Every finding on record at College Vista Post-Acute

Based on observation, interview and record review, the facility failed maintains acceptable parameters of nutritional status, to prevent unintended significant weight loss for Two of three sampled residents (Resident 28 and Resident 8) in accordance to the facility's policy and procedures titled Weight Management Policy and Nutritional Assessment. 1. For Resident 28 who lost 17.3 pounds (lbs.) with 16.29 (%) percent of body weight six months from 106.2 lbs. on10/3/2025 to 88.9 lbs. on 4/3/2026 the facility failed to: a. Reassess Resident 28's food preferences, according in which the resident reported her preferred food. b. Conduct an IDT Interdisciplinary Team- with the party responsible involved to determine the possible root cause of Resident 28's weight loss. c. Update the care plan interventions to address her continued weight loss. d. Monitor, evaluate and document how much Resident 28 consumed with each supplement provided to determine if the supplement was consumed or not. These deficient practices had resulted in Resident 28's unintended significant weight loss and continued severe weight loss. 2. For Resident 8 who had kidney failure (failure of the kidney to filter toxins and remove extra fluid in the body) and receives hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) fluid intake restriction was added to the plan of care as recommended by the Registered Dietitian's (RD) fluid recommendation of 1800 milliliters (ml, unit of measure). This failure had the potential to place Resident 8 at risk for altered hydration status which may lead to severe dehydration or fluid overload which may result in hypotension (low blood pressure) or hypertension (high blood pressure), edema (swelling), shortness of breath, heart failure (heart cannot effectively pump blood to the rest of the body) and may lead to hospitalization. Findings: 1. During a review of Resident 28's admission Record (AR), the AR indicated the facility admitted Resident 28 on 11/27/2024 with diagnoses that include type II diabetes mellitus (a condition when the blood sugar was too high) and depression (a common, serious mood disorder that causes persistent sadness, loss of interest, and physical or emotional symptoms). During a review of Resident 28's Minimum Data Set (MDS, a resident screening tool), dated 4/28/2026, indicated Resident 28's had intact cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 28 required setup or clean-up assistance with eating and personal hygiene, supervision or touching assistance with oral hygiene, and partial/moderate assistance with toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 28's IDT Care Conference, dated 12/4/2025, the IDT indicated the Director of Nursing (DON) and Registered Dietitian (RD) participated in the meeting. The IDT report indicated Resident 28 was receiving supplements such as fortified foods (the addition of one or more essential nutrients to a food), Health Shake (high-calorie, high-protein shakes are essential for managing weight loss) three times a day, snacks three times a day, and Boost (a nutritional drink) three times a day. The IDT report indicated Resident 28's average meals eaten was 61 percent with one to three meals per day, and no snack intake. The IDT indicated Resident 28 had significant weight loss of 22 pounds in six months, without new labs to review and the RD recommended for Resident 28 to receive medical evaluation for appetite stimulant (a medication to increase appetite). During a review of Resident 28's Weight summary, dated 5/14/2026, the summary indicated Resident 28's weights decreased as follows: 10/3/2026: 106.2 lbs. 10/31/2026: 93.4 lbs. 11/3/2026: 93.6 lbs. 12/2/2025: 88 lbs. 1/2/2026: 88.4 lbs. 2/2/2026: 88.6 lbs. 3/3/2026: 89.8 lbs. 4/3/2026: 88.9 lbs. During a review of Resident 28's Order Summary Report (OSR), dated 5/14/2026, the OSR indicated the physician ordered for the resident to receive fortified foods with meals, starting on 3/31/2025; Magic cup twice a day five with lunch and dinner for malnutrition, starting on 5/1/2026; snack three times a day for at risk for malnutrition/additional supplement, starting on 5/28/2025; and Boost oral liquid give one unit by mouth three times a day for additional supplement, starting on 5/28/2026. During a concurrent interview and record review on 5/14/2026 at 9:09 AM with Licensed Vocational Nurse (LVN) 1, Resident 28's Medication Administration Record (MAR)s, dated from 10/2025 to 5/2026, were reviewed. LVN 1 stated Resident 28 were on nutritional supplements, including Boost, Health Shake, Magic Cup, and snacks. LVN 1 stated he documented the supplements as given on the MAR when he provided the supplements to the resident, but he did not check and did not document how much the resident consumed from each supplement provided. LVN 1 stated the MAR for supplement only reflected that the supplement was offered to the resident and did not reflect if the resident took it or how much she took it. LVN 1 stated he was not aware that Resident 28 had any weight change issues since 10/2025. During a concurrent interview and record review on 5/14/2026 at 9:11 AM with LVN 1, Resident 28's weight summary, dated from 10/3/2025 to 5/11/2026, and Resident 28's Change in Condition Evaluation (COC), dated from 10/2025 to 5/14/2026, were reviewed. LVN 1 stated Resident 28 had weight loss within a month from 10/3/2025 to 10/31/2025 and continue to have from severe weight loss within six months from 10/3/2025 to 3/3/2026, but the nurse did not complete a COC regarding the resident's weight loss issue. LVN 1 stated the licensed nurse should complete a COC to indicate the resident's weight loss was addressed and notified to the physician and the responsible party. During a concurrent interview and record review on 5/14/2026 at 9:41 AM with Certified Nursing Assistant (CNA) 2, Resident 28's Documentation Survey Reports, dated from 10/2025 to 5/2026, were reviewed. CNA 2 stated the CNAs did not monitor and did not document how much Resident 28 consumed from the supplements, including Boost, Health Shake, Magic Cup, and snack. CNA 2 stated licensed nurses were supposed to record how much the resident completed the supplements. During an interview on 5/14/2026 at 10:40 AM with the Registered Dietitian (RD), the RD stated Resident 28 lost weight and was currently underweight, so the physician ordered different supplements to Resident 28, but the facility staff did not monitor and document the amount of the supplements Resident 28 consumed because the supplements were the extra nutritional support to the resident. During an interview on 5/15/2026 at 8:30 AM with Resident 28, Resident 28 stated she did not like the food prepared in the facility. Resident 28 stated she preferred Asian food, such as Pilipino and Chinese food, but the facility did not offer this type of food. Resident 28 stated the staff did not ask her what she liked and disliked eating. During a telephone interview on 5/15/2026 at 8:46 AM with Family Member (FM) 1, FM 1 stated he regularly visited Resident 28 and sometimes brought her food that she liked. FM 1 stated the facility did not inform him that Resident 28 had lost weight. FM 1 stated if he knew Resident 28 had lost so much weight, he would bring more food from home and work with the facility to help the resident to gain her weight back. During a concurrent interview and record review on 5/15/2026 at 9:15 AM with the Dietary Supervisor (DS), Resident's Progress Notes, dated from 10/4/2026 to 4/9/2026, and Resident 28's Meal Ticket, dated 5/16/2026, were reviewed. The DS stated she did not reassess and document what Resident 28's likes and dislikes after Resident 28 had severe weight loss since 10/2025. During a concurrent interview and record review on 5/15/2026 at 9:20 AM with the DS, the updated facility's Alternate Menu Slip, and the facility's Menu, dated from 12/21/2025 to 5/23/2026, were reviewed. The DS stated the facility did not offer any Asian food choice to Resident 28. During an interview on 5/15/2026 at 9:41 AM with the Director of Nursing (DON), the DON stated she was responsible for documenting COCs and IDT meeting for Resident 28's weight loss issue. The DON stated she failed to document key clinical actions related to Resident 28's significant weight loss, such as document the Change of Condition (COC) when the resident lost over 10% of body weight in one month (10/31/2025) or the continued loss of over 15% in six months (as of 4/3/2026). The DON also did not document required Interdisciplinary Team (IDT) meetings addressing the resident's severe and ongoing weight loss. The DON stated she spoke with the physician about an appetite stimulant, she did not document the rationale for the physician declining it. Additionally, the DON stated she did not inform the family or ask them to provide preferred foods, stating that family involvement should have occurred. She further stated the facility staff did not reassess, document, or provide foods the resident preferred, nor did they monitor or record supplement intake, preventing evaluation of whether supplements were effective. During a review of the facility's policy and procedure (P&P) titled, Dietary Services-Staffing, dated 12/19/2022, the P&P indicated the facility to take into consideration resident assessment and individual plans of care. The P&P also indicated the dietary staff to provide meals and/or supplements in accordance with residents' needs, preferences, and care plan. During a review of the facility's P&P titled, Weight Management Policy, revised on 11/1/2024, the P&P indicated Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range . The P&P indicated will a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary. The P&P also indicated Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. The P&P indicated a significant change in weight is defined as 5% change in weight in 1 month (30 days) or 10% change in weight in 6 months (180 days). The P&P indicated Documentation of significant weight changes shall be completed in accordance with the facility's documentation policies and procedures and accepted standards of practice. During a review of the facility's P&P titled, Documentation in Medical Record, dated 12/18/2025, the P&P indicated Each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress and Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical records. 2.During a review of Resident 8's admission Record (AR), the facility admitted Resident 8 on 6/22/2023 and readmitted on [DATE] with included diagnoses of: End Stage Renal Disease (ESRD – irreversible kidney failure), chronic pulmonary edema (excess fluid in your lungs). Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Minimum Data Set (MDS – a resident assessment tool) dated 3/9/2026 the MDS indicated that Resident 8 's cognitive (a resident's thought process) skills were intact. The MDS indicated that Resident 8 needed assistance (helper sets up or cleans up) for meals. During a review of Resident 8's Care Plan titled, The Resident Has Nutritional Problem or Potential Nutritional Problem . dated 3/11/2026, the care plan indicated that Resident 8 will comply with recommended diet daily. The care plan's interventions included honor residents' food preferences within diet parameters, monitor resident's weight and notify the physician and Registered Dietitian in addition to monitor intake and food eaten every meal. During a review of Resident 8's Nutritional Assessment dated 3/12/2026, done by the RD the assessment indicated that Resident 8 had significant large weight changes related to fluid shifts, it also indicated that Resident 8 had non-pitting edema (swelling cause by excess fluid trapped in the body's tissues) to the extremities. The RD recommended to continue to monitor weight trend and to monitor all intake. During an observation on 5/12/2026 at 9:31 AM in Resident 8's room, Resident 8 was observed lying in bed with a full water pitcher on top of Resident 8's bedside table (a small adjustable table designed to roll over a bed and provide a flat surface). During a review of Resident 8's Order Summary Report dated 5/13/2026, Resident 8 had a physician order for fluid restriction of 1200 ml in a 24-hour period including 8 ounces with breakfast, lunch and dinner and 8 ounces when necessary. During an observation on 5/13/2026 at 4:08 PM in Resident 8's room, Resident 8 was observed lying in bed with a full water pitcher on top of Resident 8's bedside table. During an observation on 5/14/2026 at 9:45 AM in Resident 8's room, Resident 8 was observed lying in bed with a full water pitcher on top of Resident 8's bedside table. Resident 8 stated that he was not aware that he had fluid restriction order by his physician. During an observation on 5/14/2026 at 11:49 AM in Resident 8's room, Resident 8 was observed lying in bed with a full water pitcher on top of Resident 8's bedside table. Resident 8 stated that he is on a medication named Lasix (prescribed medication that helps get rid of extra fluid in the body's tissues) stated that he has not been told by the facility that he has a fluid recommendation/restriction. Resident 8 stated that he does not have too much urine output and that is not measured by the facility. During a concurrent record review and interview with RD on 5/14/2026 at 2:29 PM stated that Resident 8 is in and out of the hospital, stated that he sees Resident 8 monthly or as needed. RD stated that on 3/12/2026 when he did the nutritional assessment, he calculated for Resident 8 the recommended fluid intake of 1800 ml based it was based on his caloric needs. RD stated that he did not include the recommended fluid intake in Resident 8's care plan. During a concurrent observation and interview on 5/14/2026 at 4:08 PM with Director of Nurses (DON) Resident 8 was observed lying in bed with a full water pitcher on top of Resident 8's bedside table. DON stated that if Resident 8 had an increase of fluid intake above the recommended it could cause fluid overload, pneumonia (an infection/inflammation in the lungs), respiratory distress and hospitalizations. DON stated that Resident 8 should have been on a fluid restriction. During a review of Resident 8' s care plan titled, The Resident Has Nutritional Problem or Potential Nutritional Problem Related to Pulmonary Edema dated 5/14/2026 indicated a fluid restriction of a total of 1200 ml every 24 hours. During a concurrent observation and interview on 5/15/2026 at 9:54 AM with Certified Nurse Assistant (CNA)1. Resident 8 was observed lying in bed with a full water pitcher on top of Resident 8's bedside table. CNA 1 stated that Resident 8 was not on a fluid water restriction. During an interview on 5/15/2026 at 9:56 AM with Licensed Vocational Nurse (LVN)1 stated that he had already administered Resident 8 his morning medications and that Resident 8 should not have had a full water pitcher at bedside due to the physician order of fluid restriction of 1200 ml. During an interview on 5/15/2026 at 3:33 PM with Resident 8's Medical Doctor (MD)1 stated that Resident 8 who is a dialysis resident should be managed with proper renal diet and appropriate hydration to avoid hospitalizations due to fluid overload. During a review of facility's policy and procedure (P&P) titled Comprehensive Care Plan dated 12/19/2022, indicated that the comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to a member of the food and nutrition services staff. During a review of facility's P&P titled, Hemodialysis dated 12/18/2025, indicated that nutritional/fluid management including documentation of the resident's weights, and compliance with intake and output measurements as ordered. In addition, it indicated that the staff would communicate with the dialysis facility, attending physician and or nephrologist of any significant weight changes, and nutritional concerns. During a review of facility 's P&P titled, Fluid Restriction dated 12/18/2025, indicated that fluid restriction will be followed to physician orders. The policy stated that fluid restrictions are basically the restriction of fluid intake for an underlying medical condition such as ESRD. The fluid restriction will be distributed into consideration of fluid to be given with mealtimes, snacks and medication passes.

Based on observation, interview and record review, the facility failed to ensure food and consumption items were handled appropriately to prevent contamination and spread of foodborne and waterborne illnesses by failing to: 1. Ensure the internal component of the ice machine, reservoir pan, was cleaned every 30 days as indicated on the manufacturer's specifications. 2. Ensure Certified Nurse Assistant (CNA) 1 performed hand hygiene after assisting in setting up Resident 23's meal tray and then immediately assisting Resident 7. These deficient practices had the potential to result in foodborne/waterborne illnesses and for the residents residing in the facility. Findings: 1.During a concurrent observation and interview on 5/12/2026 at 8:47 AM with the Dietary Supervisor (DS), the bottom of the reservoir pan located inside the ice machine was wiped with a white paper towel. After the reservoir pan was wiped, small black particles were observed on the white paper towel. The DS stated small black particles should not be inside the ice machine's reservoir pan. During a concurrent observation and interview on 5/12/2026 at 8:50 AM with [NAME] 1, [NAME] 1 stated he recently cleaned the inside of the ice machine however did not clean the reservoir pan. [NAME] 1 stated the small black particles on the white paper towel, after the reservoir pan was wiped, was mineral buildup and must be removed when routine cleaning of the ice machine was done. During a concurrent interview and record review on 5/12/2026 at 4:20 PM with the Maintenance Supervisor (MS), the facility's log for Ice Machine Cleaning Monthly, dated from 1/2026 to 5/2026, was reviewed. The MS stated the ice machine was cleaned on 1/23/2026, 2/5/2026, 3/3/2026, 4/29/2026 and 5/1/2026. The MS stated the staff did not clean the ice machine for 57 days from 3/3/2026 to 4/29/2026. During an interview on 5/15/2026 at 10:20 AM with the Infection Preventionist (IP), the IP stated the staff should thoroughly clean the inside and outside of the ice machine monthly, with the interval of every 30 days to ensure the production of ice was free of contamination and prevent infection among residents. During a review of the facility's policy and procedure (P&P) titled, Installation, Start-Up and Maintenance Manual ICE SERIES CUBERS,, dated 9/1/2015, the P&P indicated to thoroughly wash and sanitize all surfaces within the bin. During a review of the facility's P&P titled, Ice Machine Cleaning Policy, revised 6/23/2025, the P&P indicated The ice machine needs to be cleaned and sanitized monthly. The internal components are cleaned monthly or per manufacturer recommendations. 2. During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted Resident 23 on 12/10/2025 with diagnoses that include chronic congestive heart failure (CHF, a serious, progressive condition where the heart cannot pump blood efficiently) and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 3/19/2026, the MDS indicated Resident 23 had severely impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 23 required setup or clean-up assistance with eating, oral hygiene and toileting hygiene, and supervision or touching assistance with shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 7' s AR, the AR indicated the facility initially admitted Resident 7 on 1/3/2024 and readmitted on [DATE] with diagnoses that include dementia and Parkinson's disease (a progressive condition that affects movement). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had severely impaired cognition and memory. The MDS indicated Resident 7 required partial/moderate assistance with oral hygiene and personal hygiene, substantial/maximal assistance with toileting hygiene and shower/bathe self and was dependent on chair/bed-to-chair transfer. During a dining observation on 5/13/2026 at 12:29 PM, Certified Nursing Assistant (CNA) 1 picked up Resident 23's meal tray from the meal cart and entered Resident 23's room and placed the meal tray onto Resident 23's bedside table. CNA 1 prepared Resident 23's meal tray by assisting in opening food items and setting up the meal tray. CNA 1 then touched Resident 23's shoulder and assisted Resident 23 to sit up in bed. Immediately after Resident 23's meal tray was set up, CNA 1 left the room and did not perform hand hygiene. CNA 1 was then observed obtaining a meal tray for Resident 7 from the meal cart and placed the meal tray on Resident 7's bedside table. During an interview on 5/13/2026 at 12:30 PM with CNA 1, CNA 1 stated she was in a hurry and forgot to perform hand hygiene before and after passing meal trays between residents. CNA 1 stated it was important to perform hand hygiene to prevent infection. During an interview on 5/15/2026 at 3:16 PM with the Director of Nursing (DON), the DON stated it was important to perform hand hygiene when passing meal trays between residents to prevent the spread of infection. During a review of the facility's P&P titled, Personal Hygiene-Safety-Food Handling-Infection Control, revised 12/19/2022, the P&P indicated hands must always be washed after handling any unsanitary items. During a review of the facility's P&P titled, Hand Hygiene, revised on 12/18/2025, the P&P indicated all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitor. The P&P also indicated hand hygiene is indicated and will be performed between resident contacts.

