Every finding on record at Catered Manor Care Center

Based on observation, interview, and record review, the facility failed to provide appropriate treatments and services to prevent decline in range of motion ([ROM], full movement potential of a joint [where two bones meet]) on two of six sampled residents (Resident 13, and Resident 70). The facility failed to:1.Ensure Restorative Nursing Aide ([RNA] an advanced nursing assistant who helps residents maintain their function and mobility) notify licensed nurses of Resident 13's inability to tolerate application of handroll ( soft, cylindrical cushions placed in the palm to jeep joints flexible and stop the hand from curling tightly into a fist) and Resident 13's complained of pain on resident's right hand during application of a handroll.2.Ensure appropriate handroll was used on Resident 13's right hand consistently as ordered.3. Ensure Occupational Therapy (OT- profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) accurately assessed Resident 13's right hand/fingers ROM on 4/2/2026.4.Follow Resident 13's Care Plan titled, Resident needs RNA Splinting (device use to stretch, support joints to prevent contractures [a stiffening/shortening at any joint, that reduces the joint's range of motion]) Program and Resident 13 at risk for decline in ROM. limitation of right hand ROM, deformity/contracture, increased pain and decreased for functional use of extremity, initiated on 4/2/2026 which indicated to monitor Resident 13's response and tolerance to treatment (handroll), notifying the rehab department (medical unit designed to restore lost functions, skills, or independence) if resident shows decline in function, and observe for signs and symptoms of painThese failures resulted in Resident 13 complaining of pain in her right hand, and increased contracture of her right hand's third to fifth ( middle finger, ring finger and pinky) digits (fingers). 5.Ensure bilateral hand splints were consistently applied to Resident 70 as ordered five times per week for two to four hours per day.6.Ensure nursing staff notified OT of Resident 70's functional decline, including increased dependence with eating and worsening loss of hand function.7.Ensure OT monitored, reassessed, and followed up on the resident's ROM and functional status despite multiple ongoing skilled OT orders for orthotic management and self care training.8.Identify and address the resident's loss of ability to feed herself, as Resident 70 progressed from requiring supervision/touching assistance to becoming fully dependent.9.Follow the facility's policy and procedure (P&P), titled Resident Mobility and Range of Motion, dated 2/2026, which indicated, residents will not experience an avoidable reduction in range of motion (ROM) and will receive treatment, services, equipment and assistance to increase and/or prevent a further decrease in ROM.These failures resulted in Resident 70 experiencing a decline in bilateral hand function, increased dependence with eating, and worsening contractures. Findings: During a review of Resident 13's Face Sheet , the Face Sheet indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (progressive state of decline in mental abilities), primary osteoarthritis (weak and brittle bones due to lack of calcium and Vitamin D) of the right hand, gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach), muscle weakness and hypertension (HTN-high blood pressure). During a review of Resident 13's Joint Mobility Screening ( JMA- a clinical evaluation that measures how well a joint moves through its full range of motion) dated 1/16/2026 , the JMA indicated Resident 13's right hand/ fingers had minimal loss ( less than 25 percent [%] ) and right hand stiffness digit three to five ( middle finger, ring finger and pinky). The JMA indicated to continue Occupational Therapy (OT ) services and RNA services. During a review of Resident 13's History and Physical (H&P) dated 2/4/2026, the H&P indicated Resident 13 could not make medical decisions. During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool) dated 2/11/2026, the MDS indicated Resident 13 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills. The MDS indicated Resident 13 was dependent (helper does all the effort and assistance of two or more helpers was required ) on staff with toileting hygiene, bathing, dressing, and transferring to and from a bed to a chair or wheelchair. During a review of Resident 13's JMA dated 4/2/2026, the JMA indicated Resident 13 had a full range of motion on her right hand and fingers. During a review of Resident 13 Order Summary Report dated 5/1/2026, the Order Summary Report indicated RNA to apply right hand roll daily five times a week for up to two to four hours as tolerated and to check skin integrity (condition of the skin) before and after handroll application. During a review of Resident 13's Care Plan titled, Resident needs RNA Splinting (device use to stretch, support joints to prevent contractures) Program and Resident 13 at risk for decline in ROM. limitation of right hand ROM, deformity/contracture, increased pain and decreased for functional use of extremity, initiated on 4/2/2026 and revised on 5/1/2026. The Care Plan goal indicated Resident 13 will maintain/ prevent decline in ROM through the next review. The Care Plan interventions included application of splint through placement of handroll on the right hand, monitor resident's response and tolerance to treatment, notify the rehab department (medical unit designed to restore lost functions, skills, or independence) if resident shows decline in function, observe for signs and symptoms of pain, discomfort, body posture and inform charge nurse as needed. During a review of Resident 13's Medication Administration Record (MAR) dated 5/1/2026 to 5/13/2026, the MAR indicated to monitor level of pain every shift. The MAR indicated Resident 13 had no pain on the dayshift, evening shift and night shift from 5/1/2026 to 5/13/2026. During a review of Resident 13's MAR for the month of 5/2026, the MAR indicated a physician order dated 5/7/2026 of Acetaminophen (pain medication) tablet 325 milligrams (mgs. - unit of measurement) two tablets every six hours for pain levels of 1 to 10 (0 out of 10 a numeric pain scale with zero meaning no pain and 10 meaning the worst pain imaginable). The MAR indicated Resident 13 did not receive Acetaminophen from 5/7/2026 to 5/13/2026 for pain. During a review of Resident 13's RNA Record for the month of 5/2026, the RNA Record indicated RNA to apply right hand roll daily 5 times per week for up to two to four hours or as tolerated. The RNA Record indicated on 5/13/2026- RNA documented Resident 13 refused the handroll and Resident 13 complained of pain. During an observation on 5/11/2026 at 12:05 p.m. in Resident 13's room, Resident 13's right hand was observed without a hand roll in place. Resident 13 was able to open her right thumb and index finger but her middle, ring, and little fingers remained held closely together in a fist like position when asked to open them. No hand roll was present on the bed or the bedside table. During a concurrent interview and record review on 5/13/2026 at 1:15 p.m. with Restorative Nursing Assistant (RNA) 4, Resident 13's RNA Record for the month of 5/2026 was reviewed. RNA 4 stated on 5/11/2026, he applied a towel made hand roll to Resident 13's right hand at 10:00 a.m. for four hours. He stated Resident 13 complained of pain and he noticed tension in her right hand when he applied the hand roll, but he did not notify the licensed nurse. RNA 4 stated he did not check the hand roll after applying it and did not report Resident 13's right hand pain to the licensed nurse. RNA 4 stated Resident 13's pain during the hand roll application could indicate that her right hand was becoming stiffer. During a concurrent observation and interview on 5/13/2026 at 9:45 a.m. with RNA 2 in Resident 13's room, observed a small roll made of gauze (a thin fabric used for wound care) wrapped with paper tape in Resident 13's right hand. RNA 2 stated she made the hand roll using gauze and paper tape. RNA 2 removed the rolled gauze from Resident 13's right hand when asked why the hand roll was made of thin folded gauze. During an interview on 5/13/2026 at 1:45 p.m. with RNA 2, RNA 2 stated she used the rolled up gauze as a hand roll for Resident 13 because it was thinner and smaller than a hand towel, and Resident 13 could not tolerate the towel made hand roll due to pain. RNA 2 stated this was a change in condition and she should have notified the charge nurse so the charge nurse could notify the physician. RNA 2 stated she believed she could manage Resident 13's righthand contracture and her difficulty tolerating the towel hand roll, which was why she did not notify the charge nurse. RNA 2 stated RNA services were not provided consistently due to staffing issues. She stated if Resident 13's pain and inability to tolerate the appropriate hand roll were not addressed, the resident could experience a decline in mobility and worsening of the right hand contracture. During an interview on 5/13/2026 at 9:47 a.m. with RNA 3, RNA 3 stated Resident 13 always complained of pain in her fingers when she performed finger exercises on her right hand. RNA 3 stated she used the rolled up gauze as a hand roll on 5/12/2026 for Resident 13's right hand because of Resident 13's complaint of pain. During an interview on 5/13/2026 at 11:48 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she had never seen Resident 13 with a hand roll on her right hand but had seen the resident holding a folded napkin in that hand. During a concurrent interview and record review on 5/14/2026 at 10:36 a.m. with the Director of Rehab (DOR)/OT, Resident 13's OT Discharge Note dated 1/29/2026, and JMA Joint Mobility assessment dated [DATE] were reviewed. The DOR/OT stated JMA was conducted upon admission, quarterly and annually and when a resident transitioned from therapy services to RNA Services. The DOR/OT stated Resident 13 was discharged from OT on 1/29/2026. The DOR/OT stated Resident 13 had minimal loss on her right hand (minor reductions in joint flexibility or range of motion) and right-hand stiffness on digits 3 to 5 (middle finger, ring finger, and pinky). The DOR/OT stated placement of a handroll on the right hand was recommended to keep the right palm open. The DOR/OT stated a hand roll can be a carrot splint (a specialized, cone-shaped medical device used to gently open and position tightly clenched hands), rolled up face cloth or towel. The DOR/OT stated Resident 13 was using a rolled-up face cloth or towel and aqua foam roll when she was discharged from OT Services on 1/29/2026. The DOR/OT stated Resident 13's palm would not remain open if the appropriate hand roll was not applied consistently to her right hand. The DOR/OT stated she was not aware of the issue, noting that it had not been discussed during their weekly meetings. She stated it represented a change in condition due to the resident's pain and inability to tolerate the hand roll application. The DOR/OT stated Resident 13 may experience a decline in her mobility. During a concurrent observation and interview on 5/14/2026 at 11:00 a.m. with the DOR and Resident 13, observed Resident 13 eating breakfast with an aqua foam roll (a type of hand roll) placed in her right hand. Resident 13 grimaced ( a facial expression usually of disapproval or pain) and stated that she could hardly eat because of the pain in her right hand, saying, masakit, masakit (Tagalog for painful). The DOR removed the hand roll from Resident 13's right hand and stated that the resident was in pain and that she would notify the charge nurse. The DOR/OT did not asked Resident 13 to report her pain level using the pain scale ( pain scale ratine from zero to ten-screening tool using numerical value to assess the level of pain). During a concurrent interview and record review on 5/14/2026 at 11:28 a.m. with the DOR/OT, Resident 13's JMA dated 4/2/2026 was reviewed. The DOR/OT stated it was a mistake when she documented Resident 13 had a full range of motion on the right hand and fingers. The DOR/OT stated her documentation did not reflect the actual status of the resident's right hand. During an interview on 5/14/2026 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated he had administered acetaminophen (pain medication) to Resident 13 for her leg pain. LVN 3 stated he was not aware that Resident 13 was experiencing pain in her right hand. During a subsequent interview on 5/14/2026 at 11:11 a.m. with the DOR, the DOR stated RNA should have communicated to the licensed nurses about Resident 13's right hand pain and inability to apply the appropriate handroll to the licensed nurses so it will be communicated to the physician. The DOR stated the licensed nurses will obtain a physician order for a referral to the rehab department to evaluate Resident 13's right hand. The DOR stated it was definitely a change in condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) because of the presence of pain and inability to tolerate placement of appropriate handroll. The DOR stated presence of pain on the right hand means the fingers were stiff and got more contracted and this can lead to decline in mobility. The DOR stated she did not know Resident 13 was not tolerating the application of handroll on her right hand. The DOR stated Resident 13 was able to use the handroll without pain when the resident was discharged from OT Services on 1/29/2026. During an interview on 5/14/2026 at 5:10 p.m. with the Director of Nursing (DON), the DON stated the RNA staff should have reported the change in condition related to Resident 13's right hand pain and contracture to the licensed nurses so licensed nurse could obtain a physician order for a referral to the rehab department for evaluation and treatment. The DON stated failing to address Resident 13's right hand pain and her inability to consistently tolerate the appropriate hand roll would cause her contracted fingers to worsen, negatively affecting her functional mobility (physical ability to move around and do everyday tasks safely and independently). During a review of facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, dated 2/2026, the P&P indicated Residents will not experience an avoidable reduction in range of motion and residents who have limited range in motion will receive treatment and services to increase and prevent a further decrease in ROM. During a review of facility's Job Description of a Restorative Care Nurse dated 10/2020, the Job Description of a Restorative Care Nurse indicated A restorative care nurse should assist residents with ROM, and recommend modifications or changes in resident's restorative care as needed. 5.During a review of Resident 70's Face Sheet , the Face Sheet indicated Resident 70 was admitted to the facility on [DATE] with diagnoses including spinal stenosis (narrowing of the open spaces within the spine), paraplegia, (loss of movement and/or sensation, to some degree, of the legs) intervertebral disc degeneration (a condition where the rubbery, shock-absorbing cushions between the vertebrae degenerate or rupture), and contractures to both knees and contractures to both ankles. During a review of Resident 70's History and Physical (H&P) dated 7/24/2024, the H&P indicated Resident 70 was alert and oriented to name, place, and time. The H&P indicated Resident 70 was admitted to the facility for physical therapy (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) and occupational therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities). During a review of Resident 70's MDS dated [DATE], the MDS indicated Resident 70 usually had the ability to express wants and ideas. The MDS indicated Resident 70 usually had the ability to make self understood and the ability to understand others with clear comprehension. The MDS indicated Resident 70 had impairment on both sides of the upper extremities. The MDS indicated Resident 70 needed partial to moderate assistance (helper does less than half the effort) from nursing staff with eating, oral hygiene, sitting, lying down and rolling from left to right. During a review of Resident 70's Physician Orders, dated 12/17/2025 to 1/13/2026, the Physician Orders indicated order for skilled physical therapy services with treatment plan to include daily Physical Therapy treatment three times per week for four weeks for.Orthotic Management (the clinical use of externally worn devices-such as braces and splints [a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM] used to align, protect, or improve the function of a body part) and self-care training .one time only for four weeks. During a review of Resident 70's Physician Orders, dated 12/19/2025 to 1/13/2026, the Physician Orders indicated order for skilled OT services with treatment plan to include daily OT treatment three times per week for four weeks for. both hands Orthotic Management and self-care training. During a review of Resident 70's Physician Orders, dated 1/13/2025 to 2/8/2026, the Physician Orders indicated OT order for skilled occupational therapy services with treatment plan to include daily three times per week for four weeks for. both hands orthotic management and self-care training. During a review of Resident 70's Physician Orders, dated 4/3/2025 to 4/30/2026, the Physician Orders indicated OT clarification order for skilled occupational therapy services with treatment plan to include daily three times per week for four weeks for. both hands orthotic management and self-care training. During a review of Resident 70's OT Treatment Encounter Note dated 1/21/2026, the note indicated Resident 70 required supervision or touching assistance for eating During a review of Resident 70's MDS, dated [DATE], the MDS indicated Resident 70 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) on nursing staff with eating, oral hygiene, sitting, lying down and rolling from left to right. The MDS indicated Resident 70 received Restorative Nursing Programs (RNA) of Passive Range of Motion (PROM) During a review of Resident 70's Care Plan titled Resident Needs RNA Splinting Program, dated 4/30/2026, the Care Plan goal indicated Resident 70 to maintain and prevent a decline in muscle strength and in functional use of the extremities. Resident 70 to maintain and prevent a decline in ROM. The Care Plan interventions indicated to notify rehabilitation if Resident 70 shows a decline in function During a review of Resident 70's Physician Orders, dated 5/1/2026, the Physician Orders indicated RNA([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to apply bilateral resting hand splints (a rigid or semi rigid orthotic device designed to support the wrist, hand, and fingers in a neutral or relaxed position) daily 5 times per week for up two to four hours or as tolerated. Check skin integrity before and after application. every day shift - Document total number of hours tolerated. During an observation on 5/11/2026 at 12:47 p.m. in Resident 70's room, Resident 70 was sitting up in bed with no splints on both hands. Resident 70 was being fed lunch by Certified Nursing Assistant (CNA) 9 seated at Resident 70's bedside. During a concurrent observation and interview on 5/13/2026 at 9:07 a.m. with Resident 70 in Resident 70's room, Resident 70 was lying in bed with no splints on either hand. Resident 70 showed both hands, and her fingers were contracted with no splints in place. Resident 70 stated when she first came to the facility, she was able to use both hands and could feed herself. She stated she was getting worse rather than better and that she was supposed to have splints for both hands During an interview on 5/13/2026 at 10:23 a.m. with CNA 9, CNA 9 stated Resident 70 has tightness and stiffness to the joints in both hands. CNA 9 stated Resident 70 needs 100 percent (%) assistance with eating. CNA 9 stated Resident 70 can hold a piece of bread and a coffee cup. During an interview on 5/13/2026 at 1:18 p.m. with RNA 2, RNA 2 stated Resident 70 receives RNA services five times per week. RNA 2 stated two weeks earlier, Resident 70 thanked her for applying the hand splints because they had not been applied regularly. RNA 2 stated the full time RNA had quit the previous week and stated RNAs must follow the physician's orders to prevent further contractures During a concurrent interview and record review on 5/14/2026 at 10:36 a.m. with the Director of Rehabilitation/Occupational Therapist (DOR/OT), the OT Discharge Summary for Resident 70, dated 12/17/2025 to 4/28/2026, was reviewed. The OT Discharge Summary indicated Resident 70 required setup or cleanup assistance from nursing staff for eating. The DOR/OT stated Resident 70 had limitations in both hands and had physician orders for bilateral hand splints to be worn two to four hours per day. The DOR/OT stated she was not aware Resident 70 had become dependent on nursing staff for eating and stated nursing staff should have notified her so she could reassess the resident. She stated Resident 70 had experienced a decline in functional ability in both hands, progressing from needing setup or cleanup assistance to becoming totally dependent for eating. The DOR/OT stated Resident 70's decline could worsen or remain at a dependent level if she was not informed of changes in the resident's condition and if the splints were not applied as ordered. During an interview on 5/14/2026 at 5:37 p.m. with the Director of Nursing (DON), the DON stated Resident 70 had experienced a decline in the mobility of both hands. The DON stated that this decline would affect Resident 70's overall physical functioning. The DON stated Resident 70 was at risk for developing skin breakdown and further contractures During a review of the facility's policy and procedure (P&P), titled Resident Mobility and Range of Motion, dated 2/2026, the P&P indicated, Residents will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. During a review of the facility's P&P, titled Job Description/ Occupational Therapist, dated 1/19/2024, the P&P indicated, Job duties.Ability to observe and evaluate treatment effect, discusses observations with staff, Certified Occupational therapist Assistant, Physician and Rehab Director Responsible for the monitoring and documentation of resident treatment and response.

Based on observation, interview, and record review, the facility failed to follow appropriate isolation precautions and observe infection control measures for three of 19 sampled residents (Resident 31, Resident 47 and Resident 58) by failing to:1. Ensure Resident 31 with active shingles (a painful viral infection that causes a blistering skin rash) and immunocompromised (the body's defense system is weakened or not working properly) was placed in airborne precaution isolations (used to prevent the spread of germs that can float in the air) to prevent the potential transmission of shingles to other residents and staff. 2. Offer and provide hand hygiene (simple practice of cleaning your hands to remove dirt, grease and germs) to Resident 47 and Resident 58 before mealtime. These failures had the potential to to place residents, staff, and visitors at risk for exposure, transmission, and possible outbreak of shingles within the facility, increase the risk of cross-contamination (the transfer of bacteria, viruses, microorganisms or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spread infection among the residents, staff and visitors. Findings: 1. During a review of Resident 31's Face Sheet, the Face Sheet indicated Resident 31 was initially admitted to the facility on [DATE] and readmitted on [DATE], with a diagnoses including multiple myeloma ( a rare, blood cancer), cerebrovascular accident ([CVA] damage to the brain from interruption of its blood supply), and hemiplegia (paralysis of one side of the body). During a review of Resident 31's Minimum Data Set ([MDS] - a resident assessment tool), dated 4/22/2026, the MDS indicated Resident 31 required substantial/maximal assistance (helper does more than half the effort) with toileting, lower body dressing, and putting on and taking off footwear. During a review of Resident 31's Medication Administration Record (MAR), dated 5/5/2026, the MAR indicated, Contact and Droplet Precautions ( infection control measures used to stop the spread of germs transmitted through coughing and sneezing and direct and indirect physical contact) for seven days every shift for suspected shingles for 14 days. During a review of Resident 31's Situation, Background, Assessment, and Recommendation ([SBAR] a technique which is used to facilitate prompt and appropriate communication within the care team), dated 5/5/2026, the SBAR indicated, Resident 31 was noted with a rash on the left buttock to left inner thigh noted with clustered, small red and silver patched rashes. The SBAR indicated, DX: Shingles. Contact/droplet isolation initiated. During a concurrent observation and interview on 5/11/2026 at 10:22 a.m. with Certified Nurse Assistant (CNA) 1, contact precaution signage was observed posted outside Resident 31's room. The posted PPE instructions included gowns and regular surgical masks. The CNA 1 stated Resident 31 was on contact and droplet precautions for shingles. CNA 1 stated he was not aware Resident 31 required airborne precautions. CNA 1 stated he had provided care to Resident 31 utilizing a gown, gloves, and a surgical mask. CNA 1 stated that he did not use an N95 respirator mask (is a type of tight-fitting mask designed to seal closely to the face) because the resident was not identified as requiring airborne precautions. CNA 1 stated that Resident 31's shingles were not always covered during care. CNA 1 stated he follows the isolation signage posted outside resident's rooms and relies on nursing staff to determine and implement the appropriate isolation precautions. CNA 1 stated incorrect isolation precautions could potentially expose other residents and staff to infectious diseases. During an interview on 5/11/2026 at 2:40 pm with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she was made aware that Resident 31 had shingles on May 5, 2026, at 3:00 pm, by the Infection Preventionist Nurse (IPN). LVN 2 stated she performed a skin assessment and observed fluid filled lesions on the left buttock and the both inner thighs. LVN 2 stated that Resident 31 was moved to a single occupancy room on 5/5/2026. LVN 2 stated that contact precaution and droplet precaution were initiated by the IPN based on the Nurse Practitioner's order on 5/5/2026. LVN 2 stated that Resident 31's was immunocompromised (your immune system is weakened) due to her history of myeloma (is a type of blood cancer). During a concurrent interview and record review on 5/11/2026 at 3:40 pm with the Infection Preventionist Nurse (IPN), Resident 31's Order Summary dated 5/5/2026 was reviewed, the Order Summary indicated to initiate contact and droplet precautions for 7 to 14 days. The IPN stated that she was first made aware that Resident 31 had shingles on 5/5/2026 at 3:00 pm by the TN during rounds. The IPN stated that the facility had been monitoring the rash and had not been confirmed as shingles yet. The IPN stated that contact precautions should be implemented immediately for suspected shingles also droplet precaution. The IPN stated that personal protective equipment ([PPE] equipment used to prevent or minimize exposure to hazards) that the staff should use while providing care for residents in contact or droplet precaution should include for a gown, gloves, and surgical mask. The IPN stated that the residents that are in airborne precaution, the staff should wear an N95 mask. The IPN stated the lesions were located on Resident 31's left buttocks and inner thigh. The IPN stated Resident 31 was immunocompromised due to her medical condition. The IPN stated it was important to ensure proper isolation because other residents, staff and visitors could be exposed. The IPN stated \the shingle lesions were not covered for Resident 31. During an interview on 5/12/2026 at 8:50 am with the Nurse Practitioner (NP), the NP stated that he was first notified that Resident 31 had shingles on 5/5/2026 by the Treatment Nurse. The NP stated he was informed Resident 31 had a rash located on the left buttock and left inner thighs. The NP stated upon his assessment Resident 31 had localized red pinpoint fluid filled lesions noted. The NP stated that Resident 31 was immunocompromised due to her diagnosis of myeloma. The NP stated contact precautions, and droplet precautions were initiated. The NP stated Resident 31 lesions were not covered and that the lesions did not have to be covered up because the lesions may become macerated (soften and mushy). The NP acknowledged that placing residents in the wrong isolation precautions and that could have exposed other residents and staff to shingles and spread throughout the facility. During a review of the facility's policy and procedure (P&P) titled, Isolation- Categories of Transmission-Based Precautions dated 2026, the P&P indicated .Airborne Precautions; 2. Preventing the spread of airborne pathogens requires a room with special air handling and ventilation called an airborne infection isolation room (AIIR). 3. If an AIIR is not available, a resident suspected of having an airborne infectious disease shall be masked and transported to a facility with an AIIR. 2. During a dining observation on 5/11/2026 at 12:46 p.m. in Resident 47's room, Certified Nursing Assistant (CNA) 10 brought the lunch tray of Resident 47. CNA 10 did not offer or provide any hand hygiene to Resident 47. During a dining observation on 5/11/2026 at 12:48 p.m. CNA 10 brought the lunch tray to Resident 58 who was sitting in a wheelchair outside his room. CNA 10 did not offer or provide hand hygiene to Resident 58 before he ate. During a review of Resident 47's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 47 was admitted on [DATE] to the facility with diagnoses including legal blindness( severe vision loss that cannot be corrected with glasses or contacts), thoracogenic scoliosis ( unnatural sideways curvature of the spine), history of falling, anxiety disorder ( a person experiences constant, intense, uncontrollable fear or worry about everyday situations) and hypertension (HTN-high blood pressure). During a review of Resident 47's History and Physical (H&P- physician's comprehensive and initial assessment of a patient) dated 2/25/2026, the H&P indicated Resident 47 make medical decisions. During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool) dated 3/25/2026, the MDS indicated Resident 47 had an intact cognition (thought process) and was independent (resident completes activity by herself) with eating. The MDS indicated Resident 47 had severely impaired vision (no vision or sees only light, colors or shapes and eyes do not appear to follow objects). During a review of Resident 58's Face , the Face Sheet indicated Resident 58 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including ascites(abnormal buildup of excess fluid in the belly), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), cirrhosis of the liver(severe, scarring of the liver), and hyperlipidemia (elevated level of fats in the blood). During a review of Resident 58's MDS dated [DATE], the MDS indicated Resident 58 had moderately impaired cognitive skills (a person has noticeable difficulties with thinking, memory, language or problem-solving) and required set-up or clean-up assistance (helper sets up or cleans up) with eating. During an interview on 5/12/2026 at 4:38 p.m. with CNA 6, CNA 6 stated she would practice hand hygiene before passing out trays to the residents and provide hand hygiene to residents by offering wash cloth with soap and water or hand sanitizer (a liquid or gel used to kill most germs and viruses on the hands) to clean residents' hands before mealtime. CNA 6 stated residents get sick or catch a virus (tiny non-living germs that can only reproduce by sneaking inside a living cell) or germs from their hands which can make them sick if their hands are not clean before eating. During an interview on 5/14/2026 at 12:02 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated residents are encouraged to practice hand hygiene using wet towel or ABHR (alcohol-based hand rub-a liquid, gel, or foam sanitizer designed to be rubbed onto the hands to kill germs and prevent the spread of infection). The IPN stated residents could get sick if they are not offered hand hygiene by the staff before and after meals. During an interview on 5/14/2026 at 5:10 p.m. with the Director of Nursing (DON), the DON stated the staff was expected to provide wipes, wet towels and alcohol gel to the residents before meals. The DON stated residents could get sick if their hands are not sanitized or cleaned before meal because their hands could be contaminated with germs. During a review of facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 2/2026, the P&P indicated the facility considers hand hygiene is the primary means to prevent the spread of healthcare associated infections (infections that residents get while the receiving health care).

Based on interview and record review, the facility failed to accurately assess the mental capacity (the ability to understand information and make decisions) of one of four sampled residents (Resident 6) before obtaining informed consent (a voluntary agreement to accept treatment or procedures after receiving information about the risks, benefits, and alternatives) for a psychotropic medication (a drug that affects brain activity related to mental processes and behavior). Resident 6 had fluctuating capacity to make medical decisions.This failure had the potential to violate Resident 6's right to receive adequate information about the risks and benefits of taking psychotropic. Findings:During a review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (a mental health condition characterized by excessive worry or fear), unspecified dementia( a progressive state of decline in mental abilities), unspecified psychosis, (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), depression(common, serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 6's History and Physical (H&P) dated 4/202/2026, the H&P indicated Resident 2 was having memory loss and had fluctuating capacity to make medical decisions.During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 6 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills. The MDS indicated Resident 6 was dependent (helper does all the effort) on staff with toileting hygiene, bathing, and transfer to and from a bed to a chair.During a review of Resident 6's Order Summary Report dated 4/20/2026, the Order Summary Report indicated Buspirone Hydrochloride (medication that treats anxiety) 5 milligrams (mg- unit of measurement) give 0.5 mg. by mouth two times a day for anxiety manifested by verbalization of feeling anxious.During a review of Resident 6's Order Summary Report dated 5/6/2026, the Order Summary Report indicated Escitalopram Oxalate ( medication to treat depression) 5 mg one tablet by mouth in the morning for depression manifested by verbalization of sadness.During a review of Resident 6's Order Summary Report dated 5/6/2026, the Order Summary Report indicated Quetiapine Fumarate (antipsychotic [a type of medication prescribed to treat mental health problem] that treats schizophrenia [a mental illness that is characterized by disturbances in thought]and bipolar disorder[sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated] 100 mg every 12 hours for schizophrenia manifested by recurrent outburst of anger.During a concurrent interview and record review on 5/14/2026 at 2:43 p.m. with Registered Nurse (RN) 1, Resident 6's Informed Consents for Buspirone, Escitalopram Oxalate, Quetiapine Fumarate and H&P dated 4/20/2026 were reviewed. RN 1 stated Resident 6 signed the informed consents for Buspirone, Escitalopram and Quetiapine Fumarate. RN 1 stated Resident 6 should not be signing informed consents for the psychotropic medications because the resident lacked the capacity to make medical decisions. RN 1 stated the purpose of informed consents was to inform the family representative or resident about the risks and benefits of the psychotropic medications and possible side effects that these medications can cause. RN 1 stated not informing the resident or family representative has the potential to violate Resident 6' right to be informed.During an interview on 5/14/2026 at 5:10 p.m. with the Director of Nursing (DON), the DON stated legal documents such as informed consent should be signed by a family representative because Resident 6 will not understand the risks or benefits of the psychotropic medication or he would not be able to recognize or identify side effects that could be related to the psychotropic medicines.During a review of facility's policy and procedure (P&P) titled, Verification of Informed Consent for Psychotherapeutic medications, revised 6/2024, the P&P indicated each resident has the right to be free from psychotherapeutic drugs (medications that affect the mind, emotions, and behavior) and the facility should provide informed consent before treatment with psychotherapeutic drugs. The P&P indicated the physician must personally examine the resident and obtain informed written consent signed by the resident or resident representative before prescribing a psychotherapeutic drug.

