m., Resident 50's wound had an irregular shape, with visible yellowish subcutaneous (tissue under skin) fat tissue stage 3, measuring 2.5 cm x 3 cm x 0.3 cm depth. d. On 6/12/2024, Resident 50's stage 2 pressure injury had progressed to a Stage 4, and had full thickness tissue loss with exposed bone and a black appearance measuring 0.5 cm in depth. During a record review of Resident 50's wound visit progress notes dated 6/17/2024, the notes indicated Resident 50's left gluteal tissue had slough (dead tissue that is usually yellow or green in color), moderate drainage (fluid from the wound), with visible muscle tissue. During a concurrent interview and record review with TN 2 on 11/11/2024 at 3:23 p.m., Resident 50's care plan, titled Skin Condition dated 6/5/2024 was reviewed. TN 2 stated the care plan interventions indicated staff will encourage and assist Resident 50 to turn every 2 hours and encourage the resident to be up and out of bed daily. TN 2 stated as Resident 50's pressure injury worsened from a stage 1 to a stage 4 she did not update the care plan. During a concurrent observation and interview on 11/12/2024 at 11:50 a.m., with TN 2, Resident 50's was lying in bed, on her back. TN 2 stated Resident 50 would be staying in her bed all day because she would be getting visitors. During an interview on 11/13/2024 at 1:12 p.m., with the Director of Nursing (DON), the DON stated it was not the facility's practice to do a COC and update the Braden scale assessment if there was a pressure injury acquired in the facility. The DON stated TN 2 was expected to do an Event charting or observations when changes occurred with a resident. The DON stated licensed staff did not subsequently monitor the resident for 72 hours and did not need to document their observations. The DON stated the care plan should have been updated each time the pressure injury deteriorated. The DON stated this was not done for Resident 50. During a review of a Portable Document Format (PDF) published by the National Pressure Injury Prevention Advisory Panel, titled Pressure Injury Prevention Points, dated 2020, the PDF indicated the following pressure injury prevention points: 1.Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2.Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. 3.Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. 4.Continue to reposition an individual when placed on any support surface. 5.Reposition weak or immobile individuals in chairs hourly (www.npiap.com) During a record review of the facility's policy and procedure (P&P) titled Pressure Injuries/Skin Breakdown- Clinical protocol dated 03/2024, the P & P indicated the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores, for example immobility, recent weight loss and a history of pressure injury. Nutritional supplementation should be based on realistic appraisal of need and identification of medical conditions and factors that affect appetite, weight, and overall nutritional balance. During a record review of the P&P titles Change in a Resident's condition or status dated 12/2016, the P&P indicated regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatment, the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview and record review, the facility failed to provide an environment free of accident hazards for the resident who had a severely impaired cognitive (thought process) skills for daily decision-making and had a high risk for falls, for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) placed the recliner's (an armchair whose back can be lowered, and foot can be raised to allow the sitter to recline in it) remote control in a safe area away from Resident 1's reach to prevent Resident 1's from changing the positions of the recliner (which could result in her sliding out of it, or falling out of it) leading to Resident 1 falling out of the recliner. 2. Ensure a plan of care was created and implemented after safety concerns with Resident 1's daily use of the recliner were identified by the interdisciplinary (IDT - Resident 1's health care team which consists of different specialties) team. Resident 1 had a behavior of reaching for and playing with the recliner's remote control. These deficient practices of Resident 1's recliner's remote control being placed within Resident 1's reach resulted in Resident 1 changing her recliner's positions, falling out of the recliner and sustaining blunt head trauma ([BHT] the head collides with a surface or object) with a 3-centimeter ([cm] a unit of measurement) in length laceration (deep cut) to her mid-forehead and a 2 cm by 2 cm hematoma (a collection of blood due to injury or trauma) above her right eyebrow. Resident 1, who was a hospice (medical care to people who are near the end of life and have stopped treatment to cure or control their disease) resident receiving comfort measures (medical interventions to ease suffering at the end of life) only, was transferred to a general acute care hospital (GACH) and had to receive five sutures (stitching used to hold tissue together after an injury or surgery) to repair the laceration to her forehead. