Every finding on record at Beverly Hills Rehabilitation Centre

Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs of three of 28 sampled residents (Resident 3, Resident 14 and Resident 185) reviewed under care planning by failing to: -Develop and implement care plans for Resident 3 and Resident 14's use of bedrails (a metal or plastic bar attached to the side of a bed to help residents get in and out safely or prevent them from falling out). -Develop and implement care plan for Resident 185's low hemoglobin (Hgb- a protein in the red blood cells that carries oxygen from the lungs to the rest of the body). These failures had the potential to have a negative impact on Resident 3, Resident 14 and Resident 185's health, as well as the quality of care and services received. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 12/15/2017 and was readmitted on [DATE] with diagnoses that included cerebral infarction (also called stroke, a result of inadequate blood flow to the brain), dementia (a chronic or persistent disorder of mental processes caused by brain disease), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and generalized muscle weakness. During a review of Resident 3's History and Physical (H&P) dated 4/29/2026, the H&P indicated Resident 3 could raise need known but did not have the capacity to understand and make decisions. During a review of Resident 3's Devices and Physical Restraint Order/Consent (DPROC), dated 5/1/2026, DPROC indicated Resident 3 had a consent for both upper and lower (one fourth [1/4]) side rails in bed for mobility and positioning and generalized weakness. During a review of Resident 3's Order Summary Report dated 5/1/2026, the Order Summary Report indicated Resident 3 had a physician order for both upper side rails and both lower side rails up while in bed for mobility and positioning. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 8/12/2026, the MDS indicated Resident 3 had mildly impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and from moderate assistance (helper does less than half the effort) to maximal assistance (helper does more than half the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 3's Bed Rail and Entrapment (is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) Risk Observation/Assessment (BREROA) dated 8/16/2026, the BREROA indicated Resident 3 was using a right and a left full bed rail at all times when the resident was in bed to enhance mobility. During an observation and interview on 8/19/2026 at 1:55 PM with Resident 3 and Resident 3's caregiver inside the room, Resident 3 was observed lying in bed with bilateral upper and bilateral lower side rails up. During an observation on 8/20/2026 at 6:26 AM with Resident 3 inside the room, Resident 3 was observed lying in bed with bilateral (both) upper and bilateral lower side rails up. During a concurrent interview and record review on 8/20/2026 at 1:26 PM with the Nursing Services Director (NSD) Resident 3's care plan was reviewed. Resident 3's care plan indicated missing bedrails/side rails care plan. The NSD stated it was important to have a specific bed rails/side rails care plan to be able to provide the proper individualized care for residents and to make sure that staff (in general) would know interventions for residents (in general) with bed rails/side rails. b. During a review of Resident 14's admission Record, the admission Record indicated the facility originally admitted Resident 14 on 7/18/2025 and was readmitted on [DATE] with diagnoses that included dementia, depression, and generalized muscle weakness. During a review of Resident 14's Order Summary Report dated 6/1/2026, the Order Summary Report indicated Resident 14 had physician order for both upper side rails and both lower side rails up while in bed for mobility and positioning per family's request. During a review of Resident 14's Devices and Physical Restraint Order/Consent (DPROC), dated 6/1/2026, the DPROC indicated Resident 14 had a consent for both upper and lower (one fourth [1/4]) side rails in bed for mobility and positioning and generalized weakness, per family's request. During a review of Resident 14's Bed Rail and Entrapment Risk Observation/Assessment (BREROA) dated 6/1/2026, the BREROA indicated Resident 14 was using quarter rails (bilateral upper and bilateral lower) at all times when the resident was in bed to enhance mobility. During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had severely impaired cognition and needed maximal assistance (helper does more than half the effort) to dependent (helper does all of the effort) from staff for ADLs. During a review of Resident 14's H&P dated 6/8/2026, the H&P indicated Resident 14 did not have the capacity to understand and make decisions. During an observation on 8/20/2026 at 6:25 AM with Resident 14 inside the room, Resident 14 was observed lying in bed with bilateral upper and bilateral lower side rails up. During a concurrent interview and record review on 8/20/2026 at 3:00 PM with the NSD, Resident 14's care plan was reviewed. Resident 14's care plan indicated missing bedrails/side rails care plan. The NSD stated it was important to have a specific bed rails/side rails care plan to be able to provide the proper individualized care for residents and to make sure that staff (in general) would know interventions for residents with bed rails/side rails. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered reviewed on 1/30/2026, the P&P indicated that facility would develop a comprehensive, person-centered care plan for the residents to include measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs. During a review of the facility's P&P titled, Side Rails and Bed Rails Policy, reviewed on 1/30/2026, the P&P indicated care plan would be identified when bed rails are clinically indicated. P&P also indicated under documentation to include care plan interventions. c. During a review of Resident 185's admission Record, the admission Record indicated the facility admitted Resident 185 on 12/11/2023, with diagnoses that included but not limited to sequelae (a later health problem or side effect) of cerebral infarction (a stroke caused by a blood vessel in the brain becoming blocked), sepsis (a life-threatening blood infection), malignant neoplasm (cancer- a harmful growth of abnormal cells that can grow uncontrollably and may spread to other parts of the body) of right kidney, and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 185's H&P dated 12/19/2023, the H&P indicated Resident 185 had the capacity to understand and make decisions. During a review of Resident 185's laboratory report, dated 4/4/2024, the laboratory report indicated Resident 185's Hgb was 8.7 grams/deciliter (g/dL- unit used to measure how much of a substance is in a certain amount of blood). The laboratory record indicated Resident 185's Hgb decreased to 6.5 g/dL on 4/8/2024. The laboratory record indicated the reference range (the normal range of results expected for a healthy person) for Resident 185's Hgb was 11 – 18g/dL. During a review of Resident 185's MDS dated [DATE], the MDS indicated Resident 185 had modified independence (some difficulty in new situations only) cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS further indicated Resident 185 required moderate assistance with toileting hygiene, showering/bathing, upper and lower body dressing and personal hygiene. The MDS indicated Resident 185 was independent with eating and required supervision with oral hygiene. During an interview on 8/19/2026 at 10:31 AM with Registered Nurse 4 (RN 4), RN 4 stated when a resident's hemoglobin was low (in general), the licensed nurse (in general) needed to assess and monitor the resident for signs and symptoms of anemia (a condition where the body does not have enough healthy red blood cells) like weakness, shortness of breath and dizziness. RN 4 stated the licensed nurses (in general) needed to also check and monitor the vital signs (basic measurements that show how well a person's body is functioning) for a drop in blood pressure (BP-the force of blood pushing against the walls of the blood vessels as the heart pumps), increase in heart rate (HR-how many times the heart beats in one minute) and increase in respiratory rate (RR-how many breaths a person takes in one minute). RN 4 stated a care plan needed to be initiated for a low hemoglobin to individualize care for a resident. During a concurrent interview and record review on 8/20/2026 at 9:20 AM with the Nursing Services Director (NSD) Resident 185's care plan was reviewed. The care plan did not indicate a care plan was developed and implemented for Resident 185's low hemoglobin. The NSD stated Resident 185's Hgb was low and needed to be monitored for changes in vital signs and for signs of bleeding. The NSD stated that a care plan needed to be developed and implemented to monitor Resident 185 for any change in condition. During a review of the facility's policy and procedure (P&P) titled, Care plans, comprehensive person-centered, last revised on 1/30/2026, the P&P indicated the comprehensive person-centered care plan should be developed within the seven (7) days of the completion of the required MDS assessment. (Admission, annual, or significant change in status) and should be completed within 21 days of admission. The comprehensive, person-centered care plan should: -Include measurable objectives and time frames; -Describe the services That are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial well-being that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments). The interdisciplinary team should review and update the care plan when there has been a significant change in resident's condition.

Based on interview and record review, the facility failed to document the significant change in condition (a major or noticeable change in the health, physical ability, mental status, or behavior that is different from the usual condition and may require new assessment, treatment, or a change in care plan) for one of three sampled residents (Resident 185) by failing to: -Ensure the licensed nurses (in general) documented when on 8/8/2024 Resident 185's hemoglobin (Hgb- a protein in the red blood cells that carries oxygen from the lungs to the rest of the body) decreased from 8.7 grams/deciliter (g/dL- unit used to measure how much of a substance is in a certain amount of blood) to 6.5 g/dL (low-normal value 11.0 to 18.0). This failure had the potential to result in a delay in recognizing and responding to Resident 185's change in condition which could have resulted in further deterioration of Resident 185's health status. Findings:During a review of Resident 185's admission Record, the admission Record indicated the facility admitted Resident 185 on 12/11/2023 with diagnoses that included but not limited to sequelae (a later health problem or side effect) of cerebral infarction (a stroke caused by a blood vessel in the brain becoming blocked), sepsis (a life-threatening blood infection), malignant neoplasm (cancer- a harmful growth of abnormal cells that can grow uncontrollably and may spread to other parts of the body) of right kidney, and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 185's History and Physical (H&P) dated 12/19/2023, the H&P indicated Resident 185 had the capacity to understand and make decisions. During a review of Resident 185's Laboratory Report dated 4/4/2024, the Laboratory Report indicated Resident 185's Hgb was 8.7 g/dL. The Laboratory Record indicated Resident 185's Hgb decreased to 6.5 g/dL on 4/8/2024. The Laboratory Record indicated the reference range (the normal range of results expected for a healthy person) for Resident 185's Hgb was 11 - 18g/dL. During a review of Resident 185's Minimum Data Set (MDS- a resident assessment tool) dated 4/11/2024, the MDS indicated Resident 185 had modified independence (some difficulty in new situations only) cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS indicated Resident 185 required moderate assistance with toileting hygiene, showering/bathing, upper and lower body dressing and personal hygiene. The MDS indicated Resident 185 was independent with eating and required supervision with oral hygiene. During a concurrent interview and record review on 8/19/2026 at 11:02 AM with Licensed Vocational Nurse 8 (LVN 8), Resident 185's change in condition documentation dated 4/8/2024 was reviewed. The change in condition documentation did not indicate that a change in condition documentation for Resident 185's drop in hemoglobin was documented. LVN 8 stated there was no documentation. LVN 8 stated a change in condition needed to be documented when resident's Hgb dropped from 8.7 g/dL to 6.5 g/dL to ensure the physician was notified and the Resident 185's medical condition was treated immediately. During a telephone interview on 8/19/2026 at 11:30 AM with Registered Nurse 5(RN 5), RN 5 stated Resident 185's drop of hemoglobin from 8.7g/dL to 6.5 g/dL was a significant change that needed to be documented because Resident 185's Hgb was low. RN 5 stated that documentation when a resident (in general) had a change in condition was important to be able to monitor the resident, and to ensure the physician was notified and updated. During an interview on 8/20/2026 at 9:20 AM with the Nursing Services Director (NSD), the NSD stated Resident 185's drop in hemoglobin was a significant change that licensed nurses (in general) needed to document. The NSD stated licensed nurses (in general) needed to monitor Resident 185 for bleeding and for changes in vital signs (basic measurements that show how well a person's body is functioning). During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's condition or status, last revised on 1/30/2026, the P&P indicated a significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). The Nurse supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. During a review of the facility's P&P titled, Charting and documentation, last revised on 1/30/2026, the P&P indicated all incidents, accidents, or changes in the resident's condition must be recorded and include follow up documentation entries if necessary.

Based on interview and record review the facility failed to ensure the facility's policy and procedures (P&P) for indwelling urinary catheter (foley catheter, is a flexible tube inserted into the bladder to drain urine, held in place by a small, water-filled balloon) were followed for two of four sampled residents (Resident 1 and 4) by failing to ensure:1. Urine characteristics were documented on the Weekly Summary Note for Resident 1 and 4, and2. A foley catheter change procedure was documented in the medical record for Resident 1.These failures resulted in incomplete and inaccurate documentation in the medical record and had the potential to affect the residents' foley care and monitoring for signs and symptoms of infection.1. During a review of Resident 1's admission Record, dated 3/17/26, indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), hyperlipidemia (high levels of fats (lipids), such as cholesterol and triglycerides, circulating in the blood), congestive heart failure (CHF - chronic, progressive condition where the heart muscle cannot pump blood efficiently, causing blood to back up and fluid to accumulate in the lungs, liver, and extremities), muscle weakness, difficulty in walking, and chronic kidney disease (CKD - progressive loss of kidney function), and obstructive and reflux uropathy (conditions where urine flow is blocked or flows backward, causing urine backup, kidney swelling (hydronephrosis), and potential renal damage).During a review of Resident 1's History and Physical (H&P) dated 2/1/26 indicated, Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 3/11/26 indicated, Resident 1 had minor memory problems and was dependent to needing partial/moderate assistance from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS further indicated Resident 1 had an indwelling urinary catheter.During a review of Resident 1's care plan for: indwelling catheter r/t (related to) obstructive uropathy, initiated on 1/29/26, indicated interventions including; Monitor/record/report to MD for signs symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness. deepening of urine color.foul smelling urine.During a review of Resident 1's Weekly Summary notes dated 2/28/26 and 3/14/26 the Urine color, consistency, odor and clarity sections were left blank.During a review of Resident 4's admission Record, dated 3/17/26, indicated the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), fracture of left lower leg, non-displaced fracture of head of left radius (forearm bone), acute respiratory failure with hypoxia (low oxygen), endocarditis (infection of the heart), dysphagia (difficulty swallowing), atrial fibrillation (Afib - irregular heart rate, characterized by disorganized electrical activity causing the upper chambers (atria) to quiver or fibrillate instead of beating effectively)During a review of Resident 4's MDS dated [DATE] indicated, Resident 4 had minor memory problems and was dependent on staff for all Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and bed mobility. The same MDS further indicated Resident 4 had an indwelling urinary catheter.During a review of Resident 4's care plan for: indwelling catheter r/t (related to) obstructive uropathy, initiated on 3/4/26, indicated interventions including; Monitor/record/report to MD for signs symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness. deepening of urine color.foul smelling urine.During a review of Resident 4's Weekly Summary notes dated 3/7/26 and 3/14/26 the Urine color, consistency, odor and clarity sections were left blank.During an interview on 3/17/26 at 9:14 am, the MDS Nurse (MDSN) stated the Weekly Summary notes are documented by licensed nurses and should be complete including urine characteristics.During a concurrent interview and record review on 3/17/26 at 3:00 pm with the Director of Nursing (DON), Resident 1 and 4's Weekly Summary notes indicated above were reviewed. The DON verified the urine characteristics were not documented and stated the monitoring for the urine would be a risk from this omission in the documentation.During a review of the facility's P&P titled, Catheter Care, Urinary, dated January 2026, the P&P indicated Purpose. Ther purpose of this procedure is to prevent infection of the resident's urinary tract. Documentation. The following information should be recorded in the resident's medical record. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor.During a review of the facility's P&P titled, Charting and Documentation, revised January 2026, 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.2. During a review of Resident 1's admission Record, dated 3/17/26, indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), hyperlipidemia (high levels of fats (lipids), such as cholesterol and triglycerides, circulating in the blood), congestive heart failure (CHF - chronic, progressive condition where the heart muscle cannot pump blood efficiently, causing blood to back up and fluid to accumulate in the lungs, liver, and extremities), muscle weakness, difficulty in walking, and chronic kidney disease (CKD - progressive loss of kidney function), and obstructive and reflux uropathy (conditions where urine flow is blocked or flows backward, causing urine backup, kidney swelling (hydronephrosis), and potential renal damage).During a review of Resident 1's History and Physical (H&P) dated 2/1/26 indicated, Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's MDS dated [DATE] indicated, Resident 1 had minor memory problems and was dependent to needing partial/moderate assistance from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS further indicated Resident 1 had an indwelling urinary catheter.During a review of Resident 1's care plan for: indwelling catheter r/t (related to) obstructive uropathy, initiated on 1/29/26, indicated interventions including; Monitor/record/report to MD for signs symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness. deepening of urine color.foul smelling urine.During a telephone interview on 3/17/26 at 2:36 pm with Licensed Vocational Nurse (LVN) 2, LVN 2 stated when she came on her 3pm-11pm shift on 3/3/26 she was told the treatment nurse had changed out the foley catheter on Resident 1 and she was tasked with giving him pain medication. LVN 2 further stated the nurse who changes the foley should document it in the chart.During a concurrent interview and record review on 3/17/26 at 3:00 pm with the Director of Nursing (DON), Resident 1's progress notes for 3/3/26 were reviewed. The DON verified there was no documentation for the foley catheter change on 3/3/26 and if the catheter is changed the nurse should have documented it.During a review of the facility's P&P titled, Catheter Care, Urinary, dated January 2026, the P&P indicated Documentation. The following information should be recorded in the resident's medical record. The date and time that catheter care was given. The name and title of the individual(s) giving the catheter care. All assessment data obtained. any problems or complaints made by the resident related to the procedure. How the resident tolerated the procedure.During a review of the facility's P&P titled, Charting and Documentation, revised January 2026, 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.

