Every finding on record at Autumn Hills Health Care Center

Based on observation, interviews, and record reviews, the facility failed to ensure the trash bins were properly covered and in sanitary receptacles in accordance with the facility's policy and procedure titled, Sanitation and Infection Control: Waste Control and Disposal. The facility failed to ensure: 1. There was no large puddle of green, foul-smelling water pooled underneath the dumpsters and in the dumpster area on 6/23/26. 2. One of two large dumpster bins was not overflowing with trash with the lid unable to close on 6/23/26. 3. The facility staff did not dispose of an empty box carton onto the large puddle of green, foul-smelling water on the ground of the dumpster area then walked away on 6/23/26. 4. A bag of trash was not left on the ground in the dumpster area on 6/26/26. These failures had the potential to attract pests (unwanted animal or insects that can contaminate food or create unsanitary conditions, such as rodents, flies, or cockroaches) and increased the risk of contamination that could negatively affect the health and safety of residents who rely on the facility for safe food handling and environmental sanitation. Findings: During an observation on 6/23/26 at 11:57 AM, the facility's dumpster area had a large puddle of green, foul-smelling water pooled underneath the dumpsters. One of two dumpster bin was observed overflowing with trash and the lid was unable to close. During another observation on 6/23/26 at 1:45 PM, the same dumpster area was observed. A kitchen staff member was observed throwing an empty box labeled Apple Juice Base onto the puddle of green, foul-smelling water in the dumpster area then walked away. During an interview with the Maintenance Supervisor (MS) on 6/23/26 at 12 PM, the MS stated that the dumpster area was supposed to remain clean and the lid of the dumpster should remain closed to prevent attracting pests to the facility. The MS also stated that the large puddle of green, foul-smelling water had been an ongoing issue for two months and, because the puddle obstructed the path from the kitchen to the dumpster area, the kitchen staff had to step on the water to throw trash from the kitchen into the dumpster. The MS stated the puddle of green, foul-smelling water was unsanitary and risked attracting insects like flies and mosquitoes to the dumpster area. During an interview with the Dietary Supervisor (DS) on 6/23/26 at 12:08 PM, the DS stated that it was not convenient or sanitary for the kitchen staff to step into the puddle of green, foul-smelling water every time they had to throw trash into the dumpsters. The DS stated that stepping in the green, foul-smelling water posed a sanitation issue and risked tracking disease into the kitchen. During another observation on 6/26/26 at 1:51 PM, the same dumpster area was observed with a large bag of trash on the ground next to the two dumpsters in the dumpster area. During a concurrent observation and interview with the Administrator (ADM) on 6/26/26 at 1:52 PM, the dumpster area was observed with a bag of trash on the ground. The ADM stated the trash should have been placed in the dumpster because it was unsanitary to leave trash on the ground. During a review of the facility's Policy and Procedure (P&P) titled, Pest control and dated 6/14/26, the P&P indicated to keep the facility grounds free of trash and brush and to keep the dumpster area clean and the lid closed. During a review of the facility's P&P, Sanitation and Infection Control: Waste Control and Disposal and dated 2023, the P&P indicated to keep lids of outside trash dumpsters closed.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment for 86 of 86 residents, the facility's staff, and the public when water from the facility's roof leaked into a large puddle of green, foul-smelling water in the dumpster area on 6/23/26. This failure created unsanitary conditions and increased the risk of pests, odors, and potential health hazards in an area accessible to staff and visitors. Findings: During an interview and concurrent observation with the Maintenance Supervisor (MS) on 6/23/26 at 11:57 AM, the facility's dumpster area was observed with water leaking from the roof and dripping into a large puddle of green, foul-smelling water that pooled underneath the dumpsters. The MS stated that the large puddle of green, foul-smelling water had been an ongoing issue for two to three weeks and, because the puddle obstructed the path from the kitchen to the dumpster area, the kitchen staff had to step on the water to throw trash from the kitchen into the dumpster. The MS further stated that his assistant usually washed the puddle away every day with a hose, but his assistant was out sick that day. The MS stated the puddle of green, foul-smelling water was not sanitary and risked attracting insects like flies and mosquitoes to the dumpster area. During an interview with the Dietary Supervisor (DS) on 6/23/26 at 12:08 PM, the DS stated that it was not convenient or sanitary for the kitchen staff to step into the puddle of green, foul-smelling water every time they had to throw trash into the dumpsters. The DS stated that stepping in the green, foul-smelling water posed a sanitation issue and risked tracking disease into the kitchen. During another interview with MS on 6/24/26 at 2:20 PM, the MS stated that he initially thought the roof leak came from the AC system but, after investigating further on 6/23/26, discovered that the leak came from the sprinkler system. The MS further explained that the release valve for the facility's sprinkler system was damaged which caused the leak from the roof to the dumpster area. The MS stated that the leaking from the sprinklers started two to three weeks ago and required repairs from the sprinkler system's company to fix it. During a review of the facility's Policy and Procedure (P&P) titled, Pest control and dated 6/14/26, the P&P indicated to keep the facility grounds free of trash and brush and to keep the dumpster area clean and the lid closed. During a review of the facility's P&P titled Sanitation and Infection Control: Waste Control and Disposal dated 6/14/26, the P&P indicated, Facility will dispose of waste that will create the minimum amount of inconvenience, be in concert with all Federal, State, and City regulations . During a review of the facility's P&P titled Infection Control Program and dated 5/12/26, the P&P indicated that important facets of infection prevention included: Identifying possible infections or potential complications of existing infections Instituting measures to avoid complications or dissemination

Based on observation, interview, and record review, the facility failed to maintain essential mechanical equipment in safe operating condition in accordance with the facility's policy and procedures titled Fire System Maintenance and Sanitation and Infection Control: Dishwashing Procedures (Dish machine). 1. The facility's dishwashing machine's thermometer was not reading accurately for an unknown amount of time between 6/16/26 to 6/23/26. This deficient practice had the potential to expose residents to foodborne illnesses (any sickness caused by eating or drinking foods contaminated with harmful germs [like bacteria or viruses] or toxic chemicals) due to improperly sanitized dishware. 2. The facility's sprinkler system had a leak for weeks and was not repaired until 6/24/26. This deficient practice placed the sprinkler system at risk of malfunction and created the potential for compromised fire protection for residents, staff, and visitors. 1. During an interview with the Dietary Supervisor (DS) on 6/23/26 at 8:29 AM and concurrent observation of the facility's kitchen, the facility's dishwashing machine was observed. The DS stated the dishwashing machine was a low temperature dishwasher, and the staff were required to check and log two temperatures when the dishwasher ran: the Wash Temperature and Rinse Temperature. The DS stated the wash temperature, and rinse temperatures should both be at a minimum of 120 degrees Fahrenheit ( F) to properly clean the dishware. The dishwashing machine was run three times and had the following temperatures: Run 1: Wash temp 110 F, Rinse temp 110 F Run 2: Wash temp 110 F, Rinse temp 110 F Run 3: Wash temp 110 F, Rinse temp 112 F The DS stated that the dishwashing machine's water temperatures had not reached the goal temperature of at least 120 F after running it three times. The DS stated that the staff had to use the facility's two-compartment dishwashing sinks to handwash the facility's dishes while the dishwashing machine was out of order. During another interview with the DS on 6/23/26 at 8:29 AM, the DS stated it was important to make sure that the dishwashing machine's temperature goals were met to make sure that the dishware was clean. The DS further explained that if the dishes were dirty, it could contaminate clean food and residents could become sick from foodborne illnesses (also known as food poisoning caused by consuming contaminated food or water containing bacteria, toxins, or viruses leading to symptoms like nausea, vomiting, diarrhea and stomach cramps). During an interview with the Maintenance Supervisor (MS) on 6/23/26 at 9:45 AM and concurrent observation of the facility's low temperature dishwashing machine, the MS was observed manually checking the water temperature inside of the dishwashing machine. The MS's manual thermometer read 135.1 F and the dishwashing machine's thermometer read 118 F. The MS stated that the dishwashing machine's thermometer was not reading accurately. During another interview with the DS on 6/23/26 at 10:05 AM, the DS stated that she did not know how long the dishwashing machine's thermometer was not reading accurately but the last time it was inspected by the dishwashing machine's company was on 6/16/26. During a review of the facility's Policy and Procedure (P&P) titled, Sanitation and Infection Control: Dishwashing Procedures (Dish machine) and dated 2023, the P&P indicated, Chemical low temperature dish machines must maintain a water temperature of 120F - 140F. 2. During an interview with the MS on 6/23/26 at 11:57 AM and concurrent observation of the facility's dumpster area, water was observed leaking from the roof and dripping into a large puddle of green, foul-smelling water that pooled underneath the dumpsters. The MS stated the water leaking from the roof came from the facility's air-conditioning (AC) system and had been an issue for two to three weeks and needed to be repaired. During another interview with MS on 6/24/26 at 2:20 PM, the MS stated that he initially thought the roof leak came from the AC system but, after investigating further on 6/23/26, it was discovered that the leak came from the sprinkler system. The MS further explained that the release valve for the facility's sprinkler system was damaged which caused the leak from the roof to the dumpster area. The MS stated that the leaking from the sprinklers started two to three weeks ago and required repairs from the sprinkler system's company to fix it. The MS stated that it was important to make sure the sprinkler system was working so it did not leak and, in the event of a fire emergency, the system would work to stop the fire. During a review of the facility's P&P titled, Fire System Maintenance and dated 2/20/26, the P&P indicated . Sprinkler systems. are inspected and maintained periodically in accordance with applicable regulations. The P&P also indicated that a staff member verified the inspection of the sprinkler system and reported any sprinkler problems to the maintenance advisor.

Based on observation, interview, and record review, the facility failed to ensure proper food safety and sanitation to prevent foodborne illness (also known as food poisoning caused by consuming contaminated food or water containing bacteria, toxins, or viruses leading to symptoms like nausea, vomiting, diarrhea and stomach cramps) for 84 of 86 residents in accordance with the facility's policy and procedure (P&P) titled Sanitation and Infection Control: Personal Hygiene and Sanitation and Infection Control: Handwashing when: 1. [NAME] 1 did not wash his hands upon entering the kitchen and handled food during meal preparation service 2. Dietary Aid (DA) 1 did not wash his hands upon entering and starting work in the kitchen 3. DA 1 did not put on a hair net upon entering the kitchen and during meal prep service. This deficient practice had the potential to result in contamination (transfer of harmful, or dangerous substances [such as chemicals, toxins, or pathogens] into a material, environment, or product) of food and food contact surfaces, increasing the risk of foodborne illness to residents. Findings: During an observation on 6/24/26 at 11:53 AM, tray line (the assembly line used in food-service operations to prepare and portion resident meal trays), [NAME] 1 was observed leaving the kitchen and discarding chicken grease into a grease barrel located outdoors. [NAME] 1 then returned into the kitchen without washing his hands and removed a tray of chicken from the oven and placed the tray of chicken into the food warmers. During the same tray line observation on 6/24/26 at 12:04 PM, DA 1 was observed entering the kitchen with a dolly (a small, wheeled platform used to move heavy items more easily) of boxes. Upon entering the kitchen, DA 1 removed a hair net from the dispenser by the door then put it into the back pocket of his pants. DA 1 then walked to the back of the kitchen into the storage room without a hair net and without washing his hands. During an interview with DA 1 on 6/24/26 at 12:06 PM, DA 1 stated he forgot to put the hair net on when he entered the kitchen. DA 1 further stated he did not wash his hands because the boxes containing food were considered contaminated from the outside. During an interview with the Dietary Supervisor (DS) on 6/24/26 at 12:09 PM, the DS stated that the protocol upon entering the kitchen was for staff to put on a hair net and immediately wash their hands even if they were going to the storage room. The DS further explained that DA 1 and [NAME] 1 needed to wash their hands prior to touching anything in the kitchen. During a review of the facility's Policy and Procedure (P&P) titled, Sanitation and Infection Control: Handwashing and dated 2023, the P&P indicated, Hands must be properly and frequently washed to prevent cross contamination of food supplies or equipment. The P&P also indicated that staff were to wash hands: Before starting work in the kitchen After handling carts, soiled dishes, and utensils Before and after doing cleaning procedures Before and after handling foods After using the toilet, sneezing, using a handkerchief or tissue After touching the face or hair During a review of the facility's P&P titled, Sanitation and Infection Control: Personal hygiene and dated 2023, the P&P indicated, A hair net and/or head covering that covers all hair should be worn during meal preparation and service.

Based on observation, interview, and record review, the facility failed to provide safe and hazard free environment for three (3) of 18 sampled residents (Resident 46, Resident 93, and Resident 6) by failing to: 1. Ensure a bed pad alarm (a weight sensitive mat placed under a resident that alerts staff when they are attempting to get out of bed without supervision or assistance) was connected and functioning for Resident 46. 2. Identify and address potential risks of accident for Resident 93, who was diagnosed with dementia (a severe decline in memory, thinking, and reasoning skills that interferes with a person's ability to perform everyday tasks) and had a pattern of grabbing and pulling on objects including his gastrostomy tube (GT-the tube inserted into the abdomen used to deliver liquid food and medications). 3. Implement intervention consistent with resident needs and care plan in accordance with the facility's policy and procedure titled Fall Management to minimize complications from falling for Resident 6, who had history of an actual fall, a high risk for fall, and was observed in bed without a floor mattress as per physicians order. These deficient practices had the potential to result in a major injury from a fall for Resident 6 and Resident 46, and a potential to result in serious harm or injury to Resident 93 when the resident pulled his feeding tube (a flexible straw-like device that delivers food from a liquid food bag directly into the stomach), which caused his GT pole (a tall stand used to hang a bag of liquid food) fell on him on 6/23/26. 1. During a review of Resident 46's admission Record (AR), the AR indicated Resident 46 was admitted to the facility on [DATE] with the following diagnoses but not limited to; malignant neoplasm of bladder (uncontrolled growth of cells in the urinary bladder), pulmonary embolism (an obstruction that restricts blood flow to the lungs putting strain on the heart), and history of falling. During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/28/2026, the MDS indicated Resident 46 has severe problems with thinking and memory and requires supervision or touching assistance for functions of daily living. During a review of Resident 46's care plan (CP) titled Actual Fall, dated 5/20/2026, the CP indicated that Resident 46 will be included in the Falling Star Program. During an observation on 6/23/2026 at 10:07AM, in Resident 46's room, Resident 46's bed pad alarm was disconnected, and no alarm was heard when he was getting out of bed by himself. During an interview on 6/23/2026 at 10:08AM with Licensed Vocational Nurse (LVN) 1, LVN1 stated that Resident 46 should have an alarm, but he always disconnected it. During an observation on 06/24/2026 at 8:28AM, in Resident 46's room, Resident 46's pad alarm was disconnected while he was sitting in bed. During an interview on 6/24/2026 at 8:33AM, with the Director of Nursing (DON), the DON stated that Resident 46 disconnects his pad alarm all the time. The DON stated that none of Resident 46's CPs indicate interventions with his bed alarm when he unplugs it. The DON stated that this is a concern because there is no documentation about communication with staff about Resident 46's pad alarm issue. During a review of the facility's policy and procedure (P&P) titled, Safety Supervision of Residents, dated 9/12/2025, the P&P indicated that there will be an individualized, resident-centered approach to safety by communicating specific interventions, assigning responsibility for carrying out interventions, and ensuring that interventions are implemented. During a review of the facility's P&P titled Falling Star Program, dated 3/24/2026, the P&P indicated that bed pad alarms are to be used for residents in this program. 2. During a review of Resident 93's AR, the AR indicated that Resident 93 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), intracerebral hemorrhage (stroke), and dementia. During a review of Resident 93's Physician Order Report (POR), the POR indicated on 6/19/26, the physician ordered staff to observe and maintain safety precautions for Resident 93. During a review of Resident 93's SBAR (situation, background, assessment, and recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 6/21/26, the SBAR indicated that the resident had dislodged his GT. During a review of Resident 93's SBAR dated 6/22/26, the SBAR indicated that the resident had dislodged (removed forcefully) his GT for a second time. During a review of Resident 93's MDS, dated [DATE], the MDS indicated that Resident 93 has severe problems with thinking and memory, is dependent (helper does all of the effort) on or needs maximal assistance (helper does more than half the effort) from another person for functions of daily living, and maintains nutritional status (the state of a person's physical health as it relates to how their body takes in, absorbs, and uses nutrients) through the resident's GT. During a review of Resident 93's SBAR, dated 6/23/26, the SBAR indicated Resident 93 had an incident of GT pole fell on resident's abdomen on 6/23/26 at 10 AM. The SBAR indicated Resident 93 was assessed with no pain and no injury, Resident 93's physician was notified and Resident 93's family member was made aware of the accident. The SBAR indicated with an add-on note documented on 6/24/26 at 3:55 PM that Resident 93's family member complained that Resident 93 had pain and discomfort on the left lateral rib cage (the curved, bony structure located on the outer left side of the chest) with the level of 3/10 and Tylenol (medication for pain) was administered as ordered to relieve the resident's pain. During a review of Resident 93's CP, dated from 6/19/2026 to 6/22/2023, there was no documented evidence that a CP was developed and implemented to address the resident's tendency to grab and pull at objects. During an observation on 6/23/26 at 9:40 AM, in Resident 93's room, Resident 93 was lying on his back in bed with a feeding tube pole on top of his abdomen. Resident 93 was wearing a medical hand mitten (soft, padded covers worn over resident's hands to stop them from pulling at important medical tubes), and the GT extension tubing was entangled around the resident's left wrist. Registered Nurse (RN) 1 was called into Resident 93's room who immediately lifted the pole off Resident 93's abdomen, left the room and stated, does not know the resident well. During a concurrent observation and interview on 6/23/2026 at 9:50 AM with LVN 1 in Resident 93 's room, LVN1 assessed Resident 93's abdomen, head, and back for injuries related to the GT falling on top of Resident 93's abdomen. LVN1 stated that she came in and assessed the resident's skin as soon as she heard about the accident. During a concurrent observation and interview on 6/23/2026 at 9:55 AM with the DON in Resident 93's room, the DON moved the feeding tube pole further away from resident's bed. The DON stated that based on Resident 93's condition, it was kind of expected that he would pull the pole on top of himself. During an interview on 6/26/26 at 10:20 AM, the DON stated that the facility failed to address Resident 93's behavior of grabbing and pulling objects to prevent the incident of GT pole falling on the resident on 6/23/26, which increases the potential risk of serious harm or injury. During a review of the facility's Policy and Procedure (P&P) titled, Safety Supervision of Residents, dated 9/12/2025, the P&P indicated: -The facility-oriented approach to safety addresses risks for groups of residents. -Individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents -The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's P&P titled, Comprehensive Plan of Care dated 2/9/2026, the P&P indicated that staff must develop a comprehensive care plan for each resident that addresses their individual needs. 3. During a review of Resident 6's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (decline in brain function that is severe enough to interfere with daily life), heart failure (heart isn't pumping blood effectively enough to meet your body's needs), blindness on left eye, difficulty walking, and muscle wasting and atrophy (weakening, shrinking, and loss of muscle). During a review of Minimum Data Set (MDS, a resident assessment tool), dated 4/13/2026, the MDS indicated Resident 6's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 6's required substantial/maximal assistance (helper does more than half the effort) with toileting and dressing, and partial/moderate assistance (helper does less than half the effort) to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). During a review of Resident 6's care plan (CP) dated 1/14/2026, the CP indicated Resident 6 had an actual fall due to a slide from low bed, with the goal that Resident 6 will not have a major injury from possible repeat fall, and the interventions that included the use of low bed with floor mattress. During a review of Resident 6's Physician Order Report (POR), the POR indicated Resident 6 had a physician order on 4/3/2026 to use a low bed with a floor mattress. During a review of Resident 6's Fall Risk Data Collection (FRDC), dated 4/3/2026, it was noted that the resident had poor cognitive skills, had experienced one to two falls in the past three months, was regularly incontinent with assistance, had gait and balance issues, and was considered at high risk for falls. During a review of Resident 6's FRDC, dated 4/22/2026, the FRDC indicated Resident 6 was high risk for falls. During an observation on 6/24/2026 at 8 AM in Resident 6's room, Resident 6's was in bed without a floor mattress. During a concurrent observation and interview on 6/24/2026 at 10 AM with Licensed Vocational Nurse (LVN) 4, in Resident 6's room. Resident 6 was lying in bed without a floor mattress, and LVN 4 checked Resident 6's room but was unable to locate a floor mattress. LVN 4 stated, she does not know where Resident 6's floor mattress is. LVN 4 stated, Resident 6 should always have her floor mattress available to prevent potential major injury from a fall. During an interview on 6/24/2026 at 11 AM with the Director of Nurses (DON), DON stated, Resident 6 should always have a floor mattress when in bed due to her history of fall and being a high-risk for fall. The DON stated the floor mattress was an intervention to minimize complication from a fall. The DON stated, not having a floor mattress had the potential to result in a major injury from a fall which could affect Resident 6's quality of life. During a review of the facility's policy and procedure (P&P) titled, Fall Management, dated 3/24/2026, the P&P indicated: a) staff will identify interventions to the residents' specific risks and try to reduce the risk of the resident falling and to try to minimize complications from falling, and b) fall risk factors include cognitive impairment, lower extremity weakness and visual deficits. During a review of the facility's P&P titled, Comprehensive Plan of Care, dated 2/9/2026, the P&P indicated: a) must address the residents individual needs, include treatment goals and include interventions to attempt to manage risk factors.