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive loss of memory) with behavioral disturbance, anxiety disorder (feelings of unease and worry), osteoarthritis (a joint disease characterized by pain, stiffness and swelling) and pseudobulbar affect (condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 10/14/2021, the MDS indicated Resident 1's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 required extensive two-persons physical assistance for transfers, bed mobility and completion of her activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). During a review of Resident 1's physician's order dated 10/1/2021, the physician's order indicated Resident 1 was admitted under hospice care (available to people with a life expectancy of six months or less; care does not focus on treatments to cure the cause of the terminal illness, but to keep the individual comfortable and make their remaining time as meaningful as possible) with the diagnosis of senile brain degeneration (cognitive decline) .; comfort measures only and no transfers to acute hospital. During a review of Resident 1's untitled care plan (CP), dated 8/12/2016 and last updated on 1/13/2022, the CP indicated Resident 1 was at risk for falls or injury due to poor safety awareness, history of falls, use of morphine sulfate concentrate (a strong narcotic [a substance used to treat moderate to severe pain]) and Lorazepam ([Ativan] a drug used to treat anxiety). The staff's interventions dated 1/4/2022 included keeping the recliner remote fastened to the back of the recliner dated 1/4/2022 and monitor pressure pad alarm (PPA) in the recliner for proper positioning and functioning. During a review of Resident 1's Fall Risk Assessment Tool (FRAT), dated 8/30/2021 and 10/13/2021, the FRATs indicated Resident 1 had a fall score of 14. A total score of 10 or more indicated a high fall risk. During a review of Resident 1's Post-Fall Supervisory Investigation Review (PFSIR), dated 1/4/2022 and timed at 5:44 p.m., the PFSIR indicated on the same day (1/4/2022), at 12:15 p.m., Resident 1 was in a reclining chair and CNA 1 placed the remote control of the chair, within Resident 1's reach on the right side of the recliner chair and walked to the doorway of the resident's room to speak with the Director of Staff Development (DSD). The PFSIR indicated the DSD heard a noise coming from behind Resident 1's privacy curtain and Resident 1 was found on the floor in a prone (face down) position with bleeding from the mid-forehead and right eyebrow due to lacerations. During a review of Resident 1's Physician's Order, dated 1/4/2022, the order indicated to transfer Resident 1 to the emergency room (ER) for further evaluation. During a review of Resident 1's nursing progress notes (NPN) dated 1/4/2022 and timed at 2:29 p.m., and a subsequent NPN on the same day timed at 2:45 p.m., the NPNs indicated Resident 1's family member (FM 1) requested to cancel Resident 1's X-ray and to send Resident 1 directly to the GACH. The NPN indicated Resident 1's FM 1 arrived at the facility at 2:45 p.m. on 1/4/2022 and transported Resident 1 to the GACH in their personal vehicle. During a review of Resident 1's GACH ER notes, dated 1/4/2022 and timed at 3:48 p.m., the ER note indicated Resident 1 presented to the GACH with a head injury/forehead laceration and reported loss of consciousness (the state of being awake and aware of one's surroundings) following a ground level fall out of a chair at a facility. The ER note indicated Resident 1 sustained BHT with a 3 cm in length forehead laceration and a 2 cm by 2 cm hematoma just above the forehead laceration. The ER note indicated Resident 1 underwent a laceration repair using a total of five sutures before being transferred back to the skilled nursing facility (SNF) on 1/4/2022. During a review of Resident 1's NPN, dated 1/4/2022 and timed at 10:19 p.m., the NPN indicated Resident 1 returned to the facility from the GACH at approximately 7:40 p.m. on 1/4/2022 with five sutures to her mid-forehead, above her right eyebrow. During an interview on 1/21/2022 at 10:36 a.m. with CNA 1, CNA 1 stated on 1/4/2022, she transferred Resident 1 from the bed to the recliner. CNA 1 stated while Resident 1 was sitting in the recliner, she (CNA 1) was standing in the doorway of Resident 1's room talking to the DSD when she heard a loud bump. CNA 1 stated she found Resident 1 lying face