Every finding on record at Avalon Villa Care Center

Based on observation, interview and record review, the facility failed to ensure, interventions to monitor, one (1) of three (3) residents (Resident 1), aggressive behavior, impulsiveness and impulsivity were implemented as indicated in the resident's care plan titled, Positive toxicology screen (drug test ) for amphetamine (a potent central nervous system stimulant that speeds up messages between the brain and the body) use with potential risk for altered behavior, impaired judgement, cardiovascular complications and safety concerns. This deficient practice placed Resident 1 at risk for injury.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/18/2026, the MDS indicated Resident 1 had intact cognitive (ability to think and process information) ability. The MDS indicated Resident 1 required supervision for oral hygiene, showering, upper/lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 was independent for eating and toileting. During a review of Resident 1's care plan titled, Positive toxicology screen for amphetamine use with potential risk for altered behavior, impaired judgement, cardiovascular complications and safety concerns dated 6/4/2026, the interventions indicated to monitor the resident for agitation, impulsivity or aggressive behavior. During a concurrent interview and record review on 6/6/2026 at 5:11 PM with Registered Nurse (RN) 1, Resident 1's care plan titled, Positive toxicology screen for amphetamine use with potential risk for altered behavior, impaired judgement, cardiovascular complications and safety concerns, dated 6/4/2026, Resident 1's Medication Administration Record (MAR) from 6/1/2026 to 6/6/2026, and Resident 1's Progress Notes from 6/4/2026 to 6/6/2026 were reviewed. RN 1 stated Resident 1's progress notes and MAR had no documented evidence that aggressive behavior, impulsiveness and agitation were monitored as indicated in Resident 1's care plan. RN 1 stated that if the interventions in the resident's care plan were not done, Resident 1 could get hurt. During a concurrent interview and record review on 6/6/2026 at 6:56 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 1/2026, Resident 1's care plan titled, Positive toxicology screen for amphetamine use with potential risk for altered behavior, impaired judgement, cardiovascular complications and safety concerns, dated 6/4/2026, Resident 1's MAR from 6/1/2026 to 6/6/2026 and Resident 1's Progress Notes from 6/4/2026 to 6/6/2026 were reviewed. The DON stated there was no documented evidence in Resident 1's Progress Notes and MAR that monitoring for aggressive behavior, impulsiveness and agitation were done, as indicated in Resident 1's care plan, and in the facility's P&P which indicated that a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The care plan should be developed and implemented for each resident, and assessments should be ongoing, and care plans are revised, as information about the residents and the residents' conditions change. The DON stated that Resident 1's behavior was not monitored. The effectiveness of the interventions could not be assessed and his condition may worsen, could get injured if interventions for behavior monitoring were not followed. The DON stated that Resident 1 does not have monitoring for aggressive behavior, impulsiveness or agitation in his MAR or Progress Notes.

Based on interview and record review, the facility failed to implement safety measures for three of five sampled residents (Residents 1, 3 and 4) by failing to: 1.Follow its policy and procedure titled, Pass Procedures - Sending Resident Out on Pass (OOP- temporary permission for a resident to leave the facility for a specified period), which indicated staff will obtain a physician's order allowing the resident to leave the facility, including the reason (medical or social), and complete the Release of Responsibility for Leave of Absence form.2). Develop an OOP care plan for Residents 1, 3 and 4. These failures had the potential to negatively affect Resident 1, 3 and 4's safety and well-being when going OOP. Findings:a). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included epilepsy (neurological disorder characterized by seizures due to unusual electrical activity in the brain), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and neutropenia (characterized by an abnormally low number of neutrophils, a type of white blood cell essential for fighting infections). During a review of Resident 1's History and Physical (H&P) dated 4/9/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/1/2026, the MDS indicated Resident 1 had no cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with Activities of Daily Living (ADLs) such as personal oral hygiene, toileting hygiene, dressing, toilet use and transfers (the ability to transfer to and from a bed to a chair, chair or wheelchair). During a review of Resident 1's Physician's order dated 4/13/2026, the Order indicated Resident 1 may go OOP, not to exceed 4 hours. The Order did not indicate the reason for the Resident's OOP. During a review of Resident 1's Progress Note dated 4/13/2026, the Note indicated Resident 1 left OOP on 4/13/2026 at 3:15 p.m. The Progress Note did not indicate that the Release of Responsibility for Leave of Absence form was completed for Resident 1. b). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 3's diagnoses included Hypertension (HTN-high blood pressure), Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Chronic kidney disease (occurs when the kidneys are damaged, impairing their ability to remove waste, balance electrolytes, regulate blood pressure, and produce hormones for red blood cells and bone health). During a review of Resident 3's H&P dated 1/6/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Residents 3's MDS dated [DATE], the MDS indicated Resident 3 had no cognitive impairment. The MDS indicated Resident 3 required partial to moderate assistance (helper does less than half the effort. Helper lifts or holds trunk or limbs but provides less than half the effort with the ADLs such as toilet use, showering/bathing self, lower body dressing and transfers. During a review of Resident 3's Physician's order dated 4/17/2026, the Order indicated Resident 3 may go OOP for therapeutic purposes. During a review of Resident 3's undated Release of Responsibility for Leave of Absence form, the form indicated Resident 3 went OOP on 4/17 (no year indicated) at 2:20 p.m. The form did not indicate the time Resident 3 returned to the facility, a phone number where resident could be reached and the nurse's signature. c). During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 4's diagnoses included epilepsy, congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and ESRD (End Stage Renal Disease-irreversible kidney failure). During a review of Resident 4's H&P dated 9/10/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions. During a review of Residents 4's MDS dated [DATE], the MDS indicated Resident 4 had no cognitive impairment. The MDS indicated Resident 4 required partial to moderate assistance from staff with the ADLs such as dressing, toilet use, showering/bathing self, dressing and transfers. During a review of Resident 4's Physician's order dated 4/17/2026, the Order indicated Resident 4 may go OOP, not to exceed 4 hours. The Order did not indicate the reason for the residents' OOP. During an interview with Resident 4 on 4/29/2026 at 11:20 a.m., Resident 4 stated he had gone out on pass one or two times before. Resident 4 stated he believed the nurses signed an OOP form at the nurse's station. Resident 4 stated the nurses had not told him to sign or complete any form before going OOP. During a review of Resident 4's undated Release of Responsibility for Leave of Absence form, the form indicated on 4/17(no year indicated), Resident 4 went OOP to go a mobile phone store. The Form did not indicate the time Resident 4 returned to the facility, a phone number where the resident could be reached and the nurse's signature. During an interview on 4/29/2026 at 2:07 p.m., with Registered Nurse (RN) 1, RN 1 stated when residents requested to leave OOP, the nurse would call the physician to obtain an order. RN 1 stated it was important to indicate where the resident wanted to go in the physician's order. RN 1 stated there was a binder at the nurse's station with an OOP form (Release for Leave of Absence form) that must be completed accurately in all sections. RN 1 stated nurses must know the time the resident left and returned to the facility, resident's contact phone number, and the destination for the resident's safety. During an interview on 4/30/2026 at 10:53 a.m., with the Medical Doctor (MD), the MD stated the criteria for an OOP order is usually limited to four hours. The MD stated nurses must be assessed prior to going OOP to ensure the resident was self-responsible or had a family member going with them. The MD stated the facility must follow its P&P, and indicate a specific reason for the OOP and where the residents were going to ensure safety of the residents while OOP. During an interview on 4/30/2026 at 4:46 p.m., with the Director of Nursing (DON), the DON stated nurses needed to obtain an order for residents to go OOP. It was important to determine where the residents were going while OOP for resident safety. The DON stated when residents go OOP, the Resident (or RP) must sign the Release of Responsibility for Leave of Absence form. The DON stated licensed nurses must oversee to ensure the form was completed properly because it provided essential information for staff, including the time the resident left the facility, the destination, and the time the resident returned. The DON stated Resident 1 did not have a Responsibility for Leave of Absence form completed, and Resident 3 and 4's Release of Responsibility for Leave of Absence forms were not entirely completed. The DON stated it was also important to ensure licensed nurses developed a Care Plan for OOP to include interventions for nurses and address resident's mental capacity. The DON stated there were no OOP care plans developed for Residents 1, 3 and 4. During a review of the facility's P&P titled, Pass Procedures - Sending Resident Out on Pass, dated 2/2025, the P&P indicated the facility would obtain an order from the physician to allow the resident to leave the facility; include reason, medical or social. The P&P indicated the resident or responsible party is to sign the Acknowledge of the Release of Responsibility when OOP, prior to issuance of an OOP. The resident or responsible party is to list the location for the resident. This should be specific with an address or telephone number if resident going to a residence. The nurse receiving the resident is to have the resident/responsible party sign back in the OOP binder, verifying the resident has returned. The licensed nurse will advise the resident/responsible party to document the following in the OOP binder:Date and exact time the resident left the facilityWho accompanied the residentDestination and estimated time of returnPhone number where the resident can be reachedDate, time and condition of resident when he/she returned. During a review of the facility's P&P titled, Care Plans, Comprehensive person -Centered dated 3/2017, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Care Plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Grievances/Complaints Filing which indicated the Administrator and staff will make prompt efforts to resolve grievances, for one of five sampled residents (Resident 2) when Resident 2 informed the facility that a Certified Nursing Assistant (CNA) 1 was disrespectful when CNA 1 provided Activities of Daily Living (ADL) care to Resident 2 on 4/27/2026.This deficient practice violated Resident 1's rights and could negatively impact the residents' feelings and sense of self-worth.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) other disorders of nervous system (motor dysfunction (weaknesses, tremors, gait changes) and other ossification of muscle (bone tissue forms in soft tissues, following trauma or injury). During a review of Residents 2's Minimum Data Set (MDS - a resident assessment tool) dated 4/1/2026, the MDS indicated Resident 2 had no cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 was dependent on staff for ADLs such as toileting hygiene, showering/bathing self, lower body dressing, toilet use, and transfers (the ability to transfer to and from a bed to a chair or wheelchair). During a review of Resident 2's History and Physical (H&P) dated 4/2/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a concurrent interview and interview on 4/29/2026 at 9:33 a.m. in Resident 2's room, Resident 2 stated he could not get up, was only able to move his arms slowly and needed assistance from staff for ADLs. Resident 2 stated on 4/26/2026 at around 7 p.m., CNA 1 was upset and asked Resident 1 why he pressed the call light. Resident 2 stated CNA 1 provided ADL care to the resident and verbalized profanity by saying f*** as CNA 1 was leaving the Resident's room. Resident 2 stated he reported the incident involving CNA 1 to the Activities Director (AD) on 4/27/2026. Resident 2 stated he told the AD that he (Resident 2), did not like the way CNA 1 treated him and it was disrespectful to use that type of language around the resident. Resident 2 stated he requested to speak with the Social Services Director (SSD) and the AD told him she would inform the SSD. During an interview on 4/29/2026 at 12:55 p.m., with the AD, the AD stated on 4/27/2026, Resident 2 told her he wanted to speak with the SSD. The AD stated Resident 2 informed her that over the weekend (exact day unknown), Resident 2 reported that CNA 1 used the F word while providing care. The AD stated she informed the SSD via phone text on 4/27/2026 at 11:19 a.m., to speak with Resident 2 regarding a complaint involving a nurse. The SSD responded on 4/27/2026 at 11:20 a.m., acknowledging the AD's text message and indicated she (SSD) was in a meeting. The AD stated it was not acceptable for staff to use profanity while providing resident care and that such behavior could make a resident feel disrespected. The AD stated she did not know whether the SSD spoke with Resident 2 or whether the Administrator was informed. The AD stated facility staff were responsible for speaking with residents promptly and attempting to resolve their concerns.During an interview on 4/29/2026 at 1:26 p.m., with the SSD, the SSD stated on 4/27/2026, the AD informed her that Resident 2 wanted to see her (the SSD). The AD stated she did not see Resident 2 on 4/27/2026 because it was a very busy day for her due to new admissions and meetings. The SSD stated that if the AD was aware of Resident 2's complaints regarding CNA 1, she (the SSD) could have reported it to the Administrator or Director of Staff Development (DSD) and attempted to resolve the issue. The SSD stated she did not have the opportunity to speak with Resident 2 until this day (4/29/2026). During an interview on 4/30/2026 at 4:46 p.m., with the Director of Nursing (DON), the DON stated the facility should immediately address resident's complaints. The DON stated grievances should be resolved in a timely manner to help prevent residents from suffering or experiencing discomfort. During a review of the facility's P&P titled, Grievances/Complaints, Filing dated 2017, the P&P indicated the Administrator, and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and, or representative. Any resident, family member or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, or any other concerns regarding his or her stay at the facility. Grievances and/or complaints may be submitted orally or in writing.

Based on interview and record review, the facility failed to provide care and services that meet professional standards of practice for one of three sampled residents (Resident 1) by failing to provide interventions for Resident 1 and notify the physician when the resident:Had an altered level of consciousness, was unresponsive to commands and unable to accept medication. Experienced labored breathing after a previous Change in Condition (COC) for Oxygen (O2) desaturation (drop in O2 saturation [O2 sat- a measurement of how much oxygen the blood is carrying as a percentage]).This deficient practice had the potential to result in Resident 1 not receiving selective lifesaving or comfort measures and could lead to death. Findings:During a review of Resident 1 admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), influenza (respiratory infection caused by a virus that affect the nose, throat and sometimes the lungs), and chronic obstruction pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 1's Care Plan titled, (Resident 1) has Asthma (a chronic [long term] lung disease that make it difficult to breath)/COPD, nasal congestion. dated [DATE], the Care Plan nursing interventions indicated to observe for signs and symptoms of respiratory insufficiency: anxiety, confusion, shortness of breath and referral to the physician as needed. During a review of Resident 1's Physician Orders for Life Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) dated [DATE], the POLST indicated Resident 1 was a DNR (do not resuscitate- a medical order written by a doctor to instruct health care providers not to do cardiopulmonary resuscitation [CPR] if breathing stops or the heart stops beating) and to provide selective treatment (medical treatment, IV [intravenous-given directly into the blood stream] antibiotics [medication used to treat infection] and IV fluids as indicated. May use non-invasive positive airway pressure (delivery of oxygen into the lungs via positive pressure without the need for endotracheal intubation [insertion of a flexible tube through the mouth or nose into the trachea (windpipe) to maintain an open airway and enable mechanical ventilation) and transfer to hospital if comfort needs could not be met in current location. During a review of Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 was independent with Activities of Daily Living (ADLs) such as bed mobility, transfers and walking. During a review of Resident 1's Physician's Orders dated [DATE], the Orders indicated Resident 1 may O2 two liters per minute (L/min- a unit of measurement) via nasal cannula (N/C- a small plastic tube, which fits into the person's nostrils for providing supplemental O2 as needed for O2 saturation of less than 93% on room air. During a review of Resident 1's Change in Condition Evaluation (COC) dated [DATE], the COC indicated on [DATE] at 4:33 p.m., Resident 1's O2 sat was 88%.(normal resting range 95-100%, below normal 90-94%, low/hypoxemia [low levels of O2 in the blood which can lead to shortness of breath and confusion] below 90%). The COC indicated O2 was delivered with a non-rebreather (medical device used in emergencies to deliver high concentration of O2 to residents in severe respiratory distress) and (changed to) to nasal cannula (N/C- a small plastic tube, which fits into the person's nostrils for providing supplemental O2) when stabilized. During a review of Resident 1's Progress Notes dated [DATE] at 7:00 p.m., The Progress Notes indicated at 6:33 p.m., Resident 1 had O2 desaturation (a drop in O2 sat) of 88%. O2 was delivered via (non)rebreather at 3 L/min and O2 sat increased to 96%. O2 was changed to N/C and O2 was 95-96%. The Notes indicated the physician was notified and an order was obtained to make Resident 1 comfortable and continue to monitor. During a review of Resident 1's Progress Notes dated [DATE] at 10:50 p.m., the Progress Notes indicated at 6 p.m., Resident 1 had one episode of vomiting and continuous cough that lasted for few minutes. Resident 1 had an O2 sat of less than 94% (not specified), the Registered Nurse (RN) Supervisor was notified and O2 was administered. The Progress Notes indicated Resident 1 was monitored for decline. During a review of Resident 1's Progress Notes dated [DATE] at 11:35 p.m., the Progress Notes indicated Resident 1 was unable to accept medication due to partial waking and unresponsive to commands. The Progress Notes did not indicate any interventions were provided nor that the physician was notified about the resident's condition. During a review of Resident 1's Progress Notes dated [DATE] at 11:46 p.m., the Progress Notes indicated, upon (Licensed Vocational Nurse [LVN] 2) initial rounds (first purposeful check of a resident by staff to confirm the resident's safety and needs), Resident 1 was observed on a non-rebreather mask receiving O2 at 8 L/min with labored breathing noted. Attempts were made to obtain vital signs; however, vital signs were unable to be obtained. At approximately 11:46 p.m., resident was reassessed and was found unresponsive with no palpable pulse and no chest rise. No code was initiated due to residents' DNR status. The Progress Notes did not indicate any interventions were provided to the resident nor that the physician was notified regarding the resident's labored breathing identified on initial assessment. During an interview on [DATE] at 4:00 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated on [DATE] at 8:30 p.m., he was alerted by LVN 1 that Resident 1's O2 sat was 88% on room air and he administered O2 to Resident 1 with a non-rebreather mask at 3 L/min and the resident's O2 sat increased to 96%. RNS 1 stated he then decreased the O2 to 2 L/min via N/C, and Resident 1's O2 sat remained at 95-96 %. RNS 1 stated he notified the physician about the Resident's low O2 sat and the administration of O2 to Resident 1.During an interview on [DATE] at 1:10 p.m., with Certified Nurse Assistant (CNA) 2, CNA 2 stated on [DATE] during her initial rounds at approximately 11:00 p.m., Resident 1 was having labored breathing. Resident 1 was on O2 with a non-rebreather mask. CNA 2 stated she notified the LVN (not specified) about Resident 1 having labored breathing and the LVN notified her that the resident was a DNR. CNA 2 stated on [DATE] at approximately 12:00 a.m. she was called to clean Resident 1 because the resident expired. During an interview on [DATE] at 4:15 p.m., with LVN 1, LVN 1 stated on [DATE] at approximately 6:00 p.m., he was alerted by Resident 1's roommate that Resident 1 was choking. LVN 1 stated, Resident 1 vomited and was coughing and O2 sat was low. LVN 1 stated he notified the RN supervisor and O2 was administered which improved Resident 1's O2 sat. RNS 1 was aware of the changes in Resident 1's condition but LVN 1 did not know if the physician was made aware of the changes in Resident 's condition.During an interview on [DATE] at 9:20 a.m. with Resident 1's Physician (MD 1), MD 1 stated (on [DATE]) he was informed about Resident 1's COC regarding the low O2 sat which was stabilized with O2 therapy. MD 1 stated he instructed staff to continue monitoring the resident. MD 1 stated he was surprised when he received a second call from the facility (on [DATE]) at around 12:00 a.m. informing him that Resident 1 had passed away. MD 1 stated Resident 1 should have been transferred to the hospital if her condition had not improved. During an interview on [DATE] at 10:00 a.m., with LVN 2, LVN 2 stated on [DATE] (at 11:46 p.m.) she documented that Resident 1 was on O2 with non-rebreather mask, however that was incorrect documentation. LVN 2 stated on [DATE], she made her initial round at approximately 11:20 p.m. to 11:30 p.m. and Resident 1 was receiving O2 through N/C. Resident 1 was gasping for air and had no palpable pulse. RN supervisor was notified; no code was initiated because Resident was a DNR. LVN 2 stated she was not informed by CNA 2 that Resident 1 was having labored breathing at 11:00 p.m. because she arrived at the facility late that evening. During a concurrent interview and record review on [DATE] at 10:26 a.m., with the Director of Nursing (DON), Resident 1's Progress Notes dated [DATE] were reviewed. The DON stated Resident 1 had another significant COC and should have been transferred to the hospital. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021. The P&P indicated that facility promptly notifies the resident's attending physician of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly and need to transfer the resident to the hospital/treatment center. The nurse will record in the resident's medical record information relative to changes in the resident's condition or status.During a review of the facility's Charge Nurse (LVN) Job Description dated 2023, the Job Description indicated LVN duties and responsibilities included consulting with the resident's physician in providing the resident's care and treatment as necessary, implementing established nursing objectives and standards, making periodic checks to evaluate the resident's physical status and notify the resident's physician when the resident is involved in an incident. The LVN must possess the ability to plan, organize and implement goals, objectives, P&Ps etc. that are necessary for providing quality care, and must be able to relate information concerning a resident's health. During a review of the facility's RN Job Description dated 2023, the Job Description indicated RN duties and responsibilities included ongoing review of the resident's well-being and concerns and report to the appropriate department or inter-disciplinary (IDT-a group of healthcare professionals from different disciplines who work together to manage the resident's care).

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received showers and grooming when requested.This deficient practice resulted in Resident 1 not receiving scheduled showers and had the potential to result in compromised personal hygiene, skin integrity, decreased dignity and psychosocial distress.Findings: During a review of Resident 1's admission Record, dated 1/27/2026, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included generalized muscle weakness, abnormality of gait (the way a person walks) and mobility (ability to move), cerebral infarction (stroke, loss of blood flow to a part of the brain), spondylosis lumbar region (age related wear and tear of the lower spine which can cause back pain and stiffness), history of fraction/internal fixation of the right femur (a past break of the right thigh bone that was surgically repaired with metal hardware), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the right hip. During a review of Resident 1's History and Physical (H&P), dated 9/20/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's care plan titled Activities of Daily Living (ADLs), initiated on 10/27/2025, the care plan indicated Resident 1 required assistance with self-care and mobility due to decreased strength, limited balance, and reduced functional independence. The care plan interventions indicated Resident 1 required one-person assistance, including staff assistance with most bathing tasks such as washing and rinsing hard-to-reach areas. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/25/2025, the MDS indicated Resident 1's cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 1 was independent (completes the activity with no assistance) with eating, oral hygiene and personal hygiene, and required maximal assistance (helper does more than half the effort) for bathing and dressing of the upper and lower body. During a review of Resident 1's Interdisciplinary Team (IDT - a group of healthcare professionals from different healthcare roles who work together to plan and provide resident care) Conference Note dated 12/31/2025, the IDT note indicated Resident 1 preferred showers before 10:00 a.m. on Mondays, Tuesdays, Wednesdays, Thursdays, and Saturdays. The IDT note indicated Resident 1 prefered to be shaved every two days. The IDT note indicated the Director of Staff Development (DSD) would follow up to accommodate Resident 1's request. During an interview on 1/26/2026 at 1:57 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was in Bed A. CNA 1 stated residents in Bed A were scheduled showers on Mondays and Thursdays during the 3 p.m. to 11 p.m. shift. CNA 1 stated the shower schedule was based on the resident's assigned bed. CNA 1 stated Resident 1 frequently asked for showers during the day shift, and she would remind the resident his showers were scheduled from 3 p.m. to 11 p.m. CNA 1 stated Resident 1 would become upset when he was informed of his shower schedule. CNA 1 further stated she was required to complete a shower sheet after providing showers, which included documentation of the resident's skin condition. CNA 1 stated the shower sheets would then be submitted to the charge nurse for review and signature. CNA 1 stated she was also required to document if the Resident required shower assistance in the ADL task flowsheet in the electronic health record (EHR), but the ADL task flowsheet would not indicate whether a shower was completed for the resident. CNA 1 stated if a shower sheet was not completed and turned into the charge nurse, the nursing staff would not know whether a resident received a shower. During an interview on 1/26/2026 at 2:10 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated CNAs completed shower sheets for residents who received showers. LVN 1 stated she reviewed the shower sheets and then submitted the shower sheets to the DSD. LVN 1 stated she did not document showers were performed in the EHR. LVN 1 stated if a shower sheet was not completed or available, there was no way to verify through the resident's medical record whether the resident received a shower. LVN 1 stated the shower sheets were maintained by the DSD and were not incorporated into the resident's chart. During a concurrent observation and interview on 1/27/2026 at 11:03 a.m., with Resident 1, Resident 1 was observed sitting in his wheelchair. Resident 1 stated he was not offered a shower on 1/19/2026, 1/22/2026, and 1/26/2026. Resident 1 stated staff were supposed offer him a shower but did not. Resident 1 stated when he reminded staff, staff would reply they were too busy or they were not his assigned nurse. Resident 1 stated staff also refused to shave him when he requested. Resident 1 stated on 1/26/2026, his scheduled shower day, he left the facility out on a pass in the morning and returned before lunch. Resident 1 stated he was never offered a shower upon his return. Resident 1 stated he asked to receive his showers during the day and requested an additional shower on Saturdays, which he had not yet received. Resident 1 stated he required staff assistance with showering and it frustrated him when nurses made excuses. Resident 1 stated he did not like putting on clean clothes without first taking a shower. During an interview on 1/27/2026 at 3:33 p.m., with the DSD, Resident 1's shower sheets for the month of January 2026 were reviewed. The shower sheets included documentation for multiple residents, with four residents listed on each page. The DSD stated shower sheets were not part of the resident's medical record. The DSD stated after being completed by nursing, the shower sheets were submitted to her and kept in her office and were not incorporated into the resident's medical record because multiple residents were listed on each sheet. The DSD stated she did not have shower sheets for Resident 1 for 1/18/2026 and 1/26/2026. The DSD stated she spoke with nursing staff regarding Resident 1's missed shower on 1/18/2026 and was told the CNA was unaware of the resident's preference to receive showers during the day. The DSD stated when residents return to the facility from out on pass, the resident should be offered a shower. The DSD stated the CNA assigned to Resident 1 on 1/26/2026 did not offer Resident 1 a shower. The DSD stated nurses were trained on shower schedules, resident preferences, and the shower documentation process. The DSD stated showers should be charted only once a day on the ADL task flow sheet and documentation should reflect the resident's preferences. The DSD stated nursing staff were not accommodating Resident 1's shower preferences. The DSD stated staff communication regarding showers was not clear. The DSD stated when residents did not receive showers, they did not feel clean and may be unhappy or dissatisfied. The DSD stated the facility was not providing the care Resident 1 expected to receive. During a review of the facility's policy and procedure (P&P), titled Quality of Life - Dignity, revised 8/2009, the P&P indicated each resident was to be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. The P&P indicated residents were to be treated with dignity and respect at all times and assisted in maintaining and enhancing self-esteem and self-worth. The P&P further indicated residents were to be groomed as they wished to be groomed, including hair styles, nails, and facial hair. During a review of the facility's P&P titled Resident Rights, revised 8/2009, the P&P indicated employees were to treat all residents with kindness, respect, and dignity. The P&P indicated residents were entitled to exercise their rights and privileges to the fullest extent possible. The P&P further indicated the facility was to make every effort to assist each resident in exercising his or her rights to assure the resident was always treated with respect, kindness, and dignity. During a review of the facility's P&P titled Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated residents were to be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The P&P indicated appropriate care, and services were to be provided for residents unable to carry out ADLs independently, in accordance with the resident's plan of care, including support and assistance with hygiene, including bathing, dressing, grooming, and oral care.