Based on observation, interview and record review the facility failed to provide privacy and maintain dignity during the provision of personal hygiene and dressing for four of eight sampled residents (Resident 66 , 16, 10 and 77) in accordance with the facility's policy and procedure titled Resident Dignity & Personal Privacy. This deficient practice had compromise residents' privacy and dignity that could result in embarrassment, emotional distress and a loss of personal respect. Findings: 1.During a review of Resident 66's face sheet (summary of resident's medical record) indicated the resident was admitted on [DATE] with a diagnosis that included fracture of the right femur (broken thigh bone), anemia (blood has too little healthy red blood cells to carry enough oxygen) and muscle wasting and atrophy (a loss of muscle mass and strength). During a review of Resident 66's Minimum Data Set (MDS-a resident assessment tool) dated 5/24/2026, indicated the resident had severely impaired cognition (with significant memory impairment, reduced ability to make decisions and solve problems). 2. During a review of Resident 16's Face sheet (summary of resident' s medical record) indicated the resident was admitted to facility on 9/24/2023, with a diagnosis that included heart disease (general term for conditions affecting the heart), dementia (a progressive condition that causes a decline in memory, thinking and reasoning), anxiety (excessive worry, fear, or nervousness). During a review of Resident 16's History and physical (H&P) dated 11/30/2025, indicated resident 16 lacks capacity to make health care decisions. During a review of Resident 16's Minimum Data Set (MDS-a federally mandated resident assessment tool dated 5/12/2026, indicated Resident 16 is severely cognitively impaired (memory impairment, confusion and disorientation, and limited ability to communicate needs effectively) and dependent on staff for all activities of daily living (ADL's). During an observation on 6/23/2026 at 10:08AM in Resident 66's room with opened privacy curtain while Certified Nursing Assistant (CNA) 1 assisted Resident 66 with dressing after a shower and putting on an incontinent brief, exposing residents' private area. The privacy curtain was open to the hallway and between resident care areas, sliding glass door to the patio remained uncovered. During a concurrent observation and interview on 6/23/2026 at 10:11AM, with CNA 1, CNA1 stated Resident 66 should be provided privacy during personal care and draw the privacy curtains to prevent resident from exposure while dressing. The CNA 1 stated she was focused on the resident from risk of falling and failed to maintain the resident's privacy while assisting the resident with dressing after shower. During a concurrent observation and interview on 6/23/2026 at 10:16 AM with Registered Nurse (RN) 4, stated Resident 66's privacy and dignity should have been maintained during dressing after shower. RN 4 stated the privacy curtains should have been drawn while providing care to shield the resident from view. During an interview on 6/25/2026 at 2:08 PM with Director of Nursing (DON) stated, CNA1 should have kept Resident 66 covered for privacy while dressing the resident after the shower to maintain the resident's dignity. The DON stated the resident's exposure to the hallway and patio could have embarrassed the resident and made him feel bad. DON stated if he was exposed to the hallway and the patio, it will probably be embarrassing. During an observation on 6/23/2026 at 11: 15 AM in Resident 16's room with the privacy curtain not drawn closed while CNA 2 provided personal hygiene care to Resident 16 who was lying in bed, with the incontinent brief removed, exposing the resident while personal hygiene care was being provided. Resident 16 was nonverbal (unable to talk) with contractures of the upper and lower extremities. During a concurrent observation and interview on 6/23/2026 AT 11:17 AM with CNA 2 in Resident 16's room, CNA 2 she was expected to draw the privacy curtains closed while providing personal care to the residents. CNA 2 stated she knows to have the curtains drawn closed. CNA 2 further stated I should have drawn the curtain closed to provide privacy, respect and dignity to the resident. CNA 2 stated, if someone walks into the room, the resident is exposed. During an interview on 6/25/2026 at 2:08 PM with the DON, the DON stated when providing personal hygiene, the privacy curtain should be drawn to prevent resident exposure. The DON further stated the curtain should have been closed to maintain the residents' privacy and dignity. During a concurrent observation and interview on 6/23/2026 at 11:19 with Licensed Vocational Nurse (LVN 2) in Residents 16 room, LVN 2 acknowledged staff are expected to maintain resident' s privacy and dignity during personal care. LVN 2 further stated yes, we are to have the privacy curtains drawn even if the door is closed and further stated this is necessary to maintain the resident' s dignity, privacy and respect. 3.During a review of Resident 10's, admission Record (AR), (undated), indicated Resident 10 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) (progressive lung disease that makes it hard to breathe), diabetes mellitus (blood sugar is too high), and heart failure (heart isn't pumping blood effectively enough to meet your body's needs). A review of Resident 10's Minimum Data Set (MDS-a resident assessment tool) dated 5/14/2026, the MDS indicated Resident 10's cognitive status (the mental process of thinking and understanding) was severely impaired. MDS indicated Resident 10 required partial/moderate assistance (helper does less than half the effort) with eating and personal hygiene. 4. During a review of Resident 77's AR, (undated), indicated Resident 77 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses dementia (umbrella term for a loss of memory, language, and thinking abilities), atrial fibrillation (irregular heartbeat), and COPD. A review of Resident 77's Minimum Data Set, dated [DATE], the MDS indicated Resident 77's cognitive status was severely impaired. MDS indicated Resident 77 required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating and personal hygiene. During a concurrent observation and interview on 6/24/2024 at 7:55 AM in Residents 10's and 77's room (roommate's). CNA 5 was observed standing next to Resident 10, who was in bed sitting upright in bed with head of bed elevated, while feeding resident for breakfast. When interviewed, CNA 5 stated, she forgot to sit on a chair to be at the eye level of Resident 10 while feeding, it was dignity issue. During another concurrent observation and interview on 6/24/2024 at 7:55 AM, CNA 6 was also observed standing next to Resident 77, who was in bed sitting upright in bed with head of bed elevated, while feeding resident for breakfast. When interviewed, CNA 6 stated, she should have sat on a chair to be at the eye level of Resident 77 and not stand next to the resident as it violates the resident's rights, and the resident was not treated with dignity. During an interview on 6/24/2026 at 8:30 AM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, CNAs should be sitting down on a chair to be at the eye level of the resident when assisting with feeding and not stand next to the residents as it violates the resident rights and the resident was not treated with dignity. During an interview on 6/24/2026 at 9 AM with the Director of Nurses (DON), DON stated, she expected the CNAs sitting next to the resident to see eye level while feeding the resident, it was more dignified than standing next to the resident during the process, which violates resident rights and dignity. A review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 5/7/2026, indicated the company protects and promotes the rights of each resident, the right for dignified existence. A review of the facility's policy and procedure (P&P) titled, Assisting the Resident to Eat, dated 6/17/2026, indicated, if the resident needs to be fed, sit at eye level in front of the resident. During a review of the facility's policy titled Resident Dignity & Personal Privacy dated 5/7/2026, indicated Dignity means, when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth. The policy indicated the facility will provide care in a manner that respects each resident's dignity, individuality, and right to personal privacy. The policy further requires staff to use a closed door, a drawn curtain, or both to shield residents during personal care and treatment procedures: drape and dress residents appropriately at all times to avoid exposure and embarrassment by maintaining residents' privacy during toileting, bathing, and other personal hygiene activities and cover residents during transfers to the shower or toilet.

Based on observation, interview, and record review, the facility's failed to ensure one of 6 sampled residents (Resident 67) was free from physical restraints (any mechanical device or equipment that is attached to or adjacent to the resident's body, which restricts freedom of movement) in accordance with the facility 's policy and procedure titled Physical Restraints Management. Resident 67 was observed with Roll Bolster (long, firm cylindrical or wedge-shaped cushion, secured to the bed frame with straps) placed on the left side of the bed which restricted Resident 67 from shoulder to feet, which restricted her ability to sit up, or stand, resulting in the resident unable to reposition independently. The facility failed to: 1. Provide alternative methods to prevent falls prior to the use of Roll Bolster. 2. Obtain a physician order for the use of Roll Bolster to ensure resident was evaluated for appropriate use and safety for use. 3. Informed consent (written document that demonstrates the resident or the resident's legally authorized representative was informed about and voluntarily agree to the use of restraint) obtained from responsible party prior to the use of Roll Bolster. 4. Develop a care plan for the ongoing monitoring, and periodic reevaluation. This deficient practice has the potential for Resident 67 to have increased risk for decreased range of motion, development of pressure ulcer (skin injury due to prolonged unrelieved pressure on the bony portion of the body) and loss of functional mobility to participate in the activities of daily living (ADL). Findings: During a review of Resident 67's Face Sheet (admission Record) indicated the resident was originally admitted to the facility on [DATE], with a diagnosis that included dementia ( a progressive disorder affecting memory, thinking, reasoning, communication, and the ability to perform daily activities), fracture of left humerus (upper arm), and muscle wasting (the loss or shrinking of muscle tissue). During a review of Resident 67's History and physical (H&P) dated 9/25/2025, indicated Resident 67 does not have the capacity to understand and make decisions. During a review of Resident 67's [NAME] Data Set (MDS - Care- screening tool), dated 3/27/2026 indicated Resident 67's cognitive skills (mental action or process of acquiring knowledge and understanding for daily decision - making) was severely impaired. The MDS indicated Resident 1 Requires moderate assistance (meaning helper does less than half the effort with most tasks of activities of daily living (ADL's). During a review of Resident 67's active Order Summary Report for 6/2026 indicated no documented evidence the physician ordered Resident 67 to be placed on Roll Bolster. During a review of Resident 67's clinical records from 5/2026 to 6/2026 indicated no documented other alternative measured were used prior to the use of Roll Bolster. In addition, no consent was obtained from Resident 67's responsible party prior to the use of Roll Bolster. During a review of Resident 67's Fall Risk Data Collection dated 3/27/2026 indicated, Resident 67 was at high risk for falls. During an observation on 6/23/8:54 AM in Resident 67's room, Resident 67 was observed lying in bed in a low position. Roll Bolster was positioned along the resident's left side and secured to the bed frame with a black strap. The Roll bolster extended from approximately the resident's shoulder to the lower extremities, creating a padded barrier along the left side of the bed. Bilateral half side rails were in the raised position. A floor mat was observed on the floor adjacent to the left side of the bed. During a concurrent observation and interview on 6/23/2026 at 9AM with Certified Nursing Assistant (CNA) 3 in Resident 67 room, Resident 67 was observed with bolster secured to the left side of bed creating a barrier along the left side of the bed. CNA 3 stated, that is a bolster to prevent her from getting out of bed and further stated she always wants to get out of bed. CNA 3 stated she does not know how long the Roll Bolster has been in use for that remains in resident's bed at all times. During a concurrent interview and record review on 6/23/2026 at 9:10AM with RN 2, a review of Resident 67's electronic medical record (PCC) and hard copy chart were conducted. RN 2 stated there was no documented evidence an informed consent for use of Roll Bolster was obtained from the resident's responsible party. RN 2 further stated, the Roll Bolster was used to keep the resident from rolling over and getting out of bed. During a concurrent observation and interview on 6/23/2026 at 9:17 AM with Regional Director of Clinical Operations (RDCO) in Resident 67's room, Resident 67 was observed with a Roll Bolster secured to the left side of bed, creating a barrier. The (RDCO) stated, if the bolster inhibits her ability to get out of bed, it is considered a restraint. The (RDCO) further stated we are using it for safety, so she does not get out bed and an informed consent should have been obtained from the resident's responsible party because a Roll Bolster may be used as a restraint and the resident or the resident's responsible party should have been informed of the risks and benefits prior to its use. During a concurrent interview and record review on 6/25/2026 at 8:44 AM with Director of Nursing (DON), Resident 67's medical records were reviewed. The DON stated there was no documented evidence that the physician ordered the use of Roll Bolster, no informed consent was obtained from the resident's responsible party, and no care plan developed for the use of Roll Bolster. DON stated Resident 67 had a tendency to get out of bed and the Roll Bolster prevents the resident from sitting up and exiting the bed independently. During an interview on 6/25/2026 at 2:08 PM with the DON, the DON stated that staff should have obtained a physician's order, consent, and notified the resident or responsible party before placing any restraint. The DON added that placing a Roll Bolster without these steps violates the resident's right to make informed decision and may be considered acting against their free will. During an interview on 6/26/2026 at 9:00AM with Resident 67, stated she could not get out of bed or sit up in bed because of the Roll Bolster that restricted her movement. During a concurrent observation and interview on 6/26/ 2026 at 9:05 AM CNA 4 stated Resident 67 was at risk for fall a fall and tries to get out of bed alone. CNA 4 stated We use the bolster to prevent her from trying to get out of bed. During a review of the facility's policy and procedure (P&P) titled, Physical Restraints Management dated 9/12/2025 indicated: Any mechanical device attached to or adjacent to a resident's body that restricts the resident's freedom of movement or access to one's body is considered a physical restraint. The policy further indicated that physical restraints require a physician's order, informed consent obtained by the physician from the resident or resident representative, documentation in the medical record, care planning, ongoing monitoring, and periodic reevaluation. The policy also stated that a device may only be considered an enabler if it provides greater function and the resident can independently remove it on command.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 63) who was a high risk for developing pressure ulcer (a skin injury due to prolonged unrelieved pressure or friction on the skin and body areas of the body) provided with bilateral (both sides) heel protector (a soft material designed to offload pressure from the heels, to prevent pressure ulcers) as ordered by the physicians order and in accordance with the facility's policy and procedures titled Pressure Ulcer/Injury Preventive Measures. This deficient practice had the potential to result in development of pressure ulcer and/or skin breakdown, which could negatively affect Resident 's quality of life.During a review of Residents 63's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (decline in mental abilities severe enough to interfere with daily life), muscle weakness, and muscle wasting and atrophy shrinking, and loss of muscle). During a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), dated 5/25/2026, indicated Resident 63's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 63 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene and dressing, roll left and right on the bed and was dependent (helper does all the effort) with eating, toileting and bathing. During a review of Resident 63's Physician Order Report (POR) (Physician Orders) dated 5/21/2026 indicated to always apply bilateral heel protectors when the resident was in bed. During a review of Resident 63's care plan (CP) dated 5/22/2026, indicated, Resident 63 was at risk for pressure ulcer risk related to needing assistance for bed mobility, intervention includes pressure relieving/reducing device in bed. During a review of Resident 63's Braden Scale (early identification of patients at risk for forming pressure sores) for Predicting Pressure Sore (ulcer) Risk dated 5/21/2026 indicated Resident 63 had very limited mobility and high risk for pressure ulcer. During a review of Resident 63's Braden Scale for Predicting Pressure Sore (ulcer) Risk dated 6/3/2026 indicated Resident 63 had very limited mobility and high risk for developing pressure ulcer. During a concurrent observation and interview on 6/23/2026 at 11:35 AM with Licensed Vocational Nurse (LVN) 4 in Resident 63's room, Resident 63 was lying in bed and had limited mobility on both extremities and did not have on his bilateral (both sides) heel protectors. LVN 4 checked Resident 63's room and closet and could not locate the bilateral heel protectors. LVN 4 stated, Resident 63 needs his bilateral heel protector as per physician's order because Resident 63's had limited mobility. LVN 4 stated, not having the bilateral heel protector on both heels had the potential for the resident to develop pressure ulcer and/or skin breakdown. During an interview on 6/24/2026 at 9 AM with Director of Nurses (DON), DON stated, Resident 63 needs to always have his bilateral heel protector on when in bed due to the resident's limited mobility and high risk for pressure ulcer. DON stated, not having the bilateral heel protector on had the potential to result in developing pressure ulcer and/or skin breakdown that could affect Resident 63's quality of life. A review of the facility's policy and procedure (P&P) titled, Pressure Ulcer/Injury Preventive Measures, (undated), indicated a) resident at risk for the development of pressure ulcers/injuries receive interventions to reduce the risk of pressure ulcers/injuries, b) select appropriate support surfaces based on resident's risk factors and c) select medical devices with consideration to the ability to minimize tissue damage and ability to secure the device.

Based on observations, interviews, and record reviews, the facility failed maintain a safe, clean and homelike environment for one of 6 sampled residents (Resident 29) with soiled privacy curtains in the resident's room. This deficient practice had the potential to expose residents to an unsanitary environment and does not promote a clean and homelike living environment. During a review of Resident 29's Face Sheet (summary document of clinical information) indicated Resident 29 was admitted to facility on 7/3/2022 with a diagnosis that includes dementia (a decline in memory, thinking, reasoning), heart failure (heart cannot pump enough blood to meet the body' s needs), and glaucoma (eye diseases that decreases vision due to increased pressure in the eye). During a review of Resident 29's Minimum Data Set (MDS - a standardized assessment and care screening too) dated 7/31/2022, indicated the resident had severe cognitive impairment (significant memory loss, and impaired decision making) and required maximum assistance for most activities of daily living (ADLs). During an observation on 6/23/2026 at 9:59 AM, Resident 29 was observed lying in bed touching and grasping with her hand the visibly soiled window curtains hanging alongside her bed adjacent to a sliding glass door. The window curtains were had dried food spots, stains. During a concurrent observation and interview on 6/23/2026 at 10AM with the Administrator (ADM) in Resident 29's room, Admin tated, Yes, the curtains are dirty. I believe the resident grabs them with her hands. The ADM further stated maintenance would be contacted to replace the curtains. The administrator stated the curtains should not be dirty, and acknowledged they could present an infection control concern, stating the condition was not consistent with a home- like environment. During a review of the facility' s policy and procedure titled Resident' s Home- Like Environment dated 1/22/2026, indicated residents must be provided with a home - like , resident - centered environment that promotes dignity, autonomy, comfort, and quality of life while maintaining health, safety, and infection prevention standards. Further indicating the facility environment and furnishings must be : clean, safe, and well - maintained.

Based on interview and record review, the facility failed to ensure that the advance directive (a legal document that outlines your preferences for medical care) documentation was readily retrievable by any facility staff for one of 18 sampled residents (Resident 7). This deficient practice had the potential to result in the resident receiving treatment or interventions without informed consent, compromising the resident's right to make informed healthcare decisions, autonomy, dignity, and self - determination having the potential for services not to be provided during medical emergencies according to the residents' wishes. Findings: During a review of Resident 7's admission Record, the admission Record indicated that Resident 7 was admitted to the facility on [DATE] with diagnoses including but not limited to; type two diabetes (where the body either cannot make process sugars in the blood properly), chronic kidney disease (kidneys are slowly damaged over time and lose their ability to filter waste and extra fluid from the body), and malignant neoplasm of colon (uncontrolled growth of cells in the large intestine). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/31/2026, the MDS indicated that Resident 7 was cognitively impaired, confused, disoriented (lacking mental action or process of acquiring knowledge and understanding) and dependent or needed maximal assistance from another person for functions of daily living. During a review of Resident 7's Electronic Medical Record (EMR) on 6/24/2026 at 9:45AM, the advance directive documentation could not be located. During a review of Resident 7's physical medical record on 6/24/2026 at 9:55AM, the advance directive documentation could not be located. During an interview on 6/24/2026 at 9:57AM, with Registered Nurse (RN) 3, RN3 stated that she could not locate Resident 7's advance directive documentation in the EMR or physical medical record. During an interview on 6/24/2026 at 10:01AM with the Social Service Director (SSD), the SSD stated that she could not locate Resident 7's advance directive documentation in the EMR or physical medical record. The SSD stated that she provided education to Resident 7 and their family on admission to the facility, but they refused to have an advance directive on file. The SSD stated that it is not the policy to have the advance directive documentation in the resident's EMR or physical medical record. During an interview on 6/24/2026 at 10:10AM, the SSD stated that she found Resident 7's advanced directive documentation in document titled, Social Services Assessment, dated 5/31/2026. During a concurrent interview and record review on 6/25/2026 at 10:10AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Advance Directives, dated 4/25/2026, indicated that the facility must document in a prominent part of the resident's medical record whether the resident has issued an advance directive. The DON stated that by not filing Resident 7's advance directive documentation in his medical record, staff is not following the P&P correctly and there is potential for services to not be performed during medical emergencies according to the residents' wishes.

Based on observation interview and record review, the facility failed to ensure the facility obtained a signed informed consent (written document that demonstrates the resident or the resident's legally authorized representative about the resident's provision of care) prior to using bolster (a long, firm cylindrical or wedge-shaped cushion device secured to the bed frame with straps that restricted the resident to freely move in bed) for one of two sampled residents (Residents 67) as indicated in the facility Policy and Procedure (P&P) titled Informed Consent dated 11/3/2025 and Physical Restraints Management. This deficient practice resulted in the resident receiving treatment or interventions without informed consent, compromising the resident's right to make informed healthcare decisions, autonomy, dignity, and self - determination. Findings: During a review of Resident 67's Face Sheet (admission Record) indicated the resident was originally admitted to the facility on [DATE], with a diagnosis that included dementia (a progressive disorder affecting memory, thinking, reasoning, communication, and the ability to perform daily activities), fracture (broken bone) of left humerus (upper arm), and muscle wasting (the loss or shrinking of muscle tissue). During a review of Resident 67's History and Physical (H&P) dated 9/25/2025, indicated Resident 67 does not have the capacity to understand and make decisions. During a review of Resident 67's [NAME] Data Set (MDS - Care- screening tool), dated 3/27/2026 indicated Resident 67's cognitive (thought process) skills mental action or process of acquiring knowledge and understanding for daily decision - making) are severely impaired. The MDS indicated Resident 1 requires moderate assistance (helper does less than half the effort with most tasks of activities of daily living (ADL). During an observation on 6/23/8:54 AM in Resident 67's room, Resident 67 was observed lying in bed in a low position. The Bolster was positioned along the resident's left side and secured to the bed frame with a black strap. The bolster extended from approximately the resident's shoulder to the lower extremities, creating a padded barrier along the left side of the bed. Bilateral half side rails were raised up, and a floor mat was observed on the floor adjacent to the left side of the bed. During a concurrent interview and record review on 6/23/2026 at 9:10AM with RN 2, Resident 67's electronic medical record (PCC) and hard copy chart were reviewed. RN 2 stated there was no documented evidence a consent for use of bolster was obtained from the resident's RP which the resident currently uses. RN 2 further stated the bolster was used to keep the resident from rolling over and getting out of bed. During a concurrent observation and interview on 6/23/2026 at 9:17 AM with Regional Director of Clinical Operations (RDCO) in Resident 67's room, Resident 67 was observed with a bolster secured to the left side of bed, creating a barrier. The RDCO stated, if the bolster inhibits the resident's ability to get out of bed, then the bolster is considered a restraint. The RDCO further stated the bolster was used for resident's safety, so she does not get out bed. RDCO further stated that informed consent should have been obtained because a bolster may be used as a restraint and the resident or the resident's responsible party should have been informed of the risks and benefits prior to its use. During a Concurrent interview and record review on 6/25/2026 at 8:44 AM with Director of Nursing (DON) , Resident 67's medical records were reviewed. The record review revealed no informed consent had been obtained. During an interview with on 6/25/2026 at 2:08 PM with Director of Nursing, DON stated a resident or RP should have been notified, and consent should have been obtained prior to placing any kind of restraint. DON further stated by placing the bolster without consent and by not notifying the residents representatives we are not providing a choice and could be considered being against their free will. During a review of the facility's Policy and Procedures (P&P) dated 11/3/2025, indicated the policy is to ensure that all residents and / or their legally authorized representatives are fully informed and provide voluntary, written informed consent prior to the initiation of any use of physical / chemical restraints. P&P further indicated the main purpose of this Policy is to safeguard resident' s right to autonomy and informed decision - making. During a review of the facility's policy and procedure (P&P) titled, Physical Restraints Management dated 9/12/2025 indicated: Any mechanical device attached to or adjacent to a resident's body that restricts the resident's freedom of movement or access to one's body is considered a physical restraint. The policy further indicated that physical restraints require a physician's order, informed consent obtained by the physician from the resident or resident representative, documentation in the medical record, care planning, ongoing monitoring, and periodic reevaluation.

