Every finding on record at Briarcrest Nursing Center

Based on observation, interview and record review, the facility failed to ensure medication for one of 5 residents (Resident 2), who was diabetic (a person with diabetes mellitus [DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) was available for administration.This failure resulted in the resident not receiving the medication and placed the resident at risk for diabetic complications such as diabetic ketoacidosis (DKA- a life-threatening emergency from very high blood sugar, extreme dehydration, and concentrated blood), hospitalization and death.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included type 2 DM, sequelae of cerebral infraction (stroke), and difficulty in walking. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 7/19/2026, the MDS indicated Resident 2 had clear speech, understands and had the ability to express ideas and wants. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, oral hygiene, and upper body dressing. During a record review of Resident 2's Order Summary Report, dated 4/10/2026, the Order Summary Report indicated to inject Lantus Subcutaneous solution ([medicine for diabetes] long-acting insulin) subcutaneous (administration of medication by injecting a needle into the fatty tissue layer just beneath the skin) solution, 13 units at bedtime and to hold if blood sugar (BS) level is less than 100 (normal BS levels is between 70 milligrams [mg, unit of measurement] per (/) deciliter [dL, unit of measurement] and 100 mg/dL). During a review of Resident 2's document titled Blood Glucose Monitoring (checking of blood sugar levels in a person's blood), indicating Lantus Subcutaneous Insulin subcutaneous solution, 13 units at bedtime and to hold if BS level is less than 100 mg/dL, the BS level dated 8/18/2026, at 9 p.m. was left blank and did not indicate a signature. During an interview on 8/19/2026 at 11:42 a.m., with Resident 2, Resident 2 stated he is a diabetic. Resident 2 stated on 8/18/2026, the nursing staff (unidentified) checked his blood sugar, and the result was 240 mg/dL. Resident 2 stated the nursing staff brought an empty insulin pen and faked injecting insulin in his abdomen. Resident 2 stated he did not feel the injection. During a concurrent observation and interview on 8/19/2026 at 2:35 p.m., with the Registered Nurse (RN 1), RN 1 stated if Resident 2's Lantus was not available, Resident 2 was at an increased risk for complications like DKA. RN 1 provided a clear plastic bag labeled with Resident 2's name. The clear plastic bag had an empty Lantus insulin pen and was labeled with another resident's name. RN 1 was unable to locate Resident 2's Lantus insulin pen from the medication cart and the refrigerator. Resident 2 was unable to provide Resident 2's Lantus insulin pen supply. RN 1 checked the emergency kit (E-kit, a prepared collection of prescription, over-the-counter and essential medical supplies designed to ensure to continue necessary treatments during emergencies when pharmacies or healthcare providers may be inaccessible) and was unable to find Lantus insulin pen. During an interview on 8/19/2026 at 3:35 p.m., with the Director of Nursing (DON), the DON stated she did not know when Resident 2's insulin pen became missing. The DON stated she was unaware that Lantus pens are not available in the E-kit for emergency use. The DON stated if Resident 2's Lantus Solostar pen was unavailable, it placed Resident 2 at an increased risk for hyperglycemia (high blood sugar). The DON stated staff should not use another resident's insulin pen, which may cause cross contamination. During a review of the facility's undated policy and procedure (P&P) titled, Pharmacy Services Overview, the P&P indicated the facility should accurately and safely provide pharmaceutical (a medicinal drug or preparation used to treat, or prevent disease) services, including provision of routine and emergency medications and biologicals (complex medicines produced from living organisms like bacteria, yeast, human cells, or animal cells). The facility should maintain timely and appropriate pharmacy services that support resident's needs, consistent with current standards of practice, and meet state and federal requirements. The P&P indicated nursing staff are responsible for contacting the pharmacy if a resident's medication is not available for administration. Borrowing medication from other residents or from the emergency medication supply because of failure to order or reorder a medication in time for a resident to receive scheduled medication is not an acceptable practice.

Based on interview and record review, the facility failed to ensure one of 5 residents' (Resident 2) medical record was complete and accurate, in accordance with professional standards and practices. This failure had the potential for missed doses of medication; miscommunication leading to accidental overdoses and placed the affected resident at risk for health complications.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included type 2 DM, sequelae of cerebral infraction (stroke), and difficulty in walking. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 7/19/2026, the MDS indicated Resident 2 had clear speech, understands and had the ability to express ideas and wants. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, oral hygiene, and upper body dressing. During a review of Resident 2's document titled Blood Glucose Monitoring (checking of blood sugar levels in a person's blood), indicating Lantus Subcutaneous Insulin subcutaneous solution, 13 units at bedtime and to hold if BS level is less than 100 mg/dL, the BS level dated 8/18/2026, at 9 p.m. was left blank and did not indicate a signature. During a concurrent interview and record review on 8/25/2026 at 1:55 p.m., with the Assistant Director of Nursing (ADON), the document titled Blood Glucose Monitoring for 8/2026, was reviewed. The ADON acknowledged the Blood Glucose Monitoring dated 8/18/2026, at 9 p.m., was blank. The ADON stated leaving the Blood Glucose Monitoring blank meant Resident 2's blood glucose level was not checked and insulin was not given. The ADON stated if Resident 2 refused the medication, the nursing staff should have placed their initials and encircled. The ADON stated if Resident 2 did not receive the insulin, it placed the resident at increased risk of high blood sugar levels. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated medications should be administered timely, as prescribed. The P&P indicated if the drug was withheld, refused or given at a time other than the scheduled time, the individual administering the medication should initial and circle the Medication Administration space provided for that drug and dose.

Based on interview and record review, the facility did not meet professional standards, by failing to provide a hand-off report (a vital communication tool used to pass patient care responsibility, critical status updates, from one healthcare worker or team to the receiving healthcare facility) for one of 4 residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) due to a change in medical condition. This failure had the potential for miscommunication and delay in providing care and services necessary to treat the resident's health condition.Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted on [DATE] and re-admitted on [DATE].Resident 1's diagnoses included type 2 diabetes mellitus (a long-term health condition where the body cannot use insulin properly and sugar builds up in the blood), asthma (a chronic [long-term] lung disorder defined by airway inflammation, airway hyperreactivity, and recurring obstruction), and shortness of breath.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 1 had unclear speech, usually understood, and usually understands. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting, personal hygiene, shower/bathe self.During a review of the Change of Condition Evaluation (COC), dated 7/6/2026, at 12:35 p.m., the COC indicated Resident 1 had congestion, occasional non-productive cough, pain on left knee and leg. The COC indicated Resident 1 had poor endurance (stamina), gets easily fatigued when performing activities of daily living (ADLs, refer to the basic skills necessary for individuals to independently care for themselves) and generalized muscle weakness. The COC indicated Resident 1's physician ordered to transfer Resident 1 to GACH. The COC did not indicate the facility called GACH for hand-off report.During a review of Resident 1's progress notes dated 7/6/2026, the progress notes did not indicate the facility called GACH for a hand-off report prior to Resident 1's transfer on 7/6/2026 at 12:35 p.m.During an interview on 7/28/2026 at 12:56 p.m., with the Director of Nursing (DON), the DON stated the Registered Nurse (RN) who was responsible to call GACH for report prior to transferring Resident 1, did not call the GACH. The DON stated the lack of report to the receiving GACH may cause delay of treatment and continuity (the state of continuing over time without stopping, breaking, or changing) of care.

Based on interview and record review, the facility failed to ensure one of 4 residents (Resident 2), was provided with assistance with eating.This failure had the potential to result in Resident 2's poor food intake, dehydration and weight loss. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of dysphagia following cerebral infarction (difficulty swallowing after a stroke), lack of coordination, and abnormal posture. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 6/12/2026, the MDS indicated Resident 2 had no speech, rarely/never understood and rarely/never understands. The MDS indicated Resident 2 was dependent (helper does all the effort) on staff for toileting hygiene, personal hygiene, and required substantial/maximal assistance (helper does more than half the effort) with eating. During a review of Resident 2's Order Summary Report, dated 5/31/2026, the order summary report dated 2/17/2023, indicated to Feed [Resident 2] slowly.During a review of Resident 2's Documentation Survey Report for the month of 5/2026 to 7/2026, the Documentation Survey Report indicated eating assistance werenot provided/documented on the following dates and times: -On 5/11, 5/12, 5/16, 5/22, 5/23, 5/24, 5/25, 5/29, and 5/30/2026- at 7:30 a.m. and 12 noon.-On 5/5 and 5/23/2026- at 5p.m.-On 6/4, 6/5, 6/10, 6/18, 6/21, 6/27, 6/28, 6/29/2026 - at 7:30 a.m. and 12 noon. -On 6/12/2026- at 12 noon.-On 6/13/2026 at 5 p.m.-On 7/3, 7/6, 7/11, 7/12, and 7/17/2026- at 7:30 a.m. and 12 noon.-On 7/18/2026- at 12 noon. During a review of Resident 2's care plan titled, Resident 2 had potential nutritional problem or potential for weight variance related to (r/t) medication side effects, and diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), cerebral vascular accident (CVA-stroke) and dysphagia (trouble or difficulty swallowing food, liquids, or even saliva), the interventions indicated to provide, serve diet as ordered, administer medications as ordered. During a telephone interview on 7/28/2026 at 11:20 a.m., with the Director of Staff Development (DSD), the DSD stated Certified Nursing Assistants (CNA) were responsible for feeding Resident 2. The DSD stated failure to provide assistance during feeding may cause Resident 2 to lose weight and have a change of condition. During a review of the facility's undated policy and procedure (P&P) titled, Assistance with Meals, the P&P indicated residents should receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves should be fed with attention to safety, comfort and dignity. Facility staff should serve residents trays and help residents who required assistance with eating. During a review of the facility's undated P&P titled, Charting and Documentation, the P/P indicated all services or treatments provided to the resident should be documented in the resident's medical record.

Based on interview and record review, the facility failed to ensure a resident-centered care plan with interventions were developed to address food and medication allergies for one of 3 residents (Resident 1). These failures had the potential for the staff to serve resident allergic food and administer any of the allergic medications, placing the resident at risk for allergic reactions and potential health complications, including hospitalization.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive (a syndrome characterized by a gradual, unexplained decline in physical and mental functioning), depression (a serious mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest in activities previously enjoyed) and obesity (a chronic, complex disease characterized by excessive body fat accumulation that impairs health). Resident 1's information included allergies to azithromycin (medication for infection), clindamycin (medication for infection), codeine (pain medicine), erythromycin (medication for infection), guaifenesin (cough medicine), penicillin-G (medication for infection), prednisone (medicine to treat inflammation, severe allergies, and immune system problems), tramadol (pain medicine) and Keflex (medication for infection). During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool) dated 6/29/2026, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and clear understanding. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half) with oral hygiene, toileting hygiene, and shower/bathe self. The MDS indicated Resident 1 required a mechanically altered (e.g., pureed food, thickened liquids) diet. During a review of Resident 1's Multidisciplinary Care Conference, dated 6/25/2026, the Multidisciplinary Care Conference indicated Resident 1 was allergic to peaches. Resident 1 disliked pork, milk and ice cream. During a review of Resident 1's Dietary Profile Preference, dated 6/26/2026, the Dietary Profile/Preference indicated Resident 1 had no food allergies or no food intolerances. During a review of the Allergy Report, dated 6/1/2026 through 6/30/2026, the Allergy Report did not include Resident 1's allergies to foods and medications. During a review of Resident 1's care plan for the allergies listed, there were no care plans created with interventions. During a review of Resident 1's active orders as of 7/16/2026, the diet order indicated no pork, and allergy to azithromycin, clindamycin, codeine, erythromycin, guaifenesin, penicillin-G, prednisone, tramadol and Keflex. During an interview on 7/23/2026 at 9:27 a.m., with the Director of Nursing (DON), the DON stated nursing staff were responsible for formulating the care plan with interventions for Resident 1's allergies to food and medications. The DON stated lack of documentation and care plan interventions to implement placed Resident 1 for possible allergic reactions. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, undated, the P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs should be developed and implemented for each resident. The care plan interventions should be chosen after data gathering, careful consideration of the relationship between the resident's problem area(s) and their causes, and relevant clinical decision making.

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident 2), who was receiving a continuous gastrostomy tube (GT, a surgical insertion of a tube into the stomach for nutrition and medication administration) feeding, had the head of the bed (HOB) elevated to 30 to 45 degrees.This failure had the potential to result in aspiration of feeding formula (when feeding formula enter into the airway), causing difficulty breathing, lung infections including hospitalization and death.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including morbid obesity (extremely overweight with associated serious health complications), gastrostomy status, cerebral infarction (stroke) and dysphagia (difficulty swallowing food, liquids, or even saliva). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment and care planning tool), dated 6/25/2026, the MDS indicated Resident 2 had no speech, rarely/never understood, and rarely/never understands. The MDS indicated Resident 2 was dependent on staff for toileting hygiene, shower/bathe self and personal hygiene. During a review of Resident 2's care plan, titled The resident required tube feeding related to swallowing problem, aphasia (impaired ability to speak, understand, read, and write) and stroke, dated 6/27/2026, the interventions indicated to elevate head of bed 30 to 45 degrees during feeding. During a review of Resident 2's Medication Administration Record (MAR) for the month of July 2026, the MAR indicated to elevate Resident 2's HOB to 30-45 degrees during feeding, every shift. During a concurrent observation and interview on 7/15/2026 at 9:54 a.m., with Licensed Vocational Nurse (LVN 1), at Resident 2's bedside, Resident 2 was observed receiving GT feeding of Glucerna 1.5 (type of tube feeding formula) at 70 cubic centimeters (cc, a unit of measurement) an hour, with the HOB at a 20-degree angle (At minimum, HOB should be elevated at least 30 degrees to 45 degrees to prevent aspiration). LVN 1 stated the HOB was too low and should have been elevated at 30-45-degree angle when GT feeding was ongoing to prevent aspiration.

Based on observation, interview and record review, the facility failed to implement its policy and procedure (P/P) titled Handwashing/Hand Hygiene to adhere to infection control practices of removing gloves and handwashing before entering another resident's room for 1 of 7 sampled residents, Resident 4. This failure had the potential to increase the risk of spreading infection and bacteria and impeding the health and wellness of residents and staff.Findings: During a review of Resident 4's admission record dated 07/16/2026, the admission record indicated Resident 4 was originally admitted on [DATE] and re-admitted on [DATE] with diagnosis of heart failure (a chronic, progressive condition where the heart muscle is weakened or stiffened and cannot pump enough blood to meet the body's needs for blood and oxygen), pneumonia (an infection that inflames the small air sacs in one or both lungs, causing them to fill with fluid or pus) and urinary tract infection (UTI- an infection in any part of your urinary system, which includes the kidneys, bladder, ureters, and urethra). During a review of Resident 4's Minimum Data Set (MDS-a resident assessment tool), dated 05/11/2026, the MDS indicated Resident 4 had unclear speech, difficulty communicating some words or finishing thoughts but is able if prompted or given time, and understands. The MDS indicated Resident 4 was dependent (helper does all the effort) on staff for oral hygiene, toileting hygiene and personal hygiene. During a concurrent observation and interview on 07/16/2026 at 12:15 p.m. with the assigned licensed vocational nurse (LVN 2), and the infection preventionist (IP) nurse, LVN 2 was observed by the medication cart in front of another resident's room and failing to perform hand hygiene before entering Resident 4's room. LVN 2 was observed trying to put on a disposable gown that was touching the floor, LVN 2 got another gown and failed to perform hand hygiene before donning the gown. LVN 2 stated failing to perform hand hygiene before entering resident 1's room and donning the disposable gown had the potential of spreading germs/infection.During a review of Resident 4's care plan, no title, no date, the care plan indicated Resident 4 has New Delhi [NAME]-beta-lactamase (NDM)- Klebsiella pneumoniae carbapenemase (KPC) (active infections, both are highly drug-resistant enzymes) colonization. The care plan indicated Resident 4's infections will resolve with minimal complications as evidenced by negative culture, vital signs within normal limits and no signs/symptoms of acute infection through next review. The care plan nursing interventions included instructing family/visitors/caregivers to wear disposable gowns and gloves during physical contact with resident, discard in appropriate receptacle and wash hands before leaving room, to clean and disinfect all shared equipment with appropriate disinfectants, and Enhanced Barrier precautions (EBP- are an infection control measure used in nursing homes and long-term care facilities to prevent the spread of multidrug-resistant organisms) to be followed. During a review of the facility's policy and procedure titled Handwashing/Hand Hygiene, revised dated 08/2019, indicated the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:Before and after direct contact with residentsBefore preparing or handling medicationsBefore and after entering isolation precaution settings

Based on observation, interview, and record review, the facility failed to ensure opened and refrigerated soup was disposed of within three days, and frozen hashbrowns were covered and sealed for 104 medically compromised and vulnerable residents who received food from the kitchen.These deficient practices had the potential to place residents at risk for foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins).Findings:During a concurrent observation and interview on 6/1/2026 at 8:50 a.m. with the Dietary Supervisor (DS) in the kitchen, a container labeled chicken noodle soup 5/25/2026 was observed in the refrigerator. The DS stated the chicken noodle soup should not have been in the refrigerator and should have been discarded three days after being opened. An opened bag of hashbrown potatoes was observed in the freezer, not fully closed. The DS stated the bag should have been sealed The DON stated the potatoes appeared freezer burned (when frozen foods are exposed to cold, dry air, causing them to dehydrate, often resulting in ice crystal formation on the outside of food). The DS stated food should be disposed of and stored according to facility policy to preserve food integrity and prevent foodborne illnesses.During an interview on 6/4/2026 at 11:29 a.m. with the Director of Nursing (DON), the DON stated kitchen staff should ensure foods were stored according to facility policy. The DON stated failure to properly store and dispose of food placed residents at risk for foodborne illnesses.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage revised 11/2022, the P&P indicated, All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). The P&P indicated, Frozen foods are maintained at a temperature to keep the frozen food solid. Wrappers of frozen foods must stay intact until thawing.During a review of the facility's P&P titled, Refrigerated Food Items revised 1/16/2024, the P&P indicated refrigerated soups should be disposed of within 2-3 days.

Based on observation, interview, and record review, the facility failed to ensure adequate respiratory monitoring, documentation, and assessments were completed, and oxygen signage was posted for one of three sampled residents (Resident 11) when the facility failed to ensure:a. Resident 11's oxygen administration was documented.b. Resident 11's Oxygen saturation (O2 sat- measurement of percentage of oxygen in your blood) was monitored every shift.c. Resident 11's oxygen care plan was developed to address Resident 11's continuous oxygen use.d. Display a No Smoking/Oxygen in Use sign at a resident room entrance where an oxygen concentrator (a medical device that provides oxygen-enriched air to help people breathe) was in use.These deficient practices had the potential to place Resident 11 at risk of delayed assessment, identification of respiratory complications, and delayed care. This deficient practice also had the potential to place all 132 residents residing in the facility, visitors, and staff at risk of a fire hazard.Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 11's diagnoses included pneumonia (an infection/inflammation in the lungs), schizophrenia (a mental illness that is characterized by disturbances in thought), and dementia (a progressive state of decline in mental abilities).During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool) dated 4/28/2026, the MDS indicated Resident 11's cognitive (ability to think and understand) skills for daily decision making was severely impaired. The MDS indicated Resident 11 was dependent on staff for toileting, bathing, and dressing.During a review of Resident 11's Change in Condition (COC) Evaluation, dated 5/23/2026, the COC Evaluation indicated Resident 11 developed a productive cough (cough that brings up mucus or phlegm from the lungs and airways). Resident 11's physician recommended oxygen administration at three liters per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen), as needed (PRN) breathing treatments, a chest X-ray and antibiotic therapy (used to treat and prevent bacterial infections).During a review of Resident 11's physician's orders dated 5/23/2026, the physician orders indicated to administer oxygen at four liters per minute via nasal cannula as needed for an O2 saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) less than 95 percent (%).During an observation on 6/1/2026 at 10:05 a.m., Resident 11 was observed receiving three liters of continuous oxygen via nasal cannula.a. During a concurrent interview and record review on 6/3/2026 at 12:49 a.m. with Licensed Vocational Nurse (LVN) 5, Resident 11's Medication Administration Record (MAR- document used to track all medications administered to a resident) dated May through June of 2026 was reviewed. The MAR did not indicate Resident 11 was administered oxygen. LVN 5 stated the licensed nurse that administered oxygen to Resident 11 should have documented the oxygen administration in the MAR. LVN 5 stated lack of documentation placed Resident 11 at risk of improper monitoring. LVN 5 stated residents clinical records should accurately reflect the medications and treatments they received.During an interview on 6/3/2026 at 1:06 p.m. with Registered Nurse (RN) 1, RN 1 stated licensed nurses were expected to document every medication and treatment administered to residents. RN 1 stated failure to document Resident 11's oxygen administration placed the resident at risk for inconsistent nursing care and inadequate respiratory monitoring and assessments.During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration last revised 2/2024, the P&P indicated documentation of oxygen administration is to include the signature and title of the person recording the data.b. During a concurrent interview and record review on 6/3/2026 at 9:20 a.m. with LVN 5, Resident 11's Weights and Vitals Summary dated June 2026 were reviewed. Resident 11's Weights and Vitals summary did not indicate Resident 11's oxygen saturation was monitored and documented. LVN 5 stated Resident 11's oxygen saturation should have been checked every shift to ensure the O2 sat parameter of 95% was being met and monitored. LVN 5 stated failure to monitor Resident 11's oxygen saturation placed the resident at risk for delayed care and identification of respiratory complications.During a concurrent interview and record review on 6/3/2026 at 1:06 p.m. with RN 1, Resident 11's physician orders indicated there were no orders to check Resident 11's O2 sat every shift. RN 1 stated residents receiving continuous oxygen should have orders to check the O2 sat every shift to ensure the resident was meeting the parameters, and to titrate (adjusting the amount of supplemental oxygen a patient receives, either increasing or decreasing the flow rate, to reach and maintain a specific target blood oxygen level) the oxygen if needed. RN 1 stated not monitoring Resident 11's O2 sat every shift placed resident at risk for respiratory complications such as unaddressed respiratory distress, delayed identification and treatment.c. During a concurrent interview and record review on 6/3/2026 at 9:20 a.m. with LVN 5, Resident 11's medical records were reviewed. The records did not indicate a care plan was developed that addressed Resident 11's continuous oxygen use. LVN 5 stated an oxygen care plan should have been created because the interventions guide nursing care, respiratory assessments, and special precautions required for each resident. LVN 5 stated failure to develop an oxygen care plan placed Resident 11 at risk for inadequate respiratory assessments and monitoring.During an interview on 6/4/2026 at 9:32 a.m. with the DON, the DON stated care plans should be comprehensive and provide specific interventions to address resident needs. The DON stated oxygen care plans were important because they provided the respiratory assessments nursing staff should be completing. The DON stated lack of care plan placed Resident 11 at risk for delayed identification of respiratory complications, interventions, and physician notification.d. During a concurrent observation and interview on 6/1/2026 at 10:10 a.m. with LVN 2, outside of Resident 11's room, Resident 11's room entrance was observed without a No smoking/Oxygen in use sign. Resident 11 was observed lying in bed with an oxygen concentrator at the bedside. LVN 2 stated there should be a No smoking/Oxygen in use sign on Resident 11's door to ensure no open flames or smoking took place near Resident 11's room. LVN 2 stated lack of signage placed residents, visitors, and staff at risk of a fire hazard.During an interview on 6/4/2026 at 9:32 a.m. with the DON, the DON stated all residents on continuous oxygen should have a No smoking/Oxygen in use sign on their door to ensure resident safety and prevention of fire in the facility.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered last revised 3/2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.During a review of the facility's P&P titled, Oxygen Administration last revised 2/2024, the P&P indicated, Review the resident's care plan to assess for any special needs of the resident. The P&P indicated No smoking signs were necessary for oxygen administration.