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for five of six sampled residents (Resident 37, 35, 5, 110, 114) with positioning, mobility, and restorative nursing ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) concerns.a. For Resident 37, the facility failed to:1. Measure Resident 37's ROM in the joints of both arms during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 9/17/2025. 2. Measure Resident 37's ROM in the joints of both legs during the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 9/17/2025.3. Provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) exercises to both hands in accordance with Resident 37's physician orders and care plan, dated 11/11/2025.4. Provide pressure relief ankle foot orthoses ([PRAFO] device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) to both of Resident 37's legs from 11/12/2025 to 1/8/2026 in accordance with Resident 37's physician orders and care plan, dated 11/11/2025. b. For Resident 5, the facility failed to:1. Measure Resident 5's ROM in both legs during the PT Evaluations, dated 4/20/2025 and 7/27/2025.2. Measure Resident 5's ROM in both arms during the OT Evaluations, dated 7/27/2025.3. Provide bicycle exercises three times per week, from 5/2025 to 7/2025 in accordance with physician orders, dated 4/30/2025.4. Provide Resident 35 with PROM exercises on both arms and legs, three times per week, from 10/2025 to 1/2026 in accordance with physician orders and care plan, dated 10/30/2025.c. For Resident 35, the facility failed to:1. Measure Resident 35's ROM in both arms during the OT Evaluations, dated 3/23/2025 and 11/2/2025.2. Measure Resident 35's ROM in both legs during the PT Evaluations, dated 3/23/2025 and 11/2/2025.3. Provide PROM exercises for both arms and legs, three times per week, from 7/2025 to 10/2025, in accordance with the physician orders, dated 6/30/2025.d. For Resident 110, the facility failed to measure Resident 110's ROM in both arms during the OT Evaluations, dated 9/24/2025 and 12/14/2025.e. For Resident 114, the facility failed to:1. Measure Resident 114's ROM in both arms during the OT Evaluation, dated 7/23/2025 and 12/14/2025.2. Measure Resident 114's ROM in both arms during the PT Evaluation, dated 7/23/2025.These failures resulted in Resident 37's further ROM limitations of both ankles into plantarflexion (ankle bent with toes pointing away from the body) from 12-22 degrees (normal 0-45 degrees) on the left ankle and 10-12 degrees on the right ankle upon discharge from PT on 11/11/2025, to 39-58 degrees on the left ankle and 40-59 degrees on the right ankle on 1/8/2026. These failures also had the potential to result in undetected and further ROM loss in both hands, placing Resident 37 at increased risk of developing pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and further contractures (a stiffening/shortening at any joint that reduces the joint's range of motion). These failures also had the potential for Resident 5, 35, 110, and 114 to experience decreased mobility and further undetected ROM loss in both arms and legs. a. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE]. Resident 37's diagnoses included paralytic syndrome (broad term for conditions causing rapid muscle weakness) following cerebral infarction (brain damage due to a loss of oxygen to the area), paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and contractures to both hands and the right thigh. During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool), dated 12/11/2025, the MDS indicated Resident 37 had clear speech, expressed ideas and wants, understood verbal content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 37 was independent with eating. The MDS indicated Resident 37 required setup or clean-up assistance for oral hygiene. The MDS indicated Resident 37 required substantial/maximal assistance (helper does more than half the effort) for upper body dressing and rolling to both sides while lying in bed, and was dependent for toileting, lower body dressing, bathing, transferring from lying in the bed to sitting at the side of the body, and chair/bed-to-chair transfers. The MDS indicated Resident 37 had ROM limitations in both arms and legs. During a review of Resident 37's Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in each joint of both arms and legs), signed on 8/1/2025 by Physical Therapist 1 (PT 1), the JMS indicated Resident 37 had minimal ROM loss (less than 25 percent [%] of full ROM) in both elbows and moderate ROM loss (26 to 50% of full ROM) in both shoulders, both wrists and fingers, and both hips. The JMS also indicated Resident 37 had severe ROM loss (more than 50% of full ROM) in both knees and ankles. The JMS findings indicated Resident 37 had a diagnosis or condition placing the resident at risk for contracture development and indicated Resident 37 maintained joint mobility. The JMS Recommendations indicated to provide a Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) maintenance program. During a review of Resident 37's OT Evaluation and Plan of Treatment, dated 9/17/2025, the OT Evaluation indicated Resident 37 was referred to OT due to reduced participation in activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence), decreased functional mobility, decreased strength, and reduced balance. The OT Evaluation indicated Resident 37's past medical history included paraplegia, contractures of both hands, and contracture of the right thigh. The OT Evaluation did not include an assessment of Resident 37's ROM in both arms. The OT Treatment Plan included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), therapeutic activities (tasks to improve the ability to perform ADLs), and self-care management training, five times per week for four weeks.During a review of Resident 37's PT Evaluation and Plan of Treatment, dated 9/17/2025, the PT Evaluation indicated the ROM in both of Resident 37's legs were impaired (unspecified joints), the active range of motion ([AROM] performance of an exercise to move a joint without any assistance or effort of another person) of the right knee into flexion (bending the knee) measured 0-40 degrees (normal 0-135 degrees) and both knee extension (straightening out the knee) was within normal limits ([WNL] normal joint movement). The PT Evaluation did not include ROM measurements of both hips, the left knee flexion, and both ankles. The PT Evaluation indicated a goal to improve Resident 37's ROM on both knees and ankles to prevent further rigidity (state of increased, constant muscle tone causing stiffness). The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, and therapeutic activities, three times per week for four weeks.During a review of Resident 37's PT Treatment Encounter Note, dated 10/17/2025, the PT Treatment Encounter Note indicated the treatment session focused on right ankle PROM due to restriction into dorsiflexion (ankle bent toward the body). The PT Treatment Encounter Note indicated Resident 37 would benefit from application of a right PRAFO to further improve ankle mobility. During a review of Resident 37's PT Treatment Encounter Note, dated 10/24/2025, the PT Treatment Encounter Note indicated Resident 37 was provided with ankle foot orthoses ([AFOs] brace worn on the lower leg and foot to support, stabilize, control movement, or correct the ankle and foot's position) to both feet due to plantarflexion contractures. The PT Treatment Encounter Note indicated Resident 37's ROM was 10-20 degrees (normal 0-45 degrees) in the left ankle and 8-10 degrees in the right ankle. During a review of Resident 37's PT Treatment Encounter Note, dated 11/11/2025, the PT Treatment Encounter Note indicated Resident 37 tolerated wearing the AFOs for two-and-a half hours without any skin issues.During a review of Resident 37's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated interventions included applying both AFOs to prevent contractures, perform therapeutic exercises, and therapeutic activities for bed mobility. The PT Discharge Summary indicated Resident 37's ROM on the left ankle was 12-22 degrees and the right ankle was 10-12 degrees. The PT Discharge Summary indicated recommendations included applying splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and PROM. During a review of Resident 37's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated interventions included self-care management, therapeutic activities, and therapeutic exercises. The OT Discharge Summary indicated recommendations for the RNA program to apply both hand and leg splints for two hours and PROM to both arms and legs, three times per week or as tolerated.During a review of Resident 37's physician's orders, dated 11/11/2025, the physician orders indicated for the RNA to apply both hand splints for two hours, three times per week or as tolerated. Apply both leg splints for two hours, three times per week or as tolerated. Provide PROM to both arms in all planes (planes of joint motion, including forward and backward, side to side, and rotation), three times per week or as tolerated. During a review of Resident 37's care plan titled, At risk for immobility, at risk for contracture., and at risk for decline in function, initiated on 11/11/2025, the care plan indicated interventions included RNA to apply both leg splints for two hours, three times per week or as tolerated, RNA to apply both hand splints for two hours, three times per week or as tolerated, and RNA for PROM to both arms and legs in all planes, three times per week or as tolerated.During a review of Resident 37's physician's orders, dated 11/12/2025, the physician orders indicated for the RNA to provide Resident 37 with PROM to both legs in all planes, three times per week or as tolerated.During a review of Resident 37's RNA Flow Sheet (record of RNA tasks), dated 11/2025, the RNA Flow Sheet indicated Resident 37 received RNA for application of both hand splints for two hours, PROM to both arms, and PROM to both legs on 11/12/2025, 11/13/2025, 11/14/2025, 11/18/2025, 11/19/2025, 11/20/2025, 11/21/2025, and 11/25/2025. The RNA Flow Sheet did not indicate the RNA applied both leg splints for two hours. During a review of Resident 37's RNA Flow Sheet, dated 12/2025, the RNA Flow Sheet indicated Resident 37 received RNA for application of both hand splints for two hours, PROM to both arms, and PROM to both legs on 12/2/2025, 12/3/2025, 12/4/2025, 12/9/2025, 12/10/2025, 12/11/2025, 12/17/2025, 12/19/2025, 12/23/2025, 12/24/2025, 12/25/2025, and 12/30/2025. The RNA Flow Sheet did not indicate the RNA applied both leg splints for two hours.During a review of Resident 37's Physical Medicine and Rehabilitation Notes, dated 12/16/20205 and 12/30/2025 signed by the Doctor of Physical Medicine and Rehabilitation (MD 1), the Physical Medicine and Rehabilitation Notes indicated Resident 37 was to continue with PROM and splinting to both arms and legs. During a review of Resident 37's RNA Flow Sheet, dated 1/2025, the RNA Flow Sheet indicated Resident 37 received RNA for application of both hand splints for two hours, PROM to both arms, and PROM to both legs on 1/1/2025. The RNA Flow Sheet did not indicate the RNA applied both leg splints for two hours.During an interview on 1/5/2026 at 9:39 a.m. with the Director of Rehabilitation (DOR), the DOR stated the PT and/or OT perform the JMS on each resident (in general) upon admission, quarterly, and annually to determine if the resident experienced any changes that would impair the resident's function. The DOR stated residents who remained in the facility after discontinuation of therapy services were transitioned to the RNA program to maintain the residents' ROM and mobility. The DOR stated the therapists created the physician order and the care plan for a resident's RNA program upon discharge and would verbally notify the RNAs of a resident's transition from therapy to the RNA program. The DOR stated the purpose of splints was to prevent contractures which could result from increased muscle tone (muscle tenson) and rigidity (inability to bend). The DOR stated contractures could lead to skin breakdown (tissue damage caused by surfaces rubbing against each other, strain, moisture, or pressure) and difficulty with self-care. During a concurrent observation and interview on 1/5/2026 at 12:22 p.m. in Resident 37's room, Resident 37 was observed lying in bed with the head-of-bed elevated. Resident 37 had active movement in both shoulders, elbows, thumbs, index fingers, and limited movement in both middle fingers. Resident 37's middle, ring, and small fingers of both hands were observed in bent positions. Two hand splints were observed on top of Resident 37's nightstand. Resident 37 stated different RNAs performed exercises to both arms and legs and applied both hand splints at least twice per week. Resident 37 stated the hand splints helped straighten the fingers but RNAs did not consistently perform exercises and put on the splints, causing both of his hands to get worse. Resident 37 stated the RNAs placed boots on both feet one time a few weeks ago which helped straighten both feet but never reapplied the boots. Both of Resident 37's ankles were positioned in plantarflexion and rotated toward the left side. During a review of Resident 37's JMS, signed on 1/6/2026 by the DOR, the JMS indicated Resident 37 had minimal ROM loss in both elbows and moderate ROM loss in both shoulders, both wrists and fingers, and both hips. The JMS also indicated Resident 37 had severe ROM loss in both knees and ankles. The JMS indicated Resident 37 remained the same percentile of ROM loss but improved with goniometer (instrument used to measure angles of joint movement) measurements due to skilled therapy services. The JMS also indicated Resident 37 was assessed for the appropriateness of the splints (unspecified). During an observation on 1/6/2026 at 2:01 p.m. in Resident 37's room, with RNA 3, Resident 37's RNA session was observed. RNA 3 stood next to Resident 37's bed while the resident performed repetitions of right arm AROM exercises including elbow flexion (bending) and extension (straightening), shoulder horizontal adduction (lifting the shoulder at shoulder height and moving toward the body) with elbow flexion, wrist rotation, and finger flexion and extension. Resident 37 did not fully extend the right-hand middle, ring, and small fingers during the AROM exercises. Resident 37 then performed repetitions of left arm AROM exercises including elbow flexion and extension, shoulder horizontal adduction with elbow flexion, wrist rotation, and finger flexion and extension. Resident 37 did not fully extend the left-hand middle, ring, and small fingers during the AROM. RNA 3 did not provide PROM to both arms at the shoulder, elbow, wrist, and finger joints. RNA 3 applied the right hand-splint which was secured from Resident 37's right forearm to the fingertips with straps. Resident 37's right hand-splint had a cylindrical roll which was positioned in the palm to accommodate Resident 37's fingers. RNA 3 then applied the left hand-splint which was also secured from Resident 37's left forearm to the fingertips with straps. RNA 3 then provided ROM exercises to the right leg, including hip flexion (bending the leg at the hip joint toward the body) with the knee extended, hip abduction (bending at the leg at the hip joint away from the body) with knee extended, knee flexion and extension, ankle rotation, and toe flexion and extension. RNA 3 moved to the left side of Resident 37's bed to provide ROM exercises to the left leg including hip flexion with the knee extended, hip abduction with the knee extended, knee flexion and extension, ankle rotation, and toe flexion and extension. Both of Resident 37's ankles were observed in plantarflexion. During an interview on 1/6/2025 at 2:15 p.m. with RNA 3, RNA 3 stated Resident 37's hand splints will be removed after two hours. RNA 3 did not know whether AROM or PROM exercises were provided to Resident 37's arms and legs. RNA 3 stated Resident 37 did the arm exercises without assistance but could not move both legs, which required RNA 3 to move both of the resident's legs. RNA 3 stated Resident 37 did not have splints for both legs. During a concurrent interview and record review on 1/7/2026 at 10:52 a.m. with the DOR, Resident 37's OT Evaluation, dated 9/17/2025, and OT Discharge summary, dated [DATE], were reviewed. The OT Evaluation, dated 9/17/2025, did not include a ROM assessment of Resident 37's arms. The OT Discharge summary, dated [DATE], indicated recommendations for the RNA to perform PROM to both of Resident 37's arms. The DOR stated Resident 37's OT Evaluation did not include a ROM assessment of both arms. The DOR stated it was part of the OT's professional practice to objectively measure joint ROM using a goniometer to determine if there were any changes in the joint ROM. The DOR stated there was no way to determine whether Resident 37 had a change in ROM in both arms since the OT Evaluation did not include a ROM assessment. The DOR stated Resident 37 was discharged from OT with recommendations for the RNA to provide PROM to both arms and legs, apply both hand splints for two hours, and apply both leg splints for two hours, three times per week. The DOR stated AROM (in general) was when the resident performed the movement without assistance. The DOR stated PROM (in general) was when someone else moved the resident at each joint. The DOR stated the RNA should perform PROM to both of Resident 37's arms to achieve the maximum ROM at each joint. During a concurrent interview and record review on 1/7/2026 at 11:05 a.m. with the DOR and PT 1, Resident 37's PT Evaluation, dated 9/17/2025, PT Treatment Encounter Note, dated 10/24/2025, PT Discharge summary, dated [DATE], and the physician orders for RNA, dated 11/11/2025 and 11/12/2025, were reviewed. The PT Evaluation, dated 9/17/2025, did not include ROM measurements of the hips, left knee, and both ankles. The PT Treatment Encounter Note, dated 10/24/2025, indicated Resident 37 had plantarflexion contractures with the ankles measuring 10-20 degrees in the left ankle and 8-10 degrees in the right ankle. Resident 37's PT Discharge summary, dated [DATE], and physician's orders for RNA, dated 11/11/2025 and 11/12/2025, indicated to apply both hand splints and leg splints for two hours. PT 1 stated it was part of a PT's professional education to measure joint ROM using a goniometer to obtain an accurate ROM measurement of each joint. PT 1 stated the PT Evaluation did not include the measurement for left knee flexion which was a mistake since Resident 37 could bend and extend both knees. PT 1 stated Resident 37's ROM in both ankles were measured on 10/24/2025 (one month after the PT Evaluation) when Resident 37 received both PRAFOs. PT 1 stated both of Resident 37's ankles had plantarflexion contractures measuring 10-20 degrees on the left ankle and 8-10 degrees on the right ankle. The DOR reviewed the PT Discharge Summary and stated the PT Discharge Summary indicated Resident 37's ankle ROM was 12-22 degrees on the left ankle and 10-12 degrees on the right ankle. The DOR stated the PT Discharge recommendations included for the RNA to provide PROM and apply PRAFOs. The DOR stated Resident 37's physician orders indicated for the RNA to perform PROM in both arms and legs, apply both hand splints for two hours, and apply both PRAFOs for two hours. During a concurrent interview and record review on 1/7/2026 at 11:24 a.m. with the DOR and PT 1, Resident 37's RNA Flow Sheet for 11/2025, 12/2025, and 1/2026 were reviewed. Resident 37's RNA Flow Sheets for 11/2025, 12/2025, and 1/2026 did not include a task for the RNA to apply Resident 37's PRAFOs in accordance with the physician's orders. PT 1 stated Resident 37's physician orders for the RNA to apply both leg splints referred to both PRAFOs to prevent both ankles from further contractures and protect joint integrity (stabilizing and restoring proper alignment to the joint). PT 1 and the DOR stated Resident 37's RNA Flow Sheets for 11/2025, 12/2025, and 1/2026 did not include documentation the RNAs applied both PRAFOs to Resident 37's ankles. PT 1 stated Resident 37 could experience a decline in ROM in both ankles without the application of both PRAFOs.During a concurrent interview and record review on 1/7/2026 at 11:39 a.m. with the DOR, Resident 37's RNA Flow Sheet for 11/2025, 12/2025, and 1/2026 were reviewed. The RNA Flow Sheet for 11/2025, 12/2025, and 1/2026 indicated Resident 37 received three consecutive days of RNA and had gaps in-between RNA sessions. The DOR stated Resident 37 had a four-to-five-day gap between the provision of RNA services since the RNA orders were three times per week. The DOR stated it was the facility's culture to provide the residents with RNA services three times per week. During an interview on 1/8/2026 at 10:21 a.m., with Resident 37, Resident 37 stated RNA 3 did not provide RNA services consistently each week. During a concurrent observation and interview on 1/8/2026 at 10:42 a.m. with the DOR and Resident 37, in Resident 37's room, the DOR was observed measuring Resident 37's ankles using a goniometer. Resident 37 used the bed controls to place the bed flat, and the DOR removed the pillows positioned underneath Resident 37's legs. The DOR stated Resident 37's ankles were positioned in plantarflexion. The DOR used a goniometer to measure both ankle joints. The DOR stated the PROM in Resident 37's left ankle was 39-58 degrees and the right ankle was 40-59 degrees. The DOR was unable to locate Resident 37's PRAFOs in Resident 37's closet. Resident 37 stated, As I recall, they (unknown) put it back in the therapy room.During an observation on 1/8/2026 at 11:03 a.m. in the therapy room, the DOR and the Rehabilitation Aide were observed locating two PRAFOs labeled with Resident 37's name in the closet. During a concurrent observation, interview, and record review on 1/8/2026 at 11:06 a.m. with the DOR, in the conference room, Resident 37's PRAFOs were observed, and PT Discharge summary, dated [DATE], and the JMS, signed on 1/6/2026, were reviewed. The PT Discharge summary, dated [DATE], indicated Resident 37's ROM on the left ankle was 12-22 degrees and the right ankle was 10-12 degrees with recommendations for the RNA to apply Resident 37's PRAFOs for two hours, three times per week. The JMS, signed on 1/6/2026, indicated Resident 37's ankles were assessed as severe ROM limitations. The DOR stated Resident 37's PRAFOs retrieved from the therapy room's closet appeared new and unused. The DOR stated Resident 37's ankle ROM has worsened into further plantarflexion since Resident 37's discharge from PT on 11/11/2025. The DOR stated Resident 37's JMS occurred on 12/12/2025 but was not signed as complete until 1/6/2026. The DOR stated Resident 37's ankle ROM was assessed on the JMS as having severe ROM limitations since the JMS was based on observation and not on actual measurements. The DOR stated the purpose of the PRAFOs was to prevent Resident 37 from developing further contractures and loss of motion. The DOR stated Resident 37 could have experienced further ROM loss in both ankles since the PRAFOs were not applied. The DOR stated application of the PRAFOs were not appropriate at this time because Resident 37's ROM in both ankles would need to improve to fit in the PRAFOs. The DOR stated application of both PRAFOs could have prevented Resident 37's further ROM limitations into plantarflexion. During an interview on 1/8/2026 at 11:30 a.m. with RNA 3, RNA 3 stated Resident 37 had splints for both hands and did not have any splints for both legs. RNA 3 stated the RNA orders after Resident 37 was discharged from PT services included exercises to both arms and legs and application of the hand splints. RNA 3 stated the electronic documentation screen for Resident 37's RNA program did not include orders to apply both PRAFOs. During a concurrent observation record review on 1/8/2026 at 11:36 a.m. with RNA 3, in the nursing station, the RNA documentation system for Resident 37's RNA program, dated 1/8/2026, was observed on the computer screen. The computer screen displayed Resident 37's RNA program for the RNA to provide Resident 37 with PROM to both arms and legs, three times per week, and to apply both hands splints for two hours, three times per week. The computer screen did not include for the RNA to apply both of Resident 37's leg splints. RNA 3 stated the RNA documentation system did not display a task for the RNA to apply Resident 37's leg splints. During a concurrent interview and record review on 1/8/2026 at 12:05 p.m. with the Director of Medical Records (DMR), Resident 37's physician's orders, dated 11/11/2025, for RNA were reviewed to determine the reason Resident 37's RNA program did not display the physician's order to apply both leg splints on RNA 3's documentation system. The DMR stated the physician order, dated 11/11/2025, for the RNA to apply both leg splints for two hours, three times per week or as tolerated, was entered into the facility's electronic documentation system with an order type of Other Orders (no documentation required). The DMR stated the physician order to apply both leg splints would not appear on the RNA's electronic documentation screen as a task because the order type indicated no documentation required. The DMR stated the RNAs would never see the physician order to apply both legs splints on the documentation system unless it was communicated to the RNAs during the weekly RNA meetings.During a concurrent interview and record review on 1/8/2026 at 12:41 p.m. with MD 1, Resident 37's Physical Medicine and Rehabilitation Note, dated 12/16/2025 and 12/30/2025, were reviewed. The Physical Medicine and Rehabilitation Note indicated Resident 37 was to continue with PROM and splinting to both arms and legs. MD 1 stated Resident 37 had wrist-hand orthoses (hand splints) and PRAFOs for both ankle contractures. MD 1 stated the PRAFOs could help prevent the degree of plantarflexion by placing a stretch on the ankle tendon (fibrous tissue that links muscles to bones) for a period of time. MD 1 stated Resident 37's ankle contractures could worsen if the PRAFOs were not applied. During a concurrent interview and record review on 1/8/2026 at 1:37 p.m. with the DOR, the RNA Meeting Notes, dated 11/18/2025, 12/23/2025, 12/30/2025, and 1/6/2026, were reviewed. The RNA Meeting Notes did not include any notes regarding Resident 37's RNA program. The DOR stated Resident 37's RNA program was not discussed during the RNA Meetings. During a concurrent interview and record review on 1/8/2026 at 1:55 p.m. with the DOR, Resident 37's PT Treatment Encounter Notes from 9/15/2025 to 11/11/2025 and PT Discharge summary, dated [DATE], were reviewed. The PT Encounter Notes indicated the treatment provided to Resident 37 but did not include documentation of RNA training. The PT Discharge Summary also did not include RNA training regarding Resident 37's RNA program. The DOR stated the PT Treatment Encounter Notes and PT Discharge Summary did not indicate the RNAs were trained in Resident 37's recommended RNA Program. During an interview on 1/8/2026 at 2:47 p.m. with MD 1, MD 1 was informed that Resident 37's PRAFOs were not applied since 11/11/2025 and informed that the DOR stated Resident 37's ankle ROM has worsened into further plantarflexion since Resident 37's discharge from PT on 11/11/2025. MD 1 stated not applying the splint could have played a part in Resident 37's further ROM limitations. MD 1 stated contractures could not be reversed without surgical intervention. During an interview on 1/8/2026 at 4:17 p.m. with the Director of Staff Development (DSD), the DSD stated the DOR or the therapist placed the physician order for RNA into the electronic documentation system after discharge from therapy services. The DSD did not know whether there was a process for the nurses to check the RNA order after submission into the electronic documentation system.During an interview on 1/8/2026 at 5:10 p.m. with the Interim Director of Nursing (IDON) and the DSD, Resident 37's RNA Flow Sheets for 11/2025, 12/2025, and 1/2026 were reviewed. The IDON stated the physician order for the RNA to apply both of Resident 37's leg splints was entered in the computer documentation system in a manner that did not create the task on the RNA Flow Sheets. The IDON stated Resident 37 could potentially develop contractures if the leg splints were not applied.During an interview on 1/8/2026 at 5:15 p.m. with the IDON and the DSD, The IDON and the DSD stated the ROM in both of Resident 37's ankles had worsened since Resident 37's discharge from PT on 11/11/2025. The IDON stated contractures should be prevented to prevent a resident's discomfort and the development of pressure injuries. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.b. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted on [DATE] with diagnoses including hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following a cerebral vascular accident ([CVA] stroke, loss of blood flow to a part of the brain) affecting the right dominant side, dysphagia (difficulty swallowing), aphasia (disorder that makes it difficult to speak), muscle weakness, and chronic respiratory failure (airways carrying air to lungs become narrow and damaged, limiting air movement in the body) with hypoxia (body does not receive enough oxygen).During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 had unclear speech, had difficulty communicating some words or finishing thoughts, usually understood verbal content, and had intact cognition. The MDS indicated Resident 5 had limited ROM in both arms and arms. The MDS indicated Resident 5 required setup or clean-up assistance for eating, substantial/maximal assistance (helper does more than half the effort) for upper and lower body dressing, rolling to either side while lying in bed, transferring from lying in bed to sitting at the side of the, and chair/bed-to-chair transfers.During a review of Resident 5's JMS, signed on 4/20/2025 and completed by PT 1, the JMS indicated Resident 5 had minimal ROM loss in both shoulders, both elbows, the left wrist and fingers, both hips, both knees, and the left ankle. The JMS indicated Resident 5 had moderate ROM loss in the right wrist and fingers and the right ankle. The JMS indicated Resident 5 maintained joint mobility and had a diagnosis/condition that puts the resident at risk for contracture development.During a review of Resident 5's OT Evaluation and Plan of Treatment, dated 4/20/2025, the OT Evaluation indicated the ROM in both of Resident 5's arms were within fun

Based on interview and record review, the facility failed to ensure coordination of the resident's PASRR Level II (PASRR II-a federally mandated screen for individuals for Serious Mental Illness [SMI], Intellectual Disabilities [ID], or Developmental Disabilities [DD] to ensure they get the right care in the least restrictive setting, preventing inappropriate nursing home placement and identifying needs for specialized services) determination with ongoing assessment, interdisciplinary review, care planning revisions, reconsideration of appropriate placement following significant changes in the residents behavioral condition for one of three sampled residents (Resident 27). This deficient practice had the potential to result in inaccurate care for Resident 27 while residing in the facility.Findings: During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was initially admitted to the facility on [DATE]. Resident 27's diagnoses included traumatic brain injury (damage to the brain from an external force), traumatic subarachnoid hemorrhage (brain bleed) with loss of consciousness, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The admission Record indicated, on 12/19/2025, Resident 27 was diagnosed with disorganized schizophrenia (a mental illness that is characterized by disturbances in thought) and brief psychotic disorder.During a review of Resident 27's Minimum Data Set ([MDS], a resident assessment tool), dated 12/22/2025, the MDS indicated Resident 27's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 27 was entirely dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 27's History and Physical (H&P), dated 9/14/2025, the H&P indicated Resident 27 had the capacity to understand and make decisions. During a review of Resident 27's Nursing Progress Note dated 10/3/2025, the note indicated on 10/3/2025, Resident 27 hit, punched, cursed, threw feces at staff, and threw his meal plates on staff and peers. The Nursing Progress Note also indicated redirection and medication for agitation and anxiety was not effective. During a review of Resident 27's Nursing Progress Note dated 10/16/2025, the note indicated on 10/16/2025, Resident 27 ripped off the curtains in his room and started yelling profanities. During a review of Resident 27's Nursing Progress Note dated 11/24/2025, the note indicated on 11/24/2025, Resident 27 was verbally and physically aggressive towards a certified nursing assistant (CNA). During a review of Resident 27's Nursing Progress Note dated 12/17/2025, the note indicated on 12/17/2025, Resident 27 grabbed a CNA by the jacket while the CNA attempted to provide peri-care, was verbally aggressive, and kicked the CNA in the chest. The Nursing Progress Note indicated 911 was called for increased agitation. During a review of Resident 27's Nursing Progress Note dated 12/30/2025, the note indicated on 12/30/2025, Resident 27 struck a charge nurse on the stomach while passing by her. During a review of Resident 27's Nursing Progress Note dated 12/31/2025, the note indicated on 12/31/2025, Resident 27 reached forward and grazed another resident with his hand and the resident's chair. The note indicated the Department of Mental Health was notified, and two members of the Psychiatric Mobile Response Team (PMRT) came to evaluate resident for a possible 5150 (a 72- hour psychiatric hospitalization when an adult exhibits a mental health crisis and is evaluated to be a danger to others, or to himself or herself, or gravely disabled) hold. The Nursing Progress Note indicated the PMRT members agreed that Resident 27 was not fit to be in facility, but he was not transferrable at that time. During a review of Resident 27's Nursing Progress Note dated 1/1/2026, the note indicated on 1/1/2026, Resident 27 displayed three episodes of aggression. During a review of Resident 27's Nursing Progress Note dated 1/3/2026, the note indicated on 1/3/2026, Resident 27 displayed one episode of aggression. During a review of Resident 27's Nursing Progress Note dated 1/4/2026, the note indicated on 1/4/2026, Resident 27 displayed three episodes of aggression. During a review of Resident 27's Nursing Progress Note dated 1/5/2026, the note indicated on 1/5/2026, Resident 27 displayed one episode of aggression. During a review of all of Resident 27's Interdisciplinary Team (IDT) Notes, dated 10/2025 to 1/6/2026, the IDT notes did not indicate an IDT Care Conference was held following each documented episode of physical and verbal aggression. The IDT Note, dated 12/23/2025, indicated on 12/19/2025, Resident 27 was readmitted to the facility from the General Acute Care Hospital (GACH) due to striking out at staff. There was no documentation to indicate there was a reassessment of Resident 27's behavioral management needs, consideration of increased interventions, initiation of PASRR Level II re-evaluation, or discussion of discharge to a more specialized setting despite continued aggressive behaviors. During a review of Resident 27's PASRR II Care Plan, dated 10/10/2025, the care plan indicated Resident 27 was to receive psychiatry (a branch of medicine concerned with the study, diagnosis, and treatment of mental illness) and psychology (the study of the human mind and its functions, especially those affecting behavior) evaluations as indicated and supportive visits from social services and other providers as tolerated. During a review of Resident 27's PASRR Individualized Determination Report, dated 10/14/2025, the report indicated Resident 27 was recommended the following specialized add on services: mental health rehabilitation activities, psychotherapy counseling, psychology consultation, and social services consultation. During a review of Resident 27's Order Summary, dated 1/7/2026, the Order Summary did not indicate an order for a psychologist consultation. During an interview on 1/5/2026 at 12:20 p.m. with CNA 2, CNA 2 stated Resident 27 grabbed her buttocks and private area (date unknown), causing her to feel uncomfortable. CNA 2 stated Resident 27 laughed during the incident. CNA 2 stated she notified Licensed Vocational Nurse (LVN) 2 and the Director of Staffing Development (DSD) of the incident. During a concurrent interview and record review on 1/7/2026 at 12:10 p.m. with the Director of Nursing Trainer (DONT), all of Resident 27's Progress Notes, Physician Orders, IDT Notes, Physician Progress Notes, and Nursing Progress Notes, dated 7/2025 to 1/7/2026, were reviewed. The Physician Orders lacked a psychologist consultation order. The Physician Progress Notes lacked evidence a psychologist visited Resident 27. The IDT notes indicated a lack of reconvening after each episode of physical and verbal aggression. The IDT Notes indicated the most recent Behavioral Management IDT was held in 7/2025, which occurred prior to the PASRR Individualized Determination Report (10/14/2025). The Nursing Progress Notes lacked documentation to indicate a PASRR reevaluation was requested. The DONT stated Resident 27 would have benefited from a psychologist consult to engage in purposeful psychotherapy and learn behavioral management techniques. The DON stated a PSARR reevaluation should have been conducted, particularly following the continued episodes of aggression and verbal issues. The DON stated the lack of IDT meetings, and lack of psychological health resources led to missed opportunities to address Resident 27's grave behavioral and mental health needs and placed Resident 27 at risk for continued episodes of aggression and deteriorating mental health. During a concurrent interview and record review on 1/7/2026 at 3:46 p.m. with the Social Services Director (SSD), Resident 27's Social Services Progress Notes, dated 10/2025 through 1/7/2026, and PASRR Individualized Determination Report, dated 10/14/2025, were reviewed. The Progress Notes lacked documentation to indicate Resident 27 received meaningful social services visits, mental health rehabilitation activities and psychotherapy counseling to support Resident 27's mental health. The SSD stated she visited Resident 27 but did not document her visits because she did not have the time. The SSD stated it was important to adhere the PASRR'S recommendations to ensure Resident 27 received mental supportive services to ensure his psychiatric needs were met and so that his mental health did not deteriorate. During a review of the facility's Policy and Procedure (P&P) titled, Preadmission Screening and Resident Review (PASRR) (undated) the P&P indicated the facility would ensure the following:1. Not admit until the state issues a Level II determination confirming nursing facility services were appropriate, and whether specialized services were required.2. If specialized services were recommended, the facility would document ability and plan to provide or arrange them.3. If placement was not appropriate, the facility would assist in identifying alternative community options.4. Incorporate PASRR recommendations into the comprehensive care plan, including any specialized services.5. Notify the interdisciplinary team of PASRR findings and required services.

Based on observation, interview, and record review, the facility failed to ensure care plans were in initiated addressing a resident's diagnosis of stroke (loss of blood flow to a part of the brain) and cranial surgical incision, and the use of Apixaban (a type of blood thinner used to prevent and treat blood clot) for two of two sampled residents (Resident 65 and Resident 4). These deficient practices had the potential to place Resident 65 at risk for neurological deterioration, infection, and other life-threatening complications, and had the potential for Resident 4 to exhibit complications related to bleeding due to the lack of individualized monitoring, interventions and staff guidance related to anticoagulant (blood thinner) therapy. Findings: a. During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was initially admitted to the facility on [DATE]. Resident 65's diagnoses included nontraumatic intracerebral hemorrhage (a serious type of hemorrhagic stroke where a blood vessel within the brain bursts, causing bleeding directly into the brain tissue, leading to swelling and tissue damage), encephalopathy (any disease or damage that alters brain function), and chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot adequately oxygenate the blood). During a review of Resident 65's Minimum Data Sets ([MDS], a resident assessment tool), dated 9/16/2025 and 12/16/2025, the MDS' indicated Resident 65's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS' indicated Resident 65 was entirely dependent on staff for toileting, showering, and lower body dressing. The MDS' indicated Resident 65 had an active diagnosis of a cerebrovascular accident (CVA) or a stroke. The MDS' indicated Resident 65 did not have any major surgical procedures during the prior inpatient hospital stay that required active care in the facility. During a review of Resident 65's History and Physical (H&P), dated 9/11/2025, the H&P indicated Resident 65 had the capacity to understand and make decisions. During a review of Resident 65's General Acute Care Hospital (GACH) Physician Progress Note, dated 9/10/2025, the GACH note indicated Resident 65 was admitted to the intensive care unit (ICU) on 8/5/2025 for a diagnosis of intraventricular hemorrhage and required immediate intubation (a medical procedure where a tube is placed into the windpipe through the mouth or nose to secure an open airway). The GACH note indicated Resident 65 underwent ventriculostomy (a neurosurgical procedure where a catheter or small opening is placed in the brain's ventricles [fluid-filled cavities deep within the brain] to drain excess cerebrospinal fluid [CSF- brain fluid] or monitor intracranial pressure [ICP – pressure within the brain]) with EVD (a catheter is inserted into a ventricle, connected to an external drainage system to remove CSF and measure pressure) placement on 8/6/2025 and subsequent removal on 8/12/2025. The GACH note indicated Resident 65 was in the ICU for approximately 30 days. During a concurrent observation and interview on 1/6/2026 at 2:00 p.m., with Resident 65, in Resident 65's room, observed Resident 65 with three staples along a surgical incision to his scalp. There was no dressing in place. Resident 65 stated the staff had not assessed or treated the incision site. During an interview on 1/6/2026 at 2:42 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was also one of the facility's treatment nurses. LVN 1 stated she was not aware Resident 65 had a recent surgical incision. LVN 1 stated the facility had not been providing treatment or monitoring Resident 65's post-surgical incision. LVN 1 stated it was very important to monitor surgical incisions and ensure timely removal of staples because skin could potentially grow over the staples or an infection could occur. LVN 1 stated a care plan should have been initiated to address Resident 65's wound care to prevent infection and to ensure follow up orders were in place for staple removal. During a concurrent interview and record review on 1/6/2026 at 4:29 p.m. with Registered Nurse (RN) 1, Resident 65's GACH Record Physician Progress Note, dated 9/10/2025, and all of Resident 65's Care Plans, dated 9/2025 to 1/6/2026, were reviewed. RN 1 stated there were no care plans in place that addressed Resident 65's diagnosis of a stroke and the resident's surgical incision wound care. RN 1 stated care plans should have been started upon Resident 65's admission to the facility because the conditions were present upon admission, in 9/2025. RN 1 stated the absence of both care plans had the potential to lead to neurological decline, infection, seizures, and poor care of a stroke patient. During a concurrent interview and record review on 1/8/2026 at 3:23 p.m. with the Quality Assurance Nurse (QAN), Resident 65's MDS', dated 9/16/2025 and 12/16/2025, were reviewed. The QAN stated the MDS inaccurately indicated Resident 65 did not have any major surgical procedure during the prior inpatient hospital stay requiring active SNF care. The QAN stated the MDS should have reflected the resident's recent surgery so that the appropriate care area assessment could have been triggered, which would have assisted in the formulation of a care plan. The QAN stated the inaccurate assessment contributed to the absence of care planning for the resident's post-surgical and neurological needs. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person- Centered , revised 3/2022, the P&P indicated the facility was to ensure a comprehensive, person-centered care plan, that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs, was developed and implemented for each resident. The P&P indicated the following: 1. The interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan was developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. b. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and hyperlipidemia (high cholesterol). During a review of Resident 4's H&P, dated 11/15/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's physician order dated 11/7/2025, the physician order indicated to administer Apixaban Tablet 5 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount) by mouth two times a day for acute embolism and thrombosis (blood clots that block blood vessels with potential blood clot breakage) of unspecified deep veins of the lower extremities (legs). During a concurrent interview and record review on 1/6/2026 at 3:05 p.m., with LVN 4, Resident 4's medical records were reviewed. The records did not indicate there was a care plan addressing the resident's use of Apibaxan. LVN 4 stated that residents receiving anticoagulants (medication to thin the blood) should have an individualized care plan. LVN 4 stated the care plan should include the monitoring for signs and symptoms of bleeding, medication precautions, and safety interventions. LVN 4 stated that the care plan omission was an oversight and acknowledged that the care plan should have been developed and implemented to properly monitor and assist Resident 4. During a concurrent interview and record review on 1/7/2026 at 9:28 a.m., with RN 3, Resident 4's physician orders dated 11/7/2025 were reviewed. RN 3 stated Resident 4 was currently receiving Apixaban as ordered by the physician. RN 3 stated that residents on anticoagulant therapy should have a care plan that included monitoring for signs and symptoms of bleeding, fall precautions, and notification parameters for abnormal findings. RN 3 stated that nursing staff rely on the care plan to guide the resident's monitoring and interventions and acknowledged that the absence of a care plan could result in inconsistent care delivery and potential adverse events. During a review of the facility's P&P titled, Care Plans – Baseline dated 3/2022, the P&P indicated, The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to ensure a resident received appropriate post-stroke (loss of blood flow to a part of the brain) care and post-surgical wound monitoring for one of three sampled residents (Resident 65), when nursing staff failed to assess and monitor Resident 65's post-surgical cranial incision and staples since his admission on [DATE] and failed to advocate for a specialty follow-up appointment with a neurologist (a medical doctor specializing in the diagnosis and treatment of disorders affecting the brain). These deficient practices placed Resident 65 at risk for neurological (relating to disorders of the nervous system and brain) decline, infection, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and other life-threatening complications.Findings: During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was initially admitted to the facility on [DATE]. Resident 65's diagnoses included nontraumatic intracerebral hemorrhage (a serious type of hemorrhagic stroke where a blood vessel within the brain bursts, causing bleeding directly into the brain tissue, leading to swelling and tissue damage), encephalopathy (any disease or damage that alters brain function), and chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot adequately oxygenate the blood). During a review of Resident 65's Minimum Data Sets ([MDS], a resident assessment tool), dated 9/16/2025 and 12/16/2025, the MDS' indicated Resident 65's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS' indicated Resident 65 was entirely dependent on staff for toileting, showering, and lower body dressing. The MDS' indicated Resident 65 had an active diagnosis of cerebrovascular accident (CVA) or a stroke (loss of blood flow to a part of the brain). The MDS' indicated Resident 65 did not have any major surgical procedures during the prior inpatient hospital stay that required active care in the facility. During a review of Resident 65's History and Physical (H&P), dated 9/11/2025, the H&P indicated Resident 65 had the capacity to understand and make decisions. During a review of Resident 65's General Acute Care Hospital (GACH) Physician Progress Note, dated 9/10/2025, the GACH note indicated Resident 65 was admitted to the intensive care unit (ICU) on 8/5/2025 for a diagnosis of intraventricular [fluid-filled cavities deep within the brain] hemorrhage and required immediate intubation (a medical procedure where a tube is placed into the windpipe through the mouth or nose to secure an open airway). The GACH note indicated Resident 65 underwent ventriculostomy (a neurosurgical procedure where a catheter or small opening is placed in the brain's ventricles to drain excess cerebrospinal fluid [CSF- brain fluid] or monitor intracranial pressure [ICP - pressure within the brain]) with external ventricular drain (EVD-a catheter is inserted into a ventricle, connected to an external drainage system to remove CSF and measure pressure) placement on 8/6/2025 and subsequent removal on 8/12/2025. The GACH note indicated Resident 65 was in the ICU for approximately 30 days. During a review of Resident 65's Psychiatrist (a medical doctor specializing in mental health) Progress Notes, dated 12/16/2025 and 1/3/2026, the Psychiatrist Progress Notes indicated, in 10/2025, Resident 65 confirmed experiencing short-term memory loss likely related to the residual effects of a stroke. The Psychiatrist Progress Notes indicated to defer to neurology (a medical doctor specializing in the diagnosis and treatment of disorders affecting the brain, spinal cord, and nerves [the nervous system]) to address this issue. During a concurrent observation and interview on 1/6/2026 at 2:00 p.m., with Resident 65, in Resident 65's room, observed Resident 65 in bed with three staples along a surgical incision on the scalp. There was no dressing observed. Resident 65 stated staff had not assessed or treated his surgical incision site. During an interview on 1/6/2026 at 2:42 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was also the treatment nurse. LVN 1 stated she was not aware Resident 65 had a recent surgical incision related to neurosurgical intervention. LVN 1 stated the facility had not been providing treatment or monitoring related to Resident 65's post-surgical incision. LVN 1 stated it was important to monitor surgical incisions and ensure timely removal of staples because skin could potentially grow over the staples or an infection could occur. LVN 1 stated a care plan should have been initiated to address Resident 65's wound care to prevent infection and to ensure follow up orders were in place for staple removal. During a concurrent interview and record review on 1/6/2026 at 4:29 p.m. with Registered Nurse (RN) 1, Resident 65's GACH Records, dated 9/2025, Resident 65's Psychiatrist Progress Notes, dated 12/16/2025 and 1/3/2026, Nursing Progress Notes, Skin Assessments, and all of Resident 65's Care Plans, dated 9/2025 to 1/6/2026, were reviewed. RN 1 stated Resident 65's medical record lacked documentation Resident 65's post-surgical incision and staples were assessed and monitored since admission on [DATE]. RN 1 stated there was no documentation to indicate a neurologist (a medical doctor specializing in the diagnosis and treatment of disorders affecting the brain) follow up appointment was scheduled on Resident 65's behalf, despite the psychiatrist documenting to defer to neurology. RN 1 stated the facility did not provide ongoing monitoring or follow-up care related to Resident 65's stroke diagnosis or post-surgical incision. RN 1 stated licensed nursing staff should have advocated for a follow up appointment with a neurologist for Resident 65 to ensure appropriate post-surgical and neurological care was provided. RN 1 stated the licensed nursing staff should have appropriately and carefully assessed Resident 65's skin upon admission and on an ongoing basis, thereafter. RN 1 stated the lack of a diligent skin assessment contributed to the lack of identification and management of Resident 65's surgical incision and staples. RN 1 stated these failures had great potential to lead to neurological decline, infection, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and poor care for a stroke patient. During an interview on 1/8/2026 at 8:23 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she provided routine daily care for Resident 65, which included bed baths. CNA 1 stated she had not noticed the surgical incision and staples on Resident 65's scalp and stated staff should have identified and reported the resident had staples. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person- Centered , revised 3/2022, the P&P indicated the facility was to ensure the following:1. Care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.2. When possible, interventions addressed the underlying source(s) of the problem area(s), not just symptoms or triggers.3. Assessments of residents were ongoing, and care plans were revised as information about the residents and the residents' conditions change. During a review of the facility's RN Supervisor Job Description, dated 2023, the Job Description indicated the RN Supervisor was to review the new admissions of the complete of the quality assessment and the appropriate plan of care of the resident and may make clinical corrections as deemed necessary appropriate.