Based on interview and record review, the facility failed to post in the nursing stations an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 6/17/2026 up to 6/24/2026 in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. This deficient practice of posting inaccurate nurse staffing information misinforms the residents and responsible parties about sufficient staffing ratio per residents to meet their needs which affects their quality of care.Findings: During a review of the facility documents titled Nursing Staffing Daily Posting, (posting of staffing information) dated 6/17/2026 up to 6/24/2026, the document did not indicate, the number of actual time worked per shift for each category (licensed or non-licensed) and type of nursing staff (RN, LVN and CNA), instead it had a combined total number of all nursing staff per shift. During a concurrent interview and record review of the document Nursing Staffing Daily Posting, on 6/24/2026, at 8:55 AM, with the Director of Nurses (DON), the DON stated the document indicated on 6/17/2026 up to 6/24/2026 the posting reflected the combined total nursing staff per shift and not by category or type of nursing staff. DON stated that the nurse posting was inaccurate, it should indicate the actual hours worked per shift, what type and what category of nursing, because the nursing type and category determine what kind of nursing care are provided to the residents. During a concurrent interview on 6/24/2026, at 9 AM, the DON stated, the daily nursing postings are intended to inform the residents, resident's responsible parties and the visitors about the type, category, and hours of nursing care provided in the facility per shift. DON stated these nursing posting must be accurate to prevent misinformation and confusion. A review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Number (undated, indicated, a) shift staff information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift, b) the information recorded on the form shall include, type (RN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift, and c) the actual time worked during that shift for each category and type of nursing staff.

Based on interview and record review, the facility failed to protect a resident's right to privacy and dignity when staff photographed the resident without their permission while the resident was in a vulnerable position. This deficient practice resulted in Resident 1 verbalizing feelings of embarrassment and crying.FINDINGS: During a review of Resident 1's admission Record (AR), the AR indicated the Resident was admitted to the facility on [DATE], with a diagnosis that included type 2 diabetes mellitus ( the body doesn't make enough insulin or can't use it well causing high blood pressure), chronic kidney disease(long -term condition where the kidneys slowly stop working properly) , and paraplegia(loss of movement and felling in the lower half of the body) . During a review of Resident 1's History and Physical (H&P) dated 11/25/2025, the H&P indicated this resident has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/9/2026, the MDS indicated Resident 1 was cognitively intact ( a person's memory and thinking are normal) and is dependent (helper does all of the effort) with toileting hygiene requiring maximum assistance for repositioning and transfers. During a review of Resident 1's care plan titled Self-Care Deficit dated 6/19/2026, the care plan indicated a goal to assist with activities of daily living (ADLS the fundamental, routine self-care tasks that individuals perform daily to maintain independence and hygiene,) to maintain comfort and dignity. The care plans indicated interventions to inform Resident 1 prior to rendering care and providing privacy. During an interview on 4/14/2026 at 10 AM with the Director of Staff Development (DSD), the DSD stated during the Interdisciplinary Team Meeting (IDT) for Resident 1, held on 3/30/2026, Resident 1 reported that while Certified Nursing Assistant (CNA) 1 was providing personal care (changing her adult brief and hygiene assistance), a man opened the door without knocking. Resident 1 stated she felt exposed and her privacy had been violated. The SSD stated Resident 1 was being transferred by a Hoyer Lift (a mechanical device used to lift and move a person who cannot stand or walk), CNA 1 took a photo on CNA 1's cellphone of the Resident 1's private area though covered by an adult brief, to ensure Resident 1 that Resident 1 was not exposed. DSD stated that during the IDT meeting, Family Member (FM) 1 reported becoming aware of the incident after Resident 1 called FM 1 crying, and that Resident 1 stated feeling embarrassed, exposed, and had pictures taken of her. During an interview on 4/14/2026 At 11 AM with CNA 1 , CNA1 stated while providing personal care an unknown individual opened and closed the door, at that time Resident 1 began crying and expressed that she felt exposed , stating someone had seen her. CNA 1 further stated that during Resident 1 transfer using the Hoyer lift, while the resident was elevated, she pulled up Resident 1's dress exposing her adult diaper and took a photo. CNA 1 stated the intent to show the resident that her private area was not exposed but the resident began to cry more. CNA 1 stated she did not ask the resident why she continued to cry and acknowledged that she did not obtain the resident's permission prior to taking the photograph stating, she did not think about it. During an interview on 4/20/2026 at 11:30 AM with Resident 1, Resident 1 stated that while she was suspended in the Hoyer lift, an unknown individual opened the door. Resident 1 stated that although she was covered, she believed she had been exposed and was upset and cried. Resident 1 stated she believed a male individual opened the door and reported that her legs were parted during the lift, which caused her to feel that her private area may have been visible. Resident 1 further stated while she was in the Hoyer lift, CNA1 took a photograph of her private area. The Resident stated that CNA1 did not ask her permission prior to taking the photograph. During a review of facility's policies and procedures ( P&P) titled, Resident Dignity & Personal Privacy (undated), indicated the purpose of the policy to ensure resident are provided care in a manner that respects and enhances each resident dignity, individuality, and right to personal privacy. During a review of facility's policies and procedure (P&P titled, Personal Telephone Calls to/From Employees, Social [NAME] Use date (unknown), indicated cell phone camera functions shall not be used during work hours and further stated cell phone camera functions shall not be used during work hours. During a review of facility's policies and procedure ( P&P) Titled Consent to photograph, video, or Audio record Residents dated ( undated), indicated the purpose of policy is to establish a standardized, legally compliant process for obtaining and documenting resident or representative consent prior to any photography, video recording, or audio recording within the facility, ensuring protection of resident rights, dignity, privacy, and confidentiality in accordance with federal and California regulations. Further indicating the facility prohibits photographing, of any resident without prior informed consent. Consent must be voluntary, informed, specific to purpose, documented. Unauthorized photography by staff, visitors, or other residents is strictly prohibited.

Based on observations, interviews and record reviews, the facility failed to immediately report physical abuse by Physical therapist (PT) 1 towards Resident 1 to the Administrator (ADM) within two (2) hours for one of five sampled residents, in accordance with the facility's policy and procedure (P&P) titled, Abuse Prevention Program. On 2/23/2026 while Resident 1 was beginning physical therapy, Resident 1 entered the rehabilitation (rehab) room and touched PT 1 on the back of the head. PT 1 reacted by slapping Resident 1 on the right thigh. PT 2 was also in the room. Neither PT 1 or PT 2 reported this incident on 2/23/2026 to the ADM. This deficient practice resulted in the facility not immediately reporting a witnessed physical abuse to the Administrator and delayed the investigation and protection for Resident 1 from further abuse. During a review of Resident 1's admission Record ( AR) , the AR indicated the facility admitted the resident to the facility on [DATE], with a diagnosis including Hemiplegia (complete paralysis on one side of the body) and hemiparesis ( weakness on one side of the body) following a cerebral infarction (a blood clot or blocked blood vessel stops oxygen from reaching part of the brain , causing brain cells to die) affecting left side of his body. During a review of Resident 1's History and Physical (H&P) dated 02/05/2026, the H&P indicated Resident 1 has the capacity to understand and make decisions. During an interview on 02/26/2026 at 9:35 AM with the Administrator (ADM), ADM stated that PT 2 reported the incident on 2/24/2026 between Resident 1 and PT 1 one day later on 2/24/26. ADM stated PT 2 reported the incident to the Director of Rehabilitation (DOR). During an interview on 02/26/2026 at 10:26 AM with PT 2, PT 2, stated Resident 1 entered the therapy room and approached PT 1 who was seated at a computer with his back to the room. Resident 1 flicked[to move, hit, or remove something with a quick, light, and sudden jerk] PT 1 once on the back of the head to get his attention. PT 1 then rotated his chair approximately 180 degrees towards Resident 1 and struck Resident 1 once on the right thigh with an open hand. PT 2 stated the slap was very loud and sounded like someone slamming their hands down on a desk. PT 2 stated as the therapist struck the resident, Resident 1 yelled no, you can't do that. Resident 1 appeared shocked and upset and said, you beat me. PT 2 stated it appeared that PT 1 was often annoyed with Resident 1 and, on multiple occasions, she had heard PT 1 speaking loudly to the resident stating you need to be quiet, you talk too much, which was directed toward Resident 1. PT 2 stated Resident 1 did not appear to have visible injury and therapy continued with both therapists remaining in the room. PT 2 stated she did not report the incident of PT 1 slapping Resident 1's right thigh on immediately on 2/23/2026, because she believed there was a 24-hour reporting window and wanted to give PT 1 an opportunity to report the incident himself. PT 2 stated she reported the incident the following day, on 2/24/2026 to the Director of Rehabilitation (DOR) after learning the therapist PT 1 had not reported the incident. During an interview on 2/26/2026 at 11:55AM with Resident 1, Resident 1 stated on 2/23/2026, Resident 1 entered the therapy room and approached PT 1 to get his attention and touched the back of PT 1's head. Resident 1 stated PT 1 quickly turned around and slapped Resident 1 on the right leg. Resident 1 stated PT 1 appeared very angry and mean and that the slap inflicted by PT 1 stung Resident 1's leg. Resident 1 stated he felt angry and felt assaulted and went on to say he had previously considered PT 1 a friend and someone he could talk to and did not expect this kind of behavior. Resident 1 stated he did not want to complain, since he considered himself a strong person. Resident 1 stated he continued with physical therapy with PT 2 afterward while PT 1 remained in the room. Resident 1 further stated no one asked him how he was or whether he was okay following the incident. During an interview on 02/26/2026 at 1:10 PM with the Director of Nursing (DON), DON stated the incident between Resident 1 and PT 1 was considered physical abuse and should have been reported immediately to facility administration in accordance with facility policy and abuse reporting requirements. During an interview on 02/26/2026 at 1:40 PM with PT 1, PT 1 stated he did not notify the Administrator ( ADM) or Director of Rehabilitation (DOR) because in his experience when he reports concerns, no action was taken. During a review of the facility's policy and procedure ( P&P) titled Abuse investigation & Reporting, undated, the P&P indicated All allegation or resident abuse, neglect, exploitation, misappropriation or resident property, mistreatment and/ or injuries of unknown source ( Abuse) shall be promptly reported to appropriate local, state and / or federal agencies ( as defined by current regulation ) and thoroughly investigated by Company management. Findings of abuse investigations will also be reported to local law enforcement and the Office of Ombudsman. The P&P further indicated an alleged violation of abuse, neglect, exploitation or mistreatment ( including injuries of unknown source and misappropriation of resident property ) will be reported immediately. During a review of the facility's P&P titled Abuse Prevention Program, undated, the P&P indicated the facility would investigate and report any allegations of abuse within timeframes as required by federal requirements. During a review of the facility's P&P titled, Abuse and Neglect Clinical Protocol, undated, indicated the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The P&P indicated management and staff will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from physical abuse in accordance with the facility's Policy and Procedure, titled Abuse and Neglect Clinical Protocol, by failing to: 1.Identify physical abuse after Physical therapist (PT) 1 slapped Resident 1 on the right thigh on 2/23/2026. 2. Implement abuse protocols by not immediately reporting the incident to the Administrator (ADM). 3. Monitor Resident 1 immediately after the incident occurred on 2/23/2026. 4. Protect Resident 1 from PT 1 after PT 2 witnessed PT 1 slap Resident 1 on the right thigh and PT 2 continued to provide physical therapy services to Resident 1while PT 1 remained in the therapy room. These failures resulted in Resident 1 being slapped on the right thigh by PT 1 and verbalized feelings of being shocked and upset, and for Resident 1 to not be immediately protected by the facility from PT 1. During a review of Resident 1's admission Record ( AR) , the AR indicated the facility admitted the resident to the facility on [DATE], with a diagnosis including Hemiplegia (complete paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (a blood clot or blocked blood vessel stops oxygen from reaching part of the brain, causing brain cells to die) affecting left side of his body. During a review of Resident 1's History and Physical (H&P) dated 02/05/2026, the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's Progress Notes dated 2/24/2026 at 2:55 PM, the note indicated Resident 1 had reported to the nurse at approximately 3 PM that PT 1 had made physical contact towards Resident 1, and used an open hand to the resident's right leg in anger. Resident 1 reported that the incident had happened the day before [2/23/2026] but did not want to get anyone in trouble. The note indicated Resident 1 thought this nurse should know. The note indicated that Resident 1 was able to visually identify the therapist he is reporting. When asked to explain what happened, Resident 1 stated, I thumped [hit/strike]therapist [PT 1] in back of head, and he turned in anger and smacked my leg with his hand. The note indicated PT 1 tapped his [Resident 1] right leg. During a review of Physical Therapist Employee Record (PT1) dated 3/25/2025, indicated PT 1 was suspended previously for potential physical and verbal altercation and disrespectful behavior towards another employee . Investigation concluded that allegation of verbal altercation was substantiated and PT 1 would return to work after completion of eight trainings. During an interview on 2/26/2026 at 9:35 AM with the Administrator (ADM), the ADM stated that Resident 1 attended physical therapy on 2/23/2026, where two physical therapists were present in the therapy room. PT2 was cleaning and organizing the area while PT1 was documenting on the computer. According to the ADM, Resident 1 attempted to get PT1's attention by flicking (to move, hit, or remove something with a quick, light, and sudden jerk) the back of PT1's head. PT1 then turned toward Resident 1 and struck Resident 1 once with the palm of his hand. ADM stated when she spoke to PT1, PT 1 stated he had only slapped the resident's hand and told him not to do that again; however, both the resident and PT 2 reported that PT1 slapped the resident on the right thigh. ADM stated Resident 1 stated that PT 2 then yelled at him and asked, You want to beat me? Resident 1 reported feeling shocked and upset by the incident. The ADM stated that therapy continued after the incident. The ADM stated PT 2 asked Resident 1 if he was okay, and Resident 1 continued with therapy. PT 2 reported that she did not notify anyone about the incident on 2/23/2026 because Resident 1 had asked PT 2 not to report it. The incident was reported the following day to the Director of Rehabilitation (DOR) after it was learned that PT 1 had not reported the event (physical abuse). During an interview on 02/26/2026 at 10:26 AM with PT 2, PT 2, stated Resident 1 entered the therapy room and approached PT 1 who was seated at a computer with his back to the room. Resident 1 flicked PT 1 once on the back of the head to get his attention. PT 1 then rotated his chair approximately 180 degrees towards Resident 1 and struck Resident 1 once on the right thigh with an open hand. PT 2 stated the slap was very loud and sounded like someone slamming their hands down on a desk. PT 2 stated as the therapist struck the resident, Resident 1 yelled no, you can't do that. Resident 1 appeared shocked and upset and said, you beat me. PT 2 stated it appeared that PT 1 was often annoyed with Resident 1 and, on multiple occasions, she had heard PT 1 speaking loudly to the resident stating you need to be quiet, you talk too much, which was directed toward Resident 1. PT 2 stated Resident 1 did not appear to have visible injury and therapy continued with both therapists remaining in the room. PT 2 stated she did not report the incident of PT 1 slapping Resident 1's right thigh immediately on 2/23/2026, because she believed there was a 24-hour reporting window and wanted to give PT 1 an opportunity to report the incident himself. PT 2 stated she reported the incident the following day, on 2/24/2026 to the Director of Rehabilitation (DOR) after learning PT 1 had not reported the incident. During an interview on 2/26/2026 at 11:55AM with Resident 1, Resident 1 stated on 2/23/2026, Resident 1 entered the therapy room and approached PT 1 to get his attention and touched the back of PT 1's head. Resident 1 stated PT 1 quickly turned around and slapped Resident 1 on the right leg. Resident 1 stated PT 1 appeared very angry and mean and that the slap inflicted by PT 1 stung his leg. Resident 1 stated he felt angry and felt assaulted and went on to say he had previously considered PT 1 a friend and someone he could talk to and did not expect this kind of behavior. Resident 1 stated he did not want to complain, since he considered himself a strong person. Resident 1 stated he continued with physical therapy with PT 2 afterward while PT 1 remained in the room. Resident 1 further stated no one asked him how he was or whether he was okay following the incident. During an interview on 2/26/2026 at 1:10 PM with the Director of Nursing (DON), DON stated she was surprised by the incident and stated PT 1 should have never touched Resident 1. DON stated PT 1 was suspended the same day the facility became aware of the incident on 2/24/2026. DON stated the incident constituted physical abuse and should have been reported immediately. During an interview on 2/26/2026 at 1:32PM with the DOR, DOR stated not being present at the time of the incident on 2/23/2026 regarding Resident 1 and PT 1 but reported to the ADM after being informed of the event on 2/24/2026 by PT 2. DOR stated the incident constituted physical abuse and expressed concern about the situation, continuing to say Resident 1 is generally pleasant, friendly, and positive. During an interview on 2/26/2026 at 1:40PM with a PT 1, PT 1 stated on the morning of the incident on 2/23/2026 he was seated at a computer completing paperwork in the therapy room when Resident 1 approached him. PT 1 stated he did not initially notice Resident 1 in the room and reported that Resident 1 touched or slapped the back of his head trying to get his attention, which startled PT 1. PT1 stated he immediately turned around and told Resident 1 to stop and slapped Resident 1 on his hand. PT 1 stated he spoke to the resident in a low voice and told him to stop. PT 1 stated to Resident 1 hey stop it, this is not right. PT 1 continued to say that sometimes residents can make staff upset and acknowledge he is a healthcare worker. PT 1 stated not reporting the incident between him and Resident 1 since because when PT reported things, nothing happens During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program dated 05/12/2025, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. The P&P further indicated as part of the resident abuse prevention, the administration will protect residents from abuse by anyone including, but not necessarily limited to facility staff, protecting resident during abuse ingestions. The P&P indicated administration would protect residents from abuse by anyone and would implement P&P's to aid the facility in preventing abuse, neglect, or mistreatment