Based on observation, interview, and record review, the facility failed to ensure that specialized rehabilitative services were provided by qualified personal when the Director or Rehabilitation (DOR), who was a Certified Occupational Therapist Assistant (COTA), transcribed the Physical Therapist (PT) evaluation findings into the Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in each joint of both arms and legs) for two of two sample residents (Resident 5 and Resident 34). This practice resulted in Resident 5 and Resident 34's JMAs that were not independently assessed or completed by a qualified PT, as required for accurate identification of joint-mobility limitations, which lead to an inaccurate assessment of Resident 5 and Resident 34's JMA that could lead to inappropriate care planning, missed changes in functional decline, and failure to implement timely interventions to maintain or improve range of motion (ROM, full movement potential of a joint). Cross Reference with F688 and F641 Findings: 1. During a review of Resident 5's admission Record (AR), the AR indicated that the facility admitted Resident 5 on 3/31/2021 and readmitted Resident 5 on 3/17/2025 with diagnoses that include Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement) without dyskinesia (uncontrollable muscle movements), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant side, and left knee contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 5's care plan, revised 9/29/2024, the care plan indicated that Resident 5 had limited physical mobility related to weakness, osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), Parkinson's Disease, and history of stroke. The care plan's intervention included to monitor, document, report any signs and symptoms of immobility such as contractures forming or worsening, thrombus formation (blood clot), and skin breakdown as needed, and to provide gentle range of motion as tolerated with daily care. During a review of Resident 5's history and physical (H&P), dated 3/19/2025, the HP indicated that Resident 5 does not have the capacity to understand and make decisions. During a review of Resident 5's care plan, revised 4/7/2025, the care plan indicated that Resident 5 received left upper extremity PROM exercises and bilateral lower extremity ROM exercises with splint application. The care plan's interventions included applying the left knee splint and left-hand splint for 6 hours or as tolerated and the specific exercises for the left upper extremity which included elbow, wrist, and finger flexion and extension. The care plan did not provide documented evidence of the specific exercises for the bilateral lower extremity ROM. During a review of Resident 5's MDS, dated [DATE], the MDS indicated that Resident 5's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 5's active diagnoses included hemiplegia or hemiparesis and Parkinson's Disease. The MDS indicated that Resident 5 was dependent on ADLs such as lower body dressing, toileting, and showering and for functional mobility such as repositioning in bed, transitioning from sitting to lying, and transferring from chair/bed to chair. The MDS indicated that the bilateral upper extremities did not have any impairment and there was one-sided impairment on the lower extremity. During a review of Resident 5's PT Evaluation and Plan of Treatment record, written by PT 1, dated 5/8/2026 timed at 12:06 PM, the record indicated that Resident 5's right knee PROM had no movement in flexion or extension and fixed in neutral position. The record indicated that Resident 5's AROM for the bilateral lower extremities were not applicable. The record indicated that Resident 5's PROM of the right knee was fixed in a straight position with no flexion or extension in neutral position. The record indicated Resident 5's PROM of the right and left ankle was fixed in a 50-degree plantar flexion with no available dorsiflexion. The record indicated that Resident 5's PROM of the left knee was bent at 40 degrees and cannot fully straighten to neutral position. During a review of Resident 5's JMA record, written by the Director of Rehabilitation (DOR), dated 5/8/2026 timed at 3:08PM, the record indicated that Resident 5's left knee flexion was within functional limits and the right knee extension was minimally impaired. The record indicated that Resident 5's bilateral knees and bilateral ankles flexion and extension were moderately impaired. During an observation on 5/12/2026 at 10:19 AM in Resident 5's room, Resident 5 was observed sleeping in bed with her left leg bent at the knee towards the body and left foot bent forward at the ankle with toes bent away from the body. Resident 5's right leg was observed straight in bed with right foot bent forward at the ankle with toes bent away from the body. During a concurrent observation and interview on 5/14/2026 at 2:16 PM in Resident 5's room with Restorative Nurse Aide (RNA) 1, RNA 1 was observed performing PROM exercises on Resident 5's left upper extremity and bilateral lower extremities. RNA 1 stated that Resident 5's left leg was able to bend towards the body but cannot straighten all the way. RNA 1 stated Resident 5's right leg was straight and stiff, and Resident 1 opened her eyes and straight at RNA 1 as RNA 1 attempted to bend her leg towards the body. RNA 1 stated Resident 5's bilateral ankles were bent forward, and her toes were facing away from the body. RNA 1 stated Resident 5's bilateral ankles cannot bend backwards, and her toes had a little bit of flexion and extension during ROM exercises. During the concurrent interview and record review on 5/15/2026 at 12:28 PM with PT 1, Resident 5's JMA, dated 5/8/2026, was reviewed. PT 1 stated that the DOR completed the JMA in the facility. PT 1 stated that Resident 5's JMA only indicated within functional limits, mildly impaired, moderately impaired, or severely impaired. PT 1 stated, in her other place of employment, the PT completed the JMA and referenced the joint mobility assessment tool with angular measurements and visual diagrams to assess the resident's range of motion. During the same concurrent interview and record review on 5/15/2026 at 12:45 PM with PT 1, Resident 5 PT Evaluation and Plan of Treatment record, dated 5/8/2026, and JMA record, dated 5/8/2026, was reviewed. PT 1 stated, Resident 5's JMA record for the right knee extension was moderately impaired, but the PT Evaluation and Plan of Treatment, record indicated her right knee extension was fixed and contracted in a straight position with no flexion or extension available. PT 1 stated, she would consider Resident 5's JMA of the right knee flexion and extension to be severely impaired because the PT Evaluation and Plan of Treatment indicated Resident 5's right knee to be fixed and contracted in a straight position. During the same concurrent interview and record review on 5/15/2026 at 12:48 PM with PT 1, Resident 5 PT Evaluation and Plan of Treatment record, dated 5/8/2026, and JMA record, dated 5/8/2026, was reviewed. PT 1 stated, Resident 5's JMA record indicated her flexion and extension ROM of the bilateral ankles were moderately impaired. PT 1 stated, she would consider Resident 5's JMA of the bilateral ankles to be severely impaired because the PT Evaluation and Plan of Treatment record indicated that her bilateral ankles were fixed and contracted in a 50-degree plantar flexion position with no flexion or extension available at the ankles. PT 1 stated, she did not know why the JMA was inaccurate as the DOR was the one who completed the resident's JMA within the facility. During a concurrent interview and record review on 5/15/2026 at 3:43 PM with the DOR, Resident 5's JMA and PT Evaluation and Plan of Treatment, record, both dated 5/8/2026, was reviewed. The DOR stated, completes and documents the resident's JMA based on the PT's assessment on the PT Evaluation and Plan of Treatment, record, date 5/8/2026. The DOR stated, the JMA record indicated that Resident 5's bilateral ankles were moderately impaired, which meant that Resident 5's ankle only had 20 to 40-degrees of ROM. The DOR stated, the PT's Evaluation and Plan of Treatment record indicated that Resident's 5's bilateral ankle flexion and extension was fixed and contracted at 50-degrees. During the same concurrent interview and record review on 5/15/2026 3:50 PM with the DOR, the Complete Orthopedics Ankle Flexion diagram, date unknown, and Resident 5's JMA, dated 5/8/2026, were reviewed. The DOR stated, this chart was a diagram used to determine the degree of the ankle's loss of function. The DOR indicated that she did not know what minimally impaired, moderately impaired, and severely impaired indicated on the JMA, and the DOR stated, I cannot tell you the degrees of each. The DOR stated, she evaluates the PT's assessment on the PT Evaluation and Plan of Treatment record, and she transposes the PT's assessment into the JMA. 2. During a review of Resident 34's AR, the AR indicated that the facility admitted Resident 34 on 10/29/2019 and readmitted Resident 34 on 1/31/2021with diagnoses that include spinal stenosis (narrowing of the spine) of the lumbar (lower back) region, spondylolysis (small fractures or cracks in the vertebra of the spine) of the lumbar region, and dementia (a progressive state of decline in mental abilities). During a review of Resident 34's care plan, initiated 6/10/2022, the care plan indicated that Resident 34 received assisted active range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) on his bilateral lower extremities 5 times a week as tolerated. The care plan's interventions included flexion and extension exercises for his hip, knee, and ankle. During a review of Resident 34's MDS, dated [DATE], the MDS indicated that Resident 34's cognitive skills were severely impaired. The MDS indicated that Resident 34 required moderate assistance (helper does less than half the effort) for ADLs such as showering and dressing the lower body and required moderate assistance with function mobility such as transitioning from sitting to lying and transferring from chair/bed to chair. The MDS indicated that Resident 34 did not have any functional ROM limitations in his upper and lower extremities. During a review of Nurse Practitioner (NP) 1's Medical Progress Note record, dated 4/6/2026, the record indicated that Resident 34's musculoskeletal assessment included decreased range of motion or pain with ROM. During a review of Resident 34's MDS, dated [DATE], the MDS indicated that Resident 34's cognitive skills were severely impaired. The MDS indicated that Resident 34 required moderate assistance for ADLs such as showering and dressing the lower body and required moderate assistance with function mobility such as transitioning from sitting to lying and transferring from chair/bed to chair. The MDS indicated that Resident 34 had functional ROM limitations impairments on one side of his lower extremity. During a review of Resident 34's PT Evaluation and Plan of Treatment record written by PT 1, dated 4/28/2026, the record indicated that the bilateral lower extremity ROM was within functional limits. The record indicated Resident 34's right lower extremity (hip, knee, and ankle) strength was within functional limits, but his left lower extremity (hip, knee, and ankle) strength was impaired. During a review of Resident 34's JMA record, written by DOR, dated 5/11/2026, the record indicated Resident 34's bilateral lower extremities (knees and ankles) extension and flexion were within functional limits. During a concurrent observation and interview on 5/14/2026 at 11:46 AM with the DOR in Resident 34's Room, Resident 34 was observed sitting up in his wheelchair with his bilateral toes and ankles bent downwards pointed away from the body. The DOR stated that the PT were the ones who assessed the residents for the JMA and completed lower body extremities ROM with the resident. The DOR stated, since Resident 34 was not walking, his lower extremities were within functional limits. During the same concurrent interview and record review on 5/15/2026 at 12:25 PM with PT 1, Resident 34's JMA record, dated 4/28/2026, was reviewed. PT 1 stated that a resident's functional mobility assessment identified the extent the resident's functional mobility affected the resident's bed mobility, transfer mobility, and ambulation status. PT 1 stated that a resident's JMA provided an estimate of the resident's joint limitations and loss of range of motion. PT 1 stated, Resident 34's JMA indicated his bilateral lower extremities were within functional limits. PT 1 stated that Resident 34, who does not ambulate, was not considered to be within functional limits on the JMA. During a concurrent observation and interview on 5/15/2026 at 1:04 PM with PT 1 in Resident 34's room, Resident 34 was observed lying in bed with his bilateral ankles pointed away from the body and bilateral toes facing away from the body. PT 1 stated that Resident 34's right ankle strength was worse than the left ankle strength. During the same concurrent interview and record review on 5/15/2026 at 1:15 PM with PT 1, Resident 34's PT Evaluation and Plan of Treatment record, dated 4/28/2026, was reviewed. PT 1 stated that the record indicated Resident 34's ROM for the bilateral lower extremities were within functional limits. PT 1 stated that the record indicated that the left ankle strength had trace muscle contraction. PT 1 stated, she did not document Resident 34's right ankle strength on 4/28/2026 because Resident 34 complained of right ankle discomfort during the evaluation, but she did not go back to reassess Resident 34 on 4/28/2026. During the same interview on 5/15/2026 at 3:54 PM with the DOR, the DOR stated that the JMA was the functional mobility assessment. The DOR stated that the JMA was based on the resident's ability to complete a task based on the functionality of the joint not the limitation or degrees of joint loss. During an interview on 5/15/2026 at 4:11 PM with Consultant 2, Consultant 2 stated the JMA was an assessment completed by the physical therapists to determine the resident's passive range of motion and to monitor the resident's range of motion to ensure no loss of range of motion. Consultant 2 stated, JMA indicated the limitation of the joint, and nursing needs to be aware of a resident's joint limitation as it impacts their care. During a review of the facility's policies and procedures (P&P) titled Joint Mobility Assessment, dated 12/19/2022, the P&P indicated that the Rehabilitative staff will complete the Joint Mobility Assessment form to document this and the Joint Mobility Assessment form will be completed by the rehabilitative staff upon initial admission, annual assessment, and change in condition. During a review of the facility's job description titled Job Description - Occupational Therapist Assistant, dated 12/19/2022, the job description indicated that the job summary of the Occupational Therapist Assistant was to assist in providing appropriate aspects of quality patient care, under the supervision of licensed therapists. The job description indicated the Occupational Therapist Assistant's essential functions including implementing and executing on established patient treatment plan under the supervision of an occupational therapist. During a review of the facility's job description titled Job Description - Occupational Therapist, dated 12/19/2022, the job description indicated that the job summary of the Occupational Therapist was to provides, directs, and supervises all aspects of quality patient care, including, but not limited to screening, evaluation and treatment, treatment planning, goal setting, family education and documentation, in order to assure the best outcome possible for the patient. The job description indicated that the Occupational Therapist's essential functions included to appropriately and effectively completes documentation including evaluations, daily notes, progress, discharge summaries, or monthly reports as required. During a review of the facility's job description titled Job Description - Physical Therapist, dated 12/19/2022, the job description indicated the Physical Therapist job summary was to provides, directs, and supervises all aspects of quality patient care, including, but not limited to: screening, evaluation, and treatment, treatment planning, goal setting, family education, and documentation, in order to assure the best outcome possible for the patient. The job description indicated that the Physical Therapist's essential functions included to appropriately and effectively completes documentation including evaluations, daily notes, progress notes, discharge summaries, or monthly reports as required. During a review of the California Board of Occupational Therapy, as codified in the California Code of Regulations, Occupational Therapist Assistants (OTAs) may contribute to the evaluation process but OTAs may not evaluate independently. The regulation indicated that the supervising Occupational Therapist (OT) was responsible for interpretation of referrals or prescriptions for occupational therapy services and the interpretation and analysis for evaluation purposes. During a review of the California Board of Occupational Therapy, as codified in the Business and Professions Code and [NAME] Regulations, occupational therapists are not authorized to practice physical therapy.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 7). This de cient practice has a potential for Resident 7 not able to call for help when needed for comfort and safety.Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was re-admitted on [DATE] with diagnoses including parkinsonism (brain condition causing movement issues, dementia (progressive state of decline in mental abilities), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 7's Minimum Data Sheet (MDS-a resident assessment tool) dated 3/27/26, the MDS indicated Resident 7 has clear speech, minimum hearing difficulty, impaired vision, sometimes understood, sometimes understands, on mechanically altered diet (modi ed to be soft, easy to chew and swallow safely). Resident 7 bladder and bowel is always incontinent, and dependent with activities of daily living (ADLs-routine personal care). During a review of Resident 7's Care Plan dated 3/23/24, Resident 7's Care Plan indicated Resident 7 has an ADL's self-care performance de cit related to activity intolerance, impaired balance, and functional quadriplegia (the complete inability to move all four limbs and the body due to severe frailty) interventions include encourage use of call bell for assistance.During observation on 5/12/26 at 12:25 PM in Resident 7's room, Resident 7 was in bed, talking to self, and stated, her back is itchy, was trying to wiggle her back against the mattress, at call light at head of bed (HOB) above pillow.During an observation and interview on 5/12/26 at 12:25 PM of CNA 1, CNA 1 entered Resident 7's room bringing pureed (smooth thick liquid) lunch for oral gratification. CNA 1 stated call light is beyond reach of Resident 7 and she cannot use the call light because she cannot move her hands, hands are tucked under the blanket. During an observation and interview on 5/12/26 at 12:28 PM with the Director of Nursing (DON), The DON found call light hanging over HOB and stated call light is not within reach of Resident 7. During an interview on 5/12/26 at 12:54 PM with CNA 1, CNA 1 stated he usually puts call light on her chest, a bit to the right but he just forgot to put call light back on her chest after he served her lunch. CNA 1 stated call light should be placed on the chest, not hands, because hands are stiff.During an interview on 5/14/26 3:30 PM with the DON, The DON stated Resident 7 has parkinsonism, rigidity. If we provide call light with button, she would not be able to click it, so we provided the at call light for her. The DON stated resident can access it so she can just tap it. The DON stated there are two ways to put it: side of chest, she taps with her face, and within reach of her hand on abdomen. Resident 7 taps it on accident, does not have to necessarily push it hard. The DON stated Resident 7 does not call often, if she calls, she needs her back scratched.During a subsequent interview on 5/14/26 3:30 PM with DON, the DON stated if at call light is not within reach, her needs will be unmet, Resident 7's call light should be always within reach.During a review of facility's policy and procedure (P&P) dated 12/19/22, P&P indicated, Special accommodations will be identi ed on the resident's person-centered plan of care and provided accordingly. (Examples include touch pads .) Staff will ensure the call light is within reach of resident and secured, as needed.