Based on observation, interview, and record review, the facility failed to ensure staff followed transmission-based precautions (rules to prevent spreading infections) in accordance with facility policy and infection prevention standards to prevent the spread of infection, by failing to: 1.Staff properly donning (wearing) the required personal protective equipment ([PPE] - gloves, gowns, goggles, face masks) before entering the room of Resident 3 who was on contact isolation (infection control measures, requiring staff and visitors to wear gowns and gloves prior to entry),2.Develop and implement a care plan addressing contact isolation precautions for Resident 3. These deficient practices placed residents, staff, and visitors at risk for exposure to and transmission of infectious organisms. Findings: During a review of Resident 3's admission Records, the admission Records indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses including benign neoplasm of meninges (a slow-growing, non-cancerous (benign) tumor that forms on the meninges, the protective layers covering your brain and spinal cord), anemia (a condition where the body does not have enough healthy red blood cells), enterocolitis (inflammation in both of your intestines at once) due to clostridium difficile ([C. diff] - a highly contagious bacteria that causes severe diarrhea). During a review of Resident 3's Minimum Data Set ([MDS] - a resident assessment tool) dated 11/6/2025 revealed that Resident 3 has moderate cognitive impairment. Resident 3 is dependent (helper does all the effort) from staff with toileting, showering/bathing, lower body dressing, putting on/taking off footwear. During a review of Resident 3's Lab Results Report dated 12/19/2025, the Lab Results Report indicated C. Diff detected in Resident 3's stool sample. During a review of Resident 3's Order Summary Report dated 12/23/2025, the Order Summary Report indicated Resident 3 was placed on contact isolation due to C. Diff. on 12/20/2025. During a concurrent observation and interview on 12/23/2025 at 11:26 a.m. with Certified Nurse Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1, observed signage by Resident 3's door indicating Contact Isolation Precautions. CNA 1 donned his PPE inside Resident 3's room, standing in close proximity to Resident 3's bed. Observed LVN 1 standing near Resident 3's bed without any PPE. Both CNA 1 and LVN 1 were unsure of the reason why the resident was on contact isolation. CNA 1 stated that the PPE must be donned before entering the room with contact isolation signage. Donning PPE inside the room increases the risk for staff contamination and spread of the infection to other staff, residents and visitors. During an interview on 12/23/2025 at 11:36 a.m., with LVN 1, LVN 1 stated that Resident 3 was on contact isolation due to C. Diff infection. LVN 1 stated that C. Diff bacteria is transmitted through contact with spores. LVN 1 stated that to enter the rooms with contact isolation, facility personnel need to wear appropriate PPE, such as gown, gloves, and a surgical mask. PPE must be donned at the door to protect staff and prevent the spread of infectious organisms to others in the facility. During a concurrent interview on 12/23/2025 at 3:00PM with Director of Nursing (DON), and record review of Resident 3's care plan, the DON stated when a resident is on a contact isolation precaution, staff must don PPE before entering the resident's room, to protect other residents and staff, and to avoid the spread of the infectious organisms. the DON indicated there was no care plan developed addressing contact isolation for Resident 3. The DON stated that a comprehensive, resident centered care plan addressing contact isolation precautions must be created by Interdisciplinary Team ([IDT] a team of different health care professionals working together to develop care interventions for a resident). The DON added the care plan should outline the specific interventions, staff responsibilities, and monitoring needed to ensure that contact isolation precautions are implemented consistently to prevent the spread of infection. During a review of facility's Policies and Procedures (P&P) titled Isolation - Categories of Transmission-Based Precautions revised on August 2025, the policy indicated Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed when contact precautions are implemented. During a review of facility's P&P titled Care Plans, Comprehensive Person-Centered, revised on January 2024, the policy indicated The interdisciplinary team should review and updates the care plan when there has been a significant change in the resident's condition.

Based on interview and record review the facility failed to ensure blood glucose (sugar) monitoring (process of measuring your blood sugar levels) three times a day and Levemir insulin (medication to use to manage high blood sugar in people diabetes) was transcribed accurately upon admission for one of nine sampled residents (Resident 1). These deficient practices had the potential to delay knowledge of or lead to hypoglycemic (low blood sugar level) or hyperglycemic (elevated blood sugar level) episodes and resulted in Resident 1 not having her blood sugar checked throughout the day as indicated in the interfacility transfer form from the General Acute Care Hospital (GACH), as well as, not receiving long-acting insulin for five (5) days at the facility. During a review of Resident 1's admission Record , dated 8/29/25, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus (T2DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of falling, lung transplant, joint replacement surgery and retention of urine. During a review of Resident 1's History and Physical (H&P), dated 7/30/25, indicated, the resident has the capacity to understand and make decisions and had a history of T2DM with sliding scale (amount of insulin to be administered changes or slides up or down based on the person's blood sugar level) insulin. The same H&P further indicated Discharge Medication List including: Levemir FlexTouch 100 units/milliliter (3ml) insulin pen inject 2-3 units subcutaneously (under the skin) at bedtime as needed (for blood sugar greater than 250), OneTouch Ultra Test (blood glucose test strip, a small strip used with a glucometer, device used to test blood sugar level, to test blood glucose level) one (1) strip by diagnostic route three (3) times a daily and lancets (used to prick the finger to get the drop of blood for use with the blood sugar test strip) 33 gauge (the size of the needle). During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 7/31/25, indicated the resident required supervision or touching assistant with eating, and needed substantial assistance to being dependent on staff for toileting, bathing, dressing and personal hygiene, bed mobility and transfers. The same MDS indicated the resident had moderate cognitive (thinking, reasoning, learning, judgement) impairment. During an interview and a concurrent record review with the Director of Nursing (DON), on 8/27/25 at 4:56 pm Resident 1's Inter-facility Transfer Report was reviewed. The report indicated orders for Levemir FlexTouch 100 units/milliliter (3ml) insulin pen inject 2-3 units subcutaneously (under the skin) at bedtime as needed (for blood sugar greater than 250), OneTouch Ultra Test (blood glucose test strip, a small strip used with a glucometer, device used to test blood sugar level, to test blood glucose level) one (1) strip by diagnostic route three (3) times a daily and lancets (used to prick the finger to get the drop of blood for use with the blood sugar test strip) 33 gauge (the size of the needle). The DON stated when a resident is admitted to the facility they come with orders from the hospital that are reviewed by the admitting nurse and entered in the computer, acknowledging the orders for checking blood sugar three times a day and insulin at night was missed then orders for blood sugar checks and insulin at night were later entered on 8/5/25. During a review of the facility's policy and procedures (P&P) admission to the Facility, reviewed January 2025, the P&P indicated Physician's admission Orders prior to or at the time of admission the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders. Medication orders, including (as necessary) a medical condition or problem associated with each medication. routine care order to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive ass

Based on observation, interview, and record review, the facility failed to provide adequate and sufficient nursing staff to meet the needs of three of 28 sampled residents (Resident 61, Resident 76, and Resident 171).These failures had the potential to result in the inadequate availability of nursing services to assure resident safety and attainment of the highest practicable, physical, mental, and psychosocial well-being of each resident.Findings:1.During a review of Resident 61's admission Record, the admission Record indicated the facility admitted the resident on 7/15/2025 with diagnoses that included multiple fractures of the ribs (broken ribs), rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility), difficulty in walking, muscle weakness, and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).During a review of Resident 61's Minimum Data Set (MDS, a resident assessment tool) dated 7/21/2025, the MDS indicated the resident had moderate cognitive impairment (some impairment to the ability to think, understand, and reason). The MDS indicated Resident 61 had impairment on both sides of her upper and lower extremities. The MDS indicated Resident 61 required partial/moderate assistance (helper does less than half the effort) for eating and oral hygiene. The MDS indicated Resident 61 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, upper body dressing, lower body dressing, putting on footwear, taking off footwear, and personal hygiene. The MDS indicated Resident 61 was dependent on help (helper does all the effort) on showering and bathing herself.During an interview on 8/4/2025 at 12:23 PM with Resident 61, Resident 61 stated the night shift staff would take 30 to 45 minutes to respond to call lights (crucial communication tools that allow residents to summon help from nurses or staff when needed). Resident 61 stated this happened every night. Resident 61 stated she (Resident 61) felt frustrated because she (Resident 61) usually called for help to be changed. Resident 61 stated she (Resident 61) could not change herself because she (Resident 61) had arthritis in both hands. Resident 61 stated she (Resident 61) was worried about chafing (skin irritation caused by repeated rubbing against the skin, clothing, or other materials) and urine or stool irritating her skin when waiting too long to be changed.2.During a review of Resident 76's admission Record, the admission Record indicated the facility admitted the resident on 7/15/2025 with diagnoses that included cerebral infarction (stroke, a condition where the brain tissue dies due to a lack of blood supply), rheumatoid arthritis, atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), difficulty in walking, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 76's MDS dated [DATE], the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 76 required supervision or touching assistance (helper provides verbal cues and/or touching, steadying, or contact guard assistance) for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 76 required substantial/maximal assistance for upper body dressing, showering, and bathing herself. The MDS indicated Resident 76 was dependent on help for toileting hygiene, lower body dressing, putting on footwear, and taking off footwear.During an interview on 8/4/2025 at 1:54 PM with Resident 76, Resident 76 stated staff did not attend to her quick enough to clean her up and change her. Resident 76 stated she (Resident 76) once waited three hours and a half to get assistance from staff (in general). Resident 76 stated she (Resident 76) once called the front desk to get assistance from staff (unidentified). Resident 76 stated this happened more often in the evening time (unidentified time and date).During an interview on 8/6/2025 at 6:26 AM with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated the facility was short of Certified Nursing Assistants (CNAs). LVN 7 stated there were usually only four to five CNAs on the 11 PM to 7 AM shift. LVN 7 stated sometimes the CNAs (in general) were assigned up to 18 residents each. LVN 7 stated the LVNs (in general) helped the CNAs (in general) as much as they could but sometimes call lights would get answered late because they (nursing staff in general) were short staffed.3.During a review of Resident 171's admission Record, the admission Record indicated the facility admitted the resident on 7/11/2025 with diagnoses that included fracture of the lower end of the right radius (broken wrist joint), difficulty in walking, chronic kidney disease, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), dementia (a progressive state of decline in mental abilities), and a history of falling.During a review of Resident 171's MDS dated [DATE], the MDS indicated the resident was cognitively intact. The MDS indicated Resident 171 had impairment on both sides of her upper extremities. The MDS indicated Resident 171 required supervision or touching assistance for eating and oral hygiene. The MDS indicated Resident 171 required partial/moderate assistance with upper body dressing, lower body dressing, toileting hygiene, and personal hygiene. The MDS indicated Resident 171 required substantial/maximal assistance for putting on and taking off footwear.During a concurrent observation and interview on 8/6/2025 at 6:31 AM, with Resident 171 in Resident 171's room, the resident was observed pressing the call light. Resident 171 stated sometimes it would more than 30 minutes for staff (in general) to answer the call light, especially at night. Resident 171 stated that because the nursing staff (in general) would take too long, sometimes she (Resident 171) would just get up to go to the bathroom by herself even though the nursing staff would tell her to call for help first. Resident 171 stated the facility needed more nursing staff so call lights could be answered timely.During an observation on 8/6/2025 at 6:44 AM, in Resident 171's room, CNA 6 was observed answering Resident 171's call light. CNA 6 was observed asking Resident 171 if she (Resident 171) needed help with anything. CNA 6 was observed assisting resident with her bedside table.During an interview on 8/6/2025 at 6:50 AM with CNA 6, CNA 6 stated she (CNA6) answered Resident 171's call light when she (CNA6) saw it was on. CNA 6 stated answering a call light within 13 minutes was too late. CNA 6 stated call lights should be answered as soon as possible. CNA 6 stated Resident 171 could have had an emergency. CNA 6 stated call lights should be answered timely in case of an emergency.4.During a review of the facility's staff assignment dated 8/4/2025 for the 3PM - 11 PM shift, the staff assignment indicated CNA 7 was working during the 3 PM - 11 PM shift on the facility's first floor.During a review of the facility's staff assignment dated 8/4/2025 for the 11 PM - 7 AM shift, the staff assignment indicated CNA 7 was working during the 11 PM - 7 AM shift on the facility's first floor. The staff assignment indicated there were a total of five CNAs working on the first floor of the facility during the 11 PM - 7 AM shift. The staff assignment indicated there were 73 residents on the first floor.During a review of the facility's staff assignment dated 8/5/2025 for the 3 PM - 11 PM shift, the staff assignment indicated CNA 7 was working during the 3 PM - 11 PM shift on the first floor.During a review of the facility's staff assignment dated 8/5/2025 for the 11PM - 7 AM shift, the staff assignment indicated CNA 7 was working during the 11 PM - 7 AM shift on the facility's first floor. The staff assignment indicated there were a total of five CNAs working on the first floor of the facility during the 11 PM - 7 AM shift. The staff assignment indicated there were 70 residents on the first floor.During a review of the facility's staff assignment dated 8/6/2025 for the 3 PM - 11 PM shift, the staff assignment indicated CNA 7 was working during the 3 PM - 11 PM shift on the first floor.During a review of the facility's staff assignment dated 8/6/2025 for the 11 PM - 3 PM shift, the staff assignment indicated CNA 7 was working during the 11 PM - 3 PM shift on the first floor. The staff assignment indicated there were a total of six CNAs working on the first floor of the facility during the 11 PM - 7 AM shift.During an interview on 8/6/2025 at 6:54 AM with CNA 7, CNA 7 stated the facility was short of CNAs on the 11 PM to 7 AM shift. CNA 7 stated he (CNA7) worked overtime the past three nights because the facility was short of CNAs on the 11 PM to 7 AM shift. CNA 7 stated he (CNA7) usually worked the 3 PM - 11 PM shift. CNA 7 stated if he didn't work overtime there would have only been 4 CNAs working, and the CNAs would have been assigned 18 residents each. CNA 7 stated normally the CNAs are assigned 14 residents each. CNA 7 stated the residents at the facility required a lot of assistance with Activities of Daily Living (ADLs, activities such as bathing, dressing, and toileting a person performs daily). CNA 7 stated that sometimes residents had to wait longer for their call light to be answered because the facility was short-staffed CNAs. CNA 7 stated sometimes he had to clean up the residents quickly during rounds to ensure that he could attend to all the residents on his assignment. CNA 7 stated sometimes he felt he didn't do a good job cleaning up the residents because he had to clean the residents up quickly.During an interview on 8/7/2025 at 9:23 AM with the Director of Staff Development (DSD), the DSD stated depending on the census, there should be five to six CNAs on each floor with 15 to16 residents on each CNAs assignment. The DSD stated the facility was actively seeking new hires for CNAs. The DSD stated that all staff, not just CNAs, should be answering the residents' call lights. The DSD stated residents should not be waiting longer than five minutes to have their call light answered. The DSD stated call lights should be answered timely in case of emergency and to ensure residents have their needs addressed. During an interview on 8/7/2025 at 1:50 PM with the Director of Nursing (DON), the DON stated if a CNA would call off the facility would find someone to cover that CNA immediately. The DON stated the facility would ask a CNA to come early or would ask a CNA to stay later to cover the CNA who called off. The DON stated the facility had five to six CNAs working on the night shift (11 PM - 7 AM) shift. The DON stated the CNAs don't have 18 residents in their assignments because the facility had at least 5 CNAs working on each floor during the 11 PM - 7 AM shift. The DON stated the acuity is high at the facility. The DON stated the facility is always hiring CNAs. The DON stated he did not feel the facility was short staffed. The DON stated sometimes resident families state the facility is short staffed. The DON stated resident call lights should be answered as soon as possible. The DON stated 13 minutes to answer a resident's call light is too long. The DON stated there was potential for the residents' needs not to be met and the residents' to not receive proper care if the facility was short staffed and resident calls lights were not answered timely. During a review of the facility's Policy and Procedure (P&P) titled Staffing dated 1/2025, the P&P indicated Our facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan.During a review of the facility's P&P titled Answering the Call Light dated 1/2025, the P&P indicated The purpose of this procedure is to respond to the resident's requests and needs.Answer the call light as soon as possible.During a review of the facility's document titled Facility Assessment Tool Dated 8/4/2025, the document indicated Direct care staff: Depending on overall facility census on each floor. Day shift 7 AM - 3 PM shift ratio is at 8-10 CNAs 1 CNA for 7 patients for each nursing floor or 3 PM - 11 PM shift 6-8 CNAs or 1 CNA for 9 to 11 patients for each nursing floor. Night shift 11 PM - 7 AM 5-6 CNAs.