Based on interview and record review, the facility failed to ensure residents were provided accurate information necessary to make informed choices regarding their smoking preferences.The facility failed to:1.Provide consistent and accurate information during the admission process regarding whether the facility was a smoking or non smoking facility.2. Ensure staff, including the Administrator and admission Coordinator, understood and communicated the facility's smoking policy correctly.3. Ensure the admission Packet and written policies aligned with the information provided verbally to residents.4.Follow the facility's policy and procedure (P&P) titled Resident Self Determination and Participation, dated 2/2026, which indicated if the facility policy changes to one that prohibits smoking (including electronic cigarettes), residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents., and residents admitted after the No Smoking policy was adopted are informed of the policy on admission.These failures resulted in residents being incorrectly informed that the facility was non smoking, despite facility policies indicating otherwise. This inconsistent and inaccurate communication compromised residents' ability to make informed choices, thereby infringing upon their right to self determination. This deficient practice has the potential to affect all residents by limiting their ability to exercise personal preferences and rights related to smoking. Based on observation, interview, and record review, the facility failed to honor resident choice and preference for one of six sampled residents (Resident 47) by failing to accommodate Resident 47's request to receive a bed bath on Sundays. This failure resulted in Resident 47 not having their expressed preference for personal care honored. Findings: During an interview on 5/11/2026 at 2:09 p.m. with the Administrator (ADM), the ADM stated the facility had been a non smoking facility since 2010 and residents and their families were informed of the non smoking status prior to admission. During a concurrent interview and record review on 5/14/2026 at 8:57 a.m. with the admission Coordinator (AC), the facility's admission Packet was reviewed. The packet included a Smoking Policy and Guidelines section which indicated that the facility recognized residents' right to smoke and complied with local and state smoking regulations. The AC stated he was responsible for informing residents during the admission process that the facility was non smoking; however, based on the admission Packet and policy, the facility was a smoking facility, and residents who wished to smoke were given incorrect information. During an interview on 5/14/2026 at 5:04 p.m. with the Director of Nursing (DON), the DON stated based on the facility's smoking policy, the facility was not providing accurate information to residents regarding smoking and was not following its own policy. The DON stated there was no documentation indicating that the facility was a non smoking facility. The DON stated residents have the right to smoke and that their rights were being violated. During an interview on 5/14/2026 at 5:45 p.m. with the ADM, the ADM stated the facility needed to make adjustments to the smoking policy and the admission Packet. The ADM stated residents were being told the facility was non smoking but that there was no documentation indicating when the facility became non smoking. The ADM stated he was new to the facility and had been told that the facility was non smoking During a review of the facility's policy and procedure (P&P), titled Smoking Policy – Residents, undated, the P&P indicated, This facility has established and maintains safe resident smoking practices. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. During a review of the facility's P&P, titled Resident Self Determination and Participation, dated 2/2026, the P&P indicated, .If the facility policy changes to one that prohibits smoking (including electronic cigarettes), residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents, while considering the health and well-being of non-smoking residents. Residents admitted after the No Smoking policy is adopted are informed of the policy on admission. 2.During a concurrent observation and interview on 5/11/2026 at 11:19 a.m. with Resident 47, at Resident 47's bedside, there was a sign posted above the bed that indicated Resident 47 must have a bed bath every Sunday morning. Resident 47 stated she did not get a bed bath from Certified Nursing Assistant (CNA) 4 yesterday (5/10/2026) instead she was brought to the bathroom sink by CNA 4. Resident 47 stated CNA 4 gave her towels to clean herself instead of providing a bed bath. Resident 47 stated she felt like she was going to fall and had pain when she stood up in the bathroom sink to clean herself. Resident 47 stated she was blind and need help cleaning herself. Resident 47 stated she felt disappointed and sad with her care. During a review of Resident 47's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 47 was admitted on [DATE] to the facility with diagnoses including legal blindness( severe vision loss that cannot be corrected with glasses or contacts), thoracogenic scoliosis ( unnatural sideways curvature of the spine), history of falling, anxiety disorder( a person experiences constant, intense, uncontrollable fear or worry about everyday situations) and hypertension (HTN-high blood pressure). During a review of Resident 47's History and Physical (H&P- physician's comprehensive and initial assessment of a patient) dated 2/25/2026, the H&P indicated Resident 47 could make medical decisions. During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool) dated 3/25/2026, the MDS indicated Resident 47 cognition was intact (thought process) and required set-up or clean up assistance (helper sets up or cleans up) with toileting hygiene, bathing and transferring to and from a bed to a chair or wheelchair. The MDS indicated Resident 47 had severely impaired vision (no vision or sees only light, colors or shapes and eyes do not appear to follow objects), During a review of Resident 47's Care Plan titled, Resident's Preferences, initiated 3/31/2025 and revised 4/2/2026, the Care Plan's goal indicated Resident 47 would express satisfaction with her daily routine. The Care Plan interventions indicated Certified Nursing Assistants (CNA) would provide resident's care in accordance with Resident 47's wishes. During an interview on 5/14/2026 at 7:59 a.m. with CNA 4, CNA 4 stated she did not provide Resident 47 a bed bath and brought Resident 47 to the bathroom. CNA 4 stated she gave Resident 47 towels to clean herself in the bathroom. CNA 4 stated she saw the signage posted in the wall of Resident 47's room indicating provision of bed bath every Sunday. CNA 4 stated Resident 47 wanted to use the bathroom and did not know what kind of level of assistance the resident required because she was not familiar with the resident. CNA 4 stated it was important to follow the preference and choice of residents to ensure Resident 47 residents would feel satisfied and happy with their care. During an interview on 5/14/2026 at 8:53 a.m. with Resident 47, Resident 47 stated she asked CNA 4 to take her to the bathroom because she needed to move her bowels (to pass stool or excrete solid waste from the body) then CNA 4 gave her towels to clean herself instead of providing a bed bath. During an interview on 5/14/2026 at 10:26 a.m. with CNA 5, CNA 5 stated Resident 47 could not see and required assistance in taking her to the bathroom or to the shower. CNA 5 stated it was important to follow what Resident 47 choice and preference because it was a resident right. During an interview on 5/14/2026 at 12:13 p.m. with the Director of Staff Development (DSD), the DSD stated CNAs get report from CNAs from outgoing shift on how to take care of a resident. The DSD stated CNA 4 should have followed Resident 47's preferences to get a bed bath instead of providing towels to the resident to clean herself. The DSD stated Resident 47 would not feel comfortable and could violate Resident 47 right to have a bed bath on Sundays. During an interview on 5/14/2026 at 5:10 p.m. with the Director of Nursing (DON), the DON stated the staff must follow resident's preferences because it was a resident right and this would help create a home-like environment for Resident 47. During a review of facility's policy and procedure titled, Resident Self-Determination and Participation, dated 2/2026, the P&P indicated each resident is allowed to choose that are consistent with his or her interests, values, assessments and plans of care.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 6) was free of chemical restraints (use of medication to control a patient's behavior or restrict patient's movement and not required to treat the medical symptom). The facility failed to:1.Assess appropriateness of Resident 6's psychotropic medicines (drugs that affect the mind, emotions and behavior) who has a diagnosis of dementia (a progressive state of decline in mental abilities) after being admitted to the facility on [DATE]. Resident was receiving Buspirone (medication that treats anxiety) 0.5 milligram (mg.- unit of measurement) by mouth two times a day for anxiety, Quetiapine Fumarate (generic name of Seroquel- antipsychotic [a type of medication prescribed to treat mental health problem])100 mgs. by mouth every 12 hours for Schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by recurrent outburst of anger and Escitalopram (Lexapro - medication that treats depression) 5 mgs. 1 tablet in the morning for depression manifested by verbalization of sadness. Resident 6 had no documented diagnosis of Schizophrenia.This failure had the potential to put Resident 6 at risk for unnecessary medication and adverse reactions (an unintended, harmful, or unpleasant physical response to a medical treatment) affecting resident's quality of life.Findings:During a review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (a mental health condition characterized by excessive worry or fear), unspecified dementia( a progressive state of decline in mental abilities), unspecified psychosis, (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), depression(common, serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 6's History and Physical (H&P) dated 4/202/2026, the H&P indicated Resident 2 was having memory loss and had fluctuating capacity to make medical decisions.During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 6 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills. The MDS indicated Resident 6 was dependent (helper does all the effort) on staff with toileting hygiene, bathing, and transfer to and from a bed to a chair. The MDS indicated Resident 6 had diagnoses of anxiety disorder, depression and psychotic disorder (a mental health condition that causes people to lose touch with reality). The MDS indicated Resident 6 was on antipsychotic, antianxiety and antidepressant.During a review of Resident 6's Order Summary Report dated 4/20/2026, the Order Summary Report indicated Buspirone Hydrochloride (medication that treats anxiety) 5 milligrams (mg- unit of measurement) give 0.5 mg. by mouth two times a day for anxiety manifested by verbalization of feeling anxious.During a review of Resident 6's Order Summary Report dated 5/6/2026, the Order Summary Report indicated Escitalopram Oxalate ( medication to treat depression) 5 mg one tablet by mouth in the morning for depression manifested by verbalization of sadness.During a review of Resident 6's Order Summary Report dated 5/6/2026, the Order Summary Report indicated Quetiapine Fumarate (antipsychotic [a type of medication prescribed to treat mental health problem] that treats schizophrenia [a mental illness that is characterized by disturbances in thought]and bipolar disorder[sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated] 100 mg every 12 hours for schizophrenia manifested by recurrent outburst of anger.During a review of Resident 6's Care Plan titled, Resident 6 has a behavior problem, anger outbursts related to diagnosis of schizophrenia, initiated on 5/6/2026, the Care Plan goal indicated Resident 6 will have no evidence of behavior problem by review date. The Care Plan interventions included providing the medications as appropriate.During an interview on 5/13/2026 at 12:09 p.m. with Certified Nursing Assistant (CNA)7, CNA 7 stated Resident 6 was always sleepy in the morning and had to wake him up to eat breakfast. CNA 7 stated Resident 6 does not refuse care and had no behavioral problem when she was taking care of the resident.During a concurrent interview and record review on 5/14/2026 at 2:43 p.m., with Registered Nurse (RN) 1, reviewed Resident 6's electronic medical record (EMR - digital version of a resident's paper chart which contains medical and treatment history). RN 1 stated Resident 6 did not have a psychiatric evaluation addressing Resident 6's behaviors and use of psychotropic medications. RN 1 stated the Interdisciplinary Team (IDT team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) met on 4/20/2026, but the team did not discuss Resident 6's behaviors or psychotropic medication use. RN 1 stated that a psychiatric evaluation was necessary to determine whether Resident 6 still needs psychotropic medications. RN 1 stated Resident 6 was receiving Escitalopram, Buspirone, and Quetiapine fumarate, which could be unnecessary medications. She stated these medications pose risks of adverse side effects such as hypotension (low blood pressure), sleepiness, and dizziness, which can negatively affect the resident's mobility, activities of daily living (ADLs), and overall quality of life.During an interview on 5/14/2026 at 5:10 p.m. with the Director of Nursing (DON), the DON stated the facility conducts a medication review from the psychiatrist (a medical doctor who specializes in mental health) when a resident was admitted or readmitted to the facility and was on psychotropic medications. The DON stated there was no psychiatric evaluation or assessment conducted for Resident 6 and the facility should have done psychiatric referral. The DON stated Resident 6 taking psychotropic medications can be an unnecessary medication because the staff will not know if the psychotropic medications were still indicated for Resident 6. The DON stated Resident 6 can be at risk for adverse effects of the medications.During a review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 2/2026, the P&P indicated residents will only receive antipsychotic medications when indicated and necessary to treat specific conditions. The P&P indicated diagnosis of a specific condition for which the antipsychotic medications are necessary to treat is based on the comprehensive assessment of the resident.During a review of facility's P&P titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated admission or re-admission, new medications or renewal of orders are situations that will prompt an evaluation or reevaluation of the resident. The P&P indicated IDT conducts an evaluation when determining to initiate, modify or discontinue medication therapy.

During an interview and record review the facility failed to ensure two of three sampled residents (Resident 3 and Resident 6) had a PASRR level II (a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) completed to reflect Resident 3 and Resident 6's medical conditions.This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 3 and Resident 6.Findings:A. During a review of Resident 3's Face Sheet (admission record) dated 5/14/2026, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated Resident 3 had diagnosis including schizophrenia (a mental illness that is characterized by disturbances in thought), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN-high blood pressure).During a review of Resident 3's History and Physical (H&P) dated 4/20/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS -resident assessment tool) dated 5/2/2026, the MDS indicated, Resident 3 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 3 needed substantial/maximal assistance (helper does more than half the work) in 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 3 was on an antipsychotic (a type of medication prescribed to treat mental health illness).During a review of Resident 3's Order Summary Report dated 5/14/2026, the Order Summary Report indicated, Resident 3 was prescribed aripiprazole (antipsychotic medication) 30 milligrams (mg- unit of measure) give at bedtime for schizophrenia manifested by (m/b) angry outbursts, haloperidol (antipsychotic medication) 2 mg's give one at bedtime for schizophrenia m/b auditory (hearing) hallucinations (false perceptions of things that are not actually there yet feel completely real) and ziprasidone (antipsychotic medication) 80 mg's two times (bid) a day for schizophrenia m/b disordered thinking (disruption in a person's ability to process, organize and communicate thoughts).During a review of Resident 3's care plan titled The resident uses psychotropic medications dated 5/11/2026, the care plan indicated, Resident 3 was taking ziprasidone for schizophrenia m/b disorganized thinking.During a review of Resident 3's care plan titled The resident uses psychotropic medications dated 5/11/2026, the care plan indicated, Resident 3 was taking haloperidol for schizophrenia m/b auditory hallucinations.During a review of Resident 3's care plan titled The resident uses psychotropic medications dated 5/11/2026, the care plan indicated, Resident 3 was taking aripiprazole for schizophrenia m/b angry outbursts.During a review of Resident 3's PASRR level 1 screening notice dated 4/20/2026, the PASRR level 1 indicated, Resident 3 was positive for serious mental illness and a PASRR level II mental health evaluation was required. The PASRR level 1 screening indicated the facility would be contacted in two to four days to set up an appointment for a level II mental health evaluation.B. During a review of Resident 6's Face Sheet dated 5/14/2026, the Face Sheet indicated, Resident 3 was admitted to the facility on [DATE], the face sheet indicated, Resident 6 had diagnosis including anxiety (emotion characterized by feelings of tension, worried thoughts ), diabetes mellitus and depression (a mood disorder causing persistent feelings of sadness).During a review of Resident 6's H&P dated 4/20/2026, the H&P indicated, Resident 6 had fluctuating (changes continually) capacity to make medical decisions.During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had moderate cognitive impairment. The MDS indicated Resident 6 was totally dependent (helper does all the work) with ADLs. The MDS indicated Resident 6 had diagnosis of anxiety, depression and had a psychotic (severe mental illness) disorder. The MDS indicated that Resident 6 was prescribed an antipsychotic, antidepressant (treats depression) and an anti- anxiety medication.During a review of Resident 6's Order Summary Report dated 5/14/2026, the order summary report indicated, Resident 6 was prescribed buspirone (anxiety medication) 0.5 mg's BID for anxiety m/b verbalization of feeling anxious (response to stress), escitalopram (depression medication) 5 mg's daily for depression m/b verbalization of feeling sadness and quetiapine (antipsychotic medication) 100 mg's every 12 hours for schizophrenia m/b recurrent outburst of anger.During a review of Resident 6's care plan titled Resident 6 has a behavior problem of angry outbursts related to (r/t) schizophrenia dated 5/8/2026. The care plan indicated, Resident 6 was taking medication for schizophrenia. During a review of Resident 6's care plan titled Resident 6 uses anti-anxiety medication r/t an anxiety disorder m/b verbalization of feeling anxious dated 4/20/2026. The care plan indicated, Resident 6 was taking an anti-anxiety medication.During a review of Resident 6's PASRR Notice of Attempted Evaluation dated 4/20/2026, the PASRR indicated, the PASRR office was unable to complete a PASRR level II evaluation for serious mental illness because Resident 6 had no serious mental illness and no functional limitations in the last six months.During an interview on 5/14/2026 at 3:41 p.m. with the Minimum Data Set Assistant (MDSA), the MDSA stated she was responsible for following up on the PASRR level I and PASRR level II. The MDSA stated Resident 3 PASRR level 1 and Resident 6's PASRR level II should have been reviewed by staff to ensure they were followed up on correctly because Resident 3 and Resident 6 both had mental illness. The MDSA stated that PASRR's are done to ensure the residents are receiving the appropriate services.During an interview on 5/14/2026 at 5:10 p.m. with the Director of Nurses (DON), the DON stated the staff need to review the PASRR level I and PASRR level II to ensure they are coded correctly on the PASRR screening form. The DON stated treatment and services for the residents can be affected if not coded correctly.During a review of the facility's policy and procedure (P&P) titled Pre-admission Screening Level II Resident Review (PASRR Level II) dated10/2014, the P&P indicated, the facility staff will coordinate the recommendations from the level II PASRR determination and the PASRR evaluation report with the resident's assessment, care planning and transitions of care. The facility will refer all level II residents and all residents with a newly evident possible serious mental disorder, intellectual disability or a related condition for level II resident review upon a significant change in status assessment. The P&P indicated, the state is responsible for providing specialized services to residents with mental illness or intellectual disabilities residing in a skilled nursing facility. The P&P indicated, the IDT will review the level II evaluation report to develop a care plan and arrange for specialized services recommended for the residents. Specialized services are add on to the facility services- they are of higher intensity and frequency than the services provided by the facility.

Based on interview, and record review, the facility staff failed to ensure one of one sampled resident (Resident 65) received proper assistive devices to maintain hearing abilities by not assisting Resident 65 in arranging for an audiologist (a licensed healthcare professional who diagnoses, treats, and manages hearing loss) referral consult. This deficient practice resulted in Resident 65 not being able to hear adequately during a conversation, not being able to effectively communicate with staff and understand care and services being given.Findings:During a review of Resident 65's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) the Face sheet indicated Resident 65 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to ataxia, spinal stenosis, dementia (a progressive state of decline in mental abilities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 65's History and Physical (H&P), dated 7/29/2025, the H&P indicated Resident 65 was not able to make her own medical decisions at this time.During a review of Resident 65's Minimum Data Set (MDS - a resident assessment tool) dated 3/9/2026, the MDS indicated Resident 65's ability to hear was adequate with no difficulty in in normal conversation. The MDS indicated Resident 65 did not have hearing an aid (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) or other hearing appliances. The MDS indicated Resident 65 needed substantial to maximal assistance (help does more than half the effort) with oral hygiene, toileting, showering, personal hygiene, transferring and walking.During a review of resident 65's Order Summary, dated 1/28/2026, the Order Summary indicated Resident 65 had an order to have an ENT consultation with follow up treatment as indicated.During a review of Resident 65's ENT (ear, nose and throat) Notes, dated 1/8/2025, the ENT Notes indicated resident 65 had diminished hearing and a recommendation for an order for an audiogram.During a review of Resident 65's ENT Notes, dated 2/3/2026, the ENT Notes indicated Resident 65 had decreased hearing and wax was removed from both ears.During a review of resident 65's Audiogram dated 1/31/2025, the Audiogram indicated Resident 65 had hearing loss significant enough to qualify for hearing aids and is eligible for them under Medi-Cal and will start the process of obtaining the hearing aids.During an interview on 5/13/2026 at 8:22 a.m. with Resident 65, in Resident 65's room Resident 65 stated I am not able to hear. Resident 65 stated she would like to have hearing aids. Resident 65 stated no one has come to check her hearing. During an interview on 5/13/2026 at 11:32 a.m. with Certified Nursing Assistant (CNA) 11, CNA 11 stated Resident 65 had a problem with hearing and does not have hearing aids. CNA 11 stated you have to get close to Resident 65 when speaking to her.During an interview on 5/14/2026 at 12:01 p.m. with the Social Services Director (SSD), the SSD stated she was responsible for referrals, assessments and for hearing and hearing aids. The SSD stated when speaking to Resident 65 you must be directly in front of her when speaking because Resident 65 has difficulty hearing. The SSD stated Resident 65 was last seen by ENT on 2/3/2026 for ear wax removal. SSD stated she should have made a referral to the audiologist because Resident 65 still had hearing loss after the ear wax removal. The SSD stated Resident 65's hearing loss affects communication with staff and Resident 65 was unable to communicate needs effectively.During an interview on 5/14/2026 at 5:34 p.m. with the Director of Nursing (DON), the DON stated ancillary services are a part of the residents care to ensure they see a specialist. The DON stated if the hearing loss is not addressed the resident's wellbeing would be affected. The DON stated the facility needs to identify residents with hearing loss or communication would be affected and the understanding of others would so be affected. During a review of the facility's policy and procedure (P&P) titled Referrals, Social Services, dated 2/2026, the P&P indicated, .Referrals for medical services must be based on physician evaluation of resident need and a related physician order. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. Social services will document the referral in the resident's medical record.During a review of the facility's policy and procedure (P&P) titled, Social Services, dated 2/2026, the P&P indicated, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 7) received necessary care and services to prevent the development and progression of avoidable pressure injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence). The facility failed to:1. Provide consistent, accurate, and timely skin assessments and wound management for Resident 7. Inconsistent documentation in Shower Day Skin Inspections between 3/5/2026 and 3/18/2026 showing skin intact/clear despite the resident's known Stage III pressure ulcers (a severe, full-thickness skin loss extending down to the subcutaneous fat).2.Perform and document weekly skin assessments for Resident 7 as required by the facility's policy3. Follow Resident 7's Care Plan titled Potential for further pressure ulcer development.,initiated on 2/21/2017, which indicated interventions to evaluate the skin weekly, monitor skin during care, notify medical doctor promptly of any skin breakdown.and request a wound consult as needed.These deficient practices had the potential to result in delayed identification of skin breakdown, worsening of existing wounds, and inadequate wound management.Findings:During review of Resident 7's Face Sheet , the Face Sheet indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 7's diagnoses including encephalopathy (damage or disease that affects the brain), sepsis (a life-threatening blood infection) protein calorie malnutrition ( a lack of dietary protein, calories, or both), malignant neoplasm of the endometrium (type of cancer that begins in the inner lining of the uterus), and dysphagia (difficulty swallowing).During a review Order Summary Report dated 2/9/2026 to 3/2/2026, the Order Summary Report indicated Resident 7 had an order for bilateral buttocks moisture associated skin damage (MASD- skin damage caused by prolonged exposure to moisture) cleanse with normal saline (a saltwater solution) pat dry, apply collagen powder ( treatment used to manage a wound) then cover with dry dressing everyday and as needed for 30 days.During a record review of Resident 7's Order Summary Report dated 2/17/2026, the Order Summary Report indicated to transfer Resident 7 to the general acute care hospital ( GACH) for dehydration (when the body loses or uses more fluid than it takes in, leaving the body without enough water to function normally) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).During a review of resident 7's Care Plan titled Potential for further pressure ulcer development.,initiated on 2/21/2017, the Care Plan indicated a goal for Resident 7 to not develop pressure ulcers. The Care Plan indicated interventions to evaluate the skin weekly, monitor skin during care, notify medical doctor promptly of any skin breakdown., and request a wound consult as needed.During a review of Resident 7's , the GACH records dated 2/26/2026, the GACH records indicated Resident 7 had Stage III pressure ulcers present on admission [DATE]). The records indicated Resident 7 skin was not intact with area showing pink hypopigmented (skin that was lighter than the surrounding normal tissue) scarring, attached edges, and no drainage. The GACH records indicated Stage III pressure ulcer to the bilateral buttocks with skin not intact and pink and yellow moist tissue, attached edges, and no drainage.During a record review of Resident 7's GACH Pre-admission Report Sheet dated 3/2/2026 at 4:00 p.m., the Pre-admission Report Sheet indicated Resident 7 had a Stage III pressure ulcer to the coccyx, and to the left and right buttocks.During a review of Resident 7's Nursing Progress Notes dated 3/2/2026, at 8:49 p.m., the notes indicated Resident 7 returned from the GACH on 3/2/2026 at 6:15 p.m. The Nursing Progress Notes indicated upon readmission, Resident 7's skin was dry and warm to the touch, with pressure injury on the bilateral buttocks and coccyx.During a review of Resident 7's Order Summary Report dated 3/2/2026, the report indicated a physician order for the coccyx pressure ulcer to be cleansed with normal saline (wound cleanser ), followed by the application of collagen powder (type of treatment used to manage wound) , and cover with a dry dressing every day shift for wound healing for 30 days.During a review of Resident 7's Order Summary Report dated 3/2/2026, the report indicated a physician order for the left buttocks pressure injury to be cleanse with normal saline followed by application of collagen powder and cover with a dry dressing every day shift for wound healing for 30 days.During a review of Resident 7's Care Plan titled Potential for further pressure ulcer development., initiated on 3/3/2026, the Care Plan indicated interventions for daily skin inspections, including observing for redness, open areas, scratches, cuts, and bruises, and reporting any changes to the charge nurse.During a review of Shower Day Skin Inspection, the note indicatedOn 3/5/2026 Resident 7 with ulcer (sacrococcyx was circled on the diagram).On 3/7/2026 Resident 7 skin intact/clear.On 3/11/2026 Resident 7 skin intact/clear.On 3/18/2026 Resident 7 skin intact/clear.During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool), dated 4/3/2026, the MDS indicated Resident 7 was usually able to express wants and ideas. The MDS indicated Resident 7 had the ability to usually understand others. The MDS indicated Resident 7 was dependent (helper does all the effort) on nursing staff with oral hygiene, toileting, bathing, dressing, sitting, lying down and rolling from left to right. The MDS indicated Resident 7 had three Stage III pressure ulcers and no other skin problems.During a review of Resident 7's Weekly and Monthly Pressure Ulcer Management Report for the month of 4/2026, the report indicated:On 4/7/2026 Resident 7 with Stage III sacrococcyx measures 1.0 centimeter (cm-unit of measurement) in length by 1.6 cm in width by 0.2 cm in depth.Stage III left buttock measures 1.0 cm by 1.0 cm by 0.4 cm.Stage III right buttock measures 1.0 cm by 1.0 cm by 0.4 cm.Deep tissue injury (DTI- severe form of pressure injury characterized by a localized area of discolored, intact skin [purple or maroon]) right heel measures 1.0 cm by 1.0 cm.On 4/14/2026 Resident 7 with Stage III sacrococcyx measures 1.0 cm by 1.1 cm by 0.2 cm.Stage III left buttock was resolved.Stage III right buttock was resolved.DTI right heel measures 1.0 cm by 1.0 cm.On 4/21/2026 Resident 7 with Stage III sacrococcyx measures 1.0 cm by 1.4 cm by 0.2 cm.DTI right heel measures 1.0 cm by 1.0 cm.On 4/28/2026 Resident 7 with unstageable full thickness (UTD- pressure injuries in which damage cannot be determined because wound bed was obscured by slough (yellow tissue) or eschar (dead tissue) sacrococcyx measures 5.0 cm by 7.0 cm.DTI right heel measures 1.0 cm by 1.0 cm.During an interview on 5/13/2026 at 10:11 a.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated Resident 7 had pressure ulcers and was informed during huddle ( meeting held my medical team at the start of a workday) two to three weeks earlier. During a concurrent interview and record review on 5/14/2026 at 2:20 p.m. with Treatment Nurse (TN) 1, Resident 7's Shower Day Skin Inspection dated 3/5/2026 was reviewed. The Shower Day Skin Inspection indicated Resident 7 had an ulcer or blister and moisture associated dermatitis (MASD- moisture associated skin damage caused from prolonged exposure to moisture) on the sacrococcyx (tailbone) and buttocks. TN 1 stated she did not see or document any skin assessments for Resident 7 in 2/2026.During an interview on 5/14/2026 at 3:10 p.m., the Director of Nursing (DON), the DON stated Resident 7 was admitted to the facility in 2017 with no pressure ulcers. The DON stated Resident 7 developed a Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the sacrum in 2/2023 while at the facility. She stated the pressure ulcer reopened in 6/2024 and resolved in 11/2024. The DON stated the facility was not completing weekly skin assessments for Resident 7. She stated licensed nursing staff must perform weekly skin assessments, or the facility will not be able to manage the resident's skin issues or changes. The DON stated there was no documented skin assessment upon the resident's readmission from the GACH on 3/2/2026. The DON stated licensed nursing staff are responsible for assessing and documenting any changes in the resident's skin condition.During a review of the facility's policy and procedure (P&P) titled Pressure Injury/Ulcer Risk Assessment, dated 2/2026, the P&P indicated The purpose of a pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. The risk assessment/Braden scale assessment tool should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Repeat the risk assessment/Braden scale assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. The following information should be recorded in the resident's medical record utilizing facility forms are the type of assessment(s) conducted. The date and time and type of skin care provided, if appropriate. The name and title (or initials) of the individual who conducted the assessment. Any change in the resident's condition, if identified. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified.

Based on interview and record review, the facility failed to ensure employees' personnel files contained documentation of completed performance evaluations for four of eight employees (Certified Nurse Assistant [CNA] 1, CNA 3, Treatment Nurse [TN] 1, and Registered Nurse [RN] 1 ).This failure had the potential to result in unassessed staff performance, competency and training needs which may result in unsafe and ineffective care for residents.During concurrent interview and record review on 5/12/2026 at 10:20 a.m., with the Director of Staff Development (DSD), employee files were reviewed. The DSD stated CNA 1, CNA 3, TN 1, and RN 1 did not have documentation of their employee performance evaluations. The DSD stated that annual performance evaluations were important to assess whether employees can fulfill their roles and responsibilities for residents in their care. The DSD stated residents can be harmed if employees' strengths and weaknesses were not assessed in performance evaluations.During an interview on 5/12/2026 at 3:00 p.m. with the Director of Nursing (DON), the DON stated that annual performance evaluations were important to assess employees' ability to deliver safe resident care in accordance with facility's policies and procedures. The DON stated residents were at risk for harm if employees' performance were not evaluated in a timely manner.During a review of facility's Policy and Procedure (P&P) titled Performance Evaluation dated February 2026, the P&P indicated The job performance of each employee shall be reviewed and evaluated at least annually.to improve the quality of the employee's work performance.

Based on interview and record review the facility failed to ensure proper documentation of the destruction of controlled substances (Schedules II, III, or IV drug, chemical where possession, and use are strictly regulated by the government) as required for six medications in the month of 4/2026 when the pharmacist's signature was not co-signed by a registered nurse.This failure had the potential to result in mismanagement or diversion of controlled substances.Findings:During a concurrent interview and record review on 5/11/2026 at 3:48 p.m. with the Director of Nursing (DON), the controlled substance binder was reviewed. Six controlled substance medication documents for the month of 4/2026 were noted with a pharmacist signature but were not cosigned by a registered nurse. The medications noted without a registered nurse's signature were:1.Tramadol HCL (pain medication) 50 milligram (mg, unit of weight) tablet date disposed on 4/15/20262.Zolpidem Tartrate (used for short-term treatment for difficulty sleeping at night) 10 mg tablet date disposed on 4/15/20263.Temazepam (used for short-term treatment for difficulty sleeping at night) 15 mg capsule date disposed on 4/15/20264.Zolpidem Tartrate 10 mg tablet date disposed on 4/15/20265.Lorazepam (used for treatment of anxiety disorders) 0.5 mg tablet date disposed on 4/15/20266.Hydrocodone-acetaminophen (pain medication) 5-325 mg date disposed on 4/15/2026The DON stated she counts the medication with the pharmacist for destruction and will then sign the controlled substance document. The DON stated, the DON and the pharmacist must both sign the controlled substance documents but she forgot to sign the documents. The DON stated her signature was important to ensure the controlled medications that have been dispensed were the correct amount and validates that the medication were destroyed. During a review of the facility's Policy and Procedure (P&P) titled, Discarding and Destroying Medications, dated February 2026, the P&P indicated Schedule II, III, and IV (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications.The medication disposition record contains.signature of witnesses.

Based on observation, interview and record review, the facility failed to ensure food service staff was competent in testing the chlorine (deep cleaning and sanitizing agent) of the dishwashing machine for one of two dietary aides (DA)1.This failure had the potential to put residents at risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) due to inability to read and know what the proper range of sanitizer solution for the dishwashing machine.Findings:During a concurrent observation and interview on 5/11/2026 at 8:20 a.m. with Dietary Aide (AD)1, DA 1 used a test strip and dipped it in the water of the dishwashing machine during the final rinse. DA 1 compared the dipped test strip on the color chart found on the canister of the test strip bottle. The test strip read 200 parts per million (PPM- unit of measurement). DA1 stated they used chlorine to disinfect the dishes and follow 200 ppm. DA 1 stated the test strip read 200 PPM.During an interview on 5/13/2026 at 10:43 a.m. with DA1, DA 1 stated she would check the chlorine in the dishwashing machine before using and it should read 50-100 PPM not 200 PPM. DA 1 stated it was important to have the right amount of chlorine in the dishwashing machine to keep the dishes clean. DA 1 stated residents could get sick of food-borne illness if the kitchen staff was incorrectly testing the amount of chlorine of the dishwashing machine.During an interview on 5/14/2026 at 11:46 a.m. with the Dietary Supervisor (DS), the DS stated she provided an in-service to the kitchen staff on how to properly test the chlorine in the dishwashing machine. DS stated it was important that the kitchen staff was competent on how to test the chlorine of the dishwashing machine because too high or too low in the amount chlorine could affect the cleaning of the dishes by not sanitizing properly. The DS stated this could put the residents at risk for food-borne illness.During a review of facility's policy and procedure(P&P) titled, Sanitation, dated 12/2008, the P&P indicated for low temperature dishwasher with chemical sanitation should have a wash temperature of 120 degrees (unit of measurement) and 50 ppm of chlorine in the final rinse.During a review of facility's P&P titled, Dishwashing, undated, the P&P indicated the dishwasher 's chlorine should read between 50-100 ppm on dish surface on the final rinse and proper chlorine level is crucial in sanitizing the dishes.

Based on observation, interviews and record review the facility failed to identify and honor cultural food preferences for one of one sampled resident (Resident 76).This failure had the potential to result in weight loss for Resident 76.Findings:During a review of Resident 76's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 76 was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left side, muscle weakness, hypertension (HTN-high blood pressure) and hyperlipidemia (high levels of fat circulating in the blood).During a review of Resident 76's Minimum Data Set (MDS-a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 76 needed partial to moderate assistance (helper does less than half the effort) from nursing staff with toileting, showering, dressing, and transferring.During a review of Resident 76's History and Physical (H&P), dated 4/21/2026, the H&P indicated Resident 76 had the capacity to understand and make medical decisions.During a review of Resident 76's Order Summary, dated 3/5/2026, the Order Summary indicated Resident 76 had an order for a No Added Salt (NAS) diet with regular texture and thin liquid consistency.During an interview on 5/12/2026 with Resident 76, Resident 76 stated the food is horrible and he does not get food that honor his culture of being African American. Resident 76 stated he would like to have Soul Food (the traditional ethnic cuisine of African Americans)During an interview on 05/13/2026 at 11:43 a.m. with Certified Nursing Assistant (CNA) 11, CNA 11 stated she does not know what cultural foods Resident 76 likes. CNA 11 stated she does not know if the facility honors cultural food preferences.During a concurrent interview and record review on 5/14/2026 at 4:35 p.m. with the Director of Nursing (DON) Resident 76's Nutritional Screen, dated 3/12/2026, was reviewed. The Nutritional Screen indicated there was no documentation of what Resident 76's cultural preferences for meals were. The DON stated that the facility honors cultural preferences for residents upon admission. The DON stated the cultural food preferences should have been documented in Resident 76's chart and honored to provide the food wishes and nutritional needs of the resident.During a review of the facility's policy and procedure (P&P), titled Resident Self Determination and Participation, dated 2/2026, the P&P indicated, . In order to facilitate resident choices, the administration and staff. include information gathered about the resident's preferences in the care planning process.During a review of the facility's policy and procedure (P&P), titled Resident Food Preferences, dated 2/2026, the P&P indicated, .Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietitian or nursing staff will identify a resident's food preferences. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident's food and eating preferences in the care plan.