Based on interview and record review, the facility failed to ensure the Notice of Proposed Transfer/Discharge notification was sent to the Office of the State Long-Term Care Ombudsman (a state employee that advocate for the residents) for one of three sample residents (Resident 45) in accordance with the facility's policy and procedure titled Transfer and Discharge. This deficient practice had the potential to result in the Ombudsman not being aware of Resident 45's discharge to the General Acute Care Hospital (GACH) on 1/2/2026 Findings: During a review of Resident 45's admission Record (AR), the AR indicated that the facility admitted Resident 45 on 12/18/2025 with diagnoses that included acute respiratory failure (a condition where the lungs cannot get enough oxygen into the blood), Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and malignant neoplasm of the lung (lung cancer). During a review of Resident 45's History and Physical (H&P), dated12/25/2025, the H&P indicated that he had the capacity to understand and make decisions. During a review of Resident 45's Minimal Data Set (MDS, a resident assessment), dated 4/29/2026, the MDS indicated that Resident 45's cognitive (a resident's thought process) skills for daily decisions making were moderately impaired (decisions poor; cues/supervisions required). During a concurrent interview and record review on 5/15/2026 at 9:50 AM with the Medical Records Director (MRD), Resident 45's Transmission Verification Report (fax record) record, dated 1/2/2026, was reviewed. The MRD stated the fax record showed the transmission result to the Ombudsman was busy. The MRD explained this indicated the Ombudsman did not receive the required notice of Resident 45's transfer/discharge to the hospital on 1/2/2026. The MRD stated the Ombudsman must be notified to ensure they are aware of the resident's status and location and to provide advocacy related to the resident's rights and follow up needs. During a concurrent interview and record review on 5/15/2026 at 10 AM with Licensed Vocational Nurse (LVN) 1, Resident 45's Transmission Verification Report (fax record) record, dated 1/2/2026, was reviewed. LVN 1 stated, he signed Resident 45's Notice of Transfer/Discharge and faxed the notice to the Ombudsman on 1/2/2026. LVN 1 stated that he did not notice the fax record's result was busy. LVN 1 stated, it was important to verify that the Ombudsman received the Notice of Transfer/Discharge so the Ombudsman representative could follow up with the resident and their representative party. During a review of the facility's policies and procedures (P&P) titled Transfer and Discharge (including AMA [Against Medical Advice]), dated 12/19/2022, the P&P indicated that the facility will maintain evidence that the notice was sent to the Ombudsman.

Based on observation, interview, and record review, the facility failed to ensure that two of three sample residents (Resident 5 and Resident 32)'s Minimal Data Set (MDS, a resident's assessment) accurately reflected the resident's status to indicate the residents' functional range of motion (ROM, full movement potential of a joint) limitations in accordance to the facility's policy and procedure (P&P) titled Resident Assessment - RAI. This deficient practice resulted in the inaccurate documentation of Resident 5 and Resident 32's functional ROM limitations on the MDS and had the potential to negatively affect Resident 5 and Resident 32's plan of care and delivery of necessary care and services related to the range of motion. Cross Reference with F688 and F826 Findings: 1. During a review of Resident 5's admission Record (AR), the AR indicated that the facility admitted Resident 5 on 3/31/2021 and readmitted Resident 5 on 3/17/2025 with diagnoses that include Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement) without dyskinesia (uncontrollable muscle movements), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant side, and left knee contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 5's care plan, revised 9/29/2024, the care plan indicated that Resident 5 had limited physical mobility related to weakness, osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), Parkinson's Disease, and history of stroke. The care plan's intervention included to monitor, document, report any signs and symptoms of immobility such as contractures forming or worsening, thrombus formation (blood clot), and skin breakdown as needed, and to provide gentle range of motion as tolerated with daily care. During a review of Resident 5's history and physical (H&P), dated 3/19/2025, the HP indicated that Resident 5 does not have the capacity to understand and make decisions. During a review of Resident 5's care plan, revised 4/7/2025, the care plan indicated that Resident 5 received left upper extremity PROM exercises and bilateral lower extremity ROM exercises with splint application. The care plan's interventions included to apply the left knee splint and left-hand splint for 6 hours or as tolerated and the specific exercises for the left upper extremity which included elbow, wrist, and finger flexion and extension. The care plan did not provide documented evidence of the specific exercises for the bilateral lower extremity ROM. During a review of Resident 5's MDS, dated [DATE], the MDS indicated that Resident 5's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 5's active diagnoses included hemiplegia or hemiparesis and Parkinson's Disease. The MDS indicated that Resident 5 was dependent on ADLs such as lower body dressing, toileting, and showering and for functional mobility such as repositioning in bed, transitioning from sitting to lying, and transferring from chair/bed to chair. The MDS indicated that the bilateral upper extremities did not have any impairment and there was one-sided impairment on the lower extremity. During a review of Resident 5's PT Evaluation and Plan of Treatment record, written by PT 1, dated 5/8/2026 timed at 12:06 PM, the record indicated that Resident 5's right knee passive range of motion (PROM, movement of a joint through the range of motion with no effort from the person only with the assistance of another person) had no movement in flexion (bending the joint towards the body, shortening the angle between 2 body parts) or extension (straightening the joint away from the body, lengthening the angle between 2 body parts) and fixed in neutral position (the joint's natural resting position. The record indicated that Resident 5's active range of motion (AROM, performance of exercise to move a joint without any assistance or effort of another person) for the bilateral lower extremities were not applicable. The record indicated that Resident 5's PROM of the right knee was fixed in a straight position with no flexion or extension in neutral position. The record indicated Resident 5's PROM of the right and left ankle was fixed in a 50-degree plantar flexion with no available dorsiflexion. The record indicated that Resident 5's PROM of the left knee was bent at 40 degrees and cannot fully straighten to neutral position. During a review of Resident 5's Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in each joint of both arms and legs) record, written by the Director of Rehabilitation (DOR), dated 5/8/2026 timed at 3:08PM, the record indicated that Resident 5's left knee flexion was within functional limits and the right knee extension was minimally impaired. The record indicated that Resident 5's bilateral knees and bilateral ankles flexion and extension were moderately impaired. 2. During a review of Resident 34's AR, the AR indicated that the facility admitted Resident 34 on 10/29/2019 and readmitted Resident 34 on 1/31/2021with diagnoses that include spinal stenosis (narrowing of the spine) of the lumbar (lower back) region, spondylolysis (small fractures or cracks in the vertebra of the spine) of the lumbar region, and dementia (a progressive state of decline in mental abilities). During a review of Resident 34's care plan, initiated 6/10/2022, the care plan indicated that Resident 34 received assisted active range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) on his bilateral lower extremities 5 times a week as tolerated. The care plan's interventions included flexion and extension exercises for his hip, knee, and ankle. During a review of Resident 34's care plan, revised 5/9/2024, the care plan indicated Resident 34 had limited physical mobility due to spinal stenosis, and lumbar spondylosis. The care plan's interventions included monitoring signs and symptoms of pain associated with mobility and monitoring, documenting, and reporting any signs and symptoms of immobility such as contractures forming or worsening, thrombus formation, and skin breakdown as needed. During a review of Resident 34's MDS, dated [DATE], the MDS indicated that Resident 34's cognitive skills were severely impaired. The MDS indicated that Resident 34 required moderate assistance (helper does less than half the effort) for ADLs such as showering and dressing the lower body and required moderate assistance with function mobility such as transitioning from sitting to lying and transferring from chair/bed to chair. The MDS indicated that Resident 34 did not have any functional ROM limitations in his upper and lower extremities. During a review of Resident 34's MDS, dated [DATE], the MDS indicated that Resident 34's cognitive skills were severely impaired. The MDS indicated that Resident 34 required moderate assistance for ADLs such as showering and dressing the lower body and required moderate assistance with function mobility such as transitioning from sitting to lying and transferring from chair/bed to chair. The MDS indicated that Resident 34 had impaired functional ROM limitations on one side of his lower extremity. During a review of Resident 34's PT Evaluation and Plan of Treatment record written by PT 1, dated 4/28/2026, the record indicated that the bilateral lower extremity ROM was within functional limits. The record indicated Resident 34's right lower extremity (hip, knee, and ankle) strength was within functional limits, but his left lower extremity (hip, knee, and ankle) strength was impaired. During a review of Resident 34's JMA record, written by DOR, dated 4/28/2026, the record indicated Resident 34's bilateral lower extremities (knees and ankles) extension and flexion were within functional limits. During an observation on 5/12/2026 at 10:19 AM in Resident 5's room, Resident 5 was observed sleeping in bed with her left leg bent at the knee towards the body and left foot bent forward at the ankle with toes bent away from the body. Resident 5's right leg was observed straight in bed with right foot bent forward at the ankle with toes bent away from the body. During a concurrent interview and record review on 5/13/2026 at 3:28 PM with the MDS nurse (MDSN), Resident 34's MDS, dated [DATE] and 4/21/2026, and Resident 34's JMA record, dated 4/22/2026, were reviewed. The MDSN stated that the MDS, dated [DATE], indicated Resident 34 did not have any functional limitations on his bilateral lower extremities. The MDSN stated that the MDS, dated [DATE], indicated Resident 34 had an impaired on one side of his lower extremity. The MDSN stated that the JMA, dated 4/22/2026, indicated Resident 34's bilateral lower extremities were within functional limits. The MDSN stated that the information on the MDS was based on the JMA completed by the rehabilitation department. During a concurrent observation and interview on 5/14/2026 at 11:46 AM with the DOR in Resident 34's Room, Resident 34 was observed sitting up in his wheelchair with his bilateral toes and ankles bent downwards pointed away from the body. The DOR stated that the PT were the ones who assessed the residents for the JMA and completed lower body extremities ROM with the resident. The DOR stated, since Resident 34 was not walking, his lower extremities were within functional limits. During a concurrent observation and interview on 5/14/2026 at 2:16 PM in Resident 5's room with Restorative Nurse Aide (RNA) 1, RNA 1 was observed performing PROM exercises on Resident 5's left upper extremity and bilateral lower extremities. RNA 1 stated that Resident 5's left leg was able to bend towards the body but cannot straighten all the way. RNA 1 stated Resident 5's right leg was straight and stiff, and Resident 1 opened her eyes and straight at RNA 1 as RNA 1 attempted to bend her leg towards the body. RNA 1 stated Resident 5's bilateral ankles were bent forward, and her toes were facing away from the body. RNA 1 stated Resident 5's bilateral ankles cannot bend backwards, and her toes had a little bit of flexion and extension during ROM exercises. RNA 1 stated, there was no change in Resident 1's care and exercises that I have noticed. During the concurrent interview and record review on 5/15/2026 at 12:25 PM with PT 1, Resident 34's JMA record, dated 4/28/2026, was reviewed. PT 1 stated that a resident's functional mobility assessment indicated the extent a resident's functional mobility affected the resident's bed mobility, transfer mobility, and ambulation status. PT 1 stated that a resident's JMA provided an estimate of the resident's joint limitations and loss of range of motion. PT 1 stated that Resident 34, who does not ambulate, was not considered to be within functional limits on the JMA. During the concurrent interview and record review on 5/15/2026 at 12:40 PM with PT 1, Resident 5's PT Evaluation and Plan of Treatment record, dated 3/18/2025, and JMA record, dated 3/18/2025, were reviewed. PT 1 stated that according to the JMA record, Resident 5's left knee extension was minimally impaired, but the PT Evaluation and Plan of Treatment, record indicated her left knee extension was bent at 35 degrees and cannot fully straighten to neutral position. PT 1 stated, she would consider Resident 5's JMA of the left knee to be moderate/severe impairment because the knee remained bent at 35-degrees and cannot be straightened. During the same concurrent interview and record review on 5/15/2026 at 12:45 PM with PT 1, Resident 5 PT Evaluation and Plan of Treatment record, dated 5/8/2026, and JMA record, dated 5/8/2026, was reviewed. PT 1 stated, Resident 5's JMA record for the right knee extension was moderately impaired, but the PT Evaluation and Plan of Treatment, record indicated her right knee extension was fixed and contracted in a straight position with no flexion or extension available. PT 1 stated, she would consider Resident 5's JMA of the right knee flexion and extension to be severely impaired because the PT Evaluation and Plan of Treatment indicated Resident 5's right knee to be fixed and contracted in a straight position. During the same concurrent interview and record review on 5/15/2026 at 12:48 PM with PT 1, Resident 5 PT Evaluation and Plan of Treatment record, dated 5/8/2026, and JMA record, dated 5/8/2026, was reviewed. PT 1 stated, Resident 5's JMA record indicated her flexion and extension ROM of the bilateral ankles were moderately impaired. PT 1 stated, she would consider Resident 5's JMA of the bilateral ankles to be severely impaired because the PT Evaluation and Plan of Treatment record indicated that her bilateral ankles were fixed and contracted in a 50-degree plantar flexion position with no flexion or extension available at the ankles. PT 1 stated, she did not know why the JMA was inaccurate as the DOR was the one who completed the resident's JMA within the facility. During a concurrent observation and interview on 5/15/2026 at 1:04 PM with PT 1 in Resident 34's room, Resident 34 was observed lying in bed with his bilateral ankles pointed away from the body and bilateral toes facing away from the body. PT 1 stated that Resident 34's right ankle strength was worse than the left ankle strength. During the same concurrent interview and record review on 5/15/2026 at 1:15 PM with PT 1, Resident 34's PT Evaluation and Plan of Treatment record, dated 4/28/2026, was reviewed. PT 1 stated that the record indicated Resident 34's ROM for the bilateral lower extremities were within functional limits. PT 1 stated that the record indicated that the left ankle strength had trace muscle contraction. PT 1 stated, she did not document Resident 34's right ankle strength on 4/28/2026 because Resident 34 complained of right ankle discomfort during the evaluation, but she did not go back to reassess Resident 34 on 4/28/2026. During an interview and record review on 5/15/2026 at 4:36 PM with the MDSN, Resident 34's MDS, dated [DATE], was reviewed. The MDSN stated that the MDS indicated Resident 34 was impaired one side. The MDSN stated that she inputted the inaccurate information from the JMA gathered by the Rehabilitation department on 4/21/2026. The MDSN stated that it was important ensure accuracy of residents' MDS to develop the correct care plan for Resident 34 to ensure the necessary services were provided to Resident 34. During an interview on 5/15/2026 at 5:04 PM with the Director of Nursing (DON), the DON stated that if Resident 5 and Resident 34's JMA was inaccurate then their MDS was inaccurate. The DON stated it was important to ensure the MDS indicated the resident's accurate status to ensure the plan of care developed by the interdisciplinary team may prevent complications or a decline in status. During an interview on 5/15/2026 at 5:13 PM with the MDSN, Resident 5's MDS, dated [DATE], was reviewed. The MDSN stated that the MDS indicated Resident 5 was impaired on one side. The MDS stated that the information of the MDS reflected the information on the JMA on 5/8/2026. During a review of the facility's policies and procedures (P&P) titled Joint Mobility Assessment, dated 12/19/2022, the P&P indicated that Licensed Nurses will complete the appropriate sections on the MDS to reflect the residents functional and movement abilities. During a review of the facility's P&P titled Resident Assessment - RAI, dated 12/19/2022, the P&P indicated that the facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences using the resident assessment instrument (RAI) specified by CMS. The P&P indicated that the assessment process will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Based on observation, interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for two of three residents (Resident 8, and Resident 34) by failing to: Resident 8's care plan was not developed to address fluid limitation which can cause fluid overload and can cause edema (retention of fluid in the body tissues). For Resident 34, a person-centered care plan was not developed for the left ankle contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion). These failures had the potential to place Resident 8 at risk for fluid overload --and Resident 34 at risk for further joint mobility decline and contractures. Findings: During a review of Resident 8's admission Record (AR), the facility admitted Resident 8 on 6/22/2023 and readmitted on [DATE] with included diagnoses of: End Stage Renal Disease (ESRD - irreversible kidney failure), chronic pulmonary edema (excess fluid in your lungs). Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool) dated 3/9/2026 the MDS indicated that Resident 8 's cognitive (a resident's thought process) skills were intact. The MDS indicated that Resident 8 needed assistance (helper sets up or cleans up) for meals. During a review of Resident 8's Care Plan titled, The Resident Has Nutritional Problem or Potential Nutritional Problem . dated 3/11/2026, the care plan goal showed that Resident 8 will comply with recommended diet daily. The interventions included honor residents' food preferences within diet parameters, monitor resident's weight and notify the physician and Registered Dietitian in addition to monitor intake and food eaten every meal. During a review of Resident 8's Nutritional Assessment dated 3/12/2026, indicated that Resident 8 had non-pitting edema to bilateral lower extremities with history of large weight changes due to fluid shifts with a recommended fluid intake of 1800 milliliters (ml - (ml- metric unit of measurement). During an interview on 5/15/2026 at 10:12 AM with the Director of Nurses (DON) stated that Resident 8 was not in a fluid restriction diet as recommended by the Registered Dietitian on 3/12/2026 of 1800 ml. DON stated that dialysis residents unless they refused, they have a fluid restriction care plan, and that Resident 8 should have had a fluid restriction care plan. During a review of facility 's policy and procedure (P&P) titled, Fluid Restriction dated 12/18/2025, indicated that fluid restriction will be followed as ordered by the physician. The policy stated that fluid restrictions are the restriction of fluid intake for an underlying medical condition such as ESRD. During a review of Resident 34's admission Record, (AR) the AR indicated that the facility admitted Resident 34 on 10/29/2019 and readmitted Resident 34 on 1/31/2021with diagnoses that include spinal stenosis (narrowing of the spine) of the lumbar (lower back) region, spondylolysis (small fractures or cracks in the vertebra of the spine) of the lumbar region, and dementia (a progressive state of decline in mental abilities). During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2026, the MDS indicated that Resident 34's cognitive skills were severely impaired. The MDS indicated that Resident 34 required moderate assistance (helper does less than half the effort) for Activities of Daily Living (ADL) such as showering and dressing the lower body and required moderate assistance with function mobility such as transitioning from sitting to lying and transferring from chair to bed and bed to chair. The MDS indicated that Resident 34 did not have any functional Range of Motion limitations in his upper and lower extremities. During a review of Resident 34's care plan, revised 5/9/2024, the care plan indicated Resident 34 had limited physical mobility due to spinal stenosis, and lumbar spondylosis. The care plan's interventions included monitoring signs and symptoms of pain associated with mobility and monitoring, documenting, and reporting any signs and symptoms of immobility such as contractures forming or worsening, thrombus formation, and skin breakdown as needed. During a concurrent record review and interview on 5/13/2026 at 3:28 PM with the MDS Coordinator (MDSN), MDSN stated that the MDS dated [DATE] indicated that the functional limitation in range of motion was coded for impairment to lower extremity only on one side. MDSN stated there was no care plan developed for the right ankle contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) and due to the limitation of both bilateral right and left ankle there should have been a care plan to address the limitation of the joint and prevent further decline. During an interview on 5/15/2026 at 12:02 PM with the Physical Therapist (PT) 1, PT 1 stated that it is important for nurses to know when the resident has a joint mobility limitation and how it impacts their daily care. PT 1 stated that she is not responsible to initiate or update a joint mobility limitation care plan unless physical therapy is directly working with the resident. During an observation and interview on 5/15/2026 at 2:52 PM in the Resident 34's room with PT 1 assessing Resident 34's right and left ankle joint mobility PT 1 stated that Resident 34 had a joint mobility limitation on the right and left ankle. During an interview on 5/15/2026 at 5:04 PM with the Director of Nurses (DON), DON stated that Resident 32 should have a care plan to address the contracture with the purpose to prevent worsening contracture of the joints. DON stated that the MDS accuracy is important because it assist in the development of the comprehensive person-centered care plan. During a review of facility's P&P titled Comprehensive Care Plan dated 12/19/2022, indicated that a comprehensive care plan should include the services that are needed to maintain the residents highest physical, mental and psychosocial well-being. Any services that would benefit the resident but are not provided due to the resident's exercise of his or her right to refuse treatment.