Based on observation, interview, and record review the facility failed to ensure to follow infection control practices by failing to:1.Ensure Resident 186's sitter (refers to a caregiver who provides supervision and companionship to patients in healthcare settings) had proper personal protective equipment (PPE - garments designed to protect the wearer from injury or infection) [DATE] at 9:53 AM for Resident 186 who was on enhanced barrier precautions (EBP - infection control measures used in healthcare settings to reduce the spread of multidrug-resistant organisms [MDROs, bacteria that are resistant to one or more classes of antimicrobial agents]). 2. Ensure not to have expired hand sanitizer, disposal COVID-19 (a respiratory illness that can spread from person to person) testing kits, and disposable hand gloves in the facility's hallways, storage room, and medication carts. These failures had the potential to place the residents at increased risk of infection and cross-cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1.During a review of Resident 186’s admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses including heart failure (a condition where the heart muscle cannot pump enough blood and oxygen to meet the body's needs) and metabolic encephalopathy (is a condition where brain dysfunction occurs due to a chemical imbalance in the body). During a review of Resident 186’s Minimum Data Set (MDS – a resident assessment tool), dated [DATE], indicated the resident was not oriented to time and had poor recall. The MDS indicated Resident 186 had trouble concentrating on things, felt down, sad, or hopeless. During an observation on [DATE] at 9:53 AM in Resident 186’s room, before entering Resident 186’s room, outside was a plastic draw with PPE present. Resident 186 was lying in bed, the bed rails (are adjustable metal or rigid plastic bars that attach to the bed) were up on both sides of the bed. Resident 186’s sitter was sitting in a chair next to Resident 186, with no PPE donned (put on). Resident 186 had a foley catheter (a flexible tube inserted into the bladder to drain urine) with a dignity bag (a discreet covering or holder for a urine drainage bag, designed to conceal the bag from view and maintain the user's privacy and dignity) over the drainage bag. The PPE was also available at the back of the door to Resident 186’s room. During an interview on [DATE] at 10 AM with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 186’s and the roommate were on EBP. CNA 1 stated the PPE was on the back side of the resident’s room door and a green laminated page indicated which bed was on EBP. CNA 1 stated the PPE that was outside the room could also be used for the room. During an interview on [DATE] at 10:02 AM with the sitter, the sitter stated that she (sitter) did not know that Resident 186 was on enhanced barrier precautions and to wear the PPE. The sitter stated that when she (sitter) arrived to the room, there was no sign outside the room. During an interview on [DATE] at 10:05 AM with the Assistant Director of Staff Development (ADSD), the ADSD stated sitters would have to receive orientation to the facility such as EBP, and abuse training. The ADSD stated that the Infection Preventionist (IP) Nurse would give the sitters infection control orientation. The ADSD stated Resident 186 would be at risk of cross-contamination of infection between the sitter and Resident 186. During an interview on [DATE] at 10:17 AM with the Director of Staff Development (DSD), the DSD stated family members would communicate whether the resident would have a caregiver/sitter. The DSD stated education would be provided to the caregiver/sitter. The DSD stated in this instance the facility was unaware the sitter was hired by the family. The DSD stated if a visitor/family member, or sitter were without proper PPE in a resident’s room on EBP then staff would educate those individuals. The DSD stated that any staff member should be able to provide education. The DSD stated that all staff were educated on the policy regarding PPE. The DSD stated Resident 186 would be at risk of cross-contamination. During an interview on [DATE] at 10:35 AM with the Director of Nursing (DON), the DON stated that families would inform the facility that a resident would have a sitter present. The DON stated the facility was not aware that Resident 186 had a sitter. The DON stated during morning huddle, residents with sitters would be discussed. The DON stated if any residents were on contact precautions or EBP then everyone must wear the PPE. The DON stated the signage on the outside of the room indicated the room was on contact precautions, but for EBP the signage and PPE would be on the back of the resident’s door. The DON stated Resident 186 would be at risk for increased infection without the sitter donning (put on) PPE. During an interview on [DATE] at 2:45 PM with the Infection Preventionist (IP), the IP stated she would educate the sitters infection control, EBP, and on how to don and doff (take off) PPE, provide handouts, and conduct demonstration for understanding. The IP stated that only a few residents have sitters. The IP stated upon admission families would notify nursing staff that the resident (in general) would have a sitter. The IP stated the nursing staff would then notify the IP nurse. During a review of the facility’s policy and procedures (P&P) titled, “Isolation – Transmission-Based Precautions & Enhanced Barrier Precautions”, dated 4/2025, indicated that standard precautions and enhanced barrier precautions are used when always caring for residents regardless of their suspected or confirmed infection status. The P&P indicated the facility will communicate to staff which residents require the use of EBP. The P&P indicated visitors should wear gowns and gloves if participating in high-contact care activities, especially if interacting with multiple residents. During a review of the facility’s policy and procedures (P&P) titled, “Infection Control”, dated 4/2025, indicated upon admission, and the suspect or diagnosis of infection, educate the resident, family/responsible party, visitor and staff regarding the prevention of the spread of infection. The P&P indicated that a review of the importance of hand hygiene and the use of PPE would be conducted. 2.During an observation on [DATE] at 11:24 PM on the first-floor hallway, a used two-liter (a metric unit of volume) bottle of hand sanitizer with an expiration of date of 1/2024 was found on top of the nurses’ station counter. During an interview on [DATE] at 11:29 PM with the DON, the DON stated the hand sanitizer was sticky and would not be effective since the alcohol was expired. During an interview on [DATE] at 3:31 PM with Infection Preventionist Nurse (IPN), IPN stated expired hand sanitizer would be ineffective since the alcohol level would decrease, it would be an infection control issue. During an observation on [DATE] at 1 PM, in the medication storage room located on the second floor, one open box that contained 15 COVID-19 test kits with expiration date of [DATE] were observed on top of the counter. During an observation on [DATE] at 1:22 PM, in medication cart number three, two expired COVID-19 antigen test kits were observed in the bottom drawer with an expiration of [DATE]. During a concurrent observation and interview on [DATE] at 1:39 PM, with Licensed Vocational Nurse (LVN) 5, one COVID-19 test kit was observed in the bottom drawer of medication cart number two with an expiration date of [DATE]. LVN 5 stated if an expired COVID test was used, the COVID test would give a false positive. During an interview on [DATE] at 1:45 PM with the DON, and Registered Nurse (RN) 2, they (DON and RN2) stated expired COVID test kits could give an inaccurate reading. During an interview on [DATE] at 1:58 PM with the IP nurse, the IP nurse stated expired COVID kits would not give an accurate reading and could give a false positive. During an observation on [DATE] at 8:39 AM of medication cart number one, there were two open boxes of expired medium sized gloves with an expiration date of [DATE]. Three open boxes of gloves with an expiration of [DATE], found in the hallway on top of a clear plastic container with PPE supplies. During an interview on [DATE] at 8:41 AM with LVN 6, LVN 6 stated using expired gloves would not provide any protection. LVN6 stated expired gloves could cause a rash. LVN 6 stated the nursing staff (in general) had the responsibility to check for expired items. During an observation on [DATE] at 8:43 AM in the storage supply room on level 1, there were 13 boxes of medium sized gloves with an expiration date of [DATE]. There were 19 boxes of expired medium sized gloves in supply storage room on level 2 with expiration date of [DATE]. During an interview on [DATE] at 8:52 AM with the DON and RN 2, the DON and RN2 stated expired gloves would not be usable. The DON and RN2 stated expired gloves would not provide any protection for residents against the spread of germs. During an observation on [DATE] at 8:55 AM of medication cart number three had one box of medium gloves with expiration of [DATE]. During an interview on [DATE] at 9:05 AM with the IPN stated, using expired gloves could break and could cause the spread of infections. During a review of the facility's policy and procedure (P&P) titled, Infection Control, dated [DATE], the P&P indicated It the policy of this facility to prevent the spread of infection.” During a review of the facility's policy and procedure (P&P) titled, Equipment and Supply Condition and Expiration Compliance, dated 1/2025, the P&P indicated … is committed to maintaining all equipment in good working condition and ensuring that no expired supplies are used in the care of residents.” The P&P indicated, “ Damaged, malfunctioning, or outdated equipment must be reported immediately… and removed from service.”

Based on observation, interview, and record review the facility failed to provide care in a manner that maintained or enhanced the dignity and respect for one of two sampled residents (Resident 168) as evidenced by failing to ensure Resident 168's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag (a bag designed to collect urine drained from the bladder via a catheter) was covered with a privacy bag (a cover that discreetly conceals a urine drainage bag from public view).This failure had the potential for Resident 168 to experience psychosocial distress (a state of emotional suffering characterized by feelings of sadness, anxiety (nervousness), and other negative emotions) and violated Resident 168's right to be treated with dignity (the state of being worthy, honored, or respected).Findings:During a review of Resident 168's admission Record, the admission Record indicated the facility admitted the resident on 7/26/2025 with diagnoses that included multiple sclerosis (a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), urinary tract infection (an infection in the bladder/urinary tract), atherosclerosis of the renal artery (a condition where plaque buildup narrows or blocks the arteries that supply blood to the kidneys), and muscle weakness.During a review of Resident 168's Order Summary Report dated 7/26/2025, the Order Summary Report indicated the resident had a physician order for a foley catheter (a type of urinary catheter) for a neurogenic bladder (a condition where nerve damage disrupts the normal communication between the brain, spinal cord, and bladder, leading to bladder dysfunction).During a review of Resident 168's Care Plan Report dated 7/31/2025, the Care Plan Report indicated the resident was at risk for complications with the urinary system related to a neurogenic bladder. The Care Plan Report indicated a goal for Resident 168 to maintain comfort and dignity daily. The Care Plan Report indicated an intervention for a privacy cover to Resident 168's catheter bag as indicated to promote dignity.During a concurrent observation and interview on 8/4/2025 at 12:30 PM, with Resident 168's, in Resident 168's room, Resident 168 was observed without a privacy cover on her foley catheter drainage bag. Resident 168 stated she usually had a covering that goes over her foley catheter drainage bag to hide and cover the urine inside the bag, but she didn't know what happened to it. During a concurrent observation and interview on 8/4/2025 at 12:34 PM, Certified Nursing Assistant 5 (CNA 5), in Resident 168's room, Resident 168 was observed without a privacy cover on her foley catheter drainage bag. CNA 5 stated Resident 168 should have a privacy cover on her foley catheter drainage bag to maintain the resident's dignity.During an interview on 8/7/2025 at 1:31 PM with the Director of Nursing (DON), the DON stated a foley catheter urinary drainage bag should have a privacy cover in place for the resident's dignity. The DON stated there was potential for Resident 168 to experience psychosocial distress due to the resident's dignity not being upheld and respected.During a review of the facility's Policy and Procedure (P&P) titled Resident Rights dated 1/2025, the P&P indicated Employees shall treat all residents with kindness, respect, and dignity.Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interview, and record review the facility failed to ensure to provide a Physician Orders for Life-Sustaining Treatment (POLST - a document that outlines a seriously ill patient's preferences for medical treatment, particularly at the end of life) to one of one sampled resident (Resident 186).This failure had the potential not to follow Resident 186's wishes for end-of-life.Findings:During a review of Resident 186's admission Record, the admission Record indicated the facility admitted the resident on 7/28/2025 with diagnoses including heart failure (a condition where the heart muscle cannot pump enough blood and oxygen to meet the body's needs) and metabolic encephalopathy (is a condition where brain dysfunction occurs due to a chemical imbalance in the body).During a review of Resident 186's Minimum Data Set (MDS - a resident assessment tool), dated 8/3/2025, indicated the resident was not oriented to time and had poor recall. The MDS indicated Resident 186 had trouble concentrating on things, felt down, sad, or hopeless.During an observation on 8/4/2025 at 9:53 AM in Resident 186's room, Resident 186 was lying in bed, the bed rails (are adjustable metal or rigid plastic bars that attach to the bed) were up on both sides of the bed. Resident 186 was on oxygen by nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at a rate of 2 Liters/min (2 liters of oxygen should flow into the patient's nose in 1 minute) dated 8/4/2025. Resident 186 had a foley catheter (a flexible, sterile tube inserted into the bladder to drain urine) and a dignity bag (a fabric or vinyl pouch designed to conceal the urinary drainage bag attached to a catheter) in place.During a concurrent interview and record review on 8/5/2025 at 11:05 AM with the Registered Nurse Supervisor (RN 1), Resident 186's POLST document was reviewed. RN 1 stated Resident 186 was a full code (a medical term used to indicate that a patient wishes to receive all possible life-saving measures in the event of a medical emergency) from the General Acute Care Hospital (GACH). The POLST was blank, RN 1 stated that Social Services obtained the advance directive and POLST for residents (in general).During an interview on 8/5/2025 at 11:05 AM with Social Services Director (SSD), the SSD stated Resident 186's Advance Directive Acknowledgement was obtained on 7/28/2025 and signed by the resident representative. The SSD stated the POLST should be done by the nursing staff and to direct the question to the Director of Nursing (DON).During an interview on 8/5/2025 at 11:27 AM with RN 1, RN 1 was not able to answer if the licensed nurses (in general) were able to do the POLST for the residents. RN 1 stated she would have to ask the DON whether licensed nurses were able to do the POLST. RN 1 stated upon admission, she (RN1) had done a POLST for other residents in the past.During an interview on 8/5/2025 at 11:41 AM with the DON, the DON stated that Resident 186 was a full code and that if the facility obtained an advanced directive, then the POLST was not needed. The DON stated that the Advance Directive was not to be used instead of POLST. The DON stated that the POLST was voluntary according to the facility policy.During a concurrent interview and record review on 8/5/2025 at 2:50 PM with the DON, the facility policy and procedures (P&P) titled, Physician Orders for Life-Sustaining Treatment, dated 1/2024 and the California Department of Public Health All Facilities Letter (AFL) dated 1/3/2009 were reviewed. The DON stated the P&P, and the AFL indicated completing the POLST form was a voluntary option. During an interview on 8/6/2025 at 8:26 AM with the DON, the DON was informed that the AFL form was indicated for a state survey recertification and the facility was surveyed under a federal recertification. The DON stated that all residents (in general) should have a POLST. The DON stated that Resident 186 would be at risk for the facility not caring out the resident's end of life wishes in the event of an emergency.During a review of the facility's (P&P) titled, Physician Orders for Life-Sustaining Treatment (POLST), dated 01/2024, indicated the facility would use the POLST for cardiopulmonary resuscitation (medical procedure involving repeated compression of a patient's chest, performed to restore the blood circulation and breathing) and related emergency measures to maintain life functions. The P&P indicated the POLST was a legally valid physician order and complements an Advance Directive and is not intended to replace that document.

Based on observation, interview, and record review the facility failed to ensure to develop a care plan for one of one sampled resident (Resident 175) who had a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).This failure had the potential for Resident 175 not to receive the necessary care and services for the diagnosis of depression.Findings:During a review of Resident 175's admission Record, the admission Record indicated the facility admitted the resident on 3/14/2025 with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic bronchitis (persistent inflammation of the bronchial tubes, the air passages to the lungs, leading to excessive mucus production and breathing difficulties), and acute respiratory failure (a sudden and potentially life-threatening condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide).During a review of Resident 175's Physician Diagnosis Verification form, dated 3/17/2025, the Physician Diagnosis Verification form indicated no depression diagnosis identified. The Physician Diagnosis Verification form identified the resident's primary as the prescribing doctor.During a review of Resident 175's Care Plan Report dated 3/24/2025, the Care Plan Report indicated the resident had the potential for side effects, complications or adverse reactions an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof) related to the ordered use of drug, Escitalopram Oxalate (medication to treat depression). The Care Plan Report indicated there was no care plan for depression.During a review of Resident 175's Minimum Data Set (MDS - a resident assessment tool) dated 6/13/2025 indicated the resident was not oriented to time and had poor recall. The MDS indicated Resident 175 felt little interest or pleasure in doing things, felt down, sad, or hopeless, had trouble falling or staying asleep or sleeping too much nearly every day. The MDS indicated Resident 175 was not triggered for depression for active Diagnoses.During an observation on 8/4/2025 at 11:47 AM in Resident 175's room, Resident 175 was lying in bed, bed rails (are adjustable metal or rigid plastic bars that attach to the bed) were up on both sides of the bed, and the call light (a device used by a patient to signal his or her need for assistance) was within reach.During a review of Resident 175's Order Summary Report, dated 8/6/2025, the Order Summary Report indicated that Escitalopram was taken for depression manifested by withdrawn behavior.During an interview on 8/6/2025 at 1:55 PM with the Minimum Data Set Nurse (MDSN), the MDSN stated the diagnosis of depression could not be triggered without an order from the psychologist (is a person who specializes in the study of mind and behavior). The MDSN stated that any resident on psychotropic (any drug that affects the brain) medications were referred for a psychologist's evaluation. The MDSN stated the psychologist progress notes had not been updated to reflect Resident 175 was prescribed Escitalopram. The MDSN stated the psychologist nurse practitioner would give the progress note to the medical records staff to be updated and scanned, then the MDSN would be able to see the diagnosis and medication. The MDSN stated that a resident on psychotropic medications should have a diagnosis. The MDSN stated Resident 175's primary doctor ordered Escitalopram. During a review of the General Acute Care Hospital (GACH) history and physical dated 3/17/2025 and 7/22/2025 indicated no diagnosis of depression or taking Escitalopram in the hospital. The MDSN could not explain why there was no current psychologist note present. The MDSN stated that there was a break in the process because the medical diagnosis, MDS, and care plan had not been triggered for depression. The MDSN stated Resident 175 would be at risk for inappropriate use of the medication.During an interview on 8/6/2025 at 2:23 PM with the Director of Nursing (DON), the DON stated that there was no order from the psychologist which was the reason the diagnosis of depression, MDS, and the care plan were not triggered. The DON stated Resident 175 took Escitalopram or had a diagnosis of depression from the GACH when the resident was admitted . The DON stated that Resident 175's primary doctor ordered Escitalopram. The DON stated without a medical diagnosis/triggered MDS/ and depression care plan, Resident 175 would be at risk for missing side effects of the medication and progression of symptoms of the disease.During a concurrent interview and record review on 8/6/2025 at 3:10 PM with the DON and the MDSN, a Psychologist Nurse Practitioner's Progress Note dated 7/16/2025 was reviewed, the Progress Note indicated a diagnosis of depression and prescribed Lexapro (medication for depression) 5 milligrams (mg, a unit of measurement). The DON stated that the progress note did not get to the medical records for the note to be scanned and the MDSN to therefore be able to trigger the depression in the MDS and care plan. A voice message was left for the psychologist nurse practitioner on 8/7/2025 at 8:20 AM, no call back was received.During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered dated 1/2025, indicated the comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychological and functional needs. The P&P indicated the care plan should include measurable objectives and time frames, services to be furnished to assist with the resident's wellbeing and include any specialized services. The P&P indicated the interdisciplinary team should review and revise the care plan when there is a significant change in the resident's condition, when the resident was readmitted to the facility from a hospital stay.