down on the floor. CNA 1 stated the Director of Nursing (DON), the Licensed Vocational Nurse 1 (LVN 1) and the DSD assisted Resident 1 back to bed. CNA 1 stated she did not know how Resident 1 fell from the reclining chair because Resident 1 could not walk but she could move her arms. CNA 1 stated Resident 1 would usually play with the recliner' remote control causing the head of the chair to move up and down. During a telephone interview on 1/21/2022 at 11:01 a.m. with the DSD, the DSD stated on 1/4/2022 around lunch time she was looking for CNA 1 and located her in Resident 1's room. The DSD stated CNA 1 left Resident 1 behind the privacy curtain out of sight and she (CNA 1) came to the door of the resident's room to talk to her (the DSD). The DSD stated Resident 1 fell out of the reclining chair onto the floor while CNA 1 was away from the resident and talking to her. The DSD stated Resident 1 should be in a reclined position however when she went to assist Resident 1 off the floor, the recliner was in an upward position, not in a reclining position, which would have allowed the resident to fall over out of the chair. During an observation on 1/21/2022 at 11:10 a.m., Resident 1 had discoloration to her right eyelid and forehead area (16 days after the fall incident). During a subsequent phone interview on 3/9/2023 at 9:29 a.m., with the DSD, the DSD stated the recliner's remote was pressed by Resident 1 causing the recliner to change positions (from a reclined to an up position). The DSD stated after the fall incident, she provided an in-service (staff education) to CNA 1 regarding placement of the recliner's remote ensuring it was not under, or within reach of Resident 1 and it should be off to the side in a secure location. During an interview on 1/21/2022 at 11:24 a.m. with LVN 1, LVN 1 stated on 1/4/2022, the DSD paged LVN 1 to go to Resident 1's room. LVN 1 stated when she arrived in Resident 1's room, the DSD was supporting Resident 1's head and applying an ice pack to Resident 1's forehead. LVN 1 stated the day Resident 1 fell (1/4/2022) CNA 1 had placed the recliner's remote control on the right side of the reclining chair, within reach of Resident 1. During a subsequent interview on 3/7/2023 at 1:20 p.m. with LVN 1, LVN 1 stated being in the recliner was part of Resident 1's daily routine. Resident 1 would sit in the recliner until lunch time then the staff would transfer the resident back to the bed. LVN 1 stated since Resident 1 was in the recliner every day, there should have been a care plan with safety interventions to prevent falls. During an inte1rview on 1/21/2022 at 1:25 p.m., with the DON, the DON stated Resident 1's recliner remote should not have been put in a place where Resident 1 could easily reach it. The DON stated Resident 1's fall could have been prevented by placing the recliner's remote on the back of the resident's recliner where Resident 1 could not reach it. During a subsequent interview on 3/7/2023 at 1:46 p.m., the DON confirmed there and should have been a care plan developed with safety interventions for Resident 1's use of the recliner but there was not. The DON confirmed safety interventions regarding the remote and PPA were implemented after the resident sustained the fall (1/4/2022). The DON stated care plans are important to inform staff of the care needs of Resident 1. During a review of the facility's revised policy and procedure (P/P), dated 12/2007 and titled, Falls and Fall Risk Managing, the P/P indicated the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and minimize complications from falling. During a review of the facility's revised P/P dated 7/2017 and titled, Safety and Supervision of Residents, the P/P indicated interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.

Based on observation, interviews and record reviews, the facility failed to provide close supervision to a resident, who fell while using the toilet and sustained an injury, for 1 of 15 sampled residents (10). Resident 10, who had a history of [REDACTED]. The resident fell from the toilet seat on [DATE] and sustained subdural hematoma (a subdural hematoma is a collection of blood over the surface of the brain, which fills the brain very rapidly, compressing brain tissue and can result in brain injury or lead to death) and died on [DATE]. Findings: On [DATE], a review of Resident 10's closed record indicated the resident was [AGE] year-old, admitted to the facility on [DATE] and expired on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the Nursing Admission and assessment dated [DATE] indicated the resident was cognitively impaired, confused, wandered, and had a history of [REDACTED]. A review of the Fall Risk assessment dated [DATE] indicated the resident was at high risk