Based on interviews and record reviews, the facility failed to provide treatment and services in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) for one of three sampled residents (Resident 1) who had a diagnosis of Type 2 Diabetes Mellitus ([DM] when a hormone called insulin does not work properly or there is not enough of it. This causes the level of glucose [sugar] in the blood to become too high) by failing to: 1.Ensre that its licensed nursing staff reviewed Resident 1's medical history of Type 2 Diabetes Mellitus (DM) and diabetes management prior to the readmission from the GACH on 1/11/2026. This medical history included Resident 1's diabetes management, such as checking and monitoring Resident 1's blood sugar levels by performing fingerstick tests. 2. Verify and document confirmation with Resident 1's attending physician (MD 1) and/or Nurse Practitioner (NP) 1 by transcribing the fingerstick blood glucose monitoring-before meals (AC) and at bedtime (HS)-as ordered in the GACH discharge instructions dated 1/11/2026, upon Resident 1 's readmission to the facility on 1/11/2026. 3.Implement Resident 1 's written care plan dated 12/11/2025 titled Risk for unstable blood glucose levels ([low blood sugar] and [high blood sugar]), which requires the facility's licensed nurses to monitor and observe Resident 1 for signs and symptoms of low and high blood sugar levels. The care plan did not address how licensed nurses would measure Resident 1's blood glucose levels to determine if the resident was experiencing low or high blood sugar levels. 4.Document verification of RN 4 with MD 1 whether fingerstick blood sugar monitoring should be performed when MD 1 ordered for Resident 1 to be on continuous infusion of Dextrose 5% in Water (D5W) (an intravenous [IV] fluid containing 5 grams of dextrose (sugar) dissolved in 100 mL of water) for poor appetite and hydration from 2/6/2026 to 2/8/2026. 5.Ensure effective communication (LVN 1, RN 1, RN 2, RN 3, RN 4) among the interdisciplinary team regarding Resident 1's change in condition, critical lab results, and ordered treatments. As a result of these deficient practices, Resident 1 did not receive required monitoring and timely intervention for hyperglycemia and was administered D5W IV fluids from 2/6/2026 to 2/8/2026 while in a hyperglycemic state. Resident 1 experienced a significant decline in condition, including altered level of consciousness and oxygen saturation of 85 percent (normal range 95-100 percent) on 2/8/2026. Emergency medical services were activated, and paramedics recorded a critically elevated blood glucose level of 530 mg/dL upon arrival. Resident 1 was transferred to the GACH Emergency Department for further evaluation and treatment of altered level of consciousness, hypoxia, and severe hyperglycemia. At the ED, additional blood glucose readings were 530 mg/dL at 4:35 PM and 434 mg/dL at 4:55 PM. The hospital diagnoses included severe sepsis, acute hypoxemic respiratory failure, and uncontrolled diabetes mellitus. Cross referenced to F711 Findings: During a review of Resident 1's diabetes care plan titled Risk for Unstable Blood Glucose Level (low and high blood sugar levels), initiated during Resident 1's initial admission at the facility dated 12/11/2025 with a goal date of 3/31/2026, the care plan indicated that Resident 1 should be checked for blood glucose (BG) if the level is below 70 mg/dL, and that if the resident is unconscious or vital signs are absent, staff should administer 1 milligram (mg) of Glucagon (a medication used to increase BG) intramuscularly (IM) and call 911. The care plan did not address how the licensed nurses would measure Resident 1's blood glucose levels to determine if they were below 70 mg/dL. The care plan interventions further indicated to observe for signs and symptoms (S/S) of high blood glucose levels and report observed S/S to the physician. During a review of Resident 1's General Acute Care Hospital (GACH) Records titled Orders Re-Cap (short for recapitulation that means to summarize the main points of something that has already been discussed or happened) dated 1/11/2026, the Recap indicated to renew (extend validity) Resident 1's fingerstick blood sugar before meals (AC-[ante-cebum which means before meals]) and at bedtime (HS -[hour of sleep]). The GACH records indicated that Resident 1 also had blood sugar checks as needed. The GACH records indicated to notify the physician when the blood sugar was greater than 250 mg/dL, and when the blood sugar was less than 70 mg/dL and to implement hypoglycemia protocol. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was readmitted to the facility on [DATE], with diagnoses of Type 2 DM and sepsis (a life-threatening medical emergency from an infection). During a review of Resident 1's Nursing Progress Note dated 1/11/2026 at 6:30 PM, the Notes indicated that Resident 1 was readmitted from the GACH with a diagnosis of sepsis (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to tissue damage, organ failure, and potential death). During a review of Resident 1's Physician Order Report from 1/11/2026 to 1/31/2026, the Report indicated that Resident 1 was to be monitored for signs and symptoms of hypoglycemia such as dizziness, confusion and restlessness three times a day starting on 1/11/2026. The physician's orders did not include instructions to monitor the resident's blood sugar levels by performing fingerstick tests AC and HS, nor did they include instructions to monitor for signs and symptoms of hyperglycemia as reflected in the resident's GACH records. The physician order further indicated Resident 1's oral diabetes medications including Alogliptin-metformin tablet, 12.5-1,000 mg to be given twice daily for DM - 9 AM and 5 PM, and Jardiance tablet 25 mg, to give one tablet once a day for DM - 9 AM. During a review of Resident 1's Nursing Progress Note dated 1/11/2026 at 6:35PM, the Note indicated that Registered Nurse (RN) 4 notified Resident 1's attending physician Medical Doctor (MD 1) regarding Resident 1's readmission to the facility on 1/11/2026. The Note indicated Resident 1's Physician Orders were verified and carried out. There is no documented evidence that RN 4 verified with MD 1 whether Resident 1 required continued fingerstick testing to establish baseline blood sugar levels in order to manage the resident's diabetes. During a review of Resident 1's History and Physical (H&P) signed and dated on 1/26/2026 signed by NP 1 indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated that Resident 1's Type 2 DM required monitoring. During a review of a physician order dated 2/5/2026, the order indicated to perform a stat laboratory work for comprehensive metabolic panel (CMP). During a review Resident 1's Comprehensive Metabolic Panel (CMP - Blood test) dated 2/5/2026, the Panel indicated that Resident 1 blood sugar was 351 mg/dL. During a review of Resident 1's Nursing Progress Note dated 2/5/2026 at 10:11 PM, the Note indicated Licensed Vocational Nurse (LVN) 1 communicated the CMP results to MD 1. The documentation further indicated that no new orders were given by MD 1 following this notification. During a review of Resident 1's physician order dated 2/5/2026, from NP 1, the order indicated to give 0.9 % Normal Saline (NS) via IV 1 liter bolus (a single, concentrated dose of medication or fluid given rapidly to achieve a quick effect) one time. During a review of the MAR dated 2/5/2026, the MAR indicated Resident 1 received the 0.9 % NS bolus via IV one time. During a review of Resident 1's physician order dated 2/6/2026 timed at 7:12 AM, from MD 1, the order indicated to give Dextrose 5% Water (D5W) via IV at 60 cc per hour for a total of 3 liters. During a review of the MAR dated 2/5/2026 to 2/8/2026, the MAR indicated Resident 1 received (D5W) via IV at 60 cc per hour. During a review of a facility cell phone communication with the physician, dated 2/6/2026 at 5:29 AM, showed that a screenshot of Resident 1's CMP results was texted to MD 1. The text message indicated that MD 1 ordered a change in the resident's intravenous fluids to dextrose 5% in water (D5W) at a rate of 60 cc/hr, with a total of 3 liters to be administered to Resident 1. During a review of Resident 1's Nursing Progress Note dated 2/6/2026 at 7:20 AM, the Note indicated MD 1 ordered intravenous (IV-in the vein) hydration for Resident 1 due to poor appetite. The order indicated to infuse D5W via IV at 60 cc/hr times, with a total infusion of 3L's. During a review of Resident 1' Nursing Progress Note dated 2/8/2026 at 3:55 PM, the Note indicated that Resident 1 had a change of condition (COC - a significant change in residents health) that Resident 1 was non-verbal, respirations were shallow, oxygen saturation was 87% (% - unit of measurement - normal range 95 - 100%), respiratory rate was 33 breaths per minute (bpm - unit of measurement - normal range 12 - 20 bpm), temperature was 100.7 ( - unit of measurement - normal range 97 to 99 ), heart rate (HR) was 133 beats per minute (bpm - unit of measurement - normal range 60 - 100 bpm), BG level was 463 mg/dL, Resident 1 was administered oxygen at 15 L via non-rebreather (Face-mask for oxygen delivery) and the oxygen saturation (measures the percentage of hemoglobin in red blood cells carrying oxygen, indicating how well blood is transporting oxygen throughout the body) was at 95%. During a review of Resident 1's clinical record indicated no documented evidence that Resident 1's blood sugar levels were being checked or that the resident was being monitored for signs and symptoms of high and low blood sugars in accordance with the resident's care plan titled Risk For Unstable blood glucose. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a communication tool to relay health information) dated 2/8/2026, the SBAR indicated that Resident 1 was non-verbal, respirations were shallow, oxygen saturation was 87%, respiratory rate was 33 beats per minute, temperature was 100.7 Fahrenheit ( ), heart rate was 133 bpm, BG level was 463 mg/dL. The SBAR indicated Resident 1 was administered oxygen at 15 L via non-rebreather, head of bed was elevated, and the oxygen saturation was at 95%. During a review of Resident 1' Nursing Progress Note dated 2/8/2026 at 4:10 PM, the Note indicated that the paramedic's (emergency responders)/911 (emergency services) was called. During a review of Resident 1's Paramedic Run Report dated 2/8/2026, the Report indicated that Paramedic's arrive at the facility at 4:16 PM and Resident 1 had an altered level of consciousness (ALOC), was not responding to his name. The Report indicated D5W IVF was discontinued due to Resident 1's high BG level of 530 mg/dL, and the electrocardiogram (devise to measure heart rhythm) indicated Resident 1 had sinus tachycardia regular, rapid heartrate) at 130 bpm, respiratory rate was 32 with labored breathing and Resident 1 was hot to touch with a temperature of 101 . During a review of Resident 1's GACH Records title Emergency (ED) Department Notes dated 2/8/2026, authored by the ED Physician the GACH record indicated that Resident 1 was admitted for altered level of consciousness, fever and hyperglycemia on 2/8/2026. The ED Notes indicated Also notably patient had a blood sugar of 350 [mg/dL] which they [facility licensed nurses] treated with dextrose. EMS [emergency medical services] decided to bring him [Resident 1] here [GACH] for further evaluation and management . The ED report indicated Resident 1's fingerstick blood sugar result taken at 4:35 PM was 530 mg/dL and 434 mg/dL at 4:55 PM. Resident 1's urine glucose level indicated high taken at 2/8/2026 timed at 6:22 PM. During a review of the GACH H&P dated 2/9/2026, authored by MD 1, the GACH H&P indicated Resident 1 was brought in the GACH for evaluation and was hyponatremic and hyperglycemic and in Acute Kidney Injury (AKI - the sudden, temporary loss of kidney function occurring over hours or days, leading to waste buildup in the blood). The H&P indicated Resident 1' diagnosis included Uncontrolled DM 2. During a telephone interview on 2/10/2026 at 7:58 AM with the local fire department Fire Chief (FC) 1, FC 1 stated that on 2/8/2026 at approximately 4:15 PM, Engine 25 responded to a 911 call regarding Resident 1 who was experiencing oxygen desaturation (a significant, temporary drop in blood oxygen saturation levels, generally falling below 90%) , ALOC, fever, tachycardia (rapid heart rate), and tachypnea (rapid breathing). FC 1 stated that he had received report from RN 1, who stated that Resident 1 had a change in condition with abnormal laboratory results. FC 1 stated that Paramedic (PM) 1, reviewed the laboratory report and noted an elevated fasting blood glucose level of 351 mg/dL dated 2/5/2026. FC 1 stated that he requested RN 1 to check Resident 1's blood sugar at that moment, which resulted in a level of 530 mg/dL. FC 1 stated Resident 1 was observed receiving IV fluids containing D5W infusing at 60 cc/hr. FC 1 stated that RN 1 reported to him that the IV D5W was ordered by MD 1. FC 1 stated that after the paramedics' assessment, PM 1 and PM 2 requested RN 1 to discontinue the IV D5W infusion. FC 1 stated they observed RN 1 to stop the IV infusion at that time. RN 1 responded and informed PM 1, PM 2, and FC 1 that the IV D5W infusion was already stopped but FC 1, PM 1, PM 2 all observed that the D5W IV was still infusing when they arrived and RN 1 only discontinued the IV infusion after RN 1 was asked to check the blood sugar and was told to discontinue the IVF. During a telephone interview on 2/10/2026 at 10:30 AM with PM 2, PM 2 stated on 2/8/2026 at approximately 4:15 PM, the 911 emergency services responded to a 911 call from the facility regarding a resident with oxygen desaturation. PM 2 stated upon arrival to Resident 1's room, Resident 1 was on high-flow oxygen at 15 L, non-responsive, and experiencing shortness of breath and an IV of D5W was observed infusing. PM 2 stated RN 1 reported to him that Resident 1 had abnormal laboratory results but could not recall which lab was result was abnormal. PM 2 stated that PM 1 reviewed Resident 1's lab results which indicated Resident 1's fasting blood glucose level was 351 mg/dL on 2/5/2026. PM 2 stated they instructed RN 1 to discontinue the D5W infusion. PM 2 stated RN 1 stopped the IV. PM 2 stated that PM 1, and FC 1 witnessed RN 1 stopping the IV when requested. PM 2 stated Resident 1 exhibited signs and symptoms consistent with hyperglycemia, including tachycardia, rapid respirations, and non-responsiveness. PM 2 stated Resident 1 was transported to GACH for a higher level of care at 4:38 PM. During an interview on 2/10/2026 at 12:14 PM with Registered Nurse (RN 2), RN 2 stated that Resident 1 had an IV infusing D5W at 60cc/hr per MD 1orders. RN 2 stated she was aware that Resident 1 had a history of type 2 DM and that Resident 1 BG were not being monitored because MD 1's orders did not indicate to monitor BG, and that Resident 1, and other residents who had a diagnosis of DM should be monitored. During a concurrent interview and record review on 2/10/2026 at 12:25 PM with RN 2, Resident 1 Nursing Notes dated 2/5/2026 at 10:11 AM was reviewed. RN 2 stated that LVN 1 had documented that Resident 1's stat (an abbreviation meaning immediately in medical context) laboratory (lab) result, which was a complete blood count (CBC) and comprehensive metabolic panel (CMP) dated 2/5/2026, were reported to MD 1 via text message using the facility's designated cellphone on 2/6/2026 during the 11 PM to 7 AM shift. RN 2 stated that the lab results dated 2/5/2026 had an abnormal lab value but could not recall which lab result it was since RN 2 had not reviewed the CBC and CMP lab results prior to sending the text message to MD 1 on 2/5/2026. RN 2 stated after she reviewed the Stat lab results, the results indicated Resident 1's fast blood glucose (a blood test measuring glucose levels after at least 8 hours without eating, usually in the morning) was 351 mg/dL. During the same interview on 2/10/2026 at 12:25 PM, RN 2 stated that on 2/8/2026, Resident 1 was awake and alert with an IV of D5W infusing at 60 cc per hour. RN 2 stated that she failed to identify or act upon Resident 1's elevated blood sugar level lab result of 351 mg/dL dated 2/5/2026 while the D5W infusion was ongoing since 2/6/2026 because she did not review the stat lab results indicating a high fasting blood glucose level of 351 mg/dL. RN 2 further stated that RN 1 later observed that day on 2/8/2026, a change in Resident 1's condition, noting droopy eyes, non-responsiveness, and nonverbal behavior, but did not stop the D5W infusion or notify MD 1 at that time. During an interview on 2/10/2026 at 1 PM with RN 3, RN 3 stated that Licensed Vocational Nurse (LVN) 2, who was the night shift charge nurse did not endorse that Resident 1's fasting blood glucose lab result take on 2/5/2026 was high at 351 mg/dL prior to starting the IV infusion of D5W on 2/6/2026. RN 3 stated she was the nurse who received and reviewed the telephone order from MD 1 to start one of the 3 liters of D5W at 60 cc/hr for Resident 1 due to poor appetite. RN 3 stated that she started the IV D5W at around 7:30 AM on 2/6/2026. RN 3 stated she did not review Resident 1 abnormal fasting blood glucose lab result dated 2/5/2026. RN 3 stated she should have reviewed the stat lab results dated 2/5/2026 to see the abnormal lab findings of high blood glucose of 351 mg/dL. RN 3 stated Resident 1's signs and symptoms of hyperglycemia and blood sugar levels should have been monitored while at the facility, especially when the D5W started infusing on 2/6/2026. RN 3 stated that the IV D5W caused Resident 1's blood sugar level to increase. RN 3 stated that Resident 1 did not have any orders for blood sugar fingerstick monitoring since being admitted to the facility even when Resident 1 had a diagnosis of Type 2 DM. RN 3 stated that Resident 1 should have been monitored for fingerstick blood sugar levels and she should have clarified the DM monitoring parameters with MD 1. RN 3 stated she did not clarify the monitoring parameters for Resident 1's DM to ask how hypoglycemia and hyperglycemia would be monitored for Resident 1's Type 2 DM. During a concurrent interview and record review with the DON on 2/10/2026 at 2 PM, it was identified that Resident 1's facility cell phone communication to MD 1 on Friday, 2/6/2026 at 5:29 AM showed a screenshot of the STAT lab results, including the abnormal blood glucose level. The message was sent by RN 2 to MD 1 that read, MD 1, here are the STAT results of Resident 1's labs. The DON stated that MD 1 had responded on 2/6/2026 and texted an order to change Resident 1's IVF to D5W to infuse at 60cc/hr with a total of 3 Liters. The DON stated that the licensed nurses were following MD 1's order, but the order should have been clarified since Resident 1's fasting blood glucose lab result was high at 351 mg/dL. The DON stated that licensed nurses should have monitored Resident 1 for hyperglycemia while infusing D5W because the IVF D5W would cause Resident 1 to be hyperglycemic (a condition in which the level of glucose in the blood is higher than normal). The DON stated that the licensed nurses should have asked MD 1 or NP 1 for clarification as to why Resident 1 did not have fingerstick blood sugar monitoring for the diagnosis of Type 2 DM and documented the rationale (reason). The DON stated that there was no documentation on Resident 1's H&P, MD 1's or NP 1's progress notes from admission to readmission dates to indicate why Resident 1 did not receive blood sugar fingerstick monitoring at the facility and when the resident was receiving the D5W. The DON stated that by not monitoring Resident 1's blood sugar, the resident's glucose levels increased, resulting in the need for transfer to the GACH. During an interview on 2/10/2026 at 3:29 PM, LVN 1 stated that she received Resident 1's STAT CBC and CMP lab results, which included an abnormal value, on 2/5/2026. LVN 1 stated that she reported the abnormal lab result to MD 1 via a text message to MD 1's cell phone and also left a voicemail message on 2/6/2026. LVN 1 stated that she additionally faxed the lab results to MD 1's office. LVN 1 stated she documented that MD 1 was notified; however, she did not document indicating which lab result was abnormal or the specific abnormal value that was reported to MD 1. During a telephone interview on 2/11/2026 at 12 PM with RN 4, RN 4 stated that Resident 1 was readmitted from the GACH on 1/11/2026 at around 6 PM with diagnosis of Type 2 DM. RN 4 stated that he had spoken to MD 1 at 6:35 PM and verified all of Resident 1's GACH discharge orders. RN 4 stated MD 1 did not want to reorder Resident 1's fingerstick blood sugar monitoring before meals (AC) and at bedtime (HS), indicated in the GACH discharge instructions. RN 4 stated that MD 1 told RN 4 he would come to the facility on 1/12/2026 and assess and review the orders. RN 4 stated that he did not document in the nursing notes regarding the blood sugar monitoring not being reordered by MD 1 and the reason why it was not reordered. RN 4 stated he only documented that all the orders for Resident 1 were verified and carried out. RN 4 stated he did not know if MD 1 came and visited Resident 1 on 1/12/2026. During the same telephone interview on 2/11/2026 at 12 PM with MD 1, MD 1 stated that Resident 1's health was declining and had poor oral intake with weight loss. MD 1 stated Resident 1 had Type 2 DM but was controlled with oral medications and did not require blood sugar monitoring. MD 1 stated that when Resident 1 was readmitted to the facility on [DATE], MD 1 spoke with RN 3 and reviewed Resident 1's medication list and orders. MD 1 stated that he told RN 3 not to renew the fingerstick blood sugar monitoring for AC and HS and that he would assess and review Resident 1's the following day on 1/12/2026. MD 1 stated Resident 1's blood sugar level were at an acceptable level when Resident 1 was readmitted and did not require monitoring. MD 1 stated he did not document this plan in Resident 1's progress notes. MD 1 stated that the facility informed MD 1 on 2/6/2026 at 5:29 AM that Resident 1 STAT lab results had indicated that Resident 1's fasting blood glucose level was 351 mg/dL and he was in a hyperglycemic state. MD 1 stated that he ordered Resident 1 to receive 3 liters of D5W at 60cc/hr. MD 1 stated that Resident 1 needed nutrition because of his poor oral intake and the D5W was to provide nutrition. MD 1 stated he wanted to treat the poor nutrition with the D5W for comfort because Resident 1 was declining. MD 1 stated he was aware of the complications and what could happen while Resident 1 received D5W while in a hyperglycemic state, but MD 1 stated the priority for Resident 1 was nutrition and making Resident 1 comfortable. During a telephone interview on 2/11/2026 at 1:35 PM with NP 1, NP 1 stated that she worked with MD 1 and was managing the care of Resident 1. NP 1 stated that Resident 1 had a history of Type 2 DM. NP 1 stated that Resident 1 was not being monitored for fingerstick blood sugars and Resident 1's DM was being treated with oral hypoglycemic medications. NP 1 stated Resident 1's DM was monitored with random blood works such as the CBC and BMP but Resident 1 should have had a fingerstick blood sugar monitoring for AC & HS while at the facility because of his Type 2 DM. NP 1 stated she did not know that Resident 1's readmission orders on 1/11/2026 for fingerstick blood sugar monitoring for AC and HS was not reordered as indicated in the GACH discharge orders. NP 1 stated she had written an order for Normal Saline (NS) IV fluids 1 liter on 2/5/26 at around 11:30 AM for Resident 1's poor oral intake and hyponatremia (low sodium level) and did not know if that was carried out by licensed staff. NP 1 stated that she was unaware that Resident 1's fasting blood glucose level was 351 mg/dL from the STAT lab result on 2/5/2026 because no one informed her. NP 1 stated the licensed staff did not communicate to her that Resident 1 was receiving D5W IV fluids instead of the NS IV fluids she ordered on 2/5/2026. NP 1 stated that she would not have ordered D5W while Resident 1 was in a hyperglycemic state. NP 1 stated that the D5W would have caused Resident 1 to experience hyperglycemic shock (a life-threatening emergency marked by severely high blood sugar, extreme dehydration, and altered mental status) such as loss of consciousness, fast heart rate, and rapid breathing. NP 1 stated she was unaware that Resident 1 had a change in condition on 2/8/2026 and was hospitalized for altered level of consciousness (ALOC), oxygen desaturation and high blood sugar of 520 mg/dL. During an interview on 2/12/2026 at 1:07 PM with the facility's Medical Director (MD 2), MD 2 stated if a resident was left in a hyperglycemic state it would lead to a resident getting dehydrated (loss of bodily water), electrolyte imbalance, ALOC, diabetic ketoacidosis (DKA - life threatening complication from high blood sugar) and acute renal failure (kidneys stop working). MD 2 stated that it is never a sound medical decision to keep any residents in a hyperglycemic state because the outcome would not benefit the resident and would lead to other serious medical issues. MD 2 stated that infusing D5W to Resident 1 while experiencing hyperglycemia would not provide nutritional value but further elevate Resident 1's blood glucose level and cause hyperglycemic shock. MD 2 stated that any resident with Type I or 2 DM needs to be monitored for fingerstick blood sugar AC and HS. During a review of the facility P&P titled Blood Glucose Monitoring for Diabetic Residents Experiencing COC undated, the P&P indicated that it is the policy of the facility to ensure safe monitoring and management of blood glucose levels for residents with diabetes mellitus who are experiencing a change of condition that may affect glycemic control. The P&P indicated blood glucose monitoring shall be performed via fingerstick in accordance with physician orders, nursing assessment, and recognized standards of nursing practice. The P&P indicated the facility recognizes that IV fluids containing dextrose, infections, decreased oral intake, medication changes, and other clinical conditions may significantly alter blood glucose levels and require increased monitoring. The P&P indicated the failure to monitor blood glucose in these situations may place residents at risk for hyperglycemia, hypoglycemia, dehydration, and hospitalization. The P&P indicated IV Therapy (Relevant to Glucose Monitoring) Includes but is not limited to: D5W and any dextrose-containing solution. The P&P indicated that the licensed nurse shall identify residents requiring blood glucose monitoring when the resident: Has a diagnosis of DM, is receiving IV therapy (especially dextrose-containing fluids), has a change of appetite or poor oral intake, has an active infection, has medication changes affecting glucose levels, exhibits symptoms of hypo or hyperglycemia and is NPO or has reduced nutritional intake. The P&P indicated that unless otherwise ordered by the physician. the licensed nurse shall initiate blood glucose monitoring when indicated by clinical condition, recommended monitoring frequency, Before meals and at bedtime (AC, HS), or Every 6 hours if not eating, or as ordered by physician. During a review of the facility P&P titled Diabetic Management undated, the P&P indicated that the facility will provide both preventive measures and treatment of complications pertaining to the management of residents with Diabetes Mellitus. The P&P indicated the facility will provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. The P&P indicated that upon admission, physician's orders are received, which include blood glucose monitoring and anti-diabetic agents. The P&P indicated that blood glucose orders will include parameters of when to call the physician if the glucose is too low or too high. The P&P indicated that hyperglycemia, uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia. The P&P indicated that the facility would follow the provider orders for blood glucose monitoring. Examples for various situations may include: for the resident on oral medication(s) who is well controlled, monitor blood glucose levels at least twice weekly (or more frequently if there is a change in drugs or drug dosages) for the resident receiving oral medication(s) who is poorly controlled: monitor blood glucose levels twice to four times daily as needed.