Based on observation, interview, and record review, the facility failed to maintain the medication refrigerator within the required temperature range for the storage of medications intended for resident use in one of one medication refrigerators reviewed.This deficient practice had the potential to compromise the stability, potency, and effectiveness of stored medications, placing residents at risk of receiving medications that may not provide the intended therapeutic effect and potentially adversely affecting their health and safety.Findings: During a concurrent observation and interview on 6/2/2026 at 12:40 p.m., with Licensed Vocational Nurse (LVN) 4, in Medication room [ROOM NUMBER], LVN 4 stated that the refrigerator was designated for storing newly received medications that required refrigeration before resident use. Upon opening the refrigerator, the internal thermometer displayed a temperature of 28 degrees Fahrenheit (a temperature scale). The refrigerator temperature log, which was attached to the front of the refrigerator door, indicated that the acceptable storage temperature range was between 36 and 46 degrees Fahrenheit. During the observation, three emergency medication kits labeled Keep Refrigerated were stored inside the refrigerator along with one other vial of medication. The following was observed:a. Each emergency kit contained one Novolin Regular insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection pen containing 3 milliliters (mL- a measurement of volume) of insulin, one Humalog Lispro insulin injection pen containing 3 mL of insulin, and two 1 mL vials (glass container) of lorazepam (antianxiety medication). b. One vial of 1 ml of Procrit (medication used to treat anemia caused by chronic kidney disease) with pharmacy labeling stating that the medication must be refrigerated and Do Not Freeze.LVN 4 stated that a temperature of 28 degrees Fahrenheit was below the freezing point. LVN 4 stated the medications stored in the refrigerator were at risk of freezing. LVN 4 stated that refrigerated medications, particularly insulin and other temperature-sensitive medications, must be maintained within the recommended temperature range to preserve their stability, potency, and therapeutic effectiveness. LVN 4 stated that if these medications freeze, they may become ineffective or unsafe for administration and would require replacement before resident use. LVN 4 stated that licensed nursing staff were responsible for monitoring and documenting refrigerator temperatures each day and ensuring that medications were stored according to pharmacy recommendations. LVN 4 stated that when a refrigerator temperature falls outside the acceptable range, the medications should be immediately assessed, removed from use if necessary, and the issue promptly reported to the Director of Nursing and the maintenance supervisor so corrective action can be taken.During a concurrent observation and interview on 6/2/2026 at 12:48 p.m., with the Director of Maintenance (DOM), the DOM observed the medication room refrigerator thermometer displaying a temperature below the facility's recommended range of 36 F to 46 F. The DOM stated that the temperature was not within the acceptable range for medication storage. The DOM stated that the refrigerator had been set to a freezing level rather than the appropriate refrigeration setting, causing the internal temperature to fall below the recommended range. The DOM stated that medications requiring refrigeration should be maintained within the recommended temperature. The DOM stated that the refrigerator settings should have been routinely monitored appropriately and adjusted as needed to ensure compliance with medication storage requirements.During an interview on 6/3/2026 at 12:47 p.m., with the Director of Nursing (DON), the DON stated that medications requiring refrigeration must be stored and maintained within the pharmacy's recommended temperature range of 36 F to 46 F to ensure medication integrity, potency, and effectiveness. The DON stated that nursing staff were responsible for monitoring and documenting refrigerator temperatures each day and for immediately reporting and addressing any temperature readings that fall outside the acceptable range. The DON stated that a refrigerator temperature below the recommended range could expose medications to freezing conditions, potentially compromising their stability and therapeutic effectiveness. The DON stated that the refrigerator should have been adjusted as soon as the out-of-range temperature was identified and that medications stored under improper temperature conditions should be evaluated according to facility policy and pharmacy guidance before being administered to residents. The DON stated that maintaining appropriate medication storage conditions was essential to ensure safe medication administration, medication patency and protect resident health and safety.During a review of the facility's policies and procedure (P&P) titled Medication Labeling and Storage dated 2/2023, the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review, the facility failed to ensure comprehensive care plans were developed for three of three sample residents (Resident 84, Resident 53, and Resident 40) addressing the following:1. Resident 84's use of oxygen therapy.2. Resident 53's use of pioglitazone (medication used to help lower blood sugar), metformin (medication used to help lower blood sugar), and glargine (medication given by injection that helps lower blood sugar).3. Resident 40's use of midodrine (medication used to raise blood pressure).These deficient practices had the potential to place Residents 84, 53, and 40 at risk for complications related to breathing, blood sugar control, and blood pressure management due to unmet care needs, inadequate monitoring of treatment, and lack of established therapeutic goals.Findings: 1. During a review of Resident 84's admission Record, the admission Record indicated, the facility admitted Resident 84 on 5/20/2022 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), pleural effusion (excess fluid in the space between your lungs and the inside of your chest wall), chronic pulmonary edema (buildup of excess fluid in the tiny air sacs of in the lungs), and asthma (lung condition where the airways swell, tighten, and fill with mucus). During a review of Resident 84's History and Physical (H&P), dated 5/15/2026, the H&P indicated Resident 84 can make needs known but can not make medical decisions. During a review of Resident 84's Minimum Data Set (MDS - a resident assessment tool), dated 5/20/2026, the MDS indicated Resident 84 had shortness of breath or trouble breathing when lying flat. The MDS indicated Resident 84 received intermittent oxygen therapy on admission and while a resident. During an observation on 6/1/2026 at 1:10 p.m. in Resident 84's room, Resident 84 was observed lying in bed. Resident 84 was receiving 4 liters (L – metric unit of measurement, used for measuring the volume of liquids or gases) of oxygen through a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). During an observation on 6/2/2026 at 10:50 a.m. in Resident 84's room, Resident 84 was observed lying in bed, receiving 4 L of oxygen through a nasal cannula. During a concurrent interview and record review on 6/2/2026 at 11:03 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 84's medical records was reviewed. The records did not indicated a care plan was developed for Resident 84's oxygen use. LVN 1 stated, Resident 84 was at risk for inappropriate oxygen use because the nursing staff would not be able to determine if the oxygen therapy was effective in achieving Resident 84's oxygen goals or whether interventions should be continued, modified, or discontinued without a care plan. During a concurrent interview and record review on 6/2/2026 at 12:56 p.m. with the Director of Nursing (DON), Resident 84's care plan was reviewed. The DON stated, Resident 84 should have a care plan when receiving oxygen therapy. 2. During a review of Resident 53's admission Record, the admission Record indicated Resident 53 was admitted to the facility on [DATE]. Resident 53's diagnoses included anemia (a condition where the body does not have enough healthy red blood cells), dementia (a progressive state of decline in mental abilities), heart failure (heart muscle is too weak to pump enough blood and oxygen to meet your body's needs), and hyperlipidemia (high cholesterol). During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53's cognitive skills for daily decision making were intact. The MDS indicated Resident 53 required supervision for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) except for personal hygiene and oral hygiene. During a review of Resident 53's H&P dated 6/27/25, the H&P indicated Resident 53 had the capacity to understand and make decisions. During a review of Resident 53's physician's order, dated 9/24/2025, the order indicated to administer dapagliflozin pro-metformin (used to treat diabetes, a disorder characterized by difficulty in blood sugar control and poor wound healing) extended release oral tablet of 10-1000 milligrams (mg, a unit of dose measurement) one tablet in the morning for diabetes. During a review of Resident 53's physician's order, dated 9/24/2025, the order indicated to administer pioglitazone (diabetes medication) oral tablet 30 mg, 1 tablet, by mouth one time a day for diabetes. During a review of Resident 53's physician's order, dated 11/18/2025, the order indicated to inject glargine insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) 18 units subcutaneously (delivers medication into the fatty layer of tissue just below the skin), in the morning, for diabetes. During a concurrent interview and record review on 6/3/2026 at 9:27 a.m., with LVN 4, LVN 4 reviewed Resident 53's electronic medical record was reviewed. LVN 4 stated that she was unable to locate a care plan addressing the resident's prescribed diabetic medications, including dapagliflozin-pro-metformin, glargine insulin, and pioglitazone. LVN 4 stated that these medications should be reflected in the resident's individualized care plan so that all nursing staff were aware of the resident's diagnosis, medication regimen, monitoring requirements, potential adverse reactions, and interventions. LVN 4 stated that the interdisciplinary care plan was intended to provide consistent guidance for staff and ensure continuity of care across all shifts. LVN 4 stated that the absence of care plan interventions for these medications could result in inconsistent care, missed monitoring for signs and symptoms of hypo- or hyperglycemia, and staff being unaware of appropriate interventions related to the resident's diabetic management.During a concurrent interview and record review on 6/3/2026 at 2:40 p.m., with the Director of Nursing (DON), the electronic medical record for Resident 53 was reviewed. The DON stated that physician orders were present for dapagliflozin-pro-metformin, glargine insulin, and pioglitazone but was unable to locate corresponding care plan interventions addressing the resident's diabetic medication regimen. The DON stated that the facility's expectation was that every resident's care plan was comprehensive, individualized, and updated to reflect current diagnoses, physician orders, medications, and interventions. The DON stated that medications used to manage diabetes should be included in the care plan to provide guidance for nursing staff regarding blood glucose monitoring, recognition and reporting of adverse effects, prevention of complications, and appropriate resident-specific interventions. The DON stated that the absence of these care plan interventions did not reflect the facility's standard of practice and could lead to inconsistent implementation of care and communication among interdisciplinary staff responsible for the resident's treatment and ongoing diabetic management 3. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including dementia, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and heart failure. During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 40 was dependent (helper does all of the effort) on staff for ADls. During a review of Resident 40's H&P dated 7/1/2025, the H&P indicated Resident 40 had fluctuating capacity to understand and make decisions. During a review of Resident 40's physician order, dated 9/5/2025, the physician order indicated to administer Midodrine (used to treat symptomatic orthostatic hypotension [a sudden drop in blood pressure when standing up]) 10 milligrams (mg, a unit of dose measurement), one tablet by mouth three times a day for hypotension (low blood pressure). During a concurrent interview and record review on 6/2/2026 at 1:00 p.m., with LVN 3, Resident 40's medical records as reviewed. The records did not indicate a care plan was developed for Midodrine. LVN 3 stated there was no care plan developed for Resident 40's use of Midodrine. LVN 3 stated Resident 40 should have an individualized care plan for Midodrine with interventions developed to guide licensed nurses on providing education, monitoring for medication side effects, monitoring medication effectiveness, and implementing appropriate measures as needed. LVN 3 stated this failure had the potential to place Resident 40 at risk for not being monitored for side effects and effectiveness of Midodrine, and for not receiving individualized care and interventions related to the use of the medication. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated, The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes, b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P&P titled, Oxygen Administration, revised 2/2024, the P&P indicated, Review the resident's care plan to assess any special needs of the resident.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 73) was informed of the reason for being restricted from the nursing station. This deficient practice had the potential to violate Residents 73's rights, and potentially cause emotional distress and feelings of disrespect, resulting in a loss of dignity and self-worth.Findings:During a review of Resident 73's admission Record, the admission Record indicated Resident 73 was originally admitted on [DATE] and readmitted on [DATE]. Resident 73 diagnoses included type 2 diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), left acetabulum fracture (a broken part of the left hip socket that helps hold the leg bone in place), and bilateral hearing loss.During a review of Resident 73's Minimum Data Set (MDS- a resident assessment tool), dated 5/6/2026, the MDS indicated Resident 73's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 73 required moderate assistance (helper does less than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 73's had moderate difficulty (speaker must increase volume to speak) hearing. During an interview on 6/4/2026 at 8:12 a.m., with Resident 73, Resident 73 stated he did not matter at the facility because he was not told why he could not go to the nurses' station. Resident 73 stated he felt ignored and waws denied information about decisions affecting him.During an interview on 6/4/2026 at 10:45 a.m., with the Assistant Director of Nursing (ADON), the ADON stated residents have the right to be informed about decisions affecting them and deserve a clear explanation. The ADON stated failure to do so may cause residents to feel ignored, devalued, and that they do not belong or matter at the facility, negatively affecting their trust and emotional well-being.During a telephone interview on 6/4/2026 at 4:13 p.m., with Registered Nurse (RN) 3, RN 3 stated residents should be treated with dignity and kept informed. RN 3 stated without explanation, residents may feel excluded, unimportant, and that their concerns were not valued.During a telephone interview on 6/4/2026 at 4:22 p.m., with RN 1, RN 1 stated residents should be treated with respect and dignity to prevent them from feeling unwanted or insignificant. RN 1 stated unclear communication could make residents feel left out, undervalued, and as though their concerns were not acknowledged.During a telephone interview on 6/4/2026 at 4:29 p.m., with the Director of Staff Development (DSD), the DSD stated residents should be treated with kindness and have the right to be informed. The DSD stated residents without explanations may feel ignored, silenced, and their concerns disregarded.During a review of the facility's policy and procedures (P&P) titled Resident Rights undated, the P&P indicated employees must always treat residents with kindness, respect, and dignity. The P&P indicated, residents should be cared for, communicated with, and given access to people and services inside and outside the facility.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents' (Resident 18 and Resident 21) room was free of accidents and hazards when Resident 18's headboard was observed broken and hanging away from the bed frame, and Resident 21's smoking assessment was not updated and smoking paraphernalia was not appropriately stored. These deficient practices placed Resident 18 and Resident 21 at risk for injury and an unsafe environment. Findings: 1. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 18's diagnoses included dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle weakness. During a review of Resident 18's History and Physical (H&P), dated 7/31/2025, the H&P indicated Resident 18 had fluctuating capacity to understand and make decisions. During a review of Resident 18's Minimum Data Set (MDS- a resident assessment tool), dated 4/24/2026, the MDS indicated Resident 18's cognitive skills for daily decision making (the ability to think and process information) was impaired. The MDS indicated Resident 18 requird maximal assistance (helper does more than half the effort) on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation on 6/03/2026 at 12:40 p.m., at Resident 18's bedside, Resident 18 was observed sitting on a wheelchair. The headboard was broken and hanging away from the bed frame. The right lower corner of the headboard was touching the floor. During a current observation and interview on 6/3/2026 at 12:42 p.m., with the Housekeeper (HK), in Resident 18's room, Resident 18's bed headboard was observed broken and not securely attached to the bed frame. The HK stated, broken headboards should be reported immediately to Director of Maintenance (DOM) for repair or replacement to ensure residents' safety. The HK further stated broken headboards, if left broken, could tip over or have exposed edges that may cause injury to residents. During an interview on 6/3/2026 at 1:33 p.m., with the DOM, the DOM stated, the resident beds must be kept in good condition. The DOM stated a damaged headboard was unsafe and should be reported for immediate repair. The DOM further stated failure to address the issue may place residents at risk for avoidable harm. During an interview on 6/3/2026 at 1:47 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated, the staff should report the broken headboard immediately for repair and failure to report the broken headboard could place the resident at risk of injury and unsafe living environment. During an interview on 6/4/2026 at 8:07 a.m., with the Director of Nursing (DON), the DON stated, a broken headboard causes hazards such as bruising, skin injuries, and negatively impacting residents' quality of life by creating an unsafe setting. During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, dated 8/2022, the P&P indicated the maintenance staff routinely inspects all beds to identify risks and problems, any broken or malfunction (not working properly) bed system are repaired or replaced using manufacturer specifications (the instructions from the company that made the bed or equipment). 2. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE]. Resident 21's diagnoses included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), and hyperlipidemia (an excess of lipids or fats in your blood). During a review of Resident 21's H&P dated 2/22/2026, the H&P indicated Resident 21 had fluctuating capacity to understand and make decisions. During a review of Resident 21's MDS, dated [DATE], the MDS indicated resident had moderate cognitive impairment. The MDS indicated Resident 21 required staff supervision for toileting, dressing and partial assistance for personal hygiene. During a concurrent observation and interview on 6/1/2026 at 9:52 a.m. with Registered Nurse (RN) 2, in Resident 21's room, Resident 21 was observed lying in bed with a blanket covering his face. A lighter and cigarette were observed on his bedside table. RN 2 stated Resident 21 was an independent smoker and was allowed to have smoking materials in his room, but the smoking materials should be secured in a drawer. RN 2 stated failure to properly store the smoking materials could result in other residents accessing the materials which posed a safety and fire hazard. During a concurrent interview and record review on 6/3/2026 at 9:27 a.m. with RN 1, Resident 21's smoking assessment dated [DATE] and Change in Condition evaluation dated 5/2/2026 were reviewed. The smoking assessment indicated Resident 21 followed smoking guidelines per facility policy. The Change in Condition evaluation indicated Resident 21 was seen smoking in his room and was educated that he was putting other residents at risk by smoking inside. RN 1 stated per facility policy, the smoking assessment should be updated with any change of condition. RN 1 stated there were no smoking assessments completed after Resident 21 was found smoking in his room on 5/2/2026, and an updated assessment should have indicated Resident 21 did not follow smoking guidelines. RN 1 stated Resident 21 should not have been able to store his own smoking materials. RN 1 stated failure to update Resident 21's smoking assessment and ensure safe storage of smoking materials placed Resident 21 at risk for accidents and all residents, staff and visitors at risk for a fire hazard. During an interview on 6/4/2026 at 9:32 a.m. with the DON, the DON stated Resident 21's smoking assessment should have been updated and the resident should not have been able to keep his own smoking materials. The DON stated updated smoking assessments and secure storage of smoking materials were important to ensure the safety of all residents, visitors, and staff. During a review of the facility's P&P titled, Smoking Policy- Residents last revised October 2023, the P&P indicated, A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. The P&P indicated, Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision.

Based on observation, interview, and record review, the facility failed to ensure two of two staff-dependent sampled residents' (Resident 46 and Resident 12) fingernails were trimmed and maintained in a clean manner.This deficient practice had the potential to result in a negative impact on Resident 46 and Resident 12's quality of life and self-esteem, and had the potential to result in sustaining skin injury from scratching and developing an infection. Findings: 1. During a review of Resident 46's admission Record, the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 46's diagnoses included bilateral osteoarthritis of knee (arthritis in both knees, causing pain and stiffness), dementia (a progressive state of decline in mental abilities), and dysphagia (difficult swallowing). During a review of Resident 46's Minimum Data Set (MDS – a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 46's cognitive skills for daily decision making (ability to think) was moderately impaired. The MDS indicated Resident 46 required maximal assistance (helper does more than half the effort) on staff for activities of daily living (ADLs- routine tasks/activities such as eating, bathing, dressing and toileting a person performs daily to care for themselves). During an observation on 6/2/2026 at 8:51 a.m., at Resident 46's bedside, Resident 46's fingernails were observed. Resident 46's fingernails were long and untrimmed with black debris underneath the nail bed. During a concurrent observation and interview on 6/3/2026 at 1:50 p.m., at Resident 46's bedside, with Certified Nursing Assistant (CNA) 3, Resident 46's fingernails were observed. Resident 46's fingernails were long and untrimmed. CNA 3 stated Resident 46's fingernails were sharp, long and required trimming. CNA 3 stated nail care was one of the responsibilities of the CNA which included trimming and cleaning the resident's fingernails when they become long and dirty. CNA 3 stated residents' nails should be checked daily to ensure the nails remained clean and neat. CNA 3 stated residents sometimes scratched their skin, and if they scratched hard enough, they could break the skin and create an open wound. CNA 3 stated if a resident had dirty fingernails and scratched themselves, this increased the risk of infection. During an interview with the Infection Preventionist Nurse (IPN) on 6/3/2026 at 2:00 p.m., the IPN stated nail care should be assessed daily. The IPN stated residents who required assistance with cleaning or trimming their nails should be assisted by the CNA's or licensed nurses. The IPN stated fingernails were a source of bacteria, and that dirty or untrimmed nails could contribute to the spread of infection, especially among residents who may not be able to maintain their own hygiene. The IPN stated routine nail care was an essential part of both personal hygiene and infection control. During an interview on 6/3/2026 at 2:35 p.m., with the ADON, the ADON stated fingernail care was a part of the resident's ADL routine. The ADON stated if a resident had long and dirty fingernails, CNAs were expected to clean and trim them. The DON stated dirty fingernails was not acceptable, as they increased the risk of infection. 2. During a review of Resident 12's admission Record, the admission Record indicated, the facility admitted the resident on 8/27/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), polyarthritis (pain, swelling, and stiffness in multiple joints), and tinea unguium (fungal infection of the nails). During a review of Resident 12's History and Physical (H&P), dated 2/28/2026, the H&P indicated Resident 12 had the capacity to understand and make medical decisions. During a review of Resident 12's MDS, dated [DATE], the MDS indicated, Resident 12 was dependent on staff for self-care, including activities such as grooming and bathing. During an observation on 6/1/2026 at 9:58 a.m. in Resident 12's room, Resident 12 was lying in bed. Resident 12 had thick, yellow, and overgrown fingernail on her right first digit, where the fingernail curled beneath the fingertip. Resident 12 had thick and yellow fingernail on her left fifth digit. During an interview on 6/3/2026 at 1:50 p.m. with CNA 1 in the presence of CNA 2, CNA 1 stated, Resident 12's fingernails needed to be trimmed. CNA 1 stated, the CNAs were responsible for providing fingernail care for the residents when the fingernails became too long. CNA 1 stated, if she was unable to provide fingernail care for a resident, she would notify the charge nurse. CNA 1 stated, she notified the charge nurse on 1/2026 but could not state who the charge nurse she reported to. During an interview on 6/3/2026 at 2:20 p.m. with the IPN, the IPN stated, if a CNA was unable to provide fingernail care for a resident due to overgrowth, the CNA will notify the charge nurse, the charge nurse will then notify the doctor, and then the wound care doctor would be consulted for further evaluation and management of the resident's fingernail care needs. The IP stated, a resident who did not receive appropriate fingernail care was at risk for developing ingrown fingernails, scratching and injuring themself, and developing infections from microorganisms that may accumulate under the fingernails. During an interview and record review on 6/4/2026 at 8:10 a.m. with the Assistant Director of Nursing (ADON), the ADON stated, the resident's progress notes indicated a podiatrist, dermatologist, or wound care doctor has not seen the resident regarding her right first digit and left fifth digit fingernails. During a concurrent interview and record review on 6/4/2026 at 10:27 a.m. with the Director of Nursing (DON), Resident 12's Progress Note – Acute Care, dated 12/29/2025, was reviewed. The DON stated, Resident 12 should have been provided care for her right first digit fingernail and left fifth digit fingernail. Resident 12's unclean fingernails may harbor bacteria, which could contribute to infection if the bacteria was introduced into the skin through scratching. During a review of Resident 12's Progress Note – Acute Care, dated 12/29/2025, the Progress Note – Acute Care indicated, Cleanse affected fingernails with normal saline, pat dry. Apply Ciclopirox 8% topical solution (nail lacquer) to affected fingernails once daily. Continue treatment for 30 days.Consider podiatry or dermatology referral if no improvement after treatment course. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, revised February 2018, the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. The P&P indicated nail care includes daily cleaning and regular trimming to prevent infections.

Based on observation, interview, and record review, the facility failed to ensure there was a physician order for oxygen use for one of one sampled resident (Resident 84) who was receiving oxygen.This failure had the potential to result in Resident 84 experiencing respiratory complications, including excessive oxygenation and carbon dioxide retention (build up the body's natural waste gas in the bloodstream.During a review of Resident 84's admission Record, the admission Record indicated, the facility admitted Resident 84 on 5/20/2022 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), pleural effusion (excess fluid in the space between your lungs and the inside of your chest wall), chronic pulmonary edema (buildup of excess fluid in the tiny air sacs of in the lungs), and asthma (lung condition where the airways swell, tighten, and fill with mucus).During a review of Resident 84's History and Physical (H&P), dated 5/15/2026, the H&P indicated Resident 84 can make needs known but cannot make medical decisions.During a review of Resident 84's Minimum Data Set (MDS - a resident assessment tool), dated 5/20/2026, the MDS indicated Resident 84 had shortness of breath or trouble breathing when lying flat. The MDS indicated Resident 84 was receiving intermittent oxygen therapy on admission and while a resident.During an observation on 6/1/2026 at 1:10 p.m. in Resident 84's room, Resident 84 was lying in bed and receiving 4 liters (L - metric unit of measurement, used for measuring the volume of liquids or gases) of oxygen through a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen).During an observation on 6/2/2026 at 10:50 a.m. in Resident 84's room, Resident 84 was lying in bed receiving 4 L of oxygen through a nasal cannula.During a concurrent interview and record review on 6/2/2026 at 11:03 a.m. with LVN 1, Resident 84's physician orders were reviewed. The resident's physician orders indicated no order for oxygen therapy. LVN 1 stated, oxygen was considered a medication and should not be administered to Resident 84 without an active physician order. LVN 1 stated, Resident 84 was at risk for excessive oxygenation, carbon dioxide retention, and suffocation without an active physician order for oxygen therapy.During a concurrent interview and record review on 6/2/2026 at 12:56 p.m. with the Director of Nursing (DON), Resident 84's physician order was reviewed. The DON stated, Resident 84 should have an active physician order for oxygen when receiving oxygen therapy. The DON stated, without a physician's order for oxygen therapy, Resident 84 was at risk for breathing complications, including over oxygenation and carbon dioxide retention.During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised February 2024, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure that feeding assistance was provided to one of four sample residents (Resident 2) who required feeding assistance with meals.This deficit practice placed Resident 2 at risk for choking, aspiration (accidental inhalation of food, liquid, or stomach contents into the airway), inadequate nutritional and fluid intake, weight loss, dehydration, and a decline in overall health status.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included dysphagia (difficulty swallowing), lack of coordination, dementia (a progressive state of decline in mental abilities), hypertension (high blood pressure), and acute respiratory failure with hypoxia (a life-threatening medical emergency where the lungs cannot adequately oxygenate the blood).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/14/2026, the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 2's physician diet order, dated 5/11/2026, the order indicated regular, large portions diet, pureed (foods blended to a smooth, uniform, pudding-like consistency that requires no chewing) texture, mildly thick consistency. The order indicated to provide a feeder.During an observation on 6/1/2026 at 11:00 a.m., inside Resident 2's room, Resident 2 was observed scooping her pureed meal with her right index finger. No staff member was present at the bedside providing feeding assistance, cueing, or supervision.During a concurrent observation and interview on 6/3/2026 at 12:36 p.m., with Certified Nurse Assistant (CNA) 1, Resident 2 was observed sitting upright in bed. A lunch tray was positioned over the Resident 2's lap. Resident 2 was observed scooping the food with her fingers. No staff member was present at the bedside providing feeding assistance, cueing, or supervision. CNA 1 stated that Resident 2 was a feeder and required staff assistance during meals. CNA 1 stated staff were expected to assist residents identified as feeders to ensure adequate nutritional intake and to reduce the risk of choking, aspiration, and difficulty consuming meals. CNA 1 stated that Resident 2 should not have been left to eat independently and stated that staff should remain available to provide feeding assistance throughout the meal as needed. CNA 1 stated that no staff member was assisting Resident 2 at the time of the observation.During a concurrent interview and record review on 6/3/2026 at 2:46 p.m., with the Director of Nursing (DON), the DON reviewed Resident 2's clinical record, including Resident 2's physician order dated 5/11/2026. The DON stated that Resident 2 was identified as requiring feeding assistance during meals and that staff were expected to provide direct assistance, supervision, and encouragement to ensure the resident consumed meals safely and received adequate nutrition and hydration. The DON stated that residents requiring feeding assistance should never be left to eat independently without staff support, as this placed the residents at risk for inadequate nutritional intake, choking, aspiration, and other adverse outcomes. The DON stated that CNA's were responsible for following Resident 2's feeding orders and providing assistance for the duration of the meal or until the resident safely completed eating. The DON stated that Resident 2's observation of eating unsupervised was not consistent with the facility's expectations or standards of care. The DON stated that staff should have been present to assist Resident 2 to ensure safe meal consumption and Resident 2's nutritional needs were met.During a review of the facility's policies and Procedures (P&P) titled Assistance with Meals dated 3/2022, the P&P indicated Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents Requiring Full Assistance: Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.

Based on interview and record review, the facility failed to ensure the facility's consultant pharmacist's Medication Regime Review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication, to the physician) recommendations for ammonia level (a blood test used to measure the amount of ammonia [a waste product] in the blood) laboratory test were completed for two of two sampled residents (Residents 14 and 40). This deficient practice resulted in Residents 14 and 40's recommended blood laboratory tests not being performed and had the potential to place the residents at risk for delayed identification and treatment of elevated ammonia levels and adverse drug reaction. Cross reference F580Findings: a. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), epilepsy (a neurological disorder characterized by recurrent, unprovoked seizure), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool), dated 8/17/2025, the MDS indicated Resident 14's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 14 required moderate (helper does less than half the effort) 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). During a review of Resident 14's History and Physical (H&P), dated 10/4/2025, the H&P indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's physician order, dated 3/19/2026, the physician order indicated to administer Depakote 500 milligrams (mg, a unit of dose measurement), one tablet by mouth two times a day for seizure. During a review of Resident 14's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/1/2026 to 6/3/2026. The MAR indicated Resident 14 received Depakote (used to treat epilepsy) 500 mg two times a day from 3/20/2026 to 6/3/2026. During a concurrent interview and record review on 6/3/2026 at 2:20 p.m., with the Director of Nursing (DON), Resident 14's Medication Regime Review (MRR) dated 5/1/2026 to 5/11/2026, was reviewed. The MRR indicated the facility's consultant pharmacist recommended an ammonia level laboratory test. The MRR did not indicate Resident 14's physician was notified of the pharmacist's recommendation. The DON stated there was no documentation that the physician reviewed the MRR or addressed the recommendation. The DON stated Resident 14 did not have an ammonia level ordered or drawn. The DON stated the pharmacist's recommendation was not communicated to Resident 14's physician. b. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and heart failure (heart muscle is too weak to pump enough blood and oxygen to meet your body's needs). During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40's cognitive skills for daily living was moderately impaired. The MDS indicated Resident 40 was dependent (helper does all of the effort) on staff for ADLs. During a review of Resident 40's H&P dated 7/1/2025, the H&P indicated Resident 40 had fluctuating capacity to understand and make decisions. During a review of Resident 40's physician's order, dated 10/9/2025, the physician's order indicated to administer Divalproex Sodium (an anticonvulsant [mood stabilizer] medication) 125 mg, two capsules by mouth two times a day for mood swings and continuous yelling. During a concurrent interview and record review on 6/3/2026 at 2:45 p.m., with the DON, Resident 40's MRR dated 5/1/2026 to 5/11/2026, was reviewed. The MRR indicated the facility's consultant pharmacist recommended an ammonia level due to Resident 40 receiving Divalproex Sodium medication. The MRR did not indicate Resident 40's physician was notified of the pharmacist's recommendation. The DON stated there was no documentation Resident 40's physician reviewed the MRR or addressed the recommendation. The DON stated Resident 40 did not have an ammonia level ordered or drawn and the pharmacist's recommendation was not communicated to the physician. During an interview on 6/3/2026 at 3:06 p.m., with the DON, the DON stated ammonia levels were necessary for Residents 14 and 40. The DON stated the ammonia levels monitored abnormalities in the blood. The DON stated an elevated ammonia level could cause symptoms such as confusion, sleepiness, behavior changes, decreased alertness, or other serious complications if not monitored and addressed. The DON stated the facility failed to ensure the consultant pharmacist's drug regiment review recommendations were communicated to Resident 14 and 40's physicians. The DON stated this placed the residents at risk for delayed identification and treatment of elevated ammonia levels while receiving Depakote and Divalproex Sodium. During a review of the facility's policy and procedure (P&P) titled Medication Regiment Review, revised 4/2007, the P&P indicated the consultant pharmacist will provide the Director of Nursing with written, signed and a dated report listing any irregularities and recommendations. The P&P indicated the facility staff were required to manage drug regiments to optimize resident's functioning and prevent or reduce negative effects from medication therapy.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Psychotropic Medication Use/Informed Consent dated 3/2024, for two of seven sampled residents (Resident 14 and Resident 56) when the facility failed to ensure:1. Resident 14's informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained for Depakote (a psychotropic medication that affect the mind, emotions, and behavior) prior to initiation.2. Resident 56's informed consent for Duloxetine (used to treat depression, generalized anxiety disorder, and various forms of chronic pain) was updated with the correct indication.These deficient practices had the potential to result in Residents 14 and 56's rights not being honored by not being able to participate in care and be fully informed of psychotropic (drugs that treat mental health disorders, affecting mood, thoughts, and behaviors) medication use. Findings: a. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), epilepsy (a neurological disorder characterized by recurrent, unprovoked seizure), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool), dated 8/17/2025, the MDS indicated Resident 14's cognition (the ability to think and process information) was intact. The MDS indicated Resident 14 required moderate (helper does less than half the effort) 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 MDS indicated Resident 14 received antipsychotic medication (a class of psychiatric medications primarily prescribed to manage psychosis, including delusions, hallucinations, paranoia, and confused thinking). During a review of Resident 14's History and Physical (H&P), dated 10/4/2025, the H&P indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's physician order, dated 3/19/2026, the physician order indicated to administer Depakote 500 milligrams (mg, a unit of dose measurement), one tablet by mouth two times a day for seizure. During a concurrent interview and record review on 6/3/2026 at 1:19 p.m., with Registered Nurse (RN) 1, Resident 14's physician order for Depakote dated 3/19/2026, was reviewed. The physician order did not indicate informed consent was obtained from Resident 14 prior to the initiation of Depakote. RN 1 stated that psychotropic medication such as Depakote required informed consent prior to initiation of the treatment to ensure the resident understand the risks, benefits and potential side effects. RN 1 stated failure to obtain an informed consent for Depakote placed Resident 14 at risk for receiving a psychotropic medication without being fully informed, without knowledge and without the opportunity to participate in the decision regarding the treatment. RN 1 stated it was the licensed staff's responsibility to ensure that informed consent for psychotropic medication was obtained and maintained in the resident's medical record. b. During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 56's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (an excess of lipids or fats in your blood) and chronic kidney disease (CKD- kidney damage effecting its ability to filter blood). During a review of Resident 56's H&P dated 5/1/2026, the H&P indicated Resident 56 had limited decision making capacity. During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had severe cognitive impairment. The MDS indicated Resident 56 required substantial staff assistance for toileting, dressing and personal hygiene. During a review of Resident 56's physician's order dated 10/15/2025, the order indicated to administer Duloxetine Hydrochloride (medication used to help regulate mood and block pain signals) oral capsule delayed release particle 20 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount), by mouth one time a day for depression as evidenced by expressing sadness. During a review of Resident 56's informed consent for duloxetine dated 10/28/2025, the informed consent indicated the indication for use was for depression as evidenced by expressing sadness. During a review of Resident 56's physician's order dated 11/1/2025, the order indicated to administer Duloxetine Hydrochloride oral capsule delayed release particles 20 mg, one capsule, by mouth one time a day for pain management history of diabetic neuropathy (nerve damage caused by long-term high blood sugar associated with diabetes). During a review of Resident 56's informed consent for duloxetine dated 4/28/2026, the informed consent did not indicate an indication for use. During a concurrent interview and record review on 6/3/2026 at 3:49 p.m. with the Assistant Director of Nursing (ADON), Resident 56's psychiatric follow up note dated 10/31/2025 and informed consent for duloxetine dated 4/28/2026 was reviewed. Resident 56's psychiatric follow up note indicated duloxetine indication was changed to pain management for diabetic neuropathy. The ADON stated another consent should have been obtained when the indication for duloxetine changed. The ADON stated the informed consent for duloxetine dated 4/28/2026 did not include an indication at all, and should have. The ADON stated updating informed consents to include the correct indication was important because it was the residents right to be included in the planning process and fully informed of all psychotropic medications they were prescribed. During an interview on 6/4/2026 at 9:32 a.m. with the Director of Nursing (DON), the DON stated it was the residents right to be aware of the indication of each psychotropic medication they were prescribed. The DON stated Resident 56's informed consent should have the correct indication, and should have been updated when the indication changed. During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use/Informed Consent, dated 3/2024, the P&P indicated prior to initiating treatment with psychotherapeutic drugs, facility staff must verify the resident health record contains written informed consent with the required signatures. The P&P indicated Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: indications for use.

Based on interview and record review, the facility failed to ensure the physician was notified in a timely manner of a resident's repeated refusal of a prescribed medication and an ordered ammonia (a blood test used to measure the amount of ammonia [a waste product] in the blood) level laboratory test for one of two sampled residents (Resident 40). This deficient practice resulted in Resident 40's physician not being informed of Resident 40's repeated refusals, and placed Resident 40 at risk for delayed assessment, delayed intervention, treatment, unmanaged change of condition, and potential adverse outcomes related to lack of physician oversight of the laboratory monitoring. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE]. Resident 40's diagnoses included dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and heart failure (heart muscle is too weak to pump enough blood and oxygen to meet your body's needs). During a review of Resident 40's Minimum Data Set (MDS- a resident assessment tool), dated 4/7/2026, the MDS indicated Resident 40's cognitive skills for daily decision making (the ability to think and process information) was moderately impaired. The MDS indicated Resident 40 was dependent (helper does all of the effort) on 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 40's History and Physical (H&P) dated 7/1/2025, the H&P indicated Resident 40 had fluctuating (change frequently) capacity to understand and make decisions. During a review of Resident 40's physician's order, dated 9/5/2025, the physician's order indicated to administer Midodrine (used to treat orthostatic hypotension (a sudden, severe drop in blood pressure when you stand up)) 10 milligrams (mg, a unit of dose measurement), one tablet by mouth three times a day for hypotension (low blood pressure). During a review of Resident 40's physician's order, dated 10/9/2025, the physician's order indicated to administer Divalproex Sodium (an anticonvulsant [mood stabilizer] medication) 125 mg, two capsules by mouth two times a day for mood swings and continuous yelling. During a review of Resident 40's physician's order, dated 1/22/2026, the physician's order indicated to collect an ammonia (a blood test used to measure the amount of ammonia [a waste product] in the blood) level laboratory test. During a review of Resident 40's facility's consultant pharmacist's Medication Regiment Review (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication, to the physician), dated 5/1/2026 to 5/11/2026, the MRR indicated a recommendation for an ammonia level due to Resident 40 receiving Divalproex Sodium. The MRR did not indicate the physician was notified of the pharmacist's recommendation. During a concurrent interview and record review on 6/2/2026 at 1:20 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 40's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 5/1/2026 through 5/31/2026, was reviewed. The MAR did not indicate Resident 40's refusal of Midodrine on 5/26/2026, 5/27/2026, and 5/28/2026. LVN 3 stated Resident 40 refused the medication three consecutive days. LVN 3 stated the licensed nurse was responsible for accurately documenting on the progress note and notifying the resident's physician. During a concurrent interview and record review on 6/2/2026 at 1:30 p.m., with LVN 3, Resident 40's progress notes dated 5/20/2026 through 5/31/2026, was reviewed. Resident 40's progress notes did not indicate documented evidence indicating the physician was notified of Resident 40's refusal of Midodrine on 5/26/2026, 5/27/2026, and 5/28/2026. LVN 3 stated the physician should have been notified when Resident 40 refused the medication three consecutive days. LVN 3 stated the physician needed to be informed to evaluate the reason for the resident's repeated refusal, assess the resident's clinical condition, and determine whether additional interventions, monitoring, or changes to the treatment plan were necessary. During a concurrent interview and record review on 6/3/2026 at 2:30 p.m., with the Director of Nursing (DON), Resident 40's progress notes, dated 5/20/2026 through 5/31/2026, was reviewed. The progress notes indicated Resident 40 refused the ammonia level on 5/20/2026 through 5/25/2026. The DON stated Resident 40's progress notes indicated the resident refused laboratory tests five consecutive days. The DON stated Resident 40's repeated refusal of the laboratory test should have been communicated to the physician. The DON stated physician notification was necessary so the physician was aware of the resident's continued refusal and to evaluate the resident's condition, discuss alternative approaches, determine whether the ammonia level laboratory test remained necessary, and provide further orders as appropriate. The DON stated failure to obtain the ordered ammonia level laboratory test and failure to notify the physician of Resident 40's repeated refusals could delay the physician's ability to assess the effectiveness and safety of the resident's medication regimen. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated the facility must notify the resident's physician of changes in the resident's medical, mental condition, including refusal of treatment or medications two or more consecutive times.