Based on observation, interview, and record review, the facility failed to ensure that two of three sample Residents (Resident 5 and Resident 34), with limited range of motion (ROM, full movement potential of a joint) received the appropriate treatment and services by failing to: 1.Ensure Resident 5 and Resident 34's Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in each joint of both arms and legs) accurately reflected the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Treatment from on 5/8/2026 and 5/11/2026. 2.Ensure Resident 5 and Resident 34's Minimal Data Set (MDS, a resident assessment) accurately indicated the residents' functional ROM limitations. 3.Ensure that Resident 34 received the annual PT assessment in 2025. 4. Ensure that Resident 5 and Resident 34 had accurately indicated in the quarterly and yearly MDS and JMA monitoring of their joint mobility function. These deficient practices resulted in Resident 5 and Resident 34's inaccurate joint mobility and functionality in their JMA and MDS. These deficient practices resulted in a 5-degree ROM loss in Resident 5's left knee extension ROM from 2025 to 2026. These deficient practices resulted in Resident 34 right ankle strength not being assessed properly. These deficient practices had the potential to result in further decline in Resident 5 and Resident 34's range of motion. Cross Reference with F641 and F826 Findings: 1. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted Resident 5 on 3/17/2025 with diagnoses that include Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement) without dyskinesia (uncontrollable muscle movements), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant side, and left knee contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 5's care plan, revised on 9/29/2024, the care plan indicated that Resident 5 had limited physical mobility related to weakness, osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), Parkinson's Disease, and history of stroke. The care plan's intervention included to monitor, document, report any signs and symptoms of immobility such as contractures forming or worsening, thrombus formation (blood clot), and skin breakdown as needed, and to provide gentle range of motion as tolerated with daily care. During a review of Resident 5's history and physical (H&P), dated 3/19/2025, the HP indicated that Resident 5 does not have the capacity to understand and make decisions. During a review of Resident 5's PT Evaluation and Plan of Treatment record, written by Physical Therapist (PT) 2, dated 3/18/2025 timed at 6:55 PM, the record indicated Resident 5's active range of motion (AROM, performance of exercise to move a joint without any assistance or effort of another person) right knee was in fixed, in a straight position with no flexion (bending the joint towards the body, shortening the angle between 2 body parts) or extension (straightening the joint away from the body, lengthening the angle between 2 body parts) in neutral position (the joint's natural resting position). The record indicated Resident 5's AROM right and left ankle were fixed in a 50-degree plantar flexion (ankles bent away from the body) with no available dorsiflexion (ankles bent upwards towards the body for the toes to point towards the body). The record indicated that AROM Resident 5's left knee remains bent at 35 degrees and cannot fully straighten to neutral position. The record did not show any documented evidence of the passive range of motion (PROM, movement of a joint through the range of motion with no effort from the person only with the assistance of another person). During a review of Resident 5's JMA record, written by PT 2, dated 3/18/2025 timed at 6:55 PM, the record indicated that Resident 5's left knee extension was minimally impaired. The record indicated that Resident 5's right knee and bilateral ankles' flexion and extension were severely impaired. During a review of Resident 5's MDS, dated [DATE], the MDS indicated that Resident 5's cognitive (a resident's thought process) skills for daily decision making were severely impaired. The MDS indicated that Resident 5's active diagnoses included hemiplegia or hemiparesis and Parkinson's Disease. The MDS indicated that Resident 5 was dependent (helper does all the effort) for activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) such as lower body dressing, toileting, and showering and for functional mobility such as repositioning in bed, transitioning from sitting to lying, and transferring from chair/bed to chair. The MDS indicated that Resident 5 had impairment on one side for the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). During a review of Resident 5's care plan, revised 4/7/2025, the care plan indicated that Resident 5 received left upper extremity PROM exercises and bilateral lower extremity ROM exercises with splint application. The care plan's interventions included applying the left knee splint and left-hand splint for 6 hours or as tolerated and the specific exercises for the left upper extremity which included elbow, wrist, and finger flexion and extension. The care plan did not provide documented evidence of the specific exercises for the bilateral lower extremity ROM. During a review of Resident 5's PT Discharge Summary record, dated 5/9/2025 timed at 7:29 AM, the record indicated Resident 5 would receive PROM of the bilateral lower extremities and the left knee extension splint as tolerated. During a review of Resident 5's MDS, dated [DATE], the MDS indicated that Resident 5's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 5's active diagnoses included hemiplegia or hemiparesis and Parkinson's Disease. The MDS indicated that Resident 5 was dependent on ADLs such as lower body dressing, toileting, and showering and for functional mobility such as repositioning in bed, transitioning from sitting to lying, and transferring from chair/bed to chair. The MDS indicated that the bilateral upper extremities did not have any impairment and there was one-sided impairment on the lower extremity. During a review of Resident 5's PT Evaluation and Plan of Treatment record, written by PT 1, dated 5/8/2026 timed at 12:06 PM, the record indicated that Resident 5's right knee PROM had no movement in flexion or extension and fixed in neutral position. The record indicated that Resident 5's AROM for the bilateral lower extremities were not applicable. The record indicated that Resident 5's PROM of the right knee was fixed in a straight position with no flexion or extension in neutral position. The record indicated Resident 5's PROM of the right and left ankle was fixed in a 50-degree plantar flexion with no available dorsiflexion. The record indicated that Resident 5's PROM of the left knee was bent at 40 degrees and cannot fully straighten to neutral position. During a review of Resident 5's JMA record, written by the Director of Rehabilitation (DOR), dated 5/8/2026 timed at 3:08PM, the record indicated that Resident 5's left knee flexion was within functional limits and the right knee extension was minimally impaired. The record indicated that Resident 5's bilateral knees and bilateral ankles flexion and extension were moderately impaired. 2. During a review of Resident 34's AR, the AR indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted Resident 34 on 1/31/2021 with diagnoses that include spinal stenosis (narrowing of the spine) of the lumbar (lower back) region, spondylolysis (small fractures or cracks in the vertebra of the spine) of the lumbar region, and dementia (a progressive state of decline in mental abilities). During a review of Resident 34's care plan, initiated 6/10/2022, the care plan indicated that Resident 34 received assisted active range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) on his bilateral lower extremities 5 times a week as tolerated. The care plan's interventions included flexion and extension exercises for his hip, knee, and ankle. During a review of Resident 34's care plan, revised 5/9/2024, the care plan indicated Resident 34 had limited physical mobility due to spinal stenosis, and lumbar spondylosis. The care plan's interventions included monitoring signs and symptoms of pain associated with mobility and monitoring, documenting, and reporting any signs and symptoms of immobility such as contractures forming or worsening, thrombus formation, and skin breakdown as needed. During a review of Resident 34's Occupational Therapy (OT, treatment to help residents regain skills to participate in everyday life) Evaluation and Plan of Treatment record, written by Occupational Therapist (OT) 1, dated 4/22/2026, the record indicated OT 1 assessed Resident 34's bilateral upper extremities strength. The record did not show any documented evidence OT 1 assessed Resident 34's bilateral lower extremities. During a review of Resident 34's JMA record, written by OT 1, dated 4/22/2025, the record indicated Resident 34's left knee flexion and left and right ankle were minimally impaired. During a review of Resident 34's MDS, dated [DATE], the MDS indicated that Resident 34's cognitive skills were severely impaired. The MDS indicated that Resident 34 required moderate assistance (helper does less than half the effort) for ADLs such as showering and dressing the lower body and required moderate assistance with function mobility such as transitioning from sitting to lying and transferring from chair/bed to chair. The MDS indicated that Resident 34 did not have any functional ROM limitations in his upper and lower extremities. During a review of Nurse Practitioner (NP) 1's Medical Progress Note record, dated 4/9/2026, the record indicated that Resident 34's musculoskeletal assessment included decreased range of motion or pain with ROM. During a review of Resident 34's MDS, dated [DATE], the MDS indicated that Resident 34's cognitive skills were severely impaired. The MDS indicated that Resident 34 required moderate assistance for ADLs such as showering and dressing the lower body and required moderate assistance with function mobility such as transitioning from sitting to lying and transferring from chair/bed to chair. The MDS indicated that Resident 34 had impaired functional ROM limitations on one side of his lower extremity. During a review of Resident 34's PT Evaluation and Plan of Treatment record written by PT 1, dated 4/28/2026, the record indicated that the bilateral lower extremity ROM was within functional limits. The record indicated Resident 34's right lower extremity (hip, knee, and ankle) strength was within functional limits, but his left lower extremity (hip, knee, and ankle) strength was impaired. During a review of Resident 34's JMA record, written by the Director of Rehabilitation (DOR), dated 4/28/2026, the record indicated Resident 34's bilateral lower extremities (knees and ankles) extension and flexion were within functional limits. During an observation on 5/12/2026 at 10:19 AM in Resident 5's room, Resident 5 was observed sleeping in bed with her left leg bent at the knee towards the body and left foot bent forward at the ankle with toes bent away from the body. Resident 5's right leg was observed straight in bed with right foot bent forward at the ankle with toes bent away from the body. During a concurrent interview and record review on 5/13/2026 at 3:28 PM with the MDS nurse (MDSN), Resident 34's MDS, dated [DATE] and 4/21/2026, and Resident 34's JMA record, dated 4/22/2026, were reviewed. The MDSN stated that the MDS, dated [DATE], indicated Resident 34 did not have any functional limitations on his bilateral lower extremities. The MDSN stated that the MDS, dated [DATE], indicated Resident 34 was impaired on one side of his lower extremity. The MDSN stated that the JMA, dated 4/22/2026, indicated Resident 34's bilateral lower extremities were within functional limits. The MDSN stated that the information on the MDS was based on the JMA completed by the rehabilitation department. During a concurrent observation and interview on 5/14/2026 at 11:46 AM with the DOR in Resident 34's Room, Resident 34 was observed sitting up in his wheelchair with his bilateral toes and ankles bent downwards pointed away from the body. The DOR stated that the PT assessed the residents for the JMA and completed lower body extremities ROM with the resident. The DOR stated, since Resident 34 was not walking, his lower extremities were within functional limits. During a concurrent observation and interview on 5/14/2026 at 2:16 PM in Resident 5's room with Restorative Nurse Aide (RNA) 1, RNA 1 was observed performing PROM exercises on Resident 5's left upper extremity and bilateral lower extremities. RNA 1 stated that Resident 5's left leg was able to bend towards the body but cannot straighten all the way. RNA 1 stated Resident 5's right leg was straight and stiff. RNA 1 attempted to bend Resident 5's leg towards the body. RNA 1 stated Resident 5's bilateral ankles were bent forward, and her toes were facing away from the body. RNA 1 stated Resident 5's bilateral ankles cannot bend backwards, and her toes had a little bit of flexion and extension during ROM exercises. RNA 1 stated, there was no change in Resident 1's care and exercises that I have noticed. During a concurrent interview and record review on 5/15/2026 at 12:15 PM with PT 1, Resident 5's PT Evaluation and Plan of Treatment record, dated 5/8/2026, was reviewed. PT 1 stated, the record indicated that Resident 5's ankles were fixed and contracted at 50-degrees away from neutral with ankles pointed downwards and toes pointed away from the body. PT 1 stated, the record indicated that Resident 5's right knee was fixed and contracted in a straight position with no flexion or extension possible. PT 1 stated, the record indicated that Resident 5's left knee was able to bend towards the body and could can only be bent to 40-degrees, and cannot fully straighten to neutral position. During the same concurrent interview and record review on 5/15/2026 at 12:20 PM with PT 1, Resident 5's PT Evaluation and Plan of Therapy record, dated 3/18/2025, was reviewed. PT 1 stated that the record indicated that there was no documented evidence of the bilateral lower extremity PROM but stated that I think AROM was supposed to be documented as PROM. PT 1 stated, the record indicated Resident 1 already had fixed contractures of the right knee, left ankle, and right ankle on 3/18/2025 (1 year ago from 5/15/2026). PT 1 stated, the record indicated Resident 1 was able to bend her left knee towards the body but Resident 5's left knee could only be bent to 35-degrees and cannot be fully straightened to neutral position. PT 1 stated, Resident 5's right knee lost 5 degrees of ROM from 2025 (1 year ago from 5/15/2026) and was unaware of the loss of ROM. During the concurrent interview and record review on 5/15/2026 at 12:25 PM with PT 1, Resident 34's JMA record, dated 4/28/2026, was reviewed. PT 1 stated that a resident's functional mobility assessment indicated the extent a resident's functional mobility affected their bed mobility, transfer mobility, and ambulation status. PT 1 stated that a resident's JMA provided an estimate of the resident's joint limitations and loss of range of motion. PT 1 stated, Resident 34's JMA indicated his bilateral lower extremities were within functional limits. PT 1 stated that Resident 34, who does not ambulate, was not considered to be within functional limits on the JMA. During a concurrent interview and record review on 5/15/2026 at 12:28 PM with PT 1, Resident 5's JMA, dated 5/8/2026, was reviewed. PT 1 stated that the DOR completed the JMA in the facility. During a concurrent interview and record review on 5/15/2026 at 12:40 PM with PT 1, Resident 5's PT Evaluation and Plan of Treatment record, dated 3/18/2025, and JMA record, dated 3/18/2025, were reviewed. PT 1 stated that according to the JMA record, Resident 5's left knee extension was minimally impaired, but the PT Evaluation and Plan of Treatment, record indicated her left knee extension was bent at 35 degrees and cannot fully straighten to neutral position. PT 1 stated, she would consider Resident 5's JMA of the left knee to be moderate/severe impairment because the knee remained bent at 35-degrees and cannot be straightened. During the same concurrent interview and record review on 5/15/2026 at 12:45 PM with PT 1, Resident 5 PT Evaluation and Plan of Treatment record, dated 5/8/2026, and JMA record, dated 5/8/2026, was reviewed. PT 1 stated, Resident 5's JMA record for the right knee extension was moderately impaired, but the PT Evaluation and Plan of Treatment, record indicated her right knee extension was fixed and contracted in a straight position with no flexion or extension available. PT 1 stated, she would consider Resident 5's JMA of the right knee flexion and extension to be severely impaired because the PT Evaluation and Plan of Treatment indicated Resident 5's right knee to be fixed and contracted in a straight position. During the same concurrent interview and record review on 5/15/2026 at 12:48 PM with PT 1, Resident 5 PT Evaluation and Plan of Treatment record, dated 5/8/2026, and JMA record, dated 5/8/2026, was reviewed. PT 1 stated, Resident 5's JMA record indicated her flexion and extension ROM of the bilateral ankles were moderately impaired. PT 1 stated, she would consider Resident 5's JMA of the bilateral ankles to be severely impaired because the PT Evaluation and Plan of Treatment record indicated that her bilateral ankles were fixed and contracted in a 50-degree plantar flexion position with no flexion or extension available at the ankles. PT 1 stated, she did not know why the JMA was inaccurate as the DOR was the one who completed the resident's JMA within the facility. During the same interview on 5/15/2026 at 12:53 PM with PT 1, PT 1 stated that the JMA was used to determine the degree of the resident's range of motion. PT 1 stated that if the nurses were not aware of the resident's JMA, they would not be aware of the resident's joint-mobility limitations when assisting the residents with ADLs. PT 1 stated the JMA provided a baseline for nursing staff to monitor for any gradual decline in Resident 5's ROM and completing the annual JMA was too infrequent to detect gradual loss of range of motion. During a concurrent observation and interview on 5/15/2026 at 1:04 PM with the PT 1 in Resident 34's room, Resident 34 was observed sitting in his wheelchair wearing bilateral shoes. PT 1 removed Resident 34's bilateral shoes and proceeded to assess Resident 34's ankle ROM. PT 1 stated that Resident 34's right ankle PROM was more restricted and could only complete a partial ROM without gravity, which was worse than Resident 34's left ankle. During the same concurrent interview and record review on 5/15/2026 at 1:15 PM with PT 1, Resident 34's PT Evaluation and Plan of Treatment record, dated 4/28/2026, was reviewed. PT 1 stated that the record indicated Resident 34's ROM for the bilateral lower extremities were within functional limits. PT 1 stated that the record indicated that the left ankle strength had trace muscle contraction. PT 1 stated, she did not document Resident 34's right ankle strength on 4/28/2026 because Resident 34 complained of right ankle discomfort during the evaluation, but she did not go back to reassess Resident 34 on 4/28/2026. During an interview on 5/15/2026 at 2:52 PM with the DOR, the DOR stated that Resident 34 did not receive the annual evaluation of the lower extremities for the year 2025. The DOR stated, Resident 34's upper extremities were evaluated by the OT, but his lower extremities were not evaluated by the PT. During a concurrent interview and record review on 5/15/2026 at 3:43 PM with the DOR, Resident 5's JMA and PT Evaluation and Plan of Treatment, record, both dated 5/8/2026, was reviewed. The DOR stated, she documented the resident's JMA and based the information of the PT's Evaluation and Plan of Treatment record, dated 5/8/2028. The DOR stated, the JMA record indicated that Resident 5's bilateral ankles were moderately impaired, which meant that Resident 5's ankle only had 20 to 40-degrees of ROM. The DOR stated, the PT's Evaluation and Plan of Treatment record indicated that Resident's 5's bilateral ankle flexion and extension was fixed and contracted at 50-degrees. During the same concurrent interview and record review on 5/15/2026 3:50 PM with the DOR, the Complete Orthopedics Ankle Flexion diagram, date unknown, and Resident 5's JMA, dated 5/8/2026, were reviewed. The DOR stated, the diagram was used to determine the degree of the ankle's loss of function. The DOR indicated that she did not know what minimally impaired, moderately impaired, and severely impaired indicated on the JMA, and the DOR stated, I cannot tell you the degrees of each. During the same interview on 5/15/2026 at 3:54 PM with the DOR, Resident 34's JMA record, dated 4/28/2026, was reviewed. The DOR stated that the JMA was the functional mobility assessment. The DOR stated that the JMA was based on the resident's ability to complete a task based on their functionality of the joint not the limitation or degrees of joint loss. During an interview on 5/15/2026 at 4:11 PM with Consultant 2, Consultant 2 stated the JMA was an assessment completed by the physical therapists to determine the resident's PROM and to monitor the resident's ROM to ensure no loss of range of motion. Consultant 2 stated, JMA indicated the limitation of the joint, and nursing needs to be aware of a resident's joint limitation since a resident with functional limitations impact nursing care. During a review of the facility's policies and procedures (P&P) titled Joint Mobility Assessment, dated 12/19/2022, the P&P indicated that the Rehabilitative staff will complete the Joint Mobility Assessment form to document this and the Joint Mobility Assessment form will be completed by the rehabilitative staff upon initial admission, annual assessment, and change in condition. During a review of the facility's policies and procedures (P&P) titled Joint Mobility Assessment, dated 12/19/2022, the P&P indicated that the initial Joint Mobility Assessment will provide the baseline information of the resident's functional abilities including joint mobility. Subsequently information from the previous quarterly MDS assessment will be compared to the data entered in the current MDS assessment to identify changes in the resident's joint mobility. During a review of the facility's job description titled Job Description - Physical Therapist, dated 12/19/2022, the job description indicated the Physical Therapist job summary was to provides, directs, and supervises all aspects of quality patient care, including, but not limited to: screening, evaluation, and treatment, treatment planning, goal setting, family education, and documentation, in order to assure the best outcome possible for the patient. The job description indicated that the Physical Therapist's essential functions included to appropriately and effectively completes documentation including evaluations, daily notes, progress notes, discharge summaries, or monthly reports as required.