Based on interviews and record reviews, the facility failed to ensure that the resident's authorized practitioners (Medical Doctor [MD] 1 and Nurse Practitioner [NP] 1) adequately supervised and managed the medical care of Resident 1 as required under physician services for one of three sampled residents. The facility failed to: 1. Ensure licensed nursing staff and MD 1 reviewed and addressed the General Acute Care Hospital (GACH) discharge orders, including the need to reorder fingerstick blood sugar monitoring (AC & HS) upon readmission for Resident 1 with Type 2 Diabetes Mellitus (DM) at the facility on 1/11/2026. 2. Ensure that MD 1's verbal decision to the licensed nursing staff to discontinue the GACH discharge order for blood sugar monitoring for Resident 1 upon readmission on [DATE]-despite the resident's uncontrolled diabetes and risk for unstable blood glucose levels-and the rationale for this decision were documented in the medical record and communicated to NP 1. 3. Ensure the physician or practitioner responsible for the resident's care (MD 1 and NP 1) documented all assessments, clinical reasoning, treatment decisions, and licensed staff communications throughout the resident's stay, in accordance with the facility's policy and procedure titled Physician Services. 4. Ensure effective communication occurred among MD 1, NP 1, and licensed nursing staff regarding Resident 1's DM management, DM care plan titled Risk for unstable blood glucose levels ([low blood sugar] and [high blood sugar]), change in condition, critical laboratory results, and ordered treatments (from NP 1 and MD 1). 5. Ensure MD 1 communicate to NP 1 his treatment plan that Resident 1 was intentionally left without blood sugar monitoring while in a hyperglycemic state on 2/6/2026 to 2/8/2026, upon ordering D5W to be administered intravenously for nutrition, leaving NP 1 unaware of the resident's condition and treatment needs. These failures resulted in Resident 1 not receiving required monitoring and timely intervention for hyperglycemia, being administered D5W IV fluids while in a hyperglycemic state, and experiencing a significant decline in condition, including altered level of consciousness, oxygen desaturation, and critically elevated blood glucose levels requiring hospitalization. Findings: During a review of Resident 1's diabetes care plan titled Risk for Unstable Blood Glucose Level (low and high blood sugar levels), initiated during Resident 1's initial admission at the facility dated 12/11/2025 with a goal date of 3/31/2026, the care plan indicated that Resident 1 should be checked for blood glucose (BG) if the level is below 70 mg/dL, and that if the resident is unconscious or vital signs are absent, staff should administer 1 milligram (mg) of Glucagon (a medication used to increase BG) intramuscularly (IM) and call 911. The care plan did not address how the licensed nurses would measure Resident 1's blood glucose levels to determine if they were below 70 mg/dL. The care plan interventions further indicated to observe for signs and symptoms (S/S) of high blood glucose levels and report observed S/S to the physician. During a review of Resident 1's General Acute Care Hospital (GACH) Records titled Orders Re-Cap (short for recapitulation that means to summarize the main points of something that has already been discussed or happened) dated 1/11/2026, the Recap indicated to renew (extend validity) Resident 1's fingerstick blood sugar before meals (AC-[ante-cebum which means before meals]) and at bedtime (HS -[hour of sleep]). The GACH records indicated that Resident 1 also had blood sugar checks as needed. The GACH records indicated to notify the physician when the blood sugar was greater than 250 mg/dL, and when the blood sugar was less than 70 mg/dL and to implement hypoglycemia protocol. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was readmitted to the facility on [DATE], with diagnoses of Type 2 DM and sepsis (a life-threatening medical emergency from an infection). During a review of Resident 1's History and Physical (H&P) signed and dated on 1/26/2026 signed by NP 1 indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated that Resident 1's Type 2 DM required monitoring. During a review of Resident 1's Physician Order Report dated 1/1/2026 to 1/31/2026, indicated that Resident 1 was to be monitored for signs and symptoms of hypoglycemia such as dizziness, confusion and restlessness 3 times a day starting on 1/11/2026. The order report did not indicate to monitor Resident 1 BG level with fingerstick AC & HS or to monitor for hyperglycemia. During a review of Resident 1's Nursing Progress Note dated 1/11/2026 at 6:35 PM, the Note indicated that Registered Nurse (RN) 4 notified Resident 1's attending physician Medical Doctor (MD 1) regarding Resident 1's readmission to the facility on 1/11/2026. The Note indicated Resident 1's Physician Orders were verified and carried out. There is no documented evidence that RN 4 verified with MD 1 whether Resident 1 required continued fingerstick testing to establish baseline blood sugar levels in order to manage the resident's diabetes. During a review of Resident 1's Physician Order Report from 1/11/2026 to 1/31/2026, the Report indicated that Resident 1 was to be monitored for signs and symptoms of hypoglycemia such as dizziness, confusion and restlessness three times a day starting on 1/11/2026. The physician's orders did not include instructions to monitor the resident's blood sugar levels by performing fingerstick tests AC and HS, nor did they include instructions to monitor for signs and symptoms of hyperglycemia as reflected in the resident's GACH records. During a review of Resident 1's Physiatry (physical medicine and rehabilitation) Progress Note dated 1/14/2026 at 1:41 PM, The Note indicated to monitor and evaluate obstacles to therapy including hypoglycemia. During a review of Resident 1' Nursing Progress Note dated 2/8/2026 at 3:55 PM, the Note indicated that Resident 1 had a change of condition (COC - a significant change in residents health) that Resident 1 was non-verbal, respirations were shallow, oxygen saturation was 87% (% - unit of measurement - normal range 95 - 100%), respiratory rate was 33 breaths per minute (bpm - unit of measurement - normal range 12 - 20 bpm), temperature was 100.7 ( - unit of measurement - normal range 97 to 99 ), heart rate (HR) was 133 beats per minute (bpm - unit of measurement - normal range 60 - 100 bpm), BG level was 463 mg/dL, Resident 1 was administered oxygen at 15 L via non-rebreather (Face-mask for oxygen delivery) and the oxygen saturation (measures the percentage of hemoglobin in red blood cells carrying oxygen, indicating how well blood is transporting oxygen throughout the body) was at 95%. During a review of Resident 1's entire records and validated with the Medical records supervisor and administrator, there were only three documented provider visits for the resident's stay at the facility from 12/11/2025 to 2/8/2026. The documented visits were identified as one H&P signed and dated by NP 1 on 12/14/2025 and another H&P signed and dated by NP 1 again, as well as one handwritten progress note authored and signed by NP 1 dated 2/5/2026. NP 1's H&Ps and Progress Notes with date that included 2/5/2026 indicated there was no documentation about how Resident 1's blood sugar monitoring should be performed by the licensed nurses, including a coordination with MD 1 about the plan not to monitor Resident 1's blood sugar via fingerstick as indicated in the GACH Discharge Instructions dated 1/11/2026. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a communication tool to relay health information) dated 2/8/2026, the SBAR indicated that Resident 1 was non-verbal, respirations were shallow, oxygen saturation was 87%, respiratory rate was 33 beats per minute, temperature was 100.7 Fahrenheit ( ), heart rate was 133 bpm, BG level was 463 mg/dL. The SBAR indicated Resident 1 was administered oxygen at 15 L via non-rebreather, head of bed was elevated, and the oxygen saturation was at 95%. During a review of Resident 1' Nursing Progress Note dated 2/8/2026 at 4:10 PM, the Note indicated that the paramedic's (emergency responders)/911 (emergency services) was called. During a review of Resident 1's Paramedic Run Report dated 2/8/2026, the Report indicated that Paramedic's arrive at the facility at 4:16 PM and Resident 1 had an altered level of consciousness (ALOC), was not responding to his name. The Report indicated D5W IVF was discontinued due to Resident 1's high BG level of 530 mg/dL, and the electrocardiogram (devise to measure heart rhythm) indicated Resident 1 had sinus tachycardia regular, rapid heartrate) at 130 bpm, respiratory rate was 32 with labored breathing and Resident 1 was hot to touch with a temperature of 101 . During a review of Resident 1's GACH Records title Emergency (ED) Department Notes dated 2/8/2026, authored by the ED Physician the GACH record indicated that Resident 1 was admitted for altered level of consciousness, fever and hyperglycemia on 2/8/2026. The ED Notes indicated Also notably patient had a blood sugar of 350 [mg/dL] which they [facility licensed nurses] treated with dextrose. EMS [emergency medical services] decided to bring him [Resident 1] here [GACH] for further evaluation and management . The ED report indicated Resident 1's fingerstick blood sugar result taken at 4:35 PM was 530 mg/dL and 434 mg/dL at 4:55 PM. Resident 1's urine glucose level indicated high taken at 2/8/2026 timed at 6:22 PM. During an interview on 2/10/2026 at 12:14 PM with Registered Nurse (RN 2), RN 2 stated that Resident 1 had an IV infusing D5W at 60cc/hr per MD 1orders. RN 2 stated she was aware that Resident 1 had a history of type 2 DM and that Resident 1 BG were not being monitored because MD 1's orders did not indicate to monitor BG, and that Resident 1, and other residents who had a diagnosis of DM should be monitored. During a concurrent interview and record review with the DON on 2/10/2026 at 2 PM, the DON stated that MD 1 had responded on 2/6/2026 and texted an order to change Resident 1's IVF to D5W to infuse at 60cc/hr with a total of 3 Liters. The DON stated that the licensed nurses were following MD 1's order, but the order should have been clarified since Resident 1's fasting blood glucose lab result was high at 351 mg/dL . The DON stated that the licensed nurses should have asked MD 1 or NP 1 for clarification as to why Resident 1 did not have fingerstick blood sugar monitoring for the diagnosis of Type 2 DM and documented the rationale (reason). The DON stated that there was no documentation on Resident 1's H&P, MD 1's or NP 1's progress notes from admission to readmission dates to indicate why Resident 1 did not receive blood sugar fingerstick monitoring at the facility and when the resident was receiving the D5W. The DON stated that by not monitoring Resident 1's blood sugar, the resident's glucose levels increased, resulting in the need for transfer to the GACH. During a telephone interview on 2/11/2026 at 12 PM with RN 4, RN 4 stated that Resident 1 was readmitted from the GACH on 1/11/2026 at around 6 PM with diagnosis of Type 2 DM. RN 4 stated that he had spoken to MD 1 at 6:35 PM and verified all of Resident 1's GACH discharge orders. RN 4 stated MD 1 did not want to reorder Resident 1's fingerstick blood sugar monitoring before meals (AC) and at bedtime (HS), indicated in the GACH discharge instructions. RN 4 stated that MD 1 told RN 4 he would come to the facility on 1/12/2026 and assess and review the orders. RN 4 stated that he did not document in the nursing notes regarding the blood sugar monitoring not being reordered by MD 1 and the reason why it was not reordered. RN 4 stated he only documented that all the orders for Resident 1 were verified and carried out. RN 4 stated he did not know if MD 1 came and visited Resident 1 on 1/12/2026. During the same telephone interview on 2/11/2026 at 12 PM with MD 1, MD 1 stated that Resident 1's health was declining and had poor oral intake with weight loss. MD 1 stated Resident 1 had Type 2 DM but was controlled with oral medications and did not require blood sugar monitoring. MD 1 stated that when Resident 1 was readmitted to the facility on [DATE], MD 1 spoke with RN 3 and reviewed Resident 1's medication list and orders. MD 1 stated that he told RN 3 not to renew the fingerstick blood sugar monitoring for AC and HS and that he would assess and review Resident 1's the following day on 1/12/2026. MD 1 stated Resident 1's blood sugar level were at an acceptable level when Resident 1 was readmitted and did not require monitoring. MD 1 stated he did not document this plan in Resident 1's progress notes. MD 1 stated that the facility informed MD 1 on 2/6/2026 at 5:29 AM that Resident 1 STAT lab results had indicated that Resident 1's fasting blood glucose level was 351 mg/dL and he was in a hyperglycemic state. MD 1 stated that he ordered Resident 1 to receive 3 liters of D5W at 60cc/hr. MD 1 stated that Resident 1 needed nutrition because of his poor oral intake and the D5W was to provide nutrition. MD 1 stated he wanted to treat the poor nutrition with the D5W for comfort because Resident 1 was declining. MD 1 stated he was aware of the complications and what could happen while Resident 1 received D5W while in a hyperglycemic state, but MD 1 stated the priority for Resident 1 was nutrition and making Resident 1 comfortable. During a review of Resident 1's physician progress notes. There was no progress notes found written by MD 1 during Resident 1's stay at the facility from 1/11/2026 to 2/8/2026. There was no progress note documented on MD 1 on 1/12/2026 as indicated in the above interview that Resident 1 would be visited by MD 1 and assessed on 1/12/2026. During a phone interview on 2/11/2026 at 1:35 PM with Nurse Practitioner (NP) 1, NP stated that she worked with MD 1 and was managing the care of Resident 1. NP stated that Resident 1 had a history of type 2 DM. NP stated that Resident 1 was not being monitored for BG with fingerstick and Resident 1 DM was being treated with oral hypoglycemic medication. NP stated Resident 1 DM was monitored with random blood work such as the CBC and BMP but Resident 1 should have had BG monitoring for AC & HS because of his type 2 DM. NP stated she was unaware of Resident 1 readmission order for BS monitoring for AC and at bedtime was not reordered. Mg/dL. During a telephone interview on 2/11/2026 at 1:35 PM with NP 1, NP 1 stated Resident 1's DM was monitored with random blood works such as the CBC and BMP but Resident 1 should have had a fingerstick blood sugar monitoring for AC & HS while at the facility because of his Type 2 DM. NP 1 stated she did not know that Resident 1's readmission orders on 1/11/2026 for fingerstick blood sugar monitoring for AC and HS was not reordered as indicated in the GACH discharge orders. NP 1 stated she had written an order for Normal Saline (NS) IV fluids 1 liter on 2/5/26 at around 11:30 AM for Resident 1's poor oral intake and hyponatremia (low sodium level) and did not know if that was carried out by licensed staff. NP 1 stated that she was unaware that Resident 1's fasting blood glucose level was 351 mg/dL from the STAT lab result on 2/5/2026 because no one informed her. NP 1 stated the licensed staff did not communicate to her that Resident 1 was receiving D5W IV fluids instead of the NS IV fluids she ordered on 2/5/2026. NP 1 stated that she would not have ordered D5W while Resident 1 was in a hyperglycemic state. NP 1 stated that the D5W would have caused Resident 1 to experience hyperglycemic shock (a life-threatening emergency marked by severely high blood sugar, extreme dehydration, and altered mental status) such as loss of consciousness, fast heart rate, and rapid breathing. NP 1 stated she was unaware that Resident 1 had a change in condition on 2/8/2026 and was hospitalized for altered level of consciousness (ALOC), oxygen desaturation and high blood sugar of 520 mg/dL. During an interview on 2/12/2026 at 1:07 PM with the Medical Director (MD 2), MD 2 stated that it is never a sound medical decision to keep any residents in a hyperglycemic state because the outcome would not benefit the resident and would lead to other serious medical issues. MD 2 stated that infusing D5W to Resident 1 while experiencing hyperglycemia would not provide nutritional value but further elevate Resident 1's blood glucose level and cause hyperglycemic shock. MD 2 stated that any resident with type I or 2 DM needs to be monitored for BG AC & HS. During a review of the facility's P&P titled Physician Services (undated), the P&P indicated physician services included but not limited to the following: A medical evaluation of the resident and review of orders for care and treatment, resident diagnoses and plan of care, advice, treatment, and determination of appropriate level of care needed for each resident, progress notes and other appropriate entries in the resident's medical record. The P& P further indicated that the resident's plan of care (including medication and treatments) must be reviewed at each required visit. The P& P further indicated that the physician who uses the services of an NP . agrees to ensure the physician make the initial visit and may alternate subsequent required visits with the delegate (NP) ad agrees to be bound by all policies, procedures, rules, and regulations covering physician services During a review of the facility P&P titled Physician Order (undated), indicated that the physician orders are obtained to provide a clear direction in the care of the resident. The P&P indicated upon receipt of a discontinuation order, the licensed nurse must transcribe the order (This applies to discontinuation of medication and/or treatment) and the licensed nurse makes notation of discontinuation by writing the following on the MAR, TAR, and any other pertinent document.