Based on observation, interview and record review, the facility failed to ensure the quaternary sanitizer solution (disinfectant) in the red bucket used to clean kitchen surfaces was at the 200 parts per million (PPM- unit of measurement) to ensure kitchen surfaces were sanitized properly.This failure had the potential to expose all residents to food borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).Findings:During an observation on 5/11/2026 at 8:14 a.m. in the kitchen, a red bucket filled with a quaternary solution was observed to be in a kitchen sink with a dish towel submerged in the solution.During a concurrent observation and interview on 5/11/2026 at 8:25 a.m. with Dietary Aide 3 (DA 3) in the kitchen, DA 3 was observed to take a quaternary solution test strip and dip it into the red bucket quaternary solution. DA 3 then compared the color of the test strip to the color chart provided with test strip. The test strip color was observed to be teal. DA 3 stated the color should be green. DA 3 stated the quaternary solution needs to have the correct amount of solution to ensure the surfaces in the kitchen are sanitized. DA 3 stated that when kitchen surfaces are not sanitized properly there is a risk for food borne illness from cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products).Durning an interview on 5/14/2026 at 11:46 a.m. with the Dietary Supervisor (DS), the DS stated she was made aware the quaternary solution in the red bucket did not have the correct amount of quaternary solution. The DS stated that when the solution in the red bucket does not have the correct amount of the quaternary solution there is a possibility the residents could develop a food borne illness because the surfaces in the kitchen would not be properly sanitized.During a review of the policy and procedure (P&P) titled Quaternary Ammonium Log Policy dated 2023, the P&P indicated the quaternary solution is used for sanitizing clean work surfaces in the kitchen. The P&P indicated the concentration will be tested at least every shift or when solution is cloudy. The solution will be replaced when the reading is below 200 ppm.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records for one of three sampled residents (Resident 11) by not documenting restorative nursing services ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) as ordered.The facility failed to:1 Accurately document restorative nursing services, including passive range of motion ([PROM] movement at a given joint with full assistance from another person) to the bilateral lower extremities and active assistive range of motion ([AAROM]- movement at a given joint with a person's own effort and assistance from an external force or another person) to the bilateral upper extremities, as ordered five times per week.2. Ensure nursing staff recorded the number of minutes of restorative services provided each day, as required by physician orders.3. Follow facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2026, which indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.This deficient practice had the potential to result in inconsistent implementation of services, inability to monitor the resident's progress toward maintaining or improving functional abilities, and potential decline in the resident's physical functioning. Findings:During a review of Resident 11's Face Sheet, the Face Sheet indicated Resident 11 was initially admitted to the facility on [DATE], with a diagnosis of diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and depression (feeling sad).During a review of Resident 11's Care Plan, titled Resident is at risk for Self-Care/ADL Potential for decline in daily activity to complete self-care activities of daily living, related to: generalized muscle weakness. dated 6/17/2025, the Care Plan indicated a goal to prevent decline in function. The Care Plan indicated interventions including RNA five time a week as tolerated, active assistive range of motion to bilateral upper extremities ([BUE] both arms)/ PROM to bilateral lower extremities ([BLE] both legs).During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 2/24/2026, the MDS indicated Resident 11 was dependent (helper does all of the effort) with toileting, showering, lower body dressing and putting on and taking off shoes.During a concurrent observation and interview on 5/11/2026 at 12:48 p.m. with Resident 11, Resident 11 was sitting in her wheelchair inside her room with edema noted to both upper extremities. Resident 11 stated staff do not come every day to provide her exercises. She stated she becomes stiff and weak when she does not receive her exercises.During a review of Resident 11's Order Summary, dated 3/2/2026, the Order Summary indicated, RNA to perform PROM to BLE daily 5 times per week as tolerated. Document number of minutes.During a review of Resident 11's Order Summary, dated 3/2/2026, the Order Summary indicated, RNA to do AAROM to bilateral upper extremities ([BUE] both arms) daily 5 times per week as tolerated. Document number of minutes.During an observation on 5/13/2026 at 9:10 a.m., Resident 11 lying in bed, no RNA services were observed being provided at the time of observation. During an observation on 5/13/2026 11:21 a.m., Resident 11 lying in bed, no RNA services were observed being provided at the time of observation. During a concurrent interview and record review on 5/13/2026 at 1:00 p.m., with Restorative Nurse Assistant (RNA) 2, reviewed Resident 11's Restorative Nursing Documentation dated 5/11/2026, 5/12/2026, and 5/13/2026. The documentation showed no evidence RNA provided RNA services on those dates. RNA 2 acknowledged the lack of documentation and stated staff should document all RNA services on the RNA form. RNA 2 stated Resident 11's restorative nursing program includes PROM exercises to both lower extremities and AAROM to both upper extremities. She stated PROM requires stretching and guiding the resident's extremities to help maintain independence and prevent contractures (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). RNA 2 stated that Resident 11 had not received restorative services as of the time of the interview and she last personally provided services to Resident 11 the previous week. She stated staffing shortages sometimes prevent her from providing RNA services as ordered. RNA 2 stated that if the resident does not receive the ordered restorative nursing services, the resident could experience functional decline, increased stiffness, and pain.During a concurrent interview and record review on 5/14/2026 at 11:27 a.m., with the Director of Nursing (DON), Resident 11 Order Summary dated 3/2/2026. The DON stated Resident 11 with physician's orders for PROM to both upper extremities and AAROM to both lower extremities. The DON stated failure to provide the ordered services could cause a decline in mobility, decreased range of motion (ROM), contractures, and loss of independence with activities of daily living (ADLs). The DON stated the Director of Staff Development (DSD) was responsible for overseeing restorative nursing services and ensuring staff provide and document these services in accordance with physician orders, the resident's care plan, and facility policy. The DON stated failure to document restorative services appropriately prevents verification that the resident received the ordered care and treatment. The DON added that inaccurate or incomplete documentation can lead to missed services, lack of follow up, and impaired continuity of care.During a review of facility's policy and procedure (P&P) titled Charting and Documentation, dated 2026, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitated communication between the interdisciplinary team regarding the resident's condition and response to care. During a review of the facility's P&P titled, Restorative Care Nurse Job Description, dated 2020, the P&P indicated, Maintain treatment records, resident files and progress notes as required.

Based on interview, and record review, the facility failed to develop and implement comprehensive plan for one of one sample residents (Residents 1) when Resident 1 fell on 7/3/2025 from the wheelchair. This deficient practice increased Resident 1's risk of further falls and injuries. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including acute respiratory failure (when not enough oxygen passes from your lungs to your blood), muscle weakness (a reduced ability of muscle to generate force, often resulting in difficulty performing daily tasks or feeling fatigued ), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a person's kidney no longer function adequately, and they rely on a dialysis. During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 06/05/2025, the MDS indicated Resident 1 had intact cognitive (ability to think, understand, learn, and remember) function for daily decision-making. The MDS indicated Resident 1's required moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs) from staff for activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting) and with transfers between surfaces. The MDS indicated Residents 1 require supervision or touching assistance (helper provides verbal cues and/touching/steadying and/or contact guard assistance as resident completes activity) to transfer to chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair). During an interview on 08/04/2025 09:36 a.m. with Resident 1 on Resident 1's room, Resident 1 stated on 07/03/2025 she called for help, but no one comes to assist her because facility staff were having barbeque-q at the patio. Resident 1 stated she was trying to put her prosthetic leg (an artificial limb that replaces a missing leg due to amputation [the surgical removal of a limb or part of a limb]) on, transferring from the bed to wheelchair but her wheelchair was not locked by the staff after returning from dialysis, so the wheelchair slides out and flips from under her bottom and she fell face down. Resident 1 stated there were no injuries at the time but the [NAME] of her right forehead was slightly swollen but had been resolved. During a concurrent interview and record review on 08/06/2025 at 12:15 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1's electronic health record was reviewed. LVN 1 stated there were no records and documentation noted in Resident 1's electronic health record that shows fall risk assessment was done and resident centered care plan for falls were initiated. Resident 1's care plan titled Resident 1 had a fall on 7/03/2025. Paramedics arrived and residents refused, claims she fine. The Care Plan interventions indicated to reassessed and reevaluate Resident 1 by Interdisciplinary team (IDT) , will continue with the IDT recommendation and intervention, re-educating Resident 1 with the use of call light when needing assistance. LVN 1 stated they have a new system where staff worked as a team and IDT to focus on the care plan and the fall assessment when the IDT team meets. During a concurrent interview and record review on 08/04/2025 at 1:06 p.m., with Registered Nurse (RN1), RN1 stated she cannot find any fall assessment that was done on Resident 1, and Resident 1's care plan was not on the actual fall assessment after the resident fall on 7/3/2025. RN 1 stated she was not part of the IDT team, and she would not know if it was done or not, because the IDT was supposed to do it. During an interview on 08/06/26 at 2:26 p.m., with the Director of Nursing (DON), the DON stated, it was important to document a resident change of condition and implement resident centered care plans, risk assessment to be able to evaluate if the residents was getting worse or stable. During a review of the facility's policies and procedures (P&P) titled Safety and Supervision of Residents dated 2021, the P&P indicated Individualized, resident centered approach to safety addresses safety and accident hazards for individual residents. The Interdisciplinary care team shall analyze information obtained from assessment and observations to identify any specific accident hazards or risks for individual residents. The care [lam shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Cross reference F689

Based on interview and record review, the facility failed to ensure the resident environment was free of potential hazard for one of one sample residents (Resident 1). Resident 1 who had an unwitnessed fall from her wheelchair on 7/3/2025. The facility failed to: 1. Ensure Resident 1's wheelchair was locked upon Resident 1's return from dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) machine to filter their blood ) treatment on 7/3/2025. This deficient practice resulted in Resident 1 falling from her wheelchair on 7/3/2025 with no injury and had the potential for increased risk for further falls and injury.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including acute respiratory failure (when not enough oxygen passes from your lungs to your blood), muscle weakness (a reduced ability of muscle to generate force, often resulting in difficulty performing daily tasks or feeling fatigued ), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a person's kidney no longer function adequately, and they rely on a dialysis. During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 06/05/2025, the MDS indicated Resident 1 had intact cognitive (ability to think, understand, learn, and remember) function for daily decision-making. The MDS indicated Resident 1's required moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs) from staff for activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting) and with transfers between surfaces. The MDS indicated Residents 1 require supervision or touching assistance (helper provides verbal cues and/touching/steadying and/or contact guard assistance as resident completes activity) to transfer to chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair). During an interview on 08/04/2025 09:36 a.m. with Resident 1 on Resident 1's room, Resident 1 stated on 07/03/2025 she called for help, but no one comes to assist her because facility staff were having barbeque-q at the patio. Resident 1 stated she was trying to put her prosthetic leg (an artificial limb that replaces a missing leg due to amputation [the surgical removal of a limb or part of a limb]) on, transferring from the bed to wheelchair but her wheelchair was not locked by the staff after returning from dialysis, so the wheelchair slides out and flips from under her bottom and she fell face down. Resident 1 stated there were no injuries at the time but the [NAME] of her right forehead was slightly swollen but had been resolved. During a phone interview on 08/04/25 at 1:31 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she (LVN 1) was the charge nurse on 7/3/2025 when Resident 1 fell. LVN 1 stated she was in the hallway when she heard Resident 1 scream from her room. LVN 1 stated she went in the room and found Resident 1 on side lying position and was agitated and threw her prosthetic leg by the bathroom door. LVN 1 stated Resident 1 informed her (LVN 1) that she (Resident 1) was trying to put on her prosthetic leg, while the wheelchair slides from her bottom and falls face down on the floor. LVN 1 stated Resident 1 had just come from dialysis around 1pm where she did a post dialysis assessment, but forgot to make sure Resident 1's wheelchair was locked after assisting residents to transfer to bed. LVN 1 stated this was a lesson learned, next time she will make sure Resident 1's surrounding was safe, wheelchair was locked, asked if Resident 1 needs anything else, and everything was within reach before LVN 1 exited the resident room. During an interview on 08/04/25 at 2:15 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated she heard Resident 1 was calling for help. CNA 1 stated she ran into the resident room and found Resident 1 on the floor in a sitting position CNA 1 stated she called the charge nurse for assistance. The nurse in charge did an assessment and took Resident 1's vital signs. CNA 1 stated Resident 1informed her she was trying to put on her prosthetic leg. CNA 1 stated there was no injury noted at that time she found Resident 1 on the floor. CNA 1 stated Resident 1 was assisted back to the wheelchair and no swollen was observed on Resident 1's face. During an interview on 08/06/2025 at 2:26 p.m., with the Director of Nursing (DON), the DON stated, staff should be mindful of Resident 1's surroundings, avoid clutter that will cause falls, check and lock wheelchair for safety and always assess the needs of Resident 1. During a review of the facility's policies and procedures (P&P) titled Fall Risk Assessment, revised in 2018,the P&P indicated The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment. 1. Staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout.2. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities and activity tolerance.

Based on interview and record review, the facility failed to ensure that licensed nurses monitored the blood sugar (b/s) levels for one of four sampled residents (Resident 1) who had diagnosis of diabetes mellitus ([DM] disease characterized by elevated levels of blood sugar) and was receiving Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia (a condition where there's too much sugar in the bloodstream). The facility failed to:1. Ensure licensed nurses clarified with Resident 1's physician, instructions from the admitting GACH to check Resident 1's b/s levels every day before meals and at bedtime and to take diabetic medication or insulin (a medication used to manage b/s levels in people with DM) as prescribed. 2. Ensure Resident 1's b/s levels were monitored due to diagnosis of DM and use of Prednisone, from 4/11/2025 through 5/16/2025. 3. Ensure Resident 1's physician provided instructions for care, interventions and/or treatment to manage Resident 1's abnormal (high) blood and urine glucose (sugar) levels when Resident 1's b/s level of 378 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount)/deciliter ([dl] a unit of measurement) (reference range of 85 mg/dl to 125 mg/dl) was obtained via a lab report on 5/16/2025, a glucose level of more than a 1,000 mg/dl, was obtained from a urinalysis ([UA] urine test [reference range is negative]) on 5/21/2025, and a b/s level of 362 mg/dl was obtained via a lab report on 5/22/2025. 4. Notify Resident 1's physician of the resident's high b/s level of 362 mg/dl based on blood lab test report dated 5/22/2025 to obtain instructions for care, interventions and/or treatment. 5. Follow Resident 1's untitled Care Plan for DM dated 5/10/2025, to monitor Resident 1 for signs and symptoms (s/s) of hyperglycemia (high b/s level above 180 mg/dL two hours after eating and fasting blood glucose levels above 125 mg/dL) and hypoglycemia (low b/s level below 70 mg/dl) by checking (via a Glucometer [a machine that measures the concentration of glucose or blood sugar in a small sample of blood) Resident 1's b/s levels and rechecking as needed. 6. Develop a Care Plan for the use of Prednisone with interventions to monitor Resident 1 for risk, side effects, adverse reactions related to the use of Prednisone. 7. Follow the facility's Policy and Procedure (P/P) titled, Processing Physician Orders that indicated to process the physician orders and to clarify these orders with the attending physician to verify and maintain the accuracy of the physician orders to provide appropriate care and services. 8. Follow the facility's P/P titled, Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notifications that indicated the facility shall promptly notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of the residents' lab results that fall outside of the clinical reference ranges because delayed notification can contribute to delays in changing the course of treatment or care plan.9. Follow the facility's P/P titled, Diabetes Management Policy that indicated the facility shall maintain the highest level of function of the residents within the normal limitations of the disease. The primary care physician orders should address medication and laboratory tests. Every resident with the diagnosis of diabetes mellitus will be identified and their care provided based on their assessed problems. Every resident should be watched for signs and symptoms of hyperglycemia and hypoglycemia including but not limited to visual disturbances, loss of skin integrity, and dehydration and should be reported to the primary care physician.These deficient practices resulted in Resident 1's b/s level not being monitored from 4/11/2025 through 5/16/2025 to ensure it was within an acceptable range in order to provide care and treatment accordingly. On 6/22/2025 Resident 1 was transferred to a GACH due to an altered level of consciousness ([ALOC] a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe changes like coma), hypotension (low blood pressure [BP]) a high heart rate (HR), and a b/s level that indicated high (when the b/s level is too high to register) on the facility's glucometer. At the GACH Resident 1's b/s level was 1060 mg/dl and the resident was diagnosed with diabetic ketoacidosis ([DKA] a life-threatening complication of DM where the body produces too many acidic chemicals called ketones) with coma (a deep state of unconsciousness where a person is unresponsive to external forces and cannot be awakened) associated with DM hyperosmolar hyperglycemic state ([HHS] a serious life threatening complication of DM characterized by extremely high b/s and severe dehydration), sepsis (a life threatening condition that occurs when the body's immune system overreacts to an infection) due to urinary tract infection ([UTI] an infection of the urinary system that includes kidneys, ureters, bladder and urethra), and candidiasis (a fungal infection caused by an overgrowth of yeast that can occur in various parts of the body including the mouth, vagina, skin and even inside the body) of the urogenital site (a region of the body that composes of the urinary system and the reproductive system). Resident 1 was admitted to the GACH's Intensive Care Unit ([ICU] a specialized unit in the hospital that provides specialized treatment and monitoring for critically ill patients) in critical condition.Findings:During a review of Resident 1's Preadmission Report from the GACH dated 4/11/2025 and timed at 4:51 p.m., the Preadmission Report indicated Resident 1's glucose levels were routinely checked with Lispro (a type of insulin, dosage not indicated) coverage. During a review of the GACH's Reconciled Home Medications and Discharge Instructions dated 4/11/2025 and timed 3:18 p.m., the Reconciled Home Medications and Discharge Instructions indicated Resident 1 was to begin taking Prednisone 20 mg two tablets (40 mg), two times a day, DM medication and/or insulin, to ensure management of her DM. The Reconciled Home Medications and Discharge Instructions indicated a recommendation for Resident 1 to follow up with her primary care physician for b/s checks before meals and at bedtime and to inform Resident 1's physician if she showed s/s of hyperglycemia and hypoglycemia that included b/s levels over 300 mg/dl or b/s levels of less than 70 mg/dl. During a review of Resident 1's Physician's Order Summary Report, the Physician's Order Summary Report indicated the following orders:1. On 4/11/2025 - Prednisone 20 mg two tablets, two times a day for COPD. 2. On 5/10/2025 - Monitor s/s of hypoglycemia and hyperglycemia every shift and check/recheck Resident 1's b/s as needed.During a review of Resident 1's Clinical Record, the Clinical Record indicated no evidence that DM medication or insulin was prescribed and/or administered to Resident 1 from her admission to the facility on 4/11/2025. During a review of Resident 1's Medication Administration Records ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/2025, 5/2025 and 6/2025, the MARs indicated the following:1. In April 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 37 doses.2. In May 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 59 doses.3. In June 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 41 doses.During a review of Resident 1's MARs dated 4/2025, 5/2025 and 6/2025, the MARs indicated no documented evidence that Resident 1's b/s was checked.During a review of Resident 1's Care Plans in the resident's Clinical Record, the Clinical Record indicated there was no Care Plan created related to Resident 1's use of Prednisone or interventions to monitor Resident 1 for risk, side effects, or adverse reactions associated with the use of Prednisone due to this medication ability to increase blood sugar levels. According to the Nationally recognized Cleveland Clinic, Prednisone may increase blood sugar characterized by increased thirst or amount of urine, unusual weakness or fatigue, blurry vision.https://my.clevelandclinic.org/health/drugs/20469-prednisone-tabletsDuring a review of Resident 1's untitled Care Plan dated 5/10/2025, the Care Plan indicated Resident 1 had a diagnosis of DM. The Care Plan's goals indicated Resident 1 would be free from any s/s of hyperglycemia and hypoglycemia and would have no complications related to DM. The Care Plans interventions included monitoring Resident 1 for s/s of hyperglycemia and hypoglycemia by checking and rechecking Resident 1's b/s levels as needed, reporting to Resident 1's physician s/s of hyperglycemia including increased thirst/appetite, fatigue, and stupor (a condition of being extremely drowsy, almost unconscious like being in a deep sleep). During a review of Resident 1's Change of Condition (COC) form , dated 5/15/2025 and timed at 6:16 p.m., the COC indicated Resident 1 had increased confusion and was not eating well. The COC indicated Resident 1's physician ordered a complete blood count ([CBC] a blood test that analyzes the different types of cells in the blood), a basic metabolic panel ([BMP] a blood test that measures several substances in the blood to assess a person's overall health and organ function including b/s) and a UA with a culture and sensitivity ([C&S] a diagnostic lab procedure used to identify the type of bacteria and to determine which medication can successfully fight an infection). During a review of Resident 1's Physician's Order, dated 5/16/2025, the Physician's Order indicated to obtain a CBC, BMP and UA with a C&S due to Resident 1's increased confusion and poor food intake.During a review of Resident 1's Lab Result Report dated 5/16/2025, the Lab Result Report indicated Resident 1's b/s level was 378 mg/dl. During a review of Resident 1's UA with C&S dated 5/21/2025, the UA with C&S indicated a glucose level of more than 1,000 mg/dl in Resident 1's urine. During a review of Resident 1's Comprehensive Metabolic Panel [CMP] a group of blood tests that provides a broad overview of the body's chemical balance and metabolism including the kidney and liver function, blood sugar and electrolyte levels) test dated 5/22/2025, the CMP indicated Resident 1's b/s level was 362 mg/dl. During a review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) COC 911 Transfer Form dated 6/22/2025 and timed at 10:14 a.m., the SBAR COC 911 Transfer Form indicated Resident 1 was transferred to a GACH because of hyperglycemia. The SBAR COC 911 Transfer Form indicated Resident 1 had decreased consciousness and only responded to tactile stimuli (direct physical contact to produce sensations of pain, pressure, vibration, temperature and pain), the resident's breathing was labored (a manner of using more effort and energy to breathe than is typical) and rapid (a breathing rate or manner that is faster than normal for a person's age and activity level), the resident was diaphoretic (excessive sweating) with s/s of thirst and fatigue. The SBAR COC 911 Transfer Form indicated Resident 1's heart rate [HR] reference range of 60 to 100 beats per minute [bpm]) was 115, respiratory rate [(RR] reference range of 12 to 20 breaths per minute) was 26, blood pressure ([BP] reference range 120/80 millimeters of mercury (mmhg) was 70/89 mmhg, and the oxygen saturation rate ([O2 sat] a measurement of how much oxygen the blood is carrying as a percentage, reference range of 95%-100%) was of 95% while receiving supplemental oxygen via a nasal cannula (a thin tube with two small prongs that fit into a patient's nostrils to deliver supplemental oxygen). Oxygen delivery flow was not indicated. The SBAR COC 911 Transfer Form indicated Resident 1's b/s level was High. During a review of the GACH's Emergency Provider Note (ED Note) dated 6/22/2025 and timed at 11:08 a.m., the ED Note indicated Resident 1 presented in the emergency room with an altered mental status ([AMS] any noticeable change in a person's level of awareness, cognition, or behavior) and low blood pressure. The ED Note indicated Resident 1 was nonverbal with a Glasgow coma score (a neurological (related to the nervous system [brain, spinal cord, and nerves]) assessment used to determine a person's level of consciousness which assesses the key areas such as eye opening, verbal response and motor response, ranging from zero to 15) of eight (indicating the patient is in a coma with limited or no response to external stimuli), HR of 133 bpm, and a RR of 35 breaths per minute. The ED Note indicated the following lab results: 1. Blood Ph (the measure of blood acidity) of 7.19 (normal range is 7.35 to 7.45. 7.19 is a significant indicator of DKA).2. [NAME] Blood Count ([WBC] a blood test that measures the number of white blood cells in blood, reference range of 4,500 k/uL to 11,000 k/uL) of 20.8 kilounits/liter (k/uL). An elevated WBC can signify various conditions, including DKA. 3. Glucose level of 1,060 mg/dl in urine.4. Bicarbonate level (a blood test that measure a form of natural waste) of 12 millimole ([mmol] a unit of measurement for the amount of a substance) (Reference range of 21 to 32 mmol per liter. A low bicarbonate level is a key indicator of DKA).5. Anion gap (a blood test used to indicate electrolyte [minerals that carry an electrical charge when dissolved in body] imbalances) of 30 milliequivalents/liter (mEq/L) (Reference range of 5 mEq/L to 14 mEq/L. A high anion gap with high b/s levels is often indicative of DKA) 6. Troponin (protein found in the heart muscle) level (a blood test used to indicated damage to the heart muscle) of 106 nanograms/liter (ng/L) (Reference range of 0 to 54 ng/L. High troponin levels indicate injury or damage to the heart muscle and can be elevated in conditions such as hyperglycemia) 7. Lactate level (a blood test used to indicate the if the body is producing enough O2 or if there is an underlying medical condition) of 4.4 mmol/L (Referfence range of 0.9 mmol/L to 1.7 mmol/L. Severe hyperglycemia can lead to increased lactate).During a review of the ED Note dated 6/22/2025, the ED Note indicated Resident 1 was given a bolus (a large single dose) of intravenous ([IV] in the vein) fluids, IV antibiotics (medication used to treat infections) and IV insulin. The ED Note indicated Resident 1 had DKA with coma associated with type two DM HHS, sepsis due to UTI, candidiasis of the urogenital site and was admitted to the ICU in serious and/or critical condition.During a telephone interview on 7/1/2025 at 4:44 p.m., Licensed Vocational Nurse (LVN) 3 stated Resident 1 was admitted to the facility on [DATE] from the GACH with a Preadmission Report, a Reconciled Home Medication form, and Discharge Instructions. During a subsequent interview with LVN 3 on 7/3/2025 at 3:44 p.m., LVN 3 stated he called Resident 1's physician on 4/11/2025 to get approval for the list of medications that accompanied Resident 1 on admission to the facility and Resident 1's physician instructed him to continue all previously administered medication from the GACH. LVN 3 stated he did not notify Resident 1's physician of the GACH's discharge instructions to check Resident 1's b/s and he did not ask Resident 1's physician if he wanted Resident 1 to take diabetic medication and/or insulin. During a telephone interview on 7/2/2025 at 11:35 a.m., Resident 1's Family Member (FM) stated he often visited Resident 1 at the facility when he got off work and Resident 1 was usually alert and interactive with him. The FM stated on 5/15/2025, he noticed Resident 1 was more confused and would drift off to sleep during a conversation. The FM stated he told the licensed nursing staff at the facility to call Resident 1's physician to obtain an order to check Resident 1's labs and urine and evaluate Resident 1's medications. The FM stated on 6/16/2025 during the morning (time unknown), he visited Resident 1, and she appeared to be weaker, she looked sedated (in a calm, almost dreamlike state, but still somewhat aware of the surroundings), she could barely open her eyes and her speech was slurred. The FM stated Resident 1 was not doing very well in the ICU at GACH and when she was transferred from the GACH to a different facility on6/26/2025 she remained non-verbal and never woke up when he visited her there. The FM stated he was concerned that Resident 1 would not make it (recover) because her (Resident 1) condition was not good. During an interview on 7/2/2025 at 2:02 p.m., Certified Nursing Assistant (CNA) 3 stated she usually took care of Resident 1 and Resident 1 was able to verbalize her needs and interact with staff and family from 4/2025 through the first week of 5/2025. CNA 3 stated in the middle of 5/2025, Resident 1 was always thirsty and asking for more ice and water. CNA 3 stated Resident 1 began to sleep more than usual and had to be woken up in order to complete her ADLs. CNA 3 stated on 6/22/2025 at 7:30 a.m., she tried to wake Resident 1 up so she could eat breakfast but Resident 1 was very sleepy and would attempt to open her eyes and moved her hands towards her (CNA 3) as if she wanted to do something or say something to her. CNA 3 stated she came back to check on Resident 1 at 8:10 a.m. and noticed Resident 1 had not eaten any of her food. CNA 3 stated Resident 1 tried to open her eyes and tell her something but was too weak and went back to sleep. CNA 3 stated at 9 a.m., she went to recheck Resident 1, and she (Resident 1) would not answer any questions. CNA 3 stated she called the charge nurse (LVN 6) and when LVN 6 checked Resident 1, she (CNA 3) heard LVN 6 saying Resident 1's b/s was high, and the paramedics had to be called.During a telephone interview on 7/2/2025 at 2:31 p.m., LVN 6 stated earlier during the 7 a.m. to 3 p.m. shift on 6/22/2025 she observed that Resident 1 was lethargic (lacking energy and enthusiasm, feeling sluggish, slow and sleepy) and would not open her eyes when asked. LVN 6 stated, she checked Resident 1's vital signs ([v/s] measurements of the body's basic functions) and found that Resident 1 had low blood pressure of 70/89 mmHg and the glucometer indicated Resident 1's b/s was Hi. LVN 6 stated the paramedics were called and Resident 1 was transferred to the GACH. During an interview on 7/3/2025 at 5:26 p.m., the Director of Nursing (DON) stated it was the responsibility of the licensed nurses and the physician to ensure all residents were provided care.During a telephone interview on 7/3/2025 at 7:45 p.m., Resident 1's physician stated he and his team were aware of Resident 1's lab results on 5/16/2025. Resident 1's physician stated he was not notified of Resident 1's lab result dated 5/22/2025 when the resident's b/s was over 300 mg/dl and stated had he been aware he could have ordered accu-checks (a brand of b/s monitoring systems used by people with DM to measure their b/s levels) to monitor Resident 1's b/s. Resident 1's physician stated managing Resident 1's DM and b/s levels was important to prevent complications of diabetic ketoacidosis or HHS which could cause Resident 1's debility (a general state of weakness or feebleness) and/or death.During a review of the facility's policy and procedure (P/P) titled, Processing Physician Orders dated 8/2027, the P/P indicated it is practice of the facility to process the physician orders and to clarify these orders with the attending physician including communication of any system identified such as residents' allergies, contraindications as well as summary of residents' medical diagnosis, to verify and maintain accuracy of the physician orders to provide appropriate care and services, reduce medication related risks and comply with drug regimen review regulatory requirements.During a review of the facility's P/P titled, Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notifications dated 12/17/2024, the P/P indicated the facility shall promptly notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of the residents' lab results that fall outside of the clinical reference ranges because delayed notification can contribute to delays in changing the course of treatment or care plan.During a review of the facility's P/P titled, Diabetes Management Policy revised 2/5/2025, the P/P indicated the following:a. The facility shall maintain the highest level of function of the residents within the normal limitations of the diseaseb. The facility shall prevent the residents from any complications of the disease process and the primary care physician orders should address medication, diet, laboratory tests and special precautions if needed.c. Every resident with the diagnosis of diabetes mellitus will be identified and their care provided based on their assessed problems and areas to monitor shall be addressed in their care plan; andd. Every resident should be watched for signs and symptoms of hyperglycemia and hypoglycemia including but not limited to visual disturbances, loss of skin integrity, and dehydration and should be reported to the primary care physician.

Based on interview and record review, the facility failed to notify the physician when one of four sampled resident's (Resident 1) laboratory (lab) result dated 5/22/2025 indicated a high blood glucose (sugar) level, a low sodium (the electrolyte in the body crucial for maintaining fluid balance, nerve and muscle function, and blood pressure) level, and a low chloride (an essential electrolyte that plays a crucial role in body fluids, including blood, sweat and urine) level. This deficient practice resulted in Resident 1's physician being unaware of Resident 1's abnormal lab results and a delay in care and treatment. 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 readmitted on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease ([COPD] a progressive lung disease characterized by persistent airflow limitation and breathing problems) and DM. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 was able to make decisions that were consistent and reasonable, required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities]) such as bathing, dressing, personal hygiene and toileting a person performs daily to care for themselves), and was incontinent (involuntary voiding of urine and stool) of bladder and bowel functions.During a review of Resident 1's Change of Condition (COC) form, dated 5/15/2025 and timed at 6:16 p.m., the COC indicated Resident 1 had increased confusion and was not eating well. The COC indicated Resident 1's physician ordered a complete blood count ([CBC] a blood test that analyzes the different types of cells in the blood), a basic metabolic panel ([BMP] a blood test that measures several substances in the blood to assess a person's overall health and organ function including b/s) and a UA with a culture and sensitivity ([C&S] a diagnostic lab procedure used to identify the type of bacteria and to determine which medication can successfully fight an infection). During a review of Resident 1's Physician's Order, dated 5/16/2025, the Physician's Order indicated to obtain a CBC, BMP and UA with a C&S due to Resident 1's increased confusion and poor food intake.During a review of Resident 1's Lab Results Report, the Lab Results Report indicated on 5/16/2025, a glucose level of 378 milligrams (mg)/deciliter (dl), with a normal range of 85 mg/dl to 125 mg/dl.During a review of Resident 1's Nursing Progress Note dated 5/19/2025 and timed at 4:25 p.m., the Nursing Progress Note indicated Resident 1's physician was made aware of Resident 1's lab results dated 5/16/2025 and a Comprehensive Metabolic Panel ([CMP] a group of blood tests that provides a broad overview of the body's chemical balance and metabolism including the kidney and liver function, blood sugar and electrolyte levels) was ordered on 5/22/2025.During a review of Resident 1's Lab Results Report dated 5/22/2025, the Lab Results Report indicated a glucose level of 362 mg/dl, a sodium level of 130 millimoles(mmol)/Liter(L) (with a normal range of 136 mmol/L to 145 mmol/L), and a chloride level of 93 mmol/L (with a normal range of 98 mmol/L to 107 mmol/L).During a review of Resident 1's Clinical Record in 5/2025, there was no documented evidence that Resident 1's lab results dated 5/22/2025 were reported to Resident 1's Physician. During an interview on 7/3/2025 at 5:26 p.m., the Director of Nursing (DON) stated Resident 1's physician should have been notified of Resident 1's abnormal labs. During a telephone interview on 7/3/2025 at 7:45 p.m., Resident 1's physician stated he was not notified of Resident 1's lab results dated 5/22/2025 and had he been aware he could have ordered accu-checks (a brand of b/s monitoring systems used by people with DM to measure their b/s levels) to monitor Resident 1's b/s. Resident 1's physician stated managing Resident 1's DM and b/s levels was important to prevent complications of DMDuring a review of the facility's P/P titled, Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notifications dated 12/17/2024, the P/P indicated the facility shall promptly notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of the residents' lab results that fall outside of the clinical reference ranges because delayed notification can contribute to delays in changing the course of treatment or care plan.