Based on observation, interview and record review the facility failed to prevent unnecessary use of psychotropic medications (medication that affects mood and behavior) in accordance with the physician's order, and the facility policy and procedure titled, Use of Psychotropic Medication(s) for one of three sampled residents (Resident 2) by not monitoring side effects of Respirone (prescribed medication for mood and behavior) 0.5 milligrams (mg - unit of measurement). This failure had the potential to result in the resident receiving unnecessary medication or not sufficient dosage of medication to treat the behavioral disorder, and the potential to experience side effects with delayed or no treatment and prolonged use of the medication. Findings: During a review of Resident 2's admission Record, (AR), AR indicated that the facility admitted Resident 2 on 4/22/2026 with included diagnoses of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), Dementia (a progressive state of decline in mental abilities) Psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 2's Order Summary Report dated 5/11/2026, indicated a physician order for Risperidone oral tablet 0.5 milligram (mg - a metric unit of measurement, used for medication dosage and/or amount) twice a day for psychosis manifested by sudden angry outburst. During a review of Resident 2's care plan tilted, Resident 2 had a Diagnosis of Psychosis dated 4/22/2026, the care plan indicated to notify Medical Doctor (MD) if there are any present behaviors/side effects/adverse effects present for Resident 2. During an interview on 5/13/2026 at 10:22 AM with Licensed Vocational Nurse (LVN)2 stated that there was a physician order to monitor side effects, but the physician's order did not have specific side effects to monitor the resident. LVN 2 stated that for monitoring side effects, LVN 2 would monitor altered mental status. During an interview on 5/13/2026 at 10:38 AM with Licensed Vocational Nurse (LVN)1, LVN 1 stated that Resident 2 had an order to monitor side effects, LVN1 stated that when considering side effects for Risperidone he would consider nausea and vomiting which was not included in the physician's order. During an interview on 5/13/2026 at 11:28 AM with the Director of Nurses (DON) stated that the staff should know where to locate for the side effects of medication also, stated that the side effects are not included with the physician order and that the nurses need to look it up. DON stated that the side effects need to be included in the physician order. During a review of the facility's policy and procedure (P&P) titled, Use of Psychotropic Medication dated 12/19/2022 indicated that the facility will monitor the effects of the psychotropic medication on a resident's physical, mental, and psychosocial well-being this will be on an ongoing basis in accordance with nurse assessment and medication monitoring consistent with standards of practice.

Based on observation, interview, and record review, the facility failed to accurately document two of three residents (Resident 8 and Resident 4) in their electronic medical record by failing to ensure that: 1.Resident 4's indicated use of Lorazepam (a psychotropic medication [medications that affect brain chemistry, altering mood, thoughts, perceptions, and behaviors] used to treat anxiety disorder) was accurately documented in Medication Administration Record (MAR) on 5/4/2026. 2.Resident 8's accurate weight was documented on the Interdisciplinary team (IDT a team of facility staff responsible in care planning residents care) assessment. 3.the corrected amount of Dilaudid (medication used to relieve pain) medication for Resident 8 was documented on Resident 8's progress notes and pre/post dialysis assessment communication form. These deficient practices had resulted in the inaccurate documentation for the intended use of Lorazepam for Resident 4 and the potential to result in confusion regarding the validity of Resident 8's weight and medication treatment to determine the effectiveness or ineffectiveness of the therapy. Findings: 1.During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 6/11/2025 and readmitted on [DATE] with diagnoses that include dementia (a decline in mental ability severe enough to interfere with daily life) and anxiety disorder (a disorder involves persistent, excessive fear or worry that interferes with daily life). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 4's had severely impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 4 required supervision or touching assistance with toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 4's Order Summary Report, dated 5/15/2026, the report indicated the physician ordered to administer Lorazepam oral tablet 1 milligram (MG, a measurement unit) one tablet every eight hours as needed for anxiety manifested by verbalization of anxiety, excessive crying for 14 days. During a review of Resident 4's Medication Administration Record (MAR), dated 5/2026, the MAR indicated Lorazepam was administered to Resident 4 on 5/4/2026 at 10:11 AM with the behavior observation indicated of NO. The documented behavior of NO indicated Resident 4 did not exhibit any behaviors of anxiety prior to the administration of Lorazepam. During a telephone interview on 5/15/2026 at 12:33 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated he administered Lorazepam to Resident 4 and mistakenly documented 'No under behaviors observed on 5/4/2026, which indicated Resident 4 was not exhibiting behavioral symptoms prior to the administration or Lorazepam. LVN 3 stated the MAR was inaccurate since LVN 3 indicated Resident 4 did not have behavior symptoms when actually, Resident 4 did. During a concurrent interview and record review on 5/15/2026 at 2:32 PM with the Director of Nursing (DON), Resident 4's MAR, dated 5/2026, was reviewed. The DON stated the nurse mistakenly documented that Lorazepam was administered without a specific behavior indicated for the intended use of Lorazepam. The DON stated as the standard of practice, the nurses should document correctly on the MAR. During a review of the facility's P&P titled, Documentation in Medical Record, dated 12/18/2025, the P&P indicated documentation shall be factual, objective; false information shall not be documented; documentation shall be accurate and complete. 2. During a review of Resident 8's admission Record (AR), the facility admitted Resident 8 on 6/22/2023 and readmitted on [DATE] with diagnoses that included End Stage Renal Disease (ESRD – irreversible kidney failure), chronic pulmonary edema (excess fluid in the lungs). Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Minimum Data Set (MDS – a resident assessment tool) dated 3/9/2026 the MDS indicated that Resident 8 's cognitive (a resident's thought process) skills were intact. The MDS indicated that Resident 8 needed assistance (helper sets up or cleans up) with eating meals. During a review of Resident 8's Order Summary Report dated 5/8/2026 indicated a physician order to give Dilaudid (prescribed medication for severe pain) 1 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth every 6 hours as needed for severe pain. During a review of Resident 8's Progress Notes dated 5/12/2026 at 3:39 AM documentation done by staff the progress notes indicated that Resident 8 was administered Dilaudid 2 mg by mouth. The Progress Note documentation did not indicate Dilaudid 1 mg as ordered by the physician). During a concurrent observation, interview and record review on 5/14/2026 at 3:27 PM with the Director of Nurses (DON), the DON stated, it was verified that staff had given the appropriate amount dose of Dilaudid, but the licensed staff had documented inaccurately. DON stated the staff had documented the wrong amount dose given to Resident 8. During a review of Resident 8's weight record, Resident 8 on 4/3/2026 weighed 185.2 pounds (Lbs. - a standard unit used to measure how heavy something is) and on 5/12/2026 re-weighed 179.7 lbs. During a concurrent interview and record review on 5/14/2026 with the DON the Interdisciplinary Care Conference dated 5/11/2026 was reviewed with the DON, DON stated that 171.6 lbs. was documented as Resident 8's current weight and not the correct weight of 179.3 pounds when the resident was re-weighed. DON stated that the physician was not notified because that was not the correct weight of the resident and that it was documented incorrectly in Resident 8's clinical record. DON stated that it is important to document residents' information accurately in their clinical record to ensure proper and prompt treatment. During a review of the facility's policy and procedure (P&P) titled Documentation in Medical Record dated 12/19/2022, indicated that each resident's medical record should be documented with factual details and false information shall not be documented in the resident's clinical record.