Based on observation, interview, and record review, the facility failed to assess the urine characteristics and document urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) care for one of one sampled residents (Resident 127), with an indwelling urinary catheter.These deficient practices had the potential to lead to delayed treatment and identification of urinary tract infections (UTI- an infection in the bladder/urinary tract) and improper urinary catheter management for Residents 127.Findings:During a review of Resident 127's admission Record, the admission Record indicated Resident 127 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 127's diagnoses included neuromuscular dysfunction of bladder (a bladder problem caused by damaged nerves that makes it hard to control when urinate), dependence on respiratory ventilator (a medical device to help support or replace breathing), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 127's Minimum Data Set (MDS- a resident assessment tool), dated 5/5/2026, the MDS indicated Resident 127's cognitive skills for daily decision making (process of thinking) was moderately impaired. The MDS indicated Resident 127 was dependent on staff with toileting, bathing, and lower body dressing. The MDS indicated Resident 127 had an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). During a review of Resident 127's History and Physical (H&P), dated 2/10/2026, the H&P indicated Resident 127 had fluctuating capacity to understand and make decisions. During a review of Resident 127's care plan titled The resident has Foley (indwelling) catheter., dated 2/13/2026, the care plan indicated to monitor and document Resident 127's Foley catheter care every shift for urine color, sediments, cloudiness, odor, blood, and amount of output. During a concurrent interview and record review on 6/3/2026 at 10:51 a.m., with the Treatment Nurse (TN), Resident 127's Treatment Administration Record (TAR), dated 5/1/2026 through 6/1/2026, was reviewed. The TAR did not indicate Foley catheter care monitoring was performed each shift. The TN stated the lack of consistent monitoring and documentation increased Resident 127's risk of infection. During an interview on 6/3/2026 at 2:11 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Foley catheter care should be monitored and documented each shift by the TN. The ADON stated this placed Resident 127 at risk for infection, development of a catheter-associated UTI, and other preventable infection-related complications. During a review of the facility's policy and procedure (P&P) titled Catheter Care, Urinary, revised 8/2022, the P&P indicated to observe the resident for complications associated with urinary catheters. The P&P indicated the following information should be recorded in the resident's medical record:1. The date and time that catheter care was given.2. The name and title of the individual(s) giving the catheter care.3. All assessment data obtained when giving catheter care.4. Character of urine such as color, clarity, and odor.5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain.6. Any problems or complaints made by the resident related to the procedure.7. How the resident tolerated the procedure.8. If the resident refused the procedure, the reason(s) why and the intervention taken.9. The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to ensure the following for two of four sampled residents (Resident 23 and Resident 66). 1. Certified Nursing Assistant (CNA) 4 used a two person assist when performing perineal care ([peri care] the washing of the genitals and anal area) and repositioning for Resident 23. 2. The call light was within reach and fall mats were provided for Resident 66. This failure resulted in Resident 23 falling from the bed, sustaining a bilateral (pertaining to both sides) femur fractures (broken thighbone, a serious injury, often requiring surgery and extensive rehabilitation, and is typically caused by high-impact trauma like car accidents or falls) which required surgical intervention at a general acute care hospital (GACH). This failure also resulted in Resident 23 undergoing a right and left right femur open reduction internal fixation surgery (a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware, such as screws, plates, or rods) and required the transfusion of three units of packed red blood cells (a medical procedure where concentrated red blood cells (RBCs) are infused into a patient's bloodstream). This failure also placed Resident 66 at risk for falls and subsequent fall-related injuries. Findings: During a review of Resident 23's Admission Record, the Admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included fracture of the left and right femur, morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and well-being), contracture of muscle multiple sites (a permanent or prolonged shortening of muscles, tendons, or other soft tissues that results in limited range of motion and stiffness), functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), neuromuscular dysfunction of the bladder (poor bladder control), dementia (a progressive state of decline in mental abilities), and anxiety (a feeling of uneasiness). During a review of Resident 23's Minimum Data Set ([MDS], a resident assessment tool), dated 12/29/2024, the MDS indicated Resident 23's cognitive skills (ability to think and reason) for daily decision making was moderately impaired. The MDS indicated Resident 23 had an impairment on both sides of her lower extremities (legs). The MDS indicated Resident 23 was dependent on staff (helper does all the effort, resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene (ability to maintain perineal hygiene), showering or bathing, upper and lower body dressing, and performing personal hygiene. The MDS indicated Resident 23 required substantial or maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for rolling to the left and right side of the bed. During a review of Resident 23's Physical Therapy Discharge Summary, dated 12/29/2022, the discharge summary indicated Resident 23 was assessed as total dependence with attempts to initiate for bed mobility. During a review of Resident 23's Fall Risk Assessment, dated 12/27/2024, the Risk Assessment indicated Resident 23 was at risk for falls. During a review of Resident 23's Certified Nursing Assistant (CNA) Task Flowsheet, dated December 2024, the flowsheet indicated Resident 23 was assessed as dependent for the task of rolling to the left and right side of the bed, on the 7 a.m. to 3 p.m., shift, for 21 out of the 31 days in the month of December 2024. The flowsheet indicated Resident 23 was assessed as dependent for the task of toileting hygiene, on the 7 a.m. to 3 p.m. shift, for 24 out of the 31 days in the month of December 2024. During a review of Resident 23's Change of Condition Note, dated 12/31/2024, timed at 9:30 a.m., the Change of Condition Note indicated on 12/31/2024 at 9:30 a.m., while CNA 4 was changing Resident 23, CNA 4 turned Resident 23 to the right side Resident 23 reached and grabbed on to the call light slid off the bed and landed on her back. During a review of Resident 23's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/31/2024 (untimed), the SBAR indicated on 12/31/2024 at 9:30 a.m., Resident 23 fell . The SBAR indicated Registered Nurse (RN) 1 assessed Resident 23 on the floor. The SBAR indicated Resident 23's Physician ordered a STAT (without delay) right hip and right femur x-rays (imaging that creates pictures of the inside of your body) , and for Resident 23 to be transferred to a GACH. During a review of Resident 23's Physician Progress Note, dated 12/31/2024, timed at 12:42 p.m., the note indicated Resident 23 had a right anterior (the front or front surface of a structure or body part) thigh deformity (not having the normal or natural shape or form) with concern for a fracture. The note indicated Resident 23 complained of left hip and right leg pain. During a review of Resident 23's Radiology (a medical specialty that uses imaging technology to diagnose and treat diseases) Results Report, dated 12/31/2024, timed at 12:53 p.m., the Radiology Results Report indicated the following: 1. Left hip x-ray indicated Resident 23 sustained a displaced (when the broken bone snaps into two or more pieces and the ends are no longer aligned) acute fracture to the proximal (near the center of the body) femur. 2. Left femur x-ray indicated Resident 23 sustained a displaced acute subtrochanteric (a break in the femur that occurs below the lesser trochanter, a bony prominence located at the top of the femur) fracture. 3. Right femur x-ray indicated the presence of a fracture to the mid shaft femur. During a review of the GACH Internal Medicine History and Physical Note, dated 12/31/2024, timed at 9:27 p.m., the note indicated Resident 23's blood pressure was 53/39 millimeters of mercury ([MM HG]- unit of measurement that describes the amount of force blood uses to get through the vessels of the body [normal range of 120-129 [top number] and 80-84 [bottom number]). The note indicated Resident 23's oxygen saturation (the percentage of oxygen in a person's blood) was 88 percent (%) (normal range 93-100%) on room air. The note indicated Resident 23's x-ray of the bilateral femurs and bilateral hips indicated Resident 23 sustained the following: 1. A comminuted (a fracture where a bone is broken into multiple pieces or fragments) medial angulated fracture (a fracture that results when one piece of the bone points in an inward direction) of the right femur mid shaft (a break in the middle portion of the femur) with 3.5 centimeter (cm- a unit of measurement) overlap of fracture fragments. 2. A comminuted, mildly medically displaced fracture of the left femoral proximal shaft (the upper, long part of the femur bone) with extension into the lesser trochanter (a small, bony prominence located on the inner side of the femur). During a review of the GACH Operating Room Note, dated 1/2/2025, timed at 9:29 a.m., the note indicated Resident 23 underwent a right and left femur open reduction internal fixation surgery (a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware, such as screws, plates, or rods). During a review of the facility's Post Fall Review, dated 1/9/2025, timed at 10:30 a.m., the review indicated on 12/31/2024, Resident 23 suffered an assisted fall and slid off the bed while being changed and turned. During a review of the GACH Principal Discharge Diagnosis with Brief Summary Note, dated 1/16/2025, timed at 12:50 p.m., the note indicated Resident 23 was admitted the GACH on 12/31/2024 for hypovolemic shock (a life-threatening condition that occurs when there is a significant loss of blood or fluids in the body, leading to inadequate blood circulation and oxygen delivery to organs) due to blood loss and bilateral thigh hematomas (a localized collection of blood outside of blood vessels that forms due to injury or trauma) secondary to bilateral femoral fractures while receiving anticoagulation (blood thinning) medication. The GACH Note indicated Resident 23 received three units of blood. During a concurrent observation and interview on 3/10/2025 at 10:10 a.m. with Resident 23, in Resident 23's room, Resident 23 was lying on her back in bed. Resident 23's eyebrows were furrowed as the resident stated, I just wish I could be repositioned more often. During an interview on 3/11/2025 at 12:19 p.m. with Resident 23's family member ([FM] 1), FM 1 stated on 12/31/2024, Resident 23 fell and sustained a fracture to both of her femurs and right hip while CNA 4 cleaned Resident 23 in bed. During an interview on 3/11/2025 at 12:20 p.m. with Resident 23, in Resident 23's room, Resident 23 stated on 12/31/2024, while being changed she suggested CNA 4 grab another nurse for help because she felt CNA 4 could not change her alone. Resident 23 stated CNA 4 replied no and proceeded to clean Resident 23. Resident 23 stated CNA 4 rolled her to her side and she (Resident 23) fell off the bed to the ground. Resident 23 stated after the fall, she suffered excruciating pain all over Resident 23 stated she did not recall reaching for a call light. During an interview on 3/11/2025 at 2:40 p.m., with Registered Nurse (RN) 2, RN 2 stated on 12/31/2024 at 9:30 a.m., CNA 4 informed her that Resident 23 fell . RN 2 stated she (RN 2) observed Resident 23 on the floor to the right side of the bed. RN 2 stated Resident 23 was able to hold onto to the grab bars (a small railing place on the side of the bed ) on her bed during repositioning and peri care. RN 2 stated Resident 23 had poor core strength (a group of muscles that include the abdominal muscles, back muscles and the muscles around the pelvis) when assisting with repositioning or turning in bed. RN 2 stated Resident 23 had broken her leg after seeing a large deformity to the resident's right leg. RN 1 stated CNA 4 reported that while cleaning Resident 23, CNA 4 repositioned the resident away from her (CNA 4's) body. RN 1 stated CNA 4 stated that Resident 23 tried to grab the call light to break her fall as the resident slipped off the air mattress. RN 1 stated CNA 4 should have had a second nurse assist with repositioning and cleaning Resident 23 to maintain safety and to prevent falls. During an interview on 3/11/2025 at 3:20 p.m., with CNA 4, CNA 4 stated on 12/31/2024 she was the assigned CNA for Resident 23 for the 7 a.m. to 3 p.m. shift. CNA 4 stated on 12/31/2024, at approximately 9:00 a.m., she provided peri care for Resident 23. and positioned the resident on her right side in preparation for Resident 23's wound treatment. CNA 4 stated the wound nurse was at the door and she (CNA 4) did not intend on leaving Resident 23 on her right side for a long time. CNA 4 stated Resident 23 attempted to grab an area of the bed to hold on to. CNA 4 stated Resident 23's legs fell first off, the bed, and the rest of the resident's body followed. CNA 4 stated she did not ask another nurse for help because she did not usually need help with Resident 23's repositioning or peri care. CNA 4 stated the normal process to determine each resident's level of performance and the number of staff needed to perform the task was to refer to the Kardex (a type of platform (paper or electronic) that nurses use to quickly reference key patient information for care planning). CNA 4 stated no one there was no information provided about Resident 23's bed mobility in the Kardex. CNA 4 stated there was only information about the number of staff needed to perform a transfer from the bed to chair for Resident 23. CNA 4 stated Resident 23's fall may have been prevented if she asked another nurse for help before providing peri care and repositioning the resident alone. During a concurrent interview and record review on 3/11/2025 at 4:00 p.m. with Minimum Data Set Nurse (MDSN) 1, Resident 23's MDS Section GG (an assessment that evaluates the need for assistance with self-care and mobility activities, functional limitations in range of motion, and current and prior device use), dated 12/29/2024, was reviewed. MDSN 1 stated the MDS indicated Resident 23 was dependent on staff for toileting hygiene. MDSN 1 stated Resident 23's MDS Section GG indicated Resident 23 required substantial, maximal assistance when rolling left and right in bed. During an interview on 3/11/2025 at 4:15 p.m. with the Director of Rehabilitation (DOR), the DOR stated it was best practice to have a second staff member assist in changing or repositioning a resident that was identified as maximal assist or dependent for repositioning or toileting hygiene. The DOR stated that CNA 4 could have probably done better. The DOR stated Resident 23 was hurt because of the fall. During an interview on 3/12/2025 at 8:06 a.m. with Restorative Nurse Aide (RNA) 1, RNA 1 stated she was familiar with Resident 23's bed mobility before the resident's fall (on 12/31/2024). RNA 1 stated it was necessary to have a nurse on each side of Resident 23's bed for repositioning or cleaning to ensure the resident's safety and to prevent a fall. During a concurrent interview and record review on 3/12/2025 at 1:38 p.m. with Occupational Therapist (OT) 1, Resident 23's CNA Task Flowsheet, dated 12/2024, was reviewed. OT 1 stated the CNA Task Flowsheet indicated Resident 23 was dependent for the task of rolling to the left and right in bed. OT 1 stated the CNA Task Flowsheet indicated dependent meant two or more nurses were needed for repositioning. During an interview on 3/13/2025 at 9:29 a.m. with CNA 8, CNA 8 stated Resident 23 used an air mattress which caused residents to be unstable in bed because of the slippery texture of the mattress. CNA 8 stated Resident 23 required the assistance of two CNAs during care and repositioning to ensure safety. During a concurrent interview and record review on 3/13/2025 at 10:13 a.m. with CNA 5, Resident 23's CNA Task Flowsheet, dated 12/2024, was reviewed. CNA 5 stated the CNA Task Flowsheet indicated Resident 23 was dependent for bed mobility and toileting hygiene [which meant Resident 23 required two-person assistance for safely repositioning Resident 23]. CNA 5 stated Resident 23's trunk and core strength was unstable before the fall on 12/31/2024. CNA 5 stated she was always very cautious with Resident 23, especially because the resident utilized an air mattress that contributed to Resident 23's bed instability. CNA 5 stated the texture of all air mattresses were very slippery which was why she (CNA 5) always made sure she had another nurse to assist her whenever she repositioned or provided peri care to Resident 23. CNA 5 stated she always exercised caution with Resident 23 even if Resident 23 was able to grab the grab bars on her bed. CNA 5 stated the use of two nurses to reposition and provide peri care for Resident 23 was best practice to ensure Resident 23's safety, and to prevent bodily injury from a fall. During a concurrent interview and record review on 3/13/2025 at 10:26 a.m. with the (DOR), Resident 23's Physical Therapy Discharge Summary, dated 12/29/2022, was reviewed. The DOR stated he was not made aware of any improvements or decline in mobility for Resident 23 after she had been discharged from physical therapy in 2022. The DOR stated Resident 23 was assessed as total dependence with attempts to initiate for bed mobility. The DOR stated Resident 23's fall was preventable if a second nurse had assisted Resident 23 reposition in bed. During a concurrent interview and record review on 3/13/2025 on 11:31 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 23's Weekly Nursing Progress Notes, dated 12/23/2024 and 12/30/2024, were reviewed. The Weekly Nursing Progress Notes indicated Resident 23 was dependent on staff for bed mobility and toileting hygiene. LVN 3 stated she authored the Weekly Nursing Progress Notes for Resident 23 and was familiar with Resident 23's physical capabilities and necessary level of care. LVN 3 stated Resident 23 required the assistance of two staff for safe handling. LVN 3 stated Resident 23 had poor strength and relied on staff when she was repositioned and cleaned. During a concurrent interview and record review on 3/13/2025 at 2:20 p.m., with MDSN 1, Resident 23's Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) Care Plan, initiated 1/4/2023 and revised 1/21/2025, was reviewed. The care plan indicated Resident 23 was totally dependent on staff for toilet use and required two staff participation to use the toilet. The care plan did not indicate how many staff members were needed for Resident 23's bed mobility and repositioning. MDSN 1 stated it was important to ensure the number of staff needed to the complete the task was included in the ADL Care Plan to ensure that care was rendered properly. 47286 2. During a review of Resident 66's Admission Record, the Admission Record indicated Resident 66 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 66's admitting diagnoses included generalized muscle weakness, reduced mobility, and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66 had moderately impaired cognition. The MDS indicated Resident 66 required substantial to maximal assistance from staff to roll left and right in bed and was fully dependent on staff to transition from sitting to lying, and lying to sitting positions, and chair/bed-to-chair transfers. During a review of Resident 66's care plan titled The resident is at risk for unavoidable falls, created 7/6/2024, the care plan indicated goals of care were Resident 66 being free from falls and associated injury. Care plan interventions indicated staff were to ensure Resident 66's call light was within reach. During a review of Resident 66's care plan titled [Resident 66] has had an actual fall .with serious injury, created 7/6/2024, the care plan indicated goals of care were Resident 66 not having any additional fall incidents. Care plan interventions indicated staff were to ensure Resident 66 had fall mats on both sides of her bed. During a review of Resident 66's Post-Fall Review assessment, dated 1/7/2025, the assessment indicated Resident 66 had an unwitnessed fall on 1/7/2025. The assessment indicated Resident 66's care plan was reviewed after the fall on 1/7/2025. The care plan indicated Resident 66 was to have floor mats to both sides of her bed and be encouraged to request for assistance. During a review of Resident 66's Quarterly Risk Data Collection Tool assessment, dated 1/17/2025, the assessment indicated Resident 66 was at risk for falls and had fallen one to two times in the last six months. During an observation on 3/11/2025 at 11:48 AM, at Resident 66's bedside, Resident 66 was observed lying in a left-facing position, with a blanket and sheet draped over her right arm. Resident 66's call light was placed on her bedside table, on her right side. When asked to demonstrate reaching for the call light, Resident 66 was unable to reach. During a concurrent observation and interview on 3/11/2025 at 1:13 PM, with Resident 66, at Resident 66's bedside, no fall mats were observed at Resident 66's bedside. Resident 66 stated she had a fall. During an observation on 3/12/2025 at 8:29 AM, at Resident 66's bedside, no fall mats were observed. During a concurrent observation and interview on 3/12/2025 at 11:53 AM, at Resident 66's bedside, with CNA 1, no fall mats were observed. CNA 1 stated Resident 66 did not have fall mats to either side of her bed. CNA 1 stated the purpose of the fall mats was to lessen or prevent injury from a fall. CNA 1 stated the fall mats were softer than the floor, and stated that without the mat, there was increased potential for injury. During a concurrent observation and interview, on 3/12/2025 at 11:56 AM, at Resident 66's bedside, with CNA 2, CNA 2 stated she provided care to Resident 66 for the last month. CNA 2 stated that in the last month, she did not observe fall mats at Resident 66's bedside. During a concurrent interview and record review, on 3/12/2025 at 12:07 PM, with LVN 1, Resident 66's care plan titled [Resident 66] has had an actual fall .with serious injury, dated 7/6/2024, was reviewed. LVN 1 stated the care plan indicated Resident 66 required fall mats to both [NAME] of her bed. LVN 1 stated Resident 66 was high risk for falls and the fall mats would minimize potential for injury if Resident 66 fell . During an observation on 3/13/2025 at 9:31 AM, at Resident 66's bedside, no fall mats were observed. During an interview on 3/13/2025 at 9:38 AM, with LVN 1, LVN 1 stated it was important for a resident's call light to be within reach. LVN 1 stated that if the call light was not within reach, the resident's needs might not be met, or they might attempt to get up unassisted and could fall and sustain injuries. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated the facility would strive to make the environment as free from accident hazards as possible. The P&P indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated a comprehensive, person-centered care plan, was to include includes measurable objectives and timeframes and describe the services that staff were to furnish to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P&P titled, Falls and Fall Risk Managing, revised 2/7/2024, the P&P indicated the facility nursing staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling based on previous evaluations and current data. The P&P indicated that air surface support mattress (i.e. Low air loss mattress /Pressure redistribution optimization mattress) was identified as an environmental risk factor that contributes to the risk of falls. The P&P indicated cognitive impairments, lower extremity weakness, poor grip strength, functional impairments, incontinence, heart failure, anemia, neurological disorders, and balance and gait disorders contributed to the risk of falls. The P&P indicated staff were to implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for at risk residents and those with a history of falls.

Based on observation, interview, and record review, the facility failed to ensure the safety of one of eight sampled residents (Resident 1) at risk for wandering by failing to: 1. Ensure the front and back exit doors were monitored, after the front lobby exit door alarm was activated by Resident 1 on 2/24/2025 at 7:43 p.m. 2. Closely monitor Resident 1's whereabouts in the facility after he attempted to leave from the front exit door on 2/24/2025 at 7:43 p.m. 3. Educate Resident 1 on the risk of leaving the facility after his first elopement (the act of leaving a facility unsupervised and without prior authorization) attempt on 2/24/2025 at 7:43 p.m. 4. Ensure the facility's back exit door alarm was activated on 2/24/2025. As a result, Resident 1 eloped from the facility's back exit door on 2/24/2025 at 7:47 p.m., four minutes after activating the front exit door alarm. On 2/28/2025 at 2:15 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) due to the facility's failure to provide supervision to Resident 1 on 2/24/2025 at 7:43 p.m. and failure to prevent Resident 1's elopement from the facility on 2/24/2025 at 7:47 p.m. On 3/1/2025 at 1:46 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed while onsite at 3/1/2025 at 3:25 p.m., in the presence of the ADM. The IJRP included the following immediate actions: 1. On 2/24/2025 at 9:30 p.m., staff immediately initiated a search of the inside and outside of the facility including streets, and nearby areas in partnership with the local Police Department. (i) Facility-wide search for Resident 1 initiated by Registered Nurse (RN) 1 and staff on 2/24/2025 at 9:30 p.m. (ii) Headcount completed by RN 1 on 2/24/2025 after Resident 1 was found missing. (iii) The ADM, the Director of Nursing (DON), and the Maintenance Supervisor (MS) were notified by RN 1 of Resident 1's elopement on 2/24/2025. 2. Immediate in-service trainings were conducted from 2/24/2025 - 3/1/2025: a. All staff were trained on elopement policies, procedures, and risks by the Director of Staff and Development (DSD) and the DON. b. Certified Nursing Assistant (CNA) 1 and CNA 2 were counseled and retrained on reporting alarms and elopement supervision by the DON and DSD on 2/28/2025 and 2/24/2025. c. Weekly in-services would be initiated by the DSD for eight weeks for all shifts. 3. Identification of other at-risk residents: a. All residents were reassessed for elopement risk by the DON on 2/25/2025. b. On 2/27/2025, one newly admitted resident identified as high-risk for elopement. c. Care plans updated accordingly. 4. Measures to prevent recurrence: a. Admission & Care Planning Process: (i) All new/readmitted residents assessed for elopement risk by the Inter-Disciplinary Team (IDT, a group of different disciplines working together towards a common goal for a resident) members and/or the DON. (ii) Comprehensive assessments of residents conducted at least quarterly or upon status change by the Minimum Data Set (MDS) Coordinator. (iii) Residents' care plans updated to reflect elopement risk by the MDS Coordinator and/or the DON. b. Facility security measures: (i) Exit door Monitoring: 1. Backdoor exit to be constantly supervised, maintained and validated by the MS daily from Monday to Friday and manager of the day for Saturday and Sunday. The MS to maintain a log and to be audited by the ADM. 2. Before the receptionist leaves the building at 7 p.m., the receptionist would communicate to the RN supervisor and/or the charge nurse that they are leaving. The RN and/or the charge nurse would activate the alarm system to ensure continuous monitoring of the back door exit.?RN supervisor would update the monitoring log which is to be kept at the nursing station. 3. Ensure all exit doors were equipped with functioning alarms. 4. The MS to maintain a log to ensure its functioning, to be audited by the ADM weekly. 5. Installed additional alarms where necessary. 6. Maintain documentation of alarm functionality. c. Staff education & training: (i) Mandatory in-services by the DSD for all staff on 2/27/2025: 1. Elopement procedures and monitoring exit doors after alarms. 2. Proper resident supervision strategies. 3. Assessment and care planning updates for elopement risks. 4. Educating residents on elopement dangers. 6. Policy and procedures for managing wandering risk. 5. Monitoring & Compliance: a. Routine Checks: (i) Weekly elopement risk audits to be conducted by the Medical Records Supervisor (MRS). (ii) IDT meetings to review findings and ensure follow-ups. (iii) Implementation of an Elopement Performance Improvement Plan (PIP) under Quality Assessment and Assurance (QAA). b. Reporting & Drills: (i) Regular elopement drills conducted by the DSD. (ii) Reporting process established for elopement incidents. c. Quality assurance & follow-up: (i) Findings presented at QAA meeting on 3/20/2025. (ii) Ongoing audits would be reported monthly for six months, then quarterly by the DON and the ADM and/or designee. (iii) The facility would sustain compliance through continuous monitoring and training. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), difficulty in walking, and schizophrenia (a mental illness that was characterized by disturbances in thought). During a review of Resident 1's MDS (a resident assessment tool), dated 2/14/2025, the MDS indicated Resident 1's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 required set up assistance with eating, and supervision with oral hygiene, personal hygiene, and walking. The MDS indicated Resident 1 had wandering behaviors (the act of roaming around and becoming lost or confused about his location). During a review of Resident 1's History and Physical (H&P) dated 11/7/2024, the H&P indicated Resident 1 could make his needs known but could not make medical decisions. a. During a telephone interview on 2/27/2025 at 12:42 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 2/24/2025 at 7:30 p.m., he saw Resident 1 exit his room. CNA 1 stated on 2/24/2025 at 7:43 p.m., while changing Resident 3 (Resident 1's roommate) he heard the front exit door alarm. CNA 1 stated he walked out of the room to check the alarm and saw Resident 1 by the door. CNA 1 stated he redirected Resident 1 back to the hallway, and Resident 1 walked down the hallway toward the nursing station. CNA 1 stated he did not report the incident to the charge nurse for further interventions like closer monitoring of the exit doors. During a telephone interview on 2/27/2025 at 1:59 p.m. with Registered Nurse (RN) 1, RN 1 stated on 2/24/2025 at 7:43 p.m., no one reported to him that Resident 1 activated the front exit door alarm. RN 1 stated CNA 1 should have informed the RN supervisor and charge nurses for immediate interventions. During a telephone interview on 2/27/2025 at 2:18 p.m., with CNA 2, CNA 2 stated on 2/24/2025 around 7:43 p.m., she went to use the restroom located near the facility's front exit door. CNA 2 stated she heard the front exit door alarm and saw Resident 1 standing at the door. CNA 2 stated she called Resident 1 by his name but the resident did not respond and continued to walk down the hallway. CNA 2 stated she thought the alarm was activated because Resident 1 got too close to the door. CNA 2 stated she did not think Resident 1 was trying to elope. CNA 2 stated she did not report the incident to anyone. CNA 2 stated the exit doors should have been closely monitored after the front exit door was activated by Resident 1. During an interview on 2/27/2025 at 2:58 p.m. with the Director of Staff Development (DSD), the DSD stated on 2/24/2025 at 7:43 p.m., CNAs 1 and 2 were aware that Resident 1 activated the front exit door alarm. The DSD stated CNAs 1 and 2 should have notified the charge nurse so the charge nurse could follow up and ensure Resident 1's safety and ensure the exit doors were monitored. During a concurrent interview and video review on 2/28/2025 at 8:58 a.m. with the Administrator (ADM), the facility's security surveillance video footage, dated 2/24/2025 from 7:43 p.m. to 7:48 p.m., was reviewed. The ADM stated at 7:47 p.m., the surveillance footage revealed Resident 1 pushed open the back exit door and walked out of the facility through the parking lot and onto the street. The ADM stated, there was no staff present at the back exit door. The ADM stated the back door should have been supervised. During an interview on 2/28/2025 at 4:04 p.m. with RN 2, RN 2 stated on 2/24/2025 at 7:43 p.m., staff should have made sure the facility's front and back doors were secured at all times after the front exit door alarm was activated. b. During a telephone interview on 2/27/2025 at 12:42 p.m. with CNA 1, CNA 1 stated 2/24/2025 at 7:43 p.m. was his last time seeing Resident 1 after the resident activated the front exit door alarm. CNA 1 stated he did not check on Resident 1 after that because he was busy changing other residents. CNA 1 stated he should have checked on Resident 1 after the resident activated the alarm. CNA 1 stated on 2/24/2025 at 9:30 p.m., he could not find Resident 1, and did not know what time Resident 1 left the facility. During a telephone interview on 2/27/2025 at 1:59 p.m. with RN 1, RN 1 stated on 2/24/2025 around 7:43 p.m., he heard the front exit door alarm but did not see anyone. RN 1 stated he continued to work on his admission and did not inquire on who or what activated the alarm. RN 1 stated after the alarm was activated staff should have checked to see if a resident left the facility, and the resident should have been placed on close monitoring, similar to one-on-one (1:1, a dedicated nurse assigned to continuously observe and attend to a single resident at all times, providing close supervision and immediate interventions when needed) supervision. RN 1 stated he would have assigned 1:1 supervision for Resident 1 or placed Resident 1 at the nursing station so he (RN 1) could monitor Resident 1. RN 1 stated on 2/24/2025 at 9:30 p.m., Licensed Vocational Nurse (LVN) 1 and LVN 2 informed him that Resident 1 was missing. During a telephone interview on 2/27/2025 at 2:26 p.m. with LVN 2, LVN 2 stated on 2/24/2025 around 7:40 p.m., she was told by staff (unable to recall name) that Resident 1 activated the front exit door alarm. LVN 2 stated staff were to make rounds every 15 minutes to check on wandering residents and make sure the residents' wander guards (a safety system used to prevent residents from wandering into unsafe areas or elopement) were on. LVN 2 stated the charge nurse should have checked Resident 1's wander guard placement after Resident 1 activated the alarm on 2/24/2025 at 7:43 p.m. LVN 2 stated Resident 1 was not her assigned resident and that was why she did not do so. LVN 2 stated on 2/24/2025 at 9 p.m., LVN 1 notified her (LVN 2) that Resident 1 was missing. During an interview on 2/27/2025 at 2:58 p.m. with the DSD, the DSD stated all CNAs should monitor all wandering residents by keeping an eye on them. The DSD stated if residents were observed wandering, trying to go to the patio, or had their belongings with them, staff were supposed to recognize those signs as elopement risk. The DSD stated RNs were supposed to immediately perform rounds to ensure all residents were in the facility. The DSD stated if the RNs did not see anything, they were supposed to find out who activated the alarm and what happened. The DSD stated the LVNs were supposed to monitor residents who activated the alarm and perform more frequent rounds. During a telephone interview on 2/27/2025 at 3:42 p.m. with LVN 1, LVN 1 stated on 2/24/2025 around 7:40 p.m., she was in another room and did not hear the alarm. LVN 1 stated on 2/24/2025 around 7:45 p.m., she observed Resident 1 in bed. LVN 1 stated Resident 1 was on hourly monitoring for his wandering behaviors and had a wander guard. LVN 1 stated on 2/24/2025 at 9 p.m., CNA 1 reported to her that Resident 1 activated the alarm around 7:40 p.m. and was now missing. LVN 1 stated she would have notified RN 1 at 7:45 p.m. if she was aware that Resident 1 activated the front exit door alarm and ensure Resident 1 was closely monitored. LVN 1 stated all staff was responsible for ensuring residents' safety. During an interview on 2/27/2025 at 4:16 p.m. with the DON, the DON stated Resident 1 activating the alarm was an exit-door-seeking behavior. The DON stated staff should assess the needs of residents with exit-door-seeking behavior and implement interventions. The DON stated when staff observed Resident 1's exit-door-seeking behavior, the licensed nurses should have documented the exit-door-seeking behavior in the resident's medical record and implemented closer monitoring. The DON stated on 2/24/2025 at 7:43 p.m., RN 1 and LVN 1 should have inquired to find out who activated the alarm and/or whether it was a false alarm so staff could do closer monitoring to ensure Resident 1's safety. c. During a review of Resident 1's care plan titled At risk for elopement/wandering, initiated 11/8/2024, the care plan indicated Resident 1 would have no incident of elopement and wandering outside of the facility property daily. The care plan interventions indicated will remind Resident 1 regularly and as needed (PRN) and explain risks and benefits of elopement/wandering. During a telephone interview on 2/27/2025 at 12:42 p.m. with CNA 1, CNA 1 stated on 2/24/2025 at 7:43 p.m., he did not educate Resident 1 on the risks of leaving the facility without supervision after Resident 1 activated the front exit door alarm. During a telephone interview on 2/27/2025 at 2:18 p.m., with CNA 2, CNA 2 stated on 2/24/2025 around 7:43 p.m., she called Resident 1 by his name after Resident 1 activated the front exit door alarm, but did not educate Resident 1 on the risks of leaving the facility unsupervised. d. During a concurrent observation and interview on 2/26/2025 at 3:40 p.m. with the Maintenance Supervisor (MS), the back exit door alarm was flashing with a high pitched sound when activated. The MS stated the alarm lit up when activated. During a concurrent interview and video review on 2/28/2025 at 8:58 a.m. with the ADM, the facility's security surveillance video footage, dated 2/24/2025 from 7:43 p.m. to 7:48 p.m., was reviewed. The ADM stated at 7:47 p.m., the surveillance footage revealed Resident 1 pushed open the back exit door, and the alarm did not light up. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised in 7/2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . a facility-wide commitment to safety at all levels of the organization .The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. The P&P indicated Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs. The P&P indicated implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions c. Ensuring that interventions are implemented d. Ensuring that interventions are implemented correctly and consistently. During a review of the facility's P&P titled, Wandering and elopements, undated, the P&P indicated If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.