Based on interview and record review, the facility failed to ensure a resident received mental health and psychosocial treatment necessary to attain and maintain the highest practicable mental and psychosocial (focuses on emotions, thoughts, coping mechanisms, sense of self, and mental health) well-being for one of three sampled residents (Resident 27). This deficient practice led to Resident 27 continuing to exhibit repeated episodes of verbal and physical aggression without effective therapeutic mental health intervention. Findings: During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was initially admitted to the facility on [DATE]. Resident 27's diagnoses included traumatic brain injury (damage to the brain from an external force), traumatic subarachnoid hemorrhage (brain bleed) with loss of consciousness, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). The admission Record indicated, on 12/19/2025, Resident 27 was diagnosed with disorganized schizophrenia (a mental illness that is characterized by disturbances in thought) and brief psychotic disorder. During a review of Resident 27's Minimum Data Set ([MDS], a resident assessment tool), dated 12/22/2025, the MDS indicated Resident 27's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 27 was entirely dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 27's History and Physical (H&P), dated 9/14/2025, the H&P indicated Resident 27 had the capacity to understand and make decisions. During a review of Resident 27's Nursing Progress Note dated 10/3/2025, the note indicated on 10/3/2025, Resident 27 hit, punched, cursed, threw feces at staff, and threw his meal plates on staff and peers. The Nursing Progress Note also indicated redirection and medication for agitation and anxiety was not effective. During a review of Resident 27's Nursing Progress Note dated 10/16/2025, the note indicated on 10/16/2025, Resident 27 ripped off the curtains in his room and started yelling profanities. During a review of Resident 27's Nursing Progress Note dated 11/24/2025, the note indicated on 11/24/2025, Resident 27 was verbally and physically aggressive towards a certified nursing assistant (CNA). During a review of Resident 27's Nursing Progress Note dated 12/17/2025, the note indicated on 12/17/2025, Resident 27 grabbed a CNA by the jacket while the CNA attempted to provide peri-care, was verbally aggressive, and kicked the CNA in the chest. The Nursing Progress Note indicated 911 was called for increased agitation. During a review of Resident 27's Nursing Progress Note dated 12/30/2025, the note indicated on 12/30/2025, Resident 27 struck a charge nurse on the stomach while passing by her. During a review of Resident 27's Nursing Progress Note dated 12/31/2025, the note indicated on 12/31/2025, Resident 27 reached forward and grazed another resident with his hand and the resident's chair. The note indicated the Department of Mental Health was notified, and two members of the Psychiatric Mobile Response Team (PMRT) came to evaluate resident for a possible 5150 (a 72- hour psychiatric hospitalization when an adult exhibits a mental health crisis and is evaluated to be a danger to others, or to himself or herself, or gravely disabled) hold. The Nursing Progress Note indicated the PMRT members agreed that Resident 27 was not fit to be in facility, but he was not transferrable at that time. During a review of Resident 27's Nursing Progress Note dated 1/1/2026, the note indicated on 1/1/2026, Resident 27 displayed three episodes of aggression. During a review of Resident 27's Nursing Progress Note dated 1/3/2026, the note indicated on 1/3/2026, Resident 27 displayed one episode of aggression. During a review of Resident 27's Nursing Progress Note dated 1/4/2026, the note indicated on 1/4/2026, Resident 27 displayed three episodes of aggression. During a review of Resident 27's Nursing Progress Note dated 1/5/2026, the note indicated on 1/5/2026, Resident 27 displayed one episode of aggression. During a review of Resident 27's Interdisciplinary Team (IDT) Notes, dated 10/2025 to 1/6/2026, there were no IDT Notes to indicate an IDT Care Conference was held following Resident 27's documented episodes of physical and verbal aggression. The most recent IDT Note, dated 12/23/2025, indicated Resident 27 was readmitted on [DATE] from the GACH due to striking out at staff. There was no documentation to indicate reassessment of Resident 27's behavioral management needs, consideration of increased interventions, initiation of PASRR Level II re-evaluation, or discussion of discharge to a more specialized setting despite continued aggressive behaviors. During a review of Resident 27's Preadmission Screening and Resident Review II ( PASRR II-a federally mandated screen for individuals for Serious Mental Illness (SMI), Intellectual Disabilities (ID), or Developmental Disabilities (DD) to ensure they get the right care in the least restrictive setting, preventing inappropriate nursing home placement and identifying needs for specialized services) Care Plan, dated 10/10/2025, the care plan indicated Resident 27 was to receive psychiatry (a branch of medicine concerned with the study, diagnosis, and treatment of mental illness) and psychology (the study of the human mind and its functions, especially those affecting behavior) evaluations as indicated and supportive visits from social services and other providers as tolerated. During a review of Resident 27's PASRR Individualized Determination Report, dated 10/14/2025, the report indicated Resident 27 was recommended specialized add on services to address mental health needs. The recommendation included mental health rehabilitation activities, psychotherapy counseling, psychology consultation, and social services consultation. During a review of Resident 27's Order Summary, dated 1/7/2026, the Order Summary did not indicate an order for a psychologist consultation. During an interview on 1/5/2026 at 12:20 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 27 grabbed her buttocks and private area (date unknown), causing her to feel uncomfortable. CNA 2 stated Resident 27 laughed during the incident. CNA 2 stated she notified Licensed Vocational (LVN) 2 and the Director of Staffing Development (DSD) of the incident. During a concurrent interview and record review on 1/7/2026 at 12:10 p.m. with the Director of Nursing Trainer (DONT), all of Resident 27's Progress Notes, Physician Orders, IDT Notes, Physician Progress Notes, and Nursing Progress Notes, dated 7/2025 to 1/7/2026, were reviewed. The Physician Orders lacked a psychologist consultation order. The Physician Progress Notes lacked evidence a psychologist had visited Resident 27. The IDT notes indicated a lack of reconvening after each episode of physical and verbal aggression. The IDT Notes indicated the most recent Behavioral Management IDT was held in 7/2025, which occurred prior to the PASRR Individualized Determination Report (10/14/2025). The DONT stated Resident 27 would have benefited from a psychologist consult to engage in purposeful psychotherapy and learn behavioral management techniques. The DON stated the lack of IDT meetings, and lack of psychological health resources led to missed opportunities to address Resident 27's grave behavioral and mental health needs and placed Resident 27 at risk for continued episodes of aggression and deteriorating mental health. During a concurrent interview and record review on 1/7/2026 at 3:46 p.m. with the Social Services Director (SSD), Resident 27's Social Services Progress Notes, dated 10/2025 through 1/7/2026, and PASRR Individualized Determination Report, dated 10/14/2025, were reviewed. The Progress Notes lacked documentation to indicate Resident 27 received meaningful social services visits, mental health rehabilitation activities and psychotherapy counseling to support Resident 27's mental health. The SSD stated she visited Resident 27 but did not document her visits because she did not have the time. The SSD stated it was important to adhere the PASRR'S recommendations to ensure Resident 27 received mental supportive services to ensure his psychiatric needs were met and so that his mental health did not deteriorate. During a review of the facility's Facility Assessment (undated), the Facility Assessment indicated the facility had the capacity to provide mental health and behavior services that included the following: behavior management, psychotropic management, IDT meeting to identify if the use of psychotropic medications is warranted and medically justifiable, gradual dose reduction, behavior modification, psychiatrist and psychologist collaboration, medication review by the pharmacy consultant. Dementia care, psychiatric illness, intellectual or developmental disabilities. The Facility Assessment also indicated the IDT would develop and implement interventions in managing the resident's behavior and to help support individuals dealing with anxiety, cognitive impairment, depression and other psychiatric diagnoses. During a review of the facility's Policy and Procedure (P&P) titled, Behavioral Health Services, revised 2/2019, the P&P indicated the facility was to provide health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

Based on observation, interview, and record review, the facility failed to ensure licensed staff practiced safe and effective medication administration practices for three out of 14 sampled residents (Residents 63, 138, and 137) by failing to: 1. Ensure Resident 63's vitamin D3 (a crucial fat-soluble vitamin that helps your body absorb calcium for strong bones, supports immune function, and aids muscle/nerve health) was available and administered timely, as ordered by the physician during a medication pass. 2. Clarify Resident 63's physician orders to specify the location of application of the prescribed lidocaine cream (a medication in the form of a cream applied topically to treat inflammation and pain) and lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) to ensure there was no duplication of therapy, as well as documentation indicating removal of the old lidocaine patch prior to the application of a new one.3. Ensure the registered nurses (RNs) administered meropenem (antibiotic) intravenously (IV, through a vein) to Resident 138 as ordered. 4. Clarify blood pressure parameters (a numerical or other measurable factor) for Resident 137's administration of Amlodipine (medication to treat high blood pressure and certain heart conditions). These deficient practices led to the administration of medications not in accordance with physician orders, professional standards of practice and/or manufacturer specifications resulting in interruptions in treatments, and placed Residents 63, 138, and 137 at risk for medication errors and adverse health outcomes such as vitamin D deficiency, local site reactions such as skin irritation and redness, abnormal blood glucose levels, hypotension (low blood pressure) and/or uncontrolled blood pressure. Findings: 1. During a review of Resident 63's admission Record, the admission record indicated Resident 63 was admitted to the facility on [DATE]. Resident 63's diagnoses included generalized muscle weakness and other abnormalities of gait (way of walking) and mobility. During a review of Resident 63's History and Physical (H&P), dated 11/4/2025, the H&P indicated Resident 63 had the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS - a resident assessment tool), dated 11/3/2025, the MDS indicated Resident 63's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 63 was independent in performing activities of daily living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene, and needed setup or clean-up assistance from the facility staff for showering. During a medication reconciliation on 1/6/2026, Resident 63's Order Summary Report (a document containing a summary of all active physician orders), dated 1/6/2026, the order summary report indicated:1. Lidocaine external cream 5 percent ([%] a measurement of strength or potency of medication) (Lidocaine), apply to affected areas topically three times a day for affected skin areas apply 1 application topical, order date 7/20/2025, start date 7/21/2025.2. Lidocaine external patch 5% (Lidocaine), apply to left shoulder topically one time a day for pain, order date 8/12/2025, start date 8/13/2025.3. Lidocaine external patch 5% (Lidocaine), apply to low back topically one time a day for lower back pain, remove after 12 hours, order date 8/12/2025, start date 8/13/2025. During a concurrent observation and interview on 1/6/2026 at 8:23 a.m. with Licensed Vocational Nurse (LVN) 5, observed LVN 5 prepare nine medications to be administered to Resident 63 that included:a. One patch of lidocaine 5% with instructions to be applied to left shoulder and low back topically once daily for pain (on for 12 hours, and off for 12 hours). During a concurrent observation and interview on 1/6/2026 at 8:52 a.m. in Resident 63's room, observed LVN 5 write the date of application on the lidocaine patch and applied to Resident 63's lower back. LVN 5 stated Resident 63 refused to receive lidocaine 5% patch on the left shoulder and only wanted it to apply to his lower back. During a review of Resident 63's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/6/2026, the MAR indicated that on 1/6/2026, LVN 5 held the scheduled dose of Vitamin D3 capsule 25 mcg at 9:00 a.m. The MAR indicated, LVN 5 documented a 3 for the lidocaine patch administration on the lower back and left shoulder and for lidocaine cream 5%, which would mean that Resident 63 refused to receive lidocaine cream and lidocaine patch on both the lower back and left shoulder. During a review of Resident 63's MAR, dated 1/1/2026 to 1/31/2026, 12/1/2025 to 12/31/2025 and 11/1/2025 to 11/30/2025, the MAR did not indicate any documentation for the removal of the lidocaine patch 5%, 12 hours after its application. During a concurrent interview and record review on 1/6/2026 at 1:08 p.m. with LVN 5, Resident 63's administration details on the resident's electronic medication administration record (eMAR) for lidocaine patch 5% and lidocaine cream 5% for 1/6/2026 at 9:00 a.m. was reviewed. The administration details indicated Resident 63's lidocaine 5% patch was documented as 3 (drug refused) on 1/6/2026 at 8:52 a.m. The administration details for Resident 63's lidocaine cream 5% was documented as 3 (drug refused) on 1/6/2026 at 8:40 a.m. LVN 5 stated the lidocaine patch that was applied to Resident 63's lower back should have been documented as administered but it was documented as refused which was incorrect. LVN 5 stated it was important to document correctly so that the next nurse would have accurate records of the medications that were administered. LVN 5 stated Resident 63 refused to receive lidocaine cream at the same time when he was offered the lidocaine patch. LVN 5 stated she would usually apply the lidocaine cream to Resident 63's shoulder or lower back because that was where he was applying the lidocaine patch, and the physician order for lidocaine cream indicated apply to affected areas. LVN 5 stated if the resident wanted the lidocaine cream and lidocaine patch then it would be okay to apply the cream and patch to the lower back. LVN 5 then posed a question, Oh the cream could be for lower back and then patch for the shoulder? LVN 5 looked at the administration record and stated lidocaine cream 5% and lidocaine patch 5% were both applied to the lower back at the same time on the same days. LVN 5 stated the patch and cream applied at the same location at the same time could cause skin irritation. LVN 5 stated there was no documentation of the lidocaine patch being removed after 12 hours as per the instructions on the lidocaine patch order. LVN 5 stated she visually checked if the lidocaine patch was removed from Resident 63's shoulder and lower back. During an interview on 1/7/2026 between 2:50 p.m. and 3:13 p.m. with Resident 63, Resident 63 stated he usually did not like to get the lidocaine cream applied but prefers the lidocaine patch. Resident 63 stated the patch would come off by itself because it did not stick on his back well, either because it would rub against his shirt or when raising his arms or if he was sleeping in his bed, it would just come off. Resident 63 stated he did not see anyone stopping by specially to remove the patch after 12 hours. Resident 63 stated he would just take it off by himself or the patch fell off. Resident 63 stated sometimes the patch was placed on his left leg. Resident 63 stated he did not usually apply lidocaine patch to his shoulder. During a review of Resident 63's order summary report that included active, discontinued and completed lidocaine orders, there were no physician orders for lidocaine patch 5% with instructions to apply patch on resident's left leg. During a review of Resident 63's MAR, Location of Administration Report, for 1/1/2026 to 1/31/2026, the report indicated the following dates and times when lidocaine patch 5% and lidocaine cream 5% were applied at the same location (lower back):a. Lidocaine External Patch, scheduled time was 1/2/2026 at 9:00 a.m., administered on 1/2/2026 at 11:34 a.m. b. Lidocaine External Cream, scheduled time was 1/2/2026 at 9:00 a.m., administered on 1/2/2026 at 11:29 a.m.c. Lidocaine External Patch, scheduled time was 1/4/2026 at 9:00 a.m., administered on 1/4/2026 at 12:58 p.m.d. Lidocaine External Patch, scheduled time was 1/4/2026 at 9:00 a.m., administered on 1/4/2026 at 12:58 p.m. e. Lidocaine External Cream, scheduled time was 1/4/2026 at 9:00 a.m., administered on 1/4/2026 at 12:57 p.m.f. Lidocaine External Cream, scheduled time was 1/4/2026 at 1:00 p.m., administered on 1/4/2026 at 12:58 p.m. During a review of Resident 63's Medication Admin Audit Report, dated 1/1/2026 to 1/8/2026, the report indicated on 1/6/2026 at 8:57 a.m., LVN 5 documented a lidocaine patch was applied for lower back pain. The report also indicated on 1/6/2026 at 1:13 p.m. (1313, military time) a lidocaine patch was applied for lower back pain. LVN 5 stated she accidentally documented the lidocaine patch was refused by Resident 63 at 8:57 a.m. which she corrected at 1:13 p.m. During a review of Resident 63's MAR, Location of Administration Report for 12/1/2025 to 12/31/2025, the report indicated the following dates and times when the lidocaine patch and lidocaine cream were both applied to the resident's lower back (same location) around the same time:a. Lidocaine External Patch, scheduled time was 12/27/2025 at 9:00 a.m., administered on 12/27/2025 at 10:14 a.m. b. Lidocaine External Cream, scheduled time was 12/27/2025 at 9:00 a.m., administered on 12/27/2025 at 10:13 a.m.c. Lidocaine External Patch, scheduled time was 12/28/2025 at 9:00 a.m., administered on 12/28/2025 at 8:09 a.m.d. Lidocaine External Patch, scheduled time was 12/28/2025 at 9:00 a.m., administered on 12/28/2025 at 8:10 a.m.e. Lidocaine External Cream, scheduled time was 12/28/2025 at 9:00 a.m., administered on 12/28/2025 at 8:09 a.m.f. Lidocaine External Patch, scheduled time was 12/29/2025 at 9:00 a.m., administered on 12/29/2025 at 10:44 a.m.g Lidocaine External Cream, scheduled time was 12/29/2025 at 9:00 a.m., administered on 12/29/2025 at 10:43 a.m. During a review of Resident 63's MAR, Location of Administration Report for 11/1/2025 to 11/30/2025, dated 1/6/2026, the report indicated the following dates and times when lidocaine patch 5% was applied to the knee – front (left) and abdomen – left lower quadrant (LLQ), which were not in accordance with physician orders:a. Lidocaine External Patch, scheduled time was 11/14/2025 at 9:00 a.m., administered on 11/14/2025 at 8:10 a.m. (Abdomen – LLQ).b. Lidocaine External Patch, scheduled time was 11/20/2025 at 9:00 a.m., administered on 11/20/2025 at 11:26 a.m. (Left front knee). During a review of Resident 63's MAR, Location of Administration Report for 11/1/2025 to 11/30/2025, the report indicated the following dates and times when lidocaine patch 5% and lidocaine cream 5% were both applied on resident's lower back (same location) around the same time:a. Lidocaine External Patch 5%, scheduled time was 11/16/2025 at 9:00 a.m., administered on 11/16/2025 at 8:06 a.m.b. Lidocaine External Cream 5%, scheduled time was 11/16/2025 at 9:00 a.m., administered on 11/16/2025 at 8:05 a.m.c. Lidocaine External Patch 5%, scheduled time was 11/21/2025 at 9:00 a.m., administered on 11/16/2025 at 8:10 a.m.d. Lidocaine External Cream 5%, scheduled time was 11/21/2025 at 9:00 a.m., administered on 11/21/2025 at 8:10 a.m.e. Lidocaine External Patch 5%, scheduled time was 11/22/2025 at 9:00 a.m., administered on 11/22/2025 at 10:26 a.m.f. Lidocaine External Cream 5%, scheduled time was 11/22/2025 at 9:00 a.m., administered on 11/22/2025 at 10:27 a.m.g Lidocaine External Patch 5%, scheduled time was 11/23/2025 at 9:00 a.m., administered on 11/23/2025 at 11:01 a.m.h. Lidocaine External Cream 5%, scheduled time was 11/23/2025 at 9:00 a.m., administered on 11/23/2025 at 11:02 a.m. During an interview on 1/7/2026 at 4:24 p.m. with the Director of Nursing Trainer (DONT) and Interim Director of Nursing (IDON), the IDON stated the lidocaine patch should be applied for 8 to 12 hours based on his experience or based on physician orders. The IDON stated if the physician instructed to remove the lidocaine patch after 8 hours instead of 12 hours, then the patch must be removed after 12 hours. The DONT stated there should have been a separate order for lidocaine patch 5% to indicate remove after 12 hours so that it could have been documented as removed after 12 hours. The DONT stated there was a possibility that the patch could fall off sooner than 12 hours during showers or other activities. The DON'T stated if the resident kept the patch on for longer than 12 hours then there was a risk of side effects such as rash, blisters and irritation, and rare instances of systemic reactions such as nausea. The IDON and DONT stated the lidocaine patch should be labeled with the date and time so that the licensed nurse would know when to remove it. The IDON and DONT stated if the resident received the lidocaine cream and lidocaine patch at the same time on the same location, there was a risk of overmedicating the resident and possibility that the patch would not stick on the resident's site of application. The IDON stated the orders should have been clarified with the physician before they were administered. The DONT stated there should have been two separate physician orders for the lidocaine patch for the shoulder and lidocaine patch for the back. 2. During a medication reconciliation on 1/6/2026, Resident 63's Order Summary Report (a document containing a summary of all active physician orders), dated 1/6/2026, the order summary report indicated Vitamin D3 oral capsule 25 micrograms ([mcg] a unit of measurement for mass) (1000 IU) (Cholecalciferol – the chemical name of vitamin D3), give 1 capsule by mouth one time a day for supplement, order date 7/20/2025, start date 7/21/2025. During an interview on 1/6/2026 at 8:23 a.m. with LVN 5, LVN 5 stated she did not have Resident 63's vitamin D3 in stock and could not administer. During an interview on 1/6/2026 at 1:08 p.m. with LVN 5, LVN 5 stated Resident 63's vitamin D3 was ordered through central supply. LVN 5 stated vitamin D helps with strong bones, and resident may get deficient in vitamin D if he did not receive it. During an interview on 1/7/2026 at 4:24 p.m. with the DONT and Interim Director of Nursing (IDON), the DONT stated staff should have checked the medication cart at the beginning of the shift to ensure medications were in stock. IDON stated an adverse effect of Resident 63 not getting Vitamin D could cause a vitamin level deficiency, sleepiness and bone deficiency. 3. During a review of Resident 138's admission Record, the admission Record indicated Resident 138 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 138's H&P, dated 9/20/2025, the H&P indicated Resident 138 was alert and oriented times two (x2, medical assessment that indicates a person knows who they are and where they are, but not what time it is or what is happening to them). During a review of Resident 138's MDS, dated [DATE], the MDS indicated Resident 138's cognitive skills for daily decision making was intact. The MDS indicated Resident 138 required supervision for eating. The MDS indicated Resident 138 required supervision for eating. The MDS indicated Resident 138 required moderate assistance for oral hygiene and personal hygiene. The MDS indicated Resident 138 required maximal assistance for upper body dressing. The MDS indicated Resident 138 was dependent on staff for lower body dressing, putting on and taking off footwear, toileting hygiene, and showering and bathing. During a review of Resident 138's Order Summary Report, dated 1/3/2025, the Order Summary Report indicated to administer meropenem IV solution 1 gram (gm, unit of measurement) every 12 hours for sepsis (a life-threatening blood infection) for seven days. During a review of Resident 138's IV MAR, dated 1/1/2026 – 1/31/2026, the IV MAR did not indicate Resident 138 received meropenem on 1/3/2026 at 9:00 a.m., on 1/5/2026 at 9:00 p.m., and on 1/6/2026 at 9:00a.m. and 9:00 p.m. During an interview on 1/8/2026 at 10:35 a.m. with the Infection Prevention Nurse (IPN), the IPN stated she was not aware of Resident 138's missed doses of meropenem. The IPN stated it was important to administer the medication as ordered to help Resident 138 receive the treatment he needed. During a concurrent interview and record review on 1/8/2026 at 10:49 a.m. with the IPN, Resident 138's MAR, dated 1/1/2026 – 1/31/2026, was reviewed. The MAR did not indicate Resident 138 received meropenem on 1/3/2026 at 9:00 a.m., on 1/5/2026 at 9:00 p.m., and on 1/6/2026 at 9:00 a.m. and 9:00 p.m. The IPN stated she was not notified Resident 138 missed multiple doses which caused an interruption to the resident's antibiotic therapy. The IPN stated nursing staff needed to notify the doctor and inquire if the medication would be extended due to the missing doses. During an interview on 1/8/2026 at 3:56 p.m. with RN 2, RN 2 stated Resident 138 did not receive his antibiotics on several days. RN 2 stated Resident 138's doctor was not notified. RN 2 stated Resident 138's antibiotic therapy course was not extended because Resident 138's doctor was not notified. 4. During a review of Resident 137's admission Record, the admission Record indicated the facility admitted Resident 137 on 11/11/2022 with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing, hyperlipidemia (high cholesterol) and polyneuropathy (damage or disease affecting nerves). During a review of Resident 137's H&P, dated 10/4/2025, the H&P indicated Resident 137 has the capacity to understand and make decisions. During a review of Resident 137's MDS, dated [DATE], the MDS indicated Resident 137 was independent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 137's physician order dated 3/3/2025, the physician order indicated to administer amlodipine besylate oral tablet 10 mg by mouth one time a day for HTN. During a review of Resident 137's MAR for the months of 12/2025 and 1/2026, the MAR indicated amlodipine was administered to Resident 137 without blood pressure parameters. During a concurrent interview and record review on 1/6/26 at 3:05 p.m., with LVN 4, Resident 137's physician orders dated 3/3/2025 and MAR for the months of 12/2025 and 1/2026, were reviewed. LVN 4 stated the physician order for amlodipine lacked documented parameters identifying when the medication should be administered or withheld based on the resident's blood pressure reading. LVN 4 stated the absence of parameters limited nursing staff's ability to determine when the medication should be administered or held. LVN 4 stated antihypertensive medications (used to lower blood pressure) require clearly defined blood pressure parameters to ensure safe administration and to prevent potential adverse effects related to hypotension (low blood pressure). During an interview on 1/7/2026 at 09:18 a.m., with RN 3, RN 3 stated blood pressure medications required parameters to avoid causing significant drops in blood pressure. RN 3 stated that a severe decrease in blood pressure could increase a resident's chances of developing hypovolemic shock (a life-threatening emergency from severe blood or fluid loss). During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/2012, the P&P indicated all medications would be administered in a safe, timely manner and as prescribed. The P&P indicated if a dosage was believed to be inappropriate for a resident, the person administering medication should contact doctor to discuss concerns. During a review of the facility's P&P titled, Medication Orders, dated 11/2014, the P&P indicated, 1. Medication Orders – when recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. During a review of the facility's P&P titled, Administration Medications dated 4/2019, the P&P indicated If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. The P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The P&P indicated as required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered.c. the route of administration.g. the signature and title of the person. the drug.

Based on observation, interview, and record review the facility failed to follow recipes when:a. The cook (Cook 1) altered the ingredients in beef patties by adding unindicated ingredients.b. Ingredients for preparing texture-modified versions of the beef patty recipe were omitted.c. [NAME] 2 used a garnish for three of 26 soft-and-bite-sized texture diets when not indicated. These deficient practices had the potential to alter nutrition, provide the inappropriate therapeutic texture, and introduce allergens to resident meal trays.Findings:a. During a concurrent interview and initial kitchen tour on 1/5/2026 at 9:10 a.m., with Dietary Services Supervisor (DSS) and [NAME] 1, [NAME] 1 was observed preparing patties of ground beef from a large tub with large chunks of green bell peppers visible in the mixture and patties. The Dietary Services Supervisor (DSS), the DSS stated he did not know why green bell peppers were included in the patties. The DSS stated there may be a risk for an allergic reaction or offering a resident a food item that may be listed as a dislike. [NAME] 1 stated she was aware bell peppers were not included in the recipe. [NAME] 1 stated, I just wanted to add more flavor. [NAME] 1 stated this action could result in offering residents disliked food preferences or potentially causing an allergic reaction.During a record review of the recipe titled Southern Style Pattie, the recipe did not indicate green bell peppers in the ingredient list. b. During a concurrent observation of lunch service in the kitchen and interview with [NAME] 1 on 1/5/2026 at 11:45 a.m., observed texture-modified versions (changes in the physical form of original food intended as therapy for people with chewing difficulty or swallowing disorders) of beef patty were of a different texture than the ground beef. [NAME] 1 stated that it was the same recipe with a different beef that was already chopped.During a record review of the recipe titled Southern Style Pattie, the recipe indicated to follow all steps in the original recipe for regular texture, which included ground beef mixed with egg, milk, breadcrumbs, and spices, formed into patties, then to chop into 1.5 x 1.5 centimeter (cm, unit of measurement) pieces. During an interview on 1/6/2026 at 3:05 p.m., with the DSS, the DSS stated that they did not follow the recipe correctly by substituting ground beef for cubed beef stew meat and the omission of eggs, milk, and breadcrumbs. The DSS stated, The taste and texture will be different. Calories are going to be different. The DSS stated the correct steps would be to make it with ground beef, then chop. c. During an observation of lunch service on 1/6/2026 at 12:05 p.m., [NAME] 2 was observed assembling three plates of Soft-and-Bite-Sized textures. [NAME] 2 included a parsley sprig as garnish. During a review of a document titled Cooks Spreadsheet, the document indicated there was to be no garnish included for any texture modified diets. During an interview on 1/6/2026 at 3:05 p.m., with the DSS, the DSS stated the spreadsheet the [NAME] was intended to follow indicated no garnish. During a review of an in-service dated 9/5/2025, the in-service indicated the topic of the in-service included the need for cooks to follow recipes and spreadsheets. The in-service was signed by both [NAME] 1 and [NAME] 2 indicating they attended the in-service.