Based on interview and record review, the facility failed to inform and ensure that three of three sample residents (Resident 6, 20, and 12) understood the terms of the facility's arbitration agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to court) as indicated in the facility's policy and procedures titled Arbitration Agreement. This deficient practice had the result in Resident 6, 20, and 12 not being informed of their rights and choices about important aspects of the residents' health, safety, and welfare under the binding arbitration agreement. Findings: 1.During a review of Resident 6's admission Record (AR), the AR indicated that the facility admitted Resident 6 on 2/27/2026 with diagnoses that included multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), Gastro-esophageal reflux disease (GERD, chronic acid reflux causing heartburn), and hydronephrosis (swelling of the kidney due to urine blockage). During a review of Resident 6's history and physical (H&P), dated 2/28/2026, the H&P indicated that Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimal Data Set (MDS, a resident assessment), dated 5/2/2026, the MDS indicated that Resident 6's cognitive (a resident's thought process) skills were intact. During a concurrent interview and record review on 5/15/2026 at 8:32 AM with Resident 6, Resident 6's Arbitration Agreement record, signed 3/3/2026 was reviewed. Resident 6 stated, the signature on the record looked like [her] signature, but she did not recall anyone explaining or informing her what an arbitration agreement was. Resident 6 stated she either confused upon admission and she could not remember it, or the facility staff came into my room and just told me to sign it. 2.During a review of Resident 20's AR, the AR indicated that the facility admitted Resident 20 on 2/3/2026 with diagnoses that included acute kidney failure (kidneys cannot filter waste products from the blood), hypothyroidism (condition where the thyroid does not make enough hormones for bodily functions), and acute respiratory failure (condition where the lungs cannot get enough oxygen to the body) with hypoxia (the body's tissue cannot get enough oxygenated blood). During a review of Resident 20's H&P, dated 2/8/2026, the H&P indicated that Resident 20 had the capacity to understand and make decisions. During a review of Resident 20's MDS, dated [DATE], the MDS indicated that Resident 20's cognitive skills were intact. During a concurrent interview and record review, on 5/15/2026 at 9:10 AM with Resident 20, Resident 20's Arbitration Agreement record, signed 2/4/2026, was reviewed. Resident 20 stated, the Arbitration Agreement record does look vaguely familiar, but she does not recall what the arbitration agreement was about. Resident 20 stated, the Arbitration Agreement form does not look familiar to her. 3.During a review of Resident 12's AR, the AR indicated that the facility admitted Resident 12 on 1/12/2026 with diagnoses that included rhabdomyolysis (rapid muscle tissue breakdown), cardiomegaly (enlarge heart), and Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 12's H&P, dated 1/13/2026, the H&P indicated that Resident 12 had the capacity to understand and make decisions. During a review of Resident 12's MDS, dated [DATE], the MDS indicated that Resident 12's cognitive skills were intact. During a concurrent interview and record review on 5/15/2026 at 9:27 AM with Resident 12, Resident 12's Arbitration Agreement record, signed 1/13/2026, was reviewed. Resident 12 stated, the record does not look familiar to [him] and he does not remember the arbitration agreement being explained to him. During an interview on 5/15/2026 at 11:26 AM with the Admission's Coordinator (AC), the AC stated she was responsible for explaining the arbitration agreement within 48-72 hours of a new admission. The AC stated, she determines whether an alert resident understands the information by asking the resident if the resident understood the agreement, and the AC stated, some [residents] say yes while other residents will respond I know what [the arbitration agreement] is. During a review of the facility's Arbitration Agreement record, date unknown, the record indicated that the resident and/or the person executing this Agreement certifies that he/she has read this agreement, understands this Agreement, and has been given a copy of this agreement.

Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the resident ' s needs for 4 of 4 sampled residents (Residents 192, 20, 5 & 21) by failing to: 1. For Resident 192 had no care plan to address interventions and goals while receiving Lovenox (a medication or an anticoagulant or blood thinner that makes blood less likely to clot and can cause bleeding). 2. For Resident 20 the plan of care was not implement care Plan interventions who had a diagnosis of impaired immunity related to viral infection to monitor and document sign and symptom of delirium as indicated in care plan. 3. For Resident 5, there were no care plans indicating the specific activities needed since Resident 5 had impaired vision. 4. For Resident 21, there was not care plan indicting Resident 21 ' s specific needs for nutrition based on Resident 1 ' s therapeutic diet ordered. These deficient practices had the potential to delay care and services that were specific to each residents needs to produce desired outcomes. Findings: 1. During a review of Resident 192's Admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur (fracture(a break in a bone) that occurs in the area between the greater and lesser trochanters of the femur (upper thigh bone), where the fracture is displaced, meaning the broken bone fragments are out of alignment), Anemia (condition where the blood has a reduced ability to carry oxygen, can be caused by several factors), and hyperlipidemia (a condition of high cholesterol level). During a review of Resident 192's History and Physical (H&P) dated 4/29/2025, the H&P indicated Resident 192 has the capacity to understand and make decisions. During a review of Resident 192's Minimum Data Set (MDS, an assessment tool) dated 5/05/2025, indicated the resident ' s cognition (the mental process of knowing, including awareness, perception, reasoning, and judgment) was severely impaired. During a review of Resident 192's physician orders dated 5/1/2025 to 5/31/2025, the physician orders indicated Lovenox (an anticoagulant that helps prevent the formation of blood clots) Injection Solution Prefilled [NAME] 40 milligrams per 0.4 milliliters (mg/mL, a unit of measurement) inject 40 mg subcutaneously (under the skin) one time a day for deep vein thrombosis (DVT, condition where a blood clot forms in a deep vein, most commonly in the legs or arms) prophylaxis (PPX) started on 4/20/25 until 5/19/2025 . During a review of Resident 192's Medication Administration Record (MAR) from 5/1/2025 to 5/31/2025 indicated Resident 192 received Lovenox Injection Solution Prefilled [NAME] 40 MG/0.4 ml inject 40 mg subcutaneously one time for DVT PPX one time a day at 9:00 AM on 5/1/2025, 5/2/2025, 5/3/2025, 5/4/2025,and 5/5/2025, the route of administration was not recorded only the site was reordered. During a concurrent interview and record review on 5/09/2025 at 1:35 PM with the DON, Resident 192 ' s Medication Administration Record (MAR) dated 5/1/2025 to 5/31/2025 was reviewed. The DON stated Resident 192 received Lovenox Injection Solution Prefilled [NAME] 40 MG/0.4 ml inject 40 mg subcutaneously for DVT PPX at 9:00 AM on 5/1/2025, 5/2/2025, 5/3/2025, 5/4/2025, and 5/5/2025. The DON stated Lovenox was an anticoagulant and could cause major bleeding which was serious. The DON stated a care plan was necessary for anticoagulants, so nurses know what to monitor, what interventions to implement in cases of emergencies, such as bleeding. During the same interview DON reviewed Resident ' s 192 care plans and stated there was no care plan for Resident 192 taking Lovenox. The DON stated the care plan provided guidelines, and the intervention were necessary to provide quality of care to meet the residents ' needs and desired outcome 2. During a review of Resident 20's AR, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including immunodeficiency (inability of the body to produce an adequate immune response because of an insufficiency or absence of antibodies, immune cells, or both), chronic obstructive pulmonary disease(is a progressive lung disease that makes it hard to breathe. It's characterized by airflow obstruction, often caused by damage to the airways or air sacs in the lungs), and depression (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities previously enjoyed). During a review of Resident 20's H&P dated 3/28/2025, indicated Resident 20 had the capacity to understand and make decisions. During a review of Resident 20's MDS, dated [DATE], indicated the resident ' s cognition is moderately impaired. During a concurrent interview and record review on 5/09/2025 at 1:50 PM with DON, Resident 20 ' s care plan-initiated date 3/28/2025 was reviewed. DON stated the care plan indicated Resident 20 had impaired immunity related to viral (illness caused by a virus) infection, . The DON stated Resident 20 had a diagnosis of Human immunodeficiency virus (HIV, a virus that attacks the body's immune system). The DON stated the care plan intervention included to monitor, record and report to the medical doctor (MD) signs and symptoms of delirium (a sudden change in mental state causing confusion, disorientation, and difficulty concentrating, often with fluctuating alertness) such as changes in behavior, altered mental status. The care plan indicated that Resident 20 would not display any complication related to immune deficiency and Resident 20 would remain free from infection. The DON stated there was no monitoring for Resident 20 ' s delirium. DON stated it was crucial to monitor delirium to prevent any complications related to immune deficiency. The DON stated Resident 20 ' s care plan did not indicate how often staff should monitor and document the interventions. 44429 3. During a review of Resident 5 ' s AR, the AR indicated Resident 5 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (high blood sugar levels) and glaucoma (loss of vision or blindness). During a review of Resident 5 ' s H&P, dated 3/24/2025, the HP indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5 ' s MDS the MDS indicated the Resident 5 ' s cognition (thought process) was severely impaired. During a review of Resident 5 ' s active care plans did not indicate any care plans for Resident 5 ' s specific activity needs. During a concurrent interview and record review on 5/7/2025 at 3:45PM with the DON, Residents 5 ' s Care Plans were reviewed. DON stated Resident 5 did not have activities care plan specific to Resident 5's activities needs. DON stated there was no coordination with the activity director to develop specific activity care regarding Resident 5 needs relating to her glaucoma (a chronic eye disease that damages the optic nerve, potentially leading to vision loss and blindness if left untreated) and/or inability to see. DON stated by not developing a specific care plan for activities for Resident 5 there was a potential for Resident 5 to feel isolated and could lead to behavioral issues such as depression (a mental illness that negatively affects how you feel, think, act, and perceive the world). 4. During a review of Resident 21 ' s AR indicated Resident 21 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (high blood sugar levels) and chronic kidney disease (CKD - damage to the kidneys (organ in the body)). During a review of Resident 21 ' s HP, dated 4/28/2025, the HP indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21 ' s MDS dated [DATE], the MDS indicated the Resident 21 ' s cognition was moderately impaired. During a review of Resident 21 ' s active Care plans, the care plans did not indicate the specific Nutrional needs for Resident 21. During an interview on 5/9/2025 at 9:12AM with the Dietary Supervisor (DS), the DS stated that Resident 21 was on a 2 gram (unit of measurement) sodium (salt) diet because of her diabetes (chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels) and chronic kidney disease (CKD a condition where the kidneys are damaged and cannot properly filter blood, leading to waste buildup) diagnosis. DS stated that the nurses were aware of checking for food brought from home for Resident 21 since she was on a specific diet for her kidneys and diabetes. During a concurrent interview and record review on 5/9/2025 at 3:45PM with the DON, Residents 21 ' s Care Plans were reviewed. DON stated Resident 21 did not have a care plan addressing her nutritional needs related to her diabetes and CKD. DON stated that food brought to Resident 21 room without being checked by the nursing staff had the potential for nutritional intake noncompliance. DON stated by not developing a specific care plan for Resident 21 ' s nutritional needs and interventions to screen food brought into the facility from had the potential for Resident 21 ' s blood sugar to be elevated from foods that are noncompliant with her specific diet. A review of the facility ' s policy and procedure titled Comprehensive Care Plans, revised on December 2024 indicated: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. A review of the facility ' s policy and procedure titled High Risk Medications - Anticoagulants, revised in December 2024 indicated: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. Definitions: Anticoagulant refers to a class of medications that are used to prevent clot extension and formation. They do not dissolve clots. Examples include warfarin, heparin, Lovenox, Xarelto, Pradaxa, and Eliquis. Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. Indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendations and/or clinical practice guidelines. The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants included bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool), fall in hematocrit or blood pressure, Thromboembolism. The &P indicated the resident's plan of care shall include interventions to minimize risk of adverse consequences with examples include (depending on the medication), Limit venipunctures and injections, as possible. Be aware of the need to apply pressure following these procedures, Use soft toothbrush and electric razors. Limit intake of foods high in vitamin, broccoli, cabbage, collard greens, spinach, kale, turnip greens, and brussel sprouts, Avoid cranberry juice and cranberry products. Caution resident/family about alcohol use while taking anticoagulants. educate resident/family on risks of bleeding, dietary modifications, and symptoms to report to nurse/physician, and avoid (strenuous) activities that may lead to injury. 51233

Based on observation, interview, and record review the facility failed to properly store and discard expired medication, and store Lorazepam safely for two of three sampled residents (Resident 31 and 36) controlled drugs (medications that can create mental and physical addiction or dependency) in a separately locked compartment in the medication storage room in accordance with the facility ' s policy and procedure (P&P), titled Medication Storage by failing to : 1. Properly store and discard a box of expired Microdot glucose gel (a medication used to treat low blood sugar) in the medication storage room. 2. store Resident 31 and 36 ' s Lorazepam (a controlled medication that can create mental and physical addiction or dependency used to treat anxiety [fear of the unknown]) in separately locked from other non-controlled medications (not addictive or habit forming) in the refrigerator inside the medication storage room. These deficient practices had potential to result in nursing staff administering expired medication with reduced potency and ineffective blood glucose management, which may lead to adverse reactions (undesired effects) from the medication and harm to the residents. These deficient practices also had the potential for medication theft or diversion (when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed). Findings: 1. During a concurrent observation and interview on 5/9/2025 at 9:30 AM with Licensed Vocational Nurse (LVN) 1, a box of Microdot glucose gel, dated 4/2025, was inside the top cabinet in the medication room. LVN 1 stated the box of Microdot glucose gel was expired and they did not notice this expired medication in the medication storage room until the surveyor pointed out. LVN 1 stated the expired medication should be discarded right away to prevent administration of expired medication to the residents. During an interview on 5/9/2025 at 10:38 AM with the Director of Nursing (DON), the DON stated she was supposed to check and remove the expired medications weekly in the medication storages in the facility, but she missed to remove the expired Microdot glucose gel at the end of 4/2025. The DON stated it was important to check and remove the expired medications to prevent nursing staff from administering expired medications to the residents which could lead to medication errors, ineffective management of the illness, and harm to the residents. 2. a. During a review of Resident 31 ' s Admission Record (AR), the AR indicated the facility originally admitted Resident 31 on 9/23/2024 and readmitted him on 11/22/2024 with diagnoses that included sepsis (a life-threatening medical emergency caused by the body's overwhelming response to an infection) and cellulitis (a common and potentially serious skin infection) of both legs. During a review of Resident 31 ' s Minimum Data Set (MDS, a federally mandated standardized assessment and care planning tool), dated 3/18/2025, indicated Resident 31 had severely impaired memory and cognition (ability to think and reason). The MDS indicated Resident 31 required substantial/maximal assistance with oral hygiene, and was dependent with eating, toileting hygiene and personal hygiene. b. During a review Resident 36 ' s AR, the AR indicated the facility originally admitted Resident 36 on 3/21/2025 and readmitted her on 4/15/2025 with diagnosis that included sepsis and hypotension (low blood pressure). During a review of Resident 36 ' s MDS, dated [DATE], indicated Resident 36 had severely impaired memory and cognition. The MDS indicated Resident 36 was dependent with oral hygiene, toileting hygiene and personal hygiene. During a concurrent observation and interview on 5/9/2025 at 9:35 AM with LVN 1, in the locked medication storage room, two vials of Lorazepam oral (mouth) solution labeled with Resident 31 ' s name and one vial of Lorazepam labeled with Resident 36 ' s name was stored with other noncontrolled medications in a single-locked medication refrigerator. LVN 1 stated Lorazepam was a controlled medication and should be double locked. LVN 1 stated even though Resident 31 and 36 ' s Lorazepam was stored with other noncontrolled medications, it was double locked with the lock to the medication storage room and the lock to the medication refrigerator. During an interview on 5/9/2025 at 10:39 AM with the DON, the DON stated it was important to store the controlled medication and double locked in a separate space and not share the same access with the noncontrolled medication, so they could track down and manage the controlled medications and prevent medication diversion. During a review of the facility ' s P&P titled, Medication Storage, dated 12/9/2024, the P&P indicated the facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer ' s recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The P&P also indicated Scheduled II (a class of medication at high risk for both physical and psychological dependence) controlled medications are to be stored within a separately locked permanently affixed compartments when other medications are stored in the same area, such as in refrigerator.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 33 & 34) were treated with respect and dignity by ensuring residents body was covered while asleep in bed. This deficient practice resulted in Resident 33 and Resident 34 ' s unknown and/or unwanted exposure of the body and had the potential to lead to psychosocial (mental and emotional well-being) decline, resident ' s individuality, self-esteem, and self-worth. Findings: A review of Resident 33 ' s Admission Record [AR] indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (brain disorder that affects memory and thinking) and alcoholic cirrhosis (a disease that damages the liver) of the liver (organ in the body). A review of Resident 33 ' s History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the Patient ' s health status) signed by the attending physician on 2/11/2025, indicated Resident 33 could make needs known but cannot make medical decisions. A review of Resident 33 ' s Minimum Data Set (MDS, a assessment tool) dated 2/15/2025, indicated the Resident 33 ' s cognition (thought process) was impaired and was dependent on care. A review of Resident 34 ' s AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included cerebral vascular accident (CVA - blood flow interruption to the brain) and dominant side hemiplegia (severe weakness or paralysis (no movement) to one side of the body). A review of Resident 34 ' s HPE signed by the attending physician on 3/15/2025, indicated Resident 34 had the capacity to understand and make decisions. A review of Resident 34 ' s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 2/28/2025, indicated the Resident 34 ' s cognition (thought process) was moderately impaired and was dependent on care. During an observation of Resident 33 in Resident 33 ' s room on 5/6/2025 at 9:44AM, Resident 33 ' s brief (diaper) was visible, and gown was up, exposing Resident 33 ' s chest, arms and lower body. Resident 33 ' s blanket was placed on the left side of his body. During a concurrent observation and interview of Resident 33 in Resident 33 ' s room with the Director of Nursing (DON) on 05/06/25 at 9:48AM, DON stated that Resident 33 ' s lower body was exposed. DON stated this was a dignity issue since the resident was in a vulnerable state and did not have the capacity to ask for assistance. During an observation of Resident 34 in Resident 34 ' s room on 5/6/2025 at 10AM, Resident 34 ' s lower body was exposed and Resident 34 ' s brief was visible. Resident 34 ' s blanket was placed to the right side of his body. During a concurrent observation and interview of Resident 34 ' s room with Certified Nursing Assistant (CNA 1) on 05/06/25 at 9:48AM, CNA 1 stated that Resident 34 ' s lower body a was exposed. CNA 1 stated that Resident 34 ' s body should not be exposed, and it was a privacy issue. A review of the facility ' s P&P titled Promoting/Maintaining Resident Dignity revised 12/9/2024, indicated it is practice of this facility to protect and promote resident ' s rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident ' s quality of life by recognizing each resident ' s individuality. The policy indicated that it will maintain resident ' s privacy.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident tool) entries were accurate and reflect resident ' s status of one of three sampled residents (Resident 39) who was discharged home with home health services. The MDS was incorrectly coded as a transfer to a hospital which does not reflect the actual discharge disposition of the resident who was discharged home. This failure resulted in inaccurate documentation in the resident ' s medical record could impact continuity of care, facility reporting accuracy, and regulatory compliance. Incorrect discharge coding may also affect quality measures, reimbursement, and tracking of resident outcomes. Findings: During a review of Resident 39 ' s Admission Record (AD), the AD indicated the facility admitted Resident 39 on 3/21/2025 with diagnoses that included cellulites (a common and potentially serious skin infection) of right lower limb and depression (a common and serious mental illness that affects how you feel, think, and handle daily activities). During a review of Resident 39 ' s MDS dated [DATE], Section A indicated the resident had been discharged to an acute hospital. During a review of Resident 39's physician orders, dated 4/15/2025, indicated an order to discharge Resident 39 home on 4/16/2025 with home health services. During a review of Resident 39 ' s Progress Notes, dated 4/16/2025, indicated Resident discharge home and left the building in stable condition. During an interview on 5/7/2025 at 2:08 PM with the MDS Coordinator (MDSC), the MDSC stated Resident 39 was discharged home with home health service on 4/16/2025. The MDSC stated it was a mistake to document in the MDS that Resident 39 was transferred to an Acute hospital on the MDS. The MDSC stated she did not notice the discrepancy until the surveyor indicated today. The MDSC stated she did not accurately document Resident 39 ' s discharge status on the MDS to ensure consistent plan of care for the resident. During an interview on 5/9/2025 at 10:33 AM with the Director of Nursing (DON), the DON stated Resident 39 ' s discharge status was not accurately documented, and it would affect the continuation of care for the resident negatively and result in the incorrect tracking for the resident ' s outcome. During a review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, the Manual indicated that facilities must ensure MDS discharge assessments accurately reflect the resident ' s discharge location and care needs.