Based on interview and record review, the facility failed to ensure a Care Plan was created one of four sampled residents (Resident 1) who was administered Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia [a condition where there's too much sugar in the bloodstream]) with intervention to monitor Resident 1 for risk, side effects, and adverse reactions related to the use of Prednisone due to this medications ability to increase blood sugar (b/s) levels. This deficient practice resulted in Resident 1's b/s level not being monitored from 4/11/2025 through 5/16/2025 to ensure it was within an acceptable range in order to provide care and treatment accordingly. On 6/22/2025 Resident 1 was transferred to a General Acute Care Hospital (GACH) due to an altered level of consciousness ([ALOC] a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe changes like a coma [a deep state of unconsciousness where a person is unresponsive to external forces and cannot be awakened]), hypotension (low blood pressure [BP]), a high heart rate (HR), and a b/s level that indicated high (when the b/s level is too high to register) on the facility's glucometer (a machine that measures the concentration of glucose or blood sugar in a small sample of blood). At the GACH Resident 1's b/s level was 1060 milligrams([mg] metric unit of measurement, used for medication dosage and/or amount)/deciliter([dl] a unit of measurement) and she was diagnosed with diabetic ketoacidosis ([DKA] a life-threatening complication of DM where the body produces too many acidic chemicals called ketones [a byproduct of fat breakdown]) with coma associated with DM hyperosmolar hyperglycemic state ([HHS] a serious life threatening complication of DM characterized by extremely high b/s and severe dehydration). Resident 1 was admitted to the GACH's Intensive Care Unit ([ICU] a specialized unit in the hospital that provides specialized treatment and monitoring for critically ill patients) in critical condition.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 readmitted on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease ([COPD] a progressive lung disease characterized by persistent airflow limitation and breathing problems) and DM. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 was able to make decisions that were consistent and reasonable, required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities]) such as bathing, dressing, personal hygiene and toileting a person performs daily to care for themselves), and was incontinent (involuntary voiding of urine and stool) of bladder and bowel functions.During a review of Resident 1's Clinical Record (Care Plan section), the Clinical Record indicated there was no Care Plan created related to Resident 1's use of Prednisone or interventions to monitor Resident 1 for risk, side effects, or adverse reactions associated with the use of Prednisone due to this medication ability to increase blood sugar levels. During an interview and record review on 7/3/2025 at 12:09 p.m., Registered Nurse Supervisor (RNS) 3 stated a Care Plan should have been created related to Resident 1's use of Prednisone with interventions ensuring Resident 1's b/s was managed. During a review of the facility's Policy and Procedures (P/P), titled, Comprehensive Care Plans revised 2/5/2025, the P/P indicated the facility shall develop and implement a comprehensive person centered care plan for each resident after a comprehensive assessment, that includes measurable objectives and timeframes to meet the residents' medical, nursing, mental and psychosocial needs.During a review of the facility's P/P, titled, Unnecessary Drugs revised 2/5/2025, the P/P indicated the information during the initial and ongoing evaluation of the residents will be incorporated into the residents' comprehensive care plan that reflects person-centered medication related goals and parameters for monitoring the resident's condition, including the likely medication effects and potential adverse consequences.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had an order for Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia (a condition where there's too much sugar in the bloodstream) 20 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) 2 tablets, twice a day (80 mg), had a stop date and/or duration of administration. This deficient practice resulted in Resident 1 taking Prednisone 20 mg., 2 tablets twice a day (for a total of 80 mg daily), from 4/12/2025 until 6/22/2025. Resident 1 had a change of condition (COC) and was transferred via 911 to a GACH on 6/22/2025, due to an altered level of consciousness (a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe changes like coma), hypotension (low blood pressure where the normal range is less than 120 systolic [top number] and less than 80 [bottom number]), and a blood sugar (b/s) level of high (the b/s was too elevated to register, reference range of 70 mg/deciliter ([dl] a unit of volume) to 99 mg/dl, obtained from a glucometer (a machine that measures the concentration of glucose or blood sugar in a small sample of blood) Resident 1's b/s at the GACH was 1060 mg/dl and she was admitted to the GACH's Intensive Care Unit ([ICU] a specialized unit in the hospital that provides specialized treatment and monitoring for critically ill patients) comatose (a deep state of unconsciousness where a person is unresponsive to external forces and cannot be awakened) with Diabetic Ketoacidosis (a life-threatening complication of DM where the body produces too many acidic chemicals called ketones [a product of fat breakdown]) associated with type 2 DM hyperosmolar hyperglycemic [NAME] ([HsHS] a serious, life threatening complication of diabetes). 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 readmitted on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease ([COPD] a progressive lung disease characterized by persistent airflow limitation and breathing problems) and DM. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 was able to make decisions that were consistent and reasonable, required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities]) such as bathing, dressing, personal hygiene and toileting a person performs daily to care for themselves), and was incontinent (involuntary voiding of urine and stool) of bladder and bowel functions.During a review of Resident 1's Order Summary Report (Physician's Orders), the Physician's Order indicated on 4/11/2025, an order for Prednisone 20 mg two tablets two times a day, with no stop date or duration of treatment.During a review of Resident 1's Medication Administration Records ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/2025, 5/2025 and 6/2025, the MARs indicated the following:1. In April 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 37 doses.2. In May 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 59 doses.3. In June 2025 - Prednisone 20 mg, 2 tablets (40 mg) was administered twice a day for a total of 41 doses.During a telephone interview on 7/1/2025 at 4:44 p.m., Licensed Vocational Nurse (LVN) 3 stated Resident 1 was admitted to the facility on [DATE] from a GACH with a Preadmission Report, a Reconciled Home Medication form, and Discharge Instructions. During a subsequent interview with LVN 3 on 7/3/2025 at 3:44 p.m., LVN 3 stated he called Resident 1's physician on 4/11/2025 to get approval for the list of medications that accompanied Resident 1 on admission to the facility and Resident 1's physician instructed him to continue all previously administered medication from the GACH, which included the Prednisone. LVN 3 stated the Prednisone had no stop date and he should have clarified with Resident 1's physician about a stop date for the Prednisone. During a telephone interview on 7/2/2025 at 11:35 a.m., Resident 1's Family Member (FM) stated he often visited Resident 1 at the facility when he got off work and Resident 1 was usually alert and interactive with him. The FM stated on 5/15/2025, he noticed Resident 1 was more confused and would drift off to sleep during a conversation. The FM stated he told the licensed nursing staff at the facility to call Resident 1's physician to obtain an order to check Resident 1's labs and urine and evaluate Resident 1's medications. The FM stated on 6/16/2025 during the morning (time unknown), when he visited Resident 1, she appeared to be weaker, she looked sedated (in a calm, almost dreamlike state, but still somewhat aware of the surroundings), she could barely open her eyes, and her speech was slurred. The FM stated Resident 1 was not doing very well in the ICU at GACH and when she was transferred from the GACH to a different facility on 6/26/2025 she remained non-verbal and never woke up. During a telephone interview on 7/3/2025 at 3:23 p.m., the facility's Pharmacy Consultant (PC) stated Prednisone can be used long term, but the dose should be tapered (gradually reduced) down to 10 mg - 20 mg daily. The PC stated Resident 1's physician should have assessed Resident 1 regularly to determine if the dose of Prednisone Resident 1 was receiving was appropriate. During a telephone interview on 7/3/2025 at 7:45 p.m., Resident 1's Physician stated he was not aware that Resident 1's Prednisone had no stop date. Resident 1's Physician stated he could have tapered the dose Prednisone with a goal of discontinuing it because the dose Resident 1 was receiving was high and not necessary. During a review of the facility's Policy and Procedures (P/P), titled, Unnecessary Drugs revised 2/5/2025, the P/P indicated the facility shall ensure that the residents' entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs by:1. Initiating, maintaining, or discontinuing medication(s) by evaluating the resident's physical, behavioral, mental and psychological signs and symptoms in order to identify and rule out any underlying conditions, including the assessment of relative risks and benefits, and preferences and goals for treatment2. Identifying circumstances that warrant evaluation of the residents' underlying medical condition and medication(s) that include admission, readmission , a new or worsening change in condition/status3. Ensuring the attending physician of the residents assume leadership in medication management by developing, monitoring and modifying the medication regimen in collaboration with the residents and/or representatives, other professionals and the interdisciplinary team to take into consideration the dose, duration of use, indications and clinical need for medication and adequate monitoring for efficacy and adverse consequences, prevention, identifying and responding to adverse consequences.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on nursing staff for toileting hygiene, and rolling to the left and right side while lying on his back in bed, was provided assistance by two people when receiving incontinent (loss of control of bowel and/or bladder) care. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not turn and reposition Resident 1 during incontinent care without the assistance of an additional staff member, per the Minimum Data Set ([MDS] a resident assessment tool) assessment. This deficient practice resulted in Resident 1 rolling out of bed when CNA 1 turned the resident during incontinent care without the assistance of two people. Resident 1 was transferred to a General Acute Care Hospital (GACH) on [DATE] where he was diagnosed with multiple injuries to his neck and spine (see below), was intubated (a tube is inserted into a person's mouth/nose and down into their airway), and placed on a ventilator (a medical device that helps a person breath when they are unable to do so on their own). Resident 1 expired on [DATE] due sequelae (lasting health problems) of blunt traumatic injuries (getting hurt by something with a lot of force but without breaking the skin) from a ground level fall. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including a fracture (breaking of a bone) of the left humerus (the upper arm bone), congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently), generalized muscle weakness, and myasthenia gravis (an autoimmune disorder that causes muscle weakness and fatigue due to a breakdown in communication between nerves and muscles). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had mild cognitive impairment (memory and thinking problems). The MDS indicated Resident 1 was dependent on nursing staff for toileting hygiene and rolling to the left and right side while lying on his back in bed. The MDS indicated Resident 1 was incontinent of both bowel and bladder function. During a review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) Fall Report of Incident, dated [DATE] and timed at 7:25 a.m., the SBAR indicated on [DATE] at 6:35 a.m., Resident 1 was alert, oriented, and verbally responsive when Certified Nursing Assistant (CNA) 1 adjusted his bed to her waist level and repositioned Resident 1 to his right side. The SBAR indicated Resident 1 slid out of bed and landed on a floor mat (a cushioned floor pad designed to help prevent injury should a person fall) in a prone (lying face down) position. The SBAR indicated CNA 1 called for help and Licensed Vocational Nurse (LVN) 1 responded and found Resident 1 was awake and alert but unresponsive (unable to react to stimuli like touch, sound, or pain, essentially being unconscious or unaware of their surroundings). The SBAR indicated Resident 1 was placed back in bed while LVN 1 called 911. The SBAR indicated 911 transferred Resident 1 to a GACH. During a review of Resident 1's Emergency Medical Services ([EMS] a system that provides immediate medical care to individuals experiencing serious injuries, illnesses, or medical emergencies) form, dated [DATE], the EMS form indicated EMS was dispatched to the facility on [DATE] at 6:35 a.m., and arrived at the facility at 6:46 a.m. The EMS form indicated Resident 1 had a Glasgow Coma Score ([GCS] a method used to determine a patients conscious state ranging from 3-15, a score of 3-8=coma) of 4, on a Glasgow Coma Scale (a tool medical professional's use to objectively evaluate the degree to which a person is conscious or comatose. It operates on a scale of 3 to 15). The EMS form indicated, Resident 1 was lying in bed supine (on his back), was drowsy, but able to open his eyes and hit the occipital (the back region) area of his head. The EMS form indicated Resident 1 had left sided facial droop and a low oxygen saturation ([O2 sat] a measurement of how much oxygen is carried by the blood, normal range is 95% to 100%) level of 84% on room air (without the use of oxygen supplement). During a review of the GACH's admission Record, dated [DATE], the GACH's admission Record indicated Resident 1 arrived at the GACH at 7:03 a.m., with a primary diagnosis of respiratory insufficiency (a condition that cause problems with breathing, specifically at rest) and a hospital problem of lung failure ([respiratory failure] a serious condition making it difficult to breath on your own). During a review of the GACH's Emergency Department (ED) Notes, dated [DATE] and timed at 10:32 a.m., the ED Notes indicated Resident 1 was intubated and placed on a ventilator at 7:11 a.m. During a review of the ED Provider Note dated [DATE] and timed at 7:07 a.m., the ED Provider Note indicated Resident 1 presented to the ED with a GCS of 6 and had pinpoint pupils (pupils that are abnormally small, and an indication of a severe head injury) upon initial evaluation. During a review of the GACH's Imaging Note, dated [DATE], and timed at 4:25 p.m., the Imaging Note indicated an MRI ([Magnetic Resonance Imaging] a medical technique that uses strong magnetic field and radio waves to create detailed images of the body's internal structures) of Resident 1's brain indicated the following: 1. Acute traumatic (caused by trauma such as fall or accident) ligamentous (tough bands of tissue that connect bones and help stabilize the spine) injuries with slight anterior translation (movement or displacement of a body part forward from its normal position relative to another bone or joint) of the dens (a bony projection of the second neck bone that acts as a pivotal point enabling head rotation), and C1 vertebra (a ring shaped bone that begins at the base of the skull that holds the head upright 2. Superimposed hematoma (a collection of blood outside of the blood vessel occurring on top of an existing hematoma, either in the same area or in a different locations) vs an inflammatory mass (a clump of tissue that has become swollen or irritated) with secondary compression of the cervical cord (a condition where the spinal cord in the neck region is squeezed) During a review of the GACH's Imaging Note, dated [DATE], and timed at 4:52 p.m., the Imaging Note indicated an MRI of Resident 1's C-spine ([cervical spine] the upper portion of the spinal column located in the neck region) indicated the following: 1. Brain stem (the lowest part of the brain responsible for functions such as breathing) and cervical cord edema over seven centimeters ([cm] a unit of measurement) in length. 2. Cervical cord hemorrhage (bleeding) at C1. 3. Suspected ligamentous tears from the skull base (the bony floor of the skull that separates the brain from the upper neck) and C2 (second vertebra of your neck) region to the C6 through C7 (sixth and seventh vertebra of your neck) vertebra. 4. Likely disc (involves the cushion-like discs in the spine that allow movement, provide shock absorption, ad maintain spinal stability) injury at C3 through C7. 5. Indications of interspinous (located between spines, specifically between the bone projections of the adjacent vertebrae in the spine) ligamentous tears from C2 through C5. 6. Suspected acute fracture on C4 vertebral body (the main component of each vertebra in the spine, providing support and structure)/osteophyte ([bone spur] an abnormal bony projection that forms on the edges of the bones which can develop due to injury) and C3 vertebrae. 7. Multi-level cervical spinal stenosis (narrowing of the space within the neck bones where the spina cord and nerve roots run, causing compression of these delicate structures) C5 through C6 (mild), C5 through C5 (moderate). During a review of the GACH's Medicine Discharge summary, dated [DATE] the Medicine Discharge Summary indicated Resident 1 was still on a ventilator on [DATE] and neurosurgery (a medical specialty concerned with diagnosis and treatment of patients with injury of the brain, spine, spinal cord, and other nerve related body parts) consulted with Resident 1's family, and decided on comfort care (care that focuses on an end of life approach such as managing pain symptoms, and spiritual/emotional needs of both patient and family). The Medicine Discharge Summary indicated Resident 1's family was aware of Resident 1's poor prognosis (a low likelihood of recovery of improvement of a condition/disease) and was ready to withdrawal care (a discontinuation of life-prolonging treatments such as ventilators). Resident 1 was taken off the ventilator on [DATE]. The Medicine Discharge Summary indicated Resident 1 Resident 1 passed away on [DATE]. During a review of Resident 1's Certificate of Death, dated [DATE] and timed at 6:05 p.m., the Certificate of Death indicated Resident 1's immediate cause of death was sequelae (lasting health problems) of blunt traumatic injuries (getting hurt by something with a lot of force but without breaking the skin) from a ground level fall. During an interview on [DATE] at 2:47 p.m., Family Member (FM) 1 stated Resident 1 passed away on [DATE] at the GACH due to breaking his neck with a spinal cord injury from his fall on [DATE] at the facility. FM 1 stated she last talked to Resident 1 on [DATE] over the phone and he was alert, oriented, and able to speak to her normally. FM 1 stated she visited Resident 1 at the GACH from [DATE] through [DATE], and Resident 1 was not able to move, talk, or breath without the use of a ventilator. During an interview on [DATE] at 5:10 a.m., Licensed Vocational Nurse (LVN) 1 stated on [DATE] at 6:30 a.m., Certified Nursing Assistant (CNA) 1 called for help and he (LVN 1) rushed into Resident 1's room and observed Resident 1 lying on the floor face down on the right side of his bed on a floor mat. LVN 1 stated Resident 1's bed was without siderails and was approximately three feet high from the floor. LVN 1 stated when they (LVN 2 and CNA 2) turned Resident 1 over onto his back he had no visible injuries, his eyes were open, but he did not blink, and he was not able speak. LVN 1 stated when he asked CNA 1 what happened she informed him Resident 1 fell when she was changing him by herself. During an interview on [DATE] at 8:05 a.m., CNA 1 stated on [DATE], sometime in the early morning (exact time unknown) she went into Resident 1's room to provide care to him. CNA 1 stated she raised Resident 1's bed to the level of her waist (exact height unknown) and pulled Resident 1 to the left side of his bed using a draw sheet (a small bed sheet placed crosswise over the middle of the bottom sheet of a mattress to cover the area between the person's upper back and thighs, often used by medical professionals to move patients). CNA 1 stated Resident 1 was facing the window with his back to the front of her body and as she pulled him towards her he suddenly slipped out of the bed. CNA 1 stated she had worked with Resident 1 two to three times in the past and she was never informed that he required two-person assistance, and she did not think she needed help turning him because he was able to assist in turning himself. During an interview on [DATE] at 9:01 a.m., the Director of Staff Development (DSD) stated if Resident 1 was totally dependent for his care needs, for safety purposes and to prevent falls there should have been two people assisting during his care. The DSD stated he found out about Resident 1's fall on [DATE] at 8:15 a.m., during morning huddle (a meeting where nurses discuss resident updates). The DSD stated due to a suspected head/neck injury Resident 1 should have been left on the floor until the paramedics arrived to protect his head/neck from more damage. During an interview on [DATE] at 9:38 a.m., the MDS Nurse stated she completed the ADL section of the MDS and determined Resident 1 was dependent on staff when rolling from left to right, which meant he was not able to turn himself at all and required two-person assistance for turning and repositioning to prevent him from falling. During a review of the facility's P/P titled Turning and Repositioning dated [DATE], the P/P indicated the protocol for turning and repositioning included use of appropriate number of staff to perform tasks safely.

Based on interview and record review, the facility failed to ensure the resident, who had a change in condition (COC a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by oxygen (O2) saturation ( the amount of oxygen circulating in the blood) of 86 percent ([%] a reference range for O2 saturation is 95% to 100%) on room air on [DATE], was transferred to a general acute care hospital (GACH) without a delay for one of four sampled residents (Resident 1). Resident 1 was transferred to the GACH eight hours later from the onset (start) of chest pain, shortness of breath, fluctuating (change continually) blood pressure from low to high, and desaturation (the condition of a low blood oxygen concentration). The facility failed to: 1. Ensure the Licensed Vocational Nurse (LVN 2) monitored and assessed Resident 1's vital signs ([VS] a measurements of the body's most basic functions including temperature, pulse rate, respiration rate {rate of breathing} and blood pressure) including O2 saturation rate when there was a change in resident's condition and per Registered Nurse Supervisor (RNS 1) instruction. 2. Ensure the licensed nurses informed Resident 1's physician of Resident 1's continuous oxygen desaturation ranging between 86% to 87% despite continuously receiving O2, the residents complain of a chest and abdominal (stomach) pain and feeling weak on [DATE]. 3. Ensure LVN 1 and LVN 2 made Nurse Practitioner ([NP] a nurse who has advanced clinical education and training) aware about Resident 1 was having a chest pain, abdominal pain, and was short of breath. These failures resulted in eight hours delay transferring Resident 1 to the GACH from the onset of Resident 1's change in condition on [DATE]. Resident 1 had low O2 saturation of 86 % while receiving O2 continuously and complained of a chest and abdominal pain. Resident 1 was transferred to the GACH on [DATE] at 7 p.m., (eight hours after Resident 1 had the oxygen desaturation to 86 % , had shortness of breath, and complained of left chest pain and left abdominal pain rated eight out of 10 on a pain scale from zero to ten (a pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). At the GACH Resident 1 became acutely altered (sudden change) , stopped breathing and became bradycardic (a slow heart rate under 60 beats per minute) down to the 20's. Resident 1 was not spontaneously breathing and eventually had no cardiac (heart) activity. At the GACH Cardiopulmonary Resuscitation ([CPR]- emergency lifesaving procedure consisting of chest compressions combined with artificial ventilation, or mouth to mouth) was started and continued from 8:36 pm to 9:04 pm without success. Resident 1 passed away on [DATE] at 9:04 pm. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including closed fracture (a broken bone that does not pierce the skin) of the right tibia (a large bone located in the lower front portion of the leg), chest pain, hyperlipidemia (abnormal high levels of fat in the blood), hypertensive urgency (a severe elevation in blood pressure), and anemia (a blood disorder in which the blood has a reduced ability to carry oxygen). During a review of Resident 1's Order Summary (physician's orders summary) dated [DATE], the Order Summary indicated the some of the following physician's orders for Resident 1: 1. Amlodipine Besylate (blood pressure medication) 2.5 milligram ([mg] a unit of weight measurement) one tablet two times a day for angina (chest pain). Hold for systolic blood pressure ([SBP] pressure exerted when the heart beats and blood is ejected into the arteries) less than 110. 2. Chlorthalidone Tablet (blood pressure medication) 25 mg one tablet one time a day for hypertension (high blood pressure). Hold for SBP less than 110 or heart rate (HR) less than 60 beats per minute. 3. Hydralazine Hydrochloride (HCl- blood pressure medication) 25 mg one tablet as needed four times a day for SBP greater than 180. 4. Irbesartan (blood pressure medication) 300 mg one tablet one time a day for hypertension. Hold for SBP less than110 or HR less than 60. 5. Labetalol HCl 200 mg one tablet two times a day for hypertension. Hold for SBP less than 110 or heart rate less than 60. 6. Full Cardiopulmonary Resuscitation (CPR). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 was alert and oriented to self, place, time and was able to make her own medical decisions. The H&P indicated staff, nursing, and family members/care giver to call 911 (emergency number for emergency services) or go to the nearest emergency room (ER) if Resident 1 will experience chest pain, shortness of breath, loss of consciousness, change in vision, severe headache, or other alarming symptoms. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 1 was dependent on nursing staff for changing positions from sitting to standing, and transferring from a bed to the chair. The MDS indicated Resident 1 needed maximal assistance with toileting, showering, lower body dressing and putting on and off footwear. The MDS indicated Resident 1 needed moderate assistance with personal hygiene, changing positions from sitting to lying down, and lying down to sitting position. During an interview on [DATE] at 10:45 a.m., a Certified Nursing Assistant (CNA 1) stated on [DATE] between 10 a.m. and 11 a.m., he responded to a call light from Resident 1's room. CNA 1 stated he went to check on Resident 1, and observed Resident 1 having a hard time breathing, complaining of shortness of breath, holding to her chest, and verbalizing she was not feeling well and needed help. CNA 1 stated he went to report Resident 1's condition to the Licensed Vocational Nurse (LVN 1) on [DATE] at 11:00 a.m. CNA 1 stated LVN 1 went to Resident 1's room to check Resident 1's vital signs. During a concurrent interview and record review on [DATE] at 11:05 a.m., with LVN 2, a text messages sent by LVN 1 and LVN 2 to the Nurse Practitioner ([NP] a nurse who has advanced clinical education and training), dated [DATE] at 3:12 pm, were reviewed. At 3:12 p.m. LVN 1 sent a text message to NP which indicated Resident 1's was complaining of a throat ache. The text message indicated Resident 1's O2 saturation rate was 86 % (normal oxygen saturation was 95 %-100%) on room air, body temperature was 99 degrees Fahrenheit ([ F] a unit of temperature measure), blood pressure was ,d+[DATE], respirations were 22, and the pulse rate was 86. The text message indicated Resident 1's oxygen saturation went up to 94 % after administration of three liters per minute (L/min) of oxygen via nasal cannula (a device that delivers oxygen through a tube and into the nose), administered by the Registered Nurse Supervisor (RNS 1). LVN 2 stated she sent another text message right after LVN 1 indicated Resident 1's oxygen saturation was 92% on 3.0 L/min of oxygen via nasal cannula. LVN 2 stated she also sent text to the NP (both LVN 1 and LVN 2's texts were on the same thread on [DATE] at 3:12 pm text) about Resident 1's blood pressure of ,d+[DATE], pulse rate 83 and the O2 saturation rate dropped to 87 % while receiving O2 at three liters per minute via nasal cannula. LVN 2 stated Resident 1 complained of pain in the right lower abdomen and shortness of breath on [DATE] at 3 p.m. LVN 2 stated she reported Resident 1's change of condition to RNS 1 at 3 pm. LVN 2 stated RNS 1 and LVN 1 told her to monitor Resident 1's condition and if the condition worsened to send Resident 1 to the GACH. LVN 2 stated on [DATE] at 4 pm she reported Resident 1's COC to LVN 3 from incoming shift for 3 pm to 11 pm shift. LVN 2 stated on [DATE] at 5:21 pm the NP responded back by text message which indicated an order for COVID-19 (Coronavirus disease -a contagious respiratory infectious illness) test and a chest x-ray ( imaging of the chest). LVN 2 stated Resident 1 was weak and desaturating. LVN 2 stated any resident with an O2 saturation below 90 % on room air with a complain of chest pain and shortness of breath should have been transferred to GACH for further evaluation and treatment. LVN 2 stated she does not know why Resident 1 was not sent to GACH when Resident 1 had a O2 saturation of 86 % on room air and 87 % on oxygen at 3.0 L /min via nasal cannula. LVN 2 stated NP was not made aware of Resident 1's complained of abdominal pain and shortness of breath. LVN 2 stated at 7 pm she spoke with LVN 3 because she noticed Resident 1's oxygen saturation was not rising above 90 percent on 5.0 L/min of oxygen via nasal cannula and the blood pressure was fluctuating . LVN 2 stated she called the Director of Nursing (DON) around 7 p.m. on [DATE] and was instructed by the DON to call 911 (emergency number) to transfer Resident 1 to the GACH. LVN 2 stated Resident 1 started to complain of chest pain during the time 911 was called. LVN 2 stated she should have call 911 immediately when Resident 1 O2 saturation was 87% while receiving oxygen at 3.0 L/min and complained of shortness of breath. A review of the text messages communication between LVN 1, LVN 2, and NP on [DATE], at 3:12 p.m., indicated the text sent to the NP indicated Resident 1 had BP of ,d+[DATE] and O2 saturation of 87%. There was no text notifying the NP of Resident 1 having a chest pain and shortness of breath. A review of Resident 1's medical record written account of resident health history) indicated the nursing staff did not document the time the resident's vital signs were taken on [DATE]. During a concurrent interview and record review on [DATE] at 12:17 p.m., with LVN 1, the LVN 1 stated on [DATE] between 11 a.m. and 12 p.m. Resident 1 complained of weakness. LVN 1 stated he did not have time to take Resident 1's VS because he had other residents to take care of. LVN 1 stated at 1:24 p.m., he gave Resident 1 Tylenol Extra Strength (pain medication) 500 milligrams ([mg] a unit of weight measurement) for generalized body pain. LVN 1 stated at 2:30 p.m., CNA 1 came to him again and told him Resident 1 was not feeling well. LVN 1 stated the Tylenol was not working and Resident 1 looked weaker. LVN 1 stated he notified (RNS) 1 of Resident 1's condition. LVN 1 stated at 2:40 p.m., Resident 1's vital signs were taken, and the resident's temperature was 99.5 F, blood pressure was ,d+[DATE], respirations were 22, and O2 saturation was 86 % on room air. LVN 1 stated Resident 1 was placed on oxygen at 3.0 L/min via nasal cannula and the head of the bed was elevated to facilitate a better breathing. LVN 1 stated on [DATE] at 3:12 p.m., a group text message (LVN 1 and LVN 2) was sent to the NP, but NP did not respond. LVN 1 stated when Resident 1 had O2 saturation of 86% the resident's physician should have been notified and if the physician would have not responded she should have called the medical director (physician who provides guidance and leadership). Reviewed Resident 1's H&P with LVN 1 indicated to call 911 when resident experiences chest pain, shortness of breath, loss of consciousness, change in vision, severe headache, or other alarming symptoms. LVN 1 stated Resident 1 should have been transferred to a higher level of care, the GACH, from the onset of Resident 1's complains of a chest pain and O2 saturation rate of 86 % as the facility was unable to provide care to the resident. During an interview on [DATE] at 3:24 p.m., LVN 3 stated LVN 1 informed her on [DATE] (time unknown) of Resident 1's O2 saturation of 86 % on room air. LVN 3 stated she did not administer Resident 1 blood pressure medication as the resident's BP was ,d+[DATE] at 5 p.m. LVN 3 stated LVN 2 reported to her Resident 1 had chest pain on [DATE] at 4 p.m. LVN 3 stated she told LVN 2 to call 911. LVN 3 stated she did not call 911 herself because she did not want to overstep the boundaries with LVN 2, who was a charge nurse that evening shift. LVN 3 stated she should have called 911 and transfer Resident 1 to GACH when Resident 1 had O2 saturation of 86 % with receiving O2 at 3 L/min via nasal cannula, complained of shortness of breath and chest pain. During an interview on [DATE] at 12:03 p.m., RNS 1 stated on [DATE] at 2:45 p.m., LVN 1 asked for assistance with Resident 1 because the resident's O2 saturation was 86 % on room air. RNS 1 stated she was not aware of Resident 1's low blood pressure of ,d+[DATE], and oxygen saturation of 87 % on oxygen 3.0 L/min via nasal cannula. RNS 1 stated she would have sent Resident 1 to the GACH if she had known the resident's blood pressure was low and the O2 saturation was below normal values. RNS 1 reviewed the physicians' orders and stated Resident 1 was transferred to the hospital for desaturation and chest pain on [DATE] (unspecified time). Resident 1 had a roommate Resident 2. 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 epilepsy (a brain condition that causes recurring seizures), pancytopenia (a significant reduction in the number of almost all blood cells), muscle weakness and colitis (swelling or inflammation of the large intestines). During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 2 had the ability to make self-understood and the ability to express needs and wants. The MDS indicated Resident 2 had the ability to understand others and had clear comprehension (the ability to understand completely). The MDS indicated Resident 2 required substantial to maximal assistance from staff with toileting hygiene, showering, lower body dressing, and putting on and taking off footwear. During an interview on [DATE] at 11:20 a.m., with Resident 2 (Resident 1's roommate), Resident 2 stated Resident 1 was complaining of shortness of breath and unable to move her leg on [DATE] afternoon (cannot remember exact time). Resident 2 stated Resident 1 was having trouble breathing despite receiving oxygen. Resident 2 stated Resident 1 was having shortness of breath in the afternoon but was not transferred to a GACH until the evening of [DATE]. Resident 2 stated Resident 1 was also complaining of pain but does not know the exact location. During an interview on [DATE] at 12:03 p.m., with the DON, the DON stated she received a call from LVN 2 on [DATE] at 7 pm stating Resident 1 looked uncomfortable but was not in distress (emotional, social, spiritual, or physical pain or suffering). The DON stated she told LVN 2 to call 911 and transfer Resident 1 to GACH because Resident 1's vital signs were not at her baseline and did not consider Resident 1 to be in stable condition. The DON stated if a resident was complaining of shortness of breath, chest pain and desaturation of 86 % licensed staff should not delay the transfer of the resident to GACH. The DON stated the vital signs are monitored every shift and as needed and must be documented at the time the vital signs were taken. The facility did not provide a policy for monitoring vital sign when asked. During a review of Resident 1's Nurses Progress Notes, dated [DATE] and timed at 3:30 p.m., the Nurses Progress Notes indicated, the incoming shift (3 p.m. to 11 p.m.) was given report to continue monitoring Resident 1's O2 saturation and if the condition did not improve to send Resident 1 to GACH and inform the family. During a review of Resident 1's Nurses Progress Notes, dated [DATE] timed at 5:00 p.m., the Nurses Progress Notes indicated, Resident 1's blood pressure was fluctuating, and the O2 saturation ranged from 89 % to 91 % while receiving oxygen via nasal cannula. The Nurses Progress Note indicated Resident 1 had abdominal pain level rated five out of 10 and generalized weakness. The Nurses Progress Notes indicated Resident 1 was sent out to the hospital via 911 (time not indicated) due to desaturation and chest pain. During a review of Resident 1's Nurses Progress Note, Discharge Summary, dated [DATE] timed at 8:02 pm, the Nurses Progress Note indicated, Resident 1's had a fever, shortness of breath, fluctuating blood pressure, left sided pain, and difficulty catching her breath. The Nurses Progress Note Discharge Summary indicated Resident 1 complained of chest pain and the blood pressure dropped to ,d+[DATE], pulse 83, O2 saturation of 87 %. The Nurses Progress Note, Discharge Summary indicated when Resident 1's vital signs were rechecked the oxygen and blood pressure continued to fluctuate (change continually). The O2 saturation ranged from 87 % to 90 % on oxygen at 3.0 L/min via nasal cannula. The Nurses Progress Note Discharge Summary indicated Resident 1's blood pressure rose to ,d+[DATE] and dropped to a blood pressure of ,d+[DATE] and pulse 96 in less than 10 minutes. The Nurses Progress Note, Discharge Summary indicated Resident 1 was administered oxygen at 5.0 L/min via nasal cannula, but the oxygen saturation did not rise above 90 %. The Nurses Progress Note, Discharge Summary indicated LVN 2 called the DON for guidance and the DON informed LVN 2 to call 911 and send Resident 1 to the GACH. The Nurses Progress Note, Discharge Summary indicated on [DATE] at 7:06 pm 911 was called and Resident 1's blood pressure reading was ,d+[DATE], pulse 98, temperature 98.4, and oxygen saturation 91 percent on oxygen 5.0 L/min. The Nurses Progress Note, Discharge Summary indicated the paramedics arrived at the facility at 7:15 pm, Resident 1 was assessed, and the resident's oxygen saturation was 87% on 5.0 L/min via nasal cannula. During a review of Resident 1's Emergency Department (ED) Physician's Notes, dated [DATE], the ED Physician's Notes indicated, Resident 1 was brought to the ED at 7:42 pm by ambulance. The ED Physician's Notes indicated, Resident 1 had left chest pain and left abdominal pain level rated eight out of 10 on a pain scale rating. The ED Physician's Notes indicated Resident 1 complained of shortness of breath and on [DATE] at 7:47 p.m., Resident 1's O2 saturation was 79% on room air, the heart rate was 102 beats per minute and Resident 1 was administered oxygen with a non-rebreather mask (a device used to deliver higher concentrations of oxygen). The Physician's Notes indicated, Resident 1 had shortness of breath and became acutely altered, the resident stopped breathing and became bradycardic down to the 20's. Resident 1 was not spontaneously breathing and eventually had no cardiac activity. The ED Physician's Notes indicated a chest compressions were immediately started, and Resident 1 was intubated (a medical procedure that involves inserting a flexible plastic tube down a person's throat to open the airway and give oxygen). The CPR was continued from 8:36 p.m. to 9:04 p.m. After multiple rounds of medication and progression from asystole (when the heart has no electricity or movement and no heartbeat) to ventricular fibrillation (an abnormal heart rhythm in which the ventricles of the heart quiver) and back to asystole, a decision was made to stop CPR. The time of Resident 1's death was declared at 9:04 pm. During a review of the facility's policy and procedure titled, Change of Condition, dated 2016, the P&P indicated, Call 911 if the initial assessment indicates such action is necessary and this intervention is in accordance with existing Advance Directives (provide instructions for medical care if resident cannot communicate own wishes) / Physician Orders for Life-Sustaining Treatment ([POLST] written medical order from a physician that helps patients get the medical treatments they want). During a review of the facility's Registered Nurse Job Description, revised on [DATE], the Registered Nurse Job Description indicated, The Registered Nurses to provide accurate assessment, over-sight, and monitoring of patients for quality medical management and early detection of change in condition. Utilizes professional standards in performing clinical assessment and monitoring in accordance with scope of licensure. Recognizes and appropriately responds to emergent and significant change in condition and completes documentation as required. Identifies and acts upon unsafe situations . During a review of the facility's Licensed Nurse Job Description, revised on [DATE], the Licensed Nurse Job Description indicated, The Licensed Nurse to provide accurate assessment, over-sight, and monitoring of patients for quality medical management and early detection of change in condition. Responds promptly to evaluate and remedy patient concerns and complaints and manages and documents accordingly. Utilizes professional standards in performing basic assessment and clinical monitoring in accordance with scope of licensure. Recognizes and appropriately responds to emergent and significant change in condition and completes documentation as required. Identifies and acts upon unsafe situations .