Based on interview and record review, the facility failed to provide care and services to prevent a fall for one of four sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). This deficient practice caused Resident 1 to fall and sustain an acute (immediate) fracture (broken bone) of the fifth cervical (relating to the neck) (C5) vertebra (bone in the spine). Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), hypertension ([HTN]- high blood pressure), anxiety (feeling of fear, or worry), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated 10/4/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] - a federally mandated resident assessment tool), dated 10/9/2024, the MDS indicated Resident 1 had the ability to express ideas and wants, and had clear comprehension (capability of understanding something). The MDS indicated Resident 1 was totally dependent (full staff performance) on staff with a two-person physical assist for transfer (how the resident moves between surfaces) and 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 care plan titled ADL Self Care Performance Deficit , dated 10/14/2024, the care plan indicated Resident 1 had a self-care deficit related to limited mobility, and quadriplegia. The care plan interventions indicated facility staff will provide total assistance for transfers with the use of a Hoyer lift. During a review of Resident 1's situation, background, assessment, recommendation ([SBAR]- a communication tool used by healthcare workers when there is a change of condition among the residents) report, dated 11/3/2024 at 11:00 a.m., the SBAR indicated Resident 1 fell on his back and hit his head during transfer from the bed to a Geri-chair. The SBAR indicated Resident 1 was assisted back to the bed and complained of back and neck pain rated at 7 out of 10, on a pain scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain). During a review of Resident 1's progress note dated 11/3/2024 at 1:24 p.m., the progress note indicated Resident 1 was transferred to the GACH emergency room (ER) for evaluation due to a fall and pain. During a review of Resident 1's GACH ER admission record, dated 11/3/2024 at 12:19 p.m., the GACH ER admission record indicated Resident 1 was seated on a Hoyer lift when it tipped over causing the resident to fall to the ground and hit his head. The GACH ER admission record indicated Resident 1 complained of left head pain rated at 7 out of 10 post fall. During a review of Resident 1's GACH ER Computed Tomography ([CT] a procedure that uses a computer linked to a machine to make a series of detailed picture of areas inside the body) Report, dated 11/3/2024 at 1:08 p.m., the CT report indicated acute fracture through the C5 vertebral body (recent break in the bone of the central part of the fifth cervical vertebra, which is located in the neck). During a review of Resident 1's GACH ER note, dated 11/3/2024 at 1:28 p.m., the GACH ER note indicated Resident 1 was administered morphine (medication used to treat moderate to severe pain) four (4) milligrams (mg, unit of measurement) intramuscularly (IM, injection into the muscle) for pain. During a review of Resident 1's GACH ER note, dated 11/3/2024 at 2:44 p.m., the GACH ER note indicated Resident 1 required a cervical collar (a medical device that supports neck and spine) and a follow-up with neurosurgery (surgery to the brain or spinal cord) within 6 to 8 weeks. During a review of Resident 1's progress note (from the facility), dated 11/3/2024 at 6:15 p.m., the progress note indicated Resident 1 returned to the facility on [DATE] at 6:15 p.m. During a review of Resident 1's progress note, dated 11/3/2024 at 11:30 p.m., the progress note indicated Resident 1 reported an excessive tingling sensation and discomfort to all extremities (arms and legs). The progress note indicated Resident 1 reported having 10 out of 10 pain all over his body. During a review of Resident 1's progress note, dated 11/4/2024 at 1:00 a.m., the progress note indicated Resident 1 was transferred back to the GACH for evaluation and treatment. During a review of Resident 1's GACH record, dated 11/4/2024 at 1:39 a.m., the GACH record indicated Resident 1 presented to the ER for pain to the bilateral upper and lower extremities. During a review of Resident 1's GACH medication record, dated 11/6/2024 at 2:46 p.m., the GACH medication record indicated Resident 1 was administered baclofen (medication to treat muscle spasms and pain) 10 mg for pain. During a review of Resident 1's GACH medication record, dated 11/8/2024 at 9:37 a.m., the GACH medication record indicated Resident 1 was administered fentanyl (medication used to treat severe pain) 50 microgram (mcg, unit of measurement) intravenously (IV, into the vein) for pain. During a review of Resident 1's GACH medication record, dated 11/9/2024 at 10:30 p.m., the GACH medication record indicated Resident 1 was administered morphine 4 mg IV for pain. During a review of Resident 1's GACH record, dated 11/10/2024, the GACH record indicated Resident 1 was discharged back to the facility. During a telephone interview on 11/5/2024 at 10:14 a.m., with CNA 1, CNA 1 stated, Resident 1 could not get up alone and required a two-person assist for ADLs. CNA 1 stated Resident 1 required a Hoyer lift for transfer from the bed to Geri-chair. CNA 1 stated on 11/3/2024 at 10:00 a.m., she was assisting Resident 1 with a Hoyer lift transfer from the bed to a Geri-chair. CNA 1 stated Resident 1 was seated on the Hoyer lift sling (device that holds a patient during a transfer). CNA 1 stated there were four straps, two in the front of Resident 1 and two on the back of Resident 1. CNA 1 stated she attached the four sling straps to the Hoyer lift and stood behind the Hoyer lift while lifting Resident 1 from the bed. CNA 1 stated Resident 1 was approximately four (4) feet (a unit of measurement for length) from the ground. CNA 1 stated Resident 1 fell to the ground and the Hoyer lift tipped over onto Resident 1. CNA 1 stated it could have been a safer transfer had another staff assisted in transferring Resident 1, as she (CNA 1) was alone. CNA 1 stated she was busy rushing to complete the care of her other assigned residents and did not ask for assistance. CNA 1 stated Resident 1's fall could had been avoided if she asked for assistance while transferring Resident 1 with the Hoyer lift. During a telephone interview on 11/5/2024 at 11:07 a.m., with Resident 1, Resident 1 stated he was admitted to the GACH on 11/4/2024 due to a neck bone fracture and pain. Resident 1 stated on 11/3/2024 around 10:00 a.m., CNA 1 transferred him (Resident 1) from the bed to a Geri-chair using a Hoyer Lift. Resident 1 stated the Hoyer lift tipped over, he fell to the ground and the Hoyer lift fell on top of him. Resident 1 stated he sustained a neck fracture. Resident 1 stated he was in pain. During an interview on 11/5/2024 at 11:22 p.m., with CNA 2, CNA 2 stated on the morning of 11/3/2024 around 10:30 a.m., she (CNA 2) heard help, help coming from Resident 1's room. CNA 2 stated she went to Resident 1's room and observed the resident on the floor with the Hoyer lift on the resident. CNA 2 stated she and four other staff assisted Resident 1 into bed. CNA 2 stated while Resident 1 was assisted into his bed, Resident 1 complained of neck pain. CNA 2 stated to prevent accidents and keep residents safe; staff should not operate the Hoyer lift using a one person assist. During a concurrent interview and record review on 11/5/2024 at 1:20 p.m., with Occupational Therapist (OT, a healthcare provider who helps you improve your ability to perform daily tasks) 1, Resident 1's Occupational Therapy Note , dated 10/8/2024 was reviewed. OT 1 stated Resident 1's upper extremities ([UE] arms) and lower extremities ([LE] legs) were impaired (loss of a physical ability). OT 1 stated Resident 1 required total assistance (two or more persons assist) with mobility and transfer. OT 1 stated due to Resident 1's UE and LE impairment it was safer for staff to use a Hoyer lift while transferring Resident 1. OT 1 stated the Hoyer lift should have been two persons assist to prevent falls, injury, and to keep Resident 1 safe. During an interview on 11/5/2024 at 2:25 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was dependent with care and required two-person assist for transfer. The DON stated CNA 1 should have asked for assistance from another staff to transfer Resident 1 via the Hoyer lift. The DON stated there should have been a two-person physical assist when operating the Hoyer lift for the residents' safety, and to prevent falls, and injury. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents , revised 7/2017, the P&P indicated the facility will make the environment as free of accident hazards as possible. The P&P indicated the facility's priority was resident safety, supervision, and assistance to prevent accidents. During a review of the facility's P&P titled Safe Lifting and Movement of Residents , undated, the P&P indicated the facility will protect the safety and well-being of residents and staff. The P&P indicated the facility will promote quality care, use appropriate techniques and devices to lift and transfer residents. During a review of an undated Manufacturer's User Manual titled Invacare ([Invacare] manufacture of long-term care medical products), Manual/Electric Portable Patient Lift, the user manual indicated a recommendation to use two persons assist for lifting and transferring procedures. During a review of the facility's Certified Nursing Assistant (CNA) Job Description, dated 9/2020, the CNA Job Description indicated responsibilities and accountabilities include implementing care according to the care plan. The CNA Job Description indicated helping residents with their ADLs, and proper lifting and transitioning from bed to wheelchair, wheelchair to bed, etc.

Based on observation, interview, and record review, the facility failed to: 1. Maintain residents' room temperatures in a range of 71 to 81 degrees (unit of measurement) Fahrenheit (F, a scale of temperature) for 9 out of 9 resident rooms (Rooms 106, 128, 129, 130, 132, 133, 134, 135, and 136). 2. Implement the facility's contingency plan (involves making various decisions as an organization before an emergency happens) when the air conditioning (A/C) unit became inoperable on 6/22/2024 affecting 9 out of 9 resident rooms (Rooms 106, 128, 129, 130, 132, 133, 134, 135, and 136). 3. Implement cooling measures to keep residents comfortable for 10 out of 10 residents (Resident 1, 2, 12, 13, 25, 26, 27, 28, 29, and 30) when the A/C unit became inoperable on 6/22/2024, a total of 3 days. These deficient practices put the residents in the affected rooms at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures) and had the potential to negatively affect the identified 34 residents. On 6/25/2024 at 7:20 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called. The facility ' s Director of Staff Development, Director of Maintenance, and Administrator were notified of the nine residents ' rooms and residents affected by the increased room temperatures above 81.0 degrees F which could potentially put the residents at risk for dehydration and heatstroke. On 6/26/2024, the facility provided an IJ Removal Plan ([IJRP] a plan on how the facility would correct the deficient practices for the benefit of the residents) that was not acceptable. On 6/27/2024 at 3:50 p.m., the facility provided an acceptable IJRP and the IJ was removed, after the team verified through observations interviews, and record review. The IJRP was implemented as follows: 1. Eight (8) portable air conditioning systems and 11 fans were placed in the affected rooms. 2. A hydration station (a table with cold ice water and cups) was set up in the affected area and two additional hydration stations were set up outside the front dining room and the back dining room, with staff distributing water to the residents. 3. In-service training provided to staff on all shifts regarding the Extreme Weather Advisory. 4. Temporary room changes for residents in rooms that did not receive a portable air conditioning unit (rooms [ROOM NUMBER]). 5. Received diagnostics and partial repair services from the air conditioning repair vendor, with full repair of the air conditioning unit pending due to parts not being readily available. 6. Staff monitoring residents for signs and symptoms of dehydration every two (2) hours. 7. Monitoring for heat exposure by taking room temperatures every hour, and resident vital signs taken every four (4) hours from until the air conditioning is repaired. 8. Water being offered throughout the day at least once every two (2) hours. Findings: 1. During an observation on 6/25/2024, at 12:02 p.m., Resident 1 was observed awake in bed, nonverbal. Resident 1 was observed with, dry, cracked lips. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 6/8/2018. Resident 1's admitting diagnosis included dysphagia (difficulty swallowing) following a cerebral infarction (tissue death of the brain from a clot or other obstruction of blood flow), dementia (impaired ability to remember, think, and make decisions which interferes with everyday activities), and type two (2) diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/12/2024, indicated Resident 1 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 1 required total assistance (helper does all the effort) with oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene. During an interview on 6/25/2024, at 12:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1's lips looked a little dry. During an interview on 6/25/2024, at 2:02 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1's room was hot. During an interview on 6/25/2024, at 3:15 p.m., with Resident 1's Family Member (FM) 1, FM 1 stated the past 7 days, between 3 p.m., to 6 p.m., she observed Resident 1's room was hot more than usual. FM 1 she complained to a nurse but did not know the nurse's name. During an interview on 6/25/2024, at 5:50 p.m., with FM 1, FM 1 stated she had not witnessed staff offering any of the residents in Resident 1's room water, popsicles, ice cream, or other cooling foods. 2. During a concurrent observation and interview on 6/25/2024, at 12:04 p.m., with Resident 2 (Resident 1's roommate), Resident 2 was observed awake, alert, and seated on a wheelchair. Resident 2 stated the air conditioning in their room had not been working since last week. Resident 2 stated it was so humid around 5 p.m. every day since the air conditioner stopped working last week that she could not breathe. A review of Resident 2's Admission Record indicated the facility originally admitted Resident 2 on 3/20/2020, and most recently readmitted Resident 2 on 11/03/2020. Resident 2's admitting diagnosis included anxiety disorder (a disorder involving persistent and excessive worry that interferes with daily activities), and gastro-esophageal reflux disease ([GERD] a condition in which the stomach contents move up into the esophagus). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required moderate assistance (the helper does less than half the effort) with toileting hygiene, dressing the lower body, and putting on/taking off footwear. During an interview on 6/25/2024, at 3:55 p.m., with Resident 2, Resident 2 stated she was concerned about her roommate (Resident 1) because she could not ask for help. Resident 2 stated other than today (6/25/2024), in the activities room, no one offered her popsicles, ice cream, or any other cool foods to decrease the effects of the heat. 3. During a concurrent observation and interview on 6/25/2024, at 12:59 p.m., with Resident 12, Resident 12 was observed awake, alert, and in bed. Resident 12 stated it felt too hot and he had been uncomfortable. Resident 12 stated he reported the warmer temperature to unknown nursing staff a few days prior but they did not do anything about it. Resident 12 stated the room felt much hotter late in the afternoon. A review of Resident 12's Admission Record indicated the facility originally admitted Resident 12 on 7/18/2021, and most recently readmitted Resident 12 on 5/25/2022. Resident 12's admitting diagnosis included sepsis (infection of the blood) due to Escherichia coli ([E. Coli] a type of bacteria that causes disease in humans) and type 2 diabetes mellitus. A review of Resident 12's MDS, dated [DATE], indicated Resident 12 was moderately cognitively impaired. The MDS indicated Resident 12 required total assistance with showering/bathing. 4. During an observation and concurrent interview on 6/25/2024, at 1:41 p.m., with Resident 13, Resident 13 was observed awake, alert, and sitting on a wheelchair in the hallway, outside of his room. Resident 13 stated he was in the hallway because his room was too hot and had been so hot for a couple of days. Resident 13 stated he was going to buy a fan, to help keep him cool since no one was addressing the problem. A review of Resident 13's Admission Record indicated the facility admitted Resident 13 on 4/28/2023. Resident 13's admitting diagnosis included type 2 diabetes mellitus and chronic kidney disease (when the kidneys do not function normally and have difficulty filtering waste from the blood). A review of Resident 13's MDS, dated [DATE], indicated Resident 13 was cognitively intact. The MDS indicated Resident 13 required maximum assistance for toileting hygiene, showering/bathing, dressing the lower body, and putting on/taking off footwear. 5. During a concurrent observation and interview on 6/25/2024, at 3:48 p.m., with Resident 25, Resident 25 was observed awake, alert, and in bed. Resident 25 stated it had been very hot in the facility for a couple of days and wished it was colder. Resident 25 stated none of the staff offered her popsicles, ice cream, or any cool foods since it had been hot. Resident 25 stated she felt staff do not care which made her feel sad. A review of Resident 25's Admission Record indicated the facility admitted Resident 25 on 5/28/2024. Resident 25's admitting diagnosis included an unstageable (unable to determine the depth due to abnormal tissue covering healthy tissue) pressure ulcer (damage to an area of the skin or tissues because of constant pressure on the area for a long time) of the sacral region (lower back), and type 2 diabetes mellitus. A review of Resident 25's MDS, dated [DATE], indicated Resident 25 was moderately cognitively impaired. The MDS indicated Resident 25 required total assistance with showering/bathing, dressing the lower body, and putting on/taking off footwear. 6. During an interview on 6/26/2024, at 2:22 p.m., with Resident 26, Resident 26 stated his room was too hot on 6/25/2024, in the afternoon. Resident 26 stated staff did not offer him any foods like popsicles or ice cream the past week, to keep him cool. Resident 26 stated he asked the nurses (names unknown) to pat him down with a cold wet towel. A review of Resident 26's Admission Record indicated the facility admitted Resident 26 on 1/21/2023. Resident 26's admitting diagnosis included type 2 diabetes mellitus, sepsis, and acute respiratory failure (the inability of the respiratory system to oxygenate the body) with hypoxia (low oxygen in the blood). A review of Resident 26's MDS, dated [DATE], indicated Resident 26 was cognitively intact. The MDS indicated Resident 26 had required total assistance with oral hygiene, toileting hygiene, showering/bathing, dressing the upper and lower body, and personal hygiene. 7. During an interview on 6/26/2024, at 3:18 p.m., with Resident 27, Resident 27 stated yesterday (6/25/2024), her room was too hot and had been very hot for one week. Resident 27 stated she told multiple nurses on multiple occasions. Resident 27 stated she did not recall the names of the nurses she told. Resident 27 stated when she told one nurse the heat was too much the nurse stated, it is a very hot day. Resident 27 stated staff did not offer him any cooling measures such as popsicles or ice cream. Resident 27 stated she drank cold water and fanned herself to keep cool. Resident 27 stated she was uncomfortable due to the heat. Resident 27 stated her roommate (Resident 28) was sweating a lot, and the nurses had to change her (Resident 28's) sheets because she was drenched in sweat. A review of Resident 27's Admission Record indicated the facility originally admitted Resident 27 on 8/24/2016, and most recently readmitted Resident 27 on 5/29/2023. Resident 27's admitting diagnosis included type 2 diabetes mellitus and acute respiratory distress syndrome ([ARDS] a condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen). A review of Resident 27's MDS, dated [DATE], indicated Resident 27 was cognitively intact. The MDS indicated Resident 27 had required maximum assistance with toileting hygiene, showering/bathing, and dressing the lower body. 8. A review of Resident 28's Admission Record indicated the facility originally admitted Resident 28 on 8/2/2022, and most recently readmitted Resident 28 on 10/29/2023. Resident 28's admitting diagnosis included metabolic encephalopathy (a chemical imbalance in the blood effecting the brain) and type 2 diabetes mellitus. A review of Resident 28's MDS, dated [DATE], indicated Resident 28 was severely cognitively impaired. The MDS indicated Resident 28 required total assistance with toileting hygiene, and showering/bathing. 9. During an interview on 6/26/2024, at 3:45 p.m., with Resident 29, Resident 29 stated her room had been hot the past week and she had not been offered popsicles, ice cream, or other cold snacks. A review of Resident 29's Admission Record indicated the facility admitted Resident 29 on 2/14/2024. Resident 29's admitting diagnosis included fracture (broken) to the left pubis (a part of the hip bone), fracture of the sacrum (lower back bone). A review of Resident 29's MDS dated [DATE], indicated Resident 29 was cognitively intact. The MDS indicated Resident 29 had required maximum assistance with toileting hygiene, showering/bathing, dressing the lower body, and putting on/taking off footwear. 10. During a concurrent observation and interview on 6/26/2024, at 4:08 p.m., with the Housekeeping Supervisor (HS), Resident 30 was observed in bed, asleep. A thermometer reading measured 81.9 degrees. Resident 30 ' s air conditioning vent was closed. The HS stated she was going to open the vent to help cool the room. A review of Resident 30's Admission Record indicated the facility originally admitted Resident 30 on 8/8/2021, and most recently readmitted Resident 30 on 1/16/2024. Resident 30's admitting diagnosis included dementia and chronic kidney disease. A review of Resident 30's MDS, dated [DATE], indicated Resident 30 was severely cognitively impaired. The MDS indicated Resident 30 had required total assistance with oral hygiene, toileting hygiene, showering/bathing, dressing both the upper and lower body, and personal hygiene. During an interview on 6/25/2024, at 9:12 a.m., with the DOM, the DOM stated the air conditioning unit affecting rooms 128 through 138 stopped working on 6/20/2024. The DOM stated the residents ' rooms and community areas must be between 71 to 81 degrees F. During an interview on 6/25/2024, at 1:58 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated it had been crazy hot for the past few days. CNA 1 stated when he gave residents showers, he was sweating. During an observation, on 6/25/2024, at 3:06 p.m., with the Director of Maintenance (DOM), the temperature in room [ROOM NUMBER] was 84 degrees Fahrenheit (F), room [ROOM NUMBER] was 81.5 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 81.5 degrees F, and room [ROOM NUMBER] was 84 degrees F. During a concurrent observation and interview, on 6/25/2024, at 3:45 p.m., with the DOM, the DOM stated residents ' room temperatures were as follows: room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 84.5 degrees F, room [ROOM NUMBER] was 81.5 degrees F, room [ROOM NUMBER] was 86.5 degrees F, and room [ROOM NUMBER] was 84.5 degrees F. The DOM stated the room temperatures were above the regulated range which could cause discomfort to residents. During an interview on 6/25/2024, at 4:12 p.m., with the Director of Staff Development (DSD), the DSD stated the staff first started complaining of the heat on 6/19/2024. The DSD stated the facility was going to purchase fans for the residents' rooms without functioning air conditioning that day (6/25/2024). The DSD stated if residents get too hot, they could suffer from heat stroke. During an interview on 6/25/2024, at 4:21 p.m., with the DOM, the DOM stated the compressor on the air conditioner was replaced on 6/20/2024 by the Repair Vendor, but it stopped working again 6/21/2024. The DOM stated the facility took temperatures of the residents' rooms daily in the morning. The DOM stated on 6/25/2024, staff had not taken temperatures from 3:00 p.m. to 5:00 p.m., which unfortunately was the hottest part of the day. During a concurrent observation and interview, on 6/25/2024, at 4:32 p.m., with the DOM, the DOM stated the temperatures in room [ROOM NUMBER] was 81.5 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 81.5 degrees F, room [ROOM NUMBER] was 86.5 degrees F, and room [ROOM NUMBER] was 85 degrees F. During an interview on 6/25/2024, at 6:35 p.m., with the DSD, the DSD stated the facility did not have a contingency plan in place to use if the air conditioner stopped working. The DSD stated the facility did not report the air conditioning ceasing to work to any the state or federal agencies. During an interview on 6/25/2024, at 6:36 p.m., with the DOM, the DOM stated the facility did not have a contingency plan for when the air conditioner turned off. and The DOM stated the facility did not have a Preventative Maintenance ([PM] log to keep track of preventative maintenance efforts to prevent the air conditioning system from not working) log. The DOM stated the only PM log the facility had was of the room temperatures. A review of the facility's resident room temperature log, dated 6/2024, indicated on 6/5/2024 through 6/10/2024, 6/15/2024, and on 6/22/2024 through 6/24/2024 the temperatures of residents' rooms were not documented. A review of the facility's A/C Repair Company ' s Invoice, dated 6/20/2024, indicated the old burnt compressor (part responsible for transferring heat from the refrigerant [the liquid that cools the air] to the condenser [device that takes heat away from the air]) was removed and a new one was installed to A/C Unit 16 (affecting rooms 128 through 138). A review of the facility's email dated, 6/25/2024, from the A/C Repair Company to the DOM, indicated AC Unit 16 needed further repair with a recommendation to replace the condenser coil (part of the cooling system that completes the heat exchange cycle). During an interview on 6/26/2025, at 1:35 p.m., with the Administrator (ADM), the ADM stated the facility's contingency plan was located in the facility's emergency binder and would provide it. During an interview on 6/26/2024 at 2:07 p.m., with the ADM, the ADM stated as part of their plan when the air conditioning stopped working, the facility would call the facility's A/C repair company right away to come assess and fix it. The ADM stated if the vendor was not able to fix the air conditioning immediately, the facility would provide fans in the residents ' rooms. The ADM stated the DSD and DOM were not aware of what a contingency plan for the air conditioning malfunction, and he and the director of nursing (DON) were not onsite 6/25/2025. During a concurrent interview and record review on 6/26/2024, at 2:07 p.m., with the ADM, the facility ' s undated Extreme Weather - Heat Emergency Operations Plan (EOP), was reviewed. The ADM stated the facility had not implemented the EOP until 6/26/2024. The EOP indicated the facility's initial actions during extreme heat included: a. Activate facility's EOP and appoint a Facility Incident Commander (IC) if warranted (facility failed to do). b. Assess residents for signs of distress and/or discomfort. c. Call 911 if any residents appear to be suffering from heat-related illness such as a heat cramps (painful muscle spasms that can happen during activity in hot environments), heat exhaustion (when the body overheats and cannot cool itself down), or heat stroke. d. Re-locating residents to a cooler part of the facility. e. If the outdoor temperature is cooler than the internal facility temperature, consider opening windows and using fans to bring cooler air into the building. If the outdoor temperature is not cooler, keep the windows closed and shades drawn. f. If the internal temperature of the facility remains high and potentially jeopardizes the safety and health of residents, consider evacuation to another facility and if the decision to evacuate was made to initiate the Rapid Response Evacuation EOP. g. Provide cool washcloths and cooling fans for air circulation. h. Encourage residents to drink fluids to maintain hydration. i. Notify the LA County DPH health Facilities Inspection Division (HFID) to report an unusual occurrence and activation of the facility ' s EOP. During an interview on 6/26/2024, at 2:15 p.m., with the DON, the DON stated not following their EOP could result in residents feeling too hot, dehydrated or suffer a heat stroke. A review of the facility's policy and procedure (P&P) titled Room Temperature, dated 11/2/2018, indicated all buildings were required to maintain an ambient temperature throughout resident areas in a temperature range of 71 to 81 degrees F. The P&P stated the variance in temperatures must not adversely affect resident health and safety. The P&P indicated: a. The time of day that the temperatures were taken should vary to ensure the desired temperature range is achieved under a variety of conditions. b. While meeting the requirement for indoor air temperature, consideration of the effective air temperature and the impact that humidity and air movement in the building may be having on comfort. A review of the facility's P&P titled Homelike Environment, undated, indicated the purpose of the policy was to provide residents with a safe, clean, and homelike environment. The P&P indicated included in a homelike environment is comfortable temperatures, and safe temperatures (71 degrees F to 81 degrees F). A review of the California Department of Public Health's All Facilities Letter ([AFL] a letter from the Center for Health Care Quality, Licensing and Certification Program to health facilities that are licensed or certified) 23-20 titled, dated, 6/28/2023, indicated facilities are to implement precautionary measures to keep individuals safe and comfortable during extremely hot weather, and must have contingency plans in place to deal with the loss of air conditioning. The AFL 23-20 indicated the facility measures include: a. Ensuring a comfortable climate for residents with climate control and adequate ventilation. b. Contingency planning includes using portable fans and other temporary cooling devices when indicated. c. Preparation to care for heat-related illnesses. d. Take precautions to maintain adequate hydration among residents. A review of an online article by the National Institute of Health (NIH) titled, Keep it Cool with Hot Weather Advice for the older People, dated 7/24/2006, indicated older people are at a high risk for developing heat-related illnesses because the ability to respond to summer heat can be less efficient with advancing years. The article indicated that the temperature did not have to hit 100 degrees F for the elderly to be at risk for hyperthermia (temperature being abnormally high) and other heat-related conditions due to many other factors relating to age, medications receiving and /or medical diagnoses. https://www.nih.gov/news-events/news-releases/keep-it-cool-hot-weather-advice-older-people.