Based on observation, interview, and record review, the facility failed to provide appropriate texture-modified diets when:a. The cook (Cook 2) used a garnish for three of 26 soft-and-bite-sized textures when not indicated. b. [NAME] 2 used a food-processor to mince pork instead of chopping to indicated size for 26 of 114 diets. These deficient practices had the potential to cause residents with swallowing disorders to choke, and prevent the progression of residents' meals by voluntarily downgrading textures.Findings:a. During an observation of lunch service in the kitchen on 1/6/2026 at 12:05 p.m., [NAME] 2 was observed assembling three plates of Soft-and-Bite-Sized textures. [NAME] 2 included a parsley sprig as garnish. During a review of a document titled Cooks Spreadsheet, the document indicated no garnish was to be included for any texture modified diets. During an interview on 1/6/2026 at 3:05 p.m., with the Dietary Services Supervisor (DSS), the DSS stated adding a parsley sprig as garnish posed a risk for choking. The DSS stated the spreadsheet the [NAME] was intended to follow indicated no garnish. b. During a concurrent observation and interview on 1/6/2026 at 9:45 a.m., with [NAME] 2, in the kitchen, observed [NAME] 2 slice cooked pork in preparation for lunch. [NAME] 2 then placed the sliced pork into a food processor where she pulsed the machine to produce a minced texture. [NAME] 2 stated this was in preparation for Soft-and-Bite-Sized texture. During a review of the recipe, the recipe indicated to follow all the steps of the original recipe for regular texture and then to chop into 1.5 x 1.5 centimeters (cm, unit of measurement) pieces. During an interview on 1/6/2026 at 3:05 p.m., with the DSS, the DSS stated the texture provided appeared more like Minced-and-Moist texture rather than Soft-and-Bite-Sized. During a review of an in-service dated 9/5/2025, the in-service indicated topics covered with kitchen staff included the need for cooks to follow recipes and spreadsheets. The in-service was signed by [NAME] 2 indicating [NAME] 2 attended the in-service training.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices when:a. The stand mixer observed with heavy debris was not cleaned and sanitized.b. The countertop was covered with crumbs. c. The steam table had eggs remnants.These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 114 of 117 medically compromised residents who received food from the kitchen.Findings:a. During a concurrent brief initial kitchen tour and interview on 1/5/2026 at 8:50 a.m., with [NAME] 1, a stand-mixer was observed with dried, light-yellow colored debris on the safety guard (a curved metal grill designed to prevent access to the mixer while operating). The stand-mixer had similar light-yellow debris and dried white, powdery substances observed underneath the splash guard (a curved, solid piece of sheet metal designed to prevent splashing of food out of the mixing bowl during operation) which faced downward toward the mixing bowl where food was being prepared. [NAME] 1 stated, We rarely use that. Sometimes when we're making pudding. During a concurrent observation and interview on 1/5/2026 at 11:10 a.m., with the Dietary Services Supervisor (DSS), in the kitchen, the stand-mixer was observed with dried, light-yellow colored debris on the safety guard and light-yellow debris and dried white, powdery substances observed underneath the splash guard. The DSS stated, We hardly use that. The cooks usually whisk by hand. The DSS stated the stand-mixer was to be deep cleaned along with other kitchen equipment on delivery days, when additional staff was available to stock inventory and perform deep cleaning duties. During a review of the deep cleaning log dated 1/2026, in the presence of the DSS, the deep cleaning log did not identify the stand-mixer as an item to be deep cleaned. The DSS confirmed It is not there. During a concurrent interview and record review on 1/6/2026 at 3:05 p.m. with the DSS, the in-service document dated 9/5/2025, was reviewed. The document indicated topics covered during the in-service training with kitchen staff included, Make sure we are wiping down Robocoupe (food processor), blenders, microwaves daily. The DSS stated that debris observed from the stand-mixer could fall into the mixing bowl where it could potentially contaminate food served to the residents of the facility. The DSS stated this in-service included directives to clean the stand-mixer, indicated as blenders. During a review of a policy document titled Sanitation, dated 2023, the document indicated that the Food & Nutrition Director (DSS) is responsible for instructing staff in the use of equipment, including how to clean all equipment in their specific area. b. During a brief initial kitchen tour on 1/5/2026 at 8:58 a.m., the countertop near the steam table where meal trays were assembled was observed covered in crumbs spanning an area approximately 8 by (x) 12 inches. A review of the cleaning log titled AM Trayline indicated Trayline Area (after each meal) was signed off by a kitchen staff member. During a secondary kitchen tour on 1/5/2026 at 11:30 a.m., the countertop near the steam table where meal trays were assembled was observed covered in crumbs. Food was held on the steam tables in preparation for lunch service. During an interview on 1/6/2026 at 3:05 p.m. with the DSS, the DSS stated the debris observed on the countertop was a risk for contamination. During review of a policy document titled Sanitation, dated 2023, the document indicated that kitchen staff was responsible for all cleaning except for ceiling vents, light fixtures, and the hood over the stove. During a review of an in-service dated 9/5/2025, the in-service indicated topics covered with kitchen staff including Sanitizing surfaces after being wiped down when cleaning. c. During a brief initial kitchen tour on 1/5/2026 at 8:59 a.m., the steam table where meal trays were assembled was observed with chunks of yellow debris. During a review of the cleaning log titled AM Trayline, the cleaning log indicated Trayline Area (after each meal) was signed off by a kitchen staff member. During a secondary kitchen tour on 1/5/2026 at 11:30 a.m., the chunks of yellow debris was visible as food was held on the steam tables in preparation for lunch service. During an interview on 1/6/2026 at 3:05 p.m. with the DSS, the DSS stated that debris observed on the steam tables at lunchtime were eggs from breakfast service. The DSS stated this was a risk for contamination. During a review of a policy document titled Sanitation dated 2023, the document indicated kitchen staff is responsible for all cleaning except for ceiling vents, light fixtures, and the hood over the stove.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for five of 16 sampled residents (Resident 63, 12, 138, 37, and 110) by: 1. Not ensuring licensed nursing staff maintained an accurate recording of the lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) in Resident 63's medication administration record (MAR). 2. Not ensuring Resident 12's nursing progress notes, change of condition (COC) and transfer/discharge notes were completed and signed as required following the resident's transfer to the general acute care hospital (GACH) on 1/2/2026. 3. Not documenting Resident 138's missed doses of meropenem and the resident's dislodgement of his intravenous ([IV] administering fluids, medicine, blood, or nutrients directly into the bloodstream via a needle or catheter) line. 4. Not providing accurate documentation for Resident 37 and 110's Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services on 1/6/2026. These deficient practices resulted in an incomplete resident medical care record and placed Residents 63, 12, 138, 37, and 110 at risk for misunderstanding in the provision of care and services, missed medications and/or treatments and potential medical complications due to medication errors and/or interruption of treatment, leading to an overall diminished quality of life. Findings: 1. During a review of Resident 63's admission Record, dated 1/6/2026, the admission record indicated the facility admitted Resident 63 on 11/3/2022 with diagnoses that included generalized muscle weakness and other abnormalities of gait (way of walking) and mobility. During a review of Resident 63's History and Physical (H&P), dated 11/4/2025, the H&P indicated Resident 63 had the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS - a resident assessment tool), dated 11/3/2025, the MDS indicated Resident 63's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 63 was independent in performing activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene, and needed setup or clean-up assistance from the facility staff for showering. During a concurrent observation and interview on 1/6/2026 at 8:23 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 prepared nine medications to be administered to Resident 63 that included but not limited to one patch of lidocaine (a medication in patch form used to treat pain) 5 percent ([%] a measurement of strength or potency of medication) (removed from package) with instructions to be applied to left shoulder and low back topically once daily for pain (on for 12 hours, and off for 12 hours). During an interview on 1/6/2026 at 8:52 a.m. in Resident 63's room, LVN 5 stated Resident 63 refused the lidocaine 5% patch to the left shoulder. LVN 5 stated Resident 63 only wanted the patch applied to his lower back. LVN 5 wrote the date of application on the lidocaine patch and applied the patch to Resident 63's lower back. During a medication reconciliation review on 1/6/2026, Resident 63's Order Summary Report (a document containing a summary of all active physician orders), dated 1/6/2026 was reviewed. The order summary report indicated but not limited to the following physician orders:Lidocaine external patch 5% (Lidocaine), apply to left shoulder topically one time a day for pain, order date 8/12/2025, start date 8/13/2025.Lidocaine external patch 5% (Lidocaine), apply to low back topically one time a day for lower back pain, remove after 12 hours, order date 8/12/2025, start date 8/13/2025. During a concurrent interview and record review on 1/6/2026 at 1:08 p.m. with LVN 5, Resident 63's administration details on the electronic medication administration record (eMAR) for lidocaine patch 5% for 1/6/2026 at 9:00 a.m. was reviewed. The administration details for Resident 63's lidocaine 5% patch was documented as 3 (drug refused) on 1/6/2026 at 8:52 a.m. The administration details for lidocaine 5% patch was documented as 3 (drug refused) with no specific location of administration on 1/6/2026 at 8:40 a.m. LVN 5 stated lidocaine patch that was applied to Resident 63's lower back should have been documented as administered but it was documented as refused which was incorrect, so she would need to correct it by striking out. LVN 5 stated she would correct it to show administered for the same time when it was documented as refused. LVN 5 stated it was important to document correctly so that the next nurse would have accurate records of the medications that were administered. LVN 5 stated there was no documentation of lidocaine patch 5% being removed after 12 hours as per instructions on lidocaine patch order. LVN 5 stated she used to check visually if the lidocaine patch was removed from Resident 63's shoulder and lower back. During a review of Resident 63's Medication Admin Audit Report, dated 1/1/2026 to 1/8/2026, the report indicated, on 1/6/2026, LVN 5 documented the lidocaine patch administration times as 8:57 a.m. and 1:13 p.m. LVN 5 stated she accidentally documented the lidocaine patch 5% was refused by Resident 63 at 8:57 a.m. so she corrected it at 1:13 p.m. 2. During a review of Resident 12's admission Record, dated 1/9/2026, the admission record indicated Resident 12 was initially admitted to the facility on [DATE], discharged on 1/2/2026 and readmitted on 1/72026. Resident 12's diagnoses included sepsis (a life-threatening blood infection), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), non-pressure chronic ulcer of left foot with necrosis of the bone (a long-standing open wound with death of underlying bone tissue), and traumatic amputation of the right lesser toe (loss of toe on the right foot due to injury). During a review of Resident 12's H&P, dated 1/17/2025, the H&P indicated Resident 12 had capacity to understand and make decisions. During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognition was severely impaired. The MDS indicated Resident 12 was dependent on staff for toileting and bathing and required moderate assistance (helper does less than half the effort) with eating, oral and personal hygiene. During a review of Resident 12's electronic health record (EHR), which included the nursing progress notes, COC documentation, and transfer notes related to the resident's general acute care hospital (GACH) transfer on 1/2/2026, the EHR did not indicate there was a nursing progress note documenting Resident 12's GACH transfer. The EHR further indicated the COC documentation and transfer notes were still in progress and not viewable in the medical record. During a concurrent interview and record review on 1/8/2026 at 2:25 p.m., with LVN 9, Resident 12's nursing progress note, and COC related to the resident's GACH transfer on 1/2/2026 were reviewed. LVN 9 stated when a resident was transferred to the GACH, nursing staff were expected to document the reason for transfer, the time the resident left the facility, and actions taken, which would include notification of the physician and family in the nursing progress notes. LVN 9 stated nursing staff were also required to document a COC regarding the resident's GACH transfer. LVN 9 stated there was no nursing progress note documented regarding Resident 12's GACH transfer on 1/2/2026. LVN 9 stated Resident 12's COC had been initiated but was unsigned and was not viewable in the medical record. LVN 9 stated because there was no documentation, there was no way to determine the reason for Resident 12's GACH transfer. LVN 9 stated documentation of a GACH transfer was important to ensure continuity of care, communication between shifts, and the ability to follow up on the resident's condition and location. LVN 9 stated without documentation, staff would not know why the resident was transferred or where the resident was located. During an interview on 1/8/2026 at 3:13 p.m., with Registered Nurse (RN) 2, RN 2 stated Resident 12 was readmitted to the facility from the GACH the following day (1/3/2026). RN 2 reviewed Resident 12's nursing progress notes and COC to determine the reason for the resident's GACH transfer. RN 2 stated there was no nursing progress note documented regarding Resident 12's transfer on 1/2/2026. RN 2 further stated a COC regarding the transfer had been initiated but remained unsigned, incomplete, and was not viewable in the medical record. RN 2 stated it was the registered nurse's responsibility to complete and sign the nursing assessment, nursing progress note, and COC documentation when a resident was transferred to the GACH. RN 2 stated it was the expectation that all nursing documentation be completed and signed by the end of each shift. RN 2 stated because the required documentation was not complete, she was unable to determine why Resident 12 was transferred to the GACH. RN 2 stated the lack of documentation had the potential to affect continuity of care and Resident 12's quality of life because staff were unable to determine the reason for the GACH transfer. During an interview on 1/8/2026 at 3:42 p.m., with the Medical Records Director (MRD) and the Medical Records Assistant (MRA), the MRD stated the Medical Records Department reviewed records of residents discharged to the GACH on the following day to ensure required documentation was present, complete, and signed, including nursing progress notes, assessments, physician orders, transfer information, and bed hold status. The MRD stated nursing progress notes were expected to be completed the day of the occurrence and COC and transfer documentation were expected to be completed and signed the same day the resident was transferred. The MRD stated review of Resident 12's record revealed the transfer documentation and COC were unsigned, and there was no nursing progress note documenting the reason for the GACH transfer. The MRA stated her role included completing discharge audits to identify incomplete or unsigned documentation and notify nursing staff for completion. The MRA stated Resident 12's GACH transfer documentation was identified as incomplete during the discharge audit process and reiterated documentation was expected to be completed and signed the same day to prevent records from remaining incomplete or unavailable for review. During an interview on 1/8/2026 at 3:55 p.m., with the Director of Nursing Trainer (DONT), the DONT stated medical records staff generated daily reports for new admissions, COCs, and GACH transfers, which were reviewed during stand-up and clinical meetings to identify missing or incomplete documentation. The DONT stated the medical records department conducted audits to ensure required documentation related to admissions, COCs, and GACH transfers was completed and signed. The DONT stated progress notes, COC documentation, and transfer documentation were expected to be included in these reviews. The DONT stated the facility needed to implement a clear and consistent system to prevent documentation from remaining incomplete or unsigned, particularly when nursing staff were unavailable, to ensure required documentation was completed and accessible. 3. During a review of Patient 138's admission Record, the admission Record indicated Resident 138 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 138's H&P, dated 9/20/2025, the H&P indicated Resident 138 was alert and oriented times two (x2, medical assessment that indicates a person knows who they are and where they are, but not what time it is or what is happening to them). During a review of Resident 138's MDS, dated [DATE], the MDS indicated Resident 138's cognitive skills for daily decision making was intact. The MDS indicated Resident 138 required supervision for eating. The MDS indicated Resident 138 required supervision for eating. The MDS indicated Resident 138 required moderate assistance for oral hygiene and personal hygiene. The MDS indicated Resident 138 required maximal assistance for upper body dressing. The MDS indicated Resident 138 was dependent on staff for lower body dressing, putting on and taking off footwear, toileting hygiene, and showering and bathing. During a review of Resident 138's Order Summary Report, dated 1/3/2025, the Order Summary Report indicated to administer meropenem (antibiotic) intravenous ([IV] administering fluids, medicine, blood, or nutrients directly into the bloodstream via a needle or catheter) solution 1 gram ([gm, unit of measurement], every 12 hours, for sepsis (a life-threatening blood infection), for seven days. During a review of Resident 138's IV MAR, dated 1/1/2026 - 1/31/2026, the IV MAR did not indicate Resident 138 received meropenem on 1/3/2026 at 9:00 a.m., on 1/5/2026 at 9:00 p.m., and on 1/6/2026 at 9:00 a.m. and 9:00 p.m. During a review of Resident 138's electronic medical record, the electronic medical record did not indicate Resident 138 pulled out his IV or receive meropenem on 1/3/2026 at 9:00 a.m., on 1/5/2026 at 9:00 p.m., and on 1/6/2026 at 9:00a.m. and 9:00 p.m. During an interview on 1/8/2026 at 2:42 p.m. with LVN 9, LVN 9 stated on 1/5/2026 Resident 138 removed his IV line and notified Registered Nurse (RN) 2. LVN 9 stated she was supposed to document a progress note to indicate the resident removed his IV-line, the doctor was notified, and what new orders were given. LVN 9 stated if documentation was not completed it would interfere with and delay Resident 138's care During an interview on 1/8/2026 at 3:56 p.m. with RN 2, RN 2 stated Resident 138 dislodged his IV and he refused another one. RN 2 stated Resident 138 missed medication doses because he did not have an IV. RN 2 stated Resident 138 did not receive his medication at the scheduled time which was a medication error. RN 2 stated she did not document the medication error in the progress notes. RN 2 stated she was supposed to document every time Resident 138 did not receive his medication, the reason he did not receive the medication, and the doctor's notification. RN 2 stated it was important to document why Resident 138 did not receive his meropenem so staff was aware there was an interruption in his antibiotic therapy. 4. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE]. Resident 37's diagnoses included paralytic syndrome (broad term for conditions causing rapid muscle weakness) following cerebral infarction (brain damage due to a loss of oxygen to the area), paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and contractures to both hands and the right thigh. During a review of Resident 37's MDS, dated [DATE], the MDS indicated Resident 37 expressed ideas and wants, understood verbal content, and had intact cognition. The MDS indicated Resident 37 had range of motion ([ROM] full movement potential of a joint) limitations in both arms and legs. The MDS indicated Resident 37 was independent for eating, required setup or clean-up assistance for oral hygiene, required substantial/maximal assistance (helper does more than half the effort) for upper body dressing and rolling to both sides while lying in bed, and was dependent for toileting, lower body dressing, bathing, transferring from lying in the bed to sitting at the side of the body, and chair/bed-to-chair transfers. During a review of Resident 37's physician orders, dated 11/11/2025, the physician orders indicated for the RNA to apply both hand splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for two hours, three times per week or as tolerated. Apply both leg splints for two hours, three times per week or as tolerated. Provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both arms in all planes (planes of joint motion, including forward and backward, side to side, and rotation), three times per week or as tolerated. During an observation on 1/6/2026 at 2:01 p.m. in Resident 37's room, with Restorative Nursing Aide 3 (RNA 3), Resident 37's RNA session was observed. Resident 37 performed exercises on both shoulders, elbows, wrists, and hands. RNA 3 provided ROM exercises to both of Resident 37's hips, knees, ankles, and toes. RNA 3 applied Resident 37's hand splints. During a review of Resident 37's RNA Flow Sheet (record of RNA tasks) for 1/2026, the RNA Flow Sheet indicated Restorative Nursing Aide 4 (RNA 4) signed for the provision of Resident 37's RNA services on 1/6/2026 including the application of both hand splints and PROM on both arms and legs. During an interview on 1/7/2026 at 11:55 a.m. with RNA 4, RNA 4 stated the RNA providing the RNA treatment to a resident (in general) was supposed to document in the resident's clinical record. RNA 4 stated she signed Resident 37's RNA documentation for 1/6/2026 after receiving communication from RNA 3 about Resident 37's RNA session. During an interview on 1/8/2026 at 11:30 a.m. with RNA 3, RNA 3 stated RNA 4 helped RNA 3 with the documentation for Resident 37's RNA session on 1/6/2026. During an interview on 1/8/2026 at 4:06 p.m. with the Director of Staff Development (DSD), the DSD stated the RNA providing the treatment should document in the resident's clinical record. The DSD stated the resident's clinical record was not accurate if another RNA signed for the resident's RNA session. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised on 7/2017, the P&P indicated documentation of procedures and treatment will include care-specific details, including.the name and title of the individual(s) who provided the care. 5. During a review of Resident 110's admission Record, the admission Record indicated the facility admitted Resident 110 on 7/13/2020 with diagnoses including hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side, paralytic syndrome following unspecified cerebrovascular (blood vessels in the brain) disease affecting unspecified side, personal history of traumatic brain injury ([TBI] a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and contracture of unspecified hand. During a review of Resident 110's MDS, dated [DATE], the MDS indicated Resident 110 had unclear speech, had difficulty communicating some words or finishing thoughts, understood verbal content, and had intact cognition. The MDS indicated Resident 110 had ROM impairments in both arms and legs. The MDS indicated Resident 110 was independent for eating, rolling to either side while lying in bed, transferring from lying in bed to sitting at the edge of the bed, and chair/bed-to-chair transfers and partial/moderate assistance for upper body and lower body dressing. During a review of Resident 110's physician orders, dated 11/20/2019, the physician orders indicated for RNA to apply the right-hand splint for four to six hours, five times per week as tolerated. Another physician order, dated 9/14/2020, indicated RNA for PROM to the right arm, three times per week as tolerated. During an observation on 1/6/2026 at 10:17 a.m. with Restorative Nursing Aide 2 (RNA 2), Resident 110's RNA session was observed. RNA 2 performed ROM exercises to Resident 110's right shoulder, elbow, wrist, and fingers. RNA 2 retrieved a black, cylindrical hard foam from the back of Resident 110's wheelchair. RNA 2 placed the cylindrical foam in Resident 110's right palm and secured it with a stretchable cloth.During a review of Resident 110's RNA Flow Sheet for 1/2026, the RNA Flow Sheet indicated RNA 4 signed for the provision of Resident 110's RNA services on 1/6/2026 including the PROM to the right arm and application of the right-hand splint. During an interview on 1/7/2026 at 11:55 a.m. with RNA 4, RNA 4 stated the RNA providing the RNA treatment to a resident (in general) was supposed to document in the resident's clinical record. RNA 4 stated she signed Resident 110's RNA documentation for 1/6/2026 because RNA 2 had difficulty accessing Resident 110's RNA documentation. During an interview on 1/8/2026 at 10:27 a.m. with RNA 2, RNA 2 stated RNA 4 documented for Resident 110's session on 1/6/2026 because RNA 4 was Resident 110's usual RNA. During an interview on 1/8/2026 at 4:06 p.m. with the Director of Staff Development (DSD), the DSD stated the RNA providing the treatment should document in the resident's clinical record. The DSD stated the resident's clinical record was not accurate if another RNA signed for the resident's RNA session. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised on 7/2017, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's [NAME] record. The P&P indicated documentation in the resident's medical record was required to be complete and accurate and include the signature and title of the individual documenting. The P&P indicated the following should be documented in the resident medical record: 1. Objective observations, medications administered, treatments or services performed, changes in the resident's condition, events, incidents or accidents involving resident, and progress toward or changes in the care plan goals and objectives. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. The P&P indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. The P&P indicated as required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered.c. the route of administration.g. the signature and title of the person.the drug. During a review of the P&P titled Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated the nurse was responsible for recording information related to changes in the resident's medical condition or status in the resident's medical record. The P&P indicated a hospital transfer constituted a change of condition requiring documentation and that required notifications and documentation were to occur within twenty-four (24) hours of the change. During a review of the facility's P&P titled, Documentation of Medication Administration, dated 11/2022, the P&P indicated, 2. Administration of medication is documented immediately after it is given. 3. Documentation of medication administration includes, as a minimum: a. the resident's name; b. name and strength of the drug; c. dosage; d. route of administration; e. date and time of administration.i. the condition.(. intravenously).

Based on observation, interview, and record review, the facility failed to perform hand hygiene (act of cleaning hands with soap and water or an alcohol-based sanitizer to remove or destroy germs, preventing the spread of infections) before and after direct contact with three of 28 sampled residents (Resident 37, 114, 48). This deficient practice had the potential to continue the spread of infection, including influenza ([flu] a contagious respiratory infection caused by viruses). Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE]. Resident 37's diagnoses included paralytic syndrome (broad term for conditions causing rapid muscle weakness) following cerebral infarction (brain damage due to a loss of oxygen to the area), paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) to both hands and the right thigh. During a review of Resident 37's physician orders, dated 11/11/2025, the physician orders indicated for the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to apply both hand splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for two hours, three times per week or as tolerated. Apply both leg splints for two hours, three times per week or as tolerated. Provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both arms in all planes (planes of joint motion, including forward and backward, side to side, and rotation), three times per week or as tolerated. During a review of Resident 114's admission Record, the admission Record indicated the facility admitted Resident 114 on 1/25/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebral infarction affecting the right dominant side, dysphagia, and contractures of the unspecified shoulder, elbow, wrist, hand, knee, ankle, and foot. During a review of Resident 114's physician orders, dated 10/21/2025, the physician order indicated for RNA to provide PROM to both legs in all planes, three times per week as tolerated. During a review of Resident 48's admission Record, the admission Record indicated the facility admitted Resident 48 on 1/2/2026 with diagnoses including anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities) and extrapyramidal and movement disorder (drug-induced or disease-related movement disorders causing tremors, stiffness, restlessness).During an interview on 1/5/2026 at 1:20 p.m. with the Infection Prevention Nurse (IPN), the IPN stated the facility had a flu outbreak and the facility staff was required to wear N-95 respirators (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air). During an observation on 1/6/2026 at 2:01 p.m. in Resident 37's room, with Restorative Nursing Aide 3 (RNA 3), Resident 37's RNA session was observed. Resident 37 performed exercises on both shoulders, elbows, wrists, and hands. RNA 3 wore disposable gloves and provided ROM exercises to both of Resident 37's hips, knees, ankles, and toes. RNA 3 applied Resident 37's hand splints. During an observation on 1/6/2026 at 2:15 p.m., RNA 3 threw away both disposable gloves but did not perform hand hygiene.During a concurrent observation and interview on 1/6/2026 at 2:18 p.m. in the resident's room with RNA 3, Resident 114's RNA session was observed. RNA 3 wore disposable gloves and provided ROM exercises on both of Resident 114's hips, the left knee, and both ankles. The Certified Nursing Assistant (CNA, unknown) came into the room during Resident 114's RNA session and placed a package of honey graham crackers on Resident 114's bedside table. RNA 3 threw away the disposable gloves and readjusted Resident 114 position in bed at the end of the RNA session. RNA 3 did not perform hand hygiene. RNA 3 walked to the nursing station to retrieve a paper towel for Resident 114 and returned to Resident 114's room to open the package of crackers. RNA 3 did not perform hand hygiene. RNA 3 walked to Resident 48's room, switched on the bedroom lights, briefly spoke with Resident 48, and readjusted Resident 48's pillow. RNA 3 did not perform hand hygiene. RNA 3 walked to the nursing station and sat down.During an interview on 1/6/2026 at 2:29 p.m. with RNA 3, RNA 3 stated she forgot to wash or sanitize hands in-between contact with Resident 37, 114, and 48. RNA 3 stated the germs, including the flu virus, could transmit between the residents without performing hand hygiene.During an interview on 1/8/2026 at 4:01 p.m. with the IPN, the IPN stated The IPN stated the facility's flu outbreak was identified on 1/3/2026 and had 10 residents who tested positive for the flu. The IPN stated the staff should perform hand hygiene before and after direct care with residents to prevent the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 10/2023, the P&P indicated hand hygiene was the primary means to prevent the spread of healthcare-associated infections. The P&P indicated hand hygiene was indicated immediately before touching a resident, after touching a resident, after touching the resident's environment, and immediately after glove removal.

Based on observation, interview, and record review, the facility failed to ensure dignity, privacy, and respect were maintained for one of eight sampled residents (Resident 3), when the indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was not covered with a dignity bag (a privacy cover placed over a urinary catheter drainage bag to help maintain a resident's dignity and privacy by preventing exposure of the bag and its contents). This deficient practice had the potential to compromise Resident 3's dignity, privacy, and respect due to the indwelling urinary catheter drainage bag being left uncovered.Findings: During a review of Resident 3's admission Record, dated 1/9/2025, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included acute kidney failure (a sudden loss of kidney [organs that filter waste from the blood] function), urinary tract infection (UTI- an infection in the bladder/urinary tract), neuromuscular dysfunction of the bladder (a problem where the bladder [the organ that stores urine] does not function normally, causing difficulty with bladder emptying or control), myocardial infarction (MI- heart attack) and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's History and Physical (H&P), dated 12/5/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/11/2025, the MDS indicated Resident 3's cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 3 required maximal assistance (helper does more than half the effort) for eating and was dependent (helper does all of the effort) for toileting, bathing, and personal hygiene. The MDS also indicated Resident 3 had an indwelling catheter. During a concurrent observation and interview on 1/8/2026 at 8:57 a.m., with Licensed Vocational Nurse (LVN) 3, in Resident 3's room, observed Resident 3's indwelling urinary catheter. The indwelling catheter was uncovered. LVN 3 stated Resident 3's urinary catheter drainage bag did not have a dignity cover. LVN 3 stated Resident 3 should have a dignity bag because other residents, visitors, and staff could see the catheter. LVN 3 stated not covering the indwelling catheter drainage bag was a dignity issue. LVN 3 stated the lack of privacy could make Resident 3 feel different, out of place, or embarrassed. During a review of the facility's policy and procedures (P&P), titled Quality of Life - Dignity, revised August 2009, the P&P indicated residents were to be treated with dignity and respect at all times. The P&P indicated staff were to promote and protect resident dignity, including helping residents keep urinary catheter drainage bags covered.

Based on observation, interview, and record review, the facility failed to ensure dignity, privacy, and treatment were provided in a respectful manner for one of eight sampled residents (Resident 105) during a toileting request. This deficient practice resulted in Resident 105 becoming visibly frustrated and had the potential to cause psychosocial harm, including emotional distress and loss of dignity.Findings: During a review of Resident 105's admission Record, dated 1/9/2025, the admission record indicated Resident 105 was admitted to the facility on [DATE]. Resident 105's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, blocked blood flow to a part of the brain) affecting the left dominant side, history of falling, syncope and collapse (episodes of fainting), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 105's History and Physical (H&P), dated 10/25/2025, the H&P indicated Resident 105 had the capacity to understand and make decisions. During a review of Resident 105's Minimum Data Set (MDS - a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 105's cognitive skills (ability to think, remember, and reason) were severely impaired. The MDS indicated Resident 105 required maximal assistance (helper does more than half the effort) for toilet hygiene and toilet transfer (the ability to get on and off a toilet or commode). The MDS indicated Resident 105 required moderate assistance (helper does less than half the effort) for oral and personal hygiene. During a review of Resident 105's care plan titled, Activities of Daily Living (ADL - routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) initiated on 10/24/2025, the care plan indicated Resident 105 required extensive assistance by one staff member for toileting. During a review of Resident 105's care plan titled Fall risk initiated on 10/24/2025, the care plan indicated staff were to encourage the resident to maintain functional independence through safety-awareness. The care plan also indicated staff were to anticipate Resident 105's needs and complete a fall risk assessment. During an observation on 1/6/2026 at 1:04 p.m., of lunch service, staff were observed in the hallway pulling meal trays from the meal carts and delivering them to resident rooms. Resident 105, who was Spanish speaking, was observed independently propelling his wheelchair from his room into the hallway. Resident 105 was observed repeatedly calling out bano to Licensed Vocational Nurse (LVN) 5 who was standing nearby at a medication cart. A Spanish-speaking visitor (Visitor 1) was observed translating for Resident 105. Visitor 1 informed the nurse Resident 105 was requesting to use the restroom but there was no toilet paper in the bathroom. In the presence of Resident 105, LVN 5 was observed shaking her head and rolling her eyes. LVN 5 then stated, He wears briefs, he can't use the restroom. LVN 5 then proceeded to a nearby closet and retrieved a box of facial tissue. LVN 5 attempted to give the facial tissues to Resident 105, however, the resident declined and shook his head No. LVN 5 then flagged Certified Nursing Assistant (CNA) 4 from the hallway and asked the CNA to get toilet paper for Resident 105. LVN 5 then returned to the medication cart. Resident 105 returned to his room to wait for the toilet paper. CNA 4 was then observed passing meal trays in the hallway without returning to the assist Resident 105 with toileting. Resident 105 became frustrated, spoke an unknown word in Spanish, took his hat off and threw it to the floor. LVN 5 called out from the medication cart that the toilet paper was in the bathroom but never left her cart to assist Resident 105. Resident 105 independently maneuvered his wheelchair toward the bathroom and used his cane to open the door. Resident 105 entered the shared bathroom by backing into the space in his wheelchair without assistance. The adjoining bathroom door on the opposite side remained open. Residents from the adjoining room were able to look directly into the restroom. Due to space limitations, Resident 105 was unable to turn himself around or close the adjoining door while in the wheelchair. No staff member entered the bathroom to assist Resident 105 with toileting or ensure his privacy. While Resident 105 attempted to use the bathroom, the resident's roommate stated he frequently assisted Resident 105 into the restroom because the staff were busy. Resident 105's roommate stated the resident would occasionally get locked inside the bathroom and would have to assist him with opening the bathroom door. Resident 105 exited the bathroom without assistance. LVN 11 approached and asked if assistance was needed, however, Resident 105 had already completed toileting without assistance. During an interview on 1/6/2026 at 1:11 p.m., with LVN 11, LVN 11 stated when a resident needed to use the restroom, staff should assist the resident promptly. LVN 11 stated CNA 4 should not have continued passing meal trays but should have assisted Resident 105 with toileting. LVN 11 stated either LVN 5 or CNA 4 should have assisted Resident 105 immediately. LVN 11 stated Resident 105's dignity was not respected when the resident was not assisted in a timely manner. LVN 11 stated staff were present to assist residents, and the residents must come first. During an interview on 1/6/2026 at 1:24 p.m., with CNA 4, CNA 4 stated LVN 5 asked her to obtain toilet paper for Resident 105. CNA 4 stated she obtained the toilet paper and gave it to LVN 5. CNA 4 stated she then resumed passing meal trays. CNA 4 stated she did not assist Resident 105 because she thought LVN 5 was assisting the resident. During an interview on 1/6/2026 at 2:54 p.m., with LVN 5, LVN 5 stated she had done all she could for Resident 105 when the resident requested assistance with toileting. LVN 5 stated she was not Resident 105's assigned nurse. LVN 5 stated she told CNA 4 to obtain toilet paper and stated she placed the toilet paper on the roll in the restroom through the adjoining bathroom. LVN 5 stated she thought CNA 4 was assisting the resident. LVN 5 stated she initially thought Resident 105 used briefs, but stated CNA 4 indicated the resident could use the restroom independently, which was why she did not provide further assistance. LVN 5 stated she felt she had done all she could do for Resident 105 and stated, If it were me, I would have just used the tissue I provided, but he refused. LVN 5 stated she believed the issue was the lack of toilet paper but later realized Resident 105 required additional toileting assistance. LVN 5 stated she should have followed through to ensure the resident was assisted, as the resident became frustrated. LVN 5 stated Resident 105 deserved privacy and dignity. During an interview on 1/8/2026 at 3:55 p.m., with the Director of Nursing Trainer (DONT), the DONT stated LVN 5's actions were unacceptable. The DONT stated when residents needed help, staff were expected to assist them. The DONT stated residents could feel unattended and uncared for when staff did not respond to their needs which could cause psychological and emotional stress. The DONT stated the facility was the residents' home and staff were responsible for providing care to the residents. During a review of the facility's policy and procedure (P&P) titled Quality of Life - Dignity, revised 8/2009, the P&P indicated residents were to be treated with dignity and respect at all times. The P&P indicated staff were required to promptly respond to a resident's request for toileting assistance and to promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care. The P&P also indicated demeaning practices or standards of care that compromise resident dignity were prohibited. During a review of the facility's P&P titled Resident Rights, revised 12/2016, the P&P indicated residents had the right to be treated with respect, kindness, and dignity. The P&P indicated to maintain privacy during care. The P&P indicated residents were entitled to a dignified existence and to receive care that is free from neglect and practices that compromise dignity. The P&P also indicated staff were responsible for supporting residents in the exercise of these rights and for treating residents in a manner that preserved dignity and privacy at all times. During a review of the facility's P&P titled Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated residents were to be provided care, treatment, and services to maintain or improve their ability to carry out activities of daily living. The P&P indicated appropriate support and assistance were to be provided with elimination (toileting) for residents unable to carry out activities of daily living independently, in accordance with the resident's plan of care.

Based on observation and interview, the facility failed to ensure one of eight sampled residents (Resident 118) had access to a call light system to summon assistance. This deficient practice had the potential to prevent Resident 118, who was unable to communicate verbally, from requesting assistance or communicating needs in a timely manner.Findings: During a review of Resident 118's admission Record, dated 1/9/2025, the admission record indicated Resident 118 was admitted to the facility on [DATE]. Resident 118's diagnoses included compression of the brain (pressure on the brain that can affect thinking, movement, or speech), cerebral infarction (loss of blood flow to a part of the brain also known as a stroke), encephalopathy (a condition that affects how the brain works, causing changes in thinking, alertness, or behavior), encephalitis (inflammation of the brain that can affect thinking, alertness, speech, or behavior) and encephalomyelitis (inflammation of the brain and spinal cord that can affect movement, speech, and brain function), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 118's History and Physical (H&P), dated 4/26/2025, the H&P indicated Resident 118 had fluctuating capacity to understand and make decisions. During a review of Resident 118's Minimum Data Set (MDS - a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 118 cognitive skills (ability to think, remember, and reason) for daily decision making were severely impaired. The MDS indicated Resident 118 had short-term and long-term memory problems. The MDS indicated Resident 118 had no speech (absence of spoken words) and rarely or never had the ability to be understood to express ideas and wants. The MDS indicated Resident 118 was dependent (helper does all the effort) with toileting, bathing, oral and personal hygiene. During a review of Resident 118's care plan with a focus on communication limitations related to cognitive deficits, nonverbal status, impaired mobility, and the need for adaptive devices, initiated on 10/30/2025, the care plan indicated Resident 118 was nonverbal and had difficulty communicating needs verbally. The care plan indicated Resident 118 communicated needs through nonverbal methods, including eye contact, touch, and pointing. The care plan further indicated Resident 118 required a flat call light to be able to communicate needs. During a concurrent observation and interview on 1/5/2026 at 12:58 p.m., with Licensed Vocational Nurse (LVN) 8 and Resident 118, while in Resident 118's room, the resident was observed lying in bed, alert and oriented. Resident 118 was unable to respond verbally when questions were asked. Resident 118's call light was observed dangling on the left side of his bed. Resident 118 shook his head no when asked if he could reach his call light. LVN 8 acknowledged Resident 118's call light was not within reach. LVN 8 stated she should always ensure the resident's call light was within arm's reach. LVN 8 further stated if Resident 118 was in distress or needed assistance in the event of an emergency, he would need his call light, especially since the resident was nonverbal. During an interview on 1/8/2026 at 3:55 p.m., with the Director of Nursing Trainer (DONT), the DONT stated if the resident needed assistance, he could not call for help. The DONT further stated the call light was Resident 118's lifeline for emergencies. During a review of the facility's policies and procedures (P&P), titled Answering the Call Light, revised 9/2022, the P&P indicated staff were to explain and demonstrate use of the call light to residents upon admission and as needed. The P&P further indicated the call light was to be plugged in, functioning, and accessible to residents at all times, including when the resident was in bed, in the bathroom, or on the floor. The P&P also indicated staff were to respond promptly to resident call light requests and report any defective call lights to the nurse supervisor.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a significant change in condition when a resident exhibited inappropriate sexual behavior for one of eight sampled residents (Resident 27). This deficient practice resulted in a delay in physician evaluation and the development of an appropriate plan of care for Resident 27's behavioral needs. Cross reference F644 and F742.Findings: During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was initially admitted to the facility on [DATE]. Resident 27's diagnoses included traumatic brain injury (damage to the brain from an external force), traumatic subarachnoid hemorrhage (brain bleed) with loss of consciousness, disorganized schizophrenia (a mental illness that is characterized by disturbances in thought), brief psychotic disorder, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 27's Minimum Data Set ([MDS], a resident assessment tool), dated 12/22/2025, the MDS indicated Resident 27's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 27 was entirely dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 27's History and Physical (H&P), dated 9/14/2025, the H&P indicated Resident 27 had the capacity to understand and make decisions. During an interview on 1/5/2026 at 12:20 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 27 grabbed her buttocks and private area (date unknown) which caused her to feel uncomfortable. CNA 2 stated Resident 27 laughed during the incident. CNA 2 stated she notified Licensed Vocational (LVN) 2 and the Director of Staffing Development (DSD) of the incident. During an interview on 1/6/2026 at 2:13 p.m. with LVN 2, LVN 2 stated any change in a resident's condition should be relayed to the physician so orders could be placed to direct the resident's plan of care. LVN 2 recalled being notified of Resident 27's inappropriate sexual behaviors and stated the physician should have been notified because the behavior constituted a serious change in behavioral condition that required a psychiatric evaluation, possible medication adjustments, or a 5150 (a 72- hour psychiatric hospitalization when an adult exhibits a mental health crisis and is evaluated to be a danger to others, or to himself or herself, or gravely disabled). LVN 2 stated she knew Resident 27 to have a longstanding history of behavioral concerns. LVN 2 stated she did not complete a change of condition note or notify the physician because she did not think of it. During a concurrent interview and record review on 1/7/2026 at 12:10 p.m. with the Director of Nursing Trainer (DONT), the DONT stated Resident 27's inappropriate sexual behavior should have been reported by the physician so that the resident could have a psychiatric evaluation. The DONT stated that the lack of physician notification placed all the residents and the staff in danger of physical harm by Resident 27 and placed the resident at risk of worsening behavior. During a review of the facility's Policy and Procedure (P&P) titled, Change in Resident's Condition or Status, revised 2/2021, the P&P indicated the nurse would notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly. The P&P also indicated to notify the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition of a resident with a mental disorder.