Based on interview and record review, the facility failed to: 1. Ensure Certified Nursing Assistant (CNA 4) immediately initiated Resident 1's cardiopulmonary resuscitation [(CPR) an emergency procedure that can help save a person's life if their breathing or heart stops] when Resident 1 was found unresponsive, with no pulse (no heartbeat), and not breathing on [DATE] at 7:50 a.m. Resident 1 was Covid-19 (a highly contagious infectious disease that can affect various systems of the body) positive and was on isolation (separation of an infected resident to prevent further infection transmission). 2. Ensure Registered Nurse (RN 1), the Director of Staff Development (DSD 1), Licensed Vocational Nurse (LVN 1), who were summoned by CNA 4 to Resident 1's room, did not delay initiation of Resident 1's CPR while the Director of Nursing (DON) had to verify/confirm Resident 1's code status (Resident's or resident's representative's wishes on the type of resuscitation procedures, if any, they would like the health care team to conduct if their heart stops beating or they stop breathing) in Resident 1's electronic medical record first. The DON did not determine Resident 1's code status until 8:11 a.m. (approximately 21 minutes after Resident 1 was found unresponsive). 3. Have a system in place to immediately identify residents' code status during an emergency that warrants initiation of CPR without loss of valuable time to implement life saving measures. These deficient practices resulted in delayed provision of emergency resuscitation for one of two sampled residents (Resident 1) and placed 51 current residents, who had CPR status, to receive life saving measures immediately without a loss of valuable time for being successfully revived. On [DATE] at 1:56 p.m., the survey team called an Immediate Jeopardy (IJ) situation (a situation in which the facility'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) in the presence of the Administrator (ADMIN) and Director of Nursing (DON). On [DATE] at 7:12 p.m., the facility provided with Immediate Jeopardy Removal Plan (IJRP) with immediate actions including: 1. On [DATE], All Residents were checked. And we identified 17 DNR and 53 Full Code residents. 2. On [DATE], Facility DON, DSD, or Designee audited the CPR certification (credentials that qualify the holder to perform life-saving measures on someone who's heart has stopped beating) status of Licensed Nurses and CNAs to identify any individuals without evidence of adequate CPR training. All nursing were found to have current and updated CPR. 3. Residents who experience a code blue (a system/signal used to indicate a patient requires resuscitation or needs immediate medical attention) situation have the potential to be affected by delayed CPR. Facility will implement a Quality Assurance (QA) record review process to proactively review each Code Blue case within 72 hours of an emergency occurrence. 4. On [DATE], an audit was conducted of each Resident's electronic health record (EHR) to evaluate compliance with facility system of immediately communicating code status via EHR Code Status dashboard (computer screen with summarized vital resident information); and no residents were found to be absent code status information. 5. On [DATE], Licensed Nurses and CNAs received re-training by facility DON, DSD, and Resource Nurse on current American Heart Association CPR guidelines, facility CPR policy, and designated system for immediately identifying code status (within EHR - Code Status Dashboard) through [DATE]. Anyone who is not able to attend training will be in serviced prior to the start of their shift. 6. On [DATE], Licensed Nurses was provided re-training on properly designating code status within the EHR Code Status Dashboard upon admission and with CPR/Advance Directive (a written statement of a resident's wishes regarding medical treatment, made to ensure those wishes are carried out should the resident be unable to communicate them) status changes. 7. On [DATE], Medical Records staff audited code status orders of all residents to facilitate compliance with Point Click Care (PCC)Code Status Dashboard as indicated. 8. Upon a resident admission, admitting nurse will initiate the Physician Orders of Life Sustaining treatment (POLST - a written medical order from a physician for life sustaining treatment), Social Services Director (SSD)/designee will follow-up and check for completeness and MD signature. Resident will be considered full code until POLST is complete. 9. Each week, the facility Health Information Manager (HIM), or designee will audit (check) new admissions and new code status orders to facilitate compliance with EMR Code Status Dashboard [Alerts]. Completed audits will be placed at the Nurses Station for follow-up. 10. The DON, or designee will complete QA audits of Residents receiving Code Blue services to establish compliance with providing immediate CPR if order exists or obvious signs of clinical death are present. Audits will be completed each week for four weeks, then monthly for two months, then no less often than quarterly for three quarters, or until substantial compliance is maintained. 11. The DSD/designee will review valid CPR certification of all nursing staff annually. 12. Health Information Manager(HIM) and DON will be responsible for reporting audit compliance to the facility Quality Assurance and Performance Improvement (QAPI) Committee no less often than quarterly for trend identification, action planning, and on-going monitoring needs as indicated. Findings: A review of Resident 1's Admission Record (AR) indicated Resident 1 was admitted on [DATE] with diagnoses including hemiplegia (weakness of one side of the body), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and diabetes mellitus (the body's inability to efficiently process sugar for energy). A review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care planning tool) dated [DATE] indicated Resident 1 was severely cognitively (thinking and reasoning) impaired and required extensive assistance with activities of daily living (ADLs - eating, personal hygiene, getting dressed and toileting). A review of Resident 1's POLST dated [DATE], indicated if the resident had no pulse and was not breathing do not attempt to resuscitate. (DNR). During an interview on [DATE] at 11:41 a.m. with CNA 4, CNA 4 stated on [DATE] at around 7:50 a.m. when she brought Resident 1's breakfast tray, he did not respond to verbal stimuli, and CNA 4 called LVN 1 to evaluate Resident 1. CNA 4 stated LVN 4 and the DON came to the room. CNA 4 was not aware of Resident 1's code status at the time of the event. CNA 4 stated the code status is available in the EHR located at the nurses' station. During an interview on [DATE] at 1:01 p.m., with LVN 1, LVN 1 stated she was called by CNA 4 to Resident 1's room where LVN 1 found Resident 1 unresponsive and LVN 1 was unable to get any Resident 1's vital signs (measurements of the body's' basic functions breath, heart rate and temperature). LVN 1 stated the Resident 1's code status had to be verified prior to initiating CPR. LVN 1 stated she would need to go to the nursing station, log into the computer to find a resident code status documented on the POLST in EMR before knowing to initiate or not initiate CPR. Resident 1 had status of DNR and staff did not know Resident 1's code status until 21 minutes after the resident was found unresponsive. During an interview on [DATE] at 1:34 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated she responded to the emergency call to Resident 1's room. RNS 1 stated Resident 1 was not responding (to anything that would evoke a reaction in a healthy person) and had no pulse. RNS 1 stated she would need to know a resident's code status prior to initiating CPR which can be found in a resident's EMR, therefore, she did not initiate Resident 1's CPR right when the resident was found unresponsive and pulseless. During an interview and concurrent record review of Residents 1 code status on [DATE] at 3:33 p.m., with CNA 5, CNA 5 stated a resident's code status can be found in a resident's Electronic health record (EHR) but unable to find it right now. CNA 5 was observed demonstrating how to find a resident's code status in EHR dashboard. CNA 5 had to look through a couple of residents' EHR's before she could find a random resident with their code status in the dashboard of the EHR. CNA 5 stated EHR dashboard did not indicated the code status for all residents especially Resident 1. During an interview on [DATE] at 3:40 p.m. with HIM, HIM stated a resident's code status entered on EHR dashboard when the licensed nurse enters the order for a resident's code status. HIM stated that if it was not entered by the licensed nurse code status will not be in the resident's record. During an interview on [DATE] at 4:14 p.m., with LVN 4, LVN 4 stated a resident's code status can be found in the EHR. Concurrently LVN 4 was observed demonstrating how to find the code status on EHR dashboard. During the demonstration Resident 1's code status was missing on EHR dashboard. LVN 4 was observed looking under the Documents Section of the EHR scrolling through numerous documents to find Resident 1's POLST. During an interview on [DATE] at 9:51 a.m., with DON, the DON stated during a code blue, one licensed nurse checks for the code status order in the EHR. The DON stated a resident's code status can be found on EHR dashboard or in the documents section on the POLST document. In a subsequent interview at 12:10 p.m., the DON demonstrated how to find the code status of Resident 1. During the demonstration, the DON could not find Resident 1's code status on HER dashboard and had to check for Resident 1's POLST under the Documents Section. The DON stated if there is no code status on the dashboard and there is no POLST under the Documents Section, then the resident is considered a full code (requiring CPR). During an interview on [DATE] at 9:03 a.m., with the DSD, the DSD stated when he responded to the emergency in Resident 1's room, the staff were unaware of the resident's code status and did not start CPR until Resident 1's code status was verified. The DSD stated the DON verified Resident 1's the code status in the EHR in the computer located at the nurse's station. The DSD stated the DON informed the responding staff Resident 1 was DNR resulting in no initiation of CPR. During an interview on [DATE] at 11:19 a.m., with the Medical Director (MD), the MD stated he is unsure if the facility has a way to immediately identify the code status of the residents. The MD acknowledged the facility should have a method to immediately identify the resident's code status. The MD confirmed CPR should be initiated immediately. During an observation on [DATE] at 12:25 p.m., outside of Resident 1's room, the distance between the nurses' station and Resident 1's room was measured and was approximately 16 feet away or one minute walk. A review of an online article titled, American Heart Association 2020 CPR and Emergency Cardiovascular Care Committee (ECC) Guidelines, the article indicated if there was no breathing, or only gasping, and pulse not felt, to immediately begin CPR and perform cycles of thirty chest compressions and two breaths. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines A review of an online article titled, CPR success rate: how effective is CPR?, dated [DATE] indicated CPR ensures long-term survival when it is performed immediately and correctly. https://www.mycprcertificationonline.com/blog/cpr-success-rate A review of the facility's policy and procedure. titled Emergency Care, General Guidelines for dated 2006, indicated to initiate CPR unless resident's advance directive indicates refusal of CPR.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) receiving hemodialysis [(HD) a treatment to filter wastes and water from the blood], received dialysis care and services by failing to: 1. Ensure Resident 1 received hemodialysis care, treatment, and services three times a week (every Tuesday, Thursday, and Saturday) from an off-site HD center as ordered by the physician and in accordance with the Hemodialysis Care Plan initiated on 7/22/2022. 2. Notify Resident 1 ' s physician of missed HD treatment and services on 12/13/2022, 12/14/2022 and 12/15/2022. The resident ' s last HD treatment was on 12/10/2022. 3. Ensure Resident 1 was transported to and from an off-site HD center. 4. Designate a staff to coordinate dialysis treatment and services for Resident 1. The Social Services Director (SSD), Case Manager (CM), licensed vocational nurse (LVN 1) and Director of Nursing (DON) were unable to verbalize who should be the designated person to ensure Resident 1 received dialysis services in an off-site HD center as scheduled. 5. Contact and communicate with the COVID-19 (an infectious disease caused by a virus) HD center dialysis staff that Resident 1 could not go to the COVID-19 HD center for the re-scheduled dialysis treatment on 12/14/2022 at 6:30 p.m. due to problems in transportation. These deficient practices resulted in Resident 1 receiving a diagnosis of hyperkalemia (higher than normal level of potassium [maintains normal levels of fluid inside cells of the body] in the bloodstream that can lead to heart rate irregularities leading to cardiac arrest [heart stops] and death. Severe hyperkalemia is life threatening especially in patients with renal failure [when the kidneys lose the ability to remove waste and balance fluids]) with a value of 8.4 mmol/L (millimole per liter, a unit of measure. Normal range 3.5 - 5.1 mmol/L) and emergent HD on 12/16/2022 after being transferred to a general acute care hospital (GACH) on 12/16/2022. On 12/22/2022 at 6:30 p.m., the Department of Public Health (DPH) called an Immediate Jeopardy (IJ, a situation in which the facility'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) situation for the facility ' s failure to ensure Resident 1 received dialysis care and services, in the presence of the DON, Director of Staff Development (DSD), Social Service Director (SSD), Dietary Supervisor (DS) and Business Office Manager (BOM). On 12/23/2022 at 4:30 p.m., the Department of Public Health removed the IJ while onsite in the presence of the DON and Nurse Consultant after verifying and confirming the implementation the facility ' s IJ removal plan which included: 1. All dialysis residents (a total of 4) was reviewed by the Director of Nursing on 12/23/2022 to ensure current transportation arrangements are meeting dialysis needs in accordance with the physician ' s orders. 2. Each business day, the DON and Registered Nurse (RN) Supervisor will conduct a clinical management meeting and identify any dialysis transportation issues that potentially affect the care and services provided to dialysis patients. The Director of Nursing will be responsible for facilitating complete and timely physician, responsible party, and dialysis clinic notifications; and ensuring dialysis transportation contingencies are provided timely as indicated. 3. The facility reviewed their contract with the GACH to provide emergency or contingency hemodialysis treatments in the event hemodialysis clinics are unable to provide HD. 4. Facility will utilize Transportation Company 1 and Transportation Company 2 to provide emergency or contingency transportation in the event existing transportation arrangement is unable to provide services. 5. For COVID-19 positive residents, back-up dialysis centers, HD Center 1 and HD Center 2, were identified and will provide dialysis treatment. 6. Interdisciplinary Team (DON, Social Services Director, MDS [Minimum Data Set] Nurse, licensed staff, and the DSD was provided education with the Nurse Consultant on responsibilities in implementing a plan of care to meet Resident 1 ' s dialysis needs in accordance with physician orders, and on communicating HD and or transportation continency plans via individualized plans of care. 7. Utilization of daily compliance Quality Assurance (an on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards) tool implemented on 12/23/2022. Findings: During a review Resident 1's Admission Record (Face Sheet), the record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD, when kidneys are no longer able to function to meet the body ' s needs), hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), diabetes mellitus (abnormal blood sugar), and gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) of left first (1st) and second (2nd ) toes. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 11/9/2022, the MDS indicated Resident 1's cognition (ability to think, understand and reason) was intact. The MDS indicated Resident 1 required extensive assistance (the resident was involved in activity; staff provide weight bearing support) from one staff with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 1 ' s Hemodialysis Care Plan (CP), initiated on 7/22/2022, the CP indicated interventions including dialysis treatments three times a week (Tuesday, Thursday, Saturday) at 12:30 p.m. via arteriovenous shunt (AV Shunt- a U-shaped plastic tube inserted between an artery and a vein) with pick up time (at the facility for transportation to the off-site HD center) at 11 a.m. During a review of Resident 1 ' s physician ' s order dated 10/20/2022, the physician order indicated Resident 1 to receive dialysis treatment three times a week at 12 p.m. (every Tuesday, Thursday, and Saturday). During a review of Resident 1's SBAR (Situation-Background-Assessment-Recommendation, a tool for communication between members of the health care team about a resident's condition) Communication Form, dated 12/15/2022, at 3 p.m., the SBAR indicated, Resident 1 had abdominal pain of 7 out of 10 (a numeric pain scale with zero for no pain, 7 for severe pain, and 10 for worst imaginable pain), diarrhea (watery stool), and blood in stool. The SBAR, dated 12/16/2022, at 12 a.m., indicated Resident 1 complained of abdominal pain 10 out of 10, with dark stools four times in two hours. During a review of Resident 1 ' s ER (emergency room ) physician ' s note from the GACH, dated on 12/16/2022, the ER physician ' s note indicated laboratory values from blood tests: potassium 8.4 mmol/L with hyperkalemia, Blood Urea Nitrogen (BUN, a test that measures the amount of urea nitrogen in the blood. Urea nitrogen is a waste product that the kidneys remove from the blood. High BUN level means the kidney are not working well) 250 mg/dL (milligrams per deciliter, a unit of measure. Normal range 7 - 18 mg/dL), creatinine (a waste product produced by muscles. Creatinine stays in the blood until the kidneys eliminate them) 16.96 mg/dL (normal range 0.70 - 1.30 mg/dL), and severe acute upper gastrointestinal bleed. During an interview on 12/21/2022, at 10:15 a.m., with Social Service Director (SSD), the SSD stated, each resident ' s insurance company arrange each resident ' s transportation. SSD stated, the insurance company needed to be notified to arrange transportation 48 hours to 72 hours in advance. SSD stated, the facility has contracts with two emergency transportation companies (Transportation Company 1 and Transportation Company 2), but these transportation companies could not guarantee to transport the resident. The SSD stated the facility only utilized these transportation companies (Transportation Company 1 and Transportation Company 2) for emergencies. During an interview on 12/21/2022, at 11:20 a.m., with Case Manager (CM), stated, Resident 1 missed HD appointment on 12/13/2022 (Tuesday) because the resident was tested positive for COVID-19 (a contagious disease caused by a virus) on 12/12/2022. The CM stated Resident ' s 1 ' s regular HD center referred Resident 1 to a COVID-19 HD center and an appointment was made for 12/14/2022 (Wednesday) at 6:30 p.m. The CM stated, the transportation company (TC) could not accommodate Resident 1 ' s transportation needs, resulting in Resident 1 missing the appointment on 12/14/2022. The CM stated there was no follow -up HD appointment made for 12/15/2022 (Thursday) because the follow up appointment was a nursing responsibility. The CM stated Resident 1 should have transferred to GACH on 12/14/2022 after the missed appointment for emergency HD (on 12/14/2022 at 6:30 p.m.). During a phone interview on 12/21/2022, at 2:50 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 ' s HD appointment with the COVID-19 HD center on 12/14/2022 was missed due to a transportation issue. LVN 1 stated she noticed Resident 1 had two dark and loose stools during the 3-11 shift (evening shift) on 12/15/2022. LVN 1 stated an SBAR report was not completed on 12/15/2022 and the physician was not notified regarding Resident 1 ' s missed HD appointments (on 12/13/2022, 12/14/2022, and 12/15/2022) or incident of having dark stools (on 12/15/2022). LVN 1 stated, the SSD oversees the HD appointment of residents receiving dialysis and follow up with transportation (to and from the HD center). LVN 1 stated, missing HD appointments could result in life threatening issues due to electrolyte imbalance (an elevated or reduced amount of certain salts and minerals in your body). During a phone interview on 12/21/2022, at 3:28 p.m., with HD Registered Nurse (RN 2) from the COVID-19 HD center, the HD RN 2 stated, Resident 1 was a no show for a scheduled appointment on 12/14/2022 (at 6:30 p.m.). The HD RN 2 stated, there was no documentation indicating LVN 1 called and notified the HD center that Resident 1 was unable to be transported to the COVID-19 HD center. The HD RN 2 stated the COVID-19 HD center was only open on Monday, Wednesday, and Friday from 6:30 p.m. to 8:00 p.m. During a telephone interview on 12/22/2022, at 12:03 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated on 12/15/2022 during the night shift (11 pm to 7 am) shift change, LVN 4 received report from LVN 1 stating Resident 1 was having multiple dark stools and complaining of 10 out of 10 (10/10) abdominal pain. LVN 4 stated, an attempt was done to contact the primary physician (PD) (who is also the Medical Director), but LVN 4 did not receive a call back from PD on multiple attempts. LVN 4 stated, on 12/15/2022 at 11 p.m. Resident 1 was screaming from 10 out of 10 abdominal pain and was having multiple dark stools with some blood. LVN 4 stated Resident 1 was transferred to the GACH emergency room (ER) via 911 (a telephone number for emergency services) on 12/16/2022 at 2:05 a.m. per facility ' s protocol. LVN 4 stated, missing HD appointments was concerning because high potassium level could cause heart attack (a deadly medical emergency where there is blockage of blood flow to the heart muscle which can cause the heart to stop). During a concurrent interview and record review of the Emergency Preparedness Plan (EPP), dated 2022 with Director of Nursing (DON), on 12/22/2022 at 12:30 p.m., the DON stated, the facility did not have an EPP for COVID 19 positive residents with HD. The DON stated missing HD appointments could result in life threatening conditions like heart attack, kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), death, because body could not get rid of toxins (poisonous substances) without HD. During a telephone interview on 12/22/2022, at 4:34 p.m., with the primary physician (PD), the PD stated, he did not get any notification from the facility regarding Resident 1 ' s missed HD treatment and services (on 12/13/2022, 12/14/2022, and 12/15/2022, and change of condition on 12/15/2022. The PD stated, he would have ordered the resident to be transferred to the emergency room (ER) to receive emergency HD if he (PD) was informed regarding missed HD from 12/13/22 to 12/15/22. PD stated it was critically important to received HD according to the order and the schedule. A review of the article titled Missing Dialysis Treatment is Dangerous For Your Health, undated, from National Kidney Foundation website, indicated Your kidneys are responsible for helping to control your blood pressure and for keeping a safe balance of key minerals, such as potassium and phosphorus, in your body. Missing dialysis treatments places you at risk for building up high levels of these 2 minerals: High potassium, which can lead to heart problems including arrhythmia (irregular heart rate), heart attack (heart stops), and death. High phosphorus, which can weaken your bones over time and increase your risk for heart disease. In addition, if you miss your dialysis treatment, you may feel the effects of fluid overload, which include shortness of breath due to fluid in your lungs. If this happens, you may need to go to your hospital ' s emergency department for dialysis. During a review of the facility 's policy and procedure (P&P) titled, 'Hemodialysis Care, dated 9/2007, the P&P indicated, Facility and Dialysis Center Communication Guidelines: The facility and the dialysis center will communicate by telephone or in writing: Matters of difficulty with transportation Licensed Nurse -Managing Dialysis related complications: GI disturbances (diarrhea)-monitor for symptoms of electrolyte imbalance/ neurological symptoms, notify MD & dialysis clinic of manifested symptoms.

Based on observation, interviews and record review, the facility failed to ensure the resident, who had a wandering behavior, did not elope from the facility unnoticed and sustained a fall with abrasions to both knee while outside of the facility for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure the facility's exit doors Wander Guard alarm system was in working condition to alert staff when Resident 1 attempted to elope. 2. Ensure Resident 1's care plan was followed to recognize unsafe conditions. 3. Develop a policy and procedure for maintaining a Wander Guard alarm system in working condition. As a result of this deficient practice Resident 1, eloped from the facility on 9/25/21 unnoticed, fell from a wheelchair, and sustained abrasions to both knees. This deficient practice placed Resident 1 and other residents with wondering behavior at high risk for serious injury and death. On 9/27/21, the Department received a Facility Reported incident, (FRI) that Resident 1 was found outside of the facility on 9/25/21, at 5:25 p.m. lying on the ground next to a wheelchair, near the facility's parking lot area. A good Samaritan found Resident 1 and reported it to the facility staff. On 9/29/2021 at 2:31 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 in the presence of the facility's administrator (ADM), regarding the facility's failure to ensure its Wander Guard System was functional and in working condition to alert staff of residents' attempted to leave the facility building and prevent the elopement of residents with wandering behavior. On 10/3/2021, the ADM and the Director of Nursing (DON) submitted a Plan of Action (POA, immediate interventions to correct the deficient practices). On 10/3/2021, at 3:35 p.m., after the surveyor reviewed, and verified onsite POA implementations through the observation, interview, and record review the IJ was lifted in the presence of the ADM, DON, Director of Staff Development (DSD), and Maintenance Supervisor. Findings: On September 28, 2021, an unannounced visit was conducted to the facility to investigated FRI regarding Resident 1 elopement. A review of Resident 1's Admission Record indicated the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia (loss of memory and thinking abilities), anxiety disorder (mental health condition whereby the individual respond to things with fears) and altered mental status (confused mental functioning). A review of the Physician's order dated 4/18/21, indicated to apply a wander guard to Resident 1's lower right extremity and wheelchair for safety, and to check placement and function every shift. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 8/12/21, indicated the resident had severely impaired cognitive skills, (ability to reason and think) for daily decision making. MDS indicated Resident 1 depended on staff for activities for daily living and required two-person physical assistance and total assistance in the areas of bed mobility (how the resident moves in bed), toilet use, and personal hygiene. A review of the Elopement Risk Assessments dated 7/6/18, 4/18/19 and 9/27/21, indicated Resident 1 was assessed as a high risk for elopement. A review of Resident 1's care plan, dated 7/6/18, for the Potential Risk of Elopement Exit seeking behavior (with purpose to leave), indicated one of the interventions was to monitor the resident's whereabouts regularly and to recognize any unsafe conditions or escalating patterns. On 9/25/21 at 5:51 p.m , during an interview, CNA 1 stated unsafe conditions are situations that place the residents at risk of danger and injuries. CNA 1 stated the condition under which Resident 1 left the facility and was found outside lying on the ground was a very unsafe condition placing the resident at risk for danger and injuries. CNA stated that staff are trying to make sure this type of incident do not happen anymore because. A review of care plan dated 9/26/20, for the Potential Risk of Elopement Exit seeking behavior indicated Resident 1 was constantly seeking for the exit door, constantly wheeling self into the yellow area, constantly standing up unattended and was at risk for elopement, falls and injury. The care plan listed staff's approaches included to frequently visually observe and redirect Resident 1's behavior. A review of the nurses Progress Note dated 9/25/21, at 6 p.m. indicated Resident 1 was seen in the hallway by the kitchen door at approximately 5:05 p.m. and at 5:15 p.m. a certified nursing assistant (CNA1) had served dinner to Resident 1 near the outside of the resident's room. Ten minutes later the CNA 1 approached the charge nurse (CN) asking if the nurse had seen Resident 1. At this point facility's staff began to search for Resident 1, until a good Samaritan rang the doorbell and notified staff that Resident 1 was outside on the street lying on the ground. The CNA 1 and other staff went out and found the resident lying on the ground next to a wheelchair. A Pull-Tab alarm (a pull-string that attached magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair the pull-string magnet is pulled away from the alarm causing the alarm to sound and alerting the caregiver) was attached to the wheelchair. Resident 1 was assessed and noted to have a right and left knee abrasion. During an observation on 9/28/21, at 1:20 p.m., Resident 1 was sitting up in a wheelchair eating lunch. The resident was observed to have abrasion to the right and left knee. Concurrently, during an interview, Resident 1 stated, I was out on the other side of the door and got cut on the knee until someone brought me back to the facility. During an interview on 9/28/21, at 1:21 p.m., DON stated the exit doors did not have a functioning Wander Guard alarm. DON stated that consequently the exit door alarm did not go off when the resident exited from the facility and therefore the staff did not know when the resident left facility. She further stated, Resident 1 did have a Wander Guard device attached to the left side of the wheelchair during the time of elopement. On 9/28/21, at 1:49 p.m., CNA 2 was observed wheeling Resident 1 to the exit door where the facility suspected Resident 1 had exited. During the observation the Wander Guard alarm did not activate and did not function. The maintenance supervisor (MS) was present during the observation on 9/28/21 at 1:49 p.m. and witnessed Resident 1 being wheeled outside and inside without Wander Guard alarm activation. The administrator and DON also were present and witnessed that the exit door Wander Guard alarm did not activate and was non-functional. Concurrently, during the observation on 9/28/21, Resident 2 was also wheeled through the same exit door and Wander Guard alarm did not active to produce warning sound and was did not function. This was witnessed by the MS, administrator, DON, and CNA 2. On 9/28/21, at 2:04 p.m. during an observation, Resident 1, who had a Wander Guard alarm device attached to her right hand and to the left side of the wheelchair was transported through the front door of the facility. The Wander Guard alarm did not sound to alert staff. The door alarm system was non-functional. At the same time, Resident 2, who also had a Wander Guard alarm device in place, for elopement risk was also transported through the same door with no alarm response. This was witnessed by the administrator, DON, MS, and CNA 2. On 9/28/21, at 3:26 p.m., during an interview, CNA 1 stated the incident happened on 9/25/21, at approximately, 5:05 p.m. Resident 1 was in the hallway, close to the nursing station. CNA 1 stated he was going to pass a tray to Resident 1 in the room, however, Resident 1 was not in the room at 5:25 p.m. CNA 1 then started to search for Resident 1 in all the other rooms. On 9/28/21 at 5:30 p.m., the CN told CNA 1 that someone was knocking at the front door entrance. When CN and CNA 1 answered the front door, a good Samaritan informed them Resident 1 was outside on the street lying on the ground by the pedestrian walk. CNA 1 stated they went outside and found Resident 1 laying down on the ground with a wheelchair on the right side of the resident. CN assessed Resident 1 and noticed the resident had abrasion to the right and left knee. CN and CNA 1 assisted Resident 1 back in wheelchair and brought the resident back to the facility. CNA 1 stated they did not hear any alarm sound when Resident 1 eloped from the facility through the back exit door, even though the door had installed Wander Guard alarm system. CNA 1 stated the exit door Wander Guard alarm was not working. CNA 1 continued stating that Resident 1 constantly wandered and was monitored every hour. CNA 1 had been assigned ten residents on the day of Resident 1's elopement and could not monitor Resident 1 frequently. CNA 1 stated Resident 1 had a Pull-Tab alarm on the wheelchair on the day of elopement. CNA1 stated residents identified with wandering behaviors should be monitored every 15 minutes to hourly, and all Pull-Tab alarms and exit door Wander Guard alarms must be always checked to ensure its working condition. On 9/29/21, a 12:30 p.m., during an interview, the DON stated the Wander Guard system can replace staff monitoring of residents with wandering behaviors. However, the facility policy is to monitor residents with elopement risk behavior every two hours. Also, she stated the Wander Guard alarm will alert staff of any elopement attempts by residents. On 9/30/21, at 4:11 p.m., during an interview, the licensed vocational nurse (LVN) stated the facility had four residents with wandering behavior. LVN 1 stated that on 9/28/21 at around 5:05 p.m. Resident 1 was seen wheeling self around the hallway. The dinner trays arrived between 5:10 p.m., and 5: 25 p.m. The assigned CNA 1 started to look for Resident 1's whereabouts and asked if I had seen the resident. While we were looking for Resident 1 throughout in the facility, a bystander rang the front door doorbell. A bystander informed that there was a resident outside the facility. We went outside and saw Resident 1 lying on the ground with wheelchair on the right side. We lifted Resident 1 from the ground and placed on the wheelchair with assistance of the CNA 1 and social service personnel. CN assessed Resident 1 and noted the resident had an abrasion injury on right knee. Resident 1 was offered pain medication, however, the resident refused. LVN 1 further stated Resident 1 always wanted to leave the facility and the alarm would normally go off but, on that day, the alarm did not sound so we did not know about Resident 1's elopement. LVN 1 stated the alarm failed and needed repair so that the elopement does not occur again. On 10/2/21, at 1:37 p.m., an onsite monitoring of the four-exit doors with installed Wander Guard alarm system was conducted to check for its working condition. The exit door alarms did not activate and were not working. A review of the facility's policy and procedure titled 'Elopement and Missing Resident' dated 12/2017, indicated to monitor and evaluate residents at risk for wandering and elopement. The interdisciplinary Team (IDT) is responsible for identifying residents at risk for elopement, implementing preventative measures to reduce risk, and provide a process for action if an incident of elopement occurs. The policy indicated staff are to do the following: a. To assess, monitor and manage resident safety specific to wandering and elopement b. Upon admission, assess each resident's wandering and elopement risk and initiate a care plan as appropriate. c. Initiate interventions to address resident's elopement risk, which may include implementing an electronic alert system such as a Wander Guard bracelet. d. Check placement of alert devices daily at minimum. e. Check alert devices for proper functioning weekly, at minimum. f. When a resident observed to moving toward an unsafe situation or exiting the facility, the nearest staff member, should intervene to redirect the resident and summon help. A review of the Manufacturers Instruction Guide, titled 'Wander Management Transmitters User Guide' indicated it is the responsibility of the facility to establish and facilitate a regular maintenance schedule to include regular inspection, testing and cleaning. The manufacturer recommended monthly maintenance and testing, and to keep records of maintenance and test completions. A review of the user guide indicated that failure to provide regular maintenance and testing of the product may result in equipment and/or system failure. The manufacture cautions indicated to not rely exclusively on the resident generated alarms for resident care and safety. The alarm function of equipment in the possession of residents must be verified periodically and regular resident surveillance is recommended. On 9/29/21 at 11:35 a.m., during an interview, the MS stated it was his responsibility to make sure that all alarm doors with Wander Guard system were always functional. The MS stated he performs weekly check every Friday on all the exit doors to test functionality of the exit doors, however. could not explain the oversight. As a result of the facility's failure to ensure the Wander Guard system was in working condition to alert staff when a resident attempted to elope, Resident 1 eloped from the facility unnoticed, fell out of a wheelchair, and sustained abrasions to both knees.