Based on interview and record review the facility failed to follow their policy and procedure (P&P), Proper use of Side Rails (structural support attached to the frame of the bed used as an assistive device), for one of one sampled resident (Resident 1) by failing to: 1. Assess Resident 1 for risk of entrapment (an occurrence involving a resident who is caught, trapped, or entangled in the hospital bed system), for proper use of side rails prior to resident 1's use of the side rails. 2. Ensure side rail entrapment zones (any open space where an individual can become caught by their body part in the tight spaces around the bed rail or bedside mobility aid) were measured prior to installation and use. These deficient practices resulted in the entrapment of Resident 1's left arm, in between the side rails and the bed frame, sustaining a left humeral neck fracture (broken bone of left upper arm). Findings: During a review of the Resident 1's admission record (face sheet), the face sheet indicated the facility admitted Resident 1 on 2/25/2022. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/27/2022, the MDS indicated Resident 1 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 1 needed limited assistance (resident highly involved in activity guided by staff) with eating, and total dependence with bed mobility, transfer, toilet use, and personal hygiene. A record review of the 911 call from the facility, received on 2/27/2022 at 6:36 a.m., indicated, the caller stated, Resident 1 fell and her arm got caught between the bed and the siderail and it seems like it's broken. A record review of Resident 1's Transfer Form dated, 2/27/2022 at 7:02 a.m., indicated Resident 1 was discharged to the hospital. Per transfer form, Resident 1 was found in her room on left side of the bed on floor, on top of a blanket/pillow with the resident's left arm entangled in the siderail. During a concurrent interview and record review on 3/10/2022 at 4:56 p.m., with licensed vocational nurse 1 (LVN 1) of Resident 1's Change of Condition (COC) evaluation, dated 2/27/2022 at 6:30 a.m., the COC indicated housekeeper 1 (HK 1) called LVN 1 to report Resident 1 fell and LVN 1 came into the room and noted Resident 1 on the floor, on the left side of the bed, on top of a blanket and pillow with a discolored (changes in skin color due to injury or illness) left arm entangled in the side rail. LVN 1 stated the bed was in high position and the head of bed (HOB) at a 90-degree angle (HOB was raised straight up). LVN 1 stated, Resident 1's left arm was threaded between the bed frame, the bottom, middle and top opening of the side rail. It was as if her arm was sewn onto the side rail bar gaps. During a phone interview with registered nurse 1 (RN 1) on 3/11/2022 at 6:15 am., RN 1 stated that on the morning of 2/27/2022, upon response to Resident 1's reported fall, Resident 1's bed was noted to be elevated all the way up and the HOB at a 90-degree angle. RN 1 stated Resident 1 was facing the bed, hanging from her left arm on the left side of the bed and half her body was on the floor under the bed. RN 1 stated Resident 1's left arm was stitched or sewn in between the bed frame and the side rail. Her arm went through the bedframe and side rail, then it was threaded into the middle opening, and top opening. After much difficulty, RN 1 stated, facility staff had to release the side rail to free Resident 1 from being entangled, right before 911 responders came. RN 1 stated, in this situation, the side rail was a hazard. A record review of Resident 1's history and physical ([H&P]: initial clinical evaluation and examination of resident) dated 3/1/2022, the H&P indicated, on 2/27/2022, Resident 1 was diagnosed with left humoral neck fracture in the emergency department after sustaining a fall. During an interview with medical records staff (MR staff) on 3/11/2022 at 10:39 a.m., MR staff stated Resident 1 had no assessment for side rail usage, no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review, on 3/11/2022 at 11:23 a.m., with the Minimum Data Set coordinator (MDSC) after reviewing Resident 1's medical record, MDSC stated Resident 1 fell and her left arm was entangled in the side rails on 2/27/2022. MDSC stated, there was no documented evidence that a siderail assessment was completed, a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with maintenance director (MNT) on 3/11/2022 at 12:04 p.m., MNT stated they (facility's staff) did not have any measurements of entrapment zones for the beds and the side rails in the facility. During an interview with the director of nursing (DON) on 3/11/2022 at 1:02 p.m., the DON stated he was aware Resident 1 did not have side rail assessment, physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated, use of side rails (for residents) entailed the need for an assessment, orders, care plans and a consent prior to use. DON stated, the side rail can be a hazard to residents; therefore, there's a process in place before using the device. During an interview with DON on 3/11/2022 at 1:02 p.m., the DON stated there was no documented evidence that entrapment zone areas for the bed and side rails, prior to side rail usage for Resident 1, had been measured in the facility. During an interview with the administrator (ADM) on 3/11/2022 at 1:33 p.m., ADM stated that he does not know anything about entrapment zone measurements being completed by the facility prior to side rail usage. A record review of the facility's policy titled, Proper use of Side Rails (revised 12/2016), indicated the purpose of these guidelines were to ensure the safe use of side rails as mobility device. Per policy, an assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility; ability to change positions, transfer to and from bed or chair, and to stand and toilet; risk of entrapment from the use of side rails; and bed's dimensions are appropriate for the resident's size and weight; and use of side rails as an assistive device will be addressed in the resident care plan. Consent for using devices will be obtained from the resident or legal representative per facility protocol with risks and benefits addressed. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). Documentation will indicate if less restrictive approaches were not successful, prior to considering the use of side rails. The risks and benefits of side rails will be considered for each resident.

Based on observation, interview and record review, facility failed to provide safe, functional, sanitary, and comfortable environment for 122 of 122 residents, staff, and visitors, by not maintaining the facility's roof, resulting in multiple water leakage from the ceiling in the dining room (also used for activities) and nurses' station. This deficient practice can potentially cause, structural damage including ceiling collapse, electrical outage, electrocution, and damage of medical records. During an annual recertification survey on 12/14/2021, at 6:05 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was identified and declared. The facility's Administrator (ADM) was notified of the water leaking from the ceiling in the dining room and nurses ' station. During an interview on 12/15/2021, at 4:25 p.m., the ADM was informed that the IJ was lifted after implementation of the acceptable plan of action ([POA], interventions to correct the deficient practice) was verified while on onsite via observation, interview, and record review. Findings: Facility census: 122 a. During an observation on 12/14/2021, at 10:30 a.m., during the Resident Council Meeting, two black trash cans and one gray water basin were observed on the floor by the entrance door towards the back of the dining room (also used for activities) with water in the containers. The ceiling was observed to have a crack line approximately three (3) feet long with water dripping from ceiling during the Resident Council Meeting, which was attended by 13 residents. During an observation on 12/14/2021, at 12:30 p.m., during a dining observation, there were 20 residents eating in the dining room. Water was observed dripping from the ceiling into the two black trash cans and gray water basin by the entrance door towards the back of the dining room. There was no cautionary signage observed to indicate the possibility of a wet floor. During a concurrent observation and interview on 12/14/2021, at 12:35 p.m., with Licensed Vocational Nurse 5 (LVN 5), in the dining/activity room, water was observed dripping from the ceiling into the two black trash cans and the gray water basin by the entrance door towards the back of the dining room. LVN 5 stated it was raining hard today (12/14/21) and there was water dripping from the ceiling and the black trash cans and the gray water basin were used to catch the water from the ceiling. LVN 5 stated there were 20 residents inside the dining area despite water leaking from the ceiling and residents were positioned to avoid areas where the water was dripping from the ceiling. During an interview on 12/14/2021, at 2:21 p.m., with the Activities Assistant (AA1), AA1 stated it was raining hard today (12/14/21) and at 9:00 a.m. she observed water leaking from the ceiling inside the dining room, there was a water basin on the floor to catch water. AA1 stated the floor was wet and noticed there was more water leaking from the right side of the ceiling and asked Housekeeper 1 (HK1) to bring another bucket to catch the water. AA1 stated the residents did not start entering the back dining area until after 10:00 a.m. to prepare for the Resident Council Meeting. AA1 stated she ensured there were containers to catch the water dripping from the ceiling. AA1 stated she notified Maintenance Supervisor (MS) regarding the water leaking from the ceiling at the back dining area because she was concerned residents who were using the wheelchair could spread the water around and resident who were able to walk in the area might slip and fall. AA1 stated there was no signage placed around the area where water was leaking to indicate the floor was wet. AA1 stated that cautionary signage was important to alert people of a hazard that can cause slip and falls due to a wet floor. During a concurrent observation and interview, on 12/14/2021, at 2:30 p.m. with AA1, nine (9) residents were observed sitting towards the back of the dining room participating in activities. Two black trash cans and a gray water basin filled with water were observed and were initially observed during the Resident Council Meeting at 10:30 a.m. and during the dining observation at 12:30 p.m. AA1 stated the dining area was used at 10:00 a.m. by 13 residents for the Resident Council Meeting, used by 20 residents during lunch, and was currently being used for activities. AA1 stated the dining room was also scheduled for use for dinner later that evening (12/14/21). AA1 stated the staff and residents will continue to use the dining area despite the water leaking from the ceiling. During a concurrent observation and interview, on 12/14/2021, at 2:37 p.m. with MS, MS stated it was raining hard on 12/14/2021 and there was an abrupt water leakage from the ceiling in the dining/ activity room on 12/14/2021 at 6:00 a.m. MS stated there was a crack approximately three feet in length in the ceiling where the water was dripping. MS stated the cause of the crack was unknown. MS stated the facility placed buckets on the floor to prevent water from splashing everywhere but did not believe the water leaking from the ceiling was a potential hazard that could cause residents to slip and fall, get electrocuted, or injured from a ceiling collapse due to water accumulation. MS stated the facility continued to use the back dining room for activities and dining despite the continued water leakage from the ceiling. During an interview on 12/14/2021 at 3:00 p.m. with LVN 5, LVN 5 stated it was raining hard around 6:30 a.m. and when she passed by the dining room, she saw water leaking from ceiling. LVN 5 stated she was concerned that the ceiling might collapse and was scared for herself and the residents. LVN 5 stated the facility's staff continued to allow residents in the dining room for the Resident Council Meeting, dining for lunch, and activities despite water leaking from the ceiling. LVN 5 stated during dining on 12/14/2021, at around 12:00 p.m., she almost tripped on the gray water basin because there was no cautionary signage indicating the floor was wet nor that the gray water basin was on the floor. During an observation on 12/14/2021, at 4:50 p.m. water was observed dripping from the ceiling in the dining room. Water was observed dripping into the two black trash containers and gray water basin while there was one resident (Resident 112) and one staff in the dining area. During an interview on 12/14/21 at 03:23 p.m. with the Activities Director (AD), AD stated there was water dripping from the ceiling in the dining room this morning (could not specify the time) and buckets were placed on the floor to catch the water leaking from the ceiling. AD stated the facility was planning to use the room for dinner tonight (12/14/21) despite the water leaking from the ceiling. AD stated she did not know what could happen if there was accumulation of water in the ceiling. AD stated she did not think of the risks of occupying and using the dining and activities room despite the continued water leakage from the ceiling. AD stated the facility did not consider moving residents out of the dining and activities room to keep them safe from possible environmental hazard. During an interview on 12/14/2021, at 03:45 p.m. with MS, MS stated the roof, ceiling, and structure of the building, has not been assessed or inspected because he could not access the ceiling. MS stated he tried to contact Vendor 1, a third-party vendor, to assess and fix the leak in the roof but there was no response and was still waiting for a call back. During an interview on 12/14/21, at 03:51 p.m., with ADM, ADM stated the facility has not assessed the extent of the water damage caused by the rain because it was actively raining. ADM stated that the facility did not have a plan to address the leaking roof and ceiling. ADM stated the facility was not planning on evacuating or relocating the dining and activities service and will continue to use the dining and activities room despite the active water leak from the ceiling. The ADM could not verbalize whether the dining and activities room was safe to use despite the active water leak from the ceiling. b. During an observation on 12/14/2021, at 12:45 p.m., at the nurses' station (the only nurses' station in the facility), water was observed dripping from the ceiling. Six staff (LVN 5, LVN 8, Certified Nurse Assistant 9 [CNA 9], Registered Nurse 5 [RN 5], Director of Nursing [DON], and the Infection Preventionist [IP]) were present and all 122 resident medical records were observed at the nurses ' station. During an interview on 12/14/2021 at 12:35 p.m., with LVN 5, at the nurses' station, LVN 5 stated that Residents' charts were located at the nursing station and there was a continuous drip of water inside the nursing station. LVN 5 stated she was afraid that ceiling might fall. During an observation on 12/14/2021 at 3:00 p.m., at the nurses' station, water was observed continuously dripping from the ceiling. During a concurrent interview and record review, on 12/14/21, at 4:18 p.m., with ADM, the Emergency Preparedness Plan was reviewed. ADM stated the water leaking in the ceiling and pooled water in the ceiling was a safety hazard that could potentially cause anyone to fall, ceiling might collapse, and if water was leaking directly in the light fixture could cause electrical outage and short-circuit (allows a current to travel along an unintended path) and needed to be addressed right away. ADM stated the facility must close the dining room and secure the medical records until the ceiling was repaired of the water leak to ensure a safe environment where all residents, staff, and medical records are free from environmental hazards. During a review of the facility's Policy and Procedure (P/P) titled, Maintenance, dated revised 2009, the P/P indicated Maintenance service shall be provided to all areas of building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Function of maintenance personnel include but not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards. The maintenance Director is responsible for maintaining the following records/reports a. Inspection of the building, b. work order request, c. maintenance schedules d. authorize vendor listing, e. Warranties and guarantees. Records shall be maintained in the Maintenance Director's office. Maintenance personnel shall follow established safety regulations to ensure safety and well-being of all concerned.

Based on observation, interview and record review, the facility failed to implement acceptable infection control practices to prevent the spread and transmission of communicable diseases and for the prevention of coronavirus (COVID-19) and [CONDITION(S)] ([C-diff] Inflammation of the colon caused by the bacteria [CONDITION(S)]. The facility failed to: 1. Ensure Resident 170's family member (FM) was educated and made aware of the facility's infection control practices for contact isolation due to [CONDITION(S)] with active diarrhea. FM was observed to do the following: a. FM was observed not wearing gloves while feeding Resident 170. b. FM was observed bringing Resident 170's bedside table to the hallway outside of the room without disinfecting it and without performing hand hygiene (cleaning your hands can prevent the spread of germs [washing hands]). c. FM returned to the room with the previous gown and did not perform hand hygiene. d. Ensure Certified Nursing Assistant (CNA 4) wore gloves as indicated when returning the bedside table to the room of Resident 170, who was on contact isolation. 2. Ensure Certified Nursing Assistant (CNA 4) wore a Face shield while in the room of Resident 171, who was in the yellow zone (zone for residents who are mixed quarantine or symptomatic) to prevent transmission of COVID-19. 3. Ensure Certified Nursing Assistant (CNA 10) wore gloves and a gown while in a yellow zone room of Resident 319. 4. Ensure CNA 10 washed her hands between changing gloves and after completing peri care for Resident 321. 5. Ensure Housekeeper 1 (HK 1) followed the manufacturers recommended contact time to wait three minutes when using Disinfectant A wipes before wiping and drying up body fluids. HK 1 covered the body fluid and waited 10-30 seconds instead of three minutes before he wiped and dried the area. These failures placed all residents (122 total), staff, visitors, and the community at a high risk for cross contamination, and increased spread of C-Diff and COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) infection. On 12/16/2021, at 1:06 p.m., the Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) related to the failure to implement acceptable infection control practices was called in the presence of the Administrator. On 12/21/21, at 1:58 p.m., the IJ situation was removed in the presence of the Administrator after implementation of the acceptable POA was verified onsite through observation, interview, and record review. Findings: 1. A review of Resident 170's Face Sheet (admission record) indicated Resident 170 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 170's Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 12/22/21, indicated the resident had severely impaired cognitive skills for daily decision making and was totally dependent on staff for bed mobility, eating, locomotion off and on unit, transfers, dressing, toilet use, personal hygiene, and bathing. On 12/13/2021 at 12:29 p.m., Resident 170's FM was observed feeding Resident 170 in Resident 170's room without wearing gloves. FM proceeded to bring Resident 170's bedside table to the hallway outside of Resident 170's room without having table disinfected. At the same time, FM was observed not performing a hand hygiene. After FM was observed moving Resident 170's bedside table to the hallway, FM returned to Resident 170's room wearing the same gown and again did not perform a hand hygiene. Few minutes later, a Certified Nursing Assistant (CNA 4) was observed returning Resident 170's bedside table back to the resident's room without wearing gloves. Concurrently during an interview, Resident 170's FM stated that none of the facility's staff instructed her regarding proper use of required personal protective equipment (PPE) for Resident 170 contact isolation precaution due to C-diff. During an interview on 12/14/2021 at 9:06 a.m., the facility's infection preventionist ([IP] nurse in charge of infection prevention at the facility), stated when a family member wished to feed a resident, who is on isolation, the family member must be instructed and made aware that they must follow all isolation precautions and use of PPE. IP further stated when a resident is on contact isolation for C-Diff, staff and family members are required to wear a gown and gloves, and to wash their hands in between care. IP stated when any staff or family member, who has been in contact with the resident without the required PPE, does not wash their hands and goes outside the resident's room without removing their used gown, it is an infection control concern. It is very clear, when staff or family members do not follow necessary infection control practices there is a high risk for them to spread infection to other staff, residents and visitors in the facility. IP stated FM should have work gown and gloves and washed their hands between care of Resident 170. During an interview on 12/14/2021 at 9:28 a.m., the Registered Nurse supervisor (RN 1) stated that any staff or family member who provides care or visits with a resident on contact isolation for C-diff, must wear the required PPE before caring for a resident, remove the used gown and gloves, and wash their hands before leaving a resident's room, and put on clean PPE before going back to a resident's room. RN1 stated when staff or family members do not follow a required infection control practice, it becomes an infection control issue and has the potential for cross contamination and spread of infection to staff, resident, and their family members. RN 1 further stated when visitor's sign in, the receptionist must inform the charge nurse (CN) to educate the visitor regarding the required PPE for contact isolation precautions. On 12/14/2021 at 11:56 a.m., Resident 170's FM was observed at the resident's bedside interacting with the resident without wearing gloves. During an interview on 12/14/2021 at 1:10 p.m., the Licensed Vocational Nurse (LVN 3) stated that Resident 170's FM visits the facility daily and the FM must follow the required PPE requirements before going to see the resident due to contact isolation precautions related to C-diff. During an interview on 12/14/2021 at 1:18 p.m., the RN 1 supervisor stated that it is everybody's job to remind the resident's FM to follow the required isolation precautions when entering the isolation room. A review of the facility's revised policy and procedure dated October 2018 and titled, [CONDITION(S)] indicated that measures are to be taken to prevent the occurrence of [CONDITION(S)] infections (CDI) among residents. Precautions are to be taken while caring for residents with C. difficile to prevent transmission to other residents. Frequent hand washing should be performed with soap and water by staff and residents. When caring for residents with C-diff, staff are to maintain vigilant hand hygiene. Residents with diarrhea associated with C. difficile (i.e., residents who are colonized and symptomatic) are placed on contact precautions. Hand washing with soap and water is superior to antimicrobial hand-rub (ABHR) for the mechanical removal of C. difficile spores from hand. A review of facility's policy and procedure titled Visitation-Infection Control During COVID 19, revised 11/2021, indicated the facility shall establish appropriate guidelines for visitors to try and prevent the transmission of communicable diseases. The top priority at this point with COVID 19 is to prevent the virus from entering the facility. All visitors shall be screened upon entry and shall be required to wear face coverings and adhere to the guidelines of the facility. Each visitor must wear a face covering upon entry and at all times within the facility and must wear other PPE as appropriate while in the patient's room. 2. A review of Resident 171's Face Sheet (admission record) indicated Resident 171 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 12/20/21, indicated Resident 171 had an intact cognitive skill for daily decision making and required assistance with personal hygiene, toileting, and mobility. During an observation on 12/13/2021 at 3:21 p.m., CNA 4 was observed providing care to Resident 171 (a resident who was in the yellow zone who may be suspected of having COVID-19) while wearing a regular mask (not a N95 respiratory, as required for all staff providing care in the yellow zone) without out a face shield (eye protection is required for all staff who provide care to residents in the yellow zone. During an interview on 12/13/2021 at 3:23 p.m., CNA 4 stated that she should wear all required PPE when attending a resident while inside the isolation room, including a N95 and a face shield. CNA 4 stated that she does not have an excuse for not wearing all the required PPE. CNA 4 admitted that it was an infection control issue that can lead to cross contamination of staff and all the residents that she will encounter. During an interview on 12/14/2021 at 9:08 a.m., the IP stated that based on what is posted outside the resident room for isolation precautions, an N95, face shield, gown and gloves were required to provide care for Resident 171, who was on contact and respiratory droplets isolation. If one of the required PPE is not worn while providing care to the resident it becomes an infection control issue that can lead to cross contamination and places the resident at risk for getting infected. During an observation on 12/16/21 at 3:15 pm, a family member of Resident 171 was observed in the resident's room without a gown, face shield, and a N95 mask. At the same time there was a Respiratory Therapist 3 (RT 3) present and was providing respiratory care. RT 3 did not instruct the Family member about observing isolation precautions by wearing necessary PPE and of the potential risk for spread of infection if not followed the requirement for PPE. On 12/16/21 at 3:15 pm, during an interview, Resident 171's family member stated the facility staff did not instruct her to wash her hands, or to wear gloves and a face shield, but she was only told to bring a N95 mask or wear a gown when visiting. on 12/16/21 at 3:44 pm, during an interview, Respiratory Therapist 3 (RT) stated that he did not instruct the visitor about observing isolation precautions and of the potential for infection spread if isolation precautions were not practiced in the facility. 3. On 12/13/2021 at 11:04 a.m. inside the room for three residents, Resident 10, Resident 38, and Resident 55 there was a yellowish-brown semi-liquid substance observed on the floor. This room was on the green zone (zone for residents who do not have COVID-19). Concurrently, during an interview, CNA 1 stated that it could be apple sauce, but it could also be feces or body fluids. CNA 1 stated she would ask the housekeeper to clean it. During a concurrent observation and interview on 12/13/2021 at 11:11 a.m., LVN 5 stated the yellowish-brown substance on the floor in the room of Resident 10, Resident 38, and Resident 55 could be applesauce, feces, or could be body fluids and will have housekeeper to clean it. During a concurrent observation and interview on 12/13/2021 at 11:13 a.m., Housekeeper (HK1) stated the yellowish brownish substance in the room for Resident 10, Resident 38, and Resident 55, looks like feces. HK1 observed cleaning the yellowish-brown substance on the floor by using Disinfectant A wipes and immediately wiping it with a dry cloth towel. During an interview on 12/13/2021 at 11:25 a.m., HK1 stated he cleaned the potential body fluids by squeezing the disinfectant wipes so bleach will cover the potential body fluids then immediately wiped it using the same disinfectant wipes with contact time of 10 to 30 seconds and then he dried it with a dry rag. HK1 stated no additional steps were needed when cleaning potential body fluids. HK1 read the manufacturer recommended contact time on the bleach container and stated, according to the instruction on the bottle, contact time should be three (3) minutes. HK1 stated he normally disinfect with 10-30 seconds contact time because he has a lot of things to do. During an interview on 12/15/2021 at 12:15 p.m., Maintenance Supervisor (MS) stated the proper way to clean body fluids was first to remove the feces, clean the surface, then disinfect. MS stated when using Disinfectant A wipes the contact time should be three (3) minutes. During an interview on 12/15/2021 at 2:53 p.m., IP stated to clean potential body fluids or feces on the floor, the housekeeper needed to clean the feces first, then disinfect and follow manufacture recommended contact time. IP stated Disinfectant A's (disinfecting wipes) manufacturer recommended contact time was three minutes. IP stated not cleaning and disinfecting potential body fluids or contaminated surfaces can potentially infect residents, staff, and other visitors, and can cause illness, hospitalization , or death. A review of the facility's revised facility's policy and procedure dated January 2012 and titled, Cleaning Spills or Splashes of Blood or Body fluids, indicated spills or splashes of blood or other body fluids must be cleaned and the spill or splash area decontaminated as soon as practical. A review of the manufacturer label for Disinfectant A, indicated to clean and disinfect visibly soiled surfaces; pre-cleaning was required prior to disinfecting and contact time was 3 minutes. 4. On 12/13/21, at 12:22 p.m., a Certified Nursing Assistant (CNA 10) was observed in yellow zone room (area for newly admitted residents with incomplete or unknown COVID-19 [a highly contagious infection, caused by a corona virus that can easily spread from person to person] vaccination status), setting up Resident 319's lunch tray. CNA 10 was observed wearing a personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses,), a N95 mask (PPE worn on the face, covers at least the nose and mouth, and is used to filter out at least 95% of airborne (infection virus-containing smaller particles that can remain suspended in the air over long distances) and a face shield, but was not wearing gloves or gown. CNA 10 was observed leaving Resident 319's room without performing hand-hygiene and walking across the hallway holding a plate cover and placing it on the food delivery cart. CNA 10 observed to performed hand-hygiene with ABHR near the food cart. During an interview on 12/13/21, at 12:30 p.m. CNA 10 stated it is required to wear a gown, a N95 mask, goggles or face shield, and gloves, and to sanitize hands before and after delivering the food tray in the yellow zone. CNA 10 stated she forgot to wear a gown and gloves when was in the yellow zone room. CNA 10 stated without wearing full PPE, there is a potential to spread an infection. CNA 10 confirmed that she must perform hand hygiene after delivering the meal trays for all residents but did not perform the hand hygiene after delivering Resident 319's meal tray. During an interview on 12/14/21, at 11:55 a.m. the IP stated Resident 319 was in room in the yellow zone for isolation because Resident 319 has not completed her full dose of the COVID-19 vaccine. IP stated Resident 319 received her second dose of the COVID-19 vaccine upon admission to the facility and has not completed her 14 days of quarantine in the yellow zone room. A review of Resident 319's admission record (Face sheet), indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 12/15/21, indicated Resident 319 moderately impaired cognitive skills for daily decision making and required extensive assistance from staff with bed mobility, dressing, and toileting and was totally dependent on staff with bathing. A review of Resident 319's COVID-19 vaccination record card, indicated the resident received her first dose of the Pfizer vaccine on 7/27/21, and the second dose on 12/10/21, while residing at the facility. During an interview on 12/15/21, at 3:33 p.m. the IP stated she provides education to her staff on PPE requirements and hand hygiene. IP stated staff going into the rooms on the yellow zone were required to perform hand hygiene prior to donning (putting on) PPE and were required to wear gloves, gown, N95 mask, and eye protection with googles or a face shield. When leaving the room, staff required to perform hand hygiene after removing PPE. IP stated if proper PPE and hand hygiene is not done, there is a risk to spread infection. A review of the facility's COVID-19 Mitigation Plan indicated the residents assigned in a yellow zone room will be treated with contact and droplets isolation precautions. When caring for patients with confirmed or suspected COVID-19, face shield or goggles, N95 mask or higher respirator, gloves, and isolation gown were to be used. A review of the facility's policy, Isolation - Categories of Transmission-Based Precautions, revised 10/2018, indicated staff caring for residents on contact precautions will wear gloves and gown upon entering the room. Staff caring for residents on droplet precautions will wear masks, gloves, a gown and googles should be worn if there is risk of spraying respiratory secretions. A review of the facility's policy, Handwashing/Hand Hygiene, revised 8/2019, indicated an alcohol-based hand rub containing at least 62% alcohol should be used or, alternatively soap (antimicrobial or non-antimicrobial) and water should be used before and after direct contact with residents; after contact with objects in the immediate vicinity of the resident; after removing gloves; before and after entering isolation precaution setting; before and after eating or handling food; before and after assisting a resident with meals. Hand hygiene is the final step after removing and disposing of personal protective equipment. 5. During a concurrent observation and interview, on 12/13/21, at 10:44 a.m., with CNA 10, CNA 10 was observed performing incontinence (the loss of bowel and/or bladder control) care to Resident 321. CNA 10 was observed wearing a N95 face mask and a face shield and putting gloves on after performing hand hygiene with ABHR. CNA 10 stated Resident 321 had a bowel movement. CNA 10 was observed wiping Resident 321's bottom with a pad, then cleaning the residents bottom with soap and water, and with a new towel patting dry the resident's bottom. CNA 10 then removed used gloves and put on a new pair of gloves to clean the resident's private parts with a clean towel without performing a hand hygiene between changing gloves. CNA 10 was observed to use a new towel to pat dry the resident's private area and then removing her gloves. CNA 10 was observed not performing hand hygiene with hand sanitizer or wash her hands with soap and water after removing gloves. Concurrently, during an interview, CNA 10 stated she forgot to get a new pad to place under the Resident 321. CAN 10 opened Resident 321's closet, went outside of the room to get a new incontinent pad from the clean linen cart in the hallway. Then CNA 10 returned to the room and washed her hands with soap and water, put on a new pair of gloves to complete the resident's care. She then removed her gloves and washed her hands with soap and water after finishing care. CNA 10 stated she usually changed gloves during care and would wash her hands after completing care. During an interview on 12/13/21, at 11:00 a.m., CNA 10 stated when performing patient care, one should gather equipment that will be used during care and wash hands prior to performing care. CNA 10 stated she was trained to change gloves if they become soiled during care, and to clean with hand sanitizer in between changing gloves, and to wash hands when done with care. During an interview on 12/15/21, at 2:52 p.m., the IP stated she provides education to her staff on proper handwashing. IP stated hand-hygiene was required before putting on or taking off PPE and before and after coming in contact with the resident. IP stated hand washing with soap and water was required if touching bowel movement because of possible contamination when going from dirty area to clean area. A review of Resident 321's Face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 321's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making and required extensive assistance from staff with bed mobility, dressing, and toileting and required a total dependence from staff in bathing. A review of the facility's policy, titled Handwashing/Hand Hygiene, revised August 2019, indicated to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after direct contact with residents; after contact with objects in the immediate vicinity of the resident; after removing gloves; before moving from a contaminated body site to a clean body site during resident care. The use of gloves does not replace hand washing/hand hygiene. Integrating glove use along with routine hand hygiene as it is recognized as the best practice for preventing healthcare-associated infections.