Based on observations, interviews and reviews, the facility failed to ensure monitoring and supervision was provided to one of three sampled residents (Resident 1), who was assessed as a high-fall-risk resident, by failing to: Develop and implement individualized care plan interventions to minimize the occurrence of falls in accordance with the Policy and Procedure (P&P) titled Falling Star Program. Identify specific monitoring required while Resident 1 was on the Falling Star Program. Conduct resident observations in accordance with the P&P for the Falling Star Program.Perform and document scheduled safety round as indicated by the P&P for the Falling Star Program. Determine and identify the type and frequency of supervision required in accordance with the facility's P&P for Safety and Supervision. Ensure interventions were implemented and documented in accordance with the facility's P&P for Safety and Supervision. These deficient practices resulted in Resident 1 sustaining two unwitnessed falls at the facility on 12/15/2025 and 1/25/2026, with the second fall requiring transfer to the General Acute Care Hospital (GACH) on 1/25/2026 where Resident 1 was diagnosed with a left femur fracture and had to undergo open reduction internal fixation (ORIF - surgery to repair a severely broken bone) surgery on 1/26/2026. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 1/27/2025, with diagnoses of unsteadiness on feet (poor balance), a history of falling and osteoarthritis (bones breaks over time from lack of cushion). During a review of Resident 1's History and Physical (H&P) dated 8/28/2025, the H&P indicated Resident 1 had a fluctuating capacity to understand and make decisions but was in cognitive decline (problems with a person's ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/31/2025, the MDS indicated the resident had moderately impaired cognition. MDS indicated that Resident 1 was partial/moderate assistance for activities of daily living (basic self-care tasks). During a review of Resident 1's Fall Risk Collection record dated 12/15/2025, the Record indicated that Resident 1 was at a high risk for falls with a score of 14 (Score of 14 or above represents a higher risk of falling exist and resident requires increased supervision. During a review of Resident 1's Care Plan for Self transfer without using call light, dated 6/30/2025, the Care Plan indicated to continue use of pad alarm (a pressure-sensitive, wearable, or moisture-detecting device used to alert caregivers when a person leaves a bed/chair) while in the wheelchair and bed. During a review of Resident 1's Care Plan for non -compliant, Resident turns off pad alarm, dated 7/8/2025, the Care Plan indicated to educate resident not to turn off pad alarm. There were no newly updated interventions on the care plan. During a review of Resident 1's Care Plan for Actual Fall, dated 8/23/2025, the Care Plan indicated interventions that Resident 1 would continue the use of pad alarm in bed. During a review of Resident 1's Care Plan titled Falls, dated 8/27/2025, and revied 1/27/2025, the Care Plan interventions indicated that Resident 1 was on the falling star program, had a self release soft belt (a patient safety device designed to prevent falls and unassisted exits from beds or wheelchairs while allowing for limited, independent movement), and a pad alarm. During a review of Resident 1's Care Plan titled Falls dated 12/15/2025, the Care Plan interventions indicated that Resident 1 had an actual fall in her room on 12/15/25. The care plan indicated that Resident 1's goal was to minimize repeat fall as much as possible. The care plan indicated interventions to continue use of pad alarm. There was not indication of any additional monitoring on the care plan. During a review of Resident 1's Situation Background Assessment Recommendations (SBAR - a tool used to relay critical healthcare information) dated 12/15/2025 at 1 PM, the SBAR indicated that Resident 1's bed pad alarm was sounding and Registered Nurse (RN 1) found Resident 1 on the floor lying on her left side next to her bed with no apparent injury. During a review of Resident 1's Risk Meeting Notes Weekly dated 12/20/2025, the Notes indicated that Resident 1 will have no further falls, will have self-release soft belt to wheelchair to prevent falling, and pad alarm on bed. During a review of Resident 1's SBAR dated 1/25/2026 at 1 PM, the SBAR indicated that Certified Nursing Assistant (CNA) 1 heard Resident 1's bed pad alarm sounding and when CNA 1 entered Resident 1's room, CNA 1 found Resident 1 lying on the floor, flat on her back. CNA 1 reported to Licensed Vocation Nurse (LVN) 1. The SBAR indicated that Resident 1 was assessed, and no injuries were observed. The SBAR indicated that Resident 1 was assessed for pain and reported a level 3 out of 10 pain on a pain scale (a subjective tool, most commonly a 0-10 numeric rating system, used by clinicians to measure pain intensity and guide treatment). Resident 1 was administered pain medication. During a review of Residents 1's Care Plan titled Falls dated 1/25/2026, the Care Plan indicated that Resident 1 had an actual fall and was found on the floor lying on her back. The care plan indicated interventions to continue pad alarm in bed and soft belt in the wheelchair. There was not additional interventions to indicate monitoring. During a review of Resident 1's Nursing Progress Notes dated 1/25/2026 at 5 AM, the Note indicated that Resident 1 bed pad alarm sounded, and when CNA 1 entered Resident 1's room, Resident 1 was on the floor lying on her back. The Note indicated that LVN 1 had assessed Resident 1 and no bodily injuries were observed, however Resident 1 complained of left leg pain and was medicated for pain. During a review of Resident 1's Medication Administration Record for 1/1/26 to 1/31/26, the Record indicated that Resident 1 was medicated with Tylenol (pain medication) 500 milligrams (mg - unit of measurement) for pain on 1/25/2026 at 4:54 AM. During a review of Resident 1's Medication Administration Records for 1/1/26 to 1/31/26, the record indicated that Resident 1 was medicated with Tylenol (pain medication) 500 milligrams (mg - unit of measurement) for pain on 1/25/2026 at 12:03 PM for complaints of left leg pain 8/10. During a review of Resident 1's Nursing Progress Notes dated 1/25/2026 at 12:10 PM, the Notes indicated that Resident 1's left leg was observed slightly externally rotated and RN supervisor was notified. The Note indicated at 12:20 PM the Nurse Practitioner (NP) was notified with orders to transfer Resident 1 to the General Acute Care Hospital (GACH) 1 for further evaluation. The Note indicated at 1:05 PM Emergency Medical Technician (EMT) arrived and transported Resident 1 to GACH 1. During a review of Resident 1's General Acute Care Hospital (GACH 1) records dated 1/25/2026, the records indicated that Resident 1 was brought to the emergency room because Resident 1 had a fall with leg pain. The GACH indicated that an x-ray of Resident 1's left hip with 2 to 3 views resulted in left femur (largest bone in the body) fracture and Resident 1 had to undergo ORIF surgery on 1/26/2026. During a review of Resident 1's Risk Meeting Notes Weekly dated 1/25/2026, the Notes indicated that Resident 1's fall incident was an isolated incident, unavoidable and Resident 1's plan of care included the bed pad alarm, bed in low position and falling star program for closer monitoring. During a review of Resident 1's Observation Detail List Report for Interdisciplinary Team (IDT) risk meeting notes initial week one status post fall, dated 1/26/26 at 10 AM, the report indicated the plan of care included bed alarm, and falling star program for closer monitoring. The Report indicated IDT would recommend impact pad when Resident [1] is in bed to reduce risk of injury from fall, upon return from the hospital. During a review of Resident 1's Nursing Progress Notes dated 2/3/2026 at 2 PM, the Note indicated Resident 1 was readmitted back to the facility with a diagnosis of left femur fracture and ORIF of the left femur. During an observation of Resident 1 room on 2/4/2026 at 1:25 PM, Resident 1 room did not have a fall mat at the side of her bed. During an interview on 2/4/2026 at 1:50 PM with CNA 2, CNA 2 stated that Resident 1 was a high fall risk and was on the falling stars program (Identifies residents at high risk for falls/injuries and visually monitors them) because she had more than 1 fall while in the facility. CNA 2 stated that Resident 1 was alert to self and required frequent reminders to use the call light for assistance. CNA 2 stated that Resident 1 did not have a fall mat. During an interview on 2/4/2026 at 2:45 PM with RN 1, RN 1 stated that Resident 1 was assessed as a high risk for falls resident and was on the falling stars program after Resident 1 sustained a second fall on 1/25/2026. RN 1 stated that residents on the falling stars program were all residents who were assessed as a high fall risk, and that a designated staff from the activities department and one CNA monitored these residents in the morning at 8 AM to 4 PM and afternoon starting at 4 PM to 11 PM. There was no monitoring conducted from 11 PM to 7 AM. RN 1 stated that Resident 1 had a fall on 12/15/2025 at around 1 PM without any injuries and a second fall, which was unwitnessed on 1/25/2026 at around 5 AM. RN 1 stated that CNA 1 heard Resident 1's bed pad alarm alerting and found Resident 1 on the floor lying on her back. RN 1 stated that Resident 1 was assessed for any displacement and neuro-checks were done. RN 1 stated that Resident 1 was medicated for pain with Tylenol per physician orders. RN 1 stated that Resident 1 had complained of increased pain of 8/10 to the left leg at 12 PM on 1/25/2026 and the NP was notified. The NP had ordered for Resident 1 to be transferred to GACH 1 for a higher level of care. RN 1 stated that Resident 1 was transferred to the GACH at 1:15 PM During an interview on 2/4/2026 at 3:20 PM with CNA 1, CNA 1 stated that on 1/25/2026 at 5 AM, she had started her rounds since she heard Resident 1 pad alarm alerting. CNA 1 stated when she had entered Resident 1's room she observed Resident 1 lying on her back on the floor. CNA 1 stated that she then called for help and LVN 1 came to help. CNA 1 that LVN 1 had assessed Resident 1 for any injuries, then Resident 1 was assisted back in bed. During an interview on 2/4/2026 at 3:45 PM with the Director of Nursing (DON), DON stated that Resident 1 was identified as a high risk for falls since admission to the facility should have been placed on the falling star program to increase monitoring and supervision of Resident 1. The DON stated that the falling star program may have prevented Resident 1 from sustaining a fall, since staff would provide more observations. DON stated that Resident 1 had her first fall without injury on 12/15/2025 at around 1 PM. DON stated that Resident 1 had a second fall with an injury on 1/25/2026 at 5 AM. DON stated that Resident 1 was transported to GACH 1 on 1/25/2026 at around 1 PM. DON stated that when Resident 1 was first assessed at 5 AM, Resident 1 did not present with any injuries and was medicated for pain with Tylenol. DON stated that around 12 PM Resident 1 had increased pain, Resident 1 left leg was assessed and appeared to be slightly externally rotated. DON stated that the NP was notified and ordered for Resident 1 to be transferred to GACH 1 for further evaluation. DON stated that GACH 1 reported that Resident 1 had sustained a left femur fracture. The DON stated Resident 1's care plans interventions were general and not specific to Resident 1 to address the type and frequency of monitoring required for Resident 1. The DON could not state what type of monitoring should be implemented for Resident 1 and that only visual monitoring was conducted, however the monitoring was not documented. The DON stated that when a resident was on a falling star program, it was because the resident was at high risk for falls and required more supervision. The DON stated when a resident was provided increased monitoring supervision, it may prevent the occurrence of falls. DON stated that Resident 1 did not have a fall mat because the floor mat presented an environmental hazard. DON stated that Resident 1 had an unsteady balance and the spongy surface of the fall mat would cause Resident 1 to lose her balance and fall, therefore use of a floor mat was never done for Resident 1. During a review of the facility P&P titled Safety Supervision of Residents revised on 9/12/2025, the P&P indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. The P&P indicated resident supervision is a core component of the systems approach to safety and the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P indicated the type and frequency of resident supervision may vary among residents and over time for the same resident, for example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. During a review of the facility P&P titled Fall Management undated, indicated based on previous evaluations and current data, the staff will Identify interventions related to the resident's specific risks and causes to try to reduce the risk of the resident falling and to try to minimize complications from falling. The P&P indicated if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. The P&P indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. During a review of the facility P&P titled Falling Star Program undated, indicated that The Falling Star Program identifies residents at highest risk for falls and/or injuries. The P&P indicated that the program is designed to monitor these residents and determine the predisposing factors and underlying reasons for the fall incidents, develop and implement a plan of care to minimize the risk of falls and major injuries. The P&P indicated the Admitting Licensed Nurse/Licensed Nurse Designee will complete the Fall Risk Data Collection upon admission, quarterly, after every fall incident, and whenever there is a significant change in resident's status. The P&P indicated that residents with a total score of 14 and above will be initially placed in the Falling Star Program by the Admitting Licensed Nurse/Licensed Nurse Designee.

Based observation, interview, and record review, n 12/14/2025, the facility failed to ensure one of two sampled residents ( Resident 1) received timely assistance with activities of daily living (ADLs), specifically incontinence care (timely assistance with personal hygiene, support , maintaining comfort, dignity, skin integrity, and health). This deficient practice resulted in Resident 1 experiencing moisture - associated skin damage ( MASD a medical term for inflammation, redness, and erosion of the skin from prolonged contact with moisture (urine, sweat, wound drainage, saliva, stool), often worsened by friction, pH, or microbes, leading to skin breakdown, especially in folds or around stomas/wounds0 and having the potential for further skin breakdown, pain, discomfort, and possible infection.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE], with a diagnosis of Heart failure( heart is not able to pump blood as well as it should), diabetes( high blood sugar) , acute embolism( sudden blockage of the blood vessel). During a review of Resident 1's History and Physical ( H&P) , dated 10/28/2025, the H&P indicated the resident 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) , the MDS indicated Resident 1 has moderate cognitive impairment (trouble with memory, and may be confused at times) requiring total assistance with toileting hygiene (personal hygiene, adjust clothes before and after voiding or having a bowel movement). During a review of Resident 1's care plans titled Non - pressure non - surgical wound: MASD type of wound site: coccyx (tailbone), dated 12/16/2025 indicated a goal that Resident 1 would experience timely healing of the wounds without complications. The Care Plan indicated resident's risk for wound infection would be minimized by intervention of Calmoseptine (protects skin from irritants like urine, feces, and sweat) topical ointment to coccyx MASD. During a review of Resident 1's care plan titled Pressure Ulcer Risk dated 10/29/2025, the Care Plan indicated a goal to minimize the development of pressure ulcers and or skin breakdown by assisting in turning and repositioning, encourage mobility and change of position when in bed or in chair, and provide skin care. During a review of Resident 1's Point of Care Responses (documentation of toileting assistance by certified nurse assistance (CNA), the responses indicated Resident 1 received toileting assistance on 12/14/2025 at 11:57 AM. The response indicated the next documented episode of assistance for toileting did not occur until 6:30 PM, 6.5 hours in- between toileting or incontinence care. During a review of Resident 1' s Situation, Background, Assessment and Recommendation (SBAR) form , dated 12/16/2025, the SBAR indicated Resident 1 had frequent bowel and bladder ( B &B) incontinence (inability to control urination or bowel movements), with small amount of bleeding on coccyx area and superficial skin breakdown. During a review of Resident 1's Physician Order Report, dated 12/16/2025, the Report indicated Calmoseptine ( topical skin protectant )ointment was ordered to be applied daily to the Coccyx MASD. During an interview on 12/18/2025 at 10:40AM, with Resident 1 and Family Member ( FM1), Resident 1 stated on Sunday 12/14/2025, Resident 1 felt she was not being cared for. Resident 1 stated after lunch she asked for help, since she was wet and needed to be changed, but no one ever came to assist Resident 1. During an interview on 12/18/2025 at 10:50AM, with FM 1, FM 1 stated that on 12/14/2025 at approximately 4 PM, Resident 1 called FM 1and reported she was not being taken care for at the facility. FM1 stated arriving at the facility at 4:15PM and observed Resident 1's brief wet. FM1 stated asking the assigned CNA ( CNA2) if her mother had been changed and that CNA 2 stated she had already checked the resident and stated she was okay, and would change the resident after dinner. FM1 stated from the time she arrived at 4:15 pm to approximately 7 PM, Resident 1's wet brief had not been changed. FM1 stated pressing the call light at 4:15 pm and no staff responded . FM1 stated she then went to the nursing station, where staff informed her the assigned CNA was on break. No other CNA provided brief change for Resident 1 for approximately 3 hours and 45 minutes. During an interview on 12/18/2025 at 11 AM, with FM 1, FM 1 stated on 12/15/2025 during the evening, the CNA showed her the buttock area of Resident 1 and informed her that the resident had a wound. Family member ( FM1) stated the CNA told her the wound had been observed the prior night on 12/14/2025. FM 1 stated on 12/16/2025 ,she was not notified by the facility regarding the wound and believed the wound care nurse would have contacted her by then. FM stated she personally went to the wound care nurse with CNA on 12/16/2025 to report the wound to the buttock area, at which time the wound care nurse applied cream to the area. During an interview on 12/18/2025 at 12:03 PM with LVN 1, LVN 1 stated Resident 1 was incontinent of Bowel and Bladder ( B&B) , and experiences frequent episodes of incontinence, including loose stools. LVN 1 emphasized the importance of frequent brief changes to prevent skin breakdown. LVN 1 stated Resident 1 had MASD to the coccyx area, which was reported on 12/16/2025 by a CNA on the 11 PM to 7 AM shift, along with notification by Resident 1's Family member LVN1 stated it was her professional opinion that this type of wound could develop within a couple of hours if a soiled brief was left, wet with urine or stool. LVN1 further stated the wound had the potential for infection and further skin breakdown. During an interview on 12/18/2025 at 2:32 PM with Administrator ( ADM) , ADM stated the Point of Care form was a form that the CNA's documented when toileting or diaper changes occur for residents. During a review of the facility' s Policy and Procedure titled, Activities of Daily Living ( ADLs) , Supporting ( undated) , indicates the purpose of the policy is for residents to receive care, treatment, and services designed to maintain or enhance their capacity to perform activities of daily living ( ADLs). For residents who cannot independently perform ADLs, necessary services will be provided to ensure adequate nutrition, grooming , and personal and oral hygiene. Appropriate care and services will be provided for resident who are unable to carry out care, including appropriate support and assistance with hygiene and elimination ( toileting). Task will be documented in Point of Care ( POC) electronically . During a review of the facility's Policy and Procedure titled, Routine Checks of Residents ( undated), indicated staff shall make routine resident checks to help maintain resident safety and wellbeing. Routine checks involve identifying the needs for toileting assistance.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices (IPCP, a set of measures designed to protect patients and healthcare workers from avoidable infections) was implemented for one of three sampled residents (Resident 1) who was diagnosed with scabies (an itchy skin condition caused by a tiny bug, mite, that burrows into the skin), by failing to: 1. Place Resident 1 under contact precaution (infection control measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with a patient or their environment) on 5/13/25 when Resident 1 was diagnosed with scabies. Resident 1 was not placed under contact precaution until 5/15/25, two days after confirmed diagnosis. 2. Monitor and assess close contact residents who were exposed to Resident 1, that included, Resident 1's roommates, Resident 2 and Resident 3 and facility staff who had direct contact with Resident 1. 3. Implement MD 1order to administer Ivermectin (antiparasitic medication used to treat a variety of parasitic infections, including scabies) 3 mg oral tablets and Permethrin (topical medication used to treat scabies, a skin condition caused by mites) 5% cream as ordered on 5/15/25. 4. Notify Medical Doctor (MD) 2 after Ivermectin and Permethrin was not administered on 5/17/25 and 5/18/25. 5. Establish a surveillance system that included an accurate line listing of symptomatic residents and healthcare workers that allowed the facility to track, analyze and interpret the data, and identify concerns such an unusual increasing number of residents and employees with new and ongoing rashes. These deficient practices had the potential to spread infection to Resident 2, Resident 3, and all other residents, staff and visitors of the facility, and had the potential for worsening of skin condition and infection by not treating scabies as ordered by the physician. Resident 1 was described by certified nurse assistant (CNA) 1 as looking very uncomfortable. As a result, Resident 1 was transferred to the General Acute Care Hosptial (GACH) for further evaluation on 6/17/25. The General Acute Care (Gach) discharge summary indicated Resident 1 was transferred to the GACH due to extensive skin rashes with probable secondary infection. Finding: 1. During a review of Resident1's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of but not limited to Type 2 diabetes mellitus (inability to use insulin properly) with hyperglycemia (too much sugar in blood). During a review of Resident 1's Dermatology Report, dated 5/15/2025, the Dermatology Report indicated Resident 1 was evaluated for a rash on the trunk, abdomen, and legs. The Report indicated a reason for visit was for the presence of red, itchy lesions that had been present for over five months. The Report indicated Resident 1 was assessed as having scabies, on the trunk, back, and legs. The Report documented that the lesions were itchy and persistent and Resident 1 was prescribed treatment with Ivermectin 3mg oral tablets and Permethrin 5 % cream to start on 5/15/25. During a review of Resident 1's Physician order Report, dated 5/16/2025, the Report indicated an order to place Resident 1 was to be on contact precautions for scabies on 5/16/2025 to 5/23/2025. During a review Resident 1's Care Plan titled Infectious disease: Scabies Type of infection: Contact Isolation, dated 5/16/2025, the Care Plan indicated Permethrin Cream 5% applied externally from neck down to toes at night on 5/17/2025 then repeat in 1 week on 5/24/2025 then wash off in AM 5/25/2025. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) Notes, dated 5/16/2025, indicated orders for Ivermectin 3mg oral to give 5 tablets today (5/16/2025) and Permethrin Cream 5% topical to be administered on (5/17/2025) and wash off on (5/18/2025). Then repeat in 1 week 5/24/2025 then wash off in AM (5/25/2025). During a review of Resident 1's Change of Condition (COC) Notes, dated 5/17/2025, the COC indicated Resident 1 was on monitoring for scabies and general body scattered and distributed open nodules with on going treatment. The COC indicate contact isolation was implemented. During a review of Resident 1's Treatment Administration History (TAR), for May 2025, the TAR indicated the following: 1. On 5/17/25, Permethrin 5% cream was not administered. The TAR indicated a note indicating, spoke to family, she will bring medication tomorrow. 2. On 5/18/2025, Permethrin 5% cream was not administered. The TAR indicated a note indicating, Spoke to family, she said she would bring medication tomorrow. The TAR indicated the first dose of Permethrin 5% cream was not administered until 5/25/2025 at 8 PM,12 days after Resident 1 was diagnosed with scabies and 8 days after the physician ordered Permethrin 5% cream. During a review of Resident 1's Progress Note dated 5/22/25 at 3:31 PM, the Note indicated MD 1 ordered to 'apply cream from head to toe and shower on 5/23/25. The Note indicated a diagnosis of scabies and to keep on contact precaution. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 1 has limited ability to understand, process, and recall information, and unable to answer questions about time, place, or memory. MDS also indicated Resident 1 required Maximal assistance with toileting, showering and walking During a review of Resident 1's History and Physical (H&P), dated 6/11/2025, the H&P indicated, Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Care Plan titled Whole Body Rash, not controlled by Derma Consult, dated 6/17/2025, the Care Plan indicated to send Resident 1 to the GACH ER for therapy. During a review of Resident 1's Transfer Form, dated 6/17/2025, the Transfer form indicated reason for transfer was for further evaluation of generalized body rash and intravenous antibiotics. There as no mention of Resident 1's history of scabies, diagnoses on 5/ 15/2025. During a review of Resident 1's Physician order Report, dated 6/17/2025, the Report indicated no new orders for Permethrin on 5/24/25, on week after Resident 1's initial treatment on 5/17/25. The Report indicated Resident 1 was transferred to the GACH emergency room (ER) for further Evaluation. 2. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted on [DATE], with a diagnosis of but not limited to Metabolic encephalopathy (general term that means damage or disease affecting the brain). During a review of Resident 2's H&P dated 1/15/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 demonstrates adequate memory and recall abilities and was capable of participating in care planning and making informed decisions. Requiring moderate assistance (helper does less than half the work) when using manual wheelchair. During a review of Resident 2's Progress notes from 5/15/2025 to 6/17/2025, there was no documented evidence that indicated monitoring, or assessment was conducted for Resident 2 who was in close contact of Resident 1 who had a confirmed diagnosis of scabies. 3. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted on [DATE], with a diagnosis of but not limited to fractures of the ribs and heart disease. During a review of Resident 3's H&P dated 8/22/2024, the H&P indicated the resident does not have the capacity to understand or make decisions. During a review of Resident 3's Progress Notes from 5/15/2025 to 6/17/2025, there was no documented evidence that that indicated monitoring, or assessment was conducted for Resident 3 who was in close contact of Resident 1 who had a confirmed diagnosis of scabies. During a review of Resident 3's MDS dated [DATE], the MDS indicated resident 3 has very limited mental functioning and requires maximum assistance when up in wheelchair. During an interview on 6/26/2025 at 8:47AM with Family Member (FM2), FM 2 stated Resident 1 was hospitalized approximately two weeks ago for open, severe skin wounds. FM 2 stated Resident 1's skin condition had worsened, so FM 2 requested for Resident 1 to go to the GACH. FM 2 stated Resident 1 had the skin condition for about a month and described Resident 1's skin condition as nonstop scratching and that the skin looked like chicken pox. FM 1 and FM 2 while visiting observed Resident 1' s skin looking completely raw with blood present everywhere. FM 2 stated after speaking to Resident 1's Primary Physician and expressing concerns about Resident 1's condition, the resident was transferred to the GACH on 6/17/2025 for evaluation. During an interview on 6/26/2025 at 10:39 AM with Director of Nursing (DON), the DON stated on 5/15/2025, Resident 1 was seen by an outside Dermatologist. The DON stated the facility received a prescription for Permethrin cream for scabies. The DON stated when Resident 1 returned from the Dermatology appointment on 5/15/2025, Resident 1 was placed back into the same room with the roommates (Resident 2 and Resident 3). The DON stated the facility did not have an available room for isolation for Resident 1. The DON stated Resident 1 was on one side of room and Residents 2 and 3 were on the other side of room. The DON stated only Resident 1 was on isolation precautions while Residents 2 and 3 were permitted to move around within the room and around the facility. During a concurrent interview and record review on 6/26/2025 at 12 PM with the DON, Resident 2 and Resident 3's Progress notes from 5/15/2025 to 6/17/2025 were reviewed. The DON stated Resident 1's Progress Notes did not indicate Resident 1 was placed on isolation precautions or was monitored for scabies. During an interview on 6/26/2025 at 1:17 PM with CNA1, CNA1 stated Resident 1 had scabies and that only Resident 1 was placed on isolation inside the same room as Resident 2 and 3. CNA 1 stated Residents 2 and 3 were not placed on isolation, even though Resident 1 shared the same room. Resident 1 scratched a lot and that his arms would bleed from scratching. CNA 1 stated Resident 1 and looked very uncomfortable. During an interview on 6/26/2025 at 1:30 PM with Licensed Vocational Nurse (LVN 1), LVN 1 stated she was informed by the facility's infection preventionist (IP) that Resident 1 had a diagnosis of scabies. LVN 1 stated Resident 1 shared a room with Residents 2 and 3, but LVN 1 only monitored Resident 1. LVN 1 stated Residents 2 and 3 were not assessed or monitored for scabies exposure from Resident 1. During a concurrent interview and record review on 6/26/26/2025 at 1:44 PM with the DON, DON stated no monitoring, or assessment was conducted on Residents 2 and 3 for the exposure of scabies. During a concurrent interview and record review on 6/27/2025 at 9 AM with LVN 2, Resident 1's Short Message Service (SMS) communication between Licensed Vocational Nurse (LVN 2) and the in-house Dermatology Nurse practitioner (NP1) was reviewed. The SMS indicated on 5/13/ 2025 at 12:10 PM, LVN 2 sent a photograph via SMS of Resident 1's torso, arms, and legs to NP 1 for dermatological evaluation. The SMS indicated LVN 1 asked NP 1Does this look like scabies to you? The SMS indicated NP 1's response was Highly suspicious for Scabies and instructed to Treat as scabies - Need weight and face sheet. LVN 2 stated Resident 1's Primary Physician and the IP were notified on 5/13/25 of Resident 1's suspected scabies with no new order was received. During an interview on 6/27/2025 at 9:59 AM with IP, the IP stated that on 5/13/2025, Resident 1 was suspected to have scabies based on a visual review by the in-house dermatology provider who received a text photograph of Resident 1's skin. IP stated the dermatologist instructed staff to Treat as scabies. IP stated Resident 1's isolation was delayed because the resident's family requested to seek an outside dermatologist for a second opinion. IP stated contact isolation was not initiated until 5/16/2025, three days after the initial recommendation to treat as scabies. During an interview on 6/27/2025 at 9:59 AM with IP, IP stated that exposure tracking began on 5/13/2025, after resident 1 was suspected of having scabies. IP stated she obtained information from a form titled Stop and Watch that would be filled out by either the CNA's or the LVN's. IP stated if no form was submitted, she documented no changes.' IP stated no formal documentation, or assessments were being conducted daily or on each shift. IP stated the facility did not perform any diagnostic testing to verify whether any residents had scabies. During a review of the facility's policy and procedure (P&P) titled Scabies, Unknown date, indicated Scabies is defined as an infestation with a mite. Prevention and risk minimization accomplished by early detection, prompt isolation and implementation of transmission- based precautions. Infection control interventions should include residents undergoing treatment for scabies should be confined to their room, including appropriate personal protective equipment and evaluation of all resident contacts, including residents on the affected unit or wing, all nursing staff, and other facility staff who have had close resident contact. Documentation should include a comprehensive plan of care, progress notes describing signs, symptoms, treatment, and follow - up and an updated infection control log to track cases and interventions. During a review of the Facility's Policy and Procedure (P&P) titled infection Control Program, (No date), the P&P indicated outbreak management is a process that includes determining the presence of an outbreak, managing affected residents, preventing the spread to other resident, documenting information related to the outbreak, and educating staff. The policy also describes infection prevention measures, which include to identify possible infections or complications from existing infections, enhanced screening and to follow established general and disease specific guidelines, including those from the Centers for Disease control and prevention (CDC). According to the Centers for Disease Control and Prevention (CDC) publication titled Public Health Strategies for Scabies Outbreaks in Institutional Settings (Published December 18, 2023), prevention of scabies outbreaks requires early detection, prompt treatment, and the implementation of appropriate isolation and infection control practices. These are essential components in preventing the spread of scabies within healthcare facilities. The CDC recommends that facilities establish an active surveillance program to promote early detection of infested Residents and Staff. Facilities should maintain detailed records that include Resident names, skin scraping results, names of all staff members who provided hands on care and documenting dates of symptoms onset and medication administration. Assessing the extent of the outbreak is based on data to guide isolation protocols, treatment coordination, and further preventive measures.