Based on interview and record review, the facility failed to notify a physician of a resident's refusal for respiratory care treatments and episodes of hyperventilation (rapid breathing) for one of three sampled residents (Resident 1). Resident 1, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in a delay of provision of care and an unexpected decline of Resident 1's health. Resident 1 had acute [CONDITION(S)] (deficiency of oxygen levels in the blood) resulting in hypercapnia (high concentration of [MEDICATION(S)] [a gas removed from the body through the lungs by exhalation] of the blood) requiring a transfer to a general acute care hospital (GACH) and died on [DATE]. On [DATE] at 12:16 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared in the presence of the administrator (ADM) and the Director of Nursing (DON). The ADM and DON were notified of the immediate action that needed to be taken and seriousness of Resident 1's health and safety threatened by the staff to identify a Change of Condition (COC). The facility submitted an acceptable POA on [DATE] of the IJ which included the following: 1. Facility Medical Director was notified of the Immediate Jeopardy on [DATE]. 2. Physical assessment was completed on Resident 2 with a [CONDITION(S)] machine to identify any changes in condition and notification was made to the physician. 3. The two Licensed nurses who were aware of Resident 1's significant change, but did not report to the physician, received in-services on physician notification, resident's refusal of treatments, COC of residents on [CONDITION(S)] machine, how to identify error messages in the [CONDITION(S)] machines and how to contact clinical support ([CONDITION(S)] Vendor/Respiratory Therapist [RT-specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine in order to work therapeutically with people suffering from acute critical conditions, cardiac and pulmonary disease]). 4. All licensed nurses were educated on resident's COC and physician notification regulations, use of [CONDITION(S)] machine including how to read error message and contact clinical support ([CONDITION(S)] machine vendor/RT) and facility policy and procedure prior to the start of their next regularly scheduled shift. Staff will not be permitted to work a shift until education is completed. 5. Certified Nursing assistants (CNA) will be educated on COC regulations to promote their situational understanding and facilitate communication with licensed nurses prior to their next regularly scheduled shift. Staff will not be permitted to work a shift until education is completed. 6. New hire licensed nurses will be educated on COC and physician notification regulations, use of [CONDITION(S)] machine including how to read an error message and contact clinical support ([CONDITION(S)] Vendor/RT) and new hire nurses' aides will be educated on change of condition regulations, as well as facility policy and procedure, accordingly. Staff will not be permitted to work until education is completed. 7. A Quality Assurance Performance Improvement ([QAPI] process used to ensure services are meeting quality standards and assuring care reaches a certain level) will implement a Performance Improvement Project (PIP) with a focus on physician notification of significant changes of residents on [CONDITION(S)] machine. The PIP will include implementation of daily DON/designee audits of the 24-hour report to monitor for change in resident condition of residents on [CONDITION(S)] machine. The DON/designee will also complete chart audits/health document assessment of three residents weekly for four weeks then; two residents weekly for two weeks then quarterly chart audit/health document assessment for the next two quarters. The regional/corporate/consultant nurse will visit the facility at least quarterly to provide general oversight and monitoring of the PIP. On [DATE] at 1:16 p.m., the IJ was removed in the presence of the ADM and DON after implementation of the acceptable POA were verified and confirmed on an onsite visit via observation, interview, and record review. Findings: During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care planning tool, dated [DATE], the MDS indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and understood others. The MDS indicated Resident 1 required extensive assistance of a one-person physical staff assistance for dressing, toileting, personal hygiene, and bed mobility (how the resident moves). During a review of Resident 1's electronic Medication Administration Record (eMAR), dated [DATE], the eMAR indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Once at nighttime, check heart rate (pulse), respirations, oxygen saturation, and remove per schedule. According to the EMAR, nursing staff signed placement of Resident 1's [CONDITION(S)] machine daily except for a single refusal on [DATE] at 9 p.m. The EMAR indicated Resident 1's [CONDITION(S)] machine was removed daily at 6 a.m. including the date of her death on [DATE]. During a review of Resident 1's care plan title, [CONDITION(S)], dated on [DATE], the care plan goal was for Resident 1 to not experience signs or symptoms of poor oxygenation absorption. The staffs' interventions included to monitor for signs or symptoms of respiratory insufficiency such as anxiety, confusion, restlessness, shortness of breath at rest, administer oxygen by nasal cannula (thin plastic tubing inserted in the nose to deliver oxygen) at 3 liters/per minute, [CONDITION(S)] machine on at 9 p.m. off at 6 a.m. wash tubing, headgear with whisper swivel if utilized, monitor for difficulty breathing on exertion, monitor and document oxygen saturation (percentage of oxygen absorbed in blood) every shift daily, monitor and document for anxiety, and give aerosol or bronchodilators (medication use to open the lungs and allow airflow) as ordered monitor and document any side effects or effectiveness. During a review of Resident 1's Nursing Progress Notes (NPN), dated [DATE] and timed at 12:57 p.m., the NPN indicated Resident 1's and the Resident's Family Member (FM 1) had verbalized something was wrong with the [CONDITION(S)] machine. The note indicated staff called [CONDITION(S)] distributer and spoke with a representative and provided all information and distributer will call resident to verify [CONDITION(S)] machine concerns. The note indicated a staff communicated with family member (FM 1) and Resident 1. During a review of Resident 1's Skilled Care Assessment (SCA), dated [DATE] and timed at 10:40 p.m., the assessment indicated Resident 1's vital signs were as follows: blood pressure (BP) of ,d+[DATE] (Normal Reference Range [NRR] ,d+[DATE]), body temperature of 97.8 Fahrenheit ([F] NRR 97.9 to 99), and heart rate of 74 beats per minute ([bpm] NNR ,d+[DATE] bpm), respirations of 17 (NRR ,d+[DATE]), oxygen saturation of 96% (NRR 95% to 100%) with oxygen via nasal cannula at 3 liters/minute. The assessment indicated Resident 1's was provided with return demonstration respiratory care and [CONDITION(S)] machine. The assessment indicated Resident 1 refused [CONDITION(S)] when offered, continuous oxygen at 3 liters/minute via nasal cannula for shortness of breath (SOB). Head of bed (HOB) slightly elevated, alert, and oriented verbalized needs and discomforts known. During a review of Resident 1's NPN, dated [DATE], and timed at 10:46 p.m. (created and written by Licensed Vocational Nurse [LVN 3] on [DATE] at 10:49 p.m.), the NPN indicated a call was received from the [CONDITION(S)] machine distributer around 3:30 p.m. regarding the [CONDITION(S)] machine having a leak. [CONDITION(S)] machine distributer assisted by phone on how to reset [CONDITION(S)] machine. [CONDITION(S)] machine distributer instructed [CONDITION(S)] was supposed to be on Resident 1 before being turned on. Explained to Resident 1 and was able to understand. [CONDITION(S)] machine placed on Resident 1 working properly with no leaks. During a review of Resident 1's SCA, dated [DATE] and timed at 6:55 a.m., the SCA indicated Resident 1's vital signs were BP ,d+[DATE], body temperature of 97.8 F, heart rate of 74, with respirations of 18, and oxygen saturation of 96 % with oxygen via nasal cannula at 3 liters/minute. The SCA indicated Resident 1 was not provided with return demonstration regarding respiratory care and the [CONDITION(S)] machine. The assessment indicated Resident 1 was alert and oriented able to make needs known. No acute distress noted, continuous oxygen at 3 liters/ minute via nasal cannula in place. Head of bed elevated, no shortness of breath or difficulty breathing noted, denied any pain or discomfort. Resident 1 was noncompliant with [CONDITION(S)] at night. During a review of Resident 1's NPN, dated [DATE], and timed at 9:20 p.m., the NPN indicated a text: devices [CONDITION(S)] machine on at 9 p.m. and off at 6 a.m., with nose pillow at bedtime once during the night check heart rate, respiration, and oxygen saturation and remove per schedule. Resident 1 keeps removing the [CONDITION(S)] when applied, risks and benefits explained but still refused. During a review of Resident 1's NPN, dated [DATE], and timed at 11:01 p.m. the NPN indicated Resident 1 was refusing to be connected to the [CONDITION(S)] machine because she could not tolerate the machine and it was causing her to have hyperventilation (breathe at an abnormally rapid rate). The NPN indicated Resident 1 preferred to be on nasal cannula and risks and benefits were explained but resident continued to refuse to use [CONDITION(S)] machine. Resident 1 saturating was 94 % on oxygen 3 liters/minute with nasal cannula. During a review of Resident 1's SCA, dated [DATE] and timed at 7:05 a.m., the SCA indicated Resident 1's vital signs were BP of ,d+[DATE], body temperature of 98.0 F, heart rate of 95, with respirations of 22, and oxygen saturation of 99 % via mask. The assessment indicated Resident 1 was not provided with return demonstration regarding respiratory care and the [CONDITION(S)] machine. The SCA indicated Resident 1 was alert and oriented, able to make needs known noted with shortness of breath (SOB) and [CONDITION(S)] exacerbation (the process of making a problem, bad situation, or negative feeling worse). HOB elevated continuous oxygen 3 liters/ minute via mask. Oxygen saturation 98 %, [MEDICATION(S)] ([[MEDICATION(S)]] used to treat anxiety disorders) given for hyperventilation. Resident currently stable and vital signs stable, denies any pain or discomfort currently. Resident 1 was noncompliant with [CONDITION(S)] machine at night. During a review of Resident 1's NPN, dated [DATE], and timed at 7:25 a.m. (created and written by LVN 2 at 3:59 p.m.), the NPN indicated Resident 1 received awake and alert with eyes open and responding to verbal and tactile (touch) stimuli. Resident 1 was noted on continuous supplemental oxygen at 3 liters/minute via nasal cannula and noted non-compliant with the use of the [CONDITION(S)] machine, explanations of purpose of machine provided. [SIC] During a review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR), dated [DATE], and timed at 8:20 a.m. (created and written by LVN 3 on [DATE] at 1:28 p.m.), the SBAR indicated upon making rounds around 8:15 a.m., Resident 1 was noted with shallow respirations, upon assessment noted oxygen levels at 70 % and nasal cannula placed at 3 liters/minute. Non-breathable mask was placed at 10 liters/minute full (100%) oxygen tank with oxygen level fluctuating from 92 to 94 %. Resident 1 was arousable, able to open eyes and nod, alert and verbally responsive to her name. HOB elevated, unable to grasp (siderail). Call placed to 911 (emergency services) continued monitoring while paramedics arrived. BP of ,d+[DATE], heart rate of 102, and respirations 32. The SBAR indicated Resident 1 had decreased consciousness (state of being awake and aware of one's surroundings), weakness, labored rapid shallow breathing, and low oxygen saturation. During a review of Resident 1's Fire Department Emergency Response record, dated [DATE] and timed at 8:25 a.m., the report indicated Resident 1 was in moderate respiratory distress with altered level of consciousness (ALOC) and SOB. According to the Fire Department emergency response record indicated Resident 1 was found in bed complaining of a loss of consciousness (LOC), respiratory distress. The report indicated staff members stated Resident 1 was not speaking or acting normal. The report indicated Resident 1's lung sounds were diminished on both sides. During a review of Resident 1's GACH Emergency Department (ED) records, date [DATE] and timed at 8:51 a.m., the GACH's ED note indicated Resident 1 arrived with altered mental status, difficulty breathing and SOB. On the initial evaluation, Resident 1 was tachypneic (rapid, shallow breathing), with poor air movement, lethargic but arousable. Resident 1 was placed on [CONDITION(S)] machine upon arrival to the ED and treated with duonebulizers (medication aerosol used to help treat airway narrowing) and steroids (medication to reduce inflammation) 9:36 a.m., Resident 1 went into cardiac arrest (the abrupt loss of heart function, breathing and consciousness) and CPR ([cardiopulmonary resuscitation] a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) was initiated unsuccessfully. At 10:06 a.m., on [DATE] (1 hour after admission to the GACH) Resident 1 had no spontaneous respirations, no pulse, and pupils were fixed (no reaction to light) and dilated (open) and was pronounced deceased . During an interview on [DATE] at 4:12 p.m., FM 1 stated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . FM 1 stated he repeatedly notified staff of the [CONDITION(S)] machine ineffectiveness. FM 1 stated on the morning of [DATE] after several text messages with no response from Resident 1, FM 1 placed a call to the facility at 8:08 a.m. (after the initial texts starting at 6 a.m.) and asked to speak to Resident 1 because he was concerned. FM 1 stated a staff member assured him Resident 1 was resting and did not want to wake her up. FM 1 stated receiving a call from the facility's staff at 8:40 a.m., 40 minutes after he had asked the staff to check on Resident 1, was notified Resident 1 was transferred to a GACH via 911 (emergency services). During an interview on [DATE] at 4:49 p.m., FM 2 stated during visitations at the facility with Resident 1, FM 2 witnessed Resident 1 notifying the nurses in the facility of the concerns with the [CONDITION(S)] machine not working. FM 2 stated the [CONDITION(S)] machine displayed error messages constantly, and the staff did not know how to set the [CONDITION(S)] machine. During an interview on [DATE] at 10:16 p.m., LVN 1 stated the [CONDITION(S)] machine was pre-set from the hospital prior to the resident's admission to the facility. LVN 1 stated on [DATE] she placed Resident 1 on the [CONDITION(S)] machine but was removed because Resident 1 refused to wear it. LVN 1 stated she documented the refusal on the eMAR and informed Resident 1 about the risks and benefits of refusing to wear the [CONDITION(S)]. LVN 1 stated she was made aware in different times during her shift of the [CONDITION(S)] not working. LVN 1 stated placing Resident 1 on 3 Liter of oxygen via nasal cannula after Resident 1 reported in two separate occasions she (Resident 1) was experiencing hyperventilation episodes and the [CONDITION(S)] machine was not helping her. LVN 1 acknowledged seeing the error message on the [CONDITION(S)] machine due to a leakage on the mask. LVN 1 stated the leakage meant Resident 1 did not have a proper seal on her mask and oxygen was leaking. LVN 1 stated she did not informed Resident 1's physician of the [CONDITION(S)]'s malfunction and Resident 1's refusals to use the [CONDITION(S)] due to not working properly. LVN 1 stated she gave report to the oncoming shift of Resident 1's refusal to wear the [CONDITION(S)] but not of the error message displayed on it. During an interview on [DATE] at 7:23 a.m., Certified Nursing Assistant (CNA 1) stated on [DATE] at approximately 8 a.m., she responded to Resident 1's call light and saw Resident 1 unresponsive and unable to wake up. CNA 1 stated she went to get LVN 3 to help Resident 1. CNA 1 stated LVN 3 could not wake up Resident 1 and provided care for Resident 1 by checking her vital signs and oxygen saturation. CNA 1 stated an oxygen tank was brought to Resident 1's room and other staff members responded to assist LVN 3. During an interview on [DATE] at 7:58 a.m., LVN 2 stated a report was received from the overnight Registered Nurse 1 (RN 1) of Resident 1's refusal to wear the [CONDITION(S)] machine. LVN 2 stated later that morning CNA 1, notified her of Resident 1 being found unresponsive. LVN 2 stated she went to Resident 1's room along with other staff members including LVN 3. LVN 2 stated Resident 1 was slow to respond, lethargic, and was opening her eyes when called by name. LVN 2 stated she and other staff members checked Resident 1's vital signs, along with the oxygen saturation was checked and it was low. LVN 2 stated a high flow oxygen mask was placed on Resident 1's face, and 911 emergency services were called because the resident was having difficulty breathing with unresponsiveness. LVN 2 stated Resident 1 was typically noncompliant with wearing the [CONDITION(S)] machine. LVN 2 acknowledged she did not call Resident 1's physician regarding the repeated refusals to wear the [CONDITION(S)] machine, and stated it was the responsibility of the nursing staff to notify the attending physician. During an interview on [DATE] at 8:36 a.m., CNA 2 stated on [DATE] at 12 a.m., she entered Resident 1's room to change her adult brief, upon providing care to Resident 1, CNA 2 noticed Resident 1 did not respond when she had greeted her, appeared tired and was only looking at her. CNA 2 stated she noticed Resident 1 was having difficulty breathing as if she was trying to catch her breath, she immediately left the room to call RN 1 and report Resident 1's appearance. CNA 2 acknowledged not observing the [CONDITION(S)] machine mask on Resident 1's face, only the nasal cannula. During an interview on [DATE] at 8:51 a.m., LVN 3 stated on [DATE], LVN 2 told her to check on Resident 1 because the resident was not her normal self. LVN 3 stated when she responded to Resident 1's room, Resident 1 was sitting in bed and having shallow respirations, 32 bpm and oxygen saturation levels of 78 %. LVN 3 stated a non-rebreather mask was placed on Resident 1's face and 911 emergency services called. LVN 3 stated a few days earlier during her work shift Resident 1 refused to wear the [CONDITION(S)] machine at bedtime but did not notify the physician of the refusal. During an interview on [DATE] at 9:47 a.m., RN 1 stated on the night of [DATE] the prior shift told him about Resident 1's refusal to wear the [CONDITION(S)] machine and she was administered [MEDICATION(S)]. RN 1 stated Resident 1 has shortness of breath with [CONDITION(S)] exacerbation, and she was placed on a non-rebreather mask. RN 1 stated the oxygen saturation was kept on Resident 1 during the time she had the non-rebreather mask on. RN 1 stated remembering Resident 1 experiencing labor breathing. RN 1 stated he took care of Resident 1 for four consecutive days and all four days Resident 1 refused to wear the [CONDITION(S)] machine. RN 1 stated Resident 1 did not wear the [CONDITION(S)] continuously and repeatedly refused to wear the [CONDITION(S)] machine. RN 1 stated he did not think it was necessary to call Resident 1's physician regarding the refusal to wear the [CONDITION(S)] machine. RN 1 stated he did not saw an error message on the [CONDITION(S)] machine. RN 1 stated the morning of [DATE] he endorsed to the oncoming nurse of Resident 1's experiencing [CONDITION(S)] exacerbation and to keep monitoring her oxygen saturation for any change of condition. During an interview on [DATE] at 1:32 p.m., in the presence of the facility's Administrator (ADM), the Director of Nursing (DON) stated during an Interdisciplinary Team meeting ([IDT] team members from different disciplines working collaborate) regarding Resident 1's plan of care, FM 1 notified her (the DON) something was wrong with the [CONDITION(S)] machine. The DON stated she placed a call to the [CONDITION(S)] machine distributer after she was notified by FM 1 and Resident 1 of the [CONDITION(S)] ineffectiveness. The DON stated a clinical representative returned the call to the facility to assist with the problems of the [CONDITION(S)] machine. The DON stated when the [CONDITION(S)] machine was delivered to the facility the machine was pre-set and the [CONDITION(S)] distributer did not provide training to the facility nursing staff. The DON stated the facility's nurses were not in-serviced on how to apply the [CONDITION(S)] machine for Resident 1. The DON stated on [DATE] Resident had an episode of hyperventilation with anxiousness and sat up on the edge of the bed, after refusing to wear the [CONDITION(S)] machine at bedtime. The DON acknowledged the nursing staff did not call the [CONDITION(S)] distributer for the error messages on the machine and Resident 1's physician regarding the refusal to wear the [CONDITION(S)] machine because the residents' oxygen saturation was OK. The DON also acknowledged the episode of hyperventilation with anxiousness was a change of condition. The DON stated Resident 1 received [MEDICATION(S)] for having anxiety and hyperventilation at 1:48 a.m. (on [DATE]) and there was no follow-up documentation until 7:25 a.m. The DON stated FM 1 called later in the day on [DATE] and notified the Social Services Director of Resident 1's death. During an interview on [DATE] at 2:28 p.m., the facility's Medical Director (FMD) stated when a [CONDITION(S)] machine was prescribed for a resident the Pulmonologist (physician who specializes in the respiratory system) determined the settings. FMD stated the licensed nurses', and the DON were normally familiar with the [CONDITION(S)] machine. FMD stated there was an ordered with a length of time for Resident 1 to use the [CONDITION(S)] machine at bedtime for sleep apnea. If the resident's machine was not working or displaying an error message, the licensed nurses should have called the attending physician and alert them of the problem. FMD stated if the resident was desaturating (low oxygen saturation), the facility staff should have sent the resident to the emergency room for further evaluation. FMD stated, when a resident refuse to wear their [CONDITION(S)], it was the responsibility of the licensed nurses' to call and alert the attending physician of the situation. FMD stated unfortunately, there was nothing to do but to document, but the attending physician should have been alerted of Resident 1's refusal. During an interview on [DATE] at 4:37 p.m., ADM stated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facility's undated policy and procedures (P/P) titled, Refusal of Medications and Treatments the P/P indicated incidents related to a residents' refusal of medications, and/or treatments must be recorded in the resident's medical record. According to the policy the date and time the physician was notified as well as the physician's response. Inquiries concerning the resident's refusal of medications or treatments should be referred to the Director of Nursing services and /or to the medical director. During a review of the facility's policy title, Change of Condition observing, recording, and reporting dated 2006 indicated to observe, record, and report any change to the physician so proper treatment will be implemented. Including dyspnea or variations in respirations, monitor residents' condition frequently until stable. Notification of physician. Care plan documentation guidelines include identify underlying problem causing condition change. Develop a plan to treat the condition; observe and monitor resident's response to treatment. Preventative measures, safety measures, and resident education. Observation and reporting of complications. During a review of the facility's policy title, Change of Condition dated 2016 indicated to appropriately assess, document, and communicate changes of condition including diagnostic results to the primary care provider. To provide treatment and services to address changes in accordance with resident needs and existing advance directives. If the change in condition does not require an immediate 911 transfer the following steps may be followed, document assessment findings and communications as soon as practical. Notify physician and responsible party of assessment findings, if unable to communicate with the resident's attending/on-call physician, contact the facility's medical director.