Based on interview and record review the facility failed to ensure five of eight sampled residents (Resident 118, 319, 55, 99, and 117) were free of accidents and hazards by failing to: 1. Follow its policy and procedure (P&P) titled, Wandering, Unsafe Resident, which indicated the facility would identify residents at risk for harm due to unsafe wandering and elopement by failing to ensure: a. Resident 118, who was assessed as high risk for wandering (the act of roaming around and becoming lost or confused about their location) and elopement (the act of leaving a facility unsupervised and without prior authorization), did not elope from the facility on 10/13/2024 and 11/24/2024 (42 days after the first elopement). b. Staff were aware of all residents at risk for wandering and elopement. c. Staff were aware of Resident 118's high risk for elopement and how to prevent Resident 118 from leaving the facility unnoticed. d. A person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with measurable interventions was created for Resident 118, after Resident 118 eloped from the facility on 10/13/2024, to prevent Resident 118 from eloping again on 11/24/2024. e. A readmission 72-Hour Monitoring was conducted for Resident 118 after he eloped and was readmitted on [DATE], to ensure Resident 118 did not have exit seeking behaviors. f. Resident 118 was not placed in a room near the lobby exit door, after he eloped on 10/13/2024 and was readmitted to the facility. g. An interdisciplinary care team ([IDT], a group of different disciplines working together towards a common goal for a resident) meeting was conducted to address Resident 118's elopement on 10/13/2024, to prevent further elopements. h. Staff were in-serviced (a professional training on a particular subject) on how to care for residents at risk for wandering and elopement. i. The P&P titled, Safety and Supervision of Residents, was followed, which indicated each resident's risk factors were identified and interventions adjusted accordingly to meet the resident's individual needs. 2. Notify the State Agency (SA) on 11/9/2024, following an incident of Resident 117 trespassing on the facility premises with a large knife. 3. Ensure Resident 319's and 55's lighters were securely stored and inaccessible to facility residents identified as unsafe to independently use or keep a lighter in their possession. 4. Ensure a fall mat (a floor pad designed to help prevent injury should a person fall) was placed at Resident 99's bedside. As a result, on 11/24/2024, Resident 118 eloped from the facility and as of 01/29/2025 (66 days later), Resident 118 has not been found. There is a likelihood for Resident 118 to suffer medical complications such as malnutrition, dehydration, stroke, exposure to harsh environmental conditions including excessive cold, fire, possible motor vehicle accident, and and/or possible death. These deficient practices also placed all facility residents at risk for avoidable physical and psychosocial harm related to the presence of a resident trespassing onto facility premises with a large knife, and potential burn-related injuries from unsupervised use of lighters. These deficient practices also placed Resident 99 at risk for physical injury from a fall. On 1/29/2025 at 12:35 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) due to the facility's failure to monitor Resident 118, create a care plan, and conduct an IDT meeting after Resident 118 eloped on 10/13/2024 and to prevent Resident 118's elopement from the facility on 11/24/2024. On 1/31/2025 at 2:11 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed onsite at 1/31/2025 at 3:01 p.m., in the presence of the ADM. The IJRP included the following immediate actions: 1. A facility-wide assessment was conducted on 1/30/2025 by the Director of Nursing (DON), Director of Staff Development (DSD), Minimum Data Set Nurse (MDSN), and the Quality Assurance (QA) Nurse to reevaluate all in-house residents. The Medical Records Director (MRD) conducted an audit to identify other residents who were at high risk for elopement. Three residents (Residents 48, 60, and 63) were identified at high risk for elopement. 2. An IDT meeting was conducted for Residents 48, 60, and 63 to address their high risk for elopement score. 3. Residents 48, 60, and 63's care plans were updated by the DON to address their elopement and wandering risk with goals and interventions. The interventions included: a. Add a blue identifier sticker to the resident's wrist band and room door to alert staff or resident being high risk for wandering and elopement. b. The completion of the elopement/wandering assessment to be completed upon admission, quarterly, and as needed. c. Monitor wandering behavior and document in the electronic health record (eHR) in the behavior monitoring tab by the licensed nurse every shift and as needed. d. Observe for any change in condition that may indicate risk for elopement. e. Observe whereabouts of resident each shift. Elopement behavior documented in the eHR every shift and the certified nursing assistants (CNAs) would complete the Behavior Monitoring log and provide to the Medical Records daily for compliance. 4. The ADM, DON, and DSD developed a visual aide and process to assist in clearly identifying all residents who were high risk for elopement and is routinely accessed by staff. The color blue was adopted as an elopement risk identifier. After a resident was identified to be a high risk for elopement, a blue sticker would be applied to the resident's wrist band and to the resident's door tag. A blue page was added in the Change of Condition (COC) binder at each nurses' station and would have the residents' information and brought to the attention of the nursing staff during daily shift change huddles. Additional blue binders were added in the Activity, Dietary, and Laundry/Housekeeping departments and would be reviewed and/or updated at least daily by the DON and/or the registered nurse (RN). 5. The ADM updated the facility P&P titled, Safety and Supervision of Residents to include executing and implementing interventions identifiers. The ADM updated the P&P titled, Wandering, Unsafe Resident to include: a. An IDT would be arranged within two days to address the resident's wandering and elopement behavior and/or those whose assessments indicated high risk for elopement. b. Staff would apply a blue sticker to the resident's wrist band and door tag. c. Staff would include the resident's information to the Elopement section of the COC binder located at each nurse's station. d. Staff would open a behavior monitoring specific for episodes of wandering in the Medication Administration Record (MAR). e. CNAs would complete the Behavior Monitoring log to conduct hourly monitoring, and provide to the Medical Records daily for compliance. f. Staff would update resident's care plan to include the behavior or unsafe wandering and elopement, and their high risk for elopement. g. An IDT would be conducted when a resident elopes and returns to the facility, to assess the resident's behavior. 6. The ADM conducted an immediate Quality Assurance Meeting (QA) on 1/30/2025 to include a report that outlined the updated P&Ps titled, Safety and Supervision of Residents and Wandering, Unsafe Resident. 7. The DON and DSD started an immediate in-service, on 1/29/2025, with all staff regarding the updated P&Ps titled, Safety and Supervision of Residents and Wandering, Unsafe Resident, how to provide safety and supervision to residents, identification of residents who were high risk for elopement, unsafe wandering behavior, color code identifying elopement risk residents, and the location of COC and department binders. The facility will complete 100% staff in-service by 2/5/2025. Those staff who are out of the facility and not able to attend the in-services would be in-serviced upon their return to the facility. 8. The DSD would provide initial education during the employee's on-boarding orientation, thereafter the DSD and/or the DON would provide the continued in-serviced to all facility staff at least quarterly and as needed (when the facility experienced a close call or when additional in-service was needed for retraining needs). The in-service education would focus on wandering and elopement, providing safety and supervision to residents, identification of residents who were high risk for elopement, unsafe wandering behaviors, color code identification, and location of COC and department binders. 9. Upon completion of any resident's IDT or COC, where the outcome results in the resident being at risk for elopement, the DON, DSD, or ADM would assess the resident's room assignment. If the resident's room was within approximately 30 feet (ft, unit of measurement) of any exit, the DON, DSD, and/or the ADM would review the Occupational Therapy Summary to assess the resident's physician abilities to see if they had the potential to successfully elope. Findings: 1. During a review of Resident 118's Admission Record (Face Sheet), the Face Sheet indicated Resident 118 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), psychoactive substance-induced persisting dementia (a deterioration of mental function resulting from the persisting effects of alcohol use), and altered mental status (a change in mental function, such as a decline in awareness, attention, or consciousness). During a review of Resident 118's Minimum Data Set ([MDS], a resident assessment tool), dated 10/3/2024, the MDS indicated Resident 118's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 118 normally used a walker (a mobility aide that helps people walk by providing stability and balance). The MDS indicated Resident 118 required moderate assistance (helper does less than half the effort) with toileting, bathing, lower body dressing, and putting on and taking off footwear. a. During a review of Resident 118's Progress Note, dated 11/24/2024 and timed at 7:24 p.m., the Progress Note indicated on 11/24/2024 at 3:35 p.m., Resident 118 was nowhere to be found within the facility. The Progress Note indicated Resident 118 stepped out of the facility unsupervised and undetected [for] the second time. The Progress Note indicated staff make thorough search inside and outside the facility. The Progress Note indicated Resident 118's physician was made aware and instructed to report the incident to the police. During a concurrent interview and record review on 1/27/2025 at 2:07 p.m., with Registered Nurse (RN) 1, Resident 118's Elopement and Wandering Risk Scale, dated 10/21/2024, was reviewed. The Elopement and Wandering Risk Scale indicated Resident 118 was a high risk to wander. RN 1 stated when a resident was determined to be a high risk for wandering and elopement, additional interventions must be put into place to promote safety for the resident. RN 1 stated once Resident 118 was assessed as high risk for wandering and elopement, immediately the facility should have initiated a plan to put extra set of eyes on him, educate the staff of Resident 118's wandering and elopement score, updated his care plan, and conducted a room change to prevent Resident 118's second elopement on 11/24/2024. b. During an interview on 1/27/2025 at 2:10 p.m., with RN 1, RN 1 stated the facility did not have a way to easily identify residents who were at high risk for wandering and elopement. RN 1 stated the licensed nurses conducted the change-of-shift huddle (a brief meeting where nurses would discuss patient care, safety, and workload) to discuss the residents' needs within their assigned area. RN 1 stated the facility was divided into four stations and within each station and the individual change-of-shift huddles would not incorporate any resident information outside of the station. RN 1 stated when a resident was assessed as high risk for elopement, the CNAs would be instructed verbally to keep an eye on them. During an interview on 1/28/2025 at 12:26 p.m., with RN 2, RN 2 stated during change-of-shift huddle, they do not communicate any high risk for elopement residents in other stations and only focus on the residents within their station. During an interview on 1/28/2025 at 2:52 p.m., with the Director of Nursing (DON), the DON stated once a resident was assessed as high risk for wandering and elopement, that individual information would be included in the change-of-shift huddle for the station they resided in. The DON stated if a resident who was high risk for wandering and elopement ambulated to a different station, the nurses would not be aware of the resident's status. The DON stated the staff had access to an electronic communication tool, where residents at risk for wandering and wandering could be posted, however, the posted communication would move down the board and eventually disappear, unless the information was moved forward. c. During an interview on 1/27/2025 at 2:10 p.m., with RN 1, RN 1 stated Resident 118's risk for wandering and elopement was only communicated to the nurses and CNAs within East Station and would not be communicated to the other three stations. RN 1 stated Resident 118 was ambulatory (able to walk) and if Resident 118 walked to a different station, the staff would not know Resident 118 required close supervision to prevent wandering and elopement. During an interview on 1/27/2025 at 3:40 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was assigned to Resident 118 on 11/24/2024 and last saw him at 3:30 p.m. in the dining room. CNA 2 stated during change-of-shift huddle, she would be instructed to just keep an eye on [Resident 118], however, there was no direction on how often to indicate Resident 118's whereabouts and there was nowhere to document their observations. During an interview on 1/28/2025 at 10:32 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 118 was very sneaky and was able to elope from the facility two times. LVN 2 stated Resident 118 was ambulatory with a walker and would walk around the facility LVN 2 stated during his rounds on 11/24/2024 at 3:35 p.m., he realized Resident 118 was nowhere to be found. LVN 2 stated he was unsure how Resident 118 eloped from the facility. LVN 2 stated Resident 118 required close supervision and when an extra CNA was available, the CNA would be assigned to Resident 118 to closely monitor and supervise him through the shift. LVN 2 stated this type of close monitoring would not always be possible and the RN on duty would take it upon herself to have Resident 118 sit with her in the nurse's station during the shift to ensure Resident 118's whereabouts. LVN 2 stated they did not have a documented plan of care to address Resident 119's behaviors, however, the nurses and CNAs would be verbally instructed to monitor him closely. During an interview on 1/29/2025 at 9:10 a.m., with LVN 1, LVN 1 stated the CNAs were verbally instructed to do frequent visual checks on the residents that required close monitoring. LVN 1 stated she did not document any visual checks, Resident 118's whereabouts, nor any redirection interventions for Resident 118. LVN 1 stated she was only aware of the residents in her station and did not know about any other high risk for wandering and elopement in the other stations. During an interview on 1/29/2025 at 2:49 p.m., with CNA 2, CNA 2 stated when a resident required monitoring for a behavior or change of condition, the nurses would initiate a Stop and Watch form where the nurses and CNAs would document on. CNA 2 stated Resident 118 did not have a Stop and Watch form, nor any other required documentation specific to his monitoring and supervision. d. During a concurrent interview and record review on 1/27/2025 at 2:13 p.m., with RN 1, Resident 118's Care Plans were reviewed. The Care Plans did not indicate Resident 118's high risk for wandering and elopement score and Resident 118's first elopement on 10/13/2024 were addressed and care planned. RN 1 stated there should have been a Care Plan developed that addressed Resident 118's high risk for wandering and elopement and his first elopement on 10/13/2024. RN 1 stated Care Plans were developed as a template on who the resident was, their problems or risk factors, goals to be accomplished, and interventions the staff were to implement to provide care. RN 1 stated without the Care Plans addressing Resident 118's risk for elopement and actual elopement, the staff was unaware how to properly care for Resident 118. RN 1 stated without a plan to properly care for Resident 118's new behavior and actual elopement, Resident 118 was able to elope again on 11/24/2024 and had not returned to the facility. During an interview on 1/28/2025 at 11:11 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 118 did not have a care plan that addressed his elopements on 10/13/2024 and 11/24/2024, nor his high risk for wandering and elopement. The MDSC stated those care plans were essential in promoting Resident 118's safety by directing the staff to implement interventions such as observing Resident 118's whereabouts frequently, utilizing a wander guard (a monitoring device), if necessary, redirecting Resident 118 if he were to be close to an exit, and utilize the social services department to frequently assess Resident 118's needs and concerns for leaving the facility. During an interview on 1/28/2025 at 2:52 p.m., with the DON, the DON stated the type, the frequency, and the person responsible of the monitoring for a high risk for wandering and elopement resident would be indicated on the Care Plan and physician's order. The DON stated without a care plan with specific interventions, Resident 118 would not receive the necessary care and monitoring to prevent Resident 118 from eloping from the facility. e. During a concurrent interview and record review on 1/27/2025 at 2:16 p.m., with RN 1, Resident 118's Progress Notes were reviewed. The Progress Notes did not indicate Resident 118 was monitored when readmitted to the facility on [DATE]. RN 1 stated the licensed nurses did not perform and did not document a 72-Hour Monitoring for Resident 118, after the resident eloped on 10/13/2024. RN 1 stated it was important to conduct the 72 Hour monitoring to assess the resident's adjustment to the facility and other behaviors such as exit-seeking. During an interview on 1/28/2025 at 2:52 p.m., with the DON, the DON stated the 72-Hour Monitoring when a resident was admitted to the facility was important to see how the resident was adjusting to the facility and if there were any concerns that needed to be addressed. f. During an interview on 1/27/2025 at 1:44 p.m., with RN 1, RN 1 stated Resident 118 was readmitted on [DATE] and was placed in a room near the lobby exit. RN 1 stated Resident 118's room placement was inappropriate because Resident 118 might have eloped the second time on 11/24/2024, through the lobby exit door. RN 1 stated Resident 118 should have been placed in a room closer to the nurse's station so Resident 118 could be easily monitored more closely. RN 1 stated she did not know how Resident 118 eloped on 10/13/2024. During an interview on 1/28/2025 at 12:26 p.m., with RN 2, RN 2 stated she readmitted Resident 118 to the facility on [DATE]. RN 2 stated Resident 118's room assignment was predetermined prior to his arrival to the facility. RN 2 stated Resident 118 was placed in a room close to the lobby door and the idea of a room change crossed her mind due to Resident 118's prior elopement but did not initiate a room change. RN 2 stated the conversation of a room change should have been brought up to initiate a room change away from an entrance/exit door and closer to the nurse's station. g. During a concurrent interview and record review on 1/28/2025 at 11:07 a.m., with the MDSC, Resident 118's IDT Meeting Notes were reviewed. The IDT Meeting Notes did not indicate Resident 118's high risk for wandering and elopement and elopement on 10/13/2024 were addressed. The MDSC stated the facility did not conduct an IDT meeting after Resident 118 was readmitted to the facility on [DATE] following his elopement on 10/13/2024 nor after Resident 118 was assessed as a high risk for wandering and elopement. The MDSC stated conducting an IDT meeting when Resident 118 was readmitted to the facility was important to find out the reason Resident 118 eloped from the facility on 10/13/2024. The MDSC stated during the IDT meeting, the facility could have assisted Resident 118 with a safe discharge if that was desired or addressed other concerns that prompted Resident 118 to elope from the facility. The MDSC stated during the IDT meeting, Resident 118 would have been educated on the important of safety and encouraged not to elope from the facility due to the risk of getting hit by a car or ultimately death. The MDSC stated because the IDT did not address Resident 118's reason for eloping nor his high risk for wandering and elopement, the IDT was unable to create a plan of care to prevent another elopement. The MDSC stated Resident 118 eloped from the facility a second time on 11/24/2024. During an interview on 1/28/2025 at 2:52 p.m., with the DON, the DON stated an IDT meeting was necessary after an elopement to have an in-depth conversation with the resident to reeducate him on safety and the process of safely leaving the facility, to create a plan of care decided by all departments, and to address any concerns and provide the necessary assistance. h. During an interview on 1/28/2025 at 12:20 p.m., with the Director of Staff Development (DSD), the DSD stated she did not in-serviced any staff on monitoring, supervision, safety, elopement, and wandering. The DSD stated any communication on monitoring and supervision would be between the licensed nurses to the CNAs regarding their assigned residents. The DSD stated there was no lesson plan that outlined how to monitor and supervise high risk for elopement and wandering residents. During an interview on 1/28/2025 at 12:26 p.m., with RN 2, RN 2 stated she did not receive any in-services on elopement and wandering residents nor how to monitor them. RN 2 stated she would instruct the other nurses and CNAs to conduct more visual monitoring if they had residents at risk for wandering and elopement. During an interview on 1/29/2025 at 9:10 a.m., with LVN 1, LVN 1 stated she was never in serviced or trained on how to monitor residents at risk for wandering and elopement. LVN 1 stated she used her nursing judgement to ensure Resident 118 and other residents at risk did not wander off or elope from the facility. During an interview on 1/29/2025 at 2:49 p.m., with CNA 2, CNA 2 stated she had not received an in-service on monitoring and supervising high risk for elopement residents. CNA 2 stated she knew those residents required close monitoring and to keep an eye them, however, it was impossible to watch them every moment of the shift. During an interview on 1/28/2025 at 2:52 p.m., with the DON, the DON stated in-services on monitoring high risk for wandering and elopement residents was important to bring awareness to the staff and to allow any staff member to ask questions if they did not know how to handle the situation. The DON stated in-services ensured a standard level of education and competency between all staff members. During a review of the facility's P&P titled, Safety and Supervision of Residents, undated, the P&P indicated, The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. The P&P indicated to reduce accident risks and hazards, the facility shall provide training, as necessary. The P&P indicated, The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjust interventions accordingly. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. During a review of the facility's P&P titled, Wandering, Unsafe Resident, revised 8/2014, the P&P indicated, The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Cross Reference F656. 47286 2. During a review of Resident 117's Admission Record, the Admission Record indicated Resident 117 was admitted on [DATE]. Resident 117's diagnoses included a broken right thigh bone and displacement of internal fixation device of the right thigh bone (when a surgical implant, like a plate, screw, or rod used to stabilize a broken bone, has moved out of its original position). During a review of Resident 117's History and Physical (H&P), dated 5/7/2024, the H&P indicated Resident 117 had the capacity to understand and make decisions. During a review of Resident 117's admission Minimum Data Set (MDS, a resident assessment tool), dated 5/16/2024, the MDS indicated Resident 117 did not have cognitive impairments (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 117 was independent with mobility while in bed and was dependent on staff to walk. During a review of Resident 117's discharge MDS, dated [DATE], the MDS indicated Resident 117 was independent in making decisions regarding tasks of daily life, and decisions were consistent and reasonable. The MDS indicated Resident 117 could walk independently. During a review of Resident 117's progress note, dated 11/6/2024, the progress note indicated Resident 117 was non-compliant with facility rules and had displayed aggressive behavior towards facility staff. During a review of Resident 117's progress note, dated 11/9/2024 at 12:33 a.m., the progress note indicated Resident 117 was out of the facility on a pre-approved four-hour leave, and did not return within four hours. The progress note indicated Resident 117 was discharged from the facility, and indicated staff attempts to contact Resident 117 were unsuccessful. During a review of Resident 117's progress note, dated 11/9/24 at 7:15 a.m., the progress note indicated Resident 117 arrived at the facility by bicycle and entered through a back door. The progress note indicated Resident 117 was informed he was discharged from the facility and was trespassing and indicated Resident 117 refused to leave. The progress note indicated nursing Registered Nurse (RN) 1 called law enforcement and Resident 117 was escorted from the facility by law enforcement. During a review of Resident 117's progress note, dated 11/9/24 at 2:26 p.m., the progress note indicated Resident 117 returned to the facility on bicycle, accompanied by a vehicle with two unidentified individuals. The progress note indicated Resident 117 arrived at the facility through a staff-only gated entrance that required a code. The progress note indicated Resident 117 knew the code. The progress note indicated Resident 117 then entered the building through a door used by housekeeping staff and was very aggressive and brandishing a large knife. The progress note indicated Resident 117 was yelling expletives and indicated law enforcement was contacted but never arrived. On 1/31/2024 at 9:29 a.m., an attempt was made to contact Resident 117 by telephone. Resident 117's contact number was disconnected. During an interview on 1/31/2025 at 10:16 a.m., with RN 1, RN 1 stated Resident 117 trespassed onto the facility premises on 11/9/2024 in the morning and stated the Director of Nursing (DON) was notified by phone. RN 1 stated Resident 117 returned to the facility later in the day on 11/9/2024, with a huge knife. RN 1 stated Resident 117 was irate and super aggressive towards staff. RN 1 stated law enforcement was contacted and never arrived at the facility. RN 1 stated that during both trespassing incidents, Resident 117 snuck through the staff-only gate, using the code to gain entry. During an interview on 1/31/2025 at 12:05 p.m., with the DON, the DON stated Resident 117 trespassed onto the facility premises with a large knife and entered through entrances not approved for visitors or residents. The DON stated the gate code to the parking lot was not changed between both trespassing incidents. The DON stated knowing the code created a potential for Resident 117 to trespass onto the facility premises. During a concurrent interview and record review, on 1/31/2025 at 12:57 p.m., with the Administrator (ADM), the facility policy and procedure (P&P) titled Unusual Occurrence Reporting, undated, was reviewed. The ADM stated the P&P indicated occurrences that affect the welfare and safety of facility residents were to be reported to the State agency (SA). The ADM stated Resident 117's trespass onto the facility premises with a large knife was an immediate risk to the welfare and safety of the facility residents and staff, and state it should have been reported to the SA. The ADM stated the facility staff and residents were in fear, and stated Resident 117 created an unsafe environment. During a review of the facility P&P titled Unusual Occurrence Reporting, undated, the P&P indicated occurrences that affect the welfare and safety of facility residents and staff were to be reported via telephone to the SA within 24 hours, and a written report detailing the incident was to be sent to the SA within 48 hours. 3. a. During a review of Resident 319's Admission Record, the Admission Record indicated Resident 319 was admitted on [DATE]. Resident 319's admitting diagnoses included generalized muscle weakness and schizophrenia (mental illness that is characterized by disturbances in thought). During a review of Resident 319's H&P, dated 1/2/2025, the H&P indicate Resident 319 had the capacity to understand and make decisions. During a review of Resident 319's MDS, dated [DATE], the MDs indicated Resident 319 did not have cognitive impairments or impairments to his upper extremities (shoulders, elbows, wrists, hands). During a review of Resident 319's Smoking Assessment, dated 1/24/2025, the assessment indicated Resident 319 could light his own cigarettes and the facility did not need to store his lighter and cigarettes. During an observation on 1/27/2025 at 8:58 a.m., at Resident 319's bedside, a pack of cigarettes and a disposable lighter were observed resting on Resident 319's bedside table, readily visible. Resident 319 was observed lying in bed, with his face covered by a blanket. b. During a review of Resident 55's Admission Record, the Admission Record indicated Resident 55 was admitted on [DATE]. Resident 55's admitting diagnoses included dementia (a progressive state of decline in mental abilities) and generalized muscle weakness. During a review of Resident 55's H&P, dated 1/5/2024, the H&P indicated Resident