Based on interview, and record review the facility failed to ensure one of three sampled Residents (Resident 1) who had diagnosis of Non- ST (represents the interval between ventricular depolarization [blood flow into the left ventricle[[one of two large chambers located toward the bottom of the heart]]and repolarization [resting state of the heart]) segment elevation myocardial infarction (NSTEMI, a type of heart attack where a coronary artery is partially blocked, causing reduced blood flow to the heart and resulting in some heart muscle damage) received treatment and services in accordance with professional standards of practice, care plan and the physician's order for the management of the resident's chest pain. The facility failed to: 1. Administer Nitroglycerine tablet (medication used to treat chest pain) as needed for chest pain after Resident 1 's chest pain was re-evaluated as Not effective (NE). 2. Administer Nitroglycerine tablet as needed for chest pain after Resident 1 's chest pain was reevaluated as ' somewhat effective ' (SE) on 3/17/2025 at 3:50 PM by licensed vocational nurse (LVN) 6, on 3/18/2025 at 11:58 AM by LVN 2 and on 3/19/2025 at 9:23 AM by LVN 2. 3. Monitor and document Resident 1 's complaints of chest pain every shift for 72 hours when Resident 1 complained some-what relieved chest pain after LVN 1 administered one dose of Nitroglycerine tablet on 3/17/2025 at 3:50 PM, and on 3/18/2025 at 11:58 AM in accordance with the facility ' s Policy and Procedure for Change in Condition. 4. Notify Resident 1 ' s attending physician (Physician 1) of Resident l's change of condition on 3/18/2025 when Resident 1 complained of unrelieved chest pain around 11:58 AM. 5. Ensure there was no delay in carrying out the physician's order on 3/19/2025 that was placed at around 11:58 AM to perform an electrocardiogram (EKG- a test to check the heartbeat) and to send Resident 1 to the General Acute Care Hospital (GACH) if Resident 1 ' s chest pain continues. Resident l's EKG was done on 3/19/2025, three (3) hours after the EKG order was placed. 911 Emergency Services (EMS a system that provides emergency medical care) arrived at the facility approximately 5 hours after Resident 1 continued to complain of chest pain on 3/19/25. As a result of noncompliance described above, on 3/19/2025 at 3:39 PM, Resident l's EKG result indicated an acute myocardial infarction (Nil) and at 4:50 PM, Resident 1 complained of chest pain of 8 out of 10 on a pain scale (a numerical rating scale used to measure the intensity of pain where 0 to 2 indicated mild pain, 3 to 6 indicated moderate pain, 7 to 10 indicated severe, excruciating pain) , heart rate (HR) of 136 (regular heart rate range is 60-100 beats per minute [bpm]) bpm, and blood pressure (BP) of 81/54 (regular BP range is 120/90 millimeters of mercury (mm/Hg (unit of measurement). Resident 1 was sent to the General Acute Care Hospital (GACH) via 911 EMS on 3/19/2025 at 5 PM. While in the GACH on 3/20/25 at 2:30 AM, a code blue (a rapid response system developed for emergency resuscitation and stabilization of any sudden cardiac arrest [SCA]) was called for Resident 1 and a return of spontaneous circulation (ROSC, resumption of a sustained heart rhythm that perfuses the body after cardiac arrest.) after Resident 1 was intubated (the process of inserting a tube called an endotracheal tube (ET) into the mouth or nose and then into the airway ([trachea]). On 3/20/25 at 4:28 AM, Resident 1 was pronounced dead by the GACH's physician. The GACH ' s Death summary, and the cause of death was Myocardial Infarction (heart attack). On 4/4/2025 at 3:47 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (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 of a resident) regarding the facility ' s failure to ensure a resident with a diagnosis of NSTEMI received treatment and services for chest pain. The survey team notified the Administrator (ADM) of an IJ situation on 4/4/2025 at 3:47 PM, due to the facility ' s failure to ensure Resident 1 received the appropriate care and management for NSTEMI, provided by a physician. On 4/4/2025 at 6:16 PM the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 4/5/2025 at 11:45 AM, while onsite and after the surveyor verified/confirmed the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the Director of Nursing (DON). Following the removal of the IJ, the facility ' s noncompliance remained at a scope (refers to how widespread a deficiency is) and severity (level of harm) of G (isolated [one or a very limited number of residents are affected], actual harm, that was not immediate jeopardy). The IJ Removal Plan dated 4/4/2025, included the following: On 4/4/25, LVN 1 and LVN 2 were provided a one-to one- re-education and training by the DON focusing on the proper evaluation of resident ' s change in condition (COC) particularly about residents experiencing chest pain, accurate administration of medications, timely notification of physicians, laboratory ad diagnostic testing procedures (verifying that the vendor will perform the testing without delay) and appropriate documentation practices. On 4/4/25 the DON and the Registered Nurse Supervisor evaluated all other 9 residents who were receiving Nitroglycerin for any change in condition (COC). The facility would designate RN or Nursing Supervisor to evaluate residents experiencing a COC, particularly chest pain, to ensure timely and appropriate interventions. On 4/4/25 the DON initiated daily morning meetings for COC audits, focusing on residents with chest pain, diagnosis of NSTEMI or with prescribed nitroglycerin. On 4/4/25, the DON will initiate in-services for all licensed nurses (LN) for proper evaluation of residents ' change in condition, with an emphasis on residents experiencing chest paint, diagnosed with NSTEMI, and prescribed nitroglycerin. The Inservice will be repeated quarterly, and incorporated into the orientation program for newly- hired LN. Findings: 1. During a review of Resident 1 ' s Admission Records (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included NSTEMI, Parkinson ' s disease ( progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement without involuntary, abnormal, and uncontrolled movements), and Atherosclerotic heart disease of the native coronary artery (heart disease caused by the buildup of plaque in the coronary arteries). During a review of Resident 1 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 5/8/2024, the H&P indicated Resident 1 had fluctuating (sometimes)capacity to understand and make decisions. During a review of Resident 1 ' s Care Plan (CP) for At Risk for Chest Pain, dated 7/07/2024, the CP indicated to administer medication as ordered, inform the physician for any changes and abnormalities in condition, and to monitor for chest pain. During a review of Resident 1 ' s Minimum Data Set (MDS, resident assessment tool), dated 1/28/2025, the MDS indicated the resident had severely impaired (significantly limits one person ' s physical or mental ability to do basic work activities) cognition (thought process). The MDS indicated Resident 1 required maximum assistance (helper does more than half the effort) with sit to lying, lying to sitting, sit to stand, toilet transfer, tub/shower transfer. During a review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST medical order forms that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself. ), dated 2/9/2023, and signed by Resident 1, the POLST indicated Resident 1 requested attempt resuscitation (the action or process of reviving someone from unconsciousness or apparent death) and medical interventions as full treatment with a primary goal of prolonging life by all medically effective means. During a review of Resident 1 ' s Physician Order Report dated from 03/01/2025 to 03/31/2025, the Physician Order Report indicated the following physician orders: Nitroglycerin (a vasodilatory drug that causes blood vessels to widen [dilate], used primarily to provide relief from chest pain) tablet, sublingual (under the tongue); Special Instructions: Give 1 tablet sublingual every 5 min three times for chest pain, then call the physician. As needed Pro re Nata (PRN) 1, PRN 2, PRN 3 (may give three times every 5 minutes). Lorazepam (a drug to treat anxiety disorders) tablet; 0.5 mg; oral (by mouth) Special Instructions: Give 1 tablet by mouth once a day as needed for anxiety as evidence by excessive verbal worry for 14 days once a day as needed. During a review of Resident 1 ' s Medication Administration Record (MAR), from 03/01/2025 to 03/19/2025, the MAR indicated the following: 1. On 3/16/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 1 at 11:27 PM for chest pain. The MAR indicated one dose was administered and documented as Not Effective (NE). 2. On 3/18/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 2 at 11:58 AM for chest pain. The MAR indicated one dose was administered and documented as Somewhat Effective (SE). 3. On 3/19/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 2 at 9:23 AM for chest pain. The MAR indicated one dose was administered and documented as SE. 4. On 3/19/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 3 at 4:57 PM for chest pain. The MAR indicated one dose was administered and documented as SE. During a review of a facility provided text message obtained on the facility ' s physician communication phone called Red phone, between Physician 1 and the facility ' s Registered Nurse (RN)1, the text message indicated the following text on 3/19/25 at 11:55 AM, that facility RN1 texted Physician 1 that Resident 1 complained of chest pain with Nitroglycerine given and still complained of chest pain. The Text messages indicated on 3/19/25 at 11:58 AM, Physician 1 responded and ordered to perform an EKG and chest X-ray. The text message indicated Physician 1 responded to RN 1 and stated Resident 1 had been hospitalized twice, and that the cardiologist did not want to do anything. The text message indicated that Physician 1 told RN 1 if Resident 1 ' s chest pain continued, to send Resident 1 to the GACH ER. During a review of Resident 1 ' s Physician 1 Telephone order documented by RN 1, dated 03/19/2025 at 1:03 PM, the Telephone order indicated: Stat EKG today. During a review of Resident 1 ' s Progress Notes for the MAR, dated 3/19/25, documented by Registered Nurse (RN) 1, the Progress Notes indicated at 2:37 PM, RN 1 documented that Physician 1 ordered a Stat (immediately/without delay) Xray (a type of medical imaging that uses radiation to take pictures of the inside of your body) and EKG test. During a review of Resident 1 ' s electrocardiogram EKG result (test to record the electrical signals in the heart. It helps doctors diagnose and monitor various heart conditions by measuring the heart's rate, rhythm, and electrical activity) dated 3/19/2025, the EKG indicated an Acute myocardial infarction (MI, a serious medical condition where blood flow to the heart muscle is suddenly blocked, leading to tissue damage). During a review of a facility provided text message obtained on the facility ' s physician communication phone called Red phone, between Physician 1 and LVN 2, the text messages indicated on 3/19/2025 at 3:52 PM, the text message indicated LVN 4 texted Physician 1 an image of Resident 1 ' s EKG and chest x ray results. On 3/19/2025 at 4:29 PM, LVN 4 texted Physician 1 and asked if there were any physician orders. On 3/19/2025 at 4:38 PM, Physician 1 responded via text message to send Resident 1 to the GACH ER. During a review of the Resident 1 ' s Progress Notes for MAR at 4:50 PM, RN 2 documented that Resident 1 complained of chest pain with pain rated at 8 out of 10 on a pain scale. The Note indicated that Resident 1 was a full code (all medical interventions are permitted to resuscitate a patient in the event of cardiac or respiratory arrest) and 911 EMS was called. The Note indicated at 5 PM, RN 2 documented that the 911 EMS arrived at the facility and Resident 1 was transferred to the GACH ER at 5:05 PM for further evaluation. During a review of the GACH records, Titled Death Summary, dated 3/21/25, the Death Summary indicated Resident 1 was brought to the General Acute Care Hospital (GACH) emergency room (ER) on 3/19/2025 for chest pain. Resident 1's cardiac enzyme (substances released into the bloodstream when the heart muscle is damaged or stressed) results indicated with brain natriuretic peptide (BNP, a hormone produced by the heart, released when the heart has to work harder than usual, particularly in cases like heart failure) of 4700 picogram per millimeter (pg/mL, a unit of measurement normal range is less than 100 pg/mL) and High-sensitivity Troponin (a test to detect protein released due to hearth muscle damage) of 7686 ng/L (nanogram per liter) (level above 14ng/l are considered elevated and heart damage or a heart attack). The Death Summary indicated on 3/20/2025 while in the GACH, a code blue was called for Resident 1 at 2:30 AM and a return of spontaneous circulation (ROSC refers to the resumption of a sustained, effective heart rhythm and breathing after a period of cardiac arrest) after Resident 1 was intubated (a tube has been inserted into someone's trachea (windpipe) to help them breathe). The GACH record indicated another code blue was called at 3:55 AM and Resident 1 was pronounced dead by the GACH's physician at 4:28 AM. During an interview on 4/03/2025 at 10:33 AM with LVN 2, LVN 2 stated she was the assigned nurse to care for Resident 1 on 3/18/2025 for the 7 AM to 3 PM shift. LVN 2 stated Resident 1 was able to answer to yes and no questions. LVN 2 stated on 3/18/2025, Resident 1 complained of chest pain at 11:58 AM. LVN 2 stated she administered one dose of Nitroglycerin to Resident 1 and after she administered the one dose of Nitroglycerin to Resident 1, LVN 1 documented Somewhat Effective (SE) after the nitroglycerin was administered. LVN 2 stated somewhat effective means that the medication was not fully effective. LVN 2 stated she did not administer a second dose of Nitroglycerin to Resident 1 after 5 minutes as indicated in the physician order, did not document in Resident 1 ' s records (Situation, Background, Action, and Response [SBAR]) form, and did not inform Physician 1 that the nitroglycerin was ' not fully effective. ' LVN 2 stated she did not inform Physician 1 of Resident 1 ' s unrelieved chest pain on 3/18/2025 because LVN 2 thought Physician 1 already knew that Resident 1 was having chest pain. During a concurrent interview and record review of Resident 1 ' s MAR, on 4/03/2025 at 10:33 AM with LVN 2, LVN 2 stated she was the assigned nurse to take care of Resident 1 on 3/19/2025 for the 7 AM to 3 PM shift. LVN 2 stated on 3/19/2025 Resident 1 reported having chest pain around 9:23 AM, so LVN 2 administered one dose of Nitroglycerin. LVN 2 stated she reassessed Resident 1 after 5 minutes and then documented on the MAR SE which meant Somewhat Effective. LVN 2 stated she documented Somewhat Effective because Resident 1 looked more comfortable, but still noticed Resident 1 was anxious, in which LVN 2 stated being anxious could be a sign of chest pain. LVN 2 stated she did not ask Resident 1 if she still had chest pain. LVN 2 stated she did not administer a second dose of nitroglycerin and did not inform Physician 1 that the nitroglycerin was not fully effective. LVN 2 stated she reported to RN 1 that Resident 1 ' s chest pain was not relieved around 9:30 AM. LVN 2 stated she thought RN 1 would report Resident 1 ' s unrelieved chest pain to Physician 1 and document in the resident ' s records (SBAR form). LVN 2 stated it was not until around noon time on 3/19/25, that RN 1 informed Physician 1 that Resident 1 still had chest pain, so Physician 1 ordered a Stat EKG and chest x-ray. LVN 2 stated Stat meant immediately, within 10 to 15 minutes, since Physician 1 needed the test results right away. LVN 2 stated it was not until around 3 PM to 3:15 PM that the EKG Technician arrived at the facility and performed the EKG test. LVN 2 stated based on Resident 1 ' s physician orders, she should have administered a second dose of Nitroglycerin and reassessed Resident 1 ' s chest pain, and if Resident 1 continued to have chest pain, LVN 2 should have notified Physician 1 immediately or transferred Resident 1 to the GACH via 911 EMS right away. During an interview on 4/03/2025 at 11:18 AM with RN 1, RN 1 stated she was the supervising nurse on 3/18/2025 for the 7 AM to 3 PM shift. RN 1 stated she texted Physician 1 around 11:55 AM on 3/18/2025 that Resident 1 still complained of chest pain after nitroglycerin was administered to Resident 1. RN 1 stated she did not re-assess Resident 1 at 11:55 AM and did not administer another dose of nitroglycerin as indicated in the physician order. RN 1 stated Physician 1 ordered an EKG Stat on 3/19/25 at 11:58 AM. RN 1 stated the EKG was done on 3/19/25 around 3 PM to 3:30 PM, and Physician 1 was informed about the EKG result on 3/19/25 which indicated an ACUTE MI around 3:52 PM. RN 1 stated she believed Physician 1 already knew about Resident 1 chest pain. During an interview on 4/03/2025 at 11:30 AM with Physician 1, Physician 1 stated when a resident complains of chest pain, the expectation from the licensed nurses was to administer Nitroglycerin 3 times every 5 minutes as needed for chest pain, and that if chest pain was unrelieved, to notify the physician or transfer the resident to the GACH via 911 EMS. Physician 1 stated it was on the morning of 3/19/25 that the licensed nurse had informed Physician 1 that Resident 1 was having chest pain, so Physician 1 ordered a STAT EKG. Physician 1 stated he instructed the licensed nurse to transfer Resident 1 to the GACH ER if Resident 1 ' s chest pain continued. Physician 1 stated as soon as he received the EKG results that indicated Resident 1 had an Acute MI, Physician 1 ordered the facility to transfer Resident 1 to the GACH via 911 EMS immediately to avoid delaying the management of Resident 1 ' s chest pain since it was an emergent situation. During an interview on 4/03/2025 at 3:52 PM with the DON, the DON stated Resident 1 was alert and verbal and was able to answer yes and no questions when asked if she had chest pain. The DON stated Resident 1 complained of chest pain and had an order for Nitroglycerin to give three times as needed every five minutes of each dose, if not effective. The DON stated after the third dose, the Nitroglycerin was administered, and chest pain was unrelieved, the physician must be notified. The DON stated when SE was documented on the MAR, the SE indicated Somewhat Effective, which the DON stated the chest pain was not fully resolved. The DON stated when SE was documented on the MAR, the expectations from the licensed nurses was to reassess the resident and administer a second dose of nitroglycerin until the chest pain was fully resolved. During an interview and record review of Resident 1 ' s MAR on 4/03/2025 at 3:58 PM with the DON, the DON stated a medication was documented as Not Effective (NE) or SE, the licensed nurse must follow up and re-assess Resident 1, and if after the first dose was administered and still ineffective, the Licensed Nurse must administer a second dose after 5 minutes. The DON stated if a third dose was necessary, and still ineffective, the physician must be notified, or Resident 1 should be transferred via 911 EMS to the GACH ER. The DON stated the SBAR form must be created with any physician notification. The DON confirmed that on 3/16/25 at 11:27 PM, 3/18/25 at 11:58 AM, and 3/19/25 at 9:23 AM and 4:57 PM LVN 6 and LVN 2 did not create an SBAR and did not notify the physician regarding Resident 1 ' s continuous, unrelieved chest pain. During an interview on 4/03/2025 at 4:19 PM with RN 2, RN 2 stated Resident 1 complained of chest pain on 3/19/2025 at 4:47 PM, and one dose of nitroglycerin was administered. RN 2 stated Resident 1 continued to have chest pain, but RN 2 documented on the SE and then sent Resident 1 to the GACH via 911. RN 2 stated SE indicated Resident 1 ' s pain was still there and that was the reason she transferred Resident 1 to the GACH. RN 2 stated she saw the Physician order on text message on 3/19/2025 timed at 4:38 PM to transfer Resident 1 to the ER. It was only after, at 5 PM, after RN 2 transferred Resident 1 to the GACH ER had RN 2 seen the text message from Physician 1. During a concurrent interview and record review of Resident 1 ' s MAR from 3/1/2025 to 3/31/2025 on 4/04/2025 at 7:20 AM with LVN 1, LVN 1 stated she was the assigned nurse for Resident 1 on 3/16/2025 from 11 PM to 3/17/2025 7 AM. LVN 1 stated Resident 1 reported chest pain to LVN 1on 3/16/2025 at 11:27 PM, so LVN 1 administered one dose of nitroglycerin and documented ' Not Effective ' (NE) which indicated Resident 1 was still having chest pain. LVN 1 stated she should have assessed Resident 1 after 5 minutes and should have administered a second dose of nitroglycerin on 3/16/2025 at 11:32 PM and notified Resident 1 ' s physician right away when chest pain continued. LVN 1 stated she did not assess Resident 1 after 5 minutes on 3/16/2025 and did not call Physician 1. LVN 1 stated she did not document her assessment of Resident 1 ' s chest pain in the resident ' s records and in the SBAR form. During a review of facility policy & procedure (P&P) titled Change in Resident Condition dated 1/31/2025, the P&P indicated The resident, attending physician and resident representative (if resident has no capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur . The Licensed Nurse will contact the physician based on the urgency of the situation. For emergencies, the Licensed Nurse will call or page the physician and request a prompt response (within approximately one-half hour or less). The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The Licensed Nurse will notify the Medical Director for additional guidance and consultation if a timely or appropriate response is not received from the Attending Physician. If the Attending Physician does not respond upon calling by Licensed Nurse in a life-threatening change of condition, the Licensed Nurse will contact the Medical Director. If the Medical Director does not respond upon calling by Licensed Nurse, emergency services (911) will be called. Changes in condition are communicated by the Licensed Nurses from shift to shift through the twenty-four (24) hour report management system. The P&P further indicated the Policy and Procedure on Daily Shift Report where changes in condition will be documented in the Change of Condition form or Nurses' Progress notes every shift for 72 hours. Changes in the resident status are documented by the Licensed Nurse in the S-B-A-R or progress notes . as soon as practicable. During the review of facility P&P titled Physician Orders with approved date 8/02/2024, the P&P indicated Physician orders are obtained to provide a clear direction in the care of the resident. Orders given by a physician or state permitted health care professional must be accepted by a licensed nurse and documented on the physician order sheet and must be co-signed and dated by the ordering physician or state permitted health care professional. During the review of facility P&P titled Comprehensive Plan of Care with approved date 12/13/2024, the P&P indicated Each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during the comprehensive assessment. Ensure that interventions specify the frequency of service provided. The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing.