Based on interview and record review the facility failed to ensure adequate monitoring of potential side effects for Lovenox (an anticoagulant or an injectable medication that thins blood or prevents development of blood clots) is documented for one of 3 sampled residents (Resident 192). This deficient practice had the potential for Resident 192 to develop adverse effect (undesired effect) and the staff not to notice sign and symptoms of bleeding and cause severe bruising and bleeding that is undetected and lead severe blood loss and eventually death. Findings: During a review of Resident 192's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur fracture (a break in a bone) that occurs in the area between the greater and lesser trochanters of the femur (upper thigh bone) where the fracture is displaced, meaning the broken bone fragments are out of alignment), anemia (condition where the blood has a reduced ability to carry oxygen, can be caused by several factors) and hyperlipidemia (a condition of high cholesterol level). During a review of Resident 192's History and Physical (H&P) dated 4/29/2025, indicated Resident 192 has the capacity to understand and make decisions. During a review of Resident 192's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 5/5/2025, indicated the resident ' s cognition was severely impaired. During a review of Resident 192's physician orders dated from 5/1/2025 to 5/31/2025 indicated to administer Lovenox injection solution prefilled syringe 40 mg/0.4 ml inject 40 mg subcutaneously (injected under the skin) one time a day for DVT (deep vein thrombosis- a blood clot inside the large vein) PPX (prophylaxis or prevention) start date 4/30/2025 until 5/19/2025. During a review of Resident 192's Medication Administration Record (MAR) from 5/1/2025 to 5/31/2025 indicated, Resident 192 received Lovenox injection solution prefilled syringe 40 mg/0.4 ml inject 40 mg subcutaneously for DVT PPX one time a day at 9AM on 5/1/2025, 5/2/2025, 5/3/2025, 5/4/2025, and 5/5/2025. During an interview and record review on 5/9/2025 at 1:40 PM with DON, Resident 192 ' s Medication Administration Record (MAR) dated 5/1/2025 to 5/31/2025 was reviewed. DON stated Resident 192 received Lovenox injection for DVT PPX at 9AM on 5/1/2025, 5/2/2025, 5/3/2025, 5/4/2025, and 5/5/2025. DON stated Lovenox was an anticoagulant and can cause major and serious bleeding. DON stated staff should monitor and document the side effect of Lovenox injection in Electric Medical Records (EMAR) which included bleeding. During the same interview the DON reviewed Resident ' s 192 EMAR dated 5/1/2025 to 5/31/2025 and stated there was no record to indicate that Resident 192 was monitored for bleeding. DON stated regular monitoring of the residents allows staff to identify early signs and symptoms of bleeding and report to MD. A review of the facility ' s policy and procedure titled High Risk Medications - Anticoagulants, revised on 12/2024 indicated: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addressed the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. Indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendations and/or clinical practice guidelines. The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include:bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool), fall in hematocrit or blood pressure, thromboembolism. The resident's plan of care shall include interventions to minimize risk of adverse consequences. Examples include (depending on the medication) and educate resident/family on risks of bleeding, dietary modifications, and symptoms to report to nurse/physician. Avoid (strenuous) activities that may lead to injury.

Based on observation and interview, the facility staff failed to ensure one of three sampled residents (Resident 192), who was on a anticoagulants (blood thinners which makes blood flow through veins and arteries more easily, which means blood is less likely to clot), was free of any significant medication errors. This deficient practice had the potential to result in an increased or delayed effectiveness of the medication due to the incorrect route of the medication administered, and could potentially lead to further health complications. Findings: During a review of Resident 192's Admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur (fracture(a break in a bone) that occurs in the area between the greater and lesser trochanters of the femur (upper thigh bone), where the fracture is displaced, meaning the broken bone fragments are out of alignment), Anemia (condition where the blood has a reduced ability to carry oxygen, can be caused by several factors), and hyperlipidemia (a condition of high cholesterol level). During a review of Resident 192's History and Physical (H&P) dated 4/29/2025, the H7P indicated Resident 192 has the capacity to understand and make decisions. During a review of Resident 192's Minimum Data Set (MDS, a assessment tool) dated 5/05/2025, the MDS indicated the resident ' s cognition is severely impaired. During a review of Resident 192's physician orders dated from 5/1/2025 to 5/31/2025, the physician orders indicated a start date of 4/30/2025 for Lovenox (an anticoagulant medication) Injection Solution Prefilled [NAME] 40 milligrams per 0.4 milliliter (mg/mL, a unit of measurement) inject 40 mg subcutaneously (under the skin) one time a day for Deep Vein Thrombosis (DVT, a condition where a blood clot forms in a deep vein, most commonly in the leg, but it can also occur in other veins), Prophylaxis (PPX) action taken to prevent disease, especially by specified means or against a specified disease until 5/19/2025 . During a review of Resident 192's Medication Administration Record (MAR) from 5/1/2025 to 5/31/2025 indicated Resident 192 received Lovenox Injection Solution Prefilled [NAME] 40 mg/0.4 ml inject 40 mg subcutaneously one time for DVT PPX one time a day at 9:00 AM on 5/1/2025, 5/2/2025, 5/3/2025, 5/4/2025, and 5/5/2025, the route of administration was not recorded only the site was reordered. During an observation on 5/7/2025 at 9:47 AM with licensed vocational nurse (LVN) 1 in the hallway, LVN 1 was observed next to Medication Cart 1 and obtained Resident 192 ' s Lovenox prior to entering Resident 192 ' s room. LVN1 was observed reviewing the Lovenox syringe to Resident 192 ' s MAR. During a concurrent observation and interview on 5/7/2025 at 9:48 AM with LVN 1 in Resident 192 ' s Room, LVN 1 cleaned Resident 192 right upper arm with an alcohol swab, held the skin taut (tight), and held the syringe needle 90 degree. LVN 1 stated the medication route of administration for the Lovenox was to be administered into the muscle. LVN 1 then verified the medication administration route, and then stated the medication should be administered subcutaneous (under the skin). LVN 1 stated she did not check the MAR prior to administrating Lovenox and she would have administered the medication via the wrong route During an interview on 5/7/2025 at 9:59 AM with LVN 1 in presence of Director of Nursing (DON), LVN 1stated she was about to administer Lovenox Intramuscular for Resident 192, and would have been an error, since Lovenox should be administered subcutaneous. During an interview on 5/7/2025 at 10:02 AM with DON, DON stated based on the medical doctors (MD) orders. Lovenox should be administered subcutaneously, and that Lovenox was a high alert medication (that pose a heightened risk of significant patient harm when used in error and can cause severe side effects). DON stated if Lovenox was administered into muscle, it could lead to complication such as increase bleeding, pain, discomfort in muscle, and would also alter the medication absorption. DON stated LVN 1 should check the MAR prior to administering any medication to residents. A review of the facility ' s policy and procedure titled Medication Administration, revised on December 2024 indicated: Medications are administered by licensed nurses, or other staff who are Legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication, name, form, dose, route, and time. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.). Correct any discrepancies and report to nurse manager. A review of the facility ' s policy and procedure titled High Risk Medications - Anticoagulants, revised on December 2024 indicated: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. Definitions: Anticoagulant refers to a class of medications that are used to prevent clot extension and formation. They do not dissolve clots. Examples include warfarin, heparin, Lovenox, Xarelto, Pradaxa, and Eliquis. Anticoagulants shall be prescribed by a physician or other authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with embolization, stroke or management of myocardial infarction.

Based on observation and interviews, the facility failed to ensure the kitchen was in safe and sanitary condition by failing to: 1. Ensure the kitchen sink area did not have white residue (a small amount of something that remains after the main part has gone or been taken or used) on the drainage pipes and on the floor. 2. Ensure the kitchen floor did not contain white paint remnants (a small remaining quantity of something) 3. Ensure the kitchen drywall was not exposed. These deficient practices had the potential for foods to be contaminated and placed residents at risk for foodborne illnesses. Findings: During the initial kitchen tour on 5/6/2025 at 8:50AM, in the presence of the Dietary Supervisor (DS), white residue was observed underneath the sink by the drainage pipe. Also observed were white paint remnants (on the floor of the kitchen due to a tile that fell off the wall and onto the floor. During a concurrent observation and interview on 5/6/2025 at 9:00AM with the DS, DS stated that underneath the food preparation table on the floor was a white and brown color residue with paint remnants on the floor, due to a tile from the wall that fell off. The DS stated there was a small area with dry wall that was exposed. DS stated that the residue, paint chips and exposed dry wall had the potential to contaminate the food which would lead to residents getting sick from food contamination. During a concurrent observation and interview in the kitchen on 5/6/2025 at 9:05AM with the Maintenance Supervisor (MS), MS stated that underneath the kitchen sink and, on the floor, there was white residue and paint remnants on the floor. During a concurrent observation and interview 5/6/2025 at 9:10AM in the kitchen, with the MS, MS stated the area in the kitchen that had exposed dry wall should be repaired since the because residue and the paint remnants could contaminate the food that was being prepared for the residents at the facility. MS stated the residents could get sick from the contamination. During a review of the facility's Policy and Procedure (P&P) titled, Food Safety and Food Storage, revised on 12/19/2022, the P&P indicated food will be stored, prepared, distributed and served in accordance with professional standard for food service safety. The P&P indicated contamination was the unintended presence of potentially harmful substances included, but not limited to microorganisms, chemicals or physical objects. The P&P indicated foodborne illness was caused by indigestion of contaminated food or beverages. The P&P indicated all equipment used in the handling of [NAME] shall be cleaned and sanitized and handled in a manner to prevent contamination.

Based on interview and record review, the facility failed to explain an Arbitration Agreement (a provide agreement that allows individual parties to resolve disputes rather than in a lawsuit) to two of three sampled residents (Residents 18 and 29) correctly and thoroughly in a manner that the residents and/or their responsible parties could understand. Residents 18 and 29 reported the facility staff did not explain in a manner that they understand what an Arbitration Agreement and Arbitration Agreement to allow them to make an informed decisions and choices about important the aspects of their health, safety, and welfare. This failure resulted in Residents 18 and 29 ' volitation of resident ' s rights and not make an informed decision about their care to ensure they receive care according to their rights and preferences. Findings: 1.During a review of Resident 18 ' s Admission Record (AR), the AR indicated the facility admitted Resident 18 on 4/1/2025 with diagnoses that included diabetes mellitus (a chronic condition that affects how the body uses blood sugar) and anxiety (a feeling of uneasiness or worry, often about a future event or situation). During a review of Resident 18 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/8/2025, the MDS indicated Resident 18 had moderately impairment memory and cognition (ability to think and reason). During a concurrent interview and record review on 5/8/2025 at 3:15 PM with Resident 18, an Arbitration Agreement for Resident 18 dated 5/8/2025, was reviewed. Resident 18 stated a staff (Director of Admission) asked her to sign a form (Arbitration Agreement) today while she was in the physical therapy (PT, a combination of exercises, stretches and movements that will increase the strength, flexibility and mobility) room during PT session. Resident 18 stated the staff did not explain what the form was about and just told to just sign the form. Resident 18 stated she did not have time to read the form because she was doing her exercise. Resident 18 stated she signed and dated the form today without knowing what she was signing for and the staff told her she would receive a copy of it for her to read later. Resident 18 stated she would have an issue if she had to give up her constitutional right to present her dispute in the court and she needed to discuss arbitration with her family members before signing it. Resident 18 stated the staff did not tell her she had 30 days to rescind the agreement. 2. During a review of Resident 29 ' s AR, the AR indicated the facility admitted Resident 29 on 8/14/2025 with diagnoses that included diabetes mellitus (a chronic condition that affects how the body uses blood sugar) and anxiety (a feeling of uneasiness or worry, often about a future event or situation). During a review of Resident 29 ' s MDS, dated [DATE], the MDS indicated Resident 29 had moderately impairment memory and cognition. During a concurrent interview and record review on 5/8/2025 at 3:20 PM with Resident 29, an Arbitration Agreement for Resident 29 dated 9/13/2024, was reviewed. Resident 29 stated two staffs came and asked him to sign an Arbitration Agreement, but he did not know what the form was about. Resident 29 stated the staff did not explain what the form was about and told him It is not something bad. Resident 29 stated he signed with his initial on the form, but he did not write the date, 9/13/2024, on the form. Resident 29 stated someone else wrote the date on the form for him and he did not know who. Resident 29 stated he did not know he had the right to not sign this form. Resident 29 stated the staff did not tell him he had 30 days to rescind this agreement. During a concurrent interview and record review on 5/8/2025 at 4:00 PM with the Director of Admission (DA), Resident 18 ' s Arbitration Agreement, dated 5/8/2025, and Resident 29 ' s Arbitration Agreement dated 9/13/2025, were reviewed. The DA stated she was responsible for providing the arbitration agreement forms and explaining the Arbitration Agreement to the residents and responsible parties when the residents were admitted to the facility. The DA stated she asked Resident 18 and 29 to sign the Arbitration Agreement forms today because these two residents ' electronic arbitration agreement forms were blank due to technical issues. The DA stated these two residents signed the arbitration agreement when they were admitted to the facility, so she asked them to resign the agreement today. The DA stated Resident 18 signed and dated today ' s date,5/8/2025, but she signed as the facility representative and back dated it to 4/7/2025. The DA stated she should date the agreement as today ' s date, 5/8/2025. The DA stated she back dated Resident 29 ' s agreement to 9/13/2025. The DA stated she should date Resident 29's agreement as today ' s date, 5/8/2025, since there was no record of arbitration which was signed on 9/13/2025. The DA stated she did not explain what Arbitration Agreement to the residents is in which they would give up their constitutional right to present their case in the court in front of the jury. The DA stated she did not know if the residents had the right to rescind the agreement. During an interview on 5/9/2025 at 9:20 AM with the Receptionist, the Receptionist stated she assisted the DA to translate for Resident 29 when the DA asked Resident 29 to sign the Arbitration Agreement. The Receptionist stated she explained the Arbitration Agreement to Resident 29 that the resident would get a lawyer, and the facility would get a lawyer, then, they would go to the court to resolve a dispute. The Receptionist stated the residents would have 60 days to rescind the signed arbitration agreement. During a concurrent interview and record review on 5/9/2025 at 10:37 AM with the Director of Nursing, Resident 18 ' s Arbitration Agreement, dated 5/8/2025, and 29 ' s Arbitration Agreement, dated 9/13/2025, were reviewed. The DON stated there were no records of Resident 18 and Resident 29 signed the Arbitration Agreement when they were admitted into the facility. The DON stated the DA should not back date the agreements for these two residents. The DON stated the arbitration meant the residents would give up their constitutional right to present their disputes in the court in front of the jury, instead, the residents and the facility would resolve the dispute through the arbitration. The DON stated the residents would have 30 days to rescind the agreement after signing it. The DON stated the staff did not understand what Arbitration Agreement was and did not provide the correct and thorough explanation about arbitration agreement to the residents, as a result, the facility violated the residents ' rights. During a review of the facility ' s policy and procedures titled, Binding Arbitration Agreements, dated 12/9/2024, indicated When explaining the arbitration agreement, the facility shall: a. Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, this facility. b. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement and The agreement must: Explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