for falls. The Pre-Restraining assessment dated [DATE] indicated the resident had a short attention span, was disoriented, unsteady on her feet, loses her balance, had history of falls, did not understand what was being said, and could not comprehend surroundings. The recommendations were to use a pressure pad alarm (PPA) in bed and seatbelt alarm in the wheelchair. A care plan dated [DATE] assessed the resident as being at risk for falls or injury due to poor safety awareness related to confusion and a history of falls. The goal was for the staff to minimize injury in an event of a fall. The plan approaches included (1) to keep close observation to minimize potential for falls during activities of daily living, (2) wear a seatbelt alarm while sitting in a wheelchair. A review of the admission assessment Minimum Data Set (a standardized assessment tool) dated [DATE], indicated the resident had short-term and long-term memory problems, was moderately impaired in cognitive skills for daily decision-making (required cues and supervision), able to make self understood and able to understand others. The MDS also indicated the resident required extensive assistance with one person physical assist in bed mobility, locomotion off the unit, dressing, toileting, and personal hygiene. The resident required limited assistance with one person assist in transferring, walking in room and corridor, and locomotion on the unit. She was continent in bowel, frequently incontinent in bladder, and on scheduled toileting plan, used trunk restraint daily, and received special care in Alzheimer's/dementia special care unit. A review of the Resident Assessment Protocol (RAP) review report dated [DATE] indicated the resident had a fall prior to admission, which resulted in a fracture to the right shoulder. The resident required the use of a seat belt alarm while up in a wheelchair at all times, and a pressure pad alarm when in bed to monitor the risk of getting out of bed without assistance. The RAP review report also indicated the resident was at risk for falls, based on history, and used anti-anxiety medication. A review of the physician orders [REDACTED]. Ecotrin 81 milligrams (mg) by mouth everyday for CVA (stroke) prevention. (Ecotrin inhibits blood clot formation in people at high risk for developing blood clots.) Plavix 75 mg by mouth everyday for acute myocardial infarction (Plavix prevents blood from clotting). A review of the Nursing Progress Notes dated [DATE] at 5:30 a.m., indicated the licensed nurse was called to Resident 10's room and found the resident lying on the floor. The resident's head was bleeding profusely from a linear laceration (straight cut) on the left side of the head measuring about ,[DATE] centimeters (cm). The nurse applied a pressure dressing and ice compresses. Resident 10 was assisted to bed by three staff members using a mechanical lift. The physician was notified and orders were received to transfer the resident to an emergency room for evaluation. At 6:30 a.m., the resident was transported to the emergency room . A review of the Post Fall 72 Hours Documentation Notes dated [DATE] at 5:30 a.m., indicated CNA 2 found the resident on the floor, lying on left side, with her head on the floor. A review of the Supervisor's Post Fall Review Documentation dated [DATE] at 10 a.m. indicated the resident was sitting on the toilet with a CNA next to her. While waiting for the resident to finish, the CNA turned his back to pick up a trash liner. When the CNA came back, Resident 10 was on the floor, lying on her left side bleeding profusely from a laceration on the left side of her forehead. The resident was sent to emergency room . The supervisor instructed the CNA not to leave Resident 10 alone in the bathroom and not to turn his back while the resident was still using the toilet. A review of the acute hospital's emergency room report dated [DATE] indicated the resident arrived at 7:02 a.m. At 7:12 a.m., Resident 10 appeared awake, non-diaphoretic (not sweating), agitated, and uncomfortable. At 7:48 a.m., the laceration (cut), approximately 4 cm, on the left side of the forehead, was cleansed and closed with a staple gun. At 8:51 a.m., the neurosurgeon saw the resident. At 8:53 a.m., Resident 10 became less responsive. A review of the resident's head computed tomography scan (CT scan uses X-ray to make detailed pictures of structures inside of the body) dated [DATE] indicated a hematoma with maximum thickness of about 1.5 cm; there was a compression (build-up of pressure on the brain) of the underlying cerebrum (brain) with mass effect (the effect of an increasing intracranial pressure and potentially causing midline shift, a shift of the brain past its central line) and edema (swelling). There was