Based on observations, interview, and record review, the facility failed to implement its written abuse prevention policy and procedure, including: 1. Investigating alleged incidents of abuse, when one (1) of two (2) residents (Resident 9) alleged that Certified Nurse Assistant 3 (CNA 3) had a fist fight with Resident 9 and Certified Nurse Assistant 2 (CNA 2) had wrung a towel soaked with hot water over Resident 9's genitals (a person's external organs for reproduction). 2. Ensuring CNA 3 and CNA 2 were suspended pending completion of an abuse investigation. 3. Reporting the results of the investigation of alleged abused perpetuated by CNA 3 and CNA 2 to the State Survey Agency (Department) within five (5) days. These deficient practices had the potential to result in an unidentified abuse of all residents who were assigned to CNA 3 and 2 and placed resident 9 at risk for the potential of ongoing abuse and resulted in Resident 9's feeling of intimidation, retaliation and neglect, and a decline in emotional wellbeing. On 12/21/2021, at 3:08 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was identified and declared under F607. The facility's Administrator (ADM) was notified of the need for immediate action and seriousness of other residents' and staff members health and safety being threatened for failure to implement written policies for abuse to investigate an allegation of abuse (by Resident 9), prevent further potential abuse by failing to remove the alleged perpetuator (CNA 3 and CNA 2) while investigation was in progress, and follow policies for reporting the results of the investigation of the abuse to the Department. On 12/22/2021, at 11:32 a.m., the ADM and the facility's Nurse Consultant were informed that the IJ situation was removed after the implementation of the acceptable Plan of Action ([POA], interventions to correct the deficient practice) was verified while on onsite through observation, interview, and record review. Cross-reference F610. Findings: During a review of the Face Sheet (admission record), dated 12/17/2021, the Face Sheet indicated the facility admitted Resident 9 on 7/22/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 7/4/2021, the MDS indicated Resident 9 had intact cognitive (process of acquiring and understanding knowledge) response. The MDS indicated Resident 9 was totally dependent on staff for bed mobility, transfer, toileting, eating, and personal hygiene. During an interview, on 12/13/21, at 11:35 a.m., with Resident 9, Resident 9 stated she suffered pain after CNA 3 pulled the towel under her buttocks real hard during incontinence care on 11/28/2021 at 2:00 a.m. Resident 9 stated a fist fight happened between her and CNA 3 because CNA 3 forced Resident 9 to be cleaned, despite her objections. Resident 9 stated she did not report the fist fight between her and CNA 3 to staff but reported the incident (date and time unknown) to her family member (FM3). Resident 9 stated there was another incident (date and time unknown) of abuse where CNA 2 burned Resident 9 by wringing a towel soaked with hot water over her private parts. Resident 9 stated she reported the incident where CNA 2 burned her genitals to FM3. During an interview on 12/13/21, at 11:40 a.m., with FM3, FM3 stated ADM was notified (date and time unknown) of the allegations of abuse (from CNA 3 and CNA 2). FM3 stated that the ADM told FM3 that it [the alleged abuse of Resident 9 by CNA 3 and 2] will be taken care of. During an interview on 12/14/2021, at 12:44 p.m., with ADM, ADM stated he was not aware of the alleged abuse incidents where Resident 9 was allegedly abused by CNA 3 and 2. ADM acknowledged that he was now made aware of an abuse allegation where Resident 9 alleges that CNA 3 and CNA 2 were abusive towards Resident 9. Administrator stated he would try to look at it. During an observation on 12/16/2021 at 03:15 p.m., Resident 9 was observed talking to LVN 7. Resident 9 was observed informing LVN 7 that she had a fist fight with CNA 3 and that something must be done. Resident 9 stated, while emotional and crying, that the incident made her feel like she is less of a person. Resident 9 stated that she wanted to go home because she's scared for her life; that CNA 3 will continue the abuse. Resident 9 stated she did not tell anybody about the incident (the fist fight between Resident 9 and CNA 3 and CNA 2 burning Resident 9) because she felt like the staff would retaliate against her. Resident 9 stated she reported abuse by CNA 3 and CNA 2 to FM3 and FM3 made complaints to ADM. LVN 7 stated that if any resident complained about abuse, the abuse coordinator must investigate the allegation and the staff involve must be taken away from the assignment. LVN 7 stated he will take care and look about it [report to the abuse coordinator the alleged abuse]. During an interview on 12/21/2021, at 9:34 a.m. with Resident 9, Resident 9 stated CNA 3 was assigned to her last night (12/20/21 at 11:00 p.m. to 12/21/21 at 7:00 a.m.). Resident 9 stated she was really scared and wanted to go home. Resident 9 stated she felt intimidated and neglected by the abuse incidents perpetuated by CNA 3 and CNA 2. During a concurrent interview and record review, on 12/21/2021, at 10:30 a.m., with Assistant Staff Developer (ASD), the assignment sheet and clock-in record from 12/17/2021 to 12/20/2021 were reviewed. ASD stated CNA 3 was scheduled and signed-in to work on 12/17/2021 from 7:00 p.m. to 7:00 a.m. and was assigned to Resident 9. CNA 3 also clocked-in again on 12/17/2021 at 10:29 pm and clocked out on 12/18/2021 at 6:30 am (CNA 3 worked a double shift). CNA 3 was scheduled and signed-in to work on 12/20/2021 from 10:30 p.m. to 6:30 a.m. and was assigned to Resident 9. During a concurrent interview and record review on 12/21/2021, at 12:44 a.m., with ADM, the facility's policies titled Resident Safety and Prevention from Potential Abuse and Resident 9's medical records were reviewed. ADM stated that there is no documented evidence CNA 3 and CNA 2 allegedly abused Resident 9 or that an investigation began. ADM stated he could not explain why he did not start the investigation of Resident 9 abuse allegations. ADM stated social services and himself would initiate the investigation and conduct interviews with staff, resident, resident family and commence self-report within 2 hours for allegation of staff to resident abuse report the alleged incidents of abuse to the ombudsman, local law enforcement. ADM stated that the results of the investigation would be submitted to the Department within 5 days. ADM stated the facility did not follow the abuse policy by immediately investigating Resident 9's allegations of abuse perpetuated by CNA 3 and CNA 2 when ADM was made aware of the alleged abuse on 12/14/2021, immediately suspend CNA 3 and CNA 2, and report the results of the investigation to the Department within 5 days. ADM stated immediately investigating abuse allegations, suspending the alleged perpetrators, and reporting abuse allegations and the conclusion of the investigations are important because it can prevent ongoing abuse, psychosocial harm, and retaliation for the alleged perpetrators and other staff. During an interview on 12/22/2021, at 9:22 a.m., with the Social Services Assistant (SSA), SSA stated if any resident alleges abuse, the alleged abuse must be reported to the abuse coordinator, ADM. SSA stated all allegations of abuse must be investigated, so that we will know which staff is responsible. SSA stated that all staff are mandated to report any form of abuse. During an interview on 12/22/2021, at 9:35 a.m., with the Social Services Director (SSD), the SSD stated that allegations of abuse from residents must be reported to the abuse coordinator, ADM, immediately. The SSD stated that reporting the alleged abuse to the abuse coordinator ensures that the abuse will be investigated properly. During an interview on 12/22/2021 at 11:01 a.m., with the Director of Nursing (DON), the DON stated that every abuse allegation must be investigated timely because that is a reportable incident, and we need to know the truth about the abuse. During a review of the facility's P/P titled, Abuse Prevention Program dated revised December 2016, the P/P indicated: the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion. verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the abuse prevention, the administrator: Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of the facility's P/P titled, Abuse Investigation and Reporting dated revised July 2017, the P/P indicated: AII reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reponed. Role of the Administrator: If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. The administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: The State licensing/certification agency responsible for surveying/licensing the facility, the local/State Ombudsman, The Resident's Representative (Sponsor) of Record, Adult Protective Services (where state law provides jurisdiction in long-term care), Law enforcement officials, The resident's attending physician; and, The facility medical director. During a review of the facility's P/P titled, Abuse Investigation and Reporting dated revised July 2017, the P/P indicated: The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within (5) working days of the occurrence of the incident.

Based on record review and interview, the facility failed to ensure the resident was not subjected to a physical abuse from a Certified Nursing Assistant (CNA 2) and CNA 3, failed to investigate the alleged abuse, protect the resident from possible further abuse, and report the results of investigation to the officials in accordance with State Law for one of two sampled residents (Resident 9). The facility failed to: 1. Conduct the investigation of Resident 9's allegation of physical abuse. Resident 9 alleged that CNA 3 had a fist fight with Resident 9 and CNA 2 had wrung a towel soaked with hot water over Resident 9's genitals (a person's external organs for reproduction). 2. Suspend the alleged perpetrators, CNA 3 and CNA 2, per facilities policy titled Abuse Investigation Reporting. 3. Ensure CNA 3 and CNA 2 were not assigned to continue to care for Resident 9 after the allegation of abuse by both CNAs was made. 4. Report Resident 9's allegation of physical abuse to the State Survey Agency Licensing & Certification (L&C) Department immediately and report the results of all investigations within 5 working days to officials in accordance with State law, including to the State Survey Agency and L&C Department. These deficient practices placed Resident 9 at risk for the potential of ongoing abuse and resulted in Resident 9's feeling of intimidation, retaliation, neglect, and a decline in emotional wellbeing. On 12/21/2021, at 3:08 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was identified and declared. The facility's Administrator (ADM) was notified of the immediacy and seriousness of other residents' and staff members health and safety being threatened for failure to investigate an allegation of abuse (by Resident 9), prevent further potential abuse by failing to remove the alleged perpetuator (CNA 3 and CNA 2) while investigation was in progress and report the results of the investigation of the abuse to the State Survey Agency L&C Department. On 12/22/2021, at 11:32 a.m., the ADM and the facility's Nurse Consultant were informed that the IJ situation was removed after the implementation of the acceptable Plan of Action ([POA], interventions to correct the deficient practice) was verified while on onsite through observation, interview, and record review. Findings: During a review of the Face Sheet (admission record), dated 12/17/2021, the Face Sheet indicated Resident 9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 9's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool), dated 7/4/2021, the MDS indicated Resident 9 had intact cognitive (process of acquiring and understanding knowledge) skills for daily decision making. The MDS indicated Resident 9 was totally dependent on staff for bed mobility, transfer, toileting, eating, and personal hygiene. During an interview, on 12/13/21, at 11:35 a.m., Resident 9 stated she suffered pain after CNA 3 pulled the towel under her buttocks real hard during incontinence care on 11/28/2021 at 2:00 a.m. Resident 9 stated a fist fight happened between her and CNA 3 because CNA 3 forced Resident 9 to be cleaned, despite her objections. Resident 9 stated she did not report the fist fight between her and CNA 3 to staff but reported the incident (date and time unknown) to her family member (FM3). Resident 9 stated there was another incident (date and time unknown) of abuse where CNA 2 burned Resident 9 by wringing a towel soaked with hot water over her private parts (genitals). Resident 9 stated she reported the incident where CNA 2 allegedly burned her genitals to FM3. During an interview on 12/13/21, at 11:40 a.m., FM3 stated ADM was notified (date and time unknown) of the allegations of abuse (from CNA 3 and CNA 2). FM3 stated that the ADM told FM3 that it [the alleged abuse of Resident 9 by CNA 3 and 2] will be taken care of. During an interview on 12/14/2021, at 12:44 p.m., ADM stated he was not aware of the alleged abuse incidents where Resident 9 was allegedly abused by CNA 3 and CNA 2. ADM acknowledged that he was now made aware of an abuse allegation where Resident 9 alleges that CNA 3 and CNA 2 were abusive towards Resident 9. Administrator stated he would try to look at it. During an observation on 12/16/2021 at 3:15 p.m., Resident 9 was observed talking to LVN 7. Resident 9 was observed informing LVN 7 that she had a fist fight with CNA 3 and that something must be done. Resident 9 stated, while emotional and crying, that the incident made her feel like she is less of a person. Resident 9 stated that she wanted to go home because she was scared for her life and that CNA 3 will continue to abuse her. Resident 9 stated she did not tell anybody about the incident (the fist fight between Resident 9 and CNA 3 and CNA 2 burning Resident 9) because she felt like the staff would retaliate against her. Resident 9 stated she reported abuse by CNA 3 and CNA 2 to FM3 and FM3 informed ADM. LVN 7 stated that if any resident complained about abuse, the abuse coordinator must investigate the allegation and the staff involved must be taken away from the assignment. LVN 7 stated he will take care and look about it [report to the abuse coordinator the alleged abuse]. During an interview on 12/21/2021, at 9:34 a.m. Resident 9 stated CNA 3 was assigned to her last night (12/20/21 at 11:00 p.m. to 12/21/21 at 7:00 a.m.). Resident 9 stated she was really scared and wanted to go home. Resident 9 stated she felt intimidated and neglected by the abuse incidents perpetuated by CNA 3 and CNA 2. During a concurrent interview and record review, on 12/21/2021, at 10:30 a.m., with Assistant Staff Developer (ASD), the assignment sheet and clock-in record from 12/17/2021 to 12/20/2021 were reviewed. ASD stated CNA 3 was scheduled and signed-in to work on 12/17/2021 from 7:00 p.m. to 7:00 a.m. and was assigned to Resident 9. CNA 3 also clocked-in again on 12/17/2021 at 10:29 pm and clocked out on 12/18/2021 at 6:30 am (CNA 3 worked a double shift). CNA 3 was scheduled and signed-in to work on 12/20/2021 from 10:30 p.m. to 6:30 a.m. and was assigned to Resident 9. During a concurrent interview and record review on 12/21/21, at 12:44 a.m., with ADM, Resident 9's medical record was reviewed. ADM stated he did not investigate Resident 9's allegation of abuse from CNA 3 and CNA 2 when the allegations of abuse were reported to him on 12/14/21. ADM stated that there is no documented evidence CNA 3 and CNA 2 allegedly abused Resident 9 or that an investigation began. ADM stated it is important to begin an investigation once an allegation of abuse is made because it can keep the resident safe by preventing ongoing abuse and possible retaliation. ADM stated he should have suspended CNA 3 and CNA 2 while an investigation took place to prevent ongoing abuse, but he did not. ADM stated the results of the investigation of the alleged abuse perpetuated by CNA 3 and CNA 2 were not reported to State Survey Agency L&C Department within 5 working days of incident because an investigation into both incidents did not begin. ADM stated he did not have an excuse for not investigating and reporting to the Department Resident 9's allegation of abuse perpetuated by CNA 3 and CNA 2. A review of the facility's policy and procedure titled, Abuse Investigation and Reporting revised July 2017, indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Role of the Administrator: If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. The administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The administrator will keep the resident and his/her representative informed of the progress of the investigation. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident.

Based on observation, interview, and record review the facility failed to; 1. Ensure two of three sampled smoking residents (Resident 2 and Resident 3) were supervised for safety while smoking cigarettes on the patio and sharing a cigarette lighter. 2. Ensure Residents 2, 3 and 4, who smoked cigarettes, were assessed, evaluated and care planned for smoking privileges based on ability to smoke safely, physically, and cognitively in accordance with the facility's policy and procedure on 'Smoking Policy-Residents'. These deficient practices placed residents and staff in the facility at risk for possible fire and associated injury. The facility census was 121 residents. Resident 2 and Resident 3 was on the patio smoking for about 30 minutes sitting in their WCs smoking without supervision On 11/16/2021 at 2:15 p.m., the facility's Administrator (ADM) was notified that an Immediate Jeopardy [(IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident(s)] was identified due to the facility's failure to assess the residents for smoking privileges based on their ability to smoke safely, physically, and cognitively, failure to supervise the residents during smoking breaks to ensure safety and prevent possible cause for fire, and failure to ensure the residents did not have lighters and cigarettes in their possession. The facility's ADM was notified of the immediacy and seriousness of the fire hazard and physical danger to other residents and facility staff. On 11/18/2021 at 8:00 a.m., the facility submitted an immediate Plan of Action (POA). After review and validation of POA implementation on site the POA was accepted on 11/18/2021 and 9:00 a.m. Findings: On 11/5/2021 at 12:30 p.m., Resident 2 and Resident 3 were observed on the patio area. Resident 2 was observed lighting his cigarette and then lighting Resident 3's cigarette. Resident 2 and Resident 3 were observed on wheelchairs smoking for 30 minutes without staff presence to supervise both residents smoking. On 11/5/21 at 1:15 p.m., Residents 2 and 3 were observed on the patio smoking. Resident 3's was holding the cigarette in right hand. His hand was observed trembling while Resident 2 was lighting his cigarette. Resident 3 was not wearing fire-retardant (material that prevents fire from spreading on the wearer) wear. A review of Resident 2's admission record indicated the resident was last admitted to the facility on [DATE], with diagnoses including essential hypertension (high blood pressure, without a known secondary cause), heart failure (an ongoing condition where the heart cannot pump enough blood to meet the bodies need for nutrients) and [CONDITION(S)] (reduced blood flow to upper and lower limbs). A review of Resident 2's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 8/11/21, indicated the resident had an intact cognitive (ability to make decisions of daily living) skills for daily decision making and required one-person physical assistance with transferring from bed to a wheelchair, toileting and getting dressed. During a concurrent review of Resident 2's medical record and interview with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 confirmed Resident 2 did not have a care plan for smoking and assessment for smoking safety and need for supervision. LVN 1 stated assessing a resident for smoking safety and having a care plan for smoking would ensure the resident was safe from potential smoking hazards. LVN 1 acknowledged, Resident 2 smoked without supervision and safety precautions, which was a safety hazard to Resident 2 and other residents and staff in the facility. During an interview with Resident 2, on 11/5/21 at 1:15 p.m. Resident 2 stated he has always kept his cigarettes and his cigarette lighter in his possession. Resident 2 confirmed he took smoking breaks whenever he wanted to, and there were no facility staff present during smoking breaks. During an interview on 11/5/2021 at 1:30 p.m., with Resident 2 and Resident 3, Resident 2 confirmed he always kept his cigarettes and lighter with him. Resident 2 confirmed he shared, his cigarettes and a lighter with other residents in the facility. Resident 2 and Resident 3 confirmed they smoked when they wanted to, and facility staff did not supervise their smoking breaks. A review of Resident 3's admission record indicated Resident 3 was last admitted to the facility on [DATE] with diagnoses including lack of coordination, (movement that may affect walking, speech, ability to swallow, eye movements, and other usually voluntary movements), muscle weakness, and Alzheimer's Disease (a brain disorder that causes problems with memory, thinking and behavior). A review of Resident 3's MDS dated [DATE] indicated the resident had severely impaired cognitive skills for daily decisions making and required one-person physical assistance for activities of daily living including getting dressed, toileting and personal hygiene. A review of Resident 3's care plan for Smoking, dated 10/6/17 indicated Resident 3 required supervision during smoking to ensure safety. During an interview on 11/5/2021 at 2:00 p.m., LVN 1 stated Resident 2 and Resident 3 often shared cigarettes and cigarette lighter. LVN 1 stated the residents should not have cigarettes and lighters in their possession and should not smoke without facility staff supervision during smoking to ensure safety. A review of Resident 4's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including unspecified [CONDITION(S)] (a mental illness that causes a disconnect with reality), abnormality of gait and mobility, unspecified convulsions (uncontrollable repetitive muscle contractions), and muscle atrophy (loss, shrinking and weakening of muscles in the body). A review of Resident 4's MDS dated [DATE], indicted Resident 4 had moderately impaired cognitive skills for daily decision making and required physical assistance of one person for activities of daily living. On 11/5/21 at 3:45 p.m., during a concurrent review of Resident 4's medical record and interview LVN 1 stated, Resident 4 was a smoker and had a history of aggression towards others without provocation. LVN 1 confirmed there was no care plan for Resident 4 smoking. LVN 1 stated Resident 4 should have been always supervised during smoking. LVN1 stated residents' supervision during smoke breaks was not implemented in the facility. During an interview on 11/5/2021 at 3:00 p.m. the Director of Nursing (DON) stated that the residents, who smoke, were not assessed for safety during smoking. DON stated all residents who smoke should have been assessed for independent smoking and smoking safety. DON acknowledged residents keeping their lighters at all time creates a safety issue. DON confirmed residents in the facility were not supervised during smoking breaks on the patio. DON stated due to residents physical and psychological diagnoses unsupervised smoking was a safety issue. During an interview on 11/5/2021 at 3:15 p.m. the administrator confirmed residents keeping lighters in their possessions placed them, other residents, and staff at risk for accident hazard, possible fire, and injuries. ADM verbalized lack of knowledge on implementing a smoking assessment and safety program. A review of the facility's policy and procedure titled, Smoking Policy - Residents, revised 7/17, indicated the facility shall establish and maintain safe resident smoking practices. The staff shall consult with the attending physician and the DON to determine if safety restrictions need to be placed on a resident needed to be placed on a resident's smoking privileges based on the safe smoking evaluation. Residents must have the ability to smoke safely physically and cognitively, and re-evaluated quarterly (every three months). Residents without independent smoking privileges may not have or keep any smoking articles including cigarettes, except when under direct supervision. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision.

Based on interview and record review, the facility failed to closely monitor and provide the necessary care and services for one of two sampled residents (Resident 1), after there was a change of condition ([COC] a sudden clinically deviation from a resident's baseline in physical, cognitive [thought process], behavioral, or functional domains) that required close monitoring after it was reported to the physician. Resident 1 had a syncopal episode ([CONDITION(S)]) reported to the physician without continued close monitoring for over three hours which lead to Resident 1's condition worsening and Resident 1 becoming hypotensive (a low blood pressure) with an altered level of consciousness ([ALOC] not as awake, alert, and reactive), difficulty breathing and diaphoresis (increased sweating). Resident 1's family member (FM 1) observed Resident 1 unarousable (unable to waken) and gasping for air and requested for the staff to call 911 (an emergency service) immediately. This deficient practice of the facility not closely monitoring Resident 1 after an initial COC resulted in a delay in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 required a transfer to the general acute care hospital (GACH) after the resident became unresponsive (not verbally responding) and unarousable on 6/19/2021 by emergency transport services (911). Resident 1 was bag to mask ventilated (a hand-held resuscitating [bring back to life] bag that delivers forceful air through the nose and mouth during an emergency) and diagnosed with septic shock (an infection that spreads throughout the blood and tissues, caused by extremely low blood pressure and can result in organ failure), severe [CONDITION(S)] (infection in the blood) and respiratory failure and acute kidney failure ([AKI] sudden episode of kidney failure or kidney damage), requiring intubation (tube insertion in the windpipe as a life saving measure when a person is not breathing independently) and ventilator (a machine that helps you breathe or breathes for you), required emergency hemodialysis (a medical procedure that clean blood for individuals with loss of normal kidney function). Resident 1 required hospitalized in the intensive care unit for 10 days. Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment tool and care screening tool, dated 5/14/2021, the MDS indicated Resident 1's cognition (thought process) was severely impaired, required extensive assistance with one-person physical assist with bed mobility, toileting and personal hygiene and a two-person assistance with a two-person assistance with transfers. During a review of Resident 1's revised care plan, dated 8/8/2020 and titled Potential for cardiovascular (heart) distress related to hypertension and CHF, the staffs' interventions included to give medications as ordered, monitor for side effects such as [CONDITION(S)] (a drop in the blood pressure measurement while lying flat or standing) and increased heart rate, obtain blood pressure readings (measurement) per physician order. During a review of Resident 1's recapitulated (a summary) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Staff to monitor blood pressure once daily every Thursday. 2. Staff to monitor oxygen saturation ([O2] amount of oxygen in the blood) every shift. 3. Staff to monitor body temperature every shift and call the physician if the temperature is greater than or equal to 100 degrees Fahrenheit (F), (Normal Reference Rate ([NRR]= 97.0-99.0 F). During a review of Resident 1's COC note, dated 6/19/2021 and timed at 12:30 p.m., the COC note indicated during lunch, Resident 1 was observed as being weak, cold, and clammy (sweaty), while sitting in his wheelchair in the middle of the room. The COC note did not indicate if the staff assisted Resident 1 back to bed and elevated the head of the resident's bed. The COC indicated Resident 1 eyes were opened and was able to nod his head indicating yes and no. The COC indicated Resident 1's vital signs (V/S) were as follow: a blood pressure (BP) of 91/56 millimeters of mercury (mmHg [NRR = 90/60- 139/79 mm/hg]), pulse of 80 beats per minute ([bpm] NRR= 60-100 bpm), an oxygen saturation ([O2] oxygen in the blood) of 92 percent ([%] NRR 95-100%). The COC indicated Resident 1's physician was notified at 12:35 p.m. and the staff received orders to administer two to three (2-3) liters ([L] units of measurement) of continuous O2 to Resident 1. During a review of Resident 1's nurse's progress note (NPN), dated 6/19/2021 and timed at 2:15 p.m., the NPN indicated Resident 1 was alert, responsive to verbal and physical stimuli (awakened by someone or something), had an O2 saturation of 92 % while on 2L of oxygen per minute, was oriented x 2, and had a blood sugar level of 85 mg/dL. The NPN indicated visual checks were rendered to Resident 1. During a review of Resident 1's clinical records, there was no documented evidence of frequent visual monitoring conducted by the staff. During a review of Resident 1's NPN, dated 6/19/2021 and timed at 3:30 p.m., the NPN indicated Resident 1 was verbally responsive, easily awaken to verbal and physical stimuli and had an O2 saturation of 90% to 92% while on 2L of oxygen per minute. The NPN indicated the staff would continue to monitor for any changes. During a review of the COC note, dated 6/19/2021 and timed at 6 p.m., the COC indicated, Resident 1 had an altered mental status ([AMS] any measure of arousal other than normal), was lying in bed with his eyes closed and unable to follow commands. The COC indicated Resident 1, had shortness of breath with a respiration rate (RR) of 18 bpm (NRR is 12-16 breaths per min), was sleepy and lethargic and V/S were as follow: an O2 desaturation of 83% while on 2L of oxygen per minute via NC, was hypotensive with a B/P of 88/56 mmHg, had an irregular pulse of 135 BPM, a body temperature of 98.3F. The COC indicated Resident 1 was placed on a non-rebreather (NRB) mask and was given 15 L of O2. The COC indicated Resident 1's physician was notified, and Resident 1 was transported to the GACH the paramedics (medical emergency trained personnel) for an evaluation. During a review of Resident 1's Paramedic Run Sheet (PRS), dated 6/19/202 indicated the paramedics arrived at the facility on 6/19/2021 at 6:04 p.m., Resident 1 had an ALOC, diaphoretic, had shortness of breath with the use of his accessory muscles breathing (noticeable neck, chest and stomach muscles used when having difficulty breathing), was unconscious with a Glasgow Coma Scale ([GSC] an assessment used to determine level of consciousness [alertness/function]) of 6. According to the GCS, a score of 15 was normal and a score between 3-8 was indicative of severe decreased brain function and/or comatose. The PRS indicated Resident 1 was [CONDITION(S)] (heart rate greater than 100 bpm) with a heart rate of 111 bpm, was tachypneic (respiration rate greater than 20 bpm) with a RR of 56 BPM, and an O2 saturation of 92%. The PRC indicated Resident 1 required a bag to mask ventilations was transported to the GACH. During a review of Resident 1's GACH face sheet, the face sheet indicated Resident 1 arrived to the Emergency Department (ED) on 6/19/2021 at 6:37 p.m. During a review of Resident 1's GACH ED H/P, dated 6/19/2021 and timed at 8:46 p.m., the H/P indicated Resident 1 arrived to the ED with altered mental status, severe [CONDITION(S)] (an infection in the blood), and respiratory failure. According to the GACH H/P, Resident 1's mental status had worsened throughout the day while at the skilled nursing facility (SNF) with an increased effort to of breathing. The H/P indicated when the family arrived at the facility, the family indicated Resident 1 was not himself and was breathing faster than usual and the family requested for the paramedics to be called. According to the H/P when the paramedics arrived to the SNF, Resident 1's O2 saturations was in the 80's, was tachypneic with his eyes open and was not responding to verbal or noxious (physically harmful) stimuli. The H/P indicated Resident 1 was being bagged by the paramedics upon his arrival to the ED. The H/P indicated Resident 1 had a B/P of 86/58, a RR of 46 bpm, a HR of 107 bpm and an elevated white blood count (WBC) of 17.48 per microliter (uL) (NRR =levels 4.00 -11.00). According to the H/P, Resident 1 received [MEDICATION(S)] (medication used to treat an infection) 2,000 mg per intravenously ([IV] into the vein), [MEDICATION(S)] (medication used to treat an infection) 1,500 mg, [MEDICATION(S)] (medication used to increase to control the blood pressure) 1 microgram ([mcg] a unit of measurement) and [MEDICATION(S)] (salt water) 0.9% continuous IV fluids. According to the H/P Resident 1 was intubated (tube insertion in the windpipe as a life saving measure when a person is not breathing independently) and on a ventilator (a machine that helps you breathe or breathes for you) for six days and received emergency hemodialysis (a medical procedure that clean blood for individuals with loss of normal kidney function) treatment. The H/P indicated Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The H/P indicated Resident 1 was hospitalized in the intensive care unit for 10 days. During a telephone interview on 7/5/2021 at 3:09 p.m., Family Member 1 (FM 1) stated on 6/19/2021, it was reported to her on the same day Resident 1 was dizzy and had his B/P was low. FM 1 stated she called the facility and spoke to Licensed Vocational Nurse (LVN 3). According to FM 1, LVN 3 stated she did not recheck Resident 1's B/P because the Resident 1 was combative, would not eat his meal and she had to feed Resident 1. According to FM 1, on the same day Resident 1's family members at the facility when the family knew Resident 1 required immediate attention because he was not responsive and was slumped over in his wheelchair. During an interview on 7/29/2021 at 1:05 p.m., LVN 1 stated during a patient's change in their condition (COC), she would assess the resident, obtain the V/S and call the physician. LVN 1 stated she would then recheck the resident's V/S 10 minutes after the initial COC, then monitor the resident's vital signs every 30 minutes. During a concurrent interview and record review of Resident 1's COC note and NPNs on 7/29/2021 at 1:32 p.m., LVN 2 stated on 6/19/2021 after 10 a.m., Resident 1 was observed by a CNA slumped over to the left side while sitting in his wheelchair. LVN 2 stated Resident 1 was cold, his B/P was 91/56 and not responsive. LVN 2 stated she and the CNA transferred Resident 1 to the bed when he slowly started to respond. LVN 2 stated she placed Resident 1 on 5L of O2 and his O2 saturation was 92 %. LVN 2 stated Resident 1's physician was notified and received orders on Resident 1. LVN 2 stated she rechecked Resident 1's V/S every 30 minutes and the Resident 1's V/S was the same, the SBP (systolic [(top number] B/P) remained in the 90's. LVN 2 was asked if she documented Resident 1's V/S after being checked every 30 minutes, LVN 2 stated she did not document Resident 1's follow-up V/S. During a concurrent interview and review of Resident 1's COC note and NPNs on 7/29/2021 at 3:08 p.m., LVN 3 stated on 6/19/2021 at 3 p.m., she received verbal report from the LVN from the prior shift that Resident 1 had episodes on [CONDITION(S)] (low blood sugar) and required monitoring. LVN 3 stated she assessed Resident 1 and Resident 1 was awake, alert. LVN 3 stated Resident 1's V/S were normal with a SBP of 130 mm/Hg, a blood sugar level of 92 mg/dL and LVN 3 stated she did not document Resident 1's B/P or his blood sugar level. LVN 3 stated after she assessed Resident 1, she began passing medications to her assigned residents. LVN 3 stated on that same day between 4 p.m.to 5 p.m., she received a call from Resident 1's FM 1. LVN 3 stated when FM 1 asked about Resident 1's B/P, LVN 3 stated that was when she saw Resident 1's documented low B/P. LVN 3 stated she informed FM 1 that Resident 1's B/P was normal and had to feed Resident 1 because his blood sugar was in the 70's, he was weak, sleepy, arousable, and he could not feed himself. LVN 3 stated she monitored Resident 1 and did not document the resident's V/S or blood sugar readings. LVN 3 stated approximately 1 to 2 hours after Resident 1's assessment, she continued with her medication pass when she observed Resident 1's family at the door. LVN 2 stated she escorted Resident 1's family to his bedside, when Resident 1 was short of breath, was gasping for air, unarousable (not awake, not aware or responding) and five minutes later the family requested for Resident 1 to be transported to the hospital. LVN 3 stated the Registered Nurse Supervisor (RNS) arrived at Resident 1's room, checked the resident B/P and Resident 1's B/P was low. LVN 3 stated Resident 3 had a O2 saturation level of 82% while receiving 15L of O2. LVN 3 stated the paramedics arrived and transported Resident 1 to the hospital. During an interview on 7/29/2021 at 3:40 p.m., RNS stated on 6/19/2021, she was on the sub-acute (24-hour inpatient care and recovery for those with a serious illness, injury or disease or health problems) unit when she heard overhead page of a code blue (facility staff alert to indicate a medical emergency, such as cardiac or respiratory arrest and the staff should respond) to ensure the staff was completely prepared before they are faced with a real situations). RNS stated when she arrived at Resident 1's room, Resident 1 was unresponsive, had an ALOC, had a low B/P and instructed the staff to call the paramedics. RNS stated residents with a SBP reading of 70-80's, 911 should be called and residents with a SBP reading of 90's the staff should monitor resident's B/P every 30 minutes and the B/P recordings should be documented in the resident's NPN. During a telephone interview on 8/3/2021 at 12:54 p.m. FM 2 stated on 6/19/2021, she and two other family members arrived at the facility. FM 2 stated when she saw Resident 1, she immediately knew something was wrong. FM 2 stated Resident 1 was totally different from his normal self, he was not talking or moving at all. FM 2 stated she asked the nursing staff to check Resident 1 because he had a strange look, his skin color was not normal and asked the nursing staff to call 911. During a concurrent interview and record review of Resident 1's COC and NPNs, on 7/29/2021 at 3:56 p.m., the Director of Nursing (DON) was asked about the frequency of monitoring Resident 1's V/S during a COC, the DON stated the staff documented a follow-up note and he would conduct an in-service for the staff. The DON was asked would the staff conduct monitoring after a resident's COC if there was no policy and procedure (P/P), the DON did not respond. The DON stated he would conduct an in-service on monitoring residents during a COC. The DON was asked what the staff would refer to after he conducted an in-service if there was no facility P/P on monitoring, the DON stated he would conduct a staff in-service on monitoring based from the facility's current P/P. The DON was asked if Resident 1's B/P of 91/51 mm/Hg considered a COC, the DON stated, No, but Resident 1 was back from the hospital and was doing fine. During a review of the facility's undated P/P titled, Change in a Resident's Condition or Status, the P/P indicated for the nurse would notify the resident's attending physician or physician on call when there has been a (an) significant change in the resident's physical/mental condition, need to transfer the resident to a hospital/treatment center, specific instruction to notify the physician of changes in the resident's condition. The P/P indicated a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by the staff or by implementing standard disease related clinical interventions (is not self-limiting), impacts more than one area of the resident's health status. The P/P indicated the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to follow its abuse policy to protect two of three sampled residents (Resident 1) from been verbally abused by Licensed Vocational Nurse (LVN 1) and terminate the staff according the policy when the allegations of abuse were confirmed. This deficient practice resulted in Resident 1 feeling angry for being yelled as if she was a child, and Resident 2 feeling demeaned and worthless. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool dated 4/22/19, indicated that Resident 1 was able to understand and make herself understood and was intact of cognition (thought process). A review of the Nurses' Note, dated 8/4/19 and created at 8:04 p.m., indicated that Resident 1 was noted screaming from room because her roommates feeding pump was beeping for 15 minutes. A review of Resident 1's care plan created on 11/7/17, indicated that Resident 1 was mocked by a Certified Nurse Assistant (CNA). The staff goals included to intervene to protect the residents right and safety. A review of the facility's summary and conclusion dated 8/9/19, indicated that on 8/4/19 Resident 1 reported to Registered Nurse 1 (RN 1) that LVN1 was disrespectful to her. The RN 1 talked to LVN 1 and educated him on customer service. The conclusion indicated that on 8/5/19, Resident 1 informed the Director of Nurses (DON) regarding the incident. The DON talked to the RN1 and the CNA 1 and both confirmed the incident. On 8/6/19 the Administrator (ADM) reported the incident of verbal abuse to the Department of Public Health (DPH) after Resident 1 informed the ADM about LVN 1 yelling at her. The summary indicated that CNA 1 overheard the argument between both Resident 1 and LVN. The conclusion indicated that verbal argument happened, but there was no threatening to Resident 1 or foul language used. The LVN 1 was suspended according to facility's policy. On 8/14/19 at 3:20 p.m., during an interview, Resident 1 stated that on 8/4/19 approximately at 8 p.m., her roommates feeding pump was beeping for over 10 minutes. Resident 1 stated that CNA 1 notified LVN 1 regarding the pump beeping. Resident 1 stated that after a few minutes, she yelled out the LVN 1's name and he then came into the room yelling at Resident 1 and calling he st@@@d. Resident 1 stated that she told the RN 1 that LVN 1 had verbally insulted her and talked to her as if she was a little kid. The Resident 1 stated that the nest day on 8/5/19, she complained to the DON and the following day 8/6/19, both the ADM and the DON talked to the Resident 1 regarding what had happened with LVN 1. Resident 1 stated that LVN 1 was suspended for one day and then returned to work in a different side of the facility. On 8/14/19 at 3:40 p.m., during an interview, Resident 2 stated that he tried to avoid LVN 1 because of his demeanor (attitude towards others that is presented by the way one stands, talks, and facial expressions) and condescending (showing feelings of superiority) attitude made him angry and upset. The Resident 2 stated that LVN 1 was very rude to the residents of the facility. Resident 2 stated that he was able to identify the voice of LVN 1 when he heard him yelled at someone to shut-up that he had hear the machine beeping, but was not aware who was LVN 1 yelling at. Resident 2 stated that he tries to stay away from LVN 1 because he does not like the way he talks to him, makes him fell like he is less specially when he talks to him standing and staring at him. A review of Resident 2's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS), a standardized care screening and assessment tool dated 5/17/19, indicated that Resident 1 was able to understand and make herself understood and was intact of cognition (thought process). On 8/14/19 at 4:40 p.m., during a concurrent interview and record review of the LVN 1's schedule and in the presence of the Director of Staff Development (DSD), the ADM stated that LVN 1 was suspended for one day and returned to work after an in-service for customer service and how to talk to residents. The ADM stated that he conducted his investigation and no other residents' complaint when he asked residents how was the care in the facility. On 8/30/19 at 12:36 p.m., during a telephone interview, CNA 1 stated that she was able to hear both Resident 1 and LVN 1 yelling at each other. CNA 1 stated she overheard LVN 1 telling Resident 1 that she was hard headed like the other residents. CNA 1 stated she could hear LVN 1 raising his voice and changing his tone. The CNA 1 stated that same night Resident 1 asked to call the RN 1 to place a complaint against LVN 1. CNA 1, also stated that LVN 1 was upset that she (CNA 1) refused to sign a declaration that LVN 1 wrote himself that indicated that Resident 1 was aggressive and rude and that LVN 1 never raised his voice against her. On 9/3/19 at 12:19 p.m., during a telephone interview, the RN 1 stated that on 8/4/19 Resident 1 made a report regarding LVN 1 yelling at her and treating her like a kid and telling her what to do. The RN 1 stated that she did not notify the DON or ADM of Resident 1's allegations because the LVN 1 denied the allegations when she interviewed him. On 9/4/19 at 11:40 a.m., during a telephone interview, LVN 1 stated that he did not yelled at Resident 1, that he just raised his tone of voice, but he believed that changing his tone of voice was not consider abuse. LVN 1 stated that he was suspended one for one-day pending investigation. A review of the facility's undated policy titled, Reporting Abuse to Facility Management, indicated that the facility did not condone resident abuse by anyone. The policy indicated that verbal abuse was defined as any use of oral, written, or gestured language that willfully includes derogative terms to residents regardless of their disability. The policy indicated that mental abuse was defined as humiliation, harassment, threats of punishments, or withholding of treatments or services.