Based on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) settings for two of five sampled residents (Resident 146 and Resident 205). These failures had the potential to cause harm to Resident 146 and Resident 205 by increasing the residents' risk of skin breakdown and development of pressure ulcers/injuries (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). Findings: During a review of Resident 146’s admission Record, the admission Record indicated the facility initially admitted the resident on 7/16/2022, with diagnoses that included Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the right heel , dementia (a progressive state of decline in mental abilities), malignant neoplasm of the bone (bone cancer, uncontrolled cell growth that originates in the bone), difficulty in walking, and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 146’s Minimum Data Set (MDS, a resident assessment tool) dated 7/19/2025, the MDS indicated the resident had severe cognitive impairment (impaired ability to think, understand, and reason). The MDS indicated Resident 146 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 146 had one Stage 4 pressure ulcer that was present on the resident’s admission to the facility. The MDS indicated Resident 146 utilized a pressure reducing device for bed. During a review of Resident 146’s Weights and Vitals Summary, the Weights and Vitals Summary indicated the resident weighed 127 pounds (lbs., a unit of weight) on 8/4/2025. During a concurrent observation and interview on 8/4/2025 at 12:08 PM, with Licensed Vocational Nurse 4 (LVN 4), in Resident 146’s room, Resident 146 was observed on a “Domus 4” LALM with settings at 450 lbs. LVN 4 stated that Resident 146’s LALM settings were set at 450 lbs. LVN 4 stated the LALM settings should be based on Resident 146’s weight. LVN 4 stated Resident 146’s LALM settings at 450 lbs., were incorrect. During a review of Resident 146’s Order Summary Report dated 8/5/2025, the Order Summary Report indicated the resident was to use a LALM for skin management. The Order Summary Report indicated to set the LALM according to Resident 146’s weight. During a review of Resident 146’s Care Plan Report dated 8/5/2025, the Care Plan Report indicated the resident had a LALM for skin management. The Care Plan Report indicated to set the LALM according to Resident 146’s weight. During an interview on 8/7/2025 at 1:31 PM with the Director of Nursing (DON), the DON stated the LALM were set per manufacturer’s guidelines and on the resident’s weight. The DON stated Resident’s LALM settings at 450 lbs. were incorrect. The DON stated Resident 146 weight 127 lbs., on 8/4/2025. The DON stated Resident 146’s LALM settings should be set around the range of 127 lbs. The DON stated the purpose of the LALM was for wound management. The DON stated there could be potential for the delay in the healing process of Resident 146’s pressure ulcers when the resident’s LALM are kept on the wrong settings. During a review of the undated instruction manual titled “Domus 4 Instruction Manual”, the instruction manual indicated “General operation .According to the weight and heights of the patient, adjust the pressure setting to the most comfortable level without bottoming out, then the pressure mattress will slowly increase to the intended value after the air mattress is ready to use.” During a review of the facility’s policy and procedure (P&P) titled, “Low Air Loss Mattress General Procedure” dated 1/2025, the P&P indicated, “A physician’s order is required prior to initiating use of a low air loss or pressure redistribution mattress, as part of a clinically indicated intervention for residents assessed to be at risk…” The policy further indicated, “For residents who are cognitively impaired or non -verbal, pressure settings shall be determined based on a resident’s weight in accordance with manufacture’s specifications…” During a review of the facility’s policy and procedure (P&P) titled, “Prevention of Pressure Ulcers/Injuries” revised 1/2025, the P&P indicated, “Utilize LALM as per manufacture’s guidelines of resident comfort and in accordance with physician’s orders.” 2.During a review of Resident 205’s admission Record, the admission Record indicated the facility admitted Resident 205 on 7/28/2025, with diagnoses including malignant neoplasm of liver(cancerous tumor growing in the liver), nutritional anemia(not enough healthy red blood cells to carry oxygen),protein-calorie malnutrition( poor nutrition), ), atherosclerotic heart disease of native coronary artery( buildup of fats, cholesterol in the artery walls), acute respiratory failure with hypoxia( lungs can’t get enough oxygen into the blood and the body isn’t getting enough oxygen overall), muscle weakness, difficulty walking and adult failure to thrive(a syndrome characterized by weight loss, decreased appetite, reduced physical activity , and impaired cognitive function). During a review of Resident 205's care plan titled Risk for skin breakdown, dated 7/28/2025, indicated interventions for Resident 52's LALM for patient preference. Date initiated: 8/5/2025. During a review of Resident 205’s Order Summary Report, dated 7/29/2025, indicated there was no order for a LALM. During a review of Resident 205’s MDS dated [DATE], the MDS indicated Resident 52 had severe cognitive (ability to think and reason) impairment skills for daily decision making, and was dependent (helper does all of the effort) from the staff for toileting hygiene and transfer, lower body dressing, sit to standing, chair/bed to chair transfer and required substantial/maximal assistance (helper does more than half the effort) from the staff with upper body dressing, rolling left and right, sit to lying and lying to sitting on the side of the bed. During an observation on 8/4/25 at 10:25 a.m., Resident 205 was in bed with her eyes closed. Resident 205’s LALM was on and set to 450 pounds. During an interview on 8/5/2025 at 8:08 AM, with Licensed Vocational Nurse (LVN)3, LVN 3 stated the licensed nurses (in general) needed the orders for LAL mattress. LVN3 stated the licensed nurses (in general) needed to know how to set the LAL mattress. LVN 3 stated the licensed nurses (in general) needed to set the proper LAL mattress settings, otherwise it could cause harm to the resident. LVN3 stated the licensed nurses (unidentified) requested an order from the medical doctor for a proper setting for use. During a concurrent interview and record review on 8/5/2025 at 8:32a.m., with the Assistant Director of Nursing (ADON), the ADON stated the LAL mattress settings depended on the resident's weight, if not at the proper setting, it would defeat the purpose of the LAL mattress. The ADON stated the orders needed to be placed for settings. The ADON stated the resident’s weight was 137 pounds on admission, and no orders were placed for an LAL mattress on admission and that the orders were placed until 8/5/2025. During a review of the undated instruction manual titled “Domus 4 Instruction Manual”, the instruction manual indicated “General operation .According to the weight and heights of the patient, adjust the pressure setting to the most comfortable level without bottoming out, then the pressure mattress will slowly increase to the intended value after the air mattress is ready to use.” During a review of the facility’s policy and procedure (P&P) titled, “Low Air Loss Mattress General Procedure” dated 1/2025, the P&P indicated, “A physician’s order is required prior to initiating use of a low air loss or pressure redistribution mattress, as part of a clinically indicated intervention for residents assessed to be at risk…” The policy further indicated, “For residents who are cognitively impaired or non -verbal, pressure settings shall be determined based on a resident’s weight in accordance with manufacture’s specifications…” During a review of the facility’s e LALM as per manufacture’s guidelines of resident comfort and in accordance with physician’s orders.”

Based on observation, interview, and record review, the facility failed to provide appropriate care and services to provide respiratory care for four of four sampled residents (Resident 14, Resident 28, Resident 170, and Resident 175) by failing to ensure: 1. To label and date the oxygen (a chemical element, a gas that is colorless, odorless, and tasteless and a key component of the air we breathe) tubing according to physician's order for Resident 14. 2. To display a precaution sign on the door for Resident 170 who received continuous oxygen. 3. To provide a date for the humidifier (a medical device that adds moisture to oxygen delivered during oxygen therapy) for Resident 28 and Resident 175. These failures placed Resident 14, Resident 28, Resident 170, and Resident 175 at risk for respiratory infection and injury. Findings: 1. During a review of Resident 14’s admission Record, the admission Record indicated the facility admitted the resident on 5/4/2023 with the most recent readmission on [DATE] with diagnoses that included, but no limited to chronic heart failure (CHF - a long-term heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hypertension (HTN - high blood pressure), end stage renal disease (ESRD - irreversible kidney failure) with dependence on dialysis, (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), anemia (a condition where the body does not have enough healthy red blood cells), muscle weakness, and mild intellectual disabilities (conditions that involve limitations on intelligence, learning and everyday abilities necessary to live independently). During a review of Resident 14’s Minimum Data Set (MDS - a resident assessment tool), dated 6/25/2025, the MDS indicated Resident 14 did not have disorganized thinking and was able to make his own decisions regarding daily tasks. The MDS indicated Resident 14 required set-up or clean-up assistance (the helper assists only prior to or following the activity, the resident completes the activity) with eating. The MDS indicated Resident 14 required supervision or touch assistance (the helper provides verbal cues and/or touching/steadying as the resident completes the activity, assistance may be provided throughout the activity or intermittently) with oral hygiene, toileting hygiene, and dressing the upper body. The MDS indicated Resident 14 required partial to moderate assistance (the helper lifts, holds, or supports trunk or limbs of the resident, but provides less than half the effort) with bathing, showering, and dressing the lower body. During a review of Resident 14’s Care Plan Report with a revision date of 7/3/2025, the Care Plan Report indicated Resident 14 was on oxygen therapy (a way to help your body get enough oxygen when it's not able to do so on its own) related to CHF. The Care Plan Report indicated nursing interventions to ensure the oxygen settings were followed as ordered and to monitor for signs and symptoms of respiratory distress. The Care Plan Report indicated a goal for Resident 14 was not to have signs and symptoms of poor oxygen absorption. During a review of Resident 14’s Order Summary Report, dated 7/15/2025, the Order Summary Report indicated the oxygen tubing was to be changed weekly and to label each component with date and initials. During a concurrent observation and interview, on 8/4/2025 at 10:11 AM, in Resident 14’s room, the resident was observed to be on oxygen therapy through a nasal cannula (a small plastic tube, which fits into the person’s nostrils for providing oxygen). Resident 14 stated that he was reliant (dependent) on continuous oxygen. Resident 14 stated his nasal cannula was changed on 8/3/2025 and that it was changed at least once a week. There was no label with a date observed on the nasal cannula. During an interview on 8/6/2025 at 8:24 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 14’s nasal cannula was changed once a week and as needed. LVN 1 stated the nasal cannula should be labeled with the date and time it was changed. LVN 1 stated that if the nasal cannula was not labeled, the staff (in general) would not know if it was contaminated. LVN 1 stated Resident 14 could get an infection from an unsanitary nasal cannula so it would be important to label it. During an interview on 8/6/2025 at 8:39 AM, with Registered Nurse Supervisor (RN) 1, RN 1 stated for Resident 14 who was on oxygen therapy, staff (in general) should check if the nasal cannula was cleaned and not damaged. RN 1 stated Resident 14’s nasal cannula should be changed every seven days and as needed. RN 1 stated Resident 14’s nasal cannula should be labeled to indicate the date it was changed. RN 1 stated if there was no date on Resident 14’s nasal cannula, it may end up being used for a long time and can cause an infection or allergy, therefore, the nasal cannula should be labeled and dated. During an interview on 8/6/2025 at 8:50 AM, with the Director of Nursing (DON), the DON stated Resident 14’s nasal cannula should be changed every week and as needed and would need to have the date on the label. The DON stated the date on the label would indicate when the nasal cannula was changed. The DON stated if Resident 14’s nasal cannula was not dated, staff (in general) would not know if the nasal cannula had been changed or not. The DON stated there would be a risk for damage to the nasal cannula and risk for infection with prolonged use. The DON stated Resident 14’s nasal cannula should be labeled and dated every time it was changed. During a review of the facility’s Policy and Procedure (P&P) titled “Oxygen Administration” dated January 2025, the P&P indicated “The purpose of this procedure is to provide guidelines for safe oxygen administration…The following equipment and supplies will be necessary when performing this procedure…Nasal cannula, nasal catheter, mask (as ordered); date nasal cannula once in use…” 2. During a review of Resident 170’s admission Record, the admission Record indicated the facility admitted the resident on 7/7/2025 with diagnoses that included metabolic encephalopathy (a condition where the brain's function is impaired due to chemical imbalances in the body, often caused by an underlying illness or organ dysfunction), atelectasis (condition where part or all of a lung collapses or deflates), pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity), muscle weakness, anxiety (a feeling of worry, nervousness, or unease), and benign prostatic hyperplasia (a common condition in men where the prostate gland gets larger, but it's not cancerous). During a review of Resident 170’s MDS dated [DATE], the MDS indicated Resident 170’s speech was slurred or mumbled. The MDS indicated Resident 170 was usually able to make himself understood and had the ability to usually understand others. The MDS indicated Resident 170 was dependent (the helper does all of the effort, the resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on staff (in general) for eating, oral hygiene, toileting hygiene, bathing, and dressing. The MDS indicated Resident 170 was also dependent on staff (in general) for mobility such as rolling left and right, moving from sitting to lying position, moving from sitting to standing position, and walking. The MDS indicated Resident 170 was on continuous oxygen therapy when it's not able to do so on its own) while in the facility. During a review of Resident 170’s Order Summary Report, dated 7/15/2025, the Order Summary Report indicated the resident was to have continuous oxygen therapy at three liters a minute via nasal cannula. During a review of Resident 170’s Care Plan Report with a revised of 7/21/2025, the Care Plan Report indicated the resident was at risk for complications with the respiratory system due to pleural effusion and atelectasis. The Care Plan Report indicated interventions that included assessing for signs and symptoms of hypoxia (low levels of oxygen in your body tissues), monitoring for shortness of breath, and positioning the head of the bed elevated to facilitate breathing. The Care Plan Report indicated a goal for Resident 170 was not to exhibit signs of respiratory distress. During an observation on 8/4/2025 at 12:08 PM, in Resident 170’s room, the resident was observed to be on oxygen therapy through a nasal cannula. There was no “Oxygen in Use” sign observed posted inside or outside of Resident 170’s room. During a concurrent observation and interview on 8/6/2025 at 8:35 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 observed there was no “Oxygen in Use” sign posted outside or inside of Resident 170’s room. LVN 1 stated Resident 170, who was on oxygen, should have the sign posted because it would be dangerous if there was faulty wiring that sparked or if the resident’s roommate smoked which would cause a fire or explosion. During an interview on 8/6/2025 at 8:44 AM, with Registered Nurse Supervisor (RN) 1, RN 1 stated that not having an “Oxygen in Use” sign posted outside of Resident 170’s room would not alert staff (in general) and visitors that oxygen was being used, and would cause a fire or explosion if a person smoked or if there was a spark in the room. During an interview on 8/6/2025 at 8:57 AM, with the Director of Nursing (DON), the DON stated there should be an “Oxygen in Use” sign posted for any resident on oxygen for safety reasons. The DON stated the sign should be posted for Resident 170’s room to make everyone aware that oxygen was in use. The DON stated oxygen was combustible (capable of catching fire and burning) and there would be potential for hazard, like fire, if there was smoking paraphernalia in the room. The DON stated it was very important to have the sign as a measure to indicate that Resident 170 was on oxygen. During a review of the facility’s Policy and Procedure (P&P) titled “Respiratory Care Policy” dated January 2025, the P&P indicated “Oxygen in use sign will be placed outside the patient’s room.” 3.During a review of Resident 28’s admission Record, the admission Record indicated the facility admitted the resident on 12/10/2023 with diagnoses of bronchiectasis (chronic lung condition where the airways [bronchial tubes] become damaged and widened, making it difficult to clear mucus), and acute respiratory failure with hypoxia (a severe medical condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low blood oxygen levels [hypoxia]). During a review of Resident 28’s MDS dated [DATE], the MDS indicated the resident was not oriented to time and had poor recall. The MDS indicated that Resident 28 needed continuous, intermittent and high-concentration oxygen therapy. During a review of Resident 175’s admission Record, the admission Record indicated the facility on 3/14/2025 with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic bronchitis (persistent inflammation of the bronchial tubes, the air passages to the lungs, leading to excessive mucus production and breathing difficulties), and acute respiratory failure (a sudden and potentially life-threatening condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide). During a review of Resident 175’s MDS dated [DATE] indicated that Resident 175 needed continuous, intermittent (occurring at irregular intervals), and high concentration of oxygen therapy. During an observation on 8/4/2025 at 11:40 AM in Resident 28’s room, Resident 28 was lying in bed side rails up, and the call light was within reach. Resident 28 had a nasal cannula dated 8/4/2025, the humidifier was not labeled with the date. During an observation on 8/4/2025 at 11:47 AM in Resident 175’s room, Resident 175 was lying in bed, family at the bedside. Resident 175’s nasal cannula was dated 8/4/2025 but the humidifier was not labeled with the date. During a review of Resident 175’s Order Summary Report dated 7/17/2025 indicated the resident to have continuous oxygen via nasal cannula at 2 liters/min and the oxygen tubing changed weekly and label each component with date and initials. During a concurrent observation and interview on 8/4/2025 at 11:43 AM with LVN 1 in Resident 28’s and Resident 175’s rooms, the humidifiers were observed not to be labeled with a date when it was changed. LVN 1 stated that the humidifiers should be labeled. LVN 1 stated that he (LVN1) was not sure if the practice of labeling the humidifier was per the facility policy. LVN 1 stated Resident 28 and Resident 175 were at risk of the humidifiers expiring if not labeled when the last time it was changed. During an interview on 8/6/2025 at 2:18 PM with the DON, the DON stated oxygen tubing and humidifiers should be labeled with the dated and changed weekly and as needed. The DON stated small sticky notes were provided for labeling the date. The DON stated Residents 28 and 175 were at risk of infections. The DON stated labeling the humidifier indicated when it needed to be changed, and the labeling is a good indicator for cleanliness and safety. During a review of the facility’s policy and procedures (P&P) titled, “Oxygen Administration,” dated 1/2025, indicated to verify that there was a physician’s order for the procedure and to review the physician's order or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 37) received Balsalazide Disodium (medication used to treat ulcerative colitis [a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum]) 750 milligrams (mg, a unit of measurement) with meals as ordered.This failure had the potential for Resident 37 to experience an upset stomach and pain.Findings:During a review of Resident 37's admission Record, the admission Record indicated the facility admitted Resident 37 on 7/18/2025, with diagnoses including peritoneal abscess(a localized collection of pus within the abdominal cavity),other specified disorders of the peritoneum ( a range of conditions affecting the thin lining of the abdominal cavity), ulcerative colitis(a chronic inflammatory bowel disease that causes ulcers in the lining of the large intestine), acute duodenal ulcer with both hemorrhage and perforation (a sudden severe sore in the upper part of the small intestine that is both bleeding and has created a hole), and surgical aftercare following surgery on the digestive system. During a review of Resident 37's Care Plan Report dated 7/18/2025 indicated Resident 37 was at risk for pain or discomfort due to Gastroesophageal reflux disease (stomach acid flows into the esophagus and causes heartburn), the Care Plan Report indicated nursing interventions to administer medications as ordered. During a review of Resident 37's Order Summary Report dated 7/19/2025, the Order Summary Report indicated for the resident to receive Balsalazide Disodium 750mg one capsule by mouth with meals three times a day. During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool) dated 7/19/2025, the MDS indicated Resident 37 had moderate cognitive (ability to think and reason) impairment skills for daily decision making. During a medication pass observation on 8/5/2025 at 11:39 a.m., of Resident 37, Licensed Vocational Nurse (LVN)2, LVN 2 administered Balsalazide disodium 750mg PO (taken by mouth) to Resident 37. No lunch/ meal observed at bedside. The medication package had an additional blue label indicated with meals and green label indicating NOON, in capitalized letters. During an interview on 8/5/2025 at 11:44 a.m., LVN 2 stated lunch was served around 12 noon. During an interview on 8/5/2025 at 8:08a.m., with LVN 1, LVN1 stated medications that were not taken with food as ordered could cause an upset stomach, gastrointestinal (digestive system) problems. LVN1 stated medications that required to be taken with meals were to prevent an upset stomach and stomach pain. During an interview on 8/7/2025 at 10:34a.m., with the Director of Nursing (DON), the DON stated if medications that were given without food as ordered, a resident (in general) could experience gastric irritation (stomach lining getting irritated or inflamed), and discomfort. During a review of the facility's policy and procedure (P&P) titled, Administering Medications dated 1/2025, the P&P indicated, Medications must be administered in accordance with the orders.