Based on observation, interview, and record review, the facility failed to implement the care plan after a resident's refusal of Levetiracetam (medication used to treat seizures [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness]) and implement interventions to monitor for seizure activity for one of six sampled residents (Resident 2) as per the resident's care plan. As a result, Resident 2 had an unwitnessed fall in the bathroom during a seizure activity and sustained a right ankle fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. It also resulted in a decline in Resident 2's functional mobility and activities of daily living (ADLs, self-care activities performed daily such as grooming, dressing, and personal hygiene). Findings: During a review of Resident 2's admission record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included epilepsy (a neurological condition involving the brain that causes seizure), diabetes (abnormal blood sugar), dysphagia (swallowing difficulties), muscle weakness (lack of muscle strength), and hypertension (high blood pressure). During a review of Resident 2's History and Physical (H&P) dated 11/17/2023, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/28/2203, the MDS indicated Resident 2 required maximal assistance from staff with toileting, bathing, and personal hygiene. During a review of Resident 2's Physician's Order dated, 11/16/20203, the Physician's order indicated Levetiracetam 1000 milligrams ([MG] unit of measurement), give 1 tablet by mouth two times a day for seizure. During a review of Resident 2's Care Plan titled, Resident has a seizure disorder, dated 11/30/2023, the care plan's goal indicated the resident would remain free of seizure activity. The staff's interventions indicated to monitor Resident 2 for seizure activity every shift and give Levetiracetam 1 tablet by mouth two times a day for seizure. During a review of Resident 2's Medication Administration Record (MAR) for the month of January 2024, the MAR indicated Resident 2 refused the 9 AM dose of Levetiracetam from January 1, 2024, to January 7, 2024. During a review of Resident 2's Progress Note dated 1/8/2024, the progress note indicated on 1/8/2024, Resident 2 was found in the bathroom on the floor near the toilet in vomit. The progress note indicated while assessing Resident 2, Resident 2 had one episode of an active seizure that lasted approximately 10-15 seconds. During a review of Resident 2's GACH Admission Record, dated 1/8/2024, the record indicated Resident 2 was admitted to the GACH on 1/8/2024 with diagnosis of seizures. The GACH record indicated an Orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) consult was scheduled on 1/10/2024 for an ankle fracture. The GACH record indicated a posterior (back) short leg splint (used to stabilize injuries by decreasing movement and providing support to prevent further injury) was applied, and that based on imaging and physical exam, Resident 1 did not require emergent surgical intervention at time but would require surgical intervention when a durable power of attorney ([DPOA], someone appointed to make decisions on one's behalf) was obtained. The GACH record indicated Resident 1 was stable for discharge to the facility and to follow up outpatient with an orthopedic provider, for surgical planning. During a review of Resident 2's GACH X-ray (process of creating pictures of the inside of your body) of the right ankle, dated 1/9/2024, the X-ray indicated Resident 2 sustained a closed right trimalleoloar (the lower leg sections that forms the ankle joint) ankle fracture dislocation. During an interview on 1/24/2024 at 10:46 AM with Registered Nurse (RN) 1, RN 1 stated on 1/8/2024 during the 11 PM to 7 AM (night) shift, she was doing morning rounds and observed she (RN 1) Resident 2 on the restroom floor near the toilet. RN 1 stated Resident 2's fall was unwitnessed. RN 1 stated during the resident assessment, she observed Resident 2 had one episode of an active seizure that lasted 10 to 15 seconds. During a concurrent observation and interview on 1/24/2024 at 11:33 AM with Resident 2, in Resident 2's room, Resident 2 was observed in bed awake and alert. Resident 2 had a cast (a shell made from plaster or glass used to immobilize injured bones, promote healing, and reduce pain and swelling while the bone heals) to the right lower leg. Resident 2 stated she had a fall. Resident 2 could not recall the date of the fall or events prior to the fall incident. Resident 2 stated she was transported to a GACH and readmitted to the facility with the cast. Resident 2 stated she wanted the cast removed. Resident 2 stated she was walking prior to the fall but was not able to walk after the fall. Resident 2 stated she felt uncomfortable and unhappy. During an interview on 1/24/2024 at 12:51 PM with Licensed Vocational Nurse (LVN) 1. LVN 1 stated on 1/8/2024, Resident 2 refused her seizure medications prior to the resident's fall incident on 1/8/2024. LVN 1 stated she did not remember how many days Resident 2 refused the seizure medications. LVN 1 stated she did not notify Resident 2's physician (MD 1) that Resident 2 had refused her seizure medications. LVN 1 stated Resident 2 was not monitored for seizure activity. LVN 1 also stated it was important to follow the resident's care plan, and administer medications as ordered by MD 1. LVN 1 stated not following the care plan and physician orders placed Resident 2 at risk for seizures, falls, injuries and death. LVN 1 stated unfortunately Resident 2 had a fall and sustained an injury. During a concurrent interview and record review on 1/24/2024 at 1:34 PM with Director of Nursing (DON), Resident 2's MAR, for the month of January 2024 was reviewed. The DON stated there was no documentation to indicate Resident 2 was monitored for seizure activity. The DON stated, Resident 2 refused to take Levetiracetam oral tablet 1000 MG at 9 AM from 1/1/2024 to 1/7/2024 (a total of seven days). The DON stated Resident 2's refusal of Levetiracetam for seven consecutive days placed Resident 2 at risk for seizures and injuries. During a review of Resident 2's Physical Therapy ([PT], branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities) Recertification and Updated Plan of treatment for Progress & Response to Treatment dated 1/12/2024, the report indicated Resident 2's functional performance was improving as a result of skilled treatment. The report indicated after Resident 2's fall on 1/8/2024, Resident 2 was to have a right lower extremity (leg) non-weight bearing ([NWB], not to put any weight on the affected extremity) activity. The report indicated, the fall affected Resident 2's ability to walk and perform ADLs. The report indicated Resident 2's change in condition and decline in function required skilled therapy services to improve quality of life, increase in level of care, and patient safety. The report also indicated Resident 2 had increased anxiousness (feeling of unease, excessive worry), confusion, perseveration (continuation of something such as activity or thought) on topics unrelated to skilled therapy services with difficulty to be redirected. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The P&P indicated assessments of residents were ongoing and care plans revised as information about the residents and the residents' conditions changed.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 24) received the necessary care, which included proper positioning while being fed in accordance to the resident's plan of care and the facility's policy and procedure (P/P). Resident 24, who has eyesight impairment, a history of dysphagia (difficulty swallowing), and missing teeth was being fed lunch while laying down (not upright) in a reclining position in a Geri-chair (large, padded chair with wheeled base designed to assist a person with limited mobility) by an untrained Certified Nursing Assistant (CNA 51). This deficient practice resulted in Resident 24 aspirating (breathing in a foreign object [food] into the airway), developing aspiration pneumonia (inflammation [swelling] and/or infection of the lungs when food, saliva, liquids, or vomit is breathed in instead of being swallowed into the esophagus and stomach) for an unknown amount of time resulting in [CONDITION(S)] (a life-threatening condition when the body's response to infection causes injury to its own tissues and organs), and subsequently being transferred to a general acute care hospital (GACH). Resident 24 was admitted to the GACH and required care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: During a review of Resident 24's Admission Record (Face Sheet), the face sheet indicated the facility admitted Resident 24 on 2/4/2017 and was last readmitted [DATE]. Resident 24's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 24's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 6/28/2021, the MDS indicated Resident 24 had moderate memory problems, was unable to make needs known and sometimes understood others. According to the MDS, Resident 24 was dependent in eating and had to be fed a mechanically altered (foods prepared using a blender or a food processor to blend or ground to make smaller, softer, and easier to chew and swallow) therapeutic diet. The MDS indicated Resident 24 had poor trunk (from the neck to the groin [area of the body where the upper thighs meet the lowest part of the abdomen]) control with upper and lower extremities lacking functional limitation in range of motion ([ROM] the capability of a joint to go through the complete spectrum of movement) on both sides of the body. During a review of Resident 24's physician order, dated 7/30/2021 and timed at 3:56 p.m., the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the physician order, aspiration precautions was ongoing with strict safe swallowing precautions for Resident 24. During a review of Resident 24's Speech language pathology ([SLP] the scientific study of speech, fluency, feeding, and swallowing, including all the mechanisms of speech and language) evaluation and plan of treatment certification, dated 7/22/2021 through 8/18/2021, the SLP evaluation indicated Resident 24 required treatment due to an oral and swallowing dysfunction with feeding. The SLP referral reason was due to the resident's exacerbation (an acute increase in the severity of a condition or illness) of decreased safety during oral intake, coughing/choking during oral intake, risk for aspiration and decreased ability to use compensatory strategies indicating the need for speech therapy to assess least restrictive oral intake, behaviors that impact safety inattention to presentation, reduced attention to tasks, poor self-monitoring skills, and the resident's inability to make needs known. The SLP recommendations included diet of pureed consistency, nectar thick liquids, with close supervision during oral intake, swallow strategies and positioning to facilitate safety and efficiency. The SLP recommended Resident 24 use lingual sweep (push food out of cheek by pushing on cheek with hand) and re-swallow with alternation of liquids and solids, rate modification, bolus size modifications, chin tuck (person tilts head and gently glides the chin straight back decreasing the space between the base of the tongue and throat), throat clear with effortful re-swallow, and upright position during meals with upright posture for more than thirty (30) minutes after meals. During a review of Resident 24's physician order, dated 8/12/2021 and timed at 6:14 p.m., the order indicated a diet change to a low sodium controlled carbohydrate diet, pureed texture (paste or thick liquid suspension made from cooked food ground finely with no lumps), and nectar consistency liquids. The order indicates Resident 24 may have thin liquids between meals, without food under one to one supervision. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 24's untitled care plan initiated on 6/29/2018, the care plan identified a problem with oral or dental health problems related to missing natural teeth and carious teeth (decay or permanently damaged hard surface of the teeth resulting in tiny holes). The goal indicated Resident 24 would be free of infection or bleeding of the oral cavity by 9/30/2021. The staff's interventions included dental consult as needed, good oral hygiene every shift, consult with dietitian if chewing or swallowing problems are noted, and monitor the resident's diet texture. During a review of Resident 24's untitled care plan initiated on 7/22/2021 identified a problem with skilled speech language pathology (SLP) related to malnutrition (lack of proper nutrition caused by not consuming enough of the right foods to nourish the body), dysphagia, diet consistency, and aspiration pneumonia. The goal indicated Resident 24 would maintain adequate nutritional status as evidenced by demonstrating safe swallowing strategies and demonstrate advanced oral motor strength for functional swallowing or progression of diet with a target date of 9/30/2021. The staff interventions included diet texture analysis, compensatory strategy training, and patient caregiver training education secondary to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 24's untitled care plan initiated on 8/17/2021 identified a nutritional problem related to the resident receiving a mechanical altered diet. The goal indicated Resident 24 would have no signs of choking during meals through the review date of 9/30/2021. The staff interventions included dining assistance for all meals, allowing ample time for the resident to consume the meals and swallow, observe as needed for signs or symptoms of dysphagia, pocketing (of food in cheeks), choking, coughing, drooling, and the resident holding food in the mouth with aspiration precautions. During a review of Resident 24's GACH Emergency Department (ED) records, dated 8/18/2021 and timed at 6:38 p.m., the GACH's ED note indicated Resident 24 arrived to the ED with a complaint of an infected skin rash of the back spreading to his groin. While there the GACH ED records indicated Resident 24 had ineffective airway clearance with an oxygen saturation (measures the percentage of oxygen in the blood to supply the tissues and organs of the body) of 90 percent (%) (Normal Reference Range [NRR] 95% to 100%) on room air. The ED records indicated Resident 24 had decreased lung sounds bilaterally with suspected right anterior lung aspiration pneumonia. During a review of Resident 24's GACH ED records diagnostic results CT (computed tomography [X-ray with computer technology for detailed pictures of the organs [lungs]) chest results, dated 8/18/2021 and timed at 10:06 p.m., the CT indicated findings of aspiration pneumonia with infection, low lung volumes, right middle lobe hazy, opacity (fluid or solid material such as pus within the airways that causes a consolidation of the lung) and may represent infectious consolidation of respiratory system. During a review of Resident 24's GACH Infectious Disease progress note (PN), dated 8/24/2021 and timed at 9:44 a.m., the PN indicated the CT chest findings of pneumonia with an uptrend of leukocytosis (an increase in the number of white blood cells during an infection). Resident 24's secretions extended from the trachea (the windpipe) into the right lower lobar bronchus (large airway that leads from the trachea to a sector of the lung[s]) and distal segmental airways, partially occluded, with right basilar airspace consolidation with patchy opacities in the left lower lung lobe. The physician recommended to start Resident 24 on several antibiotics for treatment. During a review of the GACH speech therapist's (ST) evaluation, dated 8/20/2021 and timed at 9:16 a.m., the ST evaluation indicated Resident 24 was refer to ST due to having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the ST evaluation, Resident 24 had reduced strength of labials (lips), mandible (jaw), and lingual (tongue) structure. Resident 24 demonstrated oropharyngeal (part of the throat at the back of the mouth behind the oral cavity) dysphagia characterized by poor bolus (food that has been chewed and mixed in the mouth with saliva) control, reduced bolus transport, and suspicion of delayed swallow initiation. The GACH ST recommended a puree diet puree with a one-to-one feeder and strict swallowing precautions upon discharge. During an interview on 8/20/2021 at 9:35 a.m., with Resident 13 stated he observed a staff member CNA 51 feeding Resident 24 on 8/10/2021 at lunchtime in the hallway by his room. Resident 13 stated he sits on the side of his bed in his room to eat his meals, and suddenly heard Resident 24 coughing and choking uncontrollably while being fed by a CNA (CNA 51). Resident 13 stated he looked into the hallway because he thought it was odd that CNA 51 was feeding Resident 24 while he was laying almost flat in the Geri-chair. Resident 13 stated he became worried when he saw Resident 24 continuously choking and CNA 51 continued to sit there without lifting the back of the Geri-chair to help Resident 24 to clear his airway. Resident 13 stated after a couple of minutes of Resident 24 continuously choking, other staff members rushed over to help Resident 24 and a crowd formed around the resident. Resident 13 stated, The CNA who was feeding the resident was careless and was just shoveling the food into the resident's (Resident 24) mouth because the resident (Resident 24) cannot move his arms to feed himself. Resident 13 stated he does not remember all of the staff who responded to Resident 24's choking episode but he remembered the staff had to administer oxygen to help Resident 24 breathe. Resident 13 stated he took a photo with his cell phone of Resident 24 being fed laying down. Resident 13 stated a few days later an ambulance was observed taking Resident 24 to the hospital. During a review of the photo taken on 8/10/2021 at 12:10 p.m. (the day Resident 24 was seen choking), by Resident 13 revealed Resident 24 was lying low in a supine position on a pink cushioned Ger-chair being fed a meal from a Styrofoam (rigid white lightweight plastic) food container by CNA 51 along with another unidentified staff member in the hallway by Resident 13's room. During a review of Resident 13's Face Sheet, the Face sheet indicated the resident was admitted to the facility on [DATE]. Resident 13's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 13's annual MDS, dated [DATE], the MDS indicated Resident 13 had no memory problems, no impaired decision-making, was able to make needs known and understood others. During an interview on 8/20/2021 at 9:52 a.m., the facility's director of staff development (DSD) stated CNAs were not certified for meal assistance and an in-service for assistance with meals or feeding residents with swallowing issues has not been provided to the staff. During an interview on 8/20/2021 at 9:56 a.m., a Licensed Vocational Nurse (LVN 30) stated a choking incident with Resident 24 occurred when the resident's diet was changed from puree to chopped, but after the choking his diet was changed back to pureed. LVN 30 stated she does not know the exact date of Resident 24's choking incident but stated Resident 24 had swallowing problems and have to be fed all meals. LVN 30 stated she was not working the day when Resident 24 choked, but did hear about it. During an interview on 8/20/2021 at 10:23 a.m., LVN 47 stated he was working when the choking incident occurred with Resident 24 on 8/10/2021 while the resident was being fed at lunch. LVN 47 stated he was called by the Registered Nurse Supervisor (RN 2) to go see Resident 24. LVN 47 stated he pulled Resident 24 up in the Geri chair to sit in an upright position at 90 degrees and firmly patted Resident 24's back repeatedly. LVN 47 stated the food came out of Resident 24's mouth while the resident continued to cough to clear his airway to breathe. LVN 47 stated oxygen was applied to help the resident breathe. LVN 47 acknowledged there was no documentation and stated he did not document the incident in Resident 24's medical records because he was not assigned to care for Resident 24, and he assumed RN 2 would document what happened regarding the choking incident. During an interview on 8/20/2021 at 10:51 a.m., CNA 29 stated she has taken care of Resident 24 before and was assigned to feed him. CNA 29 stated Resident 24 eats slow and has to clear his throat a lot, and coughs at times while being fed. CNA 29 stated she heard about Resident 24's choking incident, but she was not the nursing assistant who was feeding him at the time. During an interview on 8/20/2021 at 11:13 a.m., CNA 51 stated she has fed Resident 24 before, but denied the resident was choking on food while she was feeding him. CNA 51 stated Resident 24 coughed a lot while she was feeding him. During an interview on 9/2/2021 at 3 p.m., Resident 37 stated he has been roommates with Resident 24 for a while and was asleep when he heard Resident 24 choking from the hallway. Resident 37 stated the choking was so loud it woke him up, but he could not see the resident choking only heard him constantly cough and choking. Resident 37 stated, I have observed some staff feeding the resident (Resident 24) way too fast and not allowing the resident to swallow his food. Resident 37 stated he was concerned because Resident 24 was his buddy and he cannot speak for himself. During a review of Resident 37's Face Sheet, the Face sheet indicated the resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 37's quarterly MDS, dated [DATE], the MDS indicated Resident 37 had no memory problems, no impaired decision-making, was able to make needs known and understood others. During a review of the facility's policy and procedure (P/P) titled, Assistance with Meals, revised 9/2013, the P/P indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents requiring full assistance: residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, keeping interactions with other staff to a minimum while assisting residents with meals. All employees who provide resident assistance with meals will be trained an shall demonstrate competency in the prevention of food borne illness, including hygiene practices, and safe food handling. During a review of the facility's P/P, revised 9/2012 and titled, Dysphagia- Clinical protocol, the P/P indicated the staff and physician will help identify individuals with a history of swallowing difficulties or related diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff will identify individuals who have difficulty swallowing or chewing food. Any staff member observing an incident or situation will document the details of the circumstances or have a nurse observe and document those details. The staff and physician will seek and identify causes of dysphagia, coughing, or choking such as oral and dental disorders, and medication side effects. The risk of aspiration pneumonia should be presented in the same balanced context as any of the other risks that face chronically ill individuals. Downgrading diet consistency from mechanical soft to pureed (food) will only occur after a review and discussion with the physician and consideration of all relevant factors. If it is decided that alterations in food or fluid consistency are indicated, the physician and/or staff will document why such alterations are right for the resident given the various risks and relevant factors involved for that individual and show that pertinent medical conditions or medication side effects have been considered.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program for one of three sampled residents (Resident 1) by failing to place Resident 1 who was positive for [CONDITION(S)]-resistant staphylococcus aureus ([CONDITION(S)]- A bacteria that causes infections in different parts of the body and is resistant to most antibiotics) of the nares (nose), and the right lower leg on contact precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the residents or the resident's environment), which included cohorting (the practice of grouping residents infected or colonized with the same infectious agent together and prevent contact with susceptible residents) of residents to prevent cross-contamination (a process by which bacteria are unintentionally transferred from one substance or object to another, with harmful effects); wearing a gown while providing care to Resident 1; and posting a contact precaution sign on an area that was easily visible outside of Resident 1's room. This deficient practice had the potential to result in uncontrolled spread of infection ([CONDITION(S)]) that can lead to life threatening conditions, including death. These failures placed Resident 2 and Resident 3 at high risk for contracting [CONDITION(S)]. On 9/16/2021 at 12:50 p.m., an Immediate Jeopardy (IJ), (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared. The facility's administrator and the Director of Nursing (DON) were notified of the failure to place Resident 1 on [CONDITION(S)] contact precautions, which had the potential to expose Residents 2 and Resident 3 at risk for contracting [CONDITION(S)]. The facility submitted a Plan of Action (POA) for the correction of the IJ, which included: 1. Resident 1 was placed on contact precaution on 9/16/2021. On 9/17/2021 at 3:10 p.m., Resident 1 was moved to Room A for contact precautions. Resident 1 is the only resident in that room. The Responsible party was made aware of the room change. 2. The facility staff started receiving training and education from the Infection Preventionist on 9/16/2021 and will be completed by 9/20/2021 regarding the facility's policy and procedure focusing on: [CONDITION(S)] contact precautions, documentation, communication, and validation per the current guidelines of CDPH Enhanced Standard Precautions for Skilled Nursing Facilities (SNF) 2019 Guidelines. 3. The residents in Room B, Bed B and C, the former room of Resident 1 who was in Bed A, were put on 72-hour charting (every shift), as of 9/16/2021 for monitoring of signs and symptoms of [CONDITION(S)]. 4. All inquiries for potential resident admission focusing on Multidrug Resistant Organism ([CONDITION(S)], microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents) will be escalated to the Clinical Consultant for review and ensure correct isolation precautions will be implemented including cohorting of resident to prevent cross-contamination. 5.The Infection Preventionist (IP) will continue to conduct surveillance (a routine collection of accurate data on infections among residents and staff, its analysis and dissemination of the resulting information so appropriate action can result) focusing on resident admitted and readmitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On weekends, the Registered Nurse (RN) Supervisor will educate facility staff immediately regarding [CONDITION(S)] contact precautions, documentation, communication, and validation per the current guidelines the CDPH Enhanced Standard Precautions for Skilled Nursing Facilities (SNF) 2019 guidelines. Issues identified will be reported to the Director of Nursing for review. 6. The IP and/or the Director of Staff Development (DSD) will do trending and analysis for the integration, review, and recommendations of the Quality Assurance and Performance Improvement (QAPI, a program to improve the quality of life and quality of care and services delivered in nursing homes) committee every month with participation of the Medical Director for evaluation of system effectiveness and to ensure the deficient practice does not re-occur. On 9/18/2021 at 12:10 p.m., while the surveyor was onsite, after the Plan of Action (POA) was verified and confirmed as implemented by observation, interviews, and record review, the IJ was removed and the Administrator and Nurse Consultant were notified. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Admission Record indicated the facility admitted Resident 1 on 2/2/2004 and last readmitted the resident from General Acute Care Hospital (GACH) on 8/30/2021. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Change in Condition (COC) dated 08/15/2021 at 11:54 a.m., the COC indicated Resident 1 was noted with bilateral lower extremity (BLE) redness, warm to touch, no open area, and no foul odor. Resident 1 had no complaint of pain or discomfort. The Medical Doctor (MD) was made aware and [MEDICATION(S)] (An Antifungal medicine. A fungus is an organism that causes infection) was ordered to apply on the resident's BLE. During a review of Resident 1's Nursing Progress Notes (NPN) dated 8/15/2021 to 8/18/2021, the NPN indicated Resident 1 was on monitoring for BLE with redness, warm to touch, no open area, no foul odor noted and treatment in progress. During a review of Resident 1's NPN dated 8/18/2021 at 6:06 p.m., the NPN indicated Resident 1 was transferred to GACH via stretcher with two (2) Emergency Medical Technicians (EMTs). Resident 1 was stable at the time and would be evaluated for a fungal rash on his abdomen and lower extremities. During a review of Resident 1's GACH's History and Physical (H&P) dated 8/19/2021 at 1:10 a.m., the H&P report from GACH physician indicated Resident 1 was brought in by ambulance from the facility due to a rash on his abdomen and lower extremities that appeared to be spreading. The H&P indicated Resident 1 had diffuse (spread over a wide area) erythematous (red) rash on the abdomen and lower extremities with apparent skin sloughing (shedding or removing). During a review of Resident 1's laboratory results from GACH dated 8/19/2021 at 11:40 p.m., Resident 1 had nasal cultures (laboratory tests that are used to identify the kind of microorganism causing an infection from secretions of the nose) collected for [CONDITION(S)]. The lab results were verified on 8/25/2021 at 7:31 a.m., that Resident 1 was positive for [CONDITION(S)] of the nares. During a review of Resident 1's laboratory results from GACH dated 8/19/2021 at 11:44 p.m., Resident 1 had wound cultures collected of the right leg. The lab results were verified on 8/25/2021 at 7:28 a.m., that Resident 1 had light growth of [CONDITION(S)] on the right leg. During a review of Resident 1's undated pictures, taken by GACH nursing staff (undated), showed the resident's right lower leg with redness, patchy skin discoloration, small open wounds, dryness and flaky skin. During a review of Resident 1's NPN dated on 8/31/2021, under Admission Summary, the NPN indicated that Resident 1 was admitted back to the facility from GACH, via stretcher with two (2) EMTs, with admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 would start antibiotic (a medication to treat infections) treatment intravenously (medication will be administered through the vein) daily for 32 days for [CONDITION(S)] in wound. During a review of Resident 1's Order Summary Report dated 9/3/2021 at 9:22 a.m. the Order Summary Report indicated [CONDITION(S)], lower extremity with [CONDITION(S)] ordered on 8/30/2021 During a review of Resident 1's Orders Summary Report dated 9/3/2021 at 9:22 a.m., the Order Summary Report indicated [MEDICATION(S)] (an antibiotic) 500 milligrams intravenously one time a day for [CONDITION(S)] on the lower extremity with [CONDITION(S)] for 32 days with a start date of 8/31/2021. During an observation of Resident 1's room dated 9/8/2021 at 12:06 p.m., no contact precaution signs were observed outside of Resident 1's room, Room B. Resident 1 was observed sharing a room with two other residents (Resident's 2, and 3). During an interview with Infection Preventionist (IP) on 9/8/2021 at 12:45 p.m., the IP stated that when a resident is returning from GACH and is not vaccinated for Covid-19 (an infectious upper respiratory disease), the resident is admitted into the yellow zone (an area within the facility where residents are cohorted while Covid-19 is being ruled out)for 14 days. If the resident is vaccinated, we admit them to the green zone (an area within the facility that is covid free). The IP stated that when there is an admission, the IP reviews GACH records and determines whether the resident needs to be placed on any transmission-based precautions (infection control precautions in health care). IP stated that contact precautions are used when residents test positive for [CONDITION(S)]. During an interview with the IP on 9/8/2021 at 12:45 p.m. the IP acknowledged that the residents who are on contact precautions should be in their own room or cohorted with Residents that have [CONDITION(S)]. IP stated that whenever she is not working on the weekends the Director of Nursing (DON) is in charge of reviewing the GACH records. During an observation on 9/15/2021 at 12:40 p.m. MDSwas observed in Resident 1's room feeding Resident 1 not wearing a gown or gloves. During an interview with Certified Nursing Assistant 1 (CNA1) on 9/15/2021 at 1:30 p.m., CNA 1 stated that she only wears gloves, and a surgical mask when providing care for residents in Room B. CNA 1 stated that for contact precautions she wears a gown, gloves, and a surgical mask. During an interview with License Vocational Nurse 1 (LVN 1) on 9/15/2021 at 2 p.m. LVN 1 stated that any resident who is positive for [CONDITION(S)] is isolated from the rest of the residents or cohorted with another resident who is [CONDITION(S)] positive. LVN 1 stated that gown, gloves, and surgical mask is required when providing care for residents with [CONDITION(S)]. LVN 1 stated that she was not made aware that Resident 1 was positive for [CONDITION(S)] of the nares and of the right lower extremity. During an interview with Registered Nurse Supervisor 1 (RN Supervisor 1) on 9/15/2021 at 3:30 p.m. RN Supervisor 1 stated that Resident 1 was admitted into the yellow zone on 8/31/2021, however, the following day 9/1/2021 RN Supervisor 1 observed that Resident 1 was in the green zone and sharing a room with two other residents (Residents 2, and 3) in Room B. During an interview with RN Supervisor 1 on 9/15/2021 at 3:30 p.m., RN Supervisor 1 stated that in the discharge summary report from GACH she read that there was a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Medical Doctor 1 (MD 1) on 9/16/2021 at 11 a.m., MD 1 stated that [MEDICATION(S)] is being used for endocarditis (inflammation of the lining of the heart), and [MEDICATION(S)] (an antibiotic) was ordered to treat [CONDITION(S)] and [CONDITION(S)]. MD 1 stated [MEDICATION(S)] has now been discontinued. MD 1 stated that Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 1 stated that because Resident 1 was infected with [CONDITION(S)] in the lower extremity, Resident 1 is a potential carrier and will always be a carrier. During an interview with MD 1 on 9/16/2021 at 11:00 a.m. MD 1 stated, Resident 1 has the potential to infect other residents and staff with [CONDITION(S)]. MD 1 stated because Resident 1 is a carrier of [CONDITION(S)] contact precautions should be used when providing care to Resident 1. A review of Centers for Disease and Prevention (CDC) guidelines for [CONDITION(S)] dated on 1/31/2019 indicated the use of contact precautions when caring for patients with [CONDITION(S)] (colonize, or carrying, and infected). CDC guidelines indicated that contact precautions means that whenever possible, patients with [CONDITION(S)] will have a single room or share a room with someone else who has [CONDITION(S)]. Also, healthcare providers need to put on gloves, and wear a gown over their clothing while taking care of patients with [CONDITION(S)]. A review of the facility policy titled, Multiple Drug Resistant Organisms, revised 4/2017, the policy indicated the staff and practitioner will evaluate each individual known or suspected to have infection with a multidrug-resistant organism for room placement and initiation of Contact Precautions on a case-by-case basis. A resident with a multi-drug resistant organism may need to be separated from a roommate. Depending on the situation, placement may include placement in a room with someone else who is colonized or infected with the same organism, but does not have any other infection (cohorting) or placement in a private room.

Based on observation, interview, and record review the facility dietary staff failed to prepare, distribute, and serve food in accordance with acceptable and safe temperatures based on professional standards for food service safety for six of six sampled residents (Residents 1, 2, 3, 4, 5 and 6) who received hot foods served at cold temperatures. The milk was served at a temperature 53.4 degrees Fahrenheit ([F] temperature scale based on 32° for the freezing point of water and 212° for the boiling point of water) and the chicken salad sandwiches were served at of 62.8 degrees F. These deficient practices resulted in improper holding of food temperatures, food was stored, uncovered with a utensil left inside of the food, which had the potential to promote the growth of pathogens that cause foodborne illness. On 8/15/2021 at 1:41 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared in the presence of the Dietary Services Manager (DSM) and Director of Nursing (DON) by telephone. The DSM and DON were notified of the immediacy for dietary staff to ensure food was served within the temperatures in the safe zone, prepare and serve food following the food distribution practices preventing potential food borne illness. The facility submitted an acceptable plan of action (POA, used to correct the deficiency) on 8/17/2021 of the IJ which included the following: 1. All residents have the potential to be affected by the deficient practices that were identified. 2. The trays served on 8/15/2021, where removed from the residents by the DSM and facility staff. The trays were replaced with a Turkey Sandwich and peaches, provided under the supervision of the DSM. The DSM immediately disposed egg salad that was observed at 66.4 degrees F, chicken salad at 62.8 degrees F and milk at 53.4 degrees F. 3. On 8/16/2021, and 8/17/2021, the Registered Dietician Consultant (RDC) with the DSM conducted in-service to facility dietary staff regarding obtaining and recording food temperatures prior to food preparation and distribution, per the facility policy and validated facility dietary staff knowledge asking verbal questions to ensure understanding and compliance. On 8/17/2021, the RDC with DSM conducted training and education regarding thermometer calibration with all dietary staff, the 4 remaining staff will be in-serviced prior to starting work. On 8/17/2021 the RDC with DSM conducted training and education regarding cooling logs for chicken and eggs with all dietary staff, the 4 remaining staff will be in-serviced prior to returning to work. 4. On 8/16/2021, and 8/17/2021 the RDC with DSM conducted training and education to the dietary staff regarding food stored in a manner (covered e.g., resident plates are covered with plate lid and the egg salad should be placed on ice, and partially open and just enough to scoop the salad to prevent food borne illness and cross contamination by facility dietary staff during tray line). 5. On 8/14/2021, 8/15/2021 and 8/17/2021 the DSM conducted dietary rounds focusing on checking temperature of foods to ensure the correct temperature per FDA and Federal regulations were followed by the facility dietary staff, no other deficient practice was identified on 8/15/2021, 8/16/2021 and 8/17/2021 by RDC. 6. On 8/15/2021 DSM observed tray line dinner to ensure the facility dietary staff were obtaining and recording the food temperature following the facility policy. 7. On 8/16/2021 RDC validated facility dietary staff knowledge, understanding and skills regarding the correct food temperatures per the FDA standards and federal regulation for food distribution and a copy was posted in the cork board for the facility dietary staff reference and ensure dietary staff are following the FDA and federal regulations prior to food distribution. 8. On 8/17/2021, the RDC along with the DSM conducted training and education regarding thermometer calibration with all dietary staff, the remaining four staff will be in-serviced prior to returning to work. 9. On 8/17/2021, the RDC along with DSM will be conducting training and education regarding cooling logs for chicken and eggs with dietary staff, the four remaining staff will be in-serviced prior to returning to work. 10. DSM will conduct and validate breakfast, lunch, and dinner five days a week and on the weekend the Dietary Cook (DC) conduct and validate to ensure facility dietary staff are preparing, distributing, and serving food in accordance with professional standards for food safety focusing on egg salad and chicken salad temperature is below 41 degrees F per facility policy and the milk temperature is below 41 degrees per facility policy, issues identified will be corrected immediately by DSM and Dietary Cook a report will be submitted to the Administrator for review, validation and immediate resolution. 11. Dietitian Consultant will conduct training and education every month for the next 6 months. 12. DSM will conduct tray line observation five days a week and a report to the Administrator for review, validation, and immediate resolution. 13. Dietitian Consultant will conduct tray line observation during her weekly visit to ensure the facility dietary staff are obtaining, and recording food temperature, thermometer calibration, and cooling logs. 14. DSM will conduct five days a week to facility dietary staff knowledge and skills regarding the correct food temperatures per the FDA standards and federal regulation for food distribution. 15. An annual skills competency will be conducted by RDC and DSM to all newly hired dietary staff to ensure the deficient practice will not recur. 16. DSM and/or Administrator will do trending and analysis for the integration, review, and recommendations of the QAPI (Governing Body) committee every month with participation of the Medical Director for evaluation of system effectiveness and to ensure the deficient practice does not recur. DSM will monitor facility compliance by conducting five days a week and on the weekend the Dietary Cook will be train & educate to conduct observation regarding thermometer calibration and cooling logs for chicken and eggs. On 8/17/2021 at 5:50 p.m., the IJ was removed in the presence of the ADM and Registered Nurse Consultant (RNC) after implementation of the acceptable POA were verified and confirmed on an onsite visit via observation, interview, and record review. Findings: a) During an interview on 7/20/2021 at 3:05 p.m. with Resident 1, Resident 1 stated the food was terrible and had no flavor. Resident 1 stated he had received rotten food, and the food sometimes was overcooked. Resident 1 stated he has a sensitive stomach, and the food is always cold. Resident 1 stated the food had no seasoning and the dessert, tiny little cakes were cut into squares, and were always sticky and chewy. During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included diabetes mellitus II (uncontrolled blood sugars), hypertension (high blood pressure), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care planning tool, dated 6/15/2021, the MDS indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and understood others. During an interview with Resident 1 on 8/14/2021 at 5:55 p.m., Resident 1 stated the chicken salad looked like cottage cheese or vomit chunks, smelled funny and made his stomach upset. During an observation of the facility's dinner tray line, food preparation on 8/14/2021, at 4:58 p.m. the following was observed: 1) Used facial tissue paper on the food preparation area countertop. 2) Large, uncovered silver pot with a thick green substance inside and the handle of a kitchen utensil sitting inside of the pot. 3) Large, uncovered plastic black square bin containing a white chunky substance with a blue scooper utensil inside, sitting on top of another large grey square bin covered with clear wrapping with yellow chunky substance inside and two flies hovering over the uncovered bin. 4) Four bread slices partially spread with chicken salad on the preparation table counter next to two open bags of bread. During an interview with Dietary Staff 1 (DS 1) in the kitchen, on 8/14/2021 at 4:59 p.m., the DS 1 stated the resident's dinner was served at 5 p.m. and the menu included chicken salad, egg salad, green salad, and split pea soup. During a concurrent observation and interview on 8/14/2021 at 5:04 p.m. with DS 1, in the kitchen during food preparation, DS 1 and the Dietary Staff Cook 1 (DSC 1) were observed preparing and serving food items for dinner on Styrofoam (a type of plastic) plates and bowls. A mounted clipboard with the food temperature log and a kitchen policy were observed taped to the wall next to the walk-in refrigerator. DS 1 stated the staff had not taken the food temperatures for the day, even though dinner tray line was almost completed. During a concurrent record review and interview on 8/14/2021 at 5:07 p.m. with DS 1, in the kitchen after reviewing the Holding Temperature log, DS1 stated the tray line Holding Temperature Log for the month of August 2021 and the 14th day column for prepared food temperatures was incomplete. DS 1 stated the tray line Holding Temperature Log indicated the minimum safe temperature for hot foods should be 135 degrees F and the maximum safe temperatures for cold foods should be 41 degrees Fahrenheit (F). DS 1 further stated not being aware how to use the facility's thermometer to check for temperatures. During a concurrent observation and interview with DS 1 on 8/14/2021 at 5:09 p.m., in the kitchen, DSC 1 was present, DS 1 obtained the food temperature of the chicken salad, which registered a reading of 62.8 degrees F and the egg salad registered at 66.4 degrees F. DS 1 stated she was not sure as to what the temperature the chicken salad should be. During a concurrent observation and interview with DS 3, in the kitchen, of the kitchen and interview with DS 3, on 8/14/2021 at 5:14 p.m., DS 3 checked the temperatures of the milks in the resident's trays and the thermometer registered at 53.4 degrees F. DS 3 stated the milk temperature should be less than 41 degrees F. DS 3 proceeded to remove a cup covered in clear plastic wrap containing milk from the facility walk-in refrigerator and obtained the temperature, which registered at 46.9 degrees F. During an interview with the Dietary Services Manager (DSM) on 8/14/2021 at 5:38 p.m., the DSM stated the chicken salad, and the egg salad food temperatures should be below 41 degrees F. DSM stated the milk temperature should be below 41 degrees F, the split peas soup temperature should be above 135 degrees F. The DSM stated there was a potential for food borne illness due to the food temperatures, and the dinner trays containing the egg salad, the chicken salad, and the split pea soup, which were not at the temperature the items should be served at. b) During an interview with Resident 2 on 8/14/2021 at 5:44 p.m., Resident 2 stated she had never enjoyed the food at the facility since her admission. Resident 2 stated the food was served on Styrofoam plates, with plastic utensils and she is unable to cut into her food to eat. Resident 2 stated the facility's food was tasteless, disgusting, and the roast beef tasted like an eraser with mushy overcooked vegetables. Resident 2 stated the coffee was served cold, and the staff would get an attitude when they were asked to heat the cold coffee. Resident 2 stated she was afraid of staff retaliation, so she just tries not to tell the staff she was unhappy with the food. During a review of Resident 2's Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included Diabetes Mellitus II and hypertension. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had no memory problems, no impaired decision-making, was able to make needs known and understood others. During an interview with Registered Nurse (RN 1) on 8/14/2021 at 6:03 p.m., RN 1 stated she heated food for the resident right after the trays were passed to the residents. RN 1 stated she has heard some of the alert residents complain about the facility's food and she offered the residents something else, but when she went to the kitchen staff would get mad. During an interview with DSM on 8/14/2021 at 6:07 p.m., the DSM stated the alternate meal in place of the chicken salad or egg salad would be a deli sandwich. DSM stated the food thermometers were calibrated every Monday and the facility had only one working food thermometer. DSM stated she did not know how long the other food thermometers had been broken. c) During an interview with Resident 3 on 8/15/2021 at 12:21 p.m., Resident 3 stated the food was lousy, and most of the time the hot food was served cold. The dietary staff did not honor the requested food alternatives, the rice was hard, and the beans had an aluminum taste like can. During a review of Resident 3's Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included hypertension (high blood pressure) and [CONDITION(S)] (elevated cholesterol). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had no memory problems, no impaired decision-making, was able to make needs known and understood others. d) During an interview with Resident 4 on 8/15/2021 at 12:24 p.m., Resident 4 stated he was diabetic with dietary restrictions and he had received food that elevated his blood glucose such as pudding with crushed graham crackers. Resident 4 stated the staff refuses to exchange his meals when he did not like the meal and were always getting upset about reheating the cold food served or exchanging the food. During a review of Resident 4's Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 4's diagnoses included Diabetes Mellitus II, muscle weakness, and obesity (overweight). During a review of Resident 4's admission MDS, dated [DATE], the MDS indicated Resident 4 had no memory problems, no impaired decision-making, was able to make needs known and understood others. e) During an interview with Resident 5 on 8/15/2021 at 12:33 p.m., Resident 5 stated the food was always awful, and she eats only because she was very hungry. Resident 5 stated the food lacks flavor and most of the time the food was served on Styrofoam dishes and cold. Resident 5 stated the hot food was always cold, which made it taste bad. Resident 5 stated she did not ask the staff to reheat the food or for food exchanges because the staff was rude and start making comments that made her feel upset. During a review of Resident 5's Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 5's diagnoses included adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments such as weight loss, decreased appetite, poor nutrition, and inactivity), [CONDITION(S)], and hypertension. During a review of Resident 5's quarterly MDS, dated [DATE], the MDS indicated Resident 5 had no memory problems, no impaired decision-making, was able to make needs known and understood others. During an interview with Anonymous Staff Member (AST 1) on 8/15/2021 at 12:40 p.m., AST 1 stated she had seen the food served on Styrofoam plates many times, even after the pandemic. AST 1 stated the residents always complained about the food and she sometimes give the residents graham crackers. AST 1 stated if she goes to the kitchen to ask for a meal alternative the DSM is rude and would respond, Just tell the resident we don't have that. AST 1 stated she does not like to ask for anything from the kitchen because it's hard to deal with the dietary staff. f) During an interview with Resident 6, on 8/15/2021 at 1:02 p.m., Resident 6 stated the only reason the food was hot on 8/15/2021 was because California Department of Public Health (CDPH) was in the facility. Resident 6 stated the hot food was always cold, and the food was like slop. Resident 6 stated he hope the food improved because he hated the food and usually orders food by delivery. During a review of Resident 6's Face Sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included Diabetes Mellitus II, muscle weakness, and morbid obesity. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had no memory problems, no impaired decision-making, was able to make needs known and understood others. During an interview with Registered Dietician Consultant (RDC), on 8/16/2021 at 2:59 p.m., the RDC stated she visited the facility two or three times a week. The RDC stated the egg salad, the chicken salad, and the milk should have been below 41 degrees F. RDC stated she was informed about the food temperatures and informed the food thermometer may have been broken. RDC stated the facility's dietary staff were recently in-serviced in July 2021. During a review of the facility's undated recipe titled, Chicken Salad Sandwich, undated the recipe indicated to keep chilled at less than 41 degrees F, covered, until served. Serve from pan placed on ice for tray line. During a review of the facility's recipe, titled Creamy Egg Salad Sandwich undated the directions indicated keep sandwiches in refrigerator, covered, at less than 41 degrees F until service. Serve in a pan placed on ice during tray line at 41 degrees or less. During a review of the facility's recipe titled, Split Pea Soup undated the directions indicated internal temperature must register at least 165 degrees F for 15 seconds. Serve on tray line at the recommended temperature of 170-190 degrees F. During a review of the facility's policy titled, Meal service dated 2018, the policy indicated meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner and served at the appropriate temperatures. The food and nutrition services staff member will take the food temperatures prior to service of the meal with a thermometer that has been cleaned and sanitized. Temperature measuring devices shall be calibrated in accordance with manufacturers as necessary to assure their accuracy. Hot food serving temperature must be at or above minimum holding temperature of 140 degrees F. Cold food items will be placed on the trays as close to serving time as possible to assure the temperature is below 41 degrees F. The cold beverages can be stored up to one to two hours prior to service in a freezer and pulled out in quantities sufficient to maintain proper temperature. Temperatures of the food when the resident receives it was based on palatability. The goal was to serve cold food cold, and hot food hot. During a review of WebMD, an online article titled, Nine Food Poisoning Myths, indicated mayonnaise does not cause food poisoning, but bacteria growth causes food poisoning. According to the article, bacteria grow best on foods that contain protein and are at temperatures between 40-140 degrees Fahrenheit (F). (http://webmd.com/food-recipes/food-poisoning/features/9-food-poisoning-myths)