Based on interview and record review, the facility failed to develop a comprehensive plan of care to address and manage a resident's care for the use of the Passy-Muir Valve ((PMV) valve that redirects air flow through the vocal folds, mouth and nose enabling voice and improved communication and swallowing), and anxiety behaviors with medications given that had side effects, for one of three sampled residents (Resident 1). Resident 1, who had history of [MEDICAL CONDITION] (not enough oxygen passing from the lungs to the blood causing low oxygen levels and carbon [MEDICATION NAME] levels accumulate in the blood), who was admitted with a [MEDICAL CONDITION] (a surgically created hole through the front of the neck and into the breathing tube that leads to the lungs), mask ((T-mask), mask placed over [MEDICAL CONDITION]), and a PMV (Cross referenced F695 and F580). This deficient practice resulted in Resident 1 being left with the PMV on while experiencing large amounts of secretions and during sleep hours when is contraindicated, and found unresponsive. Resident 1 was transferred to a general acute care hospital (GACH) on 11/7/18, for a [MEDICAL CONDITION] (emergency in which the heart and breathing stops), and expiring on 11/15/18 (8 days later) due to [MEDICAL CONDITION] (no oxygen) [MEDICAL CONDITION] (brain tissue that is deprived of oxygen causing global loss of brain function) and [MEDICAL CONDITION] (too little oxygen passing from the lungs into the blood). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was admitted to the facility from a GACH (GACH 1) on 11/5/18. Resident 1's [DIAGNOSES REDACTED].), and sudden (unexpected) [MEDICAL CONDITION] (heart function and breathing stops). A review of an undated History and Physical (H/P), indicated Resident 1 had a medical history of [REDACTED]. The H/P indicated that the resident would be monitored closely for any Changes of Condition (C[NAME]), receive appropriate medical support and treatment from the staff, and the staff will notify the physician as needed. On 11/5/18, [MEDICATION NAME] (benzodiazepine used to treat anxiety) 0.5 milligram (mg), was ordered to be given through the [DEVICE] at night (QHS) for anxiety (feeling of worry, nervousness, or unease) as manifested by hyperventilation (fast breathing). On 11/6/18, order change from routine to as needed (PRN) twice a day (BID). A review of the Medication Administration Record [REDACTED]. According to DailyMed, an FDA (Food Drug Administration) approved manufacturing labelling the use of the benzodiazepines such as [MEDICATION NAME] and other CNS depressants, sedative hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, and other opioids, can increase the risk of [MEDICAL CONDITION] (low blood pressure), respiratory depression, profound sedation, coma, and death. A review of a physician's orders [REDACTED]. On 11/26/18 at 10:33 a.m., during a concurrent interview and record review, Registered Nurse 2 (RN 2) stated that Resident 1 received [MEDICATION NAME] 0.5 mg on 11/7/18 at 1:35 a.m., for anxiety as manifested by hyperventilation. RN 2 stated that there was no documentation of non-pharmacological intervention, assessment or vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) taken prior/after the administration of the medication and the hyperventilation. RN 2 stated that the staff members should document according to care plan and physician's orders [REDACTED]. RN 2 stated that Resident 1 would experienced respiratory distress and SOB if the PMV was left on at night. RN 2 confirmed there were no documented vital signs found for 11/6/18 night-shift or any physician's notification. On 12/4/18 at 3:40 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that on 11/7/18, Resident 1 was experiencing anxiety and fast breathing approximately at midnight. LVN 1 stated that Resident 1's heart rate was 90 beats per minute, respirations 23-24 breaths per minute (normal reference range (NRR) 60-100 bpm),oxygen saturation (measure of how much oxygen the blood is carrying) was 98 percent (% (NRR) 96-100%). LVN 1 stated that the resident was moving his arms anxiously, and she administered the [MEDICATION NAME] 05 mg via [DEVICE] to help the resident's anxiety. On 12/17/18 at 5:13 p.m., during a concurrent interview and record review, the DON stated that there was no care plan created for the use of the PMV or the administration of [MEDICATION NAME] side effects to be monitored by staff. The DON stated that a care plan should had been initiated upon the initiation of the medication and the PMV. The DON stated that there was also no documentation of the resident being monitored during the use of the PMV on the clinical chart, or RT 2's documentation of vital signs and removal of the PMV on 11/6/18. There was no evidence that a plan of care was created to address these concerns. A review of the PMV manufactures guide indicated under warning, Do not use with residents who have unmanageable [MEDICAL CONDITION] secretions. Do not use while sleeping .contraindicated on residents with severe airway obstruction, thick and copious secretions .the PMV was recommended for resident that are cognitive, awake, and responsive and should not be use while the resident is sleeping .resident assessment should include vital signs, O2 saturation, resident reaction, airway patency, and breath sounds . residents with thick unmanageable secretions that may cause airway obstruction should be carefully evaluated for the use of the PMV. A review of the facility's policy and procedures (P/P) titled, Care Plans-Comprehensive, revised 9/2010, indicated that the facility developed and maintained a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The P/P indicated that each resident's care plan was designed to identify areas of concerns, incorporate risk factors, identify the professional services that were responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to follow its policy and procedures and a resident's plan of care to ensure when a resident had a change of condition (C[NAME]), that a physician was immediately notified for one of three sampled residents (Resident 1). Resident 1, who was experiencing episodes of anxiety, thick mucus secretions, and rhonchi lung sounds on [DATE] and [DATE], the licensed nurse did not notify the resident's physician, as per policy and plan of care. (Cross-Referenced to F695). This deficient practice resulted in a delay of provision of care for Resident 1 and requiring a transfer to a general acute care hospital (GACH) unresponsive (unable to wake up). Resident 1 was transferred to a GACH on [DATE], after having a C[NAME] of a [MEDICAL CONDITION] (emergency in which the heart and breathing stops), and expiring (death) on [DATE] (8 days after) due to [MEDICAL CONDITION] (no oxygen) [MEDICAL CONDITION] (brain tissue that is deprived of oxygen causing global loss of brain function) and [MEDICAL CONDITION] (too little oxygen passing from the lungs into the blood). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED].), and sudden (unexpected) [MEDICAL CONDITION] (heart function and breathing stops). A review of an undated History and Physical (H/P), indicated Resident 1had a medical history of [REDACTED]. The H/P indicated that the resident would be monitored closely for any Changes of Condition (C[NAME]), receive appropriate medical support and treatment from the staff, and the staff will notify the physician as needed. A review of Resident 1's care plan titled, [MEDICAL CONDITION] related to Impaired Breathing Mechanism, dated [DATE] indicated that the goal of the facility was for Resident 1 to have clear and equal breath sounds bilaterally (both sides). The staff interventions included to monitor and document for restlessness, agitation, confusion, increased in heart rate, respiratory rate, depth and quality, and reassure resident to decrease anxiety. The care plan indicated that the staff would call the physician if any of the symptoms were present. A review of a physician's orders [REDACTED]. -Monitor pulse rate after the [MEDICATION NAME] breathing treatment every six (Q6) hours. -Suction the [MEDICAL CONDITION]/mouth/nose Q2 hours and PRN. -Monitor for anxiety as manifested by hyperventilation Q shift. A review of a Respiratory Therapist (RT) Progress Note, dated [DATE] and timed at 1:14 a.m., indicated Resident 1's inner cannula (neck plate that extends from the sides of the outer [MEDICAL CONDITION] and has holes that attach to the velcro strap around the neck) was changed twice during the night shift, due to plugging, excessive yellowish and red thick secretions, and the PMV was removed for the night. A review of RT 1's progress note, dated [DATE] and timed at 4:41 p.m., indicated that Resident 1 PMV was placed at 9 a.m., on the same day. The progress note indicated Resident 1was receiving two (2) liters of oxygen via T-mask, had bilateral rhonchi (abnormal lung sounds that sound like snoring and were caused by secretions or obstruction in the airways and lungs) lung sounds, and moderate amount of thick/yellow secretion was suctioned. There was no documentation that the physician was notified of the rhonchi, if the PMV was removed at nighttime and when the resident was producing thick secretions. A review of a physician order, dated [DATE] and timed at 6:02 a.m., indicated to transfer Resident 1 to the GACH 2 via 911 paramedics (emergency response team) due to the resident being unresponsive. A review of the H/P from GACH 2 indicated Resident 1 presented on [DATE] in [MEDICAL CONDITION] (an emergency situation in which the heart stops) with no pulse and 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 [MEDICAL CONDITION]) initiated and regained a heartbeat after 44 minutes of CPR. Resident 1 remained comatose (state of deep unconsciousness for a prolonged or indefinite period because of severe injury) with a poor prognosis. The H/P indicated Resident 1 was down for 30 minutes in the nursing home prior to arrival to the ED, the patient has a respiratory arrest followed by [MEDICAL CONDITION] (low heart rate) due to possible mucus plug in the [MEDICAL CONDITION] site. The ED note indicated an electroencephalogram (test that records brain activity) was done on [DATE] that indicated Resident 1 suffered severe [MEDICAL CONDITION] after not receiving oxygen to the brain for a long period of time. A review of Resident 1's Certificate of Death indicated the resident's date of death was [DATE] at 2:04 p.m., with the immediate cause being [MEDICAL CONDITIONS] and [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). On [DATE] at 10:33 a.m., during a concurrent interview and record review, Registered Nurse 2 (RN 2) stated that Resident 1 received [MEDICATION NAME] 0.5 mg on [DATE] at 1:35 a.m., for anxiety as manifested by hyperventilation. RN 2 stated that there was no documentation of any non-pharmacological intervention, assessment or vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) taken prior/after the administration of the medication and the hyperventilation. No documented vital signs were found for [DATE] night shift or physician notification. On [DATE] at 3:40 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that on [DATE], Resident 1 was experiencing anxiety and fast breathing approximately at midnight. LVN 1 stated that Resident 1's heart rate was 90 beats per minute, respirations ,[DATE] breaths per minute (normal reference range (NRR) ,[DATE] bpm),oxygen saturation (measure of how much oxygen the blood is carrying) was 98 percent (% (NRR) ,[DATE]%). LVN 1 stated that the resident was moving his arms anxiously, and she administered [MEDICATION NAME] 05 mg via [DEVICE] to help the resident's anxiety. On [DATE] at 7:07 p.m., during a concurrent interview and record review, RT 2 stated that on [DATE] approximately midnight, he was called to Resident 1's room by LVN 1 to assess the resident's anxiety. RT 2 stated Resident 1, Looked weird, with anxiety, but no SOB. RT 2 stated that he forgot to document the initial vital signs for [DATE], when he started his shift as indicated in the orders, but document the removal time of the PMV on the same day. On [DATE] at 4:43 p.m., during review of Resident 1's health record and concurrent interview, the Director of Nursing (DON) stated the physician was not notified that the resident had rhonchi because is considered a C[NAME]. The DON stated that she was aware of Resident 1's GACH record from [DATE] since she reviewed the record prior to the admission. DON stated that staff should be documenting medication administration, assessments and C[NAME]'s in resident's clinical record, and notify the physician of any C[NAME]'s as soon as possible. On [DATE] at 4:59 p.m., during a telephone interview, Resident 1's physician stated that he was not made aware of the resident's C[NAME] or of the secretions found during suctioning of the trach. The physician stated that he gave orders to call him if the resident (Resident 1) experienced a C[NAME]. A review of the facility's policy and procedures titled, Change in a Resident's Condition or Status, revised on ,[DATE], indicated that the facility supervisor/charge nurse would notify the resident's physician or on-call physician when the resident has a significant change in physical/mental/or emotional condition. The P/P indicated that a significant C[NAME] was a decline or improvement in the residents' health status and notify the physician.

Based on interview and record review, the facility failed to follow its policy regarding providing care and services, follow the physician's orders to monitor closely any changes in condition (C[NAME]), notify the physician of resident's C[NAME], develop a plan of care for the use of the Passy-Muir Valve ((PMV) valve that redirects air flow through the vocal folds, mouth and nose enabling voice and improved communication and swallowing), and follow the manufactures recommendations/contraindications for the use of a PMV on residents with thick and copious (abundant in quantity), as well as leaving on when residents are sleeping for one of three sample residents (Resident 1). Resident 1, had history of [MEDICAL CONDITION] (not enough oxygen passing from the lungs to blood causing low oxygen levels in the blood and carbon [MEDICATION NAME] levels accumulate in the blood), and was admitted with a [MEDICAL CONDITION] (a surgically created hole through the front of the neck and into the breathing tube that leads to the lungs), mask ((T-mask), mask placed over [MEDICAL CONDITION]), and a PMV (crossed reference to F580). These deficient practices resulted in the staff not adhering to the manufactures guidelines of the use of the PMV, for Resident 1, who had large amounts of secretions and left-in on while the resident slept. Resident 1 was found unresponsive (not responsive) and was transferred to a general acute care hospital (GACH) on [DATE] for [MEDICAL CONDITION] (emergency in which the heart and breathing stops), and expiring (death) on [DATE] (8 days later) due to [MEDICAL CONDITION] (no oxygen) [MEDICAL CONDITION] (brain tissue that is deprived of oxygen causing global loss of brain function) and [MEDICAL CONDITION] (too little oxygen passing from the lungs into the blood). Findings: A review of GACH 1's progress note, dated [DATE] and timed at 2:03 a.m., indicated under assessment and plan that the resident's toxic (poisonous) [MEDICAL CONDITION] related to sedatives (drug taken for its calming or sleep-inducing effect) and central nervous system ((CNS) composed of the brain and the spinal cord that controls the resident's thoughts, interprets external environment, and control over body movement) affecting agents (thing producing an effect) was resolved. The progress note indicated that Resident 1's physician and neurologist (specialist in the anatomy, functions, and organic disorders of nerves and the nervous system), recommended to not start Resident 1 on sedatives, benzodiazepines (tranquilizer) or use antipsychotics (treats [MEDICAL CONDITION] effects). A review of the Discharge Summary from GACH 1, dated [DATE], indicated Resident 1's discharge [DIAGNOSES REDACTED]. The discharge summary indicated Resident 1 had a prolonged hospital stay and prolonged intensive care unit ((ICU), a special unit of a hospital that provides intensive treatment medicine) stay from altered (change) mental status (ability think and reason), [MEDICAL CONDITION], failed swallowing test due to large amounts of secretions (process of releasing saliva) and two episodes of unresponsiveness. A review of Resident 1's Admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED].), and sudden (unexpected) [MEDICAL CONDITION] (heart function and breathing stops). A review of an undated History and Physical (H/P), indicated Resident 1had a medical history of [REDACTED]. The H/P indicated that the resident would be monitored closely for any Changes of Condition (C[NAME]), receive appropriate medical support and treatment from the staff, and the staff will notify the physician as needed. A review of a care plan titled,[MEDICAL CONDITION] Change: The Resident is at risk for Respiratory Distress and/or Bleeding Secondary [MEDICAL CONDITION] and Currently Red with Suctioning of the Trach, dated [DATE] indicated that Resident 1's goal was to not experience respiratory distress in the next 72 hours. The staffs' interventions included to monitor the resident for shortness of breath, irregular respirations, rales, wheezing, sweating,[MEDICAL CONDITION] redness, swelling, and discharge. According to the plan of care, the staff would call the physician if any of the symptoms were present. A review of the Physician's Order Summary Report, active orders as of [DATE], indicated the following orders for Resident 1's: On [DATE] [MEDICATION NAME] (benzodiazepine used to treat anxiety) 0.5 milligram (mg), through the [DEVICE] at night (QHS) for anxiety (feeling of worry, nervousness, or unease) as manifested by hyperventilation (fast breathing). On [DATE], order change from routine to as needed (PRN) twice a day (BID). A review of the Medication Administration Record [REDACTED]. According to DailyMed, an FDA (Food Drug Administration) approved manufacturing labelling indicated that the use of the benzodiazepines such as [MEDICATION NAME] and other CNS depressants, sedative hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, and other opioids, can increase the risk of [MEDICAL CONDITION] (low blood pressure), respiratory depression, profound sedation, coma, and death. On [DATE] an order for [REDACTED]. A review of the Medication Administration Record [REDACTED]. According to the National Heart, Lung, and Blood Institute (NHLBI), (undated) signs and symptoms of [MEDICAL CONDITION] may include shortness of breath, air hunger (feeling like you can't breathe enough air), bluish color on the skin, and confusion. THE NHLBI indicated the main goals of treating [MEDICAL CONDITION] was to get oxygen to the lungs and organs and to remove carbon [MEDICATION NAME] from the body, and to treat the underlying cause of the condition. According to the NHLBI, the doctor would need to change or adjust treatments to relieve and treat symptoms, and it was important to seek emergency care for severe symptoms. https://www.nhlbi.nih.gov/health-topics/respiratory-failure A review of a physician's order, dated [DATE] indicated the following respiratory orders for Resident 1: -Monitor pulse rate after the [MEDICATION NAME] breathing treatment every six (Q6) hours. -Suction the [MEDICAL CONDITION]/mouth/nose Q2 hours and PRN. -Monitor for anxiety as manifested by hyperventilation Q shift. A review of a physician's order, dated [DATE] and timed at 9:36 a.m., indicated for Resident 1 to receive speech therapy (ST) five times a week for four weeks for dysphagia and speech/voice management. Use the PMV as appropriate. A review of the ST evaluation, dated [DATE] indicated that Resident 1 had reduced swallowing function and reflex (action that was performed as a response to a stimulus and without conscious thought). The ST recommendations indicated to keep the resident with nothing by mouth (NPO) due to aspiration (inhaling food into the airway). A review of a Respiratory Therapist (RT) Progress Note, dated [DATE] and timed at 1:14 a.m., indicated Resident 1's inner cannula (neck plate that extends from the sides of the outer [MEDICAL CONDITION] and has holes that attach to the velcro strap around the neck) was changed twice during the night shift, due to plugging, excessive yellowish and red thick secretions, and the PMV was removed for the night. A review of RT 1's progress note, dated [DATE] and timed at 4:41 p.m., indicated that Resident 1 PMV was placed at 9 a.m., on the same day. The progress note indicated Resident 1was receiving two (2) liters of oxygen via T-mask, had bilateral rhonchi (abnormal lung sounds that sound like snoring and were caused by secretions or obstruction in the airways and lungs) lung sounds, and moderate amount of thick/yellow secretion was suctioned. There was no documentation that the physician was notified of the rhonchi, if the PMV was removed at nighttime and when the resident was producing thick secretions. A review of a physician order, dated [DATE] and timed at 6:02 a.m., indicated to transfer Resident 1 to the GACH 2 via 911 paramedics (emergency response team) due to the resident being unresponsive. A review of a Discharge Summary, dated [DATE], indicated Resident 1 was discharged to GACH 2 after being unresponsive. A review of the paramedic's Prehospital Care Report Summary, dated [DATE] indicated estimated time of [MEDICAL CONDITION] was at 3:32 a.m., paramedics called was at 4:03 a.m., arrived at 4:09 a.m., made contact with Resident 1 at 4:12 a.m. the paramedics report indicated at 4:19 a.m., Resident 1 had no blood pressure, heart beat, or respirations. The summary indicated Resident 1 was unresponsive and apneic (absence of breathing), and chest compressions were initiated by the facility staff and continued by the paramedics upon arrival. A review of the H/P from GACH 2 indicated Resident 1 presented on [DATE] in [MEDICAL CONDITION] (an emergency situation in which the heart stops) with no pulse and 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 [MEDICAL CONDITION]) initiated and regained a heartbeat after 44 minutes of CPR. Resident 1 remained comatose (state of deep unconsciousness for a prolonged or indefinite period because of severe injury) with a poor prognosis. The H/P indicated Resident 1 was down for 30 minutes in the nursing home prior to arrival to the ED, the patient has a respiratory arrest followed by [MEDICAL CONDITION] (low heart rate) due to possible mucus plug in the [MEDICAL CONDITION] site. The ED note indicated an electroencephalogram (test that records brain activity) was done on [DATE] that indicated Resident 1 suffered severe [MEDICAL CONDITION] after not receiving oxygen to the brain for a long period of time. A review of Resident 1's Certificate of Death indicated the resident's date of death was [DATE] at 2:04 p.m., with the immediate cause being [MEDICAL CONDITIONS] and [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). On [DATE] at 9:55 a.m., during an interview, Resident 1's family member (FM1) stated that the family was planning of disconnecting the resident from life support after being informed that Resident 1 had no brain activity. On [DATE] at 10:55 a.m., during an observation in the GACH 2, Resident 1 was observed in bed, with eyes closed, chest tube on the left lateral side for the pneumothorax (presence of air in the cavity between the lungs and the chest wall), an urinary catheter (flexible plastic tube (a catheter) inserted into the bladder that remains (dwells) there to provide continuous urinary drainage), [MEDICATION NAME] (strong pain medication) drip machine (terminal sedation pump connected to the vein), and oxygen at 6 liters, and skin pale in color. On [DATE] at 10:55 a.m., during the concurrent interview, FM2 stated that on [DATE] at approximately 9 p.m., they informed facility staff they were leaving and to please removed the speech valve (PMV). FM2 stated that Resident 1 was recovering from a stroke ([MEDICAL CONDITION]) and was able to recognize family, able to move arms, communicate, and able to stand up with physical assistance. A review of Resident 1's video with FM2 showed Resident 1 alert, able to verbalized family members names with the use of the PMV, and wanting to go home after recovery to have breakfast with his family. On [DATE] at 10:33 a.m., during a concurrent interview and record review, Registered Nurse 2 (RN 2) stated that Resident 1 received [MEDICATION NAME] 0.5 mg on [DATE] at 1:35 a.m., for anxiety as manifested by hyperventilation. RN 2 stated that there was no documentation of non-pharmacological intervention, assessment or vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) taken prior/after the administration of the medication and the hyperventilation. RN 2 stated that staff members needed to document according to care plan and orders in the residents clinical chart. RN 2 stated that Resident 1 would had experienced respiratory distress and SOB if the PMV was left on at night. No documented vital signs were found for [DATE] night shift or physician notification. On [DATE] at 11:17 a.m., during a concurrent interview and record review, Speech Therapist (ST) stated that on [DATE] the Respiratory Therapist 1 (RT 1) suctioned the resident'[MEDICAL CONDITION] placed the PMV on for evaluation. The ST stated that it was not recommended to leave the PMV on due to the risk of sputum being stuck in the valve and blocking the airway. On [DATE] at 12:36 p.m., during a concurrent interview and record review, RT 1 stated that she was aware of the contraindication of the use of the PMV as indicated on the PMV's manufactures guide. On [DATE] at 3:40 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that on [DATE], Resident 1 was experiencing anxiety and fast breathing approximately at midnight. LVN 1 stated that Resident 1's heart rate was 90 beats per minute, respirations ,[DATE] breaths per minute (normal reference range (NRR) ,[DATE] bpm),oxygen saturation (measure of how much oxygen the blood is carrying) was 98 percent (% (NRR) ,[DATE]%). LVN 1 stated that the resident was moving his arms anxiously, and she administered [MEDICATION NAME] 05 mg via [DEVICE] to help the resident's anxiety. On [DATE] at 7:07 p.m., during a concurrent interview and record review, RT 2 stated that on [DATE] approximately midnight, he was called to Resident 1's room by LVN 1 to assess the resident's anxiety. RT 2 stated Resident 1, Looked weird, with anxiety, but not SOB. RT 2 stated that he forgot to document the initial vital signs for [DATE], when he started his shift as indicated in the orders, but document the removal time of the PMV on the same day. At 7:32 a.m., on [DATE] during a concurrent interview and record review, RN 3 stated that the documentation of treatments and care need to be completed by the staff providing the care as soon as it was provided. On [DATE] at 4:43 p.m., during review of Resident 1's health record and concurrent interview, the Director of Nursing (DON) stated the physician was not notified that the resident had rhonchi because is considered a C[NAME]. The DON stated that she was aware of Resident 1's GACH record from [DATE] since she reviewed the record prior to the admission. DON stated that staff should be documenting medication administration, assessments and C[NAME]'s in resident's clinical record, and notify the physician of any C[NAME]'s as soon as possible. At 4:55 p.m., on [DATE], during a concurrent interview and record review, in the presence of the DON, RT 4 stated that it was not recommended to use the PMV on residents experiencing large thick secretions or during sleeping hours. RT 4 stated that the recommendations were written in the PMV manufactures guides. On [DATE] at 4:59 p.m., during a telephone interview, Resident 1's physician stated that he was not made aware of the resident's C[NAME] or of the secretions found during suctioning of the trach. The physician stated that he gave orders to call him if the resident (Resident 1) experienced a C[NAME]. On [DATE] at 5:13 p.m., during a concurrent interview and record review, the DON stated that there was no care plan created for the use of the PMV or the administration of [MEDICATION NAME] side effects to be monitored by staff. The DON stated that a care plan should had been initiated upon the initiation of the medication and the PMV. The DON stated that there was no documentation of the monitoring of resident during the use of the PMV on the clinical chart, or RT 2's documentation of vital signs and removal of the PMV on [DATE]. A review of the PMV manufactures guide indicated under warning, Do not use with residents who have unmanageable [MEDICAL CONDITION] secretions. Do not use while sleeping .contraindicated on residents with severe airway obstruction, thick and copious secretions .the PMV was recommended for resident that are cognitive, awake, and responsive and should not be use while the resident is sleeping .resident assessment should include vital signs, O2 saturation, resident reaction, airway patency, and breath sounds . residents with thick unmanageable secretions that may cause airway obstruction should be carefully evaluated for the use of the PMV. A review of the facility's policy and procedure (P/P) titled, Suctioning the Lower Airway, revised on ,[DATE] indicated that the purpose of suctioning was to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract. The P/P indicated that dysphagia (difficulty swallowing) was a risk factor for impaired airway clearance or aspiration. The policy indicated to assess signs and symptoms such as diminished breath sounds, gurgling, wheezing sounds and restlessness. The P/P indicated that documentation of suctioning should recorded in the residents clinical chart and include date and time, size of catheter, amount, color and characteristics of secretions, the assessment before and after procedure, and the name and signature of person performing the procedure. A review of the facility's P/P titled, Resident Examination an Assessment, revised ,[DATE] indicated that the facility staff would assess the resident to any abnormalities in health status, which provided a basis for the care plan. The physical exam included lung sounds for wheezing, rales, rhonchi or crackles, cough, consistency and color of sputum. The P/P indicated that the information attain during the assessment would be recorded in the resident's medical record with the date, time and signature and tile of the staff performing the assessment.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to provide the necessary supervision for one of three sampled residents (Resident 1). Resident 1, who had dementia (thinking and social symptoms that interferes with daily functioning) and a history of wandering into other resident's room, required close supervision (Cross referenced to F[AGE]0). This deficient practice resulted in Resident 1 wandering unsupervised in another resident's room and being physically and verbally abused by a visitor (Visitor 1). Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 12/26/17, indicated Brief Interview for Mental Status (BI[CONDITION]) score was 00 (0-7 = severe impairment (thought process) skills). The MDS indicated Resident 1 required limited assistance of a one-person physical assist for ambulation in the corridors. A review of Resident 1's Elopement (to scape) Risk Assessment, dated 3/20/18, indicated Resident 1 was at High Risk for elopement. A review of a care plan titled, At Risk for Elopement/Wandering Related to Cognitive Loss, Impaired Decision Making, Wanders around Facility, initiated on 12/23/17, indicated that the staff would do frequent visual checks of Resident 1's whereabouts. A review of the Nurses' Note, dated [DATE], and timed at 11:20 p.m., indicated that a visitor (Visitor 1), at the facility was seen exiting a room holding Resident 1 by the hair and shirt. A review of a Nurses' Note, dated 4/8/18, and timed at 3:03 a.m., indicated Resident 1 was being monitor for skin discoloration after the incident related to being physical assaulted by a visitor on [DATE] inside a residents' room. On 4/10/18 at 11:20 a.m., during an interview, Resident 2 stated that Resident 1 wanders around the facility and goes into other resident's rooms. On 4/10/18 at 1:45 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated that Resident 1 needed constant monitoring, because the resident liked to go inside other residents' rooms. In the presence of CNA 1, Resident 1 stated that she remembered being grabbed by the neck, but did not remember why. On 4/10/18 at 2:20 p.m., during a telephone interview, Visitor 1 stated that Resident 1 goes into other resident's rooms constantly and she had observed Resident 1 hitting other residents. Visitor 1 stated that on [DATE] at 6:30 p.m., Resident 1 entered her family members' room and attempted to grab Visitor 1 by one hand and to slap her. Visitor 1 stated that she grabbed Resident 1 by the neck and pushed her out a room. Visitor 1 stated that upon walking outside the room with Resident 1, she informed Licensed Vocational Nurse 1 (LVN 1) that Resident 1 had slapped her on the face. The visitor stated she also called Resident 1 a B---h because the resident was always causing trouble and wandering around the facility unsupervised. On 4/10/18 at 2:44 p.m., during a telephone interview, Registered Nurse 1 (RN 1) stated that LVN 1 reported to her that he saw Visitor 1 coming out of a room holding Resident 1 by the hair and yelling at the resident. RN 1 stated that Resident 1 wanders around the facility and likes to go into other resident's room, but has not observed Resident 1 ever being aggressive towards others. At 2:55 p.m., during a telephone interview, LVN 1 stated that while sitting at the subacute nurses' station, he overheard Visitor 1 asking for help. LVN 1 stated that he observed Visitor 1 grabbing Resident 1 from behind by the hair and the shirt pushing Resident 1 out of the room. LVN 1 stated that the visitor pushed Resident 1 towards him while both the resident and Visitor 1 exchanging curse words B---h. LVN 1 stated that the visitor grabbed and pushed Resident 1 when visitor saw the resident approaching her. LVN 1 stated Resident 1 was not aggressive, but does wander into resident's room and the staff have to redirect her when they see her. On 4/10/18 at 4:30 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that they have implemented monitoring for Resident 1's wandering behavior, but the facility was not able to afford one-to-one monitoring. The DON stated that Resident 1's wandering behavior could place her at risk for injury. On 6/14/18 at 4:40 p.m., during a telephone interview, RN 3 stated that Resident 1 becomes agitated when another person grabs her. RN 3 stated that Resident 1 was not aggressive unless she was grabbed. A review of the facility's policy and procedure titled, Safety and Supervision of Resident, revised 7/2017, indicated the resident's safety need for supervision and assistance to prevent accidents were a facility-wide priority. The policy also indicated that the staff would ensure that the resident's care plan interventions were implemented correctly and consistently.