Based on interview and record review the facility failed to ensure one of five sampled facility staff Certified Nursing Assistant 1 (CNA 1) maintained the necessary qualifications for employment at the facility. This failure had the potential to result for CNA 1 not to have the knowledge and qualifications necessary to care for the facility's residents and placed the residents at risk for harm.Findings:During a review of CNA 1's timecard (a record, either physical or digital, that tracks an employee's work hours, including start and end times, breaks, and overtime) dated [DATE] to [DATE], the timecard indicated CNA 1 worked at the facility as a CNA on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].During a review of CNA 1's timecard dated [DATE] to [DATE], the timecard indicated CNA 1 worked at the facility as a CNA on [DATE], [DATE], and [DATE].During a concurrent interview and record review on [DATE] at 9:23 AM, with the Director of Staff Development (DSD), CNA 1's employee file was reviewed. The employee file indicated the CNA Certificate for CNA 1 expired on [DATE]. The DSD stated CNA 1 last worked at the facility on [DATE]. The DSD stated that she (DSD) was just made aware that CNA 1's certification was expired. The DSD stated CNA 1 was working at the facility after her CNA certification expired on [DATE]. The DSD stated the CNA certification had to be active to work at the facility. The DSD stated CNA 1 was not in compliance with the facility's policy.During an interview on [DATE] at 1:43 PM with the Director of Nursing (DON), the DON stated he and the DSD usually review the CNA certification expiration dates monthly but missed that CNA 1's certification expired on [DATE]. The DON stated CNA 1 worked at the facility while her certification was expired. The DON stated CNA 1 had to maintain an active certification to work at the facility. The DON stated CNA 1 was not in compliance with the facility's policy. The DON stated there was a potential for CNA 1 to have less knowledge to care for the facility residents with an expired certification.During a review of the facility's Job Description titled Job Description: Certified Nursing Assistant dated 2/2024, the Job Description indicated Qualifications: Must be a licensed Certified Nursing Assistant in accordance with laws of the state.

Based on observation, interview, and record review, the facility failed to ensure the call light (a device that alerts healthcare providers that the patient needs assistance) was within reach for two of 28 sampled residents (Resident 25 and Resident 164)This deficient practice had the potential to result in delay in meeting Resident 25's and Resident 164's needs for assistance. Findings: 1.During a review of Resident 25’s admission Record, the admission Record indicated the facility admitted the resident on 9/17/2024 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hypertension (HTN - high blood pressure), metabolic encephalopathy (a condition where the brain's function is impaired due to chemical imbalances in the body, often caused by an underlying illness or organ dysfunction), muscle weakness, and failure to thrive (a state of decline characterized by weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 25’s Minimum Data Set (MDS – a resident assessment tool), dated 5/27/2025, the MDS indicated the resident had the ability to sometimes make herself understood and sometimes understood others. The MDS indicated Resident 25 was dependent (the helper does all of the effort, the resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on staff (in general) for toileting hygiene, showering, and moving from sitting to standing position. The MDS indicated Resident 25 required substantial to maximum assistance (the helper lifts or holds trunk or limbs of the resident and provides more than half the effort) with oral and personal hygiene, rolling left and right, and moving from sitting to lying position. During a review of Resident 25’s care plan, reviewed and revised on 6/2/2025, Care Plan Report indicated the resident was at risk for falls related to muscle weakness and osteoarthritis. The Care Plan Report indicated intervention that included keeping the call light within reach. The Care Plan Report indicated a goal for Resident 25 to minimize risk for falls. During a concurrent observation and interview on 8/4/2025 at 11:05 AM, in Resident 25’s room, the call light was observed on the floor to the left side of the resident’s bed by her roommate’s nightstand, out of the Resident 25’s reach. Certified Nurse Assistant (CNA) 4 was observed unable to locate Resident 25’s call light. Activities Director (AT) observed Resident 25’s call light on the floor by her roommate’s nightstand. The AT stated the call light should be within Resident 25’s reach. The AT stated if there was an emergency and Resident 25 needed assistance, staff (in general) would not be alerted to the resident’s needs. During an interview on 8/6/2025 at 11:09 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the call light should be placed within Resident 25’s reach at all times. LVN 1 stated if Resident 25 could not reach the call light, she (Resident 25) would not be able to receive the help that she (Resident 25) needed. LVN 1 stated the call light could be clipped to Resident 25’s bedsheet to prevent the call light from falling off the bed. During an interview on 8/6/2025 at 11:13 AM, with Registered Nurse Supervisor (RN) 1, RN 1 stated if the call light was not within Resident 25’s reach, the resident could fall. RN 1 stated the call light should be within Resident 25’s reach. During an interview on 8/6/2025 at 1:35 PM, with the Director of Nursing (DON), the DON stated if Resident 25 could not reach the call light for assistance, the resident would not be able to have her needs met and the resident would be at risk for falling. The DON stated the call light could be clipped to Resident 25’s bedsheet or gown to keep the call light in place. The DON stated the call light should be within Resident 25’s reach at all times so that staff (in general) would be aware of the resident’s needs. During a review of the facility’s Policy and Procedure (P&P) titled “Answering the Call Light” dated January 2025, the P&P indicated “The purpose of this procedure is to respond to the resident’s requests and needs…When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident…” 2.During a review of Resident 164’s admission Record, the admission Record indicated the facility admitted the resident on 6/20/2025 with diagnoses of difficulty in walking, muscle weakness, history of falls, and age-related cataract (a common eye condition where the lens of the eye becomes cloudy, causing decreased vision). During a review of Resident 164’s Care Plan Report, dated 6/20/2025, the Care Plan Report indicated Resident 164 was at risk for falls with or without injury related to muscle weakness difficulty walking and history of falls. The Care Plan Report indicated under the interventions to keep the call light within reach. During a review of Resident 164’s Care Plan Report, dated 6/20/2025, the Care Plan Report indicated Resident 164 had impaired visual acuity which may impact activities of daily living (ADL - basic self-care tasks that individuals perform to maintain their well-being and independence). The Care Plan Report indicated under the interventions to have the call light within reach and answered timely. During a review of Resident 164’s Care Plan Report, dated 6/20/2025, the Care Plan Report indicated that Resident 164 was at risk for pain, joint stiffness, and/or spontaneous pathological fracture. The Care Plan Report indicated under the interventions to encourage the resident to use the call light to promptly notify staff of needs. During a review of Resident 164’s Care Plan Report, dated 6/20/2025, the report indicated that Resident 164 was at risk for ADL/mobility decline and requires assistant. The Care Plan Report indicated under interventions to encourage the use of the call light for assistance. During a review of Resident 164’s MDS dated [DATE], the MDS indicated the resident had impaired vision, needed some help with self-care, indoor mobility, and functional cognition. The MDS indicated that the resident needed partial and substantial assistance with eating, oral toileting, upper and lower dressing, and personal hygiene. During a concurrent observation interview on 8/4/2025 at 10:48 AM with the Director of Nursing (DON) in Resident 164’s room, Resident 164 was lying in bed, the bed rails (are adjustable metal or rigid plastic bars that attach to the bed ) were up on both sides of the bed, and the call light was on the floor. The DON picked up the call light off the floor and placed it within Resident 164’s reach. The DON stated Resident 164 was at risk for unattended needs and falls. During a review of the facility’s policy and procedures (P&P) titled, “Answering the Call Light”, dated 1/2025, indicated when the resident was confined in the bed or wheelchair to be certain the call light was within easy reach of the resident.

Based on observation, interview, and record review, facility failed to ensure one of four sampled residents (Resident 1)'s medications were not left at bedside after administering and documented according to facility's policy and procedures (P&P) titled, Administering Medications.This deficient practice increased the risk for accidents, unintended complications from receiving more or less than the required medications dose and jeopardized resident's health and safety by failing to administer necessary medications in accordance with the physician order.Findings:During a review of the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnosis including type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking and muscle weakness (weakening, shrinking, and loss of muscle)During a review of the Minimum Data Set (MDS - resident assessment tool) dated 6/30/2025 indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was mildly impaired. The MDS indicated Resident 1 required total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 1's Self-Administration of Medication Observation, dated 6/23/2025, it indicated, Resident 1 does not want to self-administer medications.During a review of Resident 1's Order Summary Report (OSR), the OSR indicated the following medications were ordered by the physician to be administered in the morning at 9 a.m.,i. Metformin (it can treat high blood sugar levels) tablet 500 milligram (MG - unit measurement) - Give 1 tablet by mouth one time a dayii. Multivitamin (used to treat or prevent vitamin deficiency) oral tablet - give 1 tablet by mouth one time a dayiii. Oyster shell calcium (s used to prevent or treat low blood calcium levels) tablet 500 mg - give 1 tablet by mouth in the morningiv. Lisinopril (lowers blood pressure and makes it easier for the heart to pump blood around the body) oral tablet 40 mg - give 40 mg by mouth one time a day v. Methocarbamol (works by calming overactive nerves in the body, which helps the muscles relax) oral tablet 500 mg - give 1 tablet by mouth three times a day.During a concurrent observation and interview with Resident 1 on 7/10/2025 at 9:20 a.m., observed Resident 1 with a medication cup filled with five different kinds of pills. Resident 1 stated she did not take the medications after they were given to her because the nurses didn't explain what her medications were. Resident 1 further stated, the staff leaves the medications on her bedside table.During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 7/10/2025 at 9:43 a.m., RN 1 observed the medication cup with pills in Resident 1's possession. RN 1 stated nurses should not leave the medications at bedside, and Resident 1 is unable to self-administer medications.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 7/10/2025 at 9:46 a.m., LVN 1 stated, he administered Resident 1's medications this morning but he left Resident 1's room without observing her taking the medications. LVN 1 stated, he needs to ensure residents take the medications after administering them so they would know if they actually took the medications.During an interview with Assistant Director of Nursing (ADON) on 7/10/2025 at 11:30 a.m., ADON stated, medications should not be left at bedside. ADON stated, Resident 1 is unable to self-administer medications. ADON stated, if medications were left at bedside, it puts residents at risk of not being able to swallow the entire medications or they won't know if those medications were ordered by the physician.During a review of the facility's policy and procedures (P&P) titled, Administering Medications, reviewed on 1/2025, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observation, interview and record review the facility failed to have one of four exit doors on the resident floors armed with an alarm that would sound when it was being opened. The failure had the potential to lead to a resident elopement (the act of leaving a facility unsupervised and without prior authorization) or accident. Findings: During an observation on 5/12/25 at 12:32 pm on the north side of the facility ' s 1st floor, to the left of room [ROOM NUMBER], a exit door to the stairwell was observed with signage CAUTION ALARM IS ON EMERGENCY EXIT ONLY and signage in red OF EMERGENCY EXIT ALARM WILL SOUND IF DOOR IS OPENED. During the same observation a tall staff member with black scrubs was observed opening the door and entering the stairwell without an alarm sounding or the staff using a key to deactivate the alarm. During a concurrent observation and interview on 5/12/25 at 12:33 pm, with Certified Nursing Assistant (CNA) 1 the exit door to the stairwell next to room [ROOM NUMBER] was observed. CNA 1 stated she does not know why the exit door is not alarming as she opens the door and verifies it then states it should alarm when it is opened. During a concurrent observation and interview on 5/12/25 at 12:36 pm, with Housekeeping Supervisor (HKS) the exit door next to room [ROOM NUMBER] was observed being opened and keys being used to arm the door with the alarm and engage it, after several tries HKS stated it must be broken it is not alarming. During an interview with on 12:50 pm with the Director of Nursing (DON), the DON stated the risk of having the exit door not alarm when opened, is that someone that is confused could open it and then have an accident or fall. During a review of the facility ' s policy and procedures revised January 2025 indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Safety risks and environmental hazards are identified no an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.

Based on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infection (UTI- an infection in the bladder/urinary tract) for two of two sampled residents (Resident 2 and Resident 3) by failing to ensure resident's indwelling urinary (foley) catheters (a hollow tube inserted into the bladder to drain or collect urine) were placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for the residents. Findings: 1. A review of the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream) and obstructive and reflux uropathy (a condition where urine flow is blocked within the urinary tract causing urine to backflow upwards into the kidneys potentially damaging the kidney tissue). A review of the Minimum Data Set (MDS - resident assessment tool) dated 10/7/2024, indicated Resident 2's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was mildly impaired. The MDS indicated Resident 2 required moderate to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS also indicated Resident 2 has an indwelling catheter. A review of Resident 2's Order Summary Report, dated 10/2/2024 indicated, physician ordered foley catheter to bedside straight drainage for diagnosis/history (hx) of obstructive uropathy (a medical condition that refers to any disorder or disease affecting the urinary tract). During an observation of Resident 2 on 12/19/2024 at 12:36 p.m., Resident 2 was observed lying in bed, with a foley catheter bag placed above Resident 2's bladder. Resident 2's indwelling catheter tubing was observed with amber color urine and was not draining into the indwelling catheter drainage bag. During an interview with Licensed Vocational Nurse (LVN 1) on 12/19/2024 at 12:58 p.m., LVN 1 observed Resident 2's indwelling catheter and stated, the indwelling catheter bag was placed too high, and the urine was not draining in the indwelling catheter drainage bag. LVN 1 stated, it (the indwelling catheter bag) should be placed below resident's bladder. LVN 1 further stated, there is urine in the indwelling catheter tubing, and it was draining into the indwelling catheter collection bag. 2. A review of the Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and retention of urine (a condition that makes it difficult to empty the bladder, either partially or completely). A review of the MDS dated [DATE], indicated Resident 3's cognitive skills for daily decisions was moderately impaired. The MDS indicated Resident 3 required total dependence from staff for ADLs. A review of Resident 3's Order Summary Report, dated 10/30/2024 indicated, physician ordered indwelling catheter to bedside straight drainage for diagnosis/history (hx) of need neurogenic bladder (a condition that causes bladder control issues due to damage to the nervous system). During an observation of Resident 3 on 12/19/2024 at 12:56 p.m., Resident 3 was observed lying in bed, with an indwelling catheter bag placed above Resident 3's bladder. Resident 3's indwelling catheter tubing was twisted and kinked. The urine was observed not draining into the indwelling catheter drainage bag. During an interview with LVN 1 on 12/19/2024 at 12:59 p.m., LVN 1 observed Resident 3's indwelling catheter and stated, the indwelling catheter bag was placed too high, and the urine was not draining in the indwelling catheter drainage bag. During an interview with Director of Nursing (DON) on 12/19/2024 at 2:50 p.m., DON stated if the indwelling catheter drainage bag was not placed below residents' bladder, it may back up in the bladder and cause infection. A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised January 2024, the P&P indicated, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.

Based on interview and record review, the facility failed to ensure resident assessment and documentation were complete concerning resident's death for one of three sampled residents (Resident 1) by failing to implement facility's policy and procedure (P&P) titled, Death of a Resident when Resident 1 expired on [DATE]. This deficient practice resulted in incomplete assessment and documentation for Resident 1 required per facility's policy and procedure upon death. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute on chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), -chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of the Minimum Data Set (MDS - resident assessment tool) dated [DATE], indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required supervision to moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's Progress Notes dated [DATE] indicated, At 12 a.m., Resident (1) asked for breathing treatment given by Charge Nurse as ordered, tolerated well . At 12:10 a.m., resident has panic attack and nurse with him (Resident 1) trying to comfort him but suddenly he passed out. Checked all vitals, cardiopulmonary resuscitation (CPR - medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) initiated right away and called 911 (three-digit telephone number '[DATE]' has been designated as the universal emergency number for citizens throughout the United States to request emergency assistance). At 12:25 a.m., paramedics came and took over the emergency . At 12:56 a.m., paramedics stop the CPR and pronounced resident's (Resident 1) death. A review of Resident 1's electronic medical record and paper medical record as of [DATE], indicated there were no physician's progress notes that was completed, and no death certificate was on file. During an interview with Medical Record Director (MRD) on [DATE] at 3:09 p.m., MRD stated, there were no death certificate on file and NO record of the cause of death in the medical records. MRD also stated she was not aware of their policy regarding requesting death certificate from the physician timely. During an interview with Director of Nursing (DON) on [DATE] at 2:53 p.m., DON stated, a death certificate should have been requested and documented per their policy. A review of facility's policy and procedure (P&P) titled, Death of a Resident, revised on revised ,d+[DATE], the P&P indicated, The Attending Physician must record the cause of death and file a death certificate with the appropriate agency within 24 hours of the resident's death or as may prescribed by state law.