Based on observation, interview, and record review, the facility failed to provide the required assistance to prevent accidents for one of three sampled residents (Resident 1) including: 1. Failure to provide Resident 1 with extensive assistance (staff provide weight-bearing support) during dressing and required two-person assist during transfer (how resident moves to and from bed, chair, wheelchair, standing position). 2. Failure to provide Certified Nursing Assistant 1 (CNA 1) with instructions and training on safe techniques on dressing Resident 1. 3. Failure to implement the facility's policy on Rehabilitation Admission and Discharge by not providing ongoing education and caregiver training. 4. Failure to implement the facility's policy on Dressing and Grooming Education, by CNA 1 not instructing Resident 1 to lie down on the bed when putting an incontinent brief on Resident 1, who could not stand without support. 5. Failure to implement the facility's policy on Fall Prevention, by not having a fall prevention program for Resident 1 that provided care staff with creative, functional strategies to prevent fall. As a result, on 5/20/19 at 10 a.m., Resident 1 fell and sustained fractures (break of bones) of both knees, the right thigh, and left lower leg requiring transfer to General Acute Care Hospital 1 (GACH 1). Resident was admitted , family opted for no surgery, and returned back to the facility on [DATE]. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1, on 5/5/14, with the most recent readmitted d 5/31/19. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 5/8/19, indicated Resident 1's cognition (mental process of acquiring knowledge and understanding) was severely impaired, required extensive assistance (staff provide weight-bearing support) with one-person physical assist with dressing, toilet use, personal hygiene and needed two-person physical assist with transfer. A review of Resident 1's Fall Risk Data Collection, dated 5/8/19, indicated Resident 1's total fall risk score was 20 (a total of 10 or above represented high risk). Resident 1 had gait (manner of walking) and balance problems. A review of Resident 1's care plan for the risk of falls and injury, initiated on 5/8/19, included in the interventions to establish Resident 1's physical function and provide Resident 1 with the necessary assistance. A review of Resident 1's care plan for self-care deficit, revised on 5/14/19, had in the approaches assisting with activities of daily living (ADLs - transferring, dressing, personal hygiene, and bathing). A review of Resident 1's care plan for the risk of spontaneous fracture related to [MEDICAL CONDITION]/[MEDICAL CONDITION], revised on 5/14/19, included in the approaches assessing Resident 1's functional limitations quarterly or as indicated and helping with ADLs. A review of the physician's orders [REDACTED]. A review of Resident 1's PT Evaluation and Plan of Treatment form, dated 2/13/19, indicated Resident 1 had a new onset of decreased functional mobility, reduced static (stationary) and dynamic (in motion) balance, and reduced ability to ambulate safely. The background assessment indicated Resident 1 had a high fall risk and poor static and dynamic standing balance (maximum assistance). The PT Discharge Summary, dated 3/19/19, indicated Resident 1 had a poor static standing balance and needed moderate assistance (required 26 percent (%) to 75 % assist from staff). A review of the physician's orders [REDACTED]. A review of Resident 1's OT Evaluation and Plan of Treatment form, dated 5/14/19, indicated Resident 1 had a decline in grooming, hygiene, dressing, and toilet transfer, due to decreased strength on both upper extremities and decreased sitting/standing balance, resulting in reduced safety and an increased need for assistance. The background assessment indicated that Resident 1 had a high fall risk with poor standing balance, requiring maximum assistance (76 % to 99 % assist from staff) during ADLs. The functional skills assessment indicated total dependence on lower body dressing. A review of Resident 1's OT Discharge Summary, dated 5/20/19, indicated Resident 1 had poor standing balance during ADLs and was dependent (maximum assistance) on staff with lower body dressing. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), dated 5/20/19 at 10 a.m., indicated Resident 1 had a fall in the shower room. CNA 1 assisted Resident 1 to stand up with a front wheel walker (FWW) against the wall for stability. CNA 1 was behind Resident 1 to pull up the incontinent brief. Resident 1's legs gave out, and CNA 1 was not able to pull Resident 1 back to the wheelchair. Resident 1 kneeled on the floor and hit her head in the wall. The physician notified, at 10:10 a.m., ordered x-rays (pictures of the inside of the body) of Resident 1's lower extremities. A review of the x-ray results, dated 5/20/19, indicated Resident 1 had left and right knee fractures with associated joint effusion (water in the joint). Resident 1 had a fracture involving left proximal tibia (the inner, long bone of the leg) and fibula (the outer, smaller bone of the leg) with mild displacement (the bone snapped into two or more parts and moved so that the two ends are not lined up straight). Resident 1 also had a complete oblique fracture (a broken bone in which the bone breaks at an angle) involving right distal femur (bone of the thigh) with mild displacement. A review of Resident 1's Progress Notes, dated 5/20/19 at 2:55 p.m., indicated the physician was informed of the x-ray results and ordered to transfer Resident 1 to GACH 1. A review of the facility's Investigation Report, Interview Record, dated 5/20/19 timed at 4:45 p.m., indicated CNA 1 gave a shower to Resident 1 around 10 a.m., then tried to put the incontinent brief by having Resident 1 stand up and hold the FWW. Resident 1 successfully and easily stood up from the shower chair, and while CNA 1 was trying to put the brief on, Resident 1's legs gave up. CNA 1 was not able to hold Resident 1. Resident 1 kneeled on the floor and hit her head on the wall. A review of the GACH 1 history and physical examination [REDACTED]. Resident 1 was admitted to be evaluated by a physician in orthopedic surgery (the branch of surgery concerned with conditions involving the musculoskeletal system (bones, muscles, and their associated tissues such as tendons and ligaments)). A review of the GACH 1 Discharge Summary, dated 5/30/19, indicated Resident 1's family decided for no surgery and placed resident on hospice care (a terminally ill person who's expected to have six months or less to live). During observation and concurrent interview, on 6/10/19, at 9:10 a.m., Resident 1 was laying on the bed, had redness on the middle of the forehead, had immobilizers (a device to prevent or restrict movement) on both lower extremities, and swollen knees and legs. Resident 1 could not recall the fall incident. During an interview, on 6/10/19 at 11:05 a.m., CNA 1 stated no one witnessed the incident, and she was the only one assisting Resident 1. CNA 1 stated nobody (licensed nurses and/or rehabilitation services) informed her that Resident 1 was not able to stand up on her own. CNA 1 stated she did not receive training from the rehabilitation services. During a record review of Resident 1's medical records and concurrent interview, on 6/10/19 at 3:10 p.m., PT 1 reviewed her documentation on 2/13/19 and 3/19/19. PT 1 stated Resident 1 had poor standing balance and required moderate assistance. PT 1 stated Resident 1 had weakness on both lower extremities. PT 1 stated staff should hold her while standing and use a gait belt for support. PT 1 stated Resident 1 should not stand up with a walker during dressing. PT 1 reviewed Resident 1's medical records, and the medical records had no documented evidence that resident's progress for the rehabilitation program was routinely discussed to caregivers by ongoing education and training. During an interview, on 6/10/19, at 4:20 p.m., Director of Staff Development (DSD) stated Resident 1 should have two-person assist in during care. DSD was unable to provide documentation that CNAs were informed of Resident 1's needs. During an interview, on 6/17/19 at 8:35 a.m., OT 1 stated he assessed and evaluated Resident 1, on 5/14/19, due to reported decline in ADL participation and regression in physical strength. OT 1 stated Resident 1 had poor standing balance during ADLs, required maximum assistance, and dependent on lower body (LB) dressing. OT 1 stated maximum assistance means 76 % to 99% physical assist from staff and dependent means staff doing everything for the resident. OT 1 stated Resident 1 was unable to stand up on her own and tendency to buckle while doing rehabilitation activity with him. OT 1 stated he used gait belt and exerted almost 100% to hold Resident 1 during rehabilitation activity to prevent a fall. OT 1 stated Resident 1 does not have much strength to grasp, and Resident 1 should not stand up in the walker during dressing, unless there were two persons assisting Resident 1. OT 1 stated the safest way to do LB dressing was on lying position for safety of the resident and staff. A review of the facility's policy and procedure titled, Rehabilitation Admission and Discharge, dated 4/2005, indicated throughout the skilled rehabilitation program, the resident's progress should be routinely discussed. Throughout therapy, ongoing education, and caregiver training should be provided and documented to prepare for the targeted discharge disposition. A review of the facility's policy and procedure titled, Dressing and Grooming Education, dated 3/2000, indicated putting on or taking off trousers, if the resident cannot stand without support, the resident should lie down on the bed or if standing balance is poor, instruct resident to lie down in the bed. A review of facility's policy and procedure titled, Fall Prevention, dated 12/1/05, indicated a fall prevention program will be developed for each patient that will provide patient care staff with creative, functional strategies to prevent fall and undue injuries from such incidents, while recognizing the patients' rights and their needs to maintain their highest level of functioning.

Based on interview and record review, the facility failed to ensure that Resident 5, who was assessed at risk for falls and who had experienced recurrent falls was provided adequate supervision and properly transferred from a shower-chair to a wheelchair using two persons, as indicated in the care plan. Certified Nursing Assistant (CAN) 5 transferred Resident 5 by herself, resulting in a fall and fractures of the right third, fourth, fifth, sixth and seventh ribs with minimal displacement that caused severe pain during breathing and pneumonia for one out of 19 sample residents (5). Findings: According to the admission record Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the history and physical examination [REDACTED]high blood pressure). The Minimum Data Set (MDS) assessment, dated October 3, 2012, indicated Resident 5 was moderately impaired in cognitive skills for daily decision-making, had the ability to make herself understood and to understand others, was totally dependent on staff with two-plus persons physical assist for transfers. The MDS also indicated Resident 5 was totally dependent on staff for toilet use, needed extensive assistance with dressing and personal hygiene and had a height and weight of 62 inches and 185 pounds respectively. The plan of care, dated June 29, 2012, indicated Resident 5 had a history of [REDACTED]. The care plan goal stated Resident 5's risk of fall and injury would be minimized. The interventions on the plan of care included to keep the environment free of hazards, clutter free, call light within reach, encourage /remind Resident 5 to ask for help when needed, provide assistance in transfers and mobility, update fall risk assessment quarterly or as needed, continue Restorative Nursing Assistant (RNA) program, and refer to rehabilitation group as needed. The plan of care was updated on October 17, 2012, when Resident 5 had the second fall in the bathroom. The goals remained the same. The updated interventions included to continue with the Restorative Nursing Assistant program as ordered and refer to Rehabilitation department as needed. A review of the quarterly Fall Risk Assessments last updated on December 25, 2012, and singed by a registered nurse indicated Resident 5 had progressively increased risk for falls as follows: 1. On April 10, 2012, the resident's fall risk score was 19. 2. On July 10, 2012, the resident's fall risk score was 21. 3. On October 3, 2012, the resident's fall risk score was 21. 4. On December 25, 2012, the resident's fall risk score was 23. According to the fall risk assessment tool, a score of 10 and above represents a high risk of falls. Resident 5 had the following recurrent falls: The first fall: According to the multidisciplinary Risk Meeting Notes, dated July 16, 2012, Resident 5 had an "assisted fall" on date unknown. The note did not indicate Resident 5 had an injury. The Second Fall: According to the plan of care dated October 16, 2012, Resident 5 had another fall in the bathroom. The fall occurred in the bathroom while the CNA assisted Resident 5 from the toilet to the wheelchair. There was no injury during this fall. On October 17, 2012, the plan of care was updated to include a two-person assist during transfers. According to Risk Meeting Notes, dated October 22, 2012, the fall occurred in the bathroom when the CNA assisted Resident 5 to stand up from the toilet seat, Resident 5's leg gave out and the CNA assisted Resident 5 to the floor. The same note indicated Resident 5 was referred to rehabilitation physical therapy and occupational therapy to restore her functional mobility and activities of daily living. Resident 5 was on rehabilitation program and required two staff members to assist from sit to stand position. A review of the interdisciplinary team (IDT) risk assessment record November 16, 2012, indicated Resident 5's range of motion (ROM) of both upper extremities were within functional limits. However, Resident 5's right shoulder had limitations secondary to arthritis. The third Fall: A review of the licensed nurse's note, dated December 20, 2012, Resident 5 had the third fall in the bathroom in the presence of Certified Nursing Assistant 5 (CNA 5). The fall was recorded as "assisted fall." During a telephone interview with CNA 5, on December 20, 2012, at 8:30 a.m. and 9:30 a.m., she stated she transferred Resident 5 from the bed onto a shower-chair and then transported Resident 5 to the bathroom. CNA 5 wheeled the shower-chair over the toilet seat for Resident 5 to use the toilet, and she returned to fix Resident 5's bed. When Resident 5 was done using the toilet, she called out for help and she attended Resident 5:- she cleaned and partially dressed Resident 5 by putting her pants on up to her knees. Then, CNA 5 asked Resident 5 to stand up and applied incontinent brief and pulled up her pants. According to CNA 5, Resident 5 sat back down on the shower-chair and left the bathroom to get the resident's wheelchair. The CNA 5 stated she asked Resident 5 to stand up to transfer her to a wheelchair. At this time Resident 5's right knee bent and she cried out...."No, no...My knees no good, my knees no good! " CNA 5 told Resident 5 that she would get help because "Resident 5's knee did not have the strength to stand;" before CNA 5 obtained assistance from another staff member, Resident 5's knee gave up and fell towards the sink hitting her chest. CNA 5 stated she assisted Resident 5 to slide down to the floor. According to CNA 5, she was alone with Resident 5 until she called for help and she was unable to support her and prevent the fall by herself. CNA 5 further stated she pulled the bathroom call light to summon assistance and Resident 5 was provide a two persons assist to be moved from the floor to her bed. Resident 5 was not provided two-persons assist first, when she was transferred from her bed to the shower-chair and then from the shower-chair to the wheelchair as it was directed on the plan of care dated on October 17, 2012. On February 11, 2013, at approximately 4 p.m., during an interview, the administrator stated the resident's condition has improved and did not need a two-persons assist. However, there was no fall risk re-assessment done after December 25, 2012, that demonstrated Resident 5's fall risk assessment had inproved or changed to require only one-person assist. In addition, the current plan of care still indicated Resident 5 required a two-person assist during transfers. According to the Pain Management Flow Sheet, dated December 20, 2012, at 10:20 a.m., Resident 5 complained of right side pain which she rated at five out of ten on a zero to ten pain rating scale (ten being the worst pain). Resident 5 was administered Tylenol 650 mg. On February 12, 2013, at 2 p.m., during an interview with Licensed Vocational Nurse 3 (LVN 3) she stated on December 20, 2012, she went into the bathroom in Resident 5's room and saw Resident 5 on the floor. RNA 1 and Occupational Therapist 1 assisted Resident 5 to the wheelchair and back to her bed. According to LVN 3 she checked range of motion for upper and lower extremities and found no functional limitations. LVN 3 stated because it was "an assisted fall" she did not think Resident 5 had sustained any injuries but Resident 5 did complained of pain. LVN 3 further stated she did "several visual checks" on Resident 5 between the initial assessment and the time she reported Resident 5's fall. LVN 3 when asked stated that each time she went in to see Resident 5. Resident 5 stated "I'm not feeling well" nothing specific just that she wasn't feeling well. However, she did not assess Resident 5's respiration and its characteristics. For example, Resident 5's respiratory rate, the presence or absence of pain during inspiration and expiration were not assessed and recorded. LVN 3 during the interview stated she reported the fall to Registered Nurse 3 (RN 3) between 11 a.m. and 11:30 a.m. and that she did not have time to document the fall or any part of the assessment she had done. During an interview on February 12, 2013 at 2:20 p.m. RN 3 stated that on December 20, 2012, between 12 noon and 12:30 p.m., she informed the physician of the fall that had occurred and the following orders were obtained: 1. X-ray of the right lower ribs to rule out fractures. 2. Apply chest belt at all times. 3. Repeat x-ray on right ribs on December 27, 2012. A review of the physician's Progress Record, dated December 20, 2012, (undated), indicated Resident 5 had a fall that morning, complained of right lower chest wall pain, was alert, "confused as usual" and comfortable. The vital signs were: blood pressure 124/74 millimeters of mercury (mm Hg), pulse was 70 beats per minute, and respirations were 19 breaths per minute. Right chest wall contusion and ordered chest x-ray to rule out rib fracture. A review of the x-ray results, dated December 20, 2012 at 7:18 p.m., revealed the resident had fractures involving the lateral portion of the right third, fourth, fifth, sixth and seventh ribs with minimal displacement. There was no pneumothorax (collapsed lung) seen. A review of the literature indicates that rib fractures are the most common type of chest injury resulting from trauma. Ribs four to nine are most commonly fractured because they are least protected by chest muscles. Clinical manifestations of fractured ribs include pain (especially on inspiration) at the site of injury. The individual splints the affected area and takes shallow breaths to try to decrease the pain. Because the individual is reluctant to take deep breaths and cough, atelectasis may develop because of decreased ventilation. The main goal in treatment is to decrease pain so that the client can breathe adequately to promote good chest expansion and prevent complications (Medical-Surgical Nursing Assessment and Management of Clinical Problems, second edition, page 538). On December 21, 2012, the following physician's orders [REDACTED]. 1. Vicodin 5/500 one tablet (tab) to be administered every six hours as needed for pain (Vicodin 5/500 is used to relieve moderate to severe pain). 2. Norco 5/325 one tablet to be administered every 6 hours as needed for pain dated (Norco 5/325 is used to relieve moderate to severe pain. According to the Nurse's Notes dated December 22, 2012 at 10 p.m. Resident 5 complained of pain to the right upper back which had swelling. One Vicodin tablet was administered that was helpful with relief. According to the Nurse's Notes dated December 23, 2012 at 6 a.m. indicated Resident 5 complained of pain to the right rib area and was noted with swelling on the right upper back; Resident 5 had no complaints of shortness of breath and was breathing even and unlabored. According to the Nurse's Notes dated December 23, 2012 at 2 p.m. Resident 5 complained of right rib pain, did not have any shortness of breath and her breathing was even and unlabored. On December 27 2012, the repeat x-ray results indicated that in addition to the fractured ribs there was moderate right lower lobe infiltrate pneumonia and modest right pleural effusion (excess fluid between the lung membranes that cover the lungs). The physician was notified and the following were obtained to treat the pneumonia: 1. Z-Pack (Erythromycin antibiotic therapy) 500 mg times one then 250 mg daily times four days. 2. Send Resident 5 to the emergency room for shortness of breath, dyspnea (difficulty breathing caused by lung disease) occurs. 3. No physical or occupational therapy, stay in bed as much as possible. 4. Repeat the chest x-ray in one week 5. Apply chest belt 6. Keep oxygen at 4 liters/minute via nasal cannula or mask, may titrate to maintain oxygen saturation greater than 95 percent (%). Oxygen saturation is the total amount of hemoglobin in the body is filled with oxygen molecules. A range of 97% to 99% is generally considered normal on room air. Anything below 90% could quickly lead to life-threatening complications. The margin between "healthy" saturation levels (95-98%) and respiratory failure (usually 85-90%) is narrow American Journal of Nursing: June 2009 - Volume 109 - No. 6, pages 52-59). A review of the chest x-ray dated January 4, 2013 indicated modest right perihilar (particular area of the lung) consolidation (pneumonia) and decreased left lung aeration (exchange of carbon dioxide for oxygen in the lungs) compared to the prior exam for December 27, 2012. The following physician's orders [REDACTED]. 1. Levaquin 500 mg to be administered daily for pneumonia times 10 days. 2. Repeat chest x-ray January 9, 2013. A review of the chest x-ray dated January 9, 2013, indicated modest right middle lobe infiltrate with slight bilateral lower lobe infiltrates. The findings were worse than January 4, 2013. The resident was still on Levaquin 500 mg per day. A review of the repeat chest x-ray dated January 25, 2013, indicated right ribs still showed fractures of the third through seventh rib with no definite healing and apparent slightly increased displacement. On January 28, 2013, the physician's orders [REDACTED]. Information whether the resident had the orthopedic consult is not available. The chest x-ray result dated February 4, 2013 indicated there was bilateral upper lobe atelectasis with no infiltrate or congestion.