Based on observation, interview, and record review, the facility failed to ensure Registered Nurse 3 (RN 3) and Licensed Vocational Nurses (LVN 7), were competent to assess, document and report changes of condition (COC) and implement their policy and procedures (P/P) Resident Examination and Assessment, to ensure two of three sampled residents (Residents 33 and 76) received treatment and care in accordance with professional standards of practice to prevent pressure sores (areas of damaged skin caused by staying in one position for too long). Resident 33, who was discharged on [DATE] home, was not assessed upon discharge from the facility. Resident 76, who had a skin opening on her buttocks, was not assessed after communicating to the nursing staff nurses of a skin tear on her back. These deficient practices Resulted in Resident 33 being discharged home with a Stage III (extends into the tissue beneath the skin, forming a small crater) wound on his coccyx (tailbone) and had the potential for Resident 76's skin tear to go untreated and worsen. Findings: a) During a review of Resident 33's Admission Record (Face Sheet) indicated the resident was first admitted on [DATE] and last readmitted on [DATE]. Resident 33's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 33's History and Physical (H&P), dated 7/11/2020, the H/P indicated Resident 33 had the capacity to understand and make decisions. During a review of resident 33's Interdisciplinary ([IDT] team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Discharge Summary, dated 4/5/2021, the discharge summary indicated Resident 33 was assessed (sic) prior to leaving the facility and instructions given for medication administration. The discharge summary indicated Resident 33 did not have any skin wounds. The discharge summary indicated Resident 33 was discharge home under the care of hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life). During a review of Resident 33's Licensed Progress Notes (LPN), dated 4/5/2021 and timed at 6:40 p.m., the LPN indicated resident 33 was discharged home on 4/5/2021 at 6:45 p.m., via regular ambulance. During a review of Resident 33's hospice care visit, dated 4/5/2021 and timed at 7:53 p.m., the report indicated Resident 3 was noted with a Stage III coccyx open wound measuring two (2) by (x) two (2) centimeters ([cm] units of measurement). During an interview and review of Resident's 33 clinical record on 4/20/2021 at 3:05 p.m., the Medical Records Director (MRD) stated Resident 33 was placed in hospice on 10/29/2020 and discharge home on 4/5/2021 per family's request. During an interview on 4/21/2021 at 8:49 a.m., Resident 33's Family Member 1 (FM 1) stated the resident was discharged home on 4/5/2021 from the facility without being notify of the wounds. FM 1 stated she became aware of the buttocks wound the same day when the hospice nurse conducted her assessment after the resident's discharge. During a review of Resident 33's Non-Pressure and Pressure Skin Assessment on 4/22/2021 at 7:48 a.m., the assessment stated Resident 33 had a skin problem to his buttocks on 1/27/2021 with orders to treat with Normal saline and barrier cream for 14 days and then reassess. The MDS nurse stated no reassessment was conducted 14 days after as indicated in the physician orders. The MDS nurse stated no documentation was found indicting Resident 33's wound. After reading the Hospice notes, the MDS nurse stated the facility's staff should had been able to identify the wound on Resident 33's buttocks before discharge to provide the appropriate treatment. During an interview on 4/22/21 1:13 p.m., RN 3 stated she discharged Resident 33 home on 4/5/2021 and provided discharge instruction to the family over the phone and not a return demonstration as she documented in the discharge summary. RN 3 stated the paramedics were in a hurry to take Resident 33 that she was not able to conduct a full body assessment upon Resident 33's discharge. RN 3 stated it was her first time conducting a discharge. RN 3 stated she conducted a visual assessment, but no physical assessment of the body was done. RN 3 stated she was not aware the resident had a wound because she did not complete a discharge assessment. During an interview and review or resident 33's Hospice report on 4/22/2021 at 2:48 p.m., the DON stated RN 3 documented there were no concerns regarding resident's skin. The DON stated he was not aware RN 3 had documented she conducted a skin assessment when she did not. The DON stated he was not aware RN 3 and CNA 7 did not noted Resident 33's buttocks wound. During an interview on 4/22/2021 at 3:56 p.m., Certified Nurse Assistant (CNA 7) stated on 4/5/2021 around dinner time, the EMTs came into the facility to pick-up Resident 33. CNA 7 stated she changed Resident 33's adult brief and did not noticed a buttock wound. b) During a review of Resident 76's Admission Record, indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 76's MDS, indicated the resident had no memory problems and was able to make her needs known and understood others. During a review of Resident 76's Order Summary Report, dated 4/21/2021, indicated the resident did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 76's care plan for skin integrity, the care plan indicated Resident 76 had the potential for skin integrity impairment related to needing assistance with bed mobility. The staffs' interventions included the need to observe resident's skin every shift for possible signs of skin breakdown and immediately notify physician as needed. The Care Plan did not indicate Resident 76 had a skin break, nor had interventions for care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 76's Licensed Nurse Daily Skin Assessment Sheet, dated 4/21/2021, indicated the resident had an abrasion to her left buttock. The Licensed Nurse Daily Skin Assessment Sheet(s), dated 4/3/ 2021, 4/7/2021, and 4/15/2021 indicated Resident 76 did not have any skin issues during the reviewed dates. During an interview on 4/20/ 2021 at 9:26 a.m., Resident 76 stated she was concerned about a scratch on her back that hurt every time she got wet. Resident 76 stated a nurse (unknown) noticed the scratch on Resident 76's back. During a concurrent observation and interview on 4/21/2021 at 10:40 a.m., LVN 7 stated not being aware of any skin issues on Resident 76. During an assessment of Resident 76 skin, LVN 7 stated a pink-colored skin opening, approximately 0.5 centimeters (cm - a unit of measurement) was observed on Resident 76's left buttock. LVN 7 stated he was not aware if the skin issue was documented. During a concurrent observation and interview on 4/22/2021, at 10:00 a.m., Resident 76 stated the middle of her buttocks hurt and rated her pain a seven out of ten (using the pain rating numeric scale from 0 to 10; 0 meaning no pain and 10 being the worst pain). Resident 76 stated a nurse had applied a honey treatment to her buttocks yesterday but did not explain to or inform her what the treatment was for. During an interview, on April 22, 2021, at 11:06 a.m., LVN 4 stated CNAs notify charge or treatment nurses when a resident is identified with a skin issue. LVN 4 sated the charge or treatment nurse is then responsible for contacting the resident's physician to obtain treatment orders, carrying out the orders, and notifying responsible parties for residents who are not self-responsible. LVN 4 stated the charge or treatment nurse is also responsible for explaining the skin issue, treatment, and treatment benefits to the resident and documented on the electronic medical records system, endorsed shift to shift, and through wound consultations. During an interview on 4/22/2021 at 2:19 p.m., CNA 9 stated Resident 76 had a tiny cut on her left buttock, which the resident had shown her a picture of on her cellphone on 4/21/2021. CNA 9. During an interview on 4/22/2021 at 3:02 p.m., Resident 76 stated she was aware of the skin issue on her buttocks because it felt like burning for two weeks. Resident 76 stated she had someone take a picture of her buttocks with her cellphone but did not want to say the staff's name because she was not a snitch. During a review of the facility's policy and procedure (P&P), entitled Charting and Documentation, revised 4/2008, the P/P indicated all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record . All incidents, accidents, or changes in the resident's condition must be recorded. During a review of the facility's P&P, entitled Resident Examination and Assessment, revised 2/2014, the P/P indicated the purpose of the P/P was for staff to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. The P&P indicated, physical examination of the skin includes assessing intactness; moisture; color; texture; and presence of bruises, pressure sores, redness, [CONDITION(S)], rashes. The P&P indicated, the staff to notify the physician of any abnormalities such as, but no limited to . wounds or rashes on the resident's skin.

Based on interview and record review, the facility's staff failed to use a gait belt (an assistive device used to assist with movement) for transferring, as per the facility's policy and procedure, for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls and required an extensive assistance in mobility was transferred from the bed to the wheelchair using a one-person physical assist without the use of gait belt, fell and sustained a fracture (broken bone). This deficient practice resulted in Resident 1 falling to the floor and sustaining a left femoral neck (the top of the femur (thigh bone), the ball that sits in the socket of the hip) fracture. Resident 1 required a transfer to a general acute care hospital (GACH) and underwent surgical repair of the fracture ((ORIF) opened reduction internal fixation)) and was hospitalized for [REDACTED]. Findings: During a review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on [DATE], and was last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. During a review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated 9/15/2020, the MDS indicated Resident 1 had severe impaired cognitive skills (thought process) and was totally dependent on staff for movement on and off the unit, toilet use and personal hygiene. The MDS indicated Resident 1 required extensive one-person physical assist with dressing, eating and bed mobility (movement from and to a lying position, turns side to side, and positions body while in bed), transferring (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), dressing, eating, and was totally dependent (full staff performance every time) for locomotion (how the resident moves) on and off unit, toilet use and personal hygiene. The MDS under G0300 for Balance during transitions and Walking indicated Resident 1 was not steady and could only stabilize with staff's assistance; under G0400. The MDS under Functional Limitations in Range of Motion indicated Resident 1 had impairment on one side at the lower extremity. During a review of Resident 1's Fall Risk Assessment, dated 9/16/2020, the Fall Assessment indicated Resident 1 had a score of 45 which was high risk for falls (45 is high risk; 25-44 moderate risk; 0-24 was no risk for falls). According to the Fall Risk Assessment, Resident 1 had impaired gait (walk) with difficulty in rising from the chair and would walk with the head down which makes the resident a high risk for falling. During a review of Resident 1's care plan, dated 9/6/18 and titled Risk for Falls related hypertension (high blood pressure), poor safety awareness and inability to stand without assistance the care plan indicated the goal was to prevent falls and injuries. The staff's interventions included to anticipate the resident's need and follow the facility's fall protocol. During a review of Certified Nursing Assistant 1's (CNA 1) Nursing Assistant Skills Checklist, dated 10/1/2020, prior to Resident 1's fall, the skill's checklist indicated CNA 1 was satisfactory in the skill set for resident transfer, ambulation, using transfer equipment and use of a gait belt, signed by the Director of Staff Development (DSD). During a review of in-services conducted by the facility, dated 8/20/2020, the in-services indicated CNAs were trained on all shifts of the use the gait belt for safe transfers. During a review of Resident 1's Change of Condition (COC) form, dated 10/28/2020 and timed at 2:59 p.m., the COC indicated CNA 1 reported to the licensed nurse that Resident 1 had complaints of left leg pain. The COC indicated Resident 1 became unsteady during a transfer from the bed to a wheelchair and CNA 1 lowered Resident 1 to the floor. Resident 1 was assessed and complained of left leg pain, the pain was assessed as of 8 out of 10 (0=being no pain, 4-5 =mild pain, 6-9 =moderate pain and 10 being excruciating pain). The Nurse Practitioner ((NP) an advanced practice of registered nurse trained to assess, diagnose and treat) was notified and ordered an x-ray of Resident 1's left upper leg. During a review of Resident 1's x-ray results, dated 10/28/2020 and timed at 7:14 p.m., the x-ray results revealed Resident 1 had an acute [MEDICAL CONDITION] (head of the hip) left femoral neck. The report of the fracture was reported to the NP and the NP gave an order to transfer Resident 1 to a GACH for evaluation of the fracture. During a review of Resident 1's Transfer Form, dated 10/28/2020 and timed at 10:07 p.m., indicated Resident 1 was transferred to a GACH for an abnormal x-ray. During a review of the emergency room (ER) GACH records, dated 10/29/2020, the ER record indicated Resident 1 was seen in theER on [DATE] at 12:10 a.m., after an injury at a nursing home with left lower leg injury with pain. A computed tomography ((CT scan) a medical imaging technique use a computer process of multiple x-rays from different angles) was ordered of the pelvic, which confirmed an acute left [MEDICAL CONDITION]. During a review of Resident 1's GACH discharge summary, dated 11/6/2020, the discharge summary indicated Resident 1 was admitted to the GACH and underwent an ORIF with three screws placed for the left compacted and displaced femoral neck fracture on 11/4/2020 and was discharged on [DATE] . During an interview, on 11/13/2020 at 11 a.m., CNA 1 stated as she was about to transfer Resident 1 from the bed to the wheelchair, she and Resident 1 lost their balance and they both went down on the floor. CNA 1 stated Resident 1 fell on her right leg as she assisted and eased her on the floor. During an interview, on 12/29/2020 at 3:35 p.m., CNA 1 stated she did not use a gait belt and it should be used for residents that cannot bear weight. CNA 1 stated it helped the residents who needed the extra help to pivot. CNA 1 stated she did not think it was necessary for Resident 1 because she had not used it prior. During an interview, on 12/29/2020 at 3:40 p.m., the Director of Staff Development (DSD) stated a gait belt was needed when transferring Resident 1 because the resident required an extensive assist with transfer. During an interview and a concurrent record review on 12/31/2020 at 3:42 p.m., the Physical Therapy (treatment of [REDACTED]. The DOR stated a gait belt should had been used to transfer Resident 1 for safety. The DOR stated it was important for the staff to use a gait belt on Resident 1 to help hold the resident and in case the resident's legs buckled (bend and give way under pressure or strain). During a review of the facility's undated policy and procedure (P/P) titled, Resident Transfer: Gait belt, the P/P indicated a gait belt was used to transfer residents who do not have full function to safely transfer without assistance.

Based on observation, interview, and record review, the facility failed to ensure and provide the necessary assessment and care to ensure that one of four sampled residents (Resident 1) nutritional needs were maintained with the acceptable parameters. The facility's registered dietician (RD) failed to accurately assess the residents needs and food preferences to encourage food intake. Resident 1 lost more than 15 percent (%) of his total body weight within four months (cross referenced to F361). This deficient practice resulted in Resident 1 having unplanned weight loss, malnutrition (condition that results from eating a diet in which nutrients are either not enough or are too much such that the diet causes health problems), poor wound healing, and reoccurring urinary tract infections ((UTIs) an infection of the bladder including pain and frequent urination). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's care plan titled, Nutritional Status manifested by leaving 25% or more of uneaten food on the plate for at most meals, dated 4/6/17. The staff's interventions included to offer a substitute when food was refused, monitor weight, report significant weight loss/gain to the physician, honor food preferences, and monitor food intake and record. A review of Resident 1's history and physical examination [REDACTED]. A review of Resident 1's monthly weights indicated the following: April 2017 (on admission) - 153 pounds (lbs.) May 2017- 148 lbs. (15 pounds weight loss). June 2017- 147 lbs. July 2017- 144 lbs. August 2017- 136 lbs. September 2017- 130 lbs. (total of 23 pounds weight loss in 6 months). A review of the Nutritional Screening and Data Collection form, dated on 4/11/17, completed by the dietician (RD), indicated Resident 1 received a regular no added salt (NAS) diet, ate independently with a good appetite and had a skin condition. According to the RD's assessment, Resident 1 required 83-105 grams (gm) of protein and 2100-2450 calories (cal) per day. Resident 1's ideal body weight (IBW) was documented as 182-202-222 lbs. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 4/12/17, indicated Resident 1's cognition was moderately impaired and was independent with meal intake, with a weight of 153 pounds. A review of the Licensed Nurses' documentations, dated 5/11/17 to 5/14/17, and 5/21/17, indicated Resident 1 was being monitored for a five pound weight loss and meal consumption of 30 %. A review of Resident 1's Nutritional Screening and Data Collection forms completed by the RD indicated the following: On 5/16/17, who had a five pound weight loss, possibly due infection. The plan included to provide a fortified (increase the nutritive value of (food), especially with vitamins) NAS diet and do weekly weights for four weeks. a. On 5/30/17, weighed 147 lbs., with a three pound weight loss, 'possibly due to an infection.' The plan was the resident to receive a four ounce (oz.) high performance nutrition (HPN) supplement. b. On 6/13/17, weighed 144 lbs., had three more pounds weight loss, possibly due to UTI, continue with current supplement. c. On 6/27/17, weighed 143 lbs., had another pound weight loss, continue with current supplement. d. On 7/7/17, weighed 144 lbs., had a one pound weight gain, continue with weekly weights. e. On 7/18/17, weighed 138 lbs., had a six pound weight loss, continue with current supplement and Boost VHC ((Very high calorie) complete nutritional drink) twice daily, remain at nutritional risk, low body weight and low body mass index. A review of the Nursing Assistant Daily Flow sheets, dated 6/1/17 to 9/1/17, Resident 1's meal substitution for breakfast and lunch indicate not applicable. A review of Resident 1's physician orders, dated 6/27/17, indicated to weigh the resident weekly on the day shift, every Monday for four weeks. A review of Resident 1's MDS, dated [DATE], indicated the resident's weight was 144 pounds and was not on a regimen for weight loss. A review of Resident 1's weight variance, dated 7/18/17, indicated the resident did not have skin issues and a supplement for boost VHC twice daily was recommended. A review of Resident 1's weight variance dated 8/1/17, indicated the resident's meal intake was 35 %. A review of the Nursing Assistant Daily Flow sheet indicated Resident 1's breakfast and lunch meal consumption was less than 50% on the following days: 8/1/17 to 8/4/17, 8/8/17 to 8/13/17, 8/19/17 and 8/20/17. A review of a nurses' progress note, dated 8/1/17 and timed at 1:56 p.m., indicated the physician was notified of Resident 1 not eating well. A review of Resident 1's [MEDICATION NAME] (most common protein found in the blood; used by the body for growth and tissue repair; a good marker for malnutrition in the physically impaired elderly) laboratory results, dated 8/2/17, indicated it was low at of 2.8 grams/deciliter (gm/dL) (normal reference range (NRR) is 3.4 g/dL to 5.4 g/dL). A review of the physician's orders [REDACTED]. A review of Resident 1's weight variance, dated 8/8/17, indicated the resident's meal intake was 40 %. A review of the Nurses' note, dated 8/15/17, and timed at 12:30 p.m., indicated the physician was aware of Resident 1's poor appetite, with a plan for the staff to monitor the resident's poor appetite by percentage of each meal, and if less than 75 % with meals for poor appetite. A review of the RD's progress note, dated 8/16/17, and timed at 8:53 a.m., indicated the physician was made aware and agreed with the RD's recommendations for Prostat (liquid protein) 30 milliliters (mL) to be given to Resident 1 and the RD would continue to monitor the resident. On 9/8/17 at 12:13 p.m., during an interview, the RD stated there were no residents in the facility that had significant weight loss or at risk for weight loss. The RD stated when residents are at risk for weight loss, a dietary assessment was completed and the resident was enrolled in weight variance for four weeks. The RD stated weight variance committee meets, which was similar to that of an interdisciplinary team (IDT) meeting (develop plan of care that meets the patient needs and goals). The RD stated if the resident continued to lose weight then additional interventions would be implemented. The RD stated she reviews residents' monthly weights to determine if there are any significant weight loss. When the RD was asked for a log/list of residents currently at risk for weight loss, the RD stated that she did not have a log or a list, but stated the progress notes were a form of tracking the resident's monthly weights. On 9/8/17 at 1:30 p.m., during a concurrent interview and record review with the RD, the facility's Weight Summary Report, dated for the week ending on 8/11/17, the RD was asked again how many residents in the facility had a significant weight loss. The RD stated that she did not know, Maybe a few and I visit three different facilities. The RD was observed calculating weights on a cheat sheet and stated, There are only two residents in the facility with a significant weight loss for the month of July (2017), but I am not sure. At 2 p.m., on 9/8/17, during a concurrent observation and interview, Resident 1 was fully clothed, lying in bed awake, alert, and oriented to person, place and time. Resident 1 stated he was able to feed himself and the facility's food taste was satisfactory, but stated fried chicken was his favorite dish. During an interview on 9/8/17 at 2:30 p.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 had been assigned to her for the past five months. CNA1 stated on some days, depending upon what was served, Resident 1 would consume 20 to 30 % of his meals. CNA1 stated when chicken or fish was served Resident 1 would consume 100 percent of his meals. On 9/8/17 at 4 p.m., during an interview, the RD was asked if Resident 1 had any food preferences, the RD stated Resident 1 ate everything and did not have any food preferences nor a food substitution card. The RD stated she was informed by the nursing staff that Resident 1 would not eat based on his mood. During an interview on 9/8/17 at 4:10 p.m., the RD was asked if Resident 1 was provided with adequate fortification, such as increased calories and protein to maintain weight, RD was unable to provide a reason for the resident's weight loss. A review of the facility's undated policy titled, Weight indicated when weight gain or loss of five pounds or more, the resident must be re-weighed in the presence of the Licensed Nurse to supervise. The residents must be re-weighed by the Licensed Nurse and the CNA together if the clinical data prompts the Consultant to consider a formula change that results in less than 1200 calories a day. The re-weigh must be done before the Consultant Dietician finalizes the recommendation. A facility's policy titled, Nutrition (Impaired) Unplanned Weight Loss, dated 9/2012, indicated the Dietician will estimate calorie, nutrient and fluid needs and with the Physician; will identify whether the resident's current intake was adequate to meet his or her nutritional needs. The staff will also evaluate the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals.

Based on interview and record review, the facility failed to notify the resident's attending physician of a change in condition for one of two sampled residents (Resident 1). Resident 1 exhibited a change of condition by vomiting and having a distended abdomen starting on [DATE] at 7 a.m. up to [DATE] at 8:40 a.m. The licensed vocational nurses (LVN 1, 2, and 3) and the registered nurse supervisor (RN 1) did not notify the resident's attending physician (Physician 1) of the resident's change of condition so that the physician could order appropriate interventions. Resident 1's physician was notified of the resident's condition on [DATE], at 8:50 a.m., 25 hours later, when the resident became unresponsive and pulseless. (Cross refer F309) This deficient practice resulted in a decline of Resident 1's health. Resident 1 died at the facility on [DATE] at 9:08 a.m. Findings: A review of Resident 1's record titled, Admission Record, indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE]. The Admission Record indicated Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's record titled, Minimum Data Set ((MDS), a resident assessment and care screening tool), dated [DATE], indicated Resident 1 was severely impaired in cognitive skills (the ability to think and reason) for daily decision making and was totally dependent on staff with activities of daily living. A review of Resident 1's record titled, Initial History and Physical, dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's record titled, Order Summary Report, indicated a physician's orders [REDACTED]. A review of CNA 3's Declaration, dated [DATE], at 1:47 p.m., indicated that on [DATE], a certified nursing assistant (CNA 3) indicated she told a licensed vocational nurse (LVN 1) that Resident 1 was vomiting and that Resident 1 looked a little yellow. CNA 3 indicated LVN 1 turned Resident 1's feeding machine off because Resident 1 was vomiting and did not look like himself. During an interview, on [DATE], at 10:36 a.m., CNA 3 stated that on [DATE], at 7:15 a.m., she observed LVN 2 administering an enema to Resident 1. CNA 3 stated Resident 1 vomited three times during her shift (7 a.m. to 3 p.m.) on [DATE]. CNA 3 stated Resident 1 did not look good and was pale, and that she notified LVN 1. During an interview on [DATE], at 10:45 a.m., LVN 1 stated he was assigned to care for Resident 1 on [DATE], during the day shift. LVN 1 stated that LVN 2 informed him that she (LVN 2) administered an enema to Resident 1 because Resident 1's abdomen was distended and had fecal impaction. LVN 1 stated he did not inform Physician 1. LVN 1 stated he did not consider a distended abdomen and vomiting as a change in condition. During an interview on [DATE], at 11:07 a.m., LVN 2 stated that on [DATE], at 7 a.m., she observed Resident 1 vomiting and had a distended abdomen. LVN 2 stated she checked Resident 1 for fecal impaction using her fingers then she administered an enema. LVN 2 stated she informed LVN 1 but she did not inform the resident's attending physician (Physician 1) regarding Resident 1's condition. LVN 2 stated she should have called Physician 1. During a telephone interview on [DATE], at 2:19 p.m., Director of Nursing 1(DON 1) stated that vomiting and a distended abdomen were considered change of condition for Resident 1 even though Resident 1 had [DIAGNOSES REDACTED]. During a telephone interview, on [DATE], at 1:39 p.m., LVN 3, the night shift (11 p.m. to 7 a.m.) licensed nurse, stated that on [DATE], at 11:30 p.m., she observed Resident 1's feeding machine off so she turned the feeding machine back on. LVN 3 stated that the she did not receive a report from the outgoing evening shift (3 p.m. to 11 p.m.) licensed nurse that Resident 1 was vomiting and she did not ask why the resident's feeding machine was turned off so she assumed that she had to turn the machine back on. LVN 3 stated she turned off the feeding machine at 4 a.m. (on [DATE]) because Resident 1 vomited. LVN 3 stated she did not notify Physician 1. During a telephone interview, on [DATE], at 2:35 p.m., CNA 4 stated that on [DATE], during his shift (11 p.m. to 7 a.m.), he observed Resident 1 with a hard stomach, and that it was unusual for Resident 1's stomach to be hard. CNA 4 stated he notified the night shift's registered nurse supervisor (RN 1). During a telephone interview, on [DATE], at 2:46 p.m., RN 1 stated that on [DATE], she was notified by CNA 4 that Resident 1 vomited. RN 1 stated she went inside Resident 1's room and observed Resident 1 with a distended abdomen. RN 1 stated she observed Resident 1 vomiting. RN 1 stated she did not inform Physician 1 of Resident 1's medical condition because she believed that it was okay to wait calling the physician until morning. RN 1 stated she was supposed to inform Physician 1 because it was a change of condition. During an interview, on [DATE], at 9:49 a.m., CNA 1 stated that on [DATE], at 7:10 a.m., Resident 1 looked pale, and was cold to the touch, CNA 1 stated she informed LVN 1. CNA 1 stated that on [DATE], at 8:40 a.m., Resident 1 vomited a lot of brown fluid from his mouth and that Resident 1 became unresponsive and had no pulse. CNA 1 stated she did not perform CPR; she left the room to look for LVN 1. CNA 1 stated LVN 1 went inside Resident 1's room; LVN 1 did not start CPR. CNA 1 stated LVN 1 left Resident 1's room to call for help. During an interview on [DATE], at 10:45 a.m., LVN 1 stated he was assigned to care for Resident 1 on [DATE]. LVN 1 stated on [DATE], at 7:30 a.m., CNA 1 informed him that Resident 1 vomited and he (LVN 1) went to check Resident 1. LVN 1 stated he observed Resident 1 drooling and Resident 1's stomach was bloated. LVN 1 stated he did not inform Physician 1 and the registered nurse regarding Resident's 1's condition. LVN 1 stated he assumed that drooling and a distended abdomen were not considered change of condition. During an interview on [DATE], at 11:30 a.m., LVN 1 stated that CNA 1 informed him on [DATE], passed 8:30 a.m., that Resident 1 did not look good. LVN 1 stated he went inside Resident 1's room and observed Resident 1 pale and could not feel a pulse. LVN 1 stated he did not start CPR immediately; he stepped out of Resident 1's room to call [DATE] and went to get the facility's crash cart (wheeled container carrying equipment for use in emergency resuscitations). During a telephone interview, on [DATE] at 9:40 a.m., RN 1 stated that LVN 1 went to nursing station (middle nursing station) to inform her that Resident 1 was unresponsive and that she (RN 1) then went to Resident 1's room and checked Resident 1's radial pulse (wrist area). RN 1 stated that she did not feel a radial pulse and that she (RN 1) did not start CPR immediately and that instead, she (RN 1) left the room to get Resident 1's medical records to check if Resident 1 was full code (to perform CPR) or DNR (do not resuscitate, no CPR) and to get the crash cart. A review of Resident 1's record titled, Licensed Nurse Documentation, indicated on [DATE], at 8:50 a.m., Registered Nurse 1 (RN 1) was called to look at Resident 1 being unresponsive. CPR was started. At 8:55 a.m., paramedics arrived at the facility. CPR was initiated 10 minutes after (at 8:50 a.m.) LVN 1 observed Resident 1 being pale and not able to feel a pulse at 8:40 a.m. A review of Resident 1's record titled, SBAR (Situation-Background-Assessment-Recommendation, a framework for communication between members of the health care team) Change of Condition Documentation, dated [DATE], at 8:50 a.m., indicated Resident 1 was lethargic (abnormal drowsiness) and unresponsive, unable to obtain vital signs (heart rate, body temperature, respiration rate, and blood pressure (a measurement of the strength of the blood pushing against the sides of the blood vessels)), CPR was initiated, and the resident's physician was informed. At 9:08 a.m., the [DATE] emergency services pronounced Resident 1 dead. A review of a document titled, Prehospital Care Report Summary (by the [DATE] emergency services), dated [DATE], indicated a call was received from the facility at 8:45 a.m., was on scene at 8:55 a.m., and patient contact at 8:56 a.m. The Prehospital Care Report Summary indicated Resident 1 was found in asystole (there was no electrical activity from the heart, showing flat line in the heart monitor), had no blood pressure, no pulse rate (heart beat), no respirations, and that Resident 1 had no change in asystole at 9:08 a.m., and left the scene at 9:10 a.m. A review of Resident 1's death certificate indicated the resident died on [DATE] and the immediate cause of death was cardiopulmonary arrest (the heart and lungs suddenly stopped functioning). During an interview, on [DATE] at 11:44 a.m., the Assistant Director of Nursing (ADON) stated the licensed nurses were supposed to notify Physician 1 regarding Resident 1's change of condition. During a telephone interview, on [DATE], at 11:20 a.m., DON 1 stated based on the records, Physician 1 did not know about Resident 1's change in medical condition from [DATE] to [DATE], before Physician 1 called Resident 1's death as cardiopulmonary arrest (loss of heart function). During a telephone interview, on [DATE], at 8 a.m., the Medical Director (Physician 2) stated the nurses should have called Physician 1 to notify him regarding Resident 1's fecal impaction, vomiting episodes, and abdominal distention so that Physician 1 could have determined what to order or what to do next for Resident 1. A review of the undated facility's policy and procedures titled, Change in Resident's Condition or Status, indicated: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; g. A need to transfer the resident to a hospital/treatment center. A review of the facility's undated policy and procedures titled, Enteral Tube Feeding via Continuous Pump, indicated the facility's staff was to report complications such as diarrhea and gastric (abdominal) distention promptly to the supervisor and the attending physician.