Based on observation, interview and record review, the facility failed to maintain an infection control measure and prevention by failing to 1. Ensure the staff wear a gown to have a complete personal protective equipment (PPE-mask, gown, eye protection, gloves) before providing close-contact care for resident on Enhanced barrier precautions during high contact resident care activities. 2. Perform proper hand hygiene including changing gloves in between procedure while doing treatment care for three of three sampled residents (Resident 1, 2, and 3) per facility policy. These deficient practices have the potential to result in the spread of disease and infection to other residents, visitors, and staff. Findings: 1. A review of the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (loss of the ability to move in one side of the body) following unspecified cerebrovascular disease (CVD - a group of conditions that affect the blood vessels and blood flow in the brain and spinal cord) affecting left dominant side, chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of the Minimum Data Set (MDS - resident assessment tool) dated 10/24/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's physician order summary report indicated: i. cleanse gastrostomy site (g-tube - a feeding tube that is surgically inserted into the stomach through the skin and stomach wall) with normal saline (a sterile solution of water and salt that is used in medicine for a variety of purposes, including wound cleaning) cover with dry dressing every day, dated 11/22/2024. ii. Enhanced barrier precautions during high contact resident care activities, dated 5/2/2024. During an observation with Treatment Nurse 2 (TXN2) in Resident 1's room on 12/16/2024 at 11:41 a.m., observed TXN1 doing dressing changes on Resident 1 g-tube dressing. TXN1 removed the old g-tube dressing, cleanse with NS and applied a new dressing. TXN2 was not wearing a gown prior to entering the room and did not do a proper hand sanitize in between changing of gloves. During an interview with TNX 2 on 12/16/2024 at 11:50 a.m., TXN 2 stated, Resident 1 is on enhanced precautions due her g-tube site and staff need to wear full PPE when doing high-contact care. When asked if he (TXN 2) was wearing full PPE while doing skin treatment, TXN 2 stated, no. TXN 2 stated, he did not check the order prior to starting the dressing changes. TXN 2 further stated, he did not hand sanitize in between changing of gloves while doing dressing changes. 2. A review of the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, DM, and respiratory failure. A review of the MDS dated [DATE], indicated Resident 2's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 required total dependence from staff for ADLs. A review of Resident 2's physician order summary report indicated: i. Enhanced barrier precautions during high contact resident care activities, dated 10/26/2024. During an observation with Certified Nursing Assistant 1 (CNA1) in Resident 2's room on 12/16/2024 at 10:56 a.m., observed CNA1 changing Resident 2's incontinent brief and changing linen with the help of Certified Nursing Assistant Student 1 (CNAS 1). CNA1 and CNAS1 was observed not wearing any gown while changing Resident 2's incontinent brief and linen change. During an interview with CNA1 on 12/16/2024 at 11:07 a.m., CNA1 stated, he did not notice the signage of enhanced barrier precaution outside Resident 2's room. CNA1 stated, staff need to wear full PPE including gown while cleaning and changing incontinent brief for residents who are on enhanced barrier precaution. CNA1 stated, him and the CNAS1 were not wearing full PPE, and this put residents at risk of infection. 3. A review of the Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including and hemiparesis following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, DM, and respiratory failure. A review of the MDS dated [DATE], indicated Resident 3's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 3 required total dependence from staff for ADLs. A review of Resident 3's physician order summary report indicated: i. Enteral feed: cleanse site daily with soap and water every day, dated 11/22/2024. ii. Foley catheter (FC - a thin, flexible tube that drains urine from the bladder into a collection bag outside the body) care daily and as needed, dated 11/22/2024. During an observation with Treatment Nurse 1 (TXN1) in Resident 3's room on 12/16/2024 at 11:14 a.m., observed TXN1 doing dressing changes on Resident 2 g-tube dressing. TXN1 removed the old g-tube dressing, cleanse with NS and applied a new dry dressing. TXN1 did not changed gloves during the whole dressing changes care. TXN1 then did a FC care by flushing the foley catheter tubing while wearing the same soiled gloves from start to finish. During an interview with TXN1 2 on 12/16/2024 at 11:25 a.m., TXN 1 stated, he wore the same gloves all throughout the procedure and did not change gloves in between. TXN 1 stated, this puts other residents and himself at risk of infection by not following the proper infection control guidelines. During an interview with Infection Preventionist Nurse (IPN) on 12/16/2024 at 12:41 p.m., IPN stated, staff must wear full PPE when doing care such as dressing changes, changing linen and incontinent brief. IPN stated, staff must perform hand hygiene such as hand sanitizing in between changing gloves and must put on new gloves when doing skin treatment and FC care. IPN stated, is it important to follow proper infection control policy and guidelines to prevent spread of infection. A review of the facility's policy and procedure (P&P) titled, Isolation - Transmission-Based Precautions and Enhanced Barrier Precautions, revised 4/2024, the P&P indicated, Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug-resistant organisms (MDRO - bacteria that are resistant to more than one antibiotic and can cause serious infections): wear gowns and gloves while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of staff hands, clothes, and the environment such as: during morning and evening care; device care, for example urinary catheter, feeding tube . any care activity where close contact with the resident is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, respiratory care. A review of the facility's P&P titled, Enteral Nutrition, revised 4/2024, the P&P indicated, gastric tube stoma site requires a daily dressing change or with frequency as ordered by the following physician. Dressing change must follow all of infection control guidelines.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had history of falls and a diagnosis of dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning that interferes with doing everyday activities) received the necessary care needs and services by failing to: -Identify and develop an appropriate care plan for Resident 1's dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. -Implement a bed alarm or provide supervision for Resident 1. As a result, on 10/20/2024, Resident 1 was found on the floor of her room and there was no proper staff assessment hours after the fall. Once Family Member 1 noticed the bruising and cut above Resident 1's right eye, the resident was then transferred to the General Acute Care Hospital (GACH) for Xray on 10/23/2024. At the GACH, Resident 1 was diagnosed with an acute impacted fracture (a type of fracture where the ends of the bone are driven into each other) of the right femoral neck (broken thigh bone), and an acute nondisplaced (pieces of bone remain aligned and do not move out of place) right anterior third rib fracture (broken rib).Findings: A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia, history of falling, difficulty walking, and muscle weakness. A review of the history and physical (H&P) dated 10/17/2024, indicated Resident 1 had advanced dementia, did not have the capacity to understand and make decisions, and had a thrombectomy (when a blood clot blocks blood flow to brain or major organ, a medical procedure to remove a blood clot from the blood vessels) on 6/24/2024. The H&P indicated Resident 1 had falls at home with risk of head bleed. A review of Resident 1's Fall Risk assessment dated [DATE], indicated Resident 1 was considered a high risk for potential falls (a score of 16 or higher indicated a resident was a high risk for falling). The fall risk assessment indicated Resident 1 had confusion, poor safety awareness, required assistance with elimination, had poor vision, and had the inability to walk without assistance. A review of the Risk for Falls care plan dated 10/17/2024, indicated this was related to Resident 1's altered mental status (confusion), difficulty walking, muscle weakness, and history of falling. The goal was to minimize the risk for falls and for Resident 1 to not have any major injuries related to falls. The care plan interventions indicated the use of safety devices such as fall mats, keeping the call light within reach, both upper side rails up, and having a low bed. The care plan interventions did not include any monitoring or supervision of Resident 1 or to anticipate and meet the resident's needs. According to a review of the Connective Tissue / Altered Mental Status / Difficulty Walking / Muscle Weakness / Difficulty in Walking care plan dated 10/17/2024, the goal for Resident 1 was to minimize risk for falls and the resident would have no major injuries related to falls. The care plan interventions indicated to monitor for changes in condition affecting risk for falls and notify physician. A review of the Impaired Cognitive Function care plan related to dementia with agitation, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety dated 10/17/2024 indicated interventions to cue, reorient and supervise Resident 1 as needed. A review of the Clinical Progress Notes dated 10/17/2024 indicated Resident 1 could not verbalize needs, was confused and staff would continue to monitor. On 10/18/2024 the progress notes indicated Resident 1 was stable and staff would continue to monitor. On 10/19/2024 the progress notes indicated Resident 1 was adjusting well to new environment, all needs were anticipated, and staff would continue with plan of care. A review of Resident 1's Change in Condition (CIC) Evaluation report dated 10/20/2024 at 8:57 PM, indicated Resident 1 tried to get up by herself, lost her balance, and fell. Resident 1 forgot to use the call light. The CIC indicated Resident 1 was able to stand up and walk a short distance with assistance, the physician and family member were informed. The CIC indicated Resident 1 was relaxing in bed with no complaints of pain or discomfort noted. The CIC did not indicate that Resident 1 had any injuries, who found the resident, or who observed the resident get up by herself and fall. A review of the Physician's Orders dated 10/20/2024 (after the fall), indicated Resident 1 to receive a tab alarm (bed alarm) while in bed and wheelchair. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/21/2024, indicated the resident had severe cognitive impairment (problems with ability to remember, understand, or make decisions), diagnosis of dementia, needed maximum assistance with bed mobility (ability to move around in bed, such as rolling, scooting, or moving from sitting to lying), and maximum assistance with toilet use. The MDS indicated that once standing, the ability to walk 10 feet was not attempted due to safety concerns and medical condition, and that Resident 1 had a fall within the last 2-6 months prior to admission. A review of the Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together toward a common resident goal) Fall review on 10/21/2024 for Resident 1, indicated that on 10/20/2024 at 8:40 PM, Resident 1 was found on the floor facing the door of her room because Resident 1 tried to get up unassisted. The IDT fall review included to continue previous interventions, neurological checks for 72 hours, and bed alarm while in bed and wheelchair. The IDT review did not indicate physician's orders for transfer to the GACH or supervision for Resident 1. A review of the Physician's Orders dated 10/23/2024, indicated to transfer Resident 1 to the GACH emergency room (ER) for CT (cat scan, noninvasive medical imaging procedure that uses X-rays to create detailed pictures of the inside of the body) of the head due to right eye discoloration. According to a review of the GACH ED Provider Notes dated 10/23/2024, Resident 1 had a bruised eye, a fall and altered mental status was brought in by ambulance for an unwitnessed fall. The ED provider notes indicated Resident 1 was admitted to the GACH for an acute impacted fracture of the right femoral neck (broken thigh bone), and an acute nondisplaced right anterior third rib fracture (broken rib) with a plan for arthroplasty (a surgical procedure that replaces a joint with an artificial joint to restore function and help relieve long-term symptoms of pain and stiffness). During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 on 11/6/2024 at 10:27 AM, Resident 1's At Risk for Falls care plan was reviewed. LVN 1 stated Resident 1 should have had a bed alarm, close supervision, and been moved closer to the nurse's station because the resident was a high risk for falls and would get out of bed unassisted. Staff members (LVN 2 and Registered Nurse 2) who were assigned to Resident 1 during the 3:30 PM - 11 PM shift on 10/20/2024 were called for an interview, but there was no answer and no return phone call. A review of Resident 1's Progress Notes on 11/6/2024 indicated there was no documentation by staff regarding Resident 1's injuries. During an interview on 11/6/2024 at 11:30 AM, Resident 1's Family Member (FM) 1 stated that on 10/23/2024 they visited Resident 1 during the day. FM 1 stated when they saw Resident 1, Resident 1 had a black eye and a cut above the right eye. When FM 1 asked the staff what happened, the staff was unsure. FM 1 stated the facility transferred her mother to a GACH and the GACH diagnosed Resident 1 with a broken rib and broken thigh bone. During an interview on 11/6/2024 at 1 PM, the Director of Nursing (DON) stated Resident 1 did not have a black eye and that it was a very small discoloration on the right eyebrow. The DON stated, The resident was constantly trying to get up, out of bed, and should have been moved to a room in front of the nurse's station. The DON stated Resident 1 should have had a bed alarm in place and a sitter for supervision since Resident 1 was a high fall risk and that this could have potentially prevented Resident 1 from falling. The DON stated he did not know how or when Resident 1 sustained the eye discoloration as there was no documentation or reports from the staff regarding any injuries or discoloration to the eye area. During a phone interview on 11/8/2024 at 11:08 AM, CNA 2 stated Resident 1 was confused most of the time and needed assistance with getting up out of bed. CNA 2 stated that before Resident 1's fall, the resident did not have a bed alarm. CNA 2 stated Resident 1 should have been moved closer to the nurse's station because Resident 1 was constantly trying to get out of the bed. A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised January 2024, indicated based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of the facility's P&P titled, Dementia-Clinical Protocol, revised January 2024, indicated staff would monitor the individual with dementia for changes in condition and decline in function and would report these findings to the physician. The P&P indicated the physician and staff would adjust interventions depending on the individual's responses to those interventions.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had history of falls and a diagnosis of dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning that interferes with doing everyday activities) received the necessary care needs and services by failing to: -Identify and develop an appropriate care plan for Resident 1's dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. -Implement a bed alarm or provide supervision for Resident 1. As a result, on 10/20/2024, Resident 1 was found on the floor of her room and there was no proper staff assessment hours after the fall. Once Family Member 1 noticed the bruising and cut above Resident 1's right eye, the resident was then transferred to the General Acute Care Hospital (GACH) for Xray on 10/23/2024. At the GACH, Resident 1 was diagnosed with an acute impacted fracture (a type of fracture where the ends of the bone are driven into each other) of the right femoral neck (broken thigh bone), and an acute nondisplaced (pieces of bone remain aligned and do not move out of place) right anterior third rib fracture (broken rib). Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia, history of falling, difficulty walking, and muscle weakness. A review of the history and physical (H&P) dated 10/17/2024, indicated Resident 1 had advanced dementia, did not have the capacity to understand and make decisions, and had a thrombectomy (when a blood clot blocks blood flow to brain or major organ, a medical procedure to remove a blood clot from the blood vessels) on 6/24/2024. The H&P indicated Resident 1 had falls at home with risk of head bleed. A review of Resident 1's Fall Risk assessment dated [DATE], indicated Resident 1 was considered a high risk for potential falls (a score of 16 or higher indicated a resident was a high risk for falling). The fall risk assessment indicated Resident 1 had confusion, poor safety awareness, required assistance with elimination, had poor vision, and had the inability to walk without assistance. A review of the Risk for Falls care plan dated 10/17/2024, indicated this was related to Resident 1's altered mental status (confusion), difficulty walking, muscle weakness, and history of falling. The goal was to minimize the risk for falls and for Resident 1 to not have any major injuries related to falls. The care plan interventions indicated the use of safety devices such as fall mats, keeping the call light within reach, both upper side rails up, and having a low bed. The care plan interventions did not include any monitoring or supervision of Resident 1 or to anticipate and meet the resident's needs. According to a review of the Connective Tissue / Altered Mental Status / Difficulty Walking / Muscle Weakness / Difficulty in Walking care plan dated 10/17/2024, the goal for Resident 1 was to minimize risk for falls and the resident would have no major injuries related to falls. The care plan interventions indicated to monitor for changes in condition affecting risk for falls and notify physician. A review of the Impaired Cognitive Function care plan related to dementia with agitation, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety dated 10/17/2024 indicated interventions to cue, reorient and supervise Resident 1 as needed. A review of the Clinical Progress Notes dated 10/17/2024 indicated Resident 1 could not verbalize needs, was confused and staff would continue to monitor. On 10/18/2024 the progress notes indicated Resident 1 was stable and staff would continue to monitor. On 10/19/2024 the progress notes indicated Resident 1 was adjusting well to new environment, all needs were anticipated, and staff would continue with plan of care. A review of Resident 1's Change in Condition (CIC) Evaluation report dated 10/20/2024 at 8:57 PM, indicated Resident 1 tried to get up by herself, lost her balance, and fell . Resident 1 forgot to use the call light. The CIC indicated Resident 1 was able to stand up and walk a short distance with assistance, the physician and family member were informed. The CIC indicated Resident 1 was relaxing in bed with no complaints of pain or discomfort noted. The CIC did not indicate that Resident 1 had any injuries, who found the resident, or who observed the resident get up by herself and fall. A review of the Physician's Orders dated 10/20/2024 (after the fall), indicated Resident 1 to receive a tab alarm (bed alarm) while in bed and wheelchair. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/21/2024, indicated the resident had severe cognitive impairment (problems with ability to remember, understand, or make decisions), diagnosis of dementia, needed maximum assistance with bed mobility (ability to move around in bed, such as rolling, scooting, or moving from sitting to lying), and maximum assistance with toilet use. The MDS indicated that once standing, the ability to walk 10 feet was not attempted due to safety concerns and medical condition, and that Resident 1 had a fall within the last 2-6 months prior to admission. A review of the Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together toward a common resident goal) Fall review on 10/21/2024 for Resident 1, indicated that on 10/20/2024 at 8:40 PM, Resident 1 was found on the floor facing the door of her room because Resident 1 tried to get up unassisted. The IDT fall review included to continue previous interventions, neurological checks for 72 hours, and bed alarm while in bed and wheelchair. The IDT review did not indicate physician's orders for transfer to the GACH or supervision for Resident 1. A review of the Physician's Orders dated 10/23/2024, indicated to transfer Resident 1 to the GACH emergency room (ER) for CT (cat scan, noninvasive medical imaging procedure that uses X-rays to create detailed pictures of the inside of the body) of the head due to right eye discoloration. According to a review of the GACH ED Provider Notes dated 10/23/2024, Resident 1 had a bruised eye, a fall and altered mental status was brought in by ambulance for an unwitnessed fall. The ED provider notes indicated Resident 1 was admitted to the GACH for an acute impacted fracture of the right femoral neck (broken thigh bone), and an acute nondisplaced right anterior third rib fracture (broken rib) with a plan for arthroplasty (a surgical procedure that replaces a joint with an artificial joint to restore function and help relieve long-term symptoms of pain and stiffness). During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 on 11/6/2024 at 10:27 AM, Resident 1's At Risk for Falls care plan was reviewed. LVN 1 stated Resident 1 should have had a bed alarm, close supervision, and been moved closer to the nurse's station because the resident was a high risk for falls and would get out of bed unassisted. Staff members (LVN 2 and Registered Nurse 2) who were assigned to Resident 1 during the 3:30 PM - 11 PM shift on 10/20/2024 were called for an interview, but there was no answer and no return phone call. A review of Resident 1's Progress Notes on 11/6/2024 indicated there was no documentation by staff regarding Resident 1's injuries. During an interview on 11/6/2024 at 11:30 AM, Resident 1's Family Member (FM) 1 stated that on 10/23/2024 they visited Resident 1 during the day. FM 1 stated when they saw Resident 1, Resident 1 had a black eye and a cut above the right eye. When FM 1 asked the staff what happened, the staff was unsure. FM 1 stated the facility transferred her mother to a GACH and the GACH diagnosed Resident 1 with a broken rib and broken thigh bone. During an interview on 11/6/2024 at 1 PM, the Director of Nursing (DON) stated Resident 1 did not have a black eye and that it was a very small discoloration on the right eyebrow. The DON stated, The resident was constantly trying to get up, out of bed, and should have been moved to a room in front of the nurse's station. The DON stated Resident 1 should have had a bed alarm in place and a sitter for supervision since Resident 1 was a high fall risk and that this could have potentially prevented Resident 1 from falling. The DON stated he did not know how or when Resident 1 sustained the eye discoloration as there was no documentation or reports from the staff regarding any injuries or discoloration to the eye area. During a phone interview on 11/8/2024 at 11:08 AM, CNA 2 stated Resident 1 was confused most of the time and needed assistance with getting up out of bed. CNA 2 stated that before Resident 1's fall, the resident did not have a bed alarm. CNA 2 stated Resident 1 should have been moved closer to the nurse's station because Resident 1 was constantly trying to get out of the bed. A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised January 2024, indicated based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of the facility's P&P titled, Dementia-Clinical Protocol, revised January 2024, indicated staff would monitor the individual with dementia for changes in condition and decline in function and would report these findings to the physician. The P&P indicated the physician and staff would adjust interventions depending on the individual's responses to those interventions.