Based on interview and record review, the facility failed to revise the care plan for one of two sampled residents who was at high risk for falls. The deficient practice had the potential to result in recurring falls for Resident 1 who sustained a fall on 3/27/2025. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility admitted Resident 1 on 5/22/2023 with diagnoses that included osteoarthritis (a degenerative joint disease, affecting joints over time, leading to pain, stiffness, and swelling) and glaucoma (a group of eye diseases that can cause vision loss and blindness). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/21/2025, the MDS indicated Resident 1 had severely impaired memory and cognition (ability to think and reason). The MDS indicated Resident 1 required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self and personal hygiene, and substantial/maximal assistance with chair/bed-to-chair transfer. During a review of Resident 1 ' s Fall Risk, dated 5/22/2023, Fall Risk indicated Resident 1 was scored at 17 (a method of assessing a patient's likelihood of falling, the higher the score, the higher of the risk for fall) and at risk for fall, with intermittent confusion, chair bound and requires assist with elimination, balance problem while standing and walking and requires use of assistive devices, takes three or more medications and has three or more predisposing diseases. During a review of Resident 1 ' s Care Plan, dated 5/2/2024, the Care Plan indicated Resident 1 is at risk for falls and the intervention including to follow facility fall protocol. During this review, the care plan was noted, not revised after Resident 1's fall on 3/27/2025, that included placing resident in the facility's Falling Star Program. During a concurrent interview and record review on 4/3/2025 at 11:32 AM with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Fall Risk, dated 5/22/25 was reviewed. LVN 1 stated the Fall Risk assessment should be completed upon admission and as needed if there was a fall. LVN 1 stated there was only one Fall Risk assessment was completed when Resident 1 was admitted and there was no Fall Risk assessment was completed afterwards. LVN 1 stated the care plan should had been revised as well after the Fall Risk was reassessed. During a concurrent observation and interview on 4/3/2025 at 11:40 AM with LVN 1, there was no yellow star sticker next to Resident 1 ' s name by the door of Resident 1 ' s room. LVN 1 stated Resident 1 was at risk for fall and should be put under the Falling Star Program prior to the fall on 3/27/2025. LVN 1 stated the staff should put a yellow star sticker next to Resident 1 ' s name by the door to alert the staff that the resident was at risk for fall and required frequent monitoring and assisting. During a review on 4/3/2025 at 1:14 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she took care Resident 1 and she was not sure if Resident 1 was at risk for fall. CNA 1 stated if a resident was at risk for fall, a yellow star sticker by the resident ' s name by the door would alert her to pay extra attention to the resident. During a concurrent interview and record review on 4/3/2025 at 1:52 PM with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled, Fall Risk Assessment, dated 12/19/2024, was reviewed. The DON stated according to the P&P, the risk assessment should be completed by the nurse or designee upon admission, annually, or when a significant change is identified. The DON stated the staff did not complete the annual Fall Risk assessment for Resident 1 for more than a year, and the staff did not complete the Fall Risk assessment after Resident 1 ' s fall with a humerus (upper arm bone) fracture. During the same interview, on 4/3/2025 at 1:52 PM, the DON stated Resident 1 should be evaluated for fall risk assessment to make sure an updated care plan was in place to prevent avoidable falls and injuries. During a concurrent interview and record review on 4/3/2025 at 2:00 PM with the DON, the facility ' s P&P titled, Fall Prevention Program, dated 12/28/2023, was reviewed. The DON stated Resident 1 was not in the Falling Star Program until now. The DON stated according to the P&P, the facility utilizes a standardized risk assessment for determining a resident ' s fall risk. The DON stated it was the facility ' s procedure that any resident whose fall risk score was above 10 would be put under the Falling Star Program to ensure the staff to monitor the resident more frequently and provided fall interventions accordingly. The DON stated Resident 1 had fall risk score of 17 upon admission and she should be put under the Falling Star Program to minimize the risk of fall. During a review of the facility ' s P&P titled, Fall Prevention Program, dated 12/28/2023, the P&P indicated The facility utilizes a standardized risk assessment for determining a resident ' s fall risk, At Risk Protocols: a. The resident will be place on the facility ' s Fall Prevention Program and when a resident who does not have a history of falling experiences a fall, the resident can be placed on the facility ' s Fall Prevention Program. During a review of the facility ' s P&P titled, Fall Risk Assessment, dated 12/19/2024, the P&P indicated the risk assessment should be completed by the nurse or designee upon admission, annually, or when a significant change is identified. During a review of the facility ' s P&P titled, Comprehensive Care Plans, dated 12/19/2024, the P&P indicated The care planning process will include an assessment of the resident ' s strengths and needs and The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observations, interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) was free from accident smoking hazards by failing to: 1. Supervise and monitor Resident 1, who was non-compliant with the facility's smoking policy, titled Resident Smoking, when the resident went to the facility's outdoor patio to smoke a cigarette while on oxygen. 2. Implement Resident 1's care plan interventions of being non-compliant with the facility's smoking schedule and policy that indicates facility staff would supervise Resident 1 while smoking. 3. Ensure the facility nursing staff maintained Resident 1's smoking materials, in accordance with the facility's policy and procedures (P&P) titled, Resident Smoking. 4. Revise and update Resident 1's care plan of being non-compliant with smoking schedule and smoking policies dated 6/17/2024, when Resident 1 attempted to go outside and smoke while on oxygen [a colorless, odorless, reactive gas] on 7/20/2024. 5. Designate a facility staff responsible in supervising residents while residents smoke, in accordance with the facility's policy and procedure, titled, Resident Smoking. As a result, on 7/31/2024, at around 3pm, Resident 1 went to the facility's outdoor patio and lit his cigarette while on oxygen via nasal cannula (NC- a thin, flexible tube that wraps around the head for oxygen administration). The resident sustained second degree burns (partial thickness burn that affects the first and second layer of the skin causing blistering [painful swellings that contain liquid], skin discoloration, and pain) to both cheeks, lips, singed (burned surface) facial hairs, and both hands when a flash fire ignited the oxygen flow from the resident's NC. Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 via 911 emergency services on 7/31/2024. Subsequently, Resident 1 was transferred to GACH 2 Burn Center (a hospital specializing in the treatment of burns) for additional treatment. On 8/1/2024 at 5:15 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to provide supervised smoking for a resident (Resident 1) who had continued non-compliance with the facility's smoking safety and policy. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of an IJ situation on 8/1/2024 at 5:15 PM, due to the facility's failure to prevent accident and provide Resident 1 with sufficient supervision during smoking while oxygen is in use. On 8/3/2024 at 11:08 AM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 8/3/2024 at 2:08 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the DON. The IJ Removal Plan dated 8/3/2024, included the following: 1.Immediate action(s) taken for the resident found to have been affected include: -Complete body assessment and inventory of his personal belongings on readmission. -Interdisciplinary team (IDT) will provide education to Resident 1 on readmission regarding Resident Smoking policy, smoking information which includes the designated smoking area (across nurse's station), smoking paraphernalia (any other item designed for the consumption, use or preparation of tobacco products) will be stored by nursing in a lockbox, smoking schedule, use of ashtrays and contraindication (not recommended). -All delivery/packages will be opened by the Activity Director (AD) in front of the resident to check for smoking paraphernalia. On 8/3/2024, IDT educated and explained to resident that the package/ deliveries will be opened in his presence to ensure that there is no smoking paraphernalia for his own safety. -Daily room sweep by the assigned department manager (DM) on Monday through Friday schedule and Manager of the Day (MOD) on weekends. -Resident 1 will be on one-on-one monitoring starting 8/2/2024. When the assigned one-on-one staff is on break, a certified nurse assistant (CNA) will relieve until the staff assigned to do one-on-one returns from his/her break. 2.Identification of other residents having the potential to be affected was accomplished by: -On 8/1/2024, IDT conducted care conference with Residents 2 and 3 that are smokers. IDT discussed smoking safety, facility's smoking practices and plan of care. Copy of smoking policy and smoking information which includes the designated smoking area (across nurses' station), smoking paraphernalia will be stored by nursing in a lock box, smoking schedule, use of ashtrays and contraindication (such as oxygen use) was provided to Residents 2 and 3. -On 7/31/2024, smoking safety assessment and care plans for Residents 2 and 3 were reviewed and revised by the DON to address physical and cognitive (mental processes) factors affecting ability to smoke safely. Revisions were made to reflect all current supervision and safety interventions. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: -On 7/31/2024, staff conducted room sweep for all residents with resident's permission to ensure there is no smoking paraphernalia stored in the rooms. 37 residents were assessed as of 7/31/2024. -Smoking schedule was revised by the IDT on 8/1/2024 to reflect assigned department who will oversee smoking schedule. Activity Director (AD) and Charge Nurse will assign a specific staff to oversee smokers on a daily basis. The assignment will be posted at the nurses' station. -Starting 7/3/2024, the Director of Staff and Development (DSD) will in-service staff with the following topics. -Smoking Safety with emphasis on Handling/ Storage of Smoking paraphernalia & Inventory Delivery of Items- All Staff -Smoking Assessment - Licensed Nurses -Smoking Schedule - All staff -Smoking Care Plan Initiation & Revision - Licensed Nurses & IDT -Medical Emergency Response (Burn Management) - All Staff -Change of Condition for Resident that Smokes - All Staff -Resident that smokes and on respiratory therapy (treatments provided for the lungs such as oxygen, or medication) - all staff -Smoking policy - all staff -On 81/2024, the DSD provided Inservice to Activity Department regarding resident's package delivery. Resident will open the package in the presence of a staff member to ensure there is no smoking paraphernalia. The IDT will obtain a written or verbal consent from the resident(s) that will not comply with this will be educated by IDT regarding the Residents Smoking policy. -New hire or staff who were not able to attend the in-service will be educated prior to start of their scheduled shift. -Tentative completion of in-services will be 8/4/2024. -On 8/2/2024, IDT created a preliminary Resident Smoking policy that reflects additional safety measure for non - compliance. This preliminary policy will be presented by the IDT on the scheduled Quality Assurance (QA) meeting. The revision to the policy is stated below: -If a resident or family does not abide by the smoking policy or care plan, the plan of care may be revised to include additional safety measures identified by the IDT team to include increased supervision (visual monitoring every hour or one on one monitoring) for non - compliant residents. -The IDT will obtain a written or verbal consent from the resident prior to the resident opening the package or delivery to ensure resident's rights are not violated. Written consent will be kept in the resident medical records. -The Nursing management team will oversee assigned caregivers and residents during designated smoking times to ensure appropriate supervision and interventions are implemented and that plans of care are followed. -Starting 8/1/2024, the IDT will review admission and readmission within 72 hours to verify if resident uses tobacco. The findings will be documented utilizing Admission - readmission Log. Once the resident is identified as a smoker, necessary documentation and assessment will be completed by licensed nurse. The DON or designee will audit utilizing the Resident that smokes form. -Starting 8/1/2024, Activity Department or designee will deliver packages(s) to the resident and will open the package in front of the resident to ensure that no smoking paraphernalia is inside. All package/delivery will be documented utilizing Package Delivery Log. -Starting 8/1/2024, Department Managers or designee will conduct room rounds on a Monday through Friday schedule, and Manager for the Day (MOD) on weekends. The room rounds will be conducted to check smoking paraphernalia in resident's rooms and will be documented utilizing Guardian Angel Rounds' form. If any smoking paraphernalia are found, the staff will immediately remove it and will notify Administrator for appropriate action. Findings: During a review of Resident 1's Admission Record indicated the facility initially admitted the resident on 8/27/2019 and readmitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD; long term inflammation of lungs that causes blockages or interference with airflow in the lungs) exacerbation(worsening of a disease), acute and chronic respiratory failure (the body's tissues does not have enough oxygen), epilepsy (seizures), and muscle weakness. During a review of a facility provided document titled Smoking Schedule updated 7/21/2023, indicated the facility's smoking scheduled times for residents who smoke listed as 9 AM, 11 AM, 1 PM, 3:30 PM, and 6:30 PM. The Smoking Schedule indicated, Smoking assessment is done upon admission for resident safety. Smoking aprons (made from a flame retardant material use for protection of smokers) are provided to residents for safety. Smoking supplies are kept by staff for safety. During a review of Resident 1's care plan titled [Resident 1] is non-compliant with oxygen, dated 10/10/2023, indicated Resident 1 was using oxygen 5 liters per minute for COPD. The care plan interventions included discussing the consequences of non-compliant behavior and accepting/supporting the resident's decision. During a review of Resident 1's Order Summary Report indicated a physician's order dated 3/13/2024, to administer oxygen via NC at 5 liters per minute, may titrate (the process of adjusting the oxygen flow) oxygen to maintain oxygen saturation (the amount of oxygen in the blood) greater or equal to 94 % (normal levels are between 95% to 100%). During a review of Resident 1's History and Physical Examination (HPE, a comprehensive physician's note regarding the assessment of the resident's health status) signed by the attending physician (Physician 1) dated 6/6/2024, indicated Resident 1 had the capacity to understand and make decisions. During a review of a facility record title Acknowledgement and Smoking Waiver signed by Resident 1 on 6/6/2024, indicated the resident wishes to exercise the right to smoke cigarettes while residing at the facility .The facility record indicated that in order to try to protect the lives and safety of all residents and staff, the facility requires that any resident smoking be conducted with the supervision of staff because the facility does not allow smoking unsupervised. The facility record indicated that the facility had explained to Resident 1 that the facility's designated smoking area was the Patio. During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 6/12/2024, indicated the resident was moderately impaired ( difficulty remembering things, thinking clearly) of cognition (thought process). The MDS indicated Resident 1 required moderate/partial assistance (helper does less than half the effort) with upper body dressing, oral hygiene, sit to stand, chair transfers, and personal hygiene while Resident 1 required substantial/maximal assistance (helper does more than half the effort) for lower body dressing, toileting hygiene, putting on/taking off footwear, and sit to lying position. During a review of Resident 1's care plan titled [Resident 1] is non-compliant with smoking protocols/schedule dated 