Based on interview and record review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 1) in accordance with the facility's policy and procedures and recognized standards of practice by failing to: 1. Conduct a comprehensive assessment when Resident 1 had a change of condition. 2. Communicate with Licensed Vocational Nurse 3 (LVN 3) that Resident 1 was vomiting and had a distended abdomen (a change of condition) and the reason for turning off his enteral feeding machine (a medical device that pumps nutrition liquid formula to the stomach through a tube). 3. Identify Resident 1's emergency situation. 4. Implement immediate basic life support or cardiopulmonary resuscitation (CPR, an emergency procedure performed during cardiopulmonary arrest (absence of heart beat and breathing) in which chest compression and artificial breathing are used to maintain blood circulation to the brain) when Resident 1 was observed unresponsive and with no pulse (heart beat) on [DATE]. Resident 1 exhibited a change of condition by vomiting and having a distended abdomen starting on [DATE] at 7 a.m. up to [DATE] at 8:40 a.m. A licensed vocational nurse (LVN 2) checked for fecal impaction (a mass of dry, hard stool that will not pass out of the colon or rectum) by digital (finger) exam and administered an enema (insertion of a tube into the rectum to infuse a liquid mixture and encourage a bowel movement) without a physician order. The night shift (11 p.m. to 7 a.m.) licensed nurse, LVN 3, did not receive a report that Resident 1 had a change of condition. LVN 1, 2, and 3 and a registered nurse (RN 1) did not conduct a comprehensive assessment and notify the resident's physician of the resident's change of condition. (Cross refer to F157 and F281) Resident 1 became unresponsive and pulseless on [DATE] at 8:40 a.m. A certified nursing assistant (CNA 1), LVN 1, and RN 1 did not start CPR immediately but instead left Resident 1's room to get the crash cart (a set of shelves on wheels containing emergency medication and equipment) and call the [DATE] emergency services. CPR was started by RN 1 at 8:50 a.m. These deficient practices caused delayed provision of appropriate medical interventions for Resident 1 for 25 hours that resulted in Resident 1's death. The emergency services ([DATE]) pronounced Resident 1 dead in the facility on [DATE], at 9:08 a.m. Findings: A review of Resident 1's record titled, Admission Record, indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE]. The Admission Record indicated Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's record titled, Physician order [REDACTED]. A review of Resident 1's record titled, Minimum Data Set ((MDS), a resident assessment and care screening tool), dated [DATE], indicated Resident 1 was severely impaired in cognitive skills (the ability to think and reason) for daily decision making and was totally dependent on staff with activities of daily living. A review of Resident 1's record titled, Initial History and Physical, dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's record titled, Order Summary Report, indicated a physician's orders [REDACTED]. A review of CNA 3's Declaration, dated [DATE], at 1:47 p.m., indicated that on [DATE], she told a licensed vocational nurse (LVN 1) that Resident 1 was vomiting and that Resident 1 looked a little yellow. CNA 3 indicated LVN 1 turned Resident 1's feeding machine off because Resident 1 was vomiting and did not look like himself. During an interview, on [DATE], at 10:36 a.m., CNA 3 stated that on [DATE], at 7:15 a.m., she observed LVN 2 administering an enema to Resident 1. CNA 3 stated Resident 1 vomited three times during her shift (7 a.m. to 3 p.m.) on [DATE]. CNA 3 stated Resident 1 did not look good and was pale, and that she notified LVN 1. During an interview, on [DATE], at 10:45 a.m., LVN 1 stated he was assigned to care for Resident 1 on [DATE], during the day shift. LVN 1 stated that LVN 2 informed him that she (LVN 2) administered an enema to Resident 1 because Resident 1's abdomen was distended and had fecal impaction. LVN 1 stated he did not conduct a comprehensive assessment on Resident 1 and that he did not inform Physician 1. During an interview, on [DATE], at 11:07 a.m., LVN 2 stated that on [DATE], at 7 a.m., she observed Resident 1 vomiting and had a distended abdomen. LVN 2 stated she checked Resident 1 for fecal impaction using her fingers then she administered a saline enema. LVN 2 stated she informed LVN 1. During an interview, on [DATE], at 11:44 a.m., the Assistant Director of Nursing (ADON) stated the licensed nurses were supposed to auscultate (listen to sounds) Resident 1's abdomen using a stethoscope (a medical instrument used for listening to sounds inside the body) when they first noticed that Resident 1's abdomen was distended. During a telephone interview, on [DATE], at 2:19 p.m., Director of Nursing 1 (DON 1) stated licensed nurses were supposed to conduct a comprehensive assessment when there was a resident change of condition. DON 1 stated that vomiting and a distended abdomen were considered change of condition for Resident 1 even though Resident 1 had [DIAGNOSES REDACTED]. During a telephone interview, on [DATE], at 1:39 p.m., LVN 3, the night shift (11 p.m. to 7 a.m.) licensed nurse, stated that on [DATE], at 11:30 p.m., she observed Resident 1's feeding machine off so she turned the feeding machine back on. LVN 3 stated that the she did not receive a report from the outgoing evening shift (3 p.m. to 11 p.m.) licensed nurse that Resident 1 was vomiting and she did not ask why the resident's feeding machine was turned off so she assumed that she had to turn the machine back on. LVN 3 stated she turned off the feeding machine at 4 a.m. (on [DATE]) because Resident 1 vomited. LVN 3 stated she did not conduct a comprehensive assessment on Resident 1 and she did not notify Physician 1. During a telephone interview, on [DATE], at 2:35 p.m., CNA 4 stated that on [DATE], during his shift (11 p.m. to 7 a.m.), he observed Resident 1 with a hard stomach, and that it was unusual for Resident 1's stomach to be hard. CNA 4 stated he notified the night shift's registered nurse supervisor (RN 1). During a telephone interview, on [DATE], at 2:46 p.m., RN 1 stated that on [DATE], she was notified by CNA 4 that Resident 1 vomited. RN 1 stated she went inside Resident 1's room and observed Resident 1 with a distended abdomen. RN 1 stated she observed Resident 1 vomiting. RN 1 stated she did not conduct a comprehensive assessment on Resident 1 and she did not inform Physician 1 of Resident 1's medical condition because she believed that it was okay to wait and call the physician until morning. During an interview, on [DATE], at 9:49 a.m., CNA 1 stated that on [DATE], at 7:10 a.m., Resident 1 looked pale, and was cold to the touch, CNA 1 stated she informed LVN 1. CNA 1 stated that on [DATE], at 8:40 a.m., Resident 1 vomited a lot of brown fluid from his mouth and that Resident 1 became unresponsive and had no pulse. CNA 1 stated she did not perform CPR; she left the room to look for LVN 1. CNA 1 stated LVN 1 went inside Resident 1's room; LVN 1 did not start CPR. CNA 1 stated LVN 1 left Resident 1's room to call for help. During an interview on [DATE], at 10:45 a.m., LVN 1 stated he was assigned to care for Resident 1on [DATE]. LVN 1 stated on [DATE], at 7:30 a.m., CNA 1 informed him that Resident 1 vomited and he (LVN 1) went to check Resident 1. LVN 1 stated he observed Resident 1 drooling and Resident 1's stomach was bloated. LVN 1 stated he did not conduct a comprehensive assessment and he did not inform Physician 1 and the registered nurse regarding Resident's 1 status. LVN 1 stated he assumed that drooling and a distended abdomen were not considered change of condition. During an interview, on [DATE], at 11:30 a.m., LVN 1 stated that CNA 1 informed him on [DATE], a little after 8:30 a.m., that Resident 1 did not look good. LVN 1 stated he went inside Resident 1's room and observed Resident 1 pale and could not feel a pulse. LVN 1 stated he did not start CPR immediately; he stepped out of Resident 1's room to call [DATE] and went to get the facility's crash cart (wheeled container carrying equipment for use in emergency resuscitations). LVN 1 stated he should have initiated CPR and that CNA 1 should have called for help. During a telephone interview, on [DATE] at 9:40 a.m., RN 1 stated that LVN 1 went to the nursing station (middle nursing station) to inform her that Resident 1 was unresponsive and that she (RN 1) then went to Resident 1's room and checked Resident 1's radial pulse (wrist area). RN 1 stated that she did not feel a radial pulse and that she (RN 1) did not start CPR immediately and that instead, she (RN 1) left the room to get Resident 1's medical records to check if Resident 1 was full code (to perform CPR) or DNR (do not resuscitate, no CPR) and to get the crash cart. RN 1 stated that she should have checked the carotid pulse (neck area) instead of the radial pulse and that she (RN 1) should have started CPR immediately. A review of Resident 1's record titled, Licensed Nurse Documentation, indicated on [DATE], at 8:50 a.m., Registered Nurse 1 (RN 1) was called to look at Resident 1 being unresponsive. CPR was started. At 8:55 a.m., paramedics arrived at the facility. Resident 1 received CPR measures 10 minutes after (at 8:50 a.m.) LVN 1 observed Resident 1 being pale and not able to feel a pulse at 8:40 a.m. A review of Resident 1's record titled, SBAR (Situation-Background-Assessment-Recommendation, a framework for communication between members of the health care team) Change of Condition Documentation, dated [DATE], at 8:50 a.m., indicated Resident 1 was lethargic (abnormal drowsiness) and unresponsive, unable to obtain vital signs (heart rate, body temperature, respiration rate, and blood pressure (a measurement of the strength of the blood pushing against the sides of the blood vessels)), and CPR was initiated. At 9:08 a.m., the [DATE] emergency services pronounced Resident 1 dead. A review of a document titled, Prehospital Care Report Summary (by the [DATE] emergency services), dated [DATE], indicated a call was received from the facility at 8:45 a.m., was on scene at 8:55 a.m., and patient contact at 8:56 a.m. The Prehospital Care Report Summary indicated Resident 1 was found in asystole (there was no electrical activity from the heart, showing flat line in the heart monitor), had no blood pressure, no pulse rate (heart beat), no respirations, and that Resident 1 had no change in asystole at 9:08 a.m., and left the scene at 9:10 a.m. A review of Resident 1's death certificate indicated the resident died on [DATE] and the immediate cause of death was cardiopulmonary arrest (the heart and lungs suddenly stopped functioning). During an interview on [DATE], at 10:55 a.m., the Director of Staff Development (DSD) stated the facility did not have any records indicating the licensed nurses received skills validations or any documents indicating the licensed nurses were monitored to ensure that they were competent with their job description and responsibilities. The DSD stated she was not sure if the facility's licensed nurses were competent to perform nursing duties. During an interview on [DATE], at 1:52 p.m., the Assistant Administrator (ASSADM) stated he arrived at the facility on [DATE] between 8:30 a.m. and 9 a.m. and once he entered the facility's building, he saw the commotion in Resident 1's room. The Assistant Administrator stated he observed RN 1 giving CPR to Resident 1 and then he assisted RN 1 with chest compressions (an effort to pump the blood in the heart to the rest of the body). The assistant administrator stated he stepped out of the room after the fire department or paramedics arrived in the room. During a telephone interview on [DATE], at 8 a.m., the Medical Director (Physician 2) stated that if a resident was full code (as indicated in the POLST) and was found unresponsive and with no pulse, the nurses should start CPR and call [DATE]. Physician 2 stated that the nurses could check Resident 1 for presence of fecal impaction and if the nurse noticed fecal impaction, the nurse was supposed to inform the physician and let the physician determine what to do next. Physician 2 stated that nurses need a physician order [REDACTED]. During a telephone interview, on [DATE] at 4:42 p.m., the fire fighter (the [DATE] emergency services personnel) stated that he took over the CPR immediately upon arrival at the facility and that he did not remember anything else. A review of the undated facility's policy and procedures titled, Change in Resident's Condition or Status, indicated, Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR Communication Form. According to https://eccguidelines.heart.org/index.php/circulation/aha-red-cross-first-aid-guidelines/part-15-first-aid/, updated [DATE] indicated that healthcare providers should call for nearby help upon finding the victim unresponsive, but it would be practical for a healthcare provider to continue to assess for breathing and pulse simultaneously before fully activating the emergency response system. However, if the first aid provider is alone with an injured or ill person and there are imminent threats to life involving the ABCs (airway, breathing, circulation), then basic care-such as opening an airway should be provided before leaving the victim to activate the emergency response system (911) or phone for help.

Based on interview and record review, the facility failed to ensure safety of a resident in an area frequented and commonly used by residents for one of three sampled residents (Resident 3). Resident 3's wheelchair tipped over to the right when a certified nursing assistant (CNA 3) fell on the resident's right arm that was resting on top of the wheelchair's tire during a physical altercation with CNA 2. This deficient practice resulted in Resident 3 experiencing swelling and severe pain on his right arm and right foot, and soreness on his right shoulder and had the potential to result in a right arm fracture. The resident received three doses of narcotic pain medication ([MEDICATION NAME]) to relieve his pain for two days and had an order for [REDACTED]. Findings: During an interview, on 7/3/17 at 1:40 p.m., Resident 3 stated while he was in the Little Lunch Room on 5/13/17 at 11 a.m., he heard CNA 2 and 3 having a verbal altercation. Resident 3 stated he was wheeling his wheelchair towards the Little Lunch Room when both CNAs started fighting. Resident 3 stated he was behind CNA 3 when CNA 2 hit CNA 3. Resident 3 stated CNA 3 fell on Resident 3's right arm that was resting on the wheelchair's tire and then the wheelchair tipped over to the right. Resident 3 stated CNA 3's body and the wheelchair's tire were pressed against his right arm when the wheelchair tipped over to the right. During the interview, Resident 3 stated he had an x-ray (an image of the structure inside the body) done to his right arm and he received medications for his pain. Resident 3 stated his right arm was swollen a few hours after the fall and that currently, he felt like the strength and range of motion (the full movement of a joint) of his right arm was not the same anymore. Resident 3 stated the two CNAs should have acted more professionally while at work because there were other residents present that could have been affected or could get hurt. During an interview, on 7/3/17, at 9:55 a.m., the licensed vocational nurse (LVN 1) stated that according to the Licensed Nurse Documentation, dated 5/13/17 (no time indicated), Resident 3 was given a pain medication ([MEDICATION NAME]) after complaining of a pain level of 6 out of 10 (severe pain is between pain level 6 to 9 out of 10 and 10 out of 10 being the excruciating pain) and swelling to his right arm. On 7/3/17, at 3:30 p.m., during an interview and concurrent review of Resident 3's Joint Mobility Screening, dated 5/17/17, the physical therapist (PT 1) stated that on 5/17/17, which was four days after the incident, he assessed Resident 3's range of motion to both upper and lower extremities. PT 1 stated Resident 3 had full range of motion to the right arm and right foot. A review of Resident 3's Face Sheet (Admission Record) indicated that Resident 3 was admitted to the facility on [DATE] and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 5/17/17, indicated that Resident 3's cognition (refers to mental ability) was intact and the resident had no communication impairments. The MDS indicated Resident 3 used the wheelchair for mobility. A review of Resident 3's Licensed Nurse Documentation, dated 5/13/17 and timed at 11 a.m., indicated that CNA 3 reported to the charge nurse how CNA 3 fell on top of Resident 3 during a Fight with another CNA. Resident 3 reported to the charge nurse how he was tipped or pushed down while on the wheelchair by CNA 3 while fighting with CNA 2. A review of Resident 3's Telephone Order Summary, dated 5/13/17 and timed at 10:41 p.m., indicated an order to apply a warm soak on Resident 3's right arm every shift for 5 days. A review of Resident 3's Pain Assessment Flowsheet for May 2017 indicated that Resident 3 received one tablet of [MEDICATION NAME] (pain medication) 5-325 milligrams (mg) on 5/13/17 timed at 10:45 a.m. for his right foot pain with a pain level of 6 out of 10 (severe pain is between 6 to 9 out of 10, and 10 being the excruciating pain) and another dose of [MEDICATION NAME] for his right elbow pain timed at 3 p.m., with a pain level of 8 out of 10. Resident 3 received another dose of [MEDICATION NAME] tablet 5-325 mg the next day (5/14/17) timed at 10 a.m., for his right elbow pain with pain level of 7 out of 10. A review of Resident 3's Social Services Notes, dated 5/15/17, 5/16/17, and 5/17/17, indicated that Resident 3's right shoulder was still feeling sore because of the fall. A review of CNA 2 and CNA 3's employee records and a document titled Employee Separation Report, dated 5/22/17, indicated that CNA 2 and 3 were terminated on 5/22/17 due to their verbal and physical altercation while on duty with each other in the residents' dining area causing a resident to fall on the floor. A review of the facility's Employee Handbook, revised on 8/5/09, indicated under Employees Conduct and Work Rules that the facility expects employees to follow rules of conduct that will protect interests and safety of all employees and the organization. These rules of conduct included discourteous treatment, inappropriate behavior toward residents, misconduct on or off duty, and acts of physical violence, which occur on facility property.

Based on observation, interview, and record review, the facility failed to handle one of seven sampled residents (Resident 1) gently and carefully during care in accordance with the plan to care. A certified nursing assistant (CNA 5) turned Resident 1 fast during provision of care. This caused Resident 1 to hit the side rail of the bed. This deficient practice resulted in Resident 1 sustaining a right eye swelling and discoloration and a broken bone to the right shoulder. Findings: On 1/5/17 at 3:20 p.m., during an observation tour of the facility, Resident 1 was sitting on the wheelchair in the hallway. Resident 1 was observed with purplish discoloration to both arms. When interviewed, Resident 1 was confused. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical, dated 12/1/15, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment and care planning tool), dated 6/27/16, indicated Resident 1 required extensive assistance (weight bearing support and at times requires full staff performance) from staff with transfer, dressing, toilet use, personal hygiene and was independent with bed mobility and eating. A review of Resident 1's care plan for [MEDICAL CONDITION], dated 12/29/15, indicated the staff will handle Resident 1 gently and carefully during care. A review of the facility's investigation report, dated 7/15/16, indicated that Resident 1 was observed with discoloration at the lower part of the right eye orbital (around the eye) slightly swollen but non-tender. The final investigation report, dated 7/15/16, indicated that when CNA 5 was doing care on Resident 1 on 7/15/16, CNA 5 turned Resident 1 towards (facing) the window (Resident 1's right side), and accidentally hit Resident 1's eye and arm on the side rail of the bed. The investigation report indicated that CNA 5 unintentionally turned Resident 1 fast while doing care and did not notice that Resident 1 was bumped (hit) on the rails. A review of Resident 1's Physician and Telephone Order, dated 7/15/16 at 8:53 a.m., indicated to obtain an x-ray for the resident's face and right arm related to discoloration on the right eye and upper right arm. A review of Resident 1's Diagnostic Laboratories, dated 7/21/16, indicated there was a tiny hairline stress fracture (a crack or break in the bone caused by repeated physical force or motion) involving the proximal (upper part nearer to the center of the body) humerus (the bone of the upper arm located between the shoulder and elbow) with medial (middle) shaft (long narrow part of the bone) humeral (of or relating to the humerus) subluxation (a partial dislocation). The conclusion indicated recent proximal right humerus fracture as described. On 1/10/17 at 1:05 p.m., during an interview, the Assistant Director of Nurses (ADON) stated that Resident 1 should have been handled gently while giving care and the staff members know it. The ADON stated, The CNA (CNA 5) was big and her strength outweighs Resident 1's small body. The ADON stated that Resident 1's body was fragile due to her age, her [MEDICAL CONDITION] and taking medication that could cause easy skin discoloration. On 1/18/17 at 4:35 p.m., during a telephone interview, CNA 4 stated that Resident 1 was capable of slowly moving his own body while lying in bed during care. On 1/18/17 at 5:08 p.m., during an interview, CNA 5 stated she could not remember what happened to Resident 1 on 7/15/16.

Based on interview and record review, the facility failed to provide the following care and services for one of seven sampled residents (Resident 2) during a change of condition on [DATE]: 1. Implement Resident 2's care plans to monitor the resident for nausea and vomiting, and signs and symptoms of chocking/aspiration (breathing foreign materials (usually food, liquids, vomit, or fluids from the mouth) into the lungs or airways) and to notify the physician of the above conditions. 2. Check Resident 2 when Resident 2's roommate (Resident 4) called for help and reported that he heard Resident 2 choking. 3. Call for help and/or report immediately and appropriately regarding Resident 2's significant change in condition. 4. Conduct a comprehensive assessment on Resident 2 when the resident had rapid breathing. 5. Identify Resident 2's emergency situation. 6. Provide emergency (first aid) procedure to Resident 2. 7. Notify Resident 2's physician (Physician 1) promptly at 5:30 a.m. when Resident 2 had a significant change in condition. The Certified Nurse Assistant (CNA 1) heard Resident 2 making unusual breath sounds on [DATE] around 2 a.m. to 3 a.m. but CNA 1 left Resident 2 without checking on the resident and did not report. On [DATE] at 5:30 a.m., the Licensed Vocational Nurse (LVN 1) observed Resident 2 with rapid breathing with respirations of 29 breaths per minute (normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute) and administered oxygen. LVN 1 did not conduct a comprehensive assessment on Resident 2 and did not immediately notify the Registered Nurse (RN 1) of the resident's significant change of condition. RN 1 observed Resident 2 on [DATE] at 6 a.m., pale and unresponsive, called 911 (emergency response team) and performed basic life support or cardiopulmonary resuscitation (CPR- an emergency procedure perform during cardiac and or respiratory arrest in which chest compression and artificial breathing are used to maintain blood circulation to the brain). Resident 2 aspirated and the facility staff took a total of three to four hours to provide emergency procedures for Resident 2. On [DATE] at 6:03 a.m., the emergency response team arrived at the facility and provided advanced cardiac life support (ACLS, refers to a set of clinical interventions for the urgent treatment of [REDACTED]. On [DATE] at 6:23 a.m., the emergency response team contacted the emergency room physician (Physician 2) regarding Resident 2's status and Physician 2 pronounced Resident 2 dead while at the facility. Physician 1, Resident 2's attending physician, was not notified about Resident 2's significant change of condition until 7 a.m. on [DATE]. Findings: A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. The Admission Record indicated Resident 2's [DIAGNOSES REDACTED]. to mental or physical conditions). A review of Resident 2's Minimum Data Set (MDS - a resident assessment and care planning tool), dated [DATE], indicated Resident 2 was able to make himself understood sometimes and was able to understand others sometimes. The MDS indicated Resident 2 required limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) from staff with bed mobility and was totally dependent on staff with transfers, eating, toilet use, and personal hygiene. A review of Resident 2's Initial History and Physical (H&P), dated [DATE], indicated Resident 2 was gravely disabled with developmental delay. The H&P indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's Physician order [REDACTED]. A review of Resident 2's care plans indicated the staff would provide the following: 1) [MEDICAL CONDITION] Reflux Disease Care Plan, dated [DATE], indicated the staff would monitor Resident 2 for abdominal pain, nausea and vomiting, heartburn, gas pain, diarrhea and position of comfort. 2) Nutritional Status Care Plan, dated [DATE], indicated the staff would monitor Resident 2 for signs and symptoms of choking/aspiration and to report to the physician. On [DATE] at 12 p.m., during an interview, Resident 4 stated that Resident 2 was making choking sounds (on [DATE]) and he used the call light but nobody came so he yelled for staff. Resident 4 stated that he told CNA 1 that Resident 2 was dying. Resident 4 stated CNA 1 looked at Resident 2 and left. Resident 4 stated CNA 1 did not do anything while Resident 2 was choking. Resident 4 stated that Resident 2 was trying to throw up but could not throw up then the whole body was shaking. Resident 4 stated that was the first time he saw Resident 2's body was shaking. Resident 4 stated that he saw a staff member checking Resident 2's vital signs (Resident 2 could not tell the time) but after that he did not see anyone come to check Resident 2's vital signs. A review of Resident 2's record titled, Licensed Nurse Documentation, by LVN 1, dated [DATE], indicated the following: 1) At 4 a.m., Resident 2 was awake with no shortness of breath. 2). At 5:30 a.m., Resident 2 was awake and had rapid breathing. Oxygen (O2) at 2 liters per minute (L/min) was started. Head of the bed was elevated. Continued monitoring. 3) At 5:45 a.m., Resident 2 was breathing rapidly. Respirations 29 breaths per minute. 4) At 6 a.m., Resident 2 stopped breathing and unable to read pulse. 911 was called. Started CPR. 5) At 6:04 a.m., paramedics arrived. 6) At 6:23 a.m., Resident 2 was pronounced dead by Physician 2. 7) At 6:25 a.m., Physician 1 was paged at this time. Awaiting response. 8) At 7 a.m., Physician 1 was notified. A review of Resident 2's record titled, Licensed Nurse Documentation, on [DATE], did not indicate that LVN 1 assessed Resident 2's breath sounds, quality of respirations, and responsiveness from 5:30 a.m. and reported Resident 2's rapid breathing to RN 1 and/or to Physician 1 at 5:30 a.m. and at 5:45 a.m. On [DATE] at 9:36 a.m., during a telephone interview, when asked if CNA 1 reported to him about Resident 2's change of condition on [DATE], LVN 1 stated CNA 1 did not report anything regarding Resident 2. LVN 1 stated that on [DATE] at 5:30 a.m., Resident 2 was observed with rapid breathing and he administered oxygen at 2 liters per minute via nasal cannula according to the standard physician's orders [REDACTED]. LVN 1 stated that he was not sure what time he reported to RN 1 regarding Resident 2's change of condition. LVN 1 stated he did not call and notify Resident 2's physician when he observed Resident 2 had a rapid breathing at 5:30 a.m. and 5:45 a.m. LVN 1 stated he was not sure if RN 1 called the physician. On [DATE] at 6:45 a.m., during an interview, CNA 1 stated, I cannot remember exactly the time, maybe between 2 a.m. to 3 a.m. (on [DATE]) when I heard the resident (Resident 2) making unusual sounds while breathing. CNA 1 stated he did not look at Resident 2 making unusual sound on breathing because he did not know what that was and just called the licensed vocational nurse (LVN 1) to check on Resident 2 at that time. CNA 1 stated, I don't remember what I did after that. On [DATE] at 7:25 a.m., during an interview, RN 1 stated he could not remember the exact time but it was before 6 a.m. on [DATE], when LVN 1 reported to check on Resident 2. RN 1 stated LVN 1 told him that Resident 2 looked like he was not breathing. RN 1 stated he immediately went to check Resident 2 and observed Resident 2's color being pale and was not breathing. RN 1 stated he immediately performed CPR on Resident 2 and 911 emergency services was called. RN 1 stated LVN 1 did not report to him that Resident 2 had rapid breathing at 5:30 a.m. RN 1 stated LVN 1 should have reported to him for any change on Resident 2's condition so he could assess and call the physician. RN 1 stated the physician should have been called immediately when Resident 2 was observed with rapid breathing. On [DATE] at 3 p.m., during an interview and review of Resident 2's clinical record, the Director of Nurses (DON) stated she did not have any knowledge of the incident when Resident 2 had a change of condition. The DON stated the physician should have been notified immediately on [DATE] at 5:30 a.m. when LVN 1 observed Resident 2 having rapid breathing. The DON stated that Resident 2 should have been assessed for the cause of rapid breathing to render immediate care and intervention. A review of the facility's policy and procedures titled, Change in Resident's Condition or Status, dated ,[DATE] indicated the facility shall promptly notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a decline or improvement in resident status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. According to https://eccguidelines.heart.org/index.php/circulation/aha-red-cross-first-aid-guidelines/part-15-first-aid/, updated [DATE] indicated the goal of first aid intervention is to recognize when help is needed and how to get it. This goal includes learning how and when to access [DATE]. Providing care for someone who is ill or injured should not usually delay calling for more advanced care if needed. However, if the first aid provider is alone with an injured or ill person and there are imminent threats to life involving the ABCs (airway, breathing, circulation), then basic care-such as opening an airway should be provided before leaving the victim to activate the emergency response system ([DATE]) or phone for help. If a person is unresponsive and breathing normally, it may be reasonable to place him or her in a lateral side-lying recovery position. There is evidence that this position will help increase total airway volume and decrease stridor (noisy breathing) severity. Extend one of the person's arms above the head and roll the body to the side so that the person's head rests on the extended arm. Once the person is on his or her side, bend both legs to stabilize the body. There is little evidence to suggest an alternative optimal recovery position. If a person is unresponsive and not breathing normally, proceed with basic life support guidelines. A review of the Prehospital Care Report Summary (by the Los Angeles County Fire Department), dated [DATE], indicated a call was received at 5:56 a.m., was on scene at 6:03 a.m. Resident 2 had no blood pressure, pulse rate was 30 beats per minute (normal pulse for healthy adults ranges from 60 to 100 beats per minute), no respirations. ACLS provided. CPR stopped at 6:23 a.m. Physician 2 pronounced Resident 2 dead at 6:23 a.m. A review of Resident 2's death certificate, dated [DATE], indicated immediate cause of death [MEDICAL CONDITION] (life-threatening complication of an infection), pneumonia aspiration (lung infection from aspiration), developmental delay, and mental [MEDICAL CONDITION].

Based on observation, interview, and record review, the facility failed to implement the interventions to prevent falls according to the residents' care plans and physician's orders [REDACTED]. The facility failed to provide the following care and services: 1a. Resident 3 had a fall on 5/17/16 at 5:30 p.m. The interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) identified Ativan (a medication that causes sedation) was a concern but did not address this concern in the Resident 3's care plan. b. Ensure the wheelchair alarm was properly placed and functional for Resident 3, who was known to the facility staff to have a behavior of getting out of bed/wheelchair without staff assistance. On 6/3/16 at 7:10 p.m., Resident 3 was able to stand up from the wheelchair unassisted without activating the alarm, attempted to walk and fell . This deficient practice resulted in Resident 3 sustaining a broken left hip bone and was transferred to the general acute care hospital (GACH). c. Revise the care plan to indicate the type and frequency of supervision needed for Resident 3, after the fall on 6/3/16 resulting in a broken left hip. d. Conduct an IDT care conference when Resident 3 had another fall on 6/26/16 at 9:15 p.m., to identify the cause of the fall, evaluate interventions and to determine the type and frequency of supervision needed for Resident 3 and revise the care plan. Resident 3 sustained bilateral (both) hip fractures, the right hip fracture being new on 6/26/16. Resident 3 was transferred to the GACH. This was the second admission of Resident 3 to the hospital within a month. 2. Provide additional mattress next to the low bed of Resident 2, who had a behavior of crawling and/or rolling his body from the bed to the floor, as ordered by the physician and as indicated on the care plan. On 6/30/16, Resident 2 was found on the floor on a floor mat with his head beneath the bed frame of Resident 2's low bed. This deficient practice resulted in Resident 2 sustaining a cut to the left outer orbit (outer corner of eye) with swelling and redness. Findings: 1a. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS - a resident assessment and care planning tool), dated 4/20/16, indicated that Resident 3 rarely/never made himself understood and rarely/never had the ability to understand others. The MDS indicated Resident 3 required limited assistance (resident highly involved in activity, staff provided guided maneuvering of limbs) with one person physical assist with bed mobility, transfer, walk in room and walk in corridor and was totally dependent on the staff with dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 3's balance was not steady and only able to move from seated to standing position with staff assistance. A review of Resident 3's History and Physical (H&P), dated 4/10/16 and 9/20/16, indicated Resident 3 did not have the capacity to understand and make decision. A review of Resident 3's Fall Risk Evaluation, dated 4/10/16, indicated Resident 3 was identified as high risk for fall. A review of Resident 3's Situation, Background, Assessment/Analysis, Request (SBAR, a technique that provides a framework for communication between members of the health care team) Change of Condition Documentation indicated the following: a. On 4/11/16 at 1:30 p.m., Resident 3 was found sitting down on the floor by the Director of Staff Development's (DSD) office. Resident 3 got out of bed without staff assistance. A review of Resident 3's Care Plan for Fall, initiated on 4/11/16, indicated the staff will do visual checks on Resident 3's whereabouts during nursing rounds, nursing care, medication pass, meal pass and activities. b. On 5/17/16 at 5:30 p.m., the Certified Nursing Assistant (CNA (not identified)) went to Resident 3's room when she heard the (bed) alarm. Resident 3 fell towards the bedside table and hit his forehead causing laceration (skin cut). A review of Resident 3's record titled, IDT Conference Record -Falls, dated 5/18/16, indicated Resident 3 received Ativan (a medication used to treat anxiety and that causes sedation) 1 milligram (mg) at 4 p.m. on 5/17/16, and it was a concern in regard to the fall. A review of Resident 3's Care Plan for Fall, dated 4/11/16, indicated an update on 5/18/16, indicating risk factor for fall was due to the use of PRN (whenever necessary) antianxiety drug. There was no change in the interventions to address the type of supervision that should be provided to Resident 3 after administration of Ativan medication. On 1/19/17 at 3:19 p.m., during an interview and review of Resident 3's record, Licensed Vocational Nurse (LVN) 2 stated there was no care plan for the concern with the use of Ativan medication and its relationship to falls and stated she did not know why there was none. c. On 6/3/16 at 7:10 p.m., Resident 3 stood up next to his wheelchair, lost his balance, and fell to the floor while attempting to walk independently. Resident 3 was assessed (not identified) with limited range of motion (refers to the extent of movement of a joint) and complained of pain to the left hip area. A review of Resident 3's IDT, dated 6/6/16, indicated the cause of fall was due to the alarm in the wheelchair that did not sound. A review of Resident 3's Care Plan for Fall, revised on 6/3/16, indicated to ensure that the alarm was placed on the adjustable side of the belt in order for the alarm to sound. The care plan was not revised to indicate the type and frequency of supervision needed for Resident 3. On 1/10/17 at 3:35 p.m., during an interview, the Licensed Vocational Nurse (LVN) 2 stated the seatbelt (of the wheelchair) was not placed correctly and they had to modify. On 1/10/17 at 4:30 p.m., during an interview and record review, the Director of Nurses (DON) stated that Resident 3's care plan for fall was not revised and updated to address the type and frequency of supervision for Resident 3. The DON stated Resident 3's care plan for fall should have been revised. A review of Resident 3's record titled, Diagnostic Laboratories, dated 6/3/16, indicated the resident had a fracture of the left femoral neck with impaction (left hip bone break in which the adjacent (next to) fragmented ends of the fractured bone are wedged together). A review of Resident 3's SBAR, dated 6/3/16 at 10 p.m., indicated the primary physician was notified of the x- ray result and gave an order to transfer Resident 3 to the GACH. A review of the GACH orthopedic (a branch of medicine that deals with the correction of muscles and bones) surgical consultation, dated 6/4/16, indicated a recommendation for hemiarthroplasty (surgical procedure in which the hip joint is replaced by a prosthetic implant) of the left hip; however, there was a high possibility of postoperative dislocation. A review of the cardiology (a branch of medicine that deals with diseases and abnormalities of the heart) follow up, dated 6/9/16, indicated, It is probably an old healing fracture. No surgical intervention needed. d. A review of Resident 3's record titled, Licensed Nurse Documentation, dated 6/26/16 at 9:15 p.m., indicated Resident 3 was found sitting on the floor by his bed, alert but confused. On 1/10/17 at 3:35 p.m., a review of Resident 3's clinical record with LVN 2 in regard to Resident 3's fall on 6/26/16 indicated there was no IDT care conference conducted to identify the cause of the fall. The care plan was not revised to address the cause of the fall and did not indicate the type and frequency of supervision needed for Resident 3. During a concurrent interview, LVN 2 stated there should have been an IDT care conference conducted and a revision of the care plan to address Resident 3's fall on 6/26/16. A review of Resident 3's record titled, Diagnostic Laboratories, dated 6/27/16, indicated the resident had bilateral hip fractures. The right hip fracture appears new. A review of Resident 3's record titled, Licensed Nurse Documentation, dated 6/28/16 at 5 p.m., indicated Resident 3's primary physician was notified of x- ray result and the physician gave an order to transfer Resident 3 to GACH. On 1/13/17 at 11:06 a.m., during an interview, the Director of Nurses (DON) stated the purpose of the bed and wheelchair alarms for residents that were identified as high risk for fall were to remind residents to call for assistance. The DON stated Resident 3 needed one staff that sits with the resident to provide close monitoring due to restlessness. On 1/18/17 at 12:15 p.m., Resident 3 was observed in the wheelchair with a small white device at the back of the wheelchair and connected to the seat belt. A sitter (a staff that provides one on one (1:1) supervision) was observed with Resident 3. On 1/18/17 at 12:15 p.m., during an interview, the sitter stated that Resident 3 was using a seat belt when seated on the wheelchair because Resident 3 kept on standing up without assistance and would fall. When asked to check Resident 3's seatbelt for proper function, the sitter removed the seatbelt but the alarm did not make a sound. The sitter stated that the alarm was supposed to make a sound when Resident 3 stands up. The sitter and the DSD assisted Resident 3 to stand up but the alarm did not sound. On 1/18/17 at 12:20 p.m., during an interview, the DSD stated the alarm should be working. On 1/20/17 at 10 a.m., during an interview, the DON stated that Resident 3's care plan should have been revised and the IDT was responsible for implementing the care plan. A review of facility's policy and procedure titled, Care Plans - Comprehensive, revised date 9/2010 indicated that an individualized, comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care planning /interdisciplinary team is responsible for the review and updating of care plans, a. when there has been a significant change in the resident's condition, b. when desired outcome is not met, c. when the resident has been readmitted to the facility from a hospital stay. 2. A review of Resident 2's Admission Record indicated Resident 2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's Initial History and Physical (H&P), dated 5/3/16, indicated Resident 2 was gravely disabled with developmental delay. The H&P indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was able to make himself understood sometimes and was able to understand others sometimes. The MDS indicated Resident 2 required limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) from staff with bed mobility and was totally dependent on staff with transfers, eating, toilet use, and personal hygiene. A review of Resident 2's Fall Risk Evaluation, dated 4/28/16, indicated Resident 2 was identified as high risk for fall. A review of Resident 2's Order Summary Report, dated 4/28/16, indicated, May have additional mattress next to bed due to having tendency to roll body out of bed. A review of Resident 2's care plan for fall, dated 4/27/16, indicated that the staff will provide the following interventions: a. Apply less restrictive devices, a bed alarm to prevent fall, and monitor the effect. b. Provide visual checks of the resident during nursing rounds, nursing care, medicine pass, meal pass and activities. c. Keep the bed on low position, provide additional mattress next to the bed due to Resident 2 rolling body out of bed. A review of Resident 2's Medication Administration Record for June 2016 indicated Resident 2's frequency of crawling/rolling body from the mattress to the floor from 6/10/16 to 6/30/16 indicated the following: a. Day shift (7 am-3 pm), Resident 2 rolled down the mattress a total of 19 times. b. Evening shift (3 pm-11 pm), a total of 20 times. c. Night shift (11 pm- 7 am), a total of one. A review of Resident 2's SBAR, dated 6/30/16 at 10:18 p.m., indicated Resident 2 was found on the floor with a left orbit (around the eye) skin cut. Resident 2 rolled out of bed onto the floor mat next to bed and landed with the head underneath the bed while the rest of his body was on the floor mat. A review of Resident 2's Physician and Telephone Order, dated 6/30/16 at 10:18 p.m., indicated to obtain an x-ray to the resident's left orbit (eye) due to complaint of pain and swelling. Conduct 72 hour neurological checks. Cleanse the resident's left outer eye skin cut with normal saline (mixture of salt and water), pat dry, apply bacitracin (antibiotic ointment), and cover with dry dressing daily for 14 days. On 1/10/17 at 6:45 a.m., during an interview, CNA 1 stated that Resident 2 was using a floor mat due to the resident's behavior of rolling out of the bed. On 1/10/17 at 10:45 a.m., during an interview, LVN 2 stated Resident 2 should have another mattress next to the bed due to rolling out of bed. On 1/19/17 at 5:15 p.m., during an observation and interview, the maintenance supervisor stated that he was never asked to place an additional mattress next to Resident 2's bed and he had never seen a mattress on the floor.