Based on interview and record review, the facility failed to follow its policy and residents' plan of care to protect one of three sampled residents (Resident 1) from been physically and verbally abused. This deficient practice resulted in Resident 1 sustaining skin discoloration to the head after been grabbed by the neck and hair by a facility's visitor (Visitor 1). Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 12/26/17, indicated Brief Interview for Mental Status (BI[CONDITION]) score was 00 (0-7 = severe impairment (thought process) skills). The MDS indicated Resident 1 required limited assistance of a one-person physical assist for ambulation in the corridors. A review of the Nurses' Note, dated [DATE], and created at 11:20 p.m., indicated that a visitor, at the facility was seen exiting a room holding Resident 1 by the hair and shirt. A review of the Nurses' Note, dated 4/8/18, and timed at 3:03 a.m., indicated Resident 1 was being monitor for head discoloration after the incident related to being assaulted by a visitor on [DATE]. On 4/10/18 at 11:20 a.m., during an interview, Resident 2 stated that Resident 1 wanders around the facility and goes into other resident's rooms. A review of a care plan titled, At Risk for Elopement/Wandering Related to Cognitive Loss, Impaired Decision Making, Wanders around Facility, initiated on 12/23/17, indicated that the staff would do frequent visual checks of Resident 1's whereabouts. On 4/10/18 at 1:45 p.m., during an interview and in the presence of Certified Nurse Assistant 1 (CNA 1), Resident 1 stated that she remembered been grabbed by the neck but did not remember why. On 4/10/18 at 2:20 p.m., during a telephone conversation, Visitor 1 stated that on [DATE] at 6:30 p.m., Resident 1 entered her family members' room and attempted to grab her by one hand and to slap her. The visitor stated that she grabbed Resident 1 by the neck and pushed her out from a room. The visitor stated that upon walking out of the room with Resident 1, she notified Licensed Vocational Nurse 1 (LVN 1) that Resident 1 had slapped her on the face. Visitor 1 stated she also called Resident 1 B---h because the resident was always causing trouble and wandering around the facility unsupervised. On 4/10/18 at 2:44 p.m., during a telephone interview, Registered Nurse 1 (RN 1) stated that LVN 1 reported to her that he saw a visitor coming out of a room holding Resident 1 by the hair and yelling at the resident. On 4/10/18 at 2:55 p.m., during a telephone interview, LVN 1 stated that while charting at the subacute nurses station, he overheard someone asking for help. LVN 1 stated that he observed a visitor grabbing Resident 1 from behind by the hair and the shirt pushing Resident 1 out of the room. LVN 1 stated that the visitor pushed Resident 1 towards him when both the resident and visitor exchanged curse words B---h. LVN 1 stated Resident 1 wanders into resident's room and the staff has to redirect her when they see her. On 4/10/18 at 4:30 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that they have implemented plan for monitoring Resident 1's wandering behavior, but the facility was not able to afford a one-to-one monitoring. The DON stated that Resident 1's wandering behavior could place her at risk for injury. A review of the facility's policy titled, Abuse Prevention Program, revised on 8/2006, indicated that the facility was committed to protect the residents from abuse by anyone including, but limited to the facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individuals.

Based on interview and record review, the facility failed to ensure the necessary care and services were provided for wound care, which included wound identification, monitoring, accurately documenting, following physician's orders [REDACTED]. Resident 1 who had a [DIAGNOSES REDACTED]. These deficient practices resulted in Resident 1 having a left toe wound that worsened, requiring a transfer to a general acute care hospital (GACH) and diagnosed with [REDACTED]. Resident 1 underwent surgery of a left second toe amputation (surgical removal). Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 7/25/17, indicated the resident had impaired cognition (ability to think and reason). The MDS indicated Resident 1 required total assistance of a two-person physical assist for bed mobility, transferring, and personal hygiene. A review of Resident 1's Podiatric Evaluation and Treatment form, dated 2/21/17, 4/24/17, and 6/26/17, indicated the resident had absent bilateral posterior tibial (pulse located near both ankles) pulses and the temperature of the resident's feet were cool. The evaluation indicated Resident 1 had [MEDICAL CONDITION]. A review of Resident 1's Podiatric Evaluation and Treatment form, dated 8/2/17, indicated the resident had an open area on the dorsal (back side) left second toe at the proximal (center location) interphalangeal (bones in the finger or toe) joint down through the dermal (tissue under the skin) layer that was one centimeter (cm) by 0.8 cm in size. The form indicated the open wound of the left second toe had red granulation tissue (new tissue on the surface of a wound) along the edges with a dark scab like area in the central area. The evaluation indicated Resident 1's both posterior tibial pulses were absent (a pulse located on the foot that could be felt to assess for circulation) and the temperature of the resident's feet were cool. The evaluation indicated to refer Resident 1 to a wound specialist for management of the left foot wounds. A review of Resident 1's nurse practitioner note, dated 8/16/17, indicated the resident had an open wound to the dorsal (backside) left second toe with [MEDICAL CONDITION]. A review of Resident 1's Wound Documentation Sheet, initiated on 8/2/17 by the nursing staff, indicated the resident had a black scab on the left second toe that was two (2) centimeters by 2 centimeters (cm) in size. The wound document indicated Resident 1's wound on the left second toe was documented to be moist and without signs and symptoms of infection for the following days: 8/9/17, 8/16/17, 8/23/17, 8/30/17, 9/7/17, 9/14/17, 9/21/17, 9/25/17, 10/5/17, 10/12/17, and 10/19/17. The sheet indicated on 10/26/17, seven days after the staff documented no signs of infection, Resident 1's left second toe was amputated. A review of Resident 1's Change of Condition note, dated 9/19/17, indicated a change of condition of the resident's left second toe that was a non-healing open wound. A review of Resident 1's nurse's progress notes, ranged from 9/20/17 to 10/4/17, the resident's left second toe wound was a non-healing wound. A review of Resident 1's Podiatric Evaluation and Treatment form, dated 10/4/17, indicated the resident left second toe had yellow slough (dead tissue that was yellow in color). The evaluation indicated Resident 1's left second toe wound was increasing in size and not improving, with a recommendation to refer Resident 1 for a follow-up with a wound specialist for management of the wound. A review of Resident 1's Wound Care Note, dated 10/5/17, indicated the resident's wound at the left foot second toe with the joint exposed was necrotic (dead tissue) with drainage and pain. The note indicated to follow up with a podiatric or an orthopedic surgeon for an amputation. A review of a physician's orders [REDACTED]. A review of Resident 1's Transfer Record form, dated 10/19/17, indicated the resident was transferred to the GACH for further evaluation of the left foot wound. A review of Resident 1's nurse's progress note, dated 10/19/17 and timed at 7:19 p.m., the resident left the facility. A review of Resident 1's GACH Admission Record indicated the resident was seen in the emergency department on 10/19/17 and admitted to the hospital on [DATE] for left second toe osteo[DIAGNOSES REDACTED] (an infection of bone). A review of Resident 1's emergency department (ED) note, dated 10/19/17, indicated the resident was complaining of left toe pain and the left toe was getting worse with drainage and discoloration. The ED note indicated Resident 1's left second toe had exposed bone with purulent drainage (pus). A review of Resident 1's GACH's History and Physical (H/P), dated 10/20/17, indicated the resident presented with worsening infected foot ulcer of the left second toe with notable exposure of the bone and with pain and tenderness. The H/P indicated Resident 1 [MEDICAL CONDITION] (life-threatening complication of an infection) with an elevated white blood count (elevated when the body was fighting an infection) and [MEDICAL CONDITION](fast heart rate). According to the H/P, Resident 1 was started on antibiotics for the infected toe ulcer [MEDICAL CONDITION]. A review of Resident 1's GACH's wound culture results of the left second toe, dated 10/20/17 indicated it was positive for two different bacteria. A review of the GACH's operative invasive report, dated 10/20/17, indicated Resident 1 had a left second toe amputation. The report also indicated Resident 1's left second toe wound was dirty and contaminated and classified as a Stage IV pressure ulcer (a wound caused by prolonged pressure that progressed to exposing muscle, tendon, and bone) with bone exposure. A review of Resident 1's hospital discharge summary, dated 10/21/17, indicated the resident's discharge [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. On 12/5/17 at 2 p.m., during a concurrent interview and record review of Resident 1's wound evaluation flow sheet initiated on 5/2017, a treatment nurse (Licensed Vocational Nurse (LVN ) 1) stated the resident had a deep tissue pressure injury ((DTPI), injury of intact skin that had a persistent red or purple discoloration and was caused by prolonged pressure to site) of the left second toe that resolved on 6/9/17. LVN 1 stated the wound was assessed as a black scab that was 2 centimeters (cm) by 2 cm in size on 8/2/17. LVN 1 stated the black scab was a previous wound from poor circulation. LVN 1 stated there should have been previous assessments of the resident's wound prior to the 8/2/17 assessment. LVN 1 stated there were no assessment and/or treatment of [REDACTED]. LVN 1 stated Resident 1's left second toe black scab was assessed for size and described as a moist and without signs and symptoms of infection on the following dates: 8/9/17, 8/16/17, 8/23/17, 8/30/17, 9/7/17, 9/14/17, 9/21/17, 9/25/17, 10/5/17, 10/12/17, and 10/19/17. LVN 1 stated the wound evaluation sheet did not reflect a complete comprehensive assessment that included the left second toe and changes with as the joint being exposed and the presence of necrosis (black colored dead tissue). LVN 1 stated a skin wound assessment should have included monitoring for changes of condition such as size of wound, signs and symptoms of infection, and presence of drainage, odor, and bleeding. LVN 1 stated a comprehensive skin assessment was important to reflect what was actually happening to the resident's wound so that the appropriate medication, treatment, and care would be determined for the resident. During the ongoing interview and record review, on 12/5/17 at 2 p.m., LVN 1 stated the podiatrist recommended a referral for a wound specialist to manage Resident 1's left foot wounds, but there was a delay, as the wound specialist first evaluated the resident on 10/5/17 (two months after the recommendation on 8/2/17). The wound specialist recommended amputation of the resident's left second toe. LVN 1 stated the wound specialist should have been immediately involved in the management of Resident 1's left second toe wound prior to 10/5/17. LVN 1 stated the facility's protocol was to immediately carry out podiatry's recommendation for a referral of the wound specialist so that the facility could provide the necessary care and treatment. On 12/11/17 at 3:10 p.m., during a telephone interview, the Director of Nursing (DON) stated the cause of Resident 1's left second toe wound was unknown. The DON stated if Resident 1's left second toe wound was initially a DTPI then it may have reopened and developed into a black scab. The DON stated there should have been an assessment of the left second toe wound before it became a black scab on 8/2/17 and the certified nurse assistants were responsible for performing body and skin checks every shift and reporting to the charge nurse for changes of the skin. The DON stated the treatment nurse was responsible for performing a comprehensive skin assessment and notifying the physician of the wound and the changes of the wound to obtain treatment orders. The DON stated a comprehensive skin assessment involved assessing for the location of the wound, color, bone exposure, the presence and characteristics of discharge, pain and tenderness, and/or necrotic tissue. The DON stated the importance of a performing a comprehensive and accurate skin wound assessment was so that the physician would know the condition of the resident's wound and provide orders for appropriate treatment and intervention for the resident. On 12/22/27 at 3:10 p.m., during a telephone interview, the DON stated the purpose of a care plan was to address a resident care problem with a plan of treatment that included the facility's interventions to manage the resident's care problem. The DON stated if the interventions were not effective in addressing the resident's care problem then the care plan should have been revised. The DON stated Resident 1 should have had a care plan that addressed the resident's history of [MEDICAL CONDITION]. DON stated a care plan to address [MEDICAL CONDITION] should include interventions such as: monitor for pain; monitor for changes in the color of skin; assess pulses; assess for gangrene (death of body tissue due to a lack of blood flow); monitor for non-healing wounds; and assess for circulation. On 12/28/17 at 1 p.m., during a telephone interview, the Registered Nurse (RN 1) stated when the podiatrist made recommendations to refer Resident 1 to a wound specialist, an RN should have followed up immediately by notifying the physician and obtaining a physician's orders [REDACTED]. RN 1 stated after a physician order [REDACTED]. On 1/2/18 at 3:12 p.m., during a telephone interview, the Director of Nursing (DON) stated that any staff, such as a registered nurse or licensed vocational nurse, should have acted on the podiatrist's recommendations for the wound care referral within 72 hours. The DON stated the staff should have notified Resident 1's physician to obtain a physician's orders [REDACTED]. The DON stated then an authorization should have been obtained. The DON stated a wound specialist was a physician who specialized in the management of non-healing wounds. The DON stated when a resident had a non-healing wound then the wound consult should have been involved in the management of the resident's non-healing wound so that treatment recommendations would be obtained to care for the non-healing wound. On 1/3/18 at 1:25 p.m., during record review of Resident 1's health record and a concurrent interview, the DON stated there was no documentation by the facility's staff that the resident was referred to wound care specialist for evaluation of the non-healing wound on the left second toe. According to the facility's policy and procedure titled, Change in a Resident's Condition or Status, revised August 2011, the facility would notify the Attending Physician when there had been the following: a significant change in the resident's physical condition; a need to alter the resident's medical treatment significantly; a need to transfer the resident to a hospital/treatment center; and instructions to notify the physician of changes in the resident's condition. The policy also indicated notifications would be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to follow its policy regarding the care of urinary catheters (tubes placed in the bladder to drain urine) and ensure residents who are catheterized had a clinical necessity. The facility failed to ensure three of three sampled residents (Residents 1, 2, and 3) who had risk for urinary tract infections ([MEDICAL CONDITION] an infection in any part of the kidneys, bladder, or urethra), received the necessary care and services for the use of the indwelling urinary catheters (a tube that drains urine from the bladder, from a hole through the stomach, or through the urethra, into a bag outside the body) to prevent UTIs. Resident 1 had multiple UTIs (2/15/17, 3/21/17, 5/24/17, and 6/23/17), and trauma to the urinary meatus (the external urinary opening) of the posterior penile area due to staff inappropriately handling the catheter. Resident 2 had no clinical indication to have an indwelling urinary catheter. The catheter bag was observe at the level of the bladder, with the potential for urinary backflow, without a stat lock device (a stabilization device) in place to hold the catheter in place (see F241 for more information). Resident 3, who had an UTI on 7/6/17 and 8/5/17, was observe to have the indwelling urinary bag positioned above the resident's bladder during a wound care treatment observation. These deficient practices resulted in Resident 1 developing a wound to the urinary meatus (the point where urine exits the urethra in males) of the penis. Residents 1 and 2 developed repeated UTIs with pain. Resident 1 required a transfer to a general acute care hospital (GACH) receiving antibiotics (drugs that kill bacteria), these frequent reoccurrences of UTI had the potential to lead [MEDICAL CONDITION] (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and death. Findings: 1. A review of Resident 1's Admission Record Face Sheet indicated the resident was originally admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's history and physical examination [REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 6/28/17, indicated Resident 1 was able to report the correct year, month, and day of the week. The MDS indicated the resident's memory was intact, and had a clear comprehension of understanding others and had the ability to express needs and wants. The MDS indicated Resident 1 was totally dependent (full staff performance every time) with two or more staff for physical assistance with bed mobility and transferring between surfaces and a one-person physical assist with toilet use and bathing. The MDS indicated the resident had an indwelling urinary catheter and was always incontinent (inability to control) of bowel movements. The MDS indicated Resident 1 had moisture associated skin damage (MASD), and was receiving antibiotics during the last two days. A review of Resident 1's wound assessment and the physician's progress note from the GACH, dated 12/13/16, and timed at 7 p.m., indicated the resident had a wound present on admission, to the posterior head of the resident's penis with dimensions size of 2 centimeters (cm) in length, 1.5 cm in width, and 0.2 cm in depth. The physician's progress note indicated the posterior head of the resident's penis had an eroded (gradually destroy) open area, secondary to the use of the indwelling urinary catheter. The progress note indicated the wound was red and moist, with full thickness tissue loss (actual depth is completely obscured) in the wound bed without no odor. A review of Resident 1's Care Plan titled, UTI Prevention/Indwelling Catheter, dated 12/16/16, indicated the resident was at risk for UTI. The care plan indicated the staff's interventions included to position the urine catheter bag below the resident's bladder and to provide good perineal (the area in front of the anus extending to vagina in female; and scrotum in the male) hygiene for comfort and skin management. A review of Resident 1's Laboratory Report titled, Urine Culture, (a test to find germs, such as bacteria, in the urine that can cause an infection). A collection dated 2/19/17, and timed at 12:50 p.m., 3/21/17, and timed at 1:35 p.m., 5/24/17 and timed at 5:03 a.m., and 6/23/17 and timed at 6:30 a.m., the resident's urine was positive for bacteria in the urine. A review of Resident 1's Change of Condition (C(NAME)) record, dated 2/15/17, indicated the resident experienced burning sensation of the bladder with white sediment (abnormal cells matter that settles to the bottom of a liquid) in the indwelling urinary catheter. A review of Resident 1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of Resident 1's Transfer Record, dated 3/22/17 and timed at 10 a.m., indicated the resident was transferred to the GACH for UTI. A review of Resident 1's MAR for the month of March 2017, indicated the resident received [MEDICATION NAME] (an antibiotic used to treat urinary tract infections) 100 mg one tablet orally twice a day for seven days (3/24/17 to 3/30/17) for the [DIAGNOSES REDACTED]. A review of Resident 1's Laboratory Report titled, Urinalysis, collection, dated 5/24/17 , and timed at 5:03 a.m., indicated the resident had many bacteria present with blood and Leukocyte Esterase (white blood cells in urine associated with infection) in the urine. A review of Resident 1's C(NAME) record, dated 5/27/17 and timed at 3 p.m., indicated the resident had a UTI and had new physician's orders [REDACTED]. A review of Resident 1's Laboratory Report titled, Urinalysis, collection dated, 6/23/17 and timed at 6:03 a.m., indicated the resident had few bacteria with blood and Leukocyte Esterase present in the urine. A review of Resident 1's C(NAME) record, dated 6/27/17, and timed at 2:15 p.m., indicated the resident had a UTI, and had new orders to received Bactrim (sulfa antibiotic) one tablet, orally twice a day. A review of Resident 1 physician's orders [REDACTED]. On 8/22/17, at 8:10 a.m., during a concurrent observation and interview, Resident 1 stated the facility resident's UTIs could be prevented. Resident 1 stated the certified nursing assistants (CNAs) would turn and reposition him, without repositioning the indwelling urinary catheter, which resulted in trauma from the catheter tubing pulling and injuring the urinary meatus of the penis. Resident 1 stated in the beginning, he would not feel the pain because of the trauma to the penis due to the lack of sensation to the lower half of the resident's body ([MEDICAL CONDITION]). On 8/22/17, at 9:22 a.m., during a telephone interview, Resident 1's family member (FM 1), stated Resident 1 initially did not feel the sensation of the urinary meatus splitting, but FM 1 stated the staff would forcefully re-insert the indwelling urinary catheter, which resulted in the meatus ripping and becoming worse. On 8/22/17, at 11:50 a.m., during an observation, with CNA 1, Resident 1's urinary meatus was observed split in the middle after CNA 1 retracted (draw or be drawn back or back in) the resident's penis. On 8/23/17, at 8:55 a.m., CNA 2 stated Resident 1 told her several times that the resident's indwelling urinary catheter was pulling at the urinary meatus. CNA 2 also stated per Resident 1, the facility's nurses would also try to reinsert the indwelling urinary catheter multiple times, unsuccessfully, causing trauma to the posterior head of the penile area. 2. A review of Resident 2's Admission Record Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's H/P, dated 8/6/17, and timed at 5:18 p.m., indicated the resident was alert and had the capacity to understand and make decisions. The H/P indicated the resident recognized and recalled daily routine, and people without prompts or repetition to self. A review of Resident 2's note signed by the Nurse Practitioner (NP), dated 8/17/17 and timed at 4:44 p.m., indicated the resident had a UTI while in the GACH. The Progress Note indicated the resident had an indwelling urinary catheter and requested to keep the catheter inserted until discharged home. The Progress Note indicated the resident informed the NP that he would urinate on himself, and that frequent changing would burden the CNAs and affect the resident's skin. According to the NP's Progress Note, Resident 1 required minimal assistance for transferring and was able to stand with maximum assistance of a two-person assist. A review of Resident 2's Care Plan titled, Foley Catheter, dated 8/5/17, indicated staff's interventions included to position the urinary catheter bag and tubing below the level of the bladder and keep away from the entrance room door. On 8/22/17 at 10:38 a.m., during an observation and interview, Resident 2 was observed lying supine (face up) in bed with the urinary drainage bag at the level of the resident's bladder. The urinary drainage bag was placed on top of the middle of the resident's bariatric (large bed to accommodate larger residents) bed frame, at the foot of the resident. CNA 3 stated the urinary drainage bag was resting on the foot of the bed frame because the resident had an oversized mattress that did not have an area on the side rails to hang the urinary drainage bag below the resident's bladder. Resident 2 stated that sometimes the staff was able to hook the urinary drainage bag at the bottom of the middle of the bed frame to keep it lower than the bladder. Resident 2 was observed without a leg strap to secure the catheter tubing to prevent trauma and secure the tubing. Resident 2 stated he never had anything used to secure his catheter tubing. On 8/22/17 at 4:11 p.m., during an interview, CNA 5 stated the urinary drainage bag should never be placed on the resident's bed, and should hang low on the sides of the resident's bed frame, always below the resident's bladder at all times. At 4:20 p.m., on 8/22/17, during an interview, Resident 2 stated sometimes during repositioning and transferring from the bed to chair and/or vice versa, the staff would cause the urinary catheter to pull on his urinary meatus resulting in pain. 3. A review of Resident 3's Admission Record Face Sheet indicated the resident was originally admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's H/P, dated 1/25/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had memory problems with severe impairment in cognitive skills for daily decision-making. The MDS indicated the resident was totally dependent on two or more staff for physical assistance with bed mobility and transferring. The MDS indicated Resident 3 required assistance from one staff with eating, toilet use, and personal hygiene. The MDS indicated Resident 3 had impairment on both sides of the lower and upper extremity, had an indwelling urinary catheter, and was always incontinent of bowel. A review of Resident 3's C(NAME) record, dated 7/6/17, and timed at 5:30 p.m., indicated the resident had dark colored foul smelling urine. A review of Resident 3's physician's orders [REDACTED]. A review of Resident 3's Nursing Note, dated 8/5/17, and timed at 12:56 p.m., indicated the resident had moderate hematuria (blood in the urine). A review of Resident 3 physician's orders [REDACTED]. A review of Resident 3's Care Plan titled UTI Prevention/Indwelling Catheter, dated 1/24/17, indicated the resident was at risk for UTI due to advanced age, history of UTI, and an indwelling urinary catheter use. The Care Plan indicated the staff's plan of approach included to position the urinary bag below the level of the resident's bladder at all times. On 8/22/17, at 1:59 p.m., during an interview, CNA 6 verified she placed Resident 3's urinary bag on top of the resident's bed between the resident's legs during the wound care treatment, and that was incorrect. CNA6 stated the urinary bag should have been placed on the side of the bed in a low position. A review of the facility's Policy and Procedure titled, Catheter Care, Urinary, revision dated 10/2010, indicated to maintain an unobstructed urine flow by ensuring the urinary drainage bag 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. The policy and procedure indicated to ensure the catheter remained secured with a leg strap to reduce friction and movement at the insertion site (catheter tubing should be strapped to the resident's inner thigh).