Based on interview, and record review the facility failed to ensure Registered Nurse (RN 1) and Licensed Vocational Nurses (LVNs 1, 2, and 3), were competent and knowledgeable on the use of a Bi-level Positive Airway Pressure ([[CONDITION(S)]] non-invasive ventilation machine that delivers oxygen to assist with breathing) and possessed skills for assessment for one of six sampled residents (Resident 1). Resident 1 complained to facility staff on numerous occasions of the ineffectiveness of the [CONDITION(S)] machine and the error message displayed on the [CONDITION(S)]. This deficient practice resulted in Resident 1 not receiving prompt pulmonary (lung care) care after exhibiting hyperventilation (rapid labored breathing) and ([[CONDITION(S)]] condition involving [MEDICATION(S)] of the airways and difficulty or discomfort in breathing) exacerbation (worsening). Resident 1 . On [DATE] at 12:16 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared in the presence of the administrator (ADM) and the Director of Nursing (DON). The ADM and DON were notified of the licensed staff not being trained to care for a resident on a [CONDITION(S)] machine and the immediate actions that needed to be taken due to residents' health and safety being threatened. The facility submitted an acceptable Plan of Action (POA) on [DATE] of the IJ which included the following: 1. Facility Medical Director was notified of the Immediate Jeopardy on [DATE]. 2. Physical assessment was completed on Resident 2 with a [CONDITION(S)] machine to identify any changes in condition and notification was made to the physician. 3. The two Licensed nurses who were aware of Resident 1's significant change, but did not report to the physician, received in-services on physician notification, resident's refusal of treatments, COC of residents on [CONDITION(S)] machine, how to identify error messages in the [CONDITION(S)] machines and how to contact clinical support [CONDITION(S)] Vendor/Respiratory Therapist [RT-specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine in order to work therapeutically with people suffering from acute critical conditions, cardiac and pulmonary disease]). 4. All licensed nurses were educated on resident's COC and physician notification regulations, use of [CONDITION(S)] machine including how to read error message and contact clinical support ([CONDITION(S)] machine vendor/RT) and facility policy and procedure prior to the start of their next regularly scheduled shift. Staff will not be permitted to work a shift until education is completed. 5. New hire licensed nurses will be educated on COC and physician notification regulations, use of [CONDITION(S)] machine including how to read an error message and contact clinical support ([CONDITION(S)] Vendor/RT) and new hire nurses' aides will be educated on change of condition regulations, as well as facility policy and procedure, accordingly. Staff will not be permitted to work until education is completed. 6. A Quality Assurance Performance Improvement ([QAPI] process used to ensure services are meeting quality standards and assuring care reaches a certain level) will implement a Performance Improvement Project (PIP) with a focus on physician notification of significant changes of residents on [CONDITION(S)] machine. The PIP will include implementation of daily DON/designee audits of the 24-hour report to monitor for change in resident condition of residents on [CONDITION(S)] machine. The DON/designee will also complete chart audits/health document assessment of three residents weekly for four weeks then; two residents weekly for two weeks then quarterly chart audit/health document assessment for the next two quarters. The regional/corporate/consultant nurse will visit the facility at least quarterly to provide general oversight and monitoring of the PIP. On [DATE] at 1:16 p.m., the IJ was removed in the presence of the ADM and DON after implementation of the acceptable POA were verified and confirmed on an onsite visit via observation, interview, and record review. Findings: During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care planning tool, dated [DATE], the MDS indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and understood others. The MDS indicated Resident 1 required extensive assistance of a one-person physical staff assistance for dressing, toileting, personal hygiene, and bed mobility (how the resident moves). During a review of Resident 1's electronic Medication Administration Record (eMAR), dated [DATE], the eMAR indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Once at nighttime, check heart rate (pulse), respirations, oxygen saturation, and remove per schedule. According to the eMAR, nursing staff signed placement of Resident 1's [CONDITION(S)] machine daily starting except for a single refusal on [DATE] at 9 p.m. The EMAR indicated Resident 1's [CONDITION(S)] machine was removed daily at 6 a.m. including the date of her death on [DATE]. During a review of Resident 1's care plan title, [CONDITION(S)], dated on [DATE], the care plan goal was for Resident 1 to not experience signs or symptoms of poor oxygenation absorption. The staffs' interventions included to monitor for signs or symptoms of respiratory insufficiency such as anxiety, confusion, restlessness, shortness of breath at rest, administer oxygen by nasal cannula (thin plastic tubing inserted in the nose to deliver oxygen) at 3 liters/per minute, [CONDITION(S)] machine on at 9 p.m. off at 6 a.m. wash tubing, headgear (attachment that fits around the head and holds the tubbing in place), monitor for difficulty breathing on exertion, monitor and document oxygen saturation (percentage of oxygen absorbed in blood) every shift daily, monitor and document for anxiety, and give bronchodilators (medication use to open the lungs and allow airflow) as ordered, monitor and document any side effects or effectiveness. During a review of Resident 1's Nursing Progress Notes (NPN), dated [DATE] and timed at 12:57 p.m., the NPN indicated Resident 1's and the Resident's Family Member (FM 1) had verbalized something was wrong with the [CONDITION(S)] machine. The note indicated staff called [CONDITION(S)] distributer and spoke with a representative and provided all information and distributer will call resident to verify [CONDITION(S)] machine concerns. During a review of Resident 1's Skilled Care Assessment (SCA), dated [DATE] and timed at 10:40 p.m., the assessment indicated Resident 1's vital signs were as follows: blood pressure (BP) of ,d+[DATE] (Normal Reference Range [NRR] ,d+[DATE]), body temperature of 97.8 Fahrenheit ([F] NRR 97.9 to 99), and heart rate of 74 beats per minute ([bpm] NNR ,d+[DATE] bpm), respirations of 17 breaths per minute ([bpm] NRR ,d+[DATE]), oxygen saturation of 96% (NRR 95% to 100%) with oxygen via nasal cannula at 3 liters/minute. The assessment indicated Resident 1's was provided with return demonstration respiratory care and [CONDITION(S)] machine. The assessment indicated Resident 1 refused [CONDITION(S)] when offered, continuous oxygen at 3 liters/minute via nasal cannula for shortness of breath (SOB). Head of bed (HOB) slightly elevated, alert, and oriented verbalized needs and discomforts known. During a review of Resident 1's NPN, dated [DATE], and timed at 10:46 p.m. (created and written by Licensed Vocational Nurse [LVN 3] on [DATE] at 10:49 p.m.), the NPN indicated a call was received from the [CONDITION(S)] machine distributer around 3:30 p.m. regarding the [CONDITION(S)] machine having a leak. [CONDITION(S)] machine distributer assisted by phone on how to reset [CONDITION(S)] machine. [CONDITION(S)] machine distributer instructed [CONDITION(S)] was supposed to be on Resident 1 before being turned on. Explained to Resident 1 and was able to understand. [CONDITION(S)] machine placed on Resident 1 working properly with no leaks. During a review of Resident 1's SCA, dated [DATE] and timed at 6:55 a.m., the SCA indicated Resident 1's vital signs were BP ,d+[DATE], body temperature of 97.8 F, heart rate of 74 beats per minute (bpm), with respirations of 18, and oxygen saturation of 96% with oxygen via nasal cannula at 3 liters/minute. The SCA indicated Resident 1 was not provided with return demonstration regarding respiratory care and the [CONDITION(S)] machine. The assessment indicated Resident 1 was alert and oriented able to make needs known. No acute distress noted, continuous oxygen at 3 liters/ minute via nasal cannula in place. Head of bed elevated, no shortness of breath or difficulty breathing noted, denied any pain or discomfort, Resident 1 was noncompliant with [CONDITION(S)] at night. During a review of Resident 1's NPN, dated [DATE], and timed at 9:20 p.m., the NPN indicated [CONDITION(S)] machine on at 9 p.m. and off at 6 a.m., with nose pillow at bedtime once during the night check heart rate, respiration, and oxygen saturation and remove per schedule. Resident 1 keeps removing the [CONDITION(S)] when applied, risks and benefits explained but still refused. During a review of Resident 1's NPN, dated [DATE], and timed at 11:01 p.m. the NPN indicated Resident 1 was refusing to be connected to the [CONDITION(S)] machine because she could not tolerate the machine and it was causing her to have hyperventilation (breathe at an abnormally rapid rate). The NPN indicated Resident 1 preferred to be on nasal cannula and risks and benefits were explained but resident continued to refuse to use [CONDITION(S)] machine. Resident 1 oxygen saturations of 94 % on oxygen 3 liters/minute with nasal cannula. During a review of Resident 1's SCA, dated [DATE] and timed at 7:05 a.m., the SCA indicated Resident 1's vital signs were BP of ,d+[DATE], body temperature of 98.0 F, heart rate of 95, with respirations of 22, and oxygen saturation of 99 % via mask. The assessment indicated Resident 1 was not provided with return demonstration regarding respiratory care and the [CONDITION(S)] machine. The SCA indicated Resident 1 was alert and oriented, able to make needs known noted with shortness of breath (SOB) and [CONDITION(S)] exacerbation (the process of making a problem, bad situation, or negative feeling worse). HOB elevated continuous oxygen 3 liters/ minute via mask. Oxygen saturation 98 %, [MEDICATION(S)] ([[MEDICATION(S)]] used to treat anxiety disorders) given for hyperventilation. Resident currently stable and vital signs stable, denies any pain or discomfort currently. Resident 1 was refusing the [CONDITION(S)] machine at night. During a review of Resident 1's NPN, dated [DATE], and timed at 7:25 a.m. (created and written by LVN 2 at 3:59 p.m.), the NPN indicated Resident 1 received awake and alert with eyes open and responding to verbal and tactile (touch) stimuli. Resident 1 was noted on continuous supplemental oxygen at 3 liters/minute via nasal cannula and noted non-compliant with the use of the [CONDITION(S)] machine, explanations of purpose of machine provided. [sic] During a review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR), dated [DATE], and timed at 8:20 a.m. (created and written by LVN 3 on [DATE] at 1:28 p.m.), the SBAR indicated upon making rounds around 8:15 a.m., Resident 1 was noted with shallow respirations, upon assessment noted oxygen levels at 70 % and nasal cannula placed at 3 liters/minute. Non-breathable mask (medical device that delivers a person with a high amount of oxygen) was placed at 10 liters/minute full (100%) oxygen tank with oxygen level fluctuating from 92 to 94 %. Resident 1 was arousable, able to open eyes and nod, alert and verbally responsive to her name. HOB elevated, unable to grasp (siderail). Call placed to 911 (emergency services) continued monitoring while paramedics arrived. BP of ,d+[DATE], heart rate of 102, and respirations 32. The SBAR indicated Resident 1 had decreased consciousness (state of being awake and aware of one's surroundings), weakness, labored rapid shallow breathing, and low oxygen saturation. During a review of Resident 1's Fire Department Emergency Response record, dated [DATE] and timed at 8:25 a.m., the report indicated Resident 1 was in moderate respiratory distress with altered level of consciousness (ALOC) and SOB. During a review of Resident 1's GACH Emergency Department (ED) records, date [DATE] and timed at 8:51 a.m., the GACH's ED note indicated Resident 1 arrived with altered mental status, difficulty breathing and SOB. On the initial evaluation, Resident 1 was tachypneic (rapid, shallow breathing), with poor air movement, lethargic (sluggish, low energy) but arousable. Resident 1 was placed on [CONDITION(S)] machine upon arrival to the ED and treated with duonebulizers (medication aerosol used to help treat airway narrowing) and steroids (medication to reduce inflammation) 9:36 a.m., Resident 1 went into cardiac arrest (the abrupt loss of heart function, breathing and consciousness) and CPR ([cardiopulmonary resuscitation] a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) was initiated unsuccessfully. At 10:06 a.m., on [DATE] (1 hour after admission to the GACH) Resident 1 had no spontaneous respirations, no pulse, and pupils were fixed (no reaction to light) and dilated (open) and was pronounced deceased . During an interview on [DATE] at 4:12 p.m., FM 1 stated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . FM 1 stated he repeatedly notified staff of the [CONDITION(S)] machine ineffectiveness. FM 1 stated on the morning of [DATE] after several text messages with no response from Resident 1, FM 1 placed a call to the facility at 8:08 a.m. (after the initial texts starting at 6 a.m.) and asked to speak to Resident 1 because he was concerned. FM 1 stated a staff member assured him Resident 1 was resting and did not want to wake her up. FM 1 stated receiving a call from the facility's staff at 8:40 a.m., 40 minutes after he had asked the staff to check on Resident 1, was notified Resident 1 was transferred to a GACH via 911 (emergency services). During an interview on [DATE] at 4:49 p.m., FM 2 stated during visitations at the facility with Resident 1, FM 2 witnessed Resident 1 notifying the nurses in the facility of the concerns with the [CONDITION(S)] machine not working. FM 2 stated the [CONDITION(S)] machine displayed error messages constantly, and the staff did not know how to set the [CONDITION(S)] machine. During an interview on [DATE] at 10:16 p.m., LVN 1 stated the [CONDITION(S)] machine was pre-set from the hospital prior to the resident's admission to the facility. LVN 1 stated on [DATE] she placed Resident 1 on the [CONDITION(S)] machine but was removed because Resident 1 refused to wear it. LVN 1 stated she documented the refusal on the eMAR and informed Resident 1 about the risks and benefits of refusing to wear the [CONDITION(S)]. LVN 1 stated she was made aware in different times during her shift of the [CONDITION(S)] not working. LVN 1 stated placing Resident 1 on 3 Liter of oxygen via nasal cannula after Resident 1 reported in two separate occasions she (Resident 1) was experiencing hyperventilation episodes and the [CONDITION(S)] machine was not helping her. LVN 1 acknowledged seeing the error message on the [CONDITION(S)] machine due to a leakage on the mask. LVN 1 stated the leakage meant Resident 1 did not have a proper seal on her mask and oxygen was leaking. LVN 1 stated she did not informed Resident 1's physician of the [CONDITION(S)]'s malfunction and Resident 1's refusals to use the [CONDITION(S)] due to not working properly. LVN 1 stated she gave report to the oncoming shift of Resident 1's refusal to wear the [CONDITION(S)] but not of the error message displayed on it. During an interview on [DATE] at 7:23 a.m., Certified Nursing Assistant (CNA 1) stated on [DATE] at approximately 8 a.m., she responded to Resident 1's call light and saw Resident 1 unresponsive and unable to wake up. CNA 1 stated she went to get LVN 3 to help Resident 1. CNA 1 stated LVN 3 could not wake up Resident 1 and provided care for Resident 1 by checking her vital signs and oxygen saturation. CNA 1 stated an oxygen tank was brought to Resident 1's room and other staff members responded to assist LVN 3. During an interview on [DATE] at 7:58 a.m., LVN 2 stated a report was received from the overnight Registered Nurse 1 (RN 1) of Resident 1's refusal to wear the [CONDITION(S)] machine. LVN 2 stated later that morning CNA 1, notified her of Resident 1 being found unresponsive. LVN 2 stated she went to Resident 1's room along with other staff members including LVN 3. LVN 2 stated Resident 1 was slow to respond, lethargic, and was opening her eyes when called by name. LVN 2 stated she and other staff members checked Resident 1's vital signs, along with the oxygen saturation was checked and it was low. LVN 2 stated a high flow oxygen mask was placed on Resident 1's face, and 911 emergency services were called because the resident was having difficulty breathing with unresponsiveness. LVN 2 stated Resident 1 was typically noncompliant with wearing the [CONDITION(S)] machine. LVN 2 acknowledged she did not call Resident 1's physician regarding the repeated refusals to wear the [CONDITION(S)] machine, and stated it was the responsibility of the nursing staff to notify the attending physician. During an interview on [DATE] at 9:47 a.m., RN 1 stated on the night of [DATE] the prior shift told him about Resident 1's refusal to wear the [CONDITION(S)] machine and she was administered [MEDICATION(S)]. RN 1 stated Resident 1 has shortness of breath with [CONDITION(S)] exacerbation, and she was placed on a non-rebreather mask. RN 1 stated the oxygen saturation was kept on Resident 1 during the time she had the non-rebreather mask on. RN 1 stated remembering Resident 1 experiencing labor breathing. RN 1 stated he took care of Resident 1 for four consecutive days and all four days Resident 1 refused to wear the [CONDITION(S)] machine. RN 1 stated Resident 1 never wore the [CONDITION(S)] continuously and repeatedly refused to wear the [CONDITION(S)] machine. RN 1 stated he did not think it was necessary to call Resident 1's physician regarding the refusal to wear the [CONDITION(S)] machine. RN 1 stated he never saw an error message on the [CONDITION(S)] machine. RN 1 stated the morning of [DATE] he endorsed to the oncoming nurse of Resident 1's experiencing [CONDITION(S)] exacerbation and to keep monitoring her oxygen saturation for any change of condition. During an interview on [DATE] at 1:32 p.m., in the presence of the facility's Administrator (ADM), the Director of Nursing (DON) stated during an Interdisciplinary Team meeting ([IDT] team members from different disciplines working collaborate) regarding Resident 1's plan of care, FM 1 notified her (the DON) something was wrong with the [CONDITION(S)] machine. The DON stated she placed a call to the [CONDITION(S)] machine distributer after FM 1 and Resident told her (the DON) about the ineffectiveness of the [CONDITION(S)] machine. The DON stated a clinical representative returned the call to the facility to assist with the problems of the [CONDITION(S)] machine. The DON stated when the [CONDITION(S)] machine was delivered to the facility the machine was pre-set and the [CONDITION(S)] distributer did not provide training to the facility nursing staff. The DON stated the facility's nurses were not in-serviced on how to apply the [CONDITION(S)] machine for Resident 1 or troubleshoot problems with the [CONDITION(S)]. The DON stated the facility licensed nurses were not in-serviced on the care of a resident on a [CONDITION(S)] machine prior to the incident. During an interview on [DATE] at 2:28 p.m., the facility's Medical Director (FMD) stated when a [CONDITION(S)] machine was prescribed for a resident the Pulmonologist determined the settings. FMD stated the licensed nurses', and the DON were normally familiar with the [CONDITION(S)] machine. FMD stated there was an ordered with a length of time for Resident 1 to use the [CONDITION(S)] machine at bedtime for sleep apnea. If the resident's machine was not working or displaying an error message, the licensed nurses should have called the attending physician and alert them of the problem. FMD stated if the resident was desaturating (low oxygen saturation), the facility staff should have sent the resident to the emergency room for further evaluation. FMD stated when a resident refuse to wear their [CONDITION(S)], it was the responsibility of the licensed nurse to call the attending physician and alert them of the situation. FMD stated unfortunately, there was nothing to do but to document, but the attending physician should have been alerted of the resident's refusal. During an interview on [DATE] at 3:44 p.m., the Nurse Practitioner (NP) stated she saw Resident 1 the morning on [DATE] and was aware of Resident 1's mild anxiety. The NP stated Resident 1 made her aware of the issues with the [CONDITION(S)] and the healthcare case manager was notified. The NP stated Resident 1 mentioned she felt the [CONDITION(S)] machine was not working properly, was beeping, and felt air leaking from the mask. The NP stated she thought the distributer should have been made aware to come and replace the [CONDITION(S)] machine for Resident 1 or the facility staff was not applying the mask properly. The NP stated the nursing staff was notified about Resident 1's concerns and if there was an air leak, the nursing staff should have called the [CONDITION(S)] distributer. The NP stated she received a call from the nursing staff the following day on [DATE] about Resident 1 being sent out to the hospital with respiratory distress and [CONDITION(S)]. During a review of the facility's undated policy titled; Bi-Level therapy, indicated Bi-level therapy was used to treat patients with obstructive sleep apnea who have difficulty tolerating [CONDITION(S)]. The goals of the therapy included improve ventilation, improve quality of sleep, decrease hospitalization s, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing, and improve lung compliance. Staff procedures include verify physician orders, assemble equipment at bedside, observe universal precautions and wash your hands, place system close to where the resident would be sleeping on a clean dry surface, insert the oxygen adapter with tubing if supplemental O2 is ordered, place mask/pillows with headgear on patient and adjust to a proper fit, ensure a proper fit, and adjust as necessary. If excessive air leaks around the eyes and nose, adjust the headgear. Resize mask for excessive leaks or to increase patient comfort. If ordered, connect humidifier to Bi-Level unit. Fill humidifier with distilled or sterile water, and if ordered adjust ramp to prescribed time. During a review of the facility's undated policy and procedures (P/P) titled, Refusal of Medications and Treatments the P/P indicated incidents related to a residents' refusal of medications, and/or treatments must be recorded in the resident's medical record. According to the policy the date and time the physician was notified as well as the physician's response. Inquiries concerning the resident's refusal of medications or treatments should be referred to the Director of Nursing services and /or to the medical director. During a review of the facility's Job Description/Performance Evaluation for LVNs, dated [DATE], the job description indicated the LVN's essential duties included to provide accurate assessment, oversight, and monitor resident's medical management and early detection of changes in condition. The job description indicated the LVN maintained and practiced high standards of nursing care and followed facility's policy and procedures, Federal and State laws, and the Nurse Practice Act. The LVN participated in continuing education and enhanced learning offered by the facility, maintains knowledge and skills to practice safe/competent caregiving.

Based on interview and record review, the facility failed to conduct a pain assessment, implement a care plan, and notify the primary physician of a change in condition (COC) for one of five sampled residents (Resident 1) by failing to: 1. Conduct a pain assessment to ensure medication effectiveness. 2. Notify the primary physician of pain medication ineffectiveness. 3. Implement Resident 1's pain management care plan to identify pain location, describe quality (e.g. sharp, burning), severity (1 to 10 scale) location, onset, duration, aggravating/relieving factors and notify the physician of changes. Resident 1 received 32 [MEDICATION NAME] (narcotic pain reliver) 5-325 milligrams ((mg) unit of measurement) tablets by mouth (PO) every six hours (hrs.) as needed (PRN) for moderate pain of 4 to 6 from a pain scale ((0-10) 0 being pain free and 10 being worse pain) for 14 days during the month of 11/2019 for pain levels of five (5) through nine (9) on the pain scale. A review of Resident 1's Medication Administration Record [REDACTED]. PRN anxiety of crying for the month of 11/2019. These deficient practices resulted in Resident 1's pain not being managed and Resident 1 experiencing unnecessary pain with uncontrolled crying. On 1/17/20 at 4:45 p.m., the Administrator (ADM) and the Assistant Director of Nursing (ADON), were notified 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 for the facility's inability to provide the necessary care and services to manage a resident's pain by failing to assess and notify the primary physician of the medications ineffectiveness. The facility's ADM and ADON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 1/19/20 at 12:38 p.m., the ADM, Interim Regional Director of Clinical Operations (RDCO), Director of Staff Development (DSD) submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. A medication audit was conducted for all residents receiving [MEDICATION NAME] completed on 1/17/2020 looking for the dose and administration. No residents found on [MEDICATION NAME]. Correct dose, route, monitoring, documentation and care plans will be in place. 2. Every licensed nurse was educated prior to administration on behavior management, behavior monitoring, documentation, care plan development and Five Rights of medication administration (right time, right dose, right medication, right patient, and right route). 3. The Interim Regional Director of Clinical Operations (IRDCO) will observe medication administration with licensed nurses. The IRDCO will observe 100% of licensed nurse by 2/20/20. 4. The Physician will review appropriateness of anti-anxiety . 5. The MD will review PRN anti-anxiety medication prior to renewing . 6. The Director of Staff Development (DSD) will in-serve 100% of available licensed nurses on behavior management by 1/31/20. Licensed nurses on level of alertness (LOA) w ill be in-serviced upon their return prior to their first shift. 7. The IRDCO will educate 100% of licensed nurses on Black box warning and medication interactions. 8. The IRDCO will educate 100% of licensed nurses on evaluating medication effectiveness and duration of evaluation. 9. The Pain assessments for residents on [MEDICATION NAME]/[MEDICATION NAME] will be reviewed for pain location, management and monitoring. 10. The Care plan for pain, monitoring patient for pain, that pain assessments are being completed, that a reassessment after pain assessment is being done, and there is complete documentation regarding the pain will be reviewed. 11. Documentation and care plans will be updated as necessary. 12. Consultant Pharmacist will observe medication administration with Licensed Nurses. 13. Physician will review appropriateness of pain medication. 14. The IRDCO will educate 100% of clinical staff members on assessing pain non-verbal residents. 15. The IRDCO will educate 100% of clinical members on no-drug interactions (NDI) for pain management. On 1/19/20 at 12:42 p.m., during a concurrent observation, interview and record review, the ADM and the DON were notified the IJ was lifted while onsite, after the team verified the POA was followed and implemented. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility 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 8/2/19 indicated Resident 1 was able to make herself understood and understand others. The MDS indicated Resident 1 required a two-person physical assist for bed mobility and a one-person physical assist for eating and personal hygiene. The MDS indicated Resident 1 was a [DEVICE] (feeding tube device used to provide nutrition to residents who cannot obtain nutrition by mouth) feeder. A review of Resident 1's care plan titled, At Risk for Pain Related to Generalized Muscle Weakness, revised on 4/29/19 indicated Resident 1 would not have interruption in normal activities due to pain through 10/28/19. The staff's interventions included to identify and record previous pain history and management of pain and impact on function, identify previous response to [MEDICATION NAME] (medication use to treat pain) including pain relief and side effects. Monitor/document cause of each pain episode, document new onset and report to the physician. To monitor/record pain characteristic every shift and PRN: quality (e.g. sharp, burning), severity (1 to 10 scale) location, onset, duration, aggravating/relieving factors. Observe and report changes in usual sleep patterns. A review of Resident 1's Order Review Report, for the month of 11/2019 indicated a physician order [REDACTED]. PRN for moderate pain (4-6 on the pain scale). A review of the MAR for the month of 11/2019 indicated Resident 1 received 32 tablets of [MEDICATION NAME] 5-325 mg in 14 days . The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of a Controlled Drug Record (CDR) for the month of 11/2019 indicated to give Resident 1 [MEDICATION NAME] 5-325 mg one tablet by PO every six (6) hrs. PRN for moderate pain. The CDR indicated Resident 1 received a total of 36 tablets of [MEDICATION NAME] 5-325 mg in 14 days, which did not correspond with the MAR. A review of Resident 1's Order Review Report for the month of 11/2019 indicated an order on 11/7/19 for [MEDICATION NAME] (([MEDICATION NAME]) anti-anxiety medication) 0.25 mg one tablet by PO every eight (8) hrs. PRN for anxiety. A revise physician order [REDACTED]. PRN anxiety for 14 days. A Review of Resident 1's MAR for the month of 11/2019 indicated Resident 1 received 12 tablets of [MEDICATION NAME] 0.25 mg PO for anxiety. A review of the CDR for the month of 11/2019 indicated to give Resident 1 [MEDICATION NAME] 0.25 mg one tablet via [DEVICE] every 12 hrs. (not as ordered by physician every 8hrs). PRN anxiety for 14 days. The CDR indicated Resident 1 received a total of 12 tablets of [MEDICATION NAME] for anxiety. A review of Resident 1's Psychiatric (physician specialized in the [DIAGNOSES REDACTED]. The psychiatrist assessment indicated Resident 1 had pain and a new concern of mom dying. The assessment indicated Resident 1 was able to communicate and verbalize concerns clearly. A review of Resident 1's Progress Nursing Notes for the month of 11/2019 did not indicate Resident 1's pain location, duration and/or onset of pain and there was no documented evidence. The Progress Notes did not indicate the physician was notified of pain medication ineffectiveness as per the residents' plan of care. On 12/3/19 at 12:30 p.m., during an interview, Resident 1's Responsible Party 1 (RP1) stated the facility's staff was overmedicating Resident 1 with [MEDICATION NAME] every eight hrs. Instead of every 24 hrs. as ordered by the physician (sic). RP1 stated Resident 1 was observed sedated on several occasions with her eyes rolling back. On 12/3/19 at 4:45 p.m., during a concurrent interview and review of the physician orders [REDACTED]. On 1/16/20 at 1:40 p.m., during a concurrent interview and review of the MAR/physician orders/narcotic sheet , Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 received [MEDICATION NAME] 5-325 mg every six (6) hrs. for pain via [DEVICE] (sic). LVN 1 recanted stating the ordered read by PO instead of [DEVICE]. LVN 1 stated pain was reassessed an hour after pain medication administration for effectiveness. LVN 1 stated no pain assessment was conducted to ensure Resident 1's pain was being managed appropriately and to identify the cause of the pain. LVN 1 stated there was no Interdisciplinary Team ((IDT) coordinated group of experts from several different fields who work together toward a common goal) done to address Resident 1's pain and constant crying and should have been. On 1/16/20 at 3:12 p.m., during a concurrent interview and review of the Resident 1's MAR/physician orders/narcotic sheet , LVN 2 stated there was a care plan created on 4/28/19 for Resident 1's pain management that indicated to monitor and identify cause of pain. LVN 2 stated he did not document the non-pharmacological interventions prior to the administration of [MEDICATION NAME] to Resident 1 because he did not consider it to be important. LVN 2 stated [MEDICATION NAME] PRN was not effective to control Resident 1's pain because Resident 1 would ask for pain medication within an hour of the [MEDICATION NAME] administration. LVN 2 stated he did not notify Resident 1's physician of [MEDICATION NAME] not being effective for Resident 1's pain management. LVN 2 stated Resident 1 was always crying, but he was not sure if it was related to pain since he did not assess the resident pain. On 1/16/20 at 4:05 p.m., during a telephone interview, Resident 1's physician stated not remembering giving an order for [REDACTED]. On 1/16/20 at 4:30 p.m., during an interview, LVN 3 stated Resident 1 would cry all the time but was not sure if it was related to pain of Resident 1 missing her family. LVN 3 admitted to not assessing Resident 1 to identify the cause of Resident 1's constant crying for proper management. On 1/17/20 at 3:25 p.m., during a concurrent interview and review of Resident 1's care plans/MAR/Progress Notes, the ADON stated there was no care plan to address Resident 1's behavior of yelling. The ADON stated the staff fail to implement Resident 1's care plan to monitor for increase on agitation, sedation and to notify the physician of any changes. The ADON stated no pain assessment was conducted after 10/3/19 to manage Resident 1's pain and not being aware why the staff would document Resident 1 received 32 [MEDICATION NAME] tablets via PO for moderate pain for the month of 11/2019, if Resident 1 had strict orders of nothing by mouth for dysphagia. The ADON stated Resident 1's pain was not being managed appropriately and the staff did not document in the nurses notes any non-pharmacological interventions appropriateness and the staff should have called the physician and inform him of Resident 1's pain and behavior of crying after an assessment was conducted so Resident 1's pain could be managed appropriately. The ADON stated there was no IDT to address Resident 1's pain was conducted for the month of 11/2019. On 1/17/20 at 4:45 p.m., during an interview, in the presence of the ADON, the ADM stated on 10/2019 an IDT was conducted to address Resident 1's behavior of crying. The ADM stated Resident 1 would cry because she wanted to leave the facility, depression and pain. On 1/18/20 at 11:30 a.m., during an interview, the IRDCO stated the staff should have assess and monitor Resident 1's pain and behavior and the reason for medication administration in the nurses' notes. The IRDCO stated there was no documentation of Resident 1's pain management for the month of 11/2019, no IDT for pain and no pain assessment conducted by the staff. On 1/18/20 at 12:10 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated Resident 1 was always crying because she was in pain. CNA 1 stated she was not assigned to care for Resident 1 directly, but the Licensed Nurses' were made aware of Resident 1's pain. On 1/18/20 at 12:30 p.m., during an interview, CNA 2 stated Resident 1 would sometimes cry because of pain and other times for no apparent reason. A review of the facility's Policy titled, Pain Management Process, dated 6/2009 indicated it was the responsibility of the licensed nurse to consistently assess, manage, and monitor pain for all residents. The policy indicated the results of the assessment, effectiveness of the pain interventions and monitoring of behaviors were necessary components within the documentation. The policy indicated to complete a Comprehensive Pain Assessment Form with the development of new symptoms of acute or chronic pain, review of continued effectiveness and appropriateness of pain management and involve the medical director for further recommendations.

Based on interview and record review, the facility failed to ensure one of five (5) sampled resident (Resident 1) was free from receiving medications without adequate monitoring and assessment, and no care plan for behaviors of crying created in accordance with the facility's policy. (Cross reference F697) Resident 1 received 12 [MEDICATION NAME] (([MEDICATION NAME]) anti-anxiety medication) 0.25 milligrams (mg) one tablet by mouth (PO) every eight (8) hours (hrs.) as needed (PRN) for anxiety as manifested by crying, for the month of 11/2019. These deficient practices resulted in Resident 1 not receiving the appropriate treatment and receiving 12 [MEDICATION NAME] tablets for seven (7) days by mouth for crying without an assessment. On 1/17/20 at 4:45 p.m., the Administrator (ADM) and the Assistant Director of Nursing (ADON), were notified 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 for the facility's inability to provide the necessary care and services to manage a resident's pain by failing to assess and notify the primary physician of the medications ineffectiveness. The facility's ADM and ADON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 1/19/20 at 12:38 p.m., the ADM, Interim Regional Director of Clinical Operations (RDCO), Director of Staff Development (DSD) submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. A medication audit was conducted for all residents receiving [MEDICATION NAME] completed on 1/17/2020 looking for the dose and administration. No residents found on [MEDICATION NAME]. Correct dose, route, monitoring, documentation and care plans will be in place. 2. Every licensed nurse was educated prior to administration on behavior management, behavior monitoring, documentation, care plan development and Five Rights of medication administration (right time, right dose, right medication, right patient, and right route). 3. The Interim Regional Director of Clinical Operations (IRDCO) will observe medication administration with licensed nurses. The RDCO will observe 100% of licensed nurse by 2/20/20. 4. The Physician will review appropriateness of anti-anxiety. 5. The MD will review PRN anti-anxiety medication prior to renewing. 6. The Director of Staff Development (DSD) will in-service 100% of available licensed nurses on behavior management by 1/31/20. Licensed nurses on level of alertness (LOA) will be in-serviced upon their return prior to their first shift. 7. The IRDCO will educate 100% of licensed nurses on Black box warning and medication interactions. 8. The IRDCO will educate 100% of licensed nurses on evaluating medication effectiveness and duration of evaluation. 9. The Pain assessments for residents on [MEDICATION NAME]/[MEDICATION NAME] (used to treat moderate to moderately severe pain) will be reviewed for pain location, management and monitoring. 10. The Care plan for pain, monitoring patient for pain, that pain assessments are being completed, that a reassessment after pain assessment is being done, and there is complete documentation regarding the pain will be reviewed. 11. Documentation and care plans will be updated as necessary. 12. Consultant Pharmacist will observe medication administration with Licensed Nurses. 13. Physician will review appropriateness of pain medication. 14. The IRDCO will educate 100% of clinical staff members on assessing pain non-verbal residents. 15. The IRDCO will educate 100% of clinical members on no-drug interactions (NDI) for pain management. On 1/19/20 at 12:42 p.m., during a concurrent observation, interview and record review, the ADM and the DON were notified the IJ was lifted while onsite, after the team verified the POA was followed and implemented. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility 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 8/2/19 indicated Resident 1 was able to make herself understood and understand others. The MDS indicated Resident 1 required a two-person physical assist for bed mobility and a one-person physical assist for eating and personal hygiene. The MDS indicated Resident 1 was a [DEVICE] (feeding tube device used to provide nutrition to residents who cannot obtain nutrition by mouth) feeder. A review of Resident 1's Order Review Report for the month of 11/2019 indicated an order on 11/7/19 for [MEDICATION NAME] (([MEDICATION NAME]) anti-anxiety medication) 0.25 mg one tablet by PO every eight (8) hrs. PRN for anxiety. A revise physician order [REDACTED]. PRN anxiety for 14 days. A Review of Resident 1's MAR for the month of 11/2019 indicated Resident 1 received 12 tablets of [MEDICATION NAME] 0.25 mg PO for anxiety. A review of the Controlled Drug Record (CDR) for the month of 11/2019 indicated to give Resident 1 [MEDICATION NAME] 0.25 mg one tablet via [DEVICE] every 12 hrs. (not as ordered by physician every 8hrs). PRN anxiety for 14 days. The CDR indicated Resident 1 received a total of 12 tablets of [MEDICATION NAME] for anxiety. A review of Resident 1's Psychiatric (physician specialized in the [DIAGNOSES REDACTED]. The psychiatrist assessment indicated Resident 1 had pain and a new concern of mom dying. The assessment indicated Resident 1 was able to communicate and verbalize concerns clearly. On 12/3/19 at 12:30 p.m., during an interview, Resident 1's Responsible Party 1 (RP1) stated the facility's staff was overmedicating Resident 1 with [MEDICATION NAME] every eight hrs. instead of every 24 hrs. as ordered by the physician (sic). RP1 stated Resident 1 was sedated on several occasions with her eyes rolling back. On 12/3/19 at 4:45 p.m., during an interview and review of Resident 1's consent, the Director of Nurses (DON) stated the staff obtained a consent for [MEDICATION NAME] every 12 hours on 6/20/19, but not for Resident 1's to receive [MEDICATION NAME] every eight hours. On 1/16/20 at 1:40 p.m., during a concurrent interview and review, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was receiving [MEDICATION NAME] for anxiety, such as fidgeting with her fingers, crying, yelling and shaking. LVN 1 stated there was no Interdisciplinary Team ((IDT) coordinated group of experts from several different fields together toward a common goal) conducted to identify the cause of Resident 1's crying behaviors. LVN 1 stated Resident 1 was transferred to a general acute care hospital (GACH) on 11/15/19 at 4:49 a.m., for yelling and unable to make eye contact. On 1/16/20 at 2:29 p.m., during a telephone interview, the facility's contracting pharmacist (professional qualified to prepare and dispense medicinal drugs) stated only receiving an order for [REDACTED]. prior to 11/13/19. On 1/16/20 2:12 p.m., during a concurrent interview and record review, LVN 2 stated Resident 1 was always yelling. LVN 2 stated he was not able to locate the order for Resident 1 to receive [MEDICATION NAME] every eight hrs. LVN 2 stated he did not monitor Resident 1's behavior prior or after the administration of [MEDICATION NAME]. LVN 2 stated he would just administer the medication without assessing the resident. On 1/16/20 at 4:05 p.m., during a telephone interview, Resident 1's physician stated he did not remember giving an order for [REDACTED]. On 1/16/20 at 4:30 p.m., during an interview, LVN 3 stated Resident 1 would cry all the time but he was not sure if it was related to pain or Resident 1's missing her family. LVN 3 stated he did not assess Resident 1 to identify the cause of the constant crying for proper care management. On 1/17/20 at 3:25 p.m., during a concurrent interview and review of Resident 1's care plans/MAR/Progress Notes, the ADON stated there was not a care plan to address Resident 1's behavior of yelling. The ADON stated the staff fail to implement Resident 1's care plan to monitor for increase on agitation, sedation and to notify the physician of any changes. The ADON stated the CDR order read [MEDICATION NAME] via [DEVICE] every 12 hours PRN for anxiety, staff was administering [MEDICATION NAME] every eight hrs. by mouth. The ADON stated there was no care plans for behavior monitoring or documentation. On 1/17/20 at 4:45 p.m., during a concurrent interview and review in the presence of the ADON, the ADM stated on 10/2019 an IDT was conducted to address Resident 1's behavior of crying. The ADM stated Resident 1 would cry because she wanted to leave the facility, depression and pain. On 1/18/20 at 11:30 a.m., during and interview and review, the IRCDO stated Resident 1 has an order for [REDACTED]. The IRCDO stated there was no IDT conducted for Resident 1's behavior. On 1/18/20 at 12:10 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated Resident 1 was always crying because she was in pain. CNA 1 stated not taking care of Resident 1 directly, but the Licensed Nurses' were made aware of her pain. On 1/18/20 at 12:30 p.m., during an interview, CNA 2 stated Resident 1 would sometimes cry because of pain and other times for no apparent reason. On 1/19/20 at 12:35 p.m., during an interview and review in the presence of the ADM, the IRDCO stated the facility fail to assess Resident 1's behavior of crying, create a care plan and document non-pharmacological interventions. A review of the facility's policy titled, General Dose Preparation and Medication Administration, revised on 1/1/13 indicated the staff should verify the medication name and dose prior to administration. Verify time a medication is administered that is the correct dose, route, rate, time, correct resident, confirm the MAR indicated [REDACTED]. A review of the facility's policy titled, Behavior Management Positive Practice, dated 2017 indicated the IDT must look at possible medical, environmental, and psychological causal factors. The policy indicated the number one cause for behavior is pain.