compression of the left lateral ventricles; and there was a tiny amount of left-to-right midline shift of about 5 millimeter (mm). The impression or result of the CT scan was acute left cerebral subdural hematoma with underlying mass effect and edema and 5 mm midline shift. On [DATE] at 9:31 a.m., the resident's status became do not resuscitate/do not intubate (DNR/DNI). Resident 10's family did not want the resident to have surgery and requested the resident be sent back to the facility for hospice care (an end-of-life care with a goal to help the person die with peace, comfort, and dignity). A review of the facility's Nursing Progress Notes dated [DATE] at 11:25 a.m. indicated Resident 10 returned to the skilled nursing facility and was placed on hospice care. On [DATE] at 2 p.m., the resident had no pulse, no respiratory, no blood pressure, and the physician was notified. On [DATE] at 6:30 a.m., an interview was conducted with CNA 1 who stated on [DATE] in the morning (exact time not indicated), she walked Resident 10 to the bathroom and sat her on the toilet to show CNA 2, whom she was orienting, how to do the task. CNA 1 stated she told CNA 2 to watch Resident 10 in the bathroom, so she could make the bed. CNA 1 was near the resident's bed when she heard CNA 2's footsteps behind her. She turned around and saw CNA 2 come out of the bathroom and approach the doorway of the resident's room. CNA 2 could no longer see Resident 10 in the bathroom. CNA 1 stated she told CNA 2 to go back to the bathroom to watch Resident 10. While CNA 2 was walking back to the bathroom, CNA 1 heard a "boom" sound and ran to the bathroom where she saw Resident 10 lying on the floor on her left side. CNA 1 stated Resident 10 could not be left alone in the bathroom because she was very confused and CNA 2 was not focused on what he was doing, he was hard to teach. On [DATE] at 7:25 a.m., an observation of Resident 10's room revealed the bathroom was approximately eight steps away from the entrance of the room. A person inside the bathroom could not be seen from the entrance doorway. On [DATE] at 1 p.m., an interview with CNA 3 revealed Resident 10 should not have been left alone on the toilet, because of her history with falls. CNA 3 stated the resident needed to be supervised at all times. On [DATE] at 9:15 a.m., during an interview, the MDS Coordinator stated the CNAs were told not to leave confused residents alone while using the toilet. On [DATE] at 4:05 p.m., an interview with the assistance director of nursing (ADON) revealed the interdisciplinary team (IDT) agreed to use a seatbelt alarm while the resident was sitting in the wheelchair, because the resident was agitated, kept on standing up, and had a history of [REDACTED]. On [DATE] at 9:30 a.m., after reviewing the resident's care plan, the ADON was asked what was meant by close observation. The ADON stated. "Close observation means the staff provides supervision within the area or close parameters and the resident should be within visual parameters all throughout the activity." The ADON also stated, "The only measure to ensure safety while the resident is on the toilet was to stay with the resident in the toilet room because she was not wearing a belt alarm." On [DATE] at 10:55 a.m., during an interview, CNA 2 stated CNA 1 told him to watch Resident 10 and stay in the bathroom with the resident. CNA 2 stated while he was in the bathroom, he noticed the trash can did not have a plastic bag, so he left the resident in the bathroom and walked towards the hamper, at the entrance of the resident's room, to get a plastic bag. After 15 seconds he came back to the bathroom, and found Resident 10 on the floor. CNA 2 stated he did not see the resident fall. A review of the facility's policy and procedure titled "Accident Prevention Program for Resident", revised on [DATE], indicated it is the intent of the facility to provide adequate supervision, both type and frequency, based on the resident's assessed individual needs and identified hazards in the resident's environment. The facility's policy and procedure also indicated the implementation of the policy is based on: 1. Accurate assessment of the individual resident and his/her environment to determine necessity of supervision to avoid an accident, and 2. Providing supervision based on the individual resident's assessed needs and identified risks in his/her environment; pertinent identified risks, goals and interventions are to be included/updated to the individual resident's care plan; such interventions are to be implemented via communication and monitor by appropriate staff members; and CNA staff are made aware of resident fall risks via their written assignment sheet which is to be checked daily for any resident care updates.