Based on interview and record review, the facility failed ensure one of three residents (Resident 1), who was assessed as a high fall risk, was not left seated on the edge of a low air loss (LAL - a pressure-relieving mattress used to prevent and treat bed sores) mattress bed unsupervised. This deficient practice resulted in Resident 1 falling on October 14, 2022, at 7:45 a.m., sustaining a fracture (break in a bone) to left lower leg. Resident 1 was transferred and admitted to a General Acute Care Hospital (GACH) on October 15, 2022. Resident 1 required open reduction and internal fixation (ORIF - a type of surgery used to stabilize and heal a broken bone) on October 17, 2022. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on October 13, 2022, with diagnoses including, generalized muscle weakness, difficulty walking, left knee arthritis (joint inflammation), severe morbid obesity (100 pounds or more above your ideal body weight), and stage 2 (two) pressure injury (when pressure reduces or cuts off blood flow to the skin and blisters or sore forms an open wound) of the sacral (a triangle-shaped bone in the lower spine that forms part of the pelvis) region. A review of Resident 1 ' s Nursing Admission/Readmission assessment dated [DATE], timed at 6 p.m., indicated Resident 1 arrived at the facility via ambulance. Resident 1 was non-ambulatory (did not walk) and used a wheelchair for mobility. A review of Resident 1 ' s Nursing Fall Risk Observation/assessment dated [DATE], indicated Resident 1 did not fall in the last 90 days and was non-ambulatory and used a wheelchair for locomotion (movement). The nursing fall risk observation/assessment indicated Resident 1 scored 22 (high risk for fall - [reference range,16 to 42]). A review of Resident 1 ' s Nursing Daily Skilled Charting Form dated October 13, 2022, indicated Resident 1 had unsteady balance and gait (manner of walking) and was on skilled (having great knowledge and experience in a trade or profession) PT (physical therapy - exercises and physical activities to help condition muscles and restore strength and movement) and OT (occupational therapy - activities with specific goals to help people of all ages prevent, lessen, or adapt to disabilities). A review of Resident 1 ' s physician orders dated October 13, 2022, indicated the following for Resident 1: -Physical Therapy Evaluation and Treatment as recommended. -Occupational Therapy Evaluation & Treatment as recommended. -Pressure relieving device for pressure relief and wound management (bariatric - relating to or specializing in the treatment of obesity) mattress -Both upper (1/4 side rails) up for mobility enablers/repositioning secondary to generalize weakness per family/resident ' s request. A review of Resident 1 ' s Devices and Physical Restraints (any action or procedure that prevents a person's free body movement to a position of choice and/or normal access to his/her body by the use of any method, attached or adjacent to a person's body that he/she cannot control or remove easily) Orders/Consent document dated October 13, 2023, timed at 6:10 p.m., indicated a physician obtained a telephone consent from Resident 1 for the use of both upper and lower 1/4 side rails up for mobility enablers/positioning secondary to generalized weakness. A review of Resident 1 ' s Progress Note dated October 14, 2022, timed at 7:45 a.m., indicated Licensed Vocational Nurse 2 (LVN 2) documented that while night shift was endorsing to AM (morning) shift (7 a.m. to 3 p.m.), we (facility staff) at the nursing station heard a loud sound coming from the room . and saw resident (Resident 1) lying flat on the floor . Resident 1 stated she was sitting on the edge of the bed when she slid to the floor. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated October 15, 2022, indicated Resident 1 had the capacity to understand and make decisions. Resident 1's cognition (mental ability to make decisions of daily living) was intact. The MDS indicated Resident 1 required extensive two staff assist for dressing, bed mobility, transfer, and toilet use. The MDS indicated Resident 1 did not walk, was not able to turn around, and had impairment on one side to the lower extremities (legs) and used a walker and wheelchair for mobility. A review of Resident 1 ' s Facility Radiology Patient Report dated October 15, 22023, at 6:52 a.m., indicated Resident 1 had . partially displaced mid-shaft (mid-bone) tibial (the inner and larger of the two bones between the knee and the ankle) fracture without extension to the tibial prosthesis (a device that replaces a body part). A review of Resident 1 ' s facility Progress Note dated October 15, 2022, timed at 8:15 a.m., indicated LVN 2 documented that a MD (Medical Doctor) was notified of Resident 1 ' s left leg Xray result and the MD ordered to transfer Resident 1 to GACH. A review of Resident 1 ' s Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form dated October 15, 2022, indicated Resident 1 received Norco (strong controlled pain medication) 10-325 milligrams (mg - unit dose measurement) for eight out of 10 (8/10- numerical pain assessment wherein zero is no pain and 10 as the worst pain) left lower leg pain on October 15, 2022, at 11 a.m. A review of Resident 1 ' s Fire Department (FD) Patient Care Report dated October 15, 2022, timed at 2:22 p.m., indicated Dispatch Complaint: Fall with blunt leg injury (an injury resulting from an impact with a dull, firm surface or object). Provider Primary Impression: Traumatic injury (physical injury of sudden onset and severity which require immediate medical attention) on October 14, 2022, at 2:44 p.m. The cause of injury was ground level fall. The facility reported Resident 1 suffered a mechanical fall (an external force [example the environment]) caused the patient to fall) on 10/14/2022 and was treated with splinting (a rigid or flexible device or compound used to support, protect, or immobilize) and imaging (Xray). Resident 1 opened eyes spontaneously at 2:53 p.m. and 3:13 p.m. Resident 1 denied any weakness, dizziness, loss of consciousness or other complaints before falling. Resident 1 was transferred to hospital (GACH) on October 15, 2022. A review of Resident 1 ' s Facility Discharge Summary report dated October 15, 2022, indicated Resident 1 was transferred to GACH emergency room (ER) via 911 (the telephone number used to reach emergency medical, fire, and police services) for left lower leg fracture following a fall. The discharge summary report indicated abnormal Xray of left tibia and fibula (the outer and usually smaller of the two bones between the knee and the ankle in humans), Xray of left knee region. A review of Resident 1 ' s GACH History and Physical (H&P) dated October 16, 2022, indicated Resident 1 had pain in the left leg and a repeat Xray showed a distal (away from the center of the body) left tibia fibula fracture. Resident 1 was scheduled for surgery on October 17, 2022. Resident 1 was admitted at the GACH for further evaluation and care. The GACH H&P indicated Resident 1 had a past history of left knee replacement (a surgical procedure to replace parts of injured or worn-out knee joints). A review of Resident 1 ' s GACH Discharge Summary dated October 25, 2022, timed at 9:22 p.m., indicated Resident 1 had ORIF of the left tibia on October 17, 2022. On February 15, 2023, at 1:30 p.m., during an interview with Registered Nurse 1 (RN 1) supervisor, stated she was not working on the day Resident 1 fell . RN 1 stated a resident must be cleared by physical therapy department staff before a resident can sit alone on the side of the bed. RN 1 stated a resident could fall and get injured if the resident was not safe to sit on the side of the bed alone. On February 23, 2023, at 12:54 p.m., Family Member 1 (FM 1) stated on October 14, 2022, either a nurse or therapist let Resident 1 ' s bed siderail down and sat Resident 1 up on the edge of the bed. FM 1 stated the nurse, or the therapist told him (FM 1) that she (nurse or therapist) needed to go get a gurney (medical transport device) and transport Resident 1 for therapy. FM 1 stated the nurse, or the therapist left the room for quite a while and left Resident 1 sitting on edge of the bed. FM 1 stated Resident 1 complained that her legs were hurting and slid off the LAL mattress bed and fell down. FM 1 stated he (FM 1) prevented Resident 1 from hitting her head on the floor. FM 1 stated Resident 1 fell forward and ended up on her back. FM 1 stated he (FM 1) yelled for the nurses to help him. FM 1 stated Resident 1 complained of a lot of pain to both legs. On March 1, 2023, at 1:38 p.m., during a telephone interview, RN 1 stated she remembered she was receiving report from the night shift (11 p.m. to 7 a.m.) nurse on October 14, 2022, morning when she saw a therapist (unnamed) working with Resident 1 in the resident ' s room. RN 1 further stated the therapist assigned to Resident 1 ' s room was the same therapist that sat Resident 1 on the edge of the bed. RN 1 stated Resident 1 was lying in the bed with the half siderails (a structural support attached to the frame of a bed and intended to prevent a patient from falling) up and the FM 1 was at the resident ' s bedside when RN 1 last saw Resident 1 a little after 7 a.m. on October 14, 2022. RN 1 stated a resident could fall if left unsupervised and seated on the edge of a bed. A review of the facility ' s undated policy and procedures titled Falls Management indicated it is the facility ' s policy that our physical environment remains free of accident hazards as possible. Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls . The Procedure for risk identification/Prevention included . 2. New or existing residents scoring as high risk will have intervention implemented to reduce the potential for falls outlined .

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by Certified Nursing Assistant 1 for one of two sampled residents (Resident 1). On 10/30/2022, Certified Nurse Assistant (CNA) 1 hit Resident 1 in the head and groin. As a result, Resident 1, who was incontinent of bowel and bladder (no control over urination or defecation) had continued pain and was tearful when remembering the incident. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 5/25/2022 with diagnoses including difficulty in walking, muscle weakness, diabetes (high blood sugar) and bed sores. A review of the alteration in bowel and bladder care plan, initiated 5/28/2022, indicated Resident 1 was incontinent of bowel and bladder function due to limited mobility. A review of the History and Physical, dated 6/16/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 8/26/2022, indicated Resident 1 required extensive assistance with one-person physical assist with bed mobility, dressing, toileting, and personal hygiene. The MDS indicated Resident 1 was not steady and only able to stabilize with staff when moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfer (transfer between bed and chair or wheelchair). According to a review of the Coaching/Counseling note, dated 9/21/2022, a resident's family member accused CNA 1 of being rude when speaking to her. A review of the Detail Time Report dated 10/30/2022, indicated CNA 1 worked a double shift from 3 PM to 7 AM. A review of Resident 1's nursing progress note, dated 10/30/2022, indicated Resident 1's Family Member called the facility and reported that a CNA hit Resident 1 in the groin and head with a closed fist. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 10/30/2022 indicated Resident 1 stated that the nurse who changed his incontinence brief, hit his face and pubic area. According to a review of Resident 1's nursing progress note, dated 10/30/2022, law enforcement came to the facility and spoke to Resident 1. A review of Resident 1's potential for injuries, pain, and emotional distress care plan, initiated on 10/30/2022 (after the abuse), indicated the interventions included to monitor for possible injuries and signs of pain, monitor mood and behavior for 72 hours and to encourage the resident to verbalize his feelings. A review of the Medication Administration Record (MAR) indicated Resident 1 received Tylenol 650 milligrams (mg, a unit of measurement) for pain on 10/31/2022, 11/4, 11/5, 11/9, 11/12, 11/13, 11/16, 11/18, 11/22, 11/23 and 11/30/2022 (twelve times). A review of Resident 1's interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) note, dated 11/3/2022 indicated Resident 1 stated that CNA 1 hit his right eye and genitals. According to a review of CNA 1's Separation Notice dated 11/4/2022, the facility terminated CNA 1 for failure to perform job duties and the last day of work was 10/31/2022. A review of the Initial Psychology Consult note dated 11/13/2022, indicated Resident 1 was feeling hopeless and helpless, and felt that one of the staff was rough with him. The Psychology Consult note indicated Resident 1 was a good candidate for psychotherapy and will be seen as medically necessary. During an interview on 11/14/2022 at 1:26 PM, Resident 1 stated that while CNA 1 was changing his incontinence brief, she was treating him roughly. Resident 1 stated CNA 1 closed the door and Next thing I know she hit me on my head and she hit me in my private parts, and it still hurts. Resident 1 became tearful. Resident 1 stated that after the incident he called his Family Member and the Family Member called the facility to report the abuse. During an interview on 11/14/2022 at 2:01 PM, Resident 2 (Resident 1's roommate at the time of the incident) stated he heard CNA 1 scream an obscenity at Resident 1 and heard what sounded like Resident 1 being hit on the back. Resident 2 further stated CNA 1 then closed the door and hit Resident 1 again. Resident 2 stated that Resident 1 can be loud, but he did not deserve to be hit. A review of Resident 2's admission record indicated the facility admitted Resident 2 on 9/19/2022 with diagnoses including muscle weakness and high blood pressure. A review of the MDS, dated [DATE], indicated Resident 2 had the ability to hear adequately, was able to express ideas and wants, and was able to understand others. During an interview on 11/14/2022 at 2:24 PM, the Director of Staff Development (DSD) stated CNA 1 had previously been counseled for a complaint of being rough with a different resident. The DSD stated after the facility conducted the investigation of Resident 1's abuse allegation, the facility fired CNA 1. The DSD stated CNA 1's last day working at the facility was 10/31/2022. During a phone interview on 11/18/2022 at 12:47 PM, CNA 1 stated that she did not hit Resident 1 and that she only cleaned him. During an interview on 12/1/2022 at 1:35 PM, Licensed Vocational Nurse (LVN) 2 stated Resident 1 continued to complain of pain in his pubic area since the abuse allegation happened and has taken Tylenol several times for pain. LVN 2 stated that since the incident, Resident 1 has become anxious or afraid that someone will hurt him again. LVN 2 further stated, Yesterday, when we tried to close the door, the resident (Resident 1) stated he was a little afraid of the door being closed. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, indicated residents have a right to be free from abuse. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, or physical abuse. The policy indicated it was the facility's objective to protect residents from abuse by anyone including facility staff and to ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. and to implement measures to address factors that may lead to abusive situations for example, adequately prepare staff for caregiving responsibilities.

Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 1), who was confused, restless, and was a risk for elopement (a resident who leaves the facility when doing so may present an imminent threat to the resident's health and safety because the resident is too impaired to make a decision to leave), was provided with a safe environment and supervision as per the resident ' s assessment and plan of care. As a result, on 2/28/2022, at 9:45 p.m., Resident 1 jumped out of the window of his room (located on a second floor) sustaining multiple fractures, broken teeth, skin cuts, and brain bleeding. Resident 1 required emergency hospitalization where he underwent multiple surgeries. Findings: A review of Resident 1 ' s Admission Record indicated the facility originally admitted Resident 1, a [AGE] year-old male, on 1/28/2022 and readmitted him on 2/24/2022 after a short-stay hospitalization from [DATE] to 2/24/2022 due to an unwitnessed fall in the facility. Resident 1 ' s diagnoses included metabolic [CONDITION(S)] (damage or brain function loss caused by a condition or illness unrelated to the brain), [CONDITION(S)] (chronic liver damage from a variety of causes leading to scarring and liver) [CONDITION(S)] (inability to sleep), other specified depressive episodes (episodes of depressed mood or loss of interest in activities, causing significant impairment in daily life), restlessness and agitation. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 2/3/2022 indicated Resident 1 had intact cognition (the person does not have hard time remembering things, making decisions, concentrating, or learning). Resident 1 required extensive assistance to walk and used a walker. A review of Resident 1 ' s nursing Progress Note, dated 2/13/2022 and time at 3:20 a.m., indicated Resident 1 was found on the floor lying on the right side facing the drawer next to the bed. Resident 1 was asked what happened and stated upon returning from the bathroom his knees buckled while trying to get back into bed and he fell . Resident 1 sustained a cut above the right eyebrow and the left upper lip with minimal bleeding. Since Resident 1, was taking the blood thinner medication [MEDICATION(S)] (making him at risk for bleeding even from minor injuries) the resident was transported to General Acute Care Hospital 1 (GACH 1) emergency room (ER). A review of GACH 1 (ER) History and Physical examination, dated 2/13/2022, indicated Resident 1 presented with a laceration (cut) to the forehead after a fall that required stitches (closure of wound with needle and thread). A review of GACH 1 computerized tomography (CT scan, combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images [slices] of the bones, blood vessels and soft tissues inside the body indicated facial soft tissue swelling and forehead laceration. A review of Resident 1 ' s re-admission (from GACH 1) Physician ' s Orders, dated 2/24/2022, indicated to arrange psychiatric (a branch of medicine that deals with mental, emotional, or behavioral disorders) consult. A review of Resident 1 ' s History and Physical examination, dated 2/24/2022 by the attending physician, indicated the resident had history of a recent fall and hospitalization secondary to polypharmacy (the simultaneous use of multiple drugs by a single patient, for one or more conditions) with recommendation to hold sedating (drugs that slow brain activity and make the person feel relaxed) medications. Resident 1 needed Physical and occupational therapy (PT and OT for rehabilitation. The physician documented Resident 1 ' s capacity to understand and make decisions on a case-by-case basis. A review of Resident 1 ' s Elopement Risk assessment dated [DATE] indicated the resident was at risk of elopement due to wandering (seemingly aimless or random movement or locomotion) and not accepting of nursing home placement. A review of Resident 1 ' s Care Plan initiated on 2/24/2022 for the resident ' s risk for elopement included in the intervention monitoring Resident 1 ' s location with visual checks at least every hour as needed. A review of Resident 1 ' s nursing Progress Notes, dated 2/24/2022 timed at 7:45 p.m., indicated the resident wandered into another room then went outside onto the patio and climbed the stairs. Staff went after Resident 1 and the resident expressed the desire to go home. Resident 1 was offered to move to another room (closer to the nursing station) but refused. Resident 1 agreed to come down the stairs after the nurse called the family to speak with Resident 1. The licensed nurse obtained a physician ' s order to administer Resident 1 one time the medication [MEDICATION(S)] (is powerful tranquilizer that works in the brain to treat some mental illnesses). A review of Resident 1 ' s nursing Progress Notes, dated 2/24/2022 timed at 10:46 p.m., indicated three hours after Resident 1 was found on the stairs, the resident 1 was missing from the room again. The nurse informed the police and drove around neighborhood to locate Resident 1. A review of Resident 1 ' s nursing Progress Notes, dated 2/24/2022 timed at 11:24 p.m., indicated staff found Resident 1 approximately 45 minutes later around the corner underneath a tree and wearing non-skid socks. Resident 1 was wheeled back to facility and placed in a different room (close to the nursing station) with one-to-one (1:1, one staff with the resident always) staff and body assessment was completed. A review of Resident 1 ' s Situation - Background - Assessment - Recommendation (SBAR - technique provides a framework for communication between members of the health care team about a patient's condition) note, dated 2/24/2022 timed at 11:40 p.m., indicated Resident 1 sustained a abrasions (scratches) on both feet after elopement. A review of Resident 1 ' s Care Plan initiated 2/24/2022 for the resident ' s episode of elopement, included in the interventions, moving the resident to a different room, providing a sitter or frequent visual monitoring by placing Resident 1 in front of the nursing station. A review of the Physician ' s Order for Resident 1, dated 2/25/2022, indicated to monitor the resident for increased agitation every shift, document, and report to the physician any significant changes. A review of Resident 1 ' s nursing Progress Notes, dated 2/25/2022 timed at 12:24 a.m., indicated the licensed nurse called the physician to obtain additional one-time order of [MEDICATION(S)] for restlessness and pacing (moving around aimless). A review of Resident 1 ' s MAR dated 2/25/2022 indicated Resident 1 received [MEDICATION(S)] (antipsychotic medication used to treat agitation and [CONDITION(S)]) one time only for agitation. A review of Resident 1 ' s MDS dated [DATE] indicated Resident 1 had severe cognitive impairment (the person has a very hard time remembering things, making decisions, concentrating, or learning). Resident 1 required extensive assistance to walk and used a walker. A review of Resident 1 ' s nursing Progress Notes, dated 2/28/2022 timed at 2:40 p.m., indicated Resident 1 received physical therapy and constantly talked about wanting to go home. Staff provided Resident 1 with frequent visual checks. A review of Resident 1 ' s nursing Progress Notes dated 2/28/2022 timed at 7:51 p.m., indicated Unit Assistant (UA) was assigned to stay with Resident 1 and sit the resident in front the nursing station after 3 p.m. At 9:37 p.m. Registered Nurse Supervisor (RNS) instructed UA to go and pass out nourishment for other residents and RNS assumed watch for Resident 1 still sitting in wheelchair in front of nursing station. A review of Resident 1 ' s the nursing Progress Notes, dated 2/28/2022 timed 9:41 p.m., indicated four minutes after RNS assumed watch, Resident 1 was no longer in the wheelchair in front of nursing station. The empty wheelchair was in front of Resident 1 ' s room. RNS looked inside the room and saw Resident 1 ' s leg going out of the window of the room (the room was on the second floor) RNS instructed the desk nurse to call 911 (emergency telephone number to request immediate assistance from police, fire, and ambulance services). A review of Resident 1 ' s the nursing Progress Notes, dated 2/28/2022 indicated at 9:45 p.m. the resident was found lying on the concrete ground outside his room face down, arousable with a pulse (heartbeat). Paramedics arrived five minutes later and transported Resident 1 to (GACH 1) (ER). A review of GACH 1 ER Notes dated 3/1/2022 indicated Resident 1 was confused upon arrival and endured the following injuries because of the fall: - Subdural hematoma (SDH - a pool of blood between the brain and its outermost covering), - Closed non-displaced fracture of pelvis (broken pelvis), - Compression fracture of T11 vertebra (broken spinal bone in lower back), - Avulsion of tooth #9 and #10 (loss of two teeth), - Closed fracture of the orbital wall (break of a bone surrounding the eye), - Left, open ankle fractur (broken left ankle with bone sticking out), - Left knee laceration (cut on left knee), and - Fracture of left 5thrib. A review of GACH 1 Surgery Trauma History and Physical examination consultation dated 3/1/2022 indicated Resident 1 presented with a 2-3 centimeters (cm) laceration to left side of face below the eye which was repaired with sutures. In addition, a 3 cm laceration to the left knee and 8 cm laceration to medial (inner) left ankle. A review of GACH 1 Neurosurgery Consult Note, dated 3/1/2022, indicated Resident 1 sustained a left temporal SDH and a history of taking a blood thinner. Resident 1 was severely anemic (low red blood cell count) requiring a blood transfusion. Resident 1 was admitted to the intensive care unit (ICU - represents the highest level of patient care and treatment designated for critically ill patients with life-threatening conditions) and given [MEDICATION(S)] (medication to prevent seizures) as a precaution and was placed on intravenous (IV- infused directly into the vein) antibiotics. Resident 1 underwent multiple surgical procedures at GACH 1 to repair the multiple injuries. On 3/2/2022 at 8:08 a.m., during an interview, Family Member 1 (FM 1) stated Resident 1 had not slept and had been up for many nights. FM 1 added resident would call in the middle of the night saying, get me out of here I am in jail. FM 1 further added Resident 1 was adamant about not being at the facility. FM 1 stated FM 2 was initially contacted by the police to notify Resident 1 jumped out of a window and was transferred to a hospital. On 3/2/2022 at 12:22 p.m., during an interview, PT assistant (PTA) stated Resident 1 was able to walk without the use of a walker. PTA went on to say during therapy session on 2/28/2022, Resident 1 constantly verbalized the desire to go home. PTA was stated not seen a 1:1 staff with Resident 1. On 3/8/2022 at 9:47 a.m., during an interview, the Director of Nursing (DON) stated they moved Resident 1 closer to the nursing station and provided frequent visual checks. On 3/8/2022 at 12:56 p.m., during an interview, RNS confirmed the UA was instructed to stay with Resident 1 and always follow if Resident 1 moved because Resident 1 was a high risk for elopement. RNS confirmed directing the UA to pass nourishments for other residents. RNS stated she was sitting at the nursing station, looking down charting (documenting in the clinical records). RNS stated a few minutes later she looked up and saw Resident 1 going out of the window. On 3/8/2022 at 3:15 p.m., during an interview, Nurse Practitioner 1 (NP 1) stated the facility called on the evening of 2/27/2022 because Resident 1 was agitated and trying to get out of bed. NP 1 went on to add the facility mentioned Resident 1 had this behavior since admission and had a history of eloping. On 3/8/2022 at 3:47 p.m., during an interview, NP 2 confirmed seeing Resident 1 on the morning of 2/28/2022 because FM 2 was concerned Resident 1 was not sleeping. NP 2 stated a psychiatric consult was ordered due to nursing stating Resident 1 had been agitated the night before and had to give the resident [MEDICATION(S)]. During an interview on 3/16/2022 at 3:35 p.m., NP 3 stated (prior to the resident falling out the window) she was coming to the second floor and seeing Resident 1 sitting in wheelchair parked in the front (center) of the nursing station and no one was sitting with or near Resident 1. NP 3 confirmed RNS was seated behind the nursing station in the center directly in front of Resident 1. NP 3 soon after heard Licensed Vocational Nurse 1 (LVN 1) yell he went out the window and ran downstairs. During an interview on 3/17/2022 at 9:24 a.m., LVN 1 was asked how Resident 1 was able to leave the building on 2/24/2022. LVN 1 stated Resident 1 was initially in a room with a sliding glass door that led out to a patio with stairs that lead down to the street. LVN 1 went onto say the curtains were closed over the door and two chairs were placed in front of curtain to keep door hidden. LVN 1 further added this room was around the corner from the nursing station and there were no other residents in the room. LVN 1 stated on 2/24/2022, Resident 1 wandered into another room with two female residents. One of the residents got upset and informed staff and Resident 1 was found in the stairwell. LVN 1 went on to say after this Resident 1 was returned to room and no sitter was provided because they did not have one available. LVN 1 stated on 2/28/2022, before Resident 1 fell out of the window, he was sitting in front of the nursing station because he was refusing to get in bed. LVN 1 added the UA was not with the resident. LVN 1 stated when Resident 1 fell out the window, she went downstairs to check on Resident 1. LVN 1 reported seeing Resident 1 on the ground bleeding from mouth, the left knee was burst open, and the right ankle was bleeding. LVN 1 said she received instructions from 911 operator not to move Resident 1 until paramedics arrived approximately five minutes later and transported Resident 1 to the hospital. During an interview on 3/17/2022 at 3:46 p.m., RN 2 stated Resident on 2/24/2022 Resident 1 went to sleep, and at the change of shift, no one was watching him, and the resident eloped. RN 2 stated the police returned the resident two hours later. On 3/29/2022 at 4:49 p.m., during an interview, UA confirmed being assigned to sit with Resident 1 on 2/28/2022. UA stated RN 1 asked to pass out nourishments to other residents and RN 1 agreed to watch Resident 1 at this time. A review of the facility policy and procedure titled, Wandering or Elopement, Unsafe Resident, dated 8/2014, indicates the facility would strive to prevent wandering while maintaining the least restrictive environment for residents who are at risk for elopement. A review of the facility policy and procedure titled, Caregiver/Sitter, revised 5/2017, indicated the facility ' s nursing staff may serve as a caregiver/sitter when approved by the Director of Nursing Services or facility care team . the sitter must follow the facility ' s established nursing care policies and procedures, and instructions issued by the Nurse Supervisor and charge nurse.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 305), who was assessed with [REDACTED]. 1. Failure to assist Resident 305 during ambulation (ability to walk from place to place independently with or without assistive device). 2. Failure to train certified nursing assistant in assisting Resident 305, who had non-weight bearing (no weight can be placed on the affected area) to the right hand and the use of a hemi walker (also known as walk-canes). 3. Failure to implement the use of gait belt (device used to transfer people from one position to another, from one thing to another, or while ambulating people that have problems with balance) during ambulation per facility's gait belt policy. As a result, Resident 305 had a ground level fall with fractures (a partial or complete break of the bone) of the 10th and eleventh 11th ribs and experienced unnecessary pain. Findings: A complaint and facility reported incident (FRI) investigation was conducted on 11/8/18 regarding Resident 305's fall. A review of the Admission Record (Face sheet) indicated Resident 305 was admitted to the facility, on 10/19/18, with [DIAGNOSES REDACTED]. A review of Resident 305's physical therapy initial evaluation, dated 10/19/18, indicated the resident required minimum assistance with sit to stand transfers, fair minus standing balance, and was a fall risk. A review of Resident 305's history and physical examination [REDACTED]. The H&P indicated the resident had intermittent dizziness. The physical examination indicated the resident was notable for right shoulder pain and the right hand was in a cast (made from plaster or fiberglass, encasing a limb to stabilize and hold anatomical structures, most often a broken bone (or bones), in place until healing). The resident was assessed to have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a comprehensive assessment and care-screening tool), dated 10/26/18, indicated Resident 305 had no cognitive impairment (ability to think, understand and make daily decisions) and needed extensive assistance from staff with transfers and bathing, requiring one person physical assistance. The resident's balance during transitions and walking was assessed to be unsteady and only able to stabilize with staff assistance. The resident's mobility devices included a cane, walker, and wheelchair. A review of Resident 305's occupational therapy care plan, dated 10/20/18, indicated the resident had limited range of motion (ROM) of the right upper extremity with non-weight bearing and required moderate assistance in bathing and toileting. A review of the physical therapy care plan, dated 10/22/18, indicated Resident 305 had decreased strength to both right and left lower extremities (legs and feet) and impaired gait (a deviation from normal walking) with non-weight bearing to the right upper extremity (hand). The resident was assessed as a fall risk. During the initial tour of the facility, on 11/08/18 at 11:45 a.m., Resident 305 was observed sitting in a wheelchair in her room, spoke predominantly in a non-dominant language with limited English speaking ability, but able to understand questions. During an interview with the resident and occupational therapy assistant 1 (OTA 1) as the translator, Resident 305 stated she had been in the facility about 20 days because she had broken her right wrist at home, from a fall due to dizziness. The resident stated she had pain to her left lower back and side, and gestured using her hand to the left side of her back. The resident stated the pain was more severe at night. A review of Resident 305's Licensed Nurse's Progress Notes, dated 10/26/18, at 9:50 a.m., indicated Registered Nurse 2 (RN 2) was called by Certified Nurse Assistant 1 (CNA 1) for assistance with Resident 305, who was found sitting on the floor with her back leaning on the wall. The nursing notes indicated the resident stated to RN 2 that the resident had pain to her back, rated at 5 out of 10 (using a numeric 0-10 pain scale, 0 no pain and 10 being the worst pain). A review of Resident 305's X-ray results of the left rib obtained from outpatient orthopedic clinic, dated 10/26/18, at 4:10 p.m., six hours after the fall incident, indicated the resident's clinical indication to have an X-ray was due to pain following a ground level fall. The X-ray findings indicated left acute (new) 10th and 11th rib fractures. During an interview, on 11/09/18 at 7:24 a.m., Registered Nurse 2 (RN 2) stated on the day of Resident 305's incident (10/26/18), she observed CNA 1 come out from the shower room and asked for assistance. RN 2 stated she went into the shower room and asked CNA 1 what had happened. CNA 1 stated that Resident 305 had a fall. RN 2 stated she observed Resident 305 sitting on the floor with her back to the wall. RN 2 stated CNA 1 translated for her. RN 2 stated she asked the resident if she had any pain and the resident replied she had pain to her left back and side. RN 2 stated she then called the nurse practitioner (NP) and was instructed to apply a hot pack to the resident's left back and was told the NP was going to come to check on the resident. RN 2 stated an order was to be placed for a stat (expedited) X-ray, but the resident had a scheduled appointment with the orthopedic surgeon (physician specializing in bone disorder) at 3 p.m., the same day. RN 2 called the orthopedic office, told them about Resident 305's fall, and got authorization to have the X-rays taken at the orthopedic office instead. RN 2 stated the NP arrived to assess the resident on 10/26/18, at 12 noon and an order was given to administer [MEDICATION NAME] gel ([MEDICATION NAME], used to relieve pain, swelling (inflammation), and joint stiffness) for the resident's pain. On 11/9/18, at 2:10 p.m., during an interview with Resident 305's family member (FM), he stated he received a call from the orthopedic office the day after her fall, notifying him that when the radiologist (a medical doctor who specializes in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays) looked at the resident's x-rays, it was determined that she had broken ribs. The family member stated the resident had continued pain from the fall. On 11/9/18, at 3 p.m., during an interview and record review with the Director of Rehabilitation (DOR), he stated prior to the fall Resident 305 was able to ambulate with a single point cane (cane with one point at the end) but the physical therapist (PT) decided to train the resident to use a hemi walker for more stability. The DOR stated that before the fall, on 10/26/18, the resident was able to ambulate 125 feet during her physical therapy sessions using a hemi walker, and was assessed to require minimal assistance, with recommendations for transfers to involve one person assistance with the hemi walker. The DOR stated residents with minimal assistance required a gait belt when ambulating and was facility protocol even with higher level ambulation residents. The DOR stated a gait belt was used in case a resident loses their balance, the staff assisting the resident was able to catch them or pull them if they were leaning one way or if they were going down, staff can use it to help the fall with less force. The DOR stated that in the training, he instructs the CNAs to use a gait belt especially if the resident was only wearing a gown. The DOR stated, if Resident 305 walked to the shower from her room, a gait belt was needed and the CNA had to stand by the side of the resident's non-weight bearing arm from her previous fracture. During a review of the physical therapy notes, dated 10/20/18, indicated Resident 305 had fair standing balance, which the DOR stated meant there was a chance the resident could lose their balance. An assessment of poor plus standing balance meant Resident 305 needed extra stability, necessitating the need of one staff member with her. The DOR stated there was no training given to CNA 1 regarding how to assist a resident with non-weight bearing to the upper extremity during shower. On 11/14/18, at 12:13 p.m., during an interview with Certified Nurse Assistant 1 (CNA 1), she stated she had been assigned to care for Resident 305, for five days prior to the incident. CNA 1 stated the resident used her cane (hemi walker) when she went to the shower. CNA 1 stated staff was trained on how to assist residents from transferring from bed to chair and from chair to bed but stated she had not seen the type of walker the resident used. CNA 1 stated on the day of the incident, she assisted the resident with her shower and after the shower and dressing the resident; Resident 305 stood up from the shower chair and had her left hand on the hemi walker. CNA 1 stated the resident could not move her right hand because she had broken it at home. CNA 1 stated the resident was attempting to take a step forward, when CNA 1 saw the floor was wet so she got a towel to put on the floor. CNA 1 stated she then asked the resident to walk forward but when the resident started to walk, she fell slowly towards her left side to the ground and hit her back. CNA 1 stated she was standing in front of Resident 305 at the time of the fall and could not hold on to the resident. CNA 1 stated the resident did not have a gait belt, because she did not need it as she always walked with a walker. CNA 1 stated she was taught to stand behind residents with mobility impairment, but was standing in front of the resident because the floor was wet. CNA 1 stated she did not expect Resident 305 to lose her balance. CNA 1 stated she always should be at the back of the resident. On 11/15/18, at 8:34 a.m., during an interview with the Director of Staff Development (DSD) and Director of Nursing (DON), the Director of Staff Development (DSD) stated the rehabilitation department educated the certified nurse assistants (CNAs) on ambulating with the residents. The DSD stated CNAs were trained to first identify if the residents have limb precautions, that would indicate if the resident was non-weight bearing. The DSD stated that in his role as educator he had not trained the CNAs in the use of the different types of walkers. The DSD stated residents required a gait belt when walking and during transfers. During concurrent interview with the DON, she stated the facility did not have a policy on the use of a hemi walker, but would obtain information on ambulation equipment from the rehabilitation department. On 11/15/18, at 9:06 a.m., during an interview and record review with the DON, she stated the facility gait belt policy indicated the use of the gait belt was to provide leverage when lifting, transferring and ambulating a resident. The DON stated during the time of the fall incident for Resident 305, the resident was not wearing a gait belt and since the resident had an impairment on the right hand due to an existing fracture, the CNA had to stand on the side weakness to be able to support the weakened side. According to the American Academy of Family Physicians (aafp.org/afp), 4/15/03, hemi walkers are broad-based aluminum devices that have a vertical component with a handle and two legs, and another component with two additional legs angled away from the user. Walk canes provide more broad-based support than standard canes or multiple-legged canes. Walk canes are ideal for persons requiring continuous weight bearing with only one arm.) A review of the facility policy titled, Gait Belt Policy and Procedure, dated 5/5/00, indicated the purpose of the use of the gait belt prevents injury and discomfort to the patient (resident) and/or employee during mobility activities: 1) to transfer a resident from bed to wheelchair or from wheelchair to bed; 2) to ambulate a resident with or without a walker; 3) to lift a resident from the floor into a wheelchair; 4) to airlift a resident ; 5) to adjust a resident's position in a chair. The policy also included a copy of the policy would be given to each nursing employee. The gait belt would be used on all residents unless contraindicated by the DON and/or the attending physician. Each nursing assistant would wear or carry a gait belt on their person, as part of their uniform, during the entire shift so that it was accessible at all times. A review of the facility policy titled, Gait Belt, dated 9/2016, indicated the clinical staff member can use gait belt for residents who were too weak to walk or stand alone, or required assistance during transfers. To make transferring and walking of resident easier and safer for the resident and for the clinical staff.