Based on interview and record review, the facility failed to update a resident's Minimum Data Set ((MDS) an assessment and resident care screening tool) and care plans after a resident had two falls to reflect the resident's care needs for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls and was identified by the facility as having a behavior of throwing herself to the floor was not assessed and considered as part Resident 1's plan of care to prevent falls and injuries during care. This deficient practice resulted in Resident 1 falling from a shower chair (stationary or mobile seat with or without upper body or head support used to support a resident who is unable to stand or sit independently in the shower), sustaining bruising to the left side of her face and a displaced (move from its original place) left femoral ((femur) leg bone) neck (top part of the femur) fracture (broken bone) requiring a transfer to the general acute care hospital (GACH) and undergoing left hip hemi (half) arthroplasty (joint replacement) surgery. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 was able to make herself understood and understand others. The MDS indicated Resident 1 required physical help in part of bathing activity, was not steady when moving from seated to standing position and required a wheelchair for mobility. There was no documentation indicating how many staff Resident 1 required during shower. A review of Resident 1's Fall Risk Assessment, dated 8/2/19 indicated Resident 1 had a score of 51 (high risk for fall if 45 is higher). The assessment indicated Resident 1 had impaired walking and difficulty rising from the chair, bounced to rise from chair, and could not walk unassisted. A review of Resident 1's care plan titled, Self-Care Deficit, dated 4/28/19 indicated. The staff's interventions included providing a one-person physical assist for bathing. A review of Resident 1's care plan titled, At Risk for Falls and Injuries, revised on 5/21/19, after Resident 1's first fall indicated Resident 1 would have decrease falls and injuries by target date of 10/31/19. The staff's interventions indicated to observe Resident 1 for unsteady gait and balance. A review of a Situation Background Assessment and Response ((SBAR) an internal communication tool), dated 9/28/19, and timed at 9:12 a.m., indicated Certified Nurse Assistants 1 and 2 (CNAs 1 and 2) assisted Resident 1 to the shower floor during a fall to prevent injuries. The SBAR indicated Resident 1 did not hit her head on the floor during the assisted fall with the two CNAs (sic). The SBAR indicated physician was called and ordered an x-ray because Resident 1 complaining of left hip pain. A review of Resident 1's X-Ray report, dated 9/28/19 indicated Resident 1 had a displaced left [MEDICAL CONDITION]. A review of the physician's telephone order, dated 9/28/19 and timed at 11:43 a.m., indicated to transfer Resident 1 to the GACH for further evaluation after a mechanical fall (the act of slipping, tripping, or loss of balance). A review of the GACH's Emergency Department (ED) Physician's note, dated 9/28/19 indicated Resident 1 arrived at the ED after sustaining a fall at a facility during a shower. The ED note indicated Resident 1's knees became weak and fell to the ground during an assisted shower by the facility's staff. The ED physical exam indicated Resident 1 was noted with swelling to the left hip with a bruise over the left eye. A review of the GACH's Discharge Summary, dated 10/3/19 indicated Resident 1 was discharge to the facility in stable condition after undergoing a left hip closed surgery after a mechanical fall on 9/28/19. On 10/7/19 at 4:27 p.m., during a telephone interview, Resident 1's Responsible Party (RP) stated on 9/28/19 she was called by the facility's registered nurse (RN 1) Resident 1's fall during a shower. The RP stated Resident 1's left eye was swollen (become larger or rounder in size) and red in color. On 10/17/19 at 4:50 p.m., during a concurrent interview and review of Resident 1's care plans, in the presence of the ADM and the Director of Nursing (DON), the DON stated Resident 1's Fall Risk care plan interventions were not updated to reflect resident's needs, which included the amount assistance required after Resident 1 had two previous falls on 5/13/19 and 5/22/19. The DON stated Resident 1 was at higher risk for falls and fractures due to Resident 1's [DIAGNOSES REDACTED]. The DON stated Resident 1's MDS did not reflect Resident 1's behaviors of throwing herself to the floor and the need for a two-person physical assist. A review of a document titled, Interact Change in Condition Evaluation V5, dated 8/13/19, Resident 1 was noted at the nursing station and was witnessed by staff attempting to throw self out of the wheelchair repeatedly. As resident was assisted by staff to get back into wheelchair the resident attempted to throw self on to the floor again. Resident was assisted back to the wheelchair but kept lunging forward. Resident was then brought back to bedroom and put back in bed for comfort. Resident noted with crying and moaning at this time with 1:1 supervision. On 10/18/19 at 8:07 a.m., during an interview, CNA 1 stated CNA 2 and himself were assisting Resident 1 shower on 9/28/19, when suddenly Resident 1 got up and attempted to grab the bathroom rails. CNA 1 stated both he and CNA 2 quickly grabbed Resident 1 arm pits and assisted both he and Resident 1 to the floor to prevent fall. CNA 1 denied Resident 1 fell . On 10/18/19 at 8:55 a.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated on 9/28/19, CNA 1 called for help stating Resident 1 fell in the shower. LVN 2 stated upon entering the shower room with LVN 1, Resident 1 was observed on the bathroom floor, holding her left hip, crying, out in pain and with a left hip abrasion (skin scrape). On 10/21/19 at 1:39 p.m., during an interview, LVN 1 stated on 9/28/19 while passing medications LVN 1 overheard CNA 1 yelling out Resident 1 fell . LVN 1 stated upon entering the shower room, Resident 1 was observed sitting on her left side on the floor. LVN 1 stated during his investigation, CNA 1 stated Resident 1 fell from the shower chair. LVN 1 stated CNA 2 was not interviewed because she was an was an orientatee. On 10/21/19 at 1:51 p.m., during an interview, CNA 2 stated during her orientation on 9/28/19, she and CNA 1 were drying Resident 1 when she (Resident 1) attempted to stand up and Resident 1's legs gave out and they (CNA1 and 2) assisted Resident 1 to the floor (sic). On 10/21/19 at 3:55 p.m., during an observation and interview, Resident 1 stated she fell and hit the left side of her face, head, left elbow and left hip on the floor. Resident 1 was observed with tears in her eyes while stating she fell . Resident 1 continue to point to her left side of her face and leg stating it hurt. Resident 1 stated hitting her face after CNA 1 dropped her. On 10/22/19 at 4:53 p.m., during an interview, RN 1 stated during Resident 1's fall investigation, CNAs 1 and 2 stated they were finishing with Resident 1's shower when the resident got up from the shower chair, lost her balance and slid from standing to the floor. A review of the facility's document titled, Verification of Incident Investigation/Administrative Summary, dated 10/23/19, signed by the facility's ADM and the DON on 10/23/19, 25 days after the fall incident, indicated the facility received a report from the GACH indicating Resident 1 arrived with a bruise (injury appearing as an area of discolored skin on the body) to the left side of her face caused by the assisted fall sustained in the facility during a shower. A review of the facility's job description titled, Performance Evaluation for CNA, revised on 11/13/17 indicated the staff would use proper techniques and equipment to ensure safe movement of resident and prevent employee injury, and to never leave a resident in an unsafe position or situation as per the plan of care. A review of the facility's policy titled, Falls Management Program, revised on 8/2014, indicated the purpose of the policy was to provide interventions to minimize risk, injury, and occurrences utilizing resident's history, MDS, and port-fall evaluation. The policy indicated the facility would review, revise and evaluate care plan effectiveness at minimizing falls and injuries as needed. The policy indicated the care plan would identify fall risk associated factors and outline fall prevention strategies.

Based on observation, interview, and record review, the facility failed to follow its policy and procedures and a resident's plan of care to provide blood glucose monitoring for one of 13 sampled residents (Resident 1) in accordance with professional standard of practice. Resident 1, who was a diabetic (high blood sugar) and had poor meal intake, was continued to receive [MEDICATION NAME] (a hormone that regulates the metabolism of carbohydrates (sugars)), without monitoring of the blood glucose levels. These failures resulted in Resident 1, having a change in condition of a low blood glucose level while continuing to receive insulin that required a transfer to a general acute care hospital (GACH) on [DATE]. Resident 1 expired five days later on [DATE]. On [DATE] at 5:21 p.m., an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared under F 684. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened and provided an acceptable plan of correction (POA) on [DATE] after it was confirmed through interview and record review and it was implemented. On [DATE], the facility submitted a POA for the correction of the IJ included the following: -A plan/process to identify other residents potentially affected by the same deficient practice and corrective actions to be taken; insulin orders were reviewed by the medical director on [DATE] to validate or establish appropriate blood glucose monitoring. Thirteen Residents were identified as diabetic and were receiving insulin. -Facility's measures and systemic changes to ensure the deficient practice does not recur, the DON or designee will begin in-servicing the Licensed nurses on [DATE] on facility's policy titled, Insulin use which outlines monitoring blood glucose levels for residents receiving insulin and establishing notification parameters when point of care blood glucose testing is the preferred monitoring method. -Training also included in recognizing and responding to emergent situations and responding to a change of condition which included checking signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. Completion date of [DATE]. -Facility included plan to monitor corrective action, sustain compliance and integrate the quality assurance process, the Director of nursing will conduct random audits of patients receiving insulin each week for the next three months to evaluate compliance with blood glucose monitoring. Audit disparities will be referred back to the nursing department for prompt resolution of any concerns. The DON will be responsible for reporting audit compliance trends to the quality assurance committee quarterly for problem analysis, action planning, and additional monitoring needs as indicated. Completion date of [DATE]. The IJ was lifted once the team confirmed that the facility's POA was implemented on [DATE] at 3:23 p.m. Findings: A review of a Clinical Summary from GACH 1 indicated Resident 1 was admitted to GACH 1 on [DATE] from home. The physician's orders [REDACTED]. A review of GACH 1's Medication Administration Records (MAR), for the month of ,[DATE] indicated Resident 1's blood glucose ranged from 156 milligrams per deciliter (mg/dL) to 257 mg/dL (normal reference range (NRR) ,[DATE]). During Resident 1's admission at GACH 1 she received insulin 3 units for a blood glucose of 257 on [DATE]. A review of GACH 1's Discharge Assessment Summary, dated [DATE], indicated Resident 1 was transferred to the nursing facility at 12:42 p.m. A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. in brain function, confusion, memory loss, and abnormal changes in judgment or thought). A review of a history and physical (H/P), dated [DATE] indicated Resident 1 was transferred to the facility after a recent hospitalization for multiple medical problems including Type 2 diabetes mellitus receiving insulin, acute onset of [MEDICAL CONDITION] ((CKD) the gradual loss of kidney function such as filtration of wastes from blood, and then excreted in urine) and alteration in mental status. According to the H/P Resident 1 was treated for [REDACTED]. A review of Resident 1's admission Minimum Data Set (MDS), a resident assessment and care screening tool, dated [DATE], indicated Resident 1 had memory problems, was severely impaired in cognitive skills (thought process) for daily decision-making and was unable to make needs known and understand others. According to the MDS, the resident was assessed as requiring extensive assistance with bed mobility, and was totally dependent with transferring, locomotion on and off the unit, and required a one-person physical assistance with eating and personal hygiene. According to the MDS, under Section N350, Resident 1 received five days of insulin injections since admission to the facility. A review of Physician 1's orders indicated for Resident 1 to receive [MEDICATION NAME] solution insulin ((Insulin [MEDICATION NAME]) a recombinant human insulin analog that is a long-acting, [MEDICATION NAME] blood-glucose-lowering agent) 10 units subcutaneously (a short needle used to inject into the tissue layer between the skin and the muscle) once a day at 9 a.m. for diabetes mellitus. A review of a care plan, initiated on [DATE], identified Resident 1's problem with diabetes mellitus. The goal indicated that Resident 1 would not have complications related to diabetes mellitus. The staff's interventions included to monitor/document the resident and family's ability to manage the treatment program, such as medications, dietary, glucose monitoring, exercise and knowledge of complications of [DIAGNOSES REDACTED] such as sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, and staggering gait (walk). A review of Resident 1's activities of daily living (ADLs) meal consumption record, dated [DATE] indicated Resident 1 consumed 50 percent (%) for breakfast, 25 percent for lunch, and 25 % for dinner with the staff's assistance. A review of the Medication Administration Record [REDACTED]. A review of Resident 1's ADLs meal consumption record, dated [DATE] indicated Resident 1 consumed 25 % for dinner with staff's assistance. The meal consumption for breakfast and lunch was left blank. A review of the MAR, dated [DATE] and timed at 1:21 p.m. indicated Resident 1 received 10 units of [MEDICATION NAME]. A review of the ADLs meal consumption record, dated [DATE] indicated Resident 1 consumed 50 % for breakfast, 50 % for lunch, and 25 % for dinner with staff's assistance. A review of the MAR, dated [DATE] and timed at 10 a.m., indicated Resident 1 received 10 units of [MEDICATION NAME]. A review of the ADLs meal consumption record dated [DATE] indicated Resident 1 consumed 75 percent for breakfast, 50 % for lunch, with staff assistance. According to the ADLs meal consumption record Resident 1 refused dinner. A review of the MAR, dated [DATE] and timed at 8:38 a.m. indicated Resident 1 received 10 units of [MEDICATION NAME]. A review of the ADLs meal consumption record, dated [DATE] indicates Resident 1 consumed 25 % for breakfast. Resident 1 was not available to eat lunch. A review of the MAR, dated [DATE] and timed at 8:41 a.m. indicated Resident 1 received 10 units of [MEDICATION NAME]. A review of the progress note, dated [DATE] and timed at 11:36 a.m., written by Licensed Vocational Nurse (LVN 1) indicated Resident 1's family member (FM 1) was in the facility and came to the nursing station and stated Resident 1 was not normal and was choking. According to the note, LVN 1 went to Resident 1's room to assess Resident 1. LVN 1 documented Resident 1 was observed with SOB (shortness of breath), and she elevated the HOB (head of bed), and assessed the vital signs. Resident 1's blood pressure was ,[DATE] (NRR ,[DATE]- ,[DATE]), pulse 58 (NRR ,[DATE] per minute), respirations 20 (NRR ,[DATE] per minute, oxygen saturation was 93% (NRR ,[DATE]%) on room air. A review of the Situation, Background, Assessment and Recommendation ((SBAR) internal comments form), dated [DATE] and timed at 11:53 a.m. written by LVN 1 indicated a change in condition for Resident 1 of the respiratory system. According to the SBAR, Resident 1 had shortness of breath and an oxygen saturation of 93% on room air. According to the SBAR, LVN 1 indicated that 93 percent oxygen saturation was a little low, but informed Resident 1's family member (FM 1) that because the vital signs were within normal range, she would have to notify the physician for further orders. The SBAR indicated FM 1 became aggressive and demanded for the to staff call the paramedics and if they did not call, she would. FM1 called 911 and the paramedics arrived and took the resident to a GACH, per FM 1 request. The SBAR indicated Resident 1 was in no acute respiratory distress at time of departure, and the Supervisor and physician (Physician 1) was notified at 11 a.m. According to the Paramedic Run Sheet, dated [DATE], the paramedics were called at 10:52 a.m., and arrived at Resident 1 at 10:55 a.m. The paramedic documented, Patient found lying supine (on back in flat position) in bed with complaint of SOB for 15 minutes with an AL[NAME] (altered level of consciousness) more than normal. Patient had bilateral rales (an abnormal rattling sound heard when examining unhealthy lungs) with a low blood pressure of ,[DATE] then ,[DATE], and a low blood glucose of 22. The Paramedics left with Resident 1 at 11:05 a.m. The paramedic run sheet indicated Resident 1 had a Glasgow Coma Scale of 7 (2,1,4) ((GCS) the summation of scores for the eye movement, verbal, and motor responses, (a score of 15 is the highest), a score of 8 or less indicates a patient is severe neurological state. A review of Resident 1's medical record indicated there was no documented evidence of Resident 1's blood glucose levels (blood glucose (sugar that the bloodstream carries to all the cells in the body to supply energy)) were being monitored while receiving [MEDICATION NAME] daily since admission at the facility [DATE]. According to the American Diabetes Association, blood glucose levels below 70 indicated [DIAGNOSES REDACTED] and the brain does not get enough glucose and stops functioning. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. If blood glucose stays low for too long, starving the brain of glucose, may lead to [MEDICAL CONDITION], coma and/or death. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html On [DATE] at 3:11 p.m., during a telephone interview, FM 1 was crying and stated that she went to visit Resident 1 and upon her arrival to the resident's room, Resident 1 had a dazed look on her face, and did not respond when FM 1 attempted to talk to her. FM 1 went to the nursing station and stated LVN 1 told her that Resident 1 was fine. FM 1 stated that she knew something was wrong with Resident 1 and asked LVN 1 to call the paramedics and LVN 1 refused. FM 1 stated that LVN 1 told her that she needed to ask her supervisor (RN 1) and call Resident 1's physician (Physician 1) to call 911. FM 1 stated that she called 911 herself. According to FM 1, LVN 1 did not check Resident 1's vital signs or blood glucose level. FM 1 stated that if she did not come to visit Resident 1 may have died at the facility. FM 1 stated that Resident 1 was in the intensive care unit (ICU) at the GACH. FM1 stated that she contacted the facility's Director of Nursing (DON) regarding her concerns of the lack of Resident 1's care, but did not receive a call back. On [DATE] at 9:24 a.m., Resident 1 was observed in the ICU with bilateral upper extremity restraints, one intravenous line was in each arm with multiple medications infusing. Resident 1 was awake, but did not respond to verbal questions. On [DATE] at 1:37 p.m., during a telephone interview, FM 1 stated that Resident 1 passed away. A review of the GACH 2's emergency room Encounter Form dated [DATE] and timed at 11:21 a.m., indicated Resident 1 arrived to the ER in AL[NAME] escorted by EMS (emergency medical services) in severe respiratory distress, and [DIAGNOSES REDACTED] with a blood glucose level at 22. According to the GACH ER form, Resident 1 was immediately placed on a [MEDICAL CONDITION] machine ((Bilevel Positive Airway Pressure) machine that delivers pressurized air through a mask to the patient's airways during the respiratory cycle while inhaling and exhaling) and given IV glucose with no improvement in her neurologic status. According to the GACH emergency room encounter form, the critical care time was 75 minutes. The ER note indicated Resident 1 medical condition placed her at an increased risk of decompensation and death. The final impression of Resident 1 was acute [MEDICAL CONDITIONS] (a condition caused by excess fluid in the lungs), altered level of consciousness, and [DIAGNOSES REDACTED]. At 9:06 a.m., on [DATE], during an interview, GACH 2's clinical nurse specialist (CSRN) stated Resident 1 was admitted to the ICU from the emergency room (ER) with a [DIAGNOSES REDACTED]. The CSRN stated that Resident 1 had was placed on a [MEDICAL CONDITION] machine, had no urine output, and received volume (intravenous fluids into the vein) due to a low blood pressure. A review of GACH 2's Discharge Summary, dated [DATE] indicated that Resident 1 was pronounced deceased on [DATE] at 2:23 a.m. by GACH 2's code blue physician. On [DATE] at 2:41 p.m., during an interview, the facility's Registered nurse 1 (RN 1) stated that she was informed by a staff member that FM 1 was calling the paramedics for Resident 1. RN 1 stated that she went to Resident 1's room, she and LVN 1 checked the vital signs and the oxygen saturation was low. RN 1 stated that Resident 1 was placed on oxygen, but they did not check Resident 1' blood glucose. RN 1 further stated that there was no order to check Resident 1's blood glucose. On [DATE] at 2:44 p.m., during a concurrent interview and record review, RN 1 was unable to provide any documentation of Resident 1's blood glucose level being checked. RN 1 stated that when a resident was receiving insulin, it was very important to check the blood glucose levels. RN 1 stated that she was not sure why the nurses were not checking blood glucose levels for a resident receiving insulin, especially if the resident needed assistance with eating. On [DATE] at 4:21 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that the ADLs are documented on the facility's IPAD and that Resident 1 only ate 25 % on the day of the incident ([DATE]). At 5:48 p.m., on [DATE], during an interview, the DON stated that any resident who was diabetic and receiving insulin, should have their blood glucose checked before receiving insulin. The DON was unable to find any documented blood glucose levels for Resident 1. On [DATE] at 8:17 a.m., during an interview, LVN 1 stated that FM1 came to the nursing station and stated Resident 1 did not look good and wanted to call 911. LVN 1 stated that she informed FM 1 that Resident 1's physician must be informed prior to being transferred to the GACH. LVN 1 stated that Resident 1's oxygen saturation was low at 93 %. LVN 1 stated she had administered [MEDICATION NAME] according to the physician's orders [REDACTED]. On [DATE] at 11:34 a.m., during an interview, Resident 1's primary physician (Physician 1) stated that ideally Resident 1's blood glucose should be checked AC (prior to meals) and HS (at bedtime) for [MEDICATION NAME] administration. Physician 1 stated Resident 1's blood glucose should have been closely monitored due to Resident 1's poor oral intake, to compare the effectiveness of the medication. Physician 1 stated that Resident 1's medications included the same orders from GACH 1 prior to her admission to the facility, which included monitoring the blood glucose. Physician 1 stated that the nurses should have monitored Resident 1's blood glucose for signs and symptoms of low blood sugar due to the cause and effect. A review of the facility's policy and procedure titled, Insulin Use dated ,[DATE] indicated it was the policy of the facility to provide adequate monitoring for patients receiving insulin. The policy and procedure indicated for newly admitted patients with insulin orders the staff should evaluate the blood glucose monitoring orders. The policy and procedure indicated if no orders exist consult with the physician regarding blood glucose monitoring activity and frequency.

Based on observation, interview, and record review, the facility failed to follow its Protocols/Responsibilities and its policy to ensure comfortable and safe temperature levels were maintained between 71-81 degrees Fahrenheit (F) inside the residents' rooms, hallway, conference room and the kitchen. The hallway and eight residents' rooms (Rooms 22, 23, 24, 25, 26, 27, 28, and 29) with 19 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) of the facility's 28 residents' room temperature were above 81.0 degrees F. This deficient practice of not maintaining proper room temperatures 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 19 residents. On 7/19/18 at 4:21 p.m., an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared under F5[AGE] Resident Rights. The facility's administrator and Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened by high temperatures in the hallways and resident rooms. On 7/19/18, the facility provided a Plan of Action (POA) that was not acceptable. On 7/20/18 at 5:01 p.m., the facility provided an acceptable POA and the IJ was removed after the team confirmed through direct observation and interview that the POA was implemented as follows: 1. To move residents in Rooms 22-29 to rooms with temperatures ranging from 71-81 degrees F. 2. Repair the Air conditioning system on the evening of 7/19/18. 3. Monitor residents for signs and symptoms of heat exposure including vital signs every shift from 7/19/18 to 7/23/18. 4. Offer residents additional fluids during medication pass from 7/19/18 to 7/23/18 and monitor for signs of dehydration. 5. The licensed nurse to monitor for changes in condition and inform the physician and document. 6. Contact the emergency services if a resident or staff member appears to be in danger of heat related stress. 7. Provide extra hydration such as popsicles; sugar free Jell-O, ice chips, ice cream, and cold water as resident diets permit as necessary targeting all residents. 8. Initiate the extreme temperature policy and procedures. 9. Monitor residents' room temperature; common areas every 30 minutes until temperatures decreased within the range of 71-81 degrees F for 90 minutes. 10. In-service staff on extreme temperature policy, signs and symptoms of heat related illness and prevention. 11. Notify the medical director and on call physician on 7/19/18. 12. The Maintenance supervisor to initiate a temperature log for residents' rooms. 13. Quality walking rounds will be conducted by the Department managers, to include residents' comfort and environmental temperature. The findings will be reported during the daily stand up meeting for correction. 14. On 7/20/18, alert and oriented residents will be interviewed utilizing the environment pathway tool. Any resident expressing concern of room temperatures will be addressed immediately, such as providing a fan to ensure comfort. 15. The facility will monitor the temperature of the rooms daily to ensure they are not less than 71 degrees F and/or greater than 81 degrees. Findings: On 7/19/18 at 3:48 p.m., during a general tour of the facility, the lights were observed off and it was very warm inside. The staff were questioned about the lights being off they stated, To help keep down the temperature in the facility it has been hot in the facility for over a few days. On 7/19/18 at 3:49 p.m., during an observation inside of room [ROOM NUMBER], Resident 4 was observed with a flushed sweaty face and a wet towel on her forehead. At 3:53 p.m., on 7/19/18, during an interview, Resident 4's family member (FM 1) stated, I give her (Resident 4) ice chips to help keep her cool and put a cool towel on her head. It is very hot, I have told the nurses, but nothing has been done. The fan does not help at all, she (Resident 4) gets exhausted from the heat and I try to cool her down. A review of Resident 4's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 4's [DIAGNOSES REDACTED]. On 7/19/18 at 3:55 p.m., the temperature of room [ROOM NUMBER] was measured by the Maintenance Supervisor ([CONDITION]) using the facility's temperature gun (device with an infrared thermometer that permits temperature measurement of a room) with a reading of [AGE].8 F. On 7/19/18 at 3:57 p.m., during an interview, the [CONDITION] stated, The air conditioning company was called yesterday, and they are coming in tonight to fix the air conditioner because the air conditioner have been broken for a few days. I do not know what the temperature should be. I do not keep temperature logs. A review of the facility's Department Specific Protocols/Responsibilities, dated 6/15/11, indicated the following maintenance responsibilities: 1. Establish temperature-monitoring logs for various resident care locations throughout the facility. 2. Assess in-house availability of accessible, functioning portable fans. 3. Procure additional portable fans as required to maintain temperature levels, with the first priority being the residents' care areas and common areas. 4. Procure alternate air cooling devices as needed, including renting/purchasing air conditioning units. On 7/19/18 at 3:59 p.m., during an observation in the presence of the DON, room [ROOM NUMBER]'s temperature was taken by the [CONDITION] using the temperature gun with a reading of 90 degrees F. On 7/19/18 at 4:01 p.m., during an observation and concurrent interview, the DON was observed sweating and stated, I feel fine, but the older residents are prone to dehydration. On 7/19/18 at 4:02 p.m., during an interview, Resident 3 stated, It's always hot in here, they do nothing about it. I have told the nurses, I have a fan, but it is blowing hot air. I am miserable and my room is like a sauna. Resident 3 stated the staff are all aware as how hot it has been in the facility, because when the staff come in to change her they are drenched in sweat. A review of Resident 3's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), an assessment and care screening tool, dated 6/19/18, indicated Resident 3 had the ability to understand and be understood by others with memory intact and a Brief Interview for Mental Status (BI[CONDITION]) score of 15 (13-15=interviewable). A review of Resident 14's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 14's MDS, dated [DATE], indicated the resident's memory was intact and had a BIMs score of 15. A review of the Accu-Weather Forecast for [STATE] cities for July 2018 indicated the following temperatures: 7/12/18=[AGE] degrees F 7/13/18=87 degrees F 7/14/18=89 degrees F 7/15/18=[AGE] degrees F 7/16/18=[AGE] degrees F 7/17/18=[AGE] degrees F 7/18/18=[AGE] degrees F 7/19/18=[AGE] degrees F On 7/19/18, at 4:03 p.m., during a concurrent observation and interview, the ambient temperatures (the temperature of the surrounding air) were taken of the resident's rooms, the hallway, kitchen and the conference room by the [CONDITION]. The facility's temperature gun was used to check the temperatures and the following was observed: a. room [ROOM NUMBER]'s temperature was 82.7 degrees F. Two residents were observed in the room and the window was closed. b. room [ROOM NUMBER]'s temperature was [AGE].4 degrees F. Three residents and one visitor (FM 1) were observed in the room and the room's window was not open. Two fans were observed in use in the room. c. room [ROOM NUMBER]'s temperature was [AGE].5 degrees F. Two residents were observed in the room and the room's window was open. Two fans were observed in use the room. d. room [ROOM NUMBER] 's temperature was [AGE].0 degrees F. One resident was observed in the room and the room's window was not open. e. room [ROOM NUMBER]'s temperature was [AGE].3 degrees F. Two residents and two unidentified family members were observed in the room and the room's window was not open. Two fans were observed in use in the room. f. room [ROOM NUMBER]'s temperature was [AGE].2 degrees F. One resident was observed in the room and the room's window was not open. No fans were observed in the room. g. The hallway near the nurse's station temperature was [AGE].1 degrees F. h. The staff's conference room was [AGE].0 degrees F. No windows were observed open. Two fans were observed in use in the room. I. The facility kitchen was 94 degrees F. Two staff members were observed in the kitchen. No windows were observed open. One swamp cooler (a device that cools air through the evaporation of water) was observed in the kitchen. On 7/19/18 at 4:35 p.m., Resident 14 stated, I have been in the facility for two weeks and it has been very hot in the mornings, afternoons and night. I thought they did not have an air conditioner. There was no water pitcher observed at the Resident 14's bedside. A review of the facility's invoice from a construction company to repair the air conditioner, dated 7/19/18, indicated the facility's air conditioner had a leak and was in need of repair. A review of the facility's Policy and Procedures (P/P) titled, Extreme Rise in Environmental or Facility Temperature, dated 6/15/11 indicated that the purpose of the facility was to provide a reasonable and necessary standard for preventing and responding to facility temperatures of [AGE] degrees. The P/P indicated comfortable facility temperatures are between 71-81 degrees Fahrenheit. 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, indicated the older person are at a high risk for developing heated-related illness 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 and other heat-related conditions due to many other factors relating to age, medications receiving and /or medical [DIAGNOSES REDACTED].nih.gov/news-events/news-releases/keep-it-cool-hot-weather-advice-older-people

Based on observation, interview and record review, the facility failed to provide adequate assistance and supervision to 1 of 24 sampled residents (Resident 20) when: 1. The resident was assisted by one person during turning while performing activities of daily living (ADL) care, and 2. Certified Nursing Assistant (CNA) 3 left Resident 20 unsupervised in a right side-lying position during ADL care. These failures resulted in Resident 20 falling off the bed, fracturing (breaking) her right lower leg. Findings: On 5/8/2018, at 8:55 a.m., during the initial tour, Resident 20 was observed with a right leg splint (a device used to support or immobilize). On 5/8/2018, at 8:56 a.m., during an interview with Licensed Vocational Nurse (LVN) 2, she stated Resident 20 sustained a right leg fracture due to a fall from her bed. A review of Resident 20's Admission Record indicated she was originally admitted to the facility on [DATE] and readmitted on [DATE]. A review of Resident 20's Fall Risk assessment dated [DATE], indicated a fall risk score of 55 (a score of 45 and higher indicates high risk for falls). A review of Resident 20's Minimum Data Set (MDS), an assessment and care screening tool, dated 2/28/2018, indicated the resident rarely/never understood staff during interviews, required extensive assistance with two-person physical assist during bed mobility (how resident moves to and from lying position, turns side to side) and transfers (how resident moves between surfaces). A review of Resident 20's Plan of Care, dated 11/17/2016, titled Self-care deficit indicated the resident needed two-person assist with activities of daily living (ADLs) including bed mobility, due to impaired cognition and mobility from a [MEDICAL CONDITION] ([MEDICAL CONDITION] - lack of blood flow to the brain). A review of the facility's Situation, Background, Appearance and Review (SBAR) and Fall Report of Incident, dated 3/25/2018, indicated Resident 20 slid and fell off the bed during morning care while CNA 3 was changing her. CNA 3 stated she turned around to get a gown and found the resident on the floor. Resident 20 was in a sitting position at her bedside with her legs crossed. The licensed nurse assessed the resident's skin, which showed no signs of injury. There was no sign of facial grimacing, moaning or pain. The licensed nurse notified the physician and received an order to x-ray the both hips. A review of the facility's SBAR Communication Form dated 3/27/2018, indicated Resident 20 had swelling on her right lower extremity and bruising to the right inner leg. The licensed nurse called the attending physician and received an order to transfer Resident 20 to a General Acute Care Hospital (GACH). On 5/10/2018, at 9:34 a.m., CNA 3 was interviewed. CNA 3 stated, on 3/25/18, she did not know Resident 20 required a two-person assist before providing care. CNA 3 stated she was changing Resident 20 by herself. CNA 3 also stated she did not ask for assistance because she thought Resident 20 only required one person assist. CNA 3 stated she turned the resident on her right side to change her bottom sheet and her adult incontinence pad. CNA 3 stated she left Resident 20 on her right side with the privacy curtain closed, to get a gown in the closet across the foot of the bed. CNA 3 stated she heard a loud sound when she was getting the gown from the closet. CNA 3 stated she checked Resident 20 and found her on the floor in a squatting position with her legs crossed. CNA 3 also stated she did not see Resident 20 fall because the privacy curtain was completely closed. On 5/10/2018, at 11:24 a.m., the Minimum Data Set (MDS) nurse stated Resident 20 required two-person physical assist with bed mobility. The MDS nurse stated the risk of Resident 20 falling could have been decreased if CNA 3 was better prepared prior to starting ADL care, by getting all of her supplies, including the gown, and calling for help before turning and repositioning the resident. The MDS nurse stated CNA 3 should not have left Resident 20 unsupervised when she was getting the gown from the closet. On 5/10/2018, at 5:01 p.m., the Director of Nursing (DON) stated the swelling on Resident 20's right lower extremity was identified and reported to the attending physician on 3/27/2018, two days later. The DON stated CNA 3 turned Resident 20 by herself. The DON also stated CNA 3 should have asked for assistance to turn the resident while providing ADL care the fall could have been prevented. A review of GACH Emergency Department (ED) final report, dated 3/27/2018, indicated, Resident 20, brought in by ambulance, whose complaint was [MEDICAL CONDITION] (swelling) of the right leg for two days. The Skilled Nursing Facility (SNF) reported the resident had a fall 2 days ago, and the hip x-ray (picture of bone) showed no fracture. No other X-ray performed. The GACH x-ray of the tibia/fibula (lower leg bones) showed a [MEDICATION NAME] fracture (a horizontal break in the bone) on the tibia and fibula. The recommendation was a knee immobilizer (type of brace or splint) and to discharge the resident back to SNF. A review of the facility's policy and procedure titled, Fall Management, dated (MONTH) 2014, indicated, to evaluate risk factors and provide interventions to minimize risk, injury, and occurrences such as initiating a fall prevention care plan, when appropriate, with strategies to minimize risk and potential for injuries, such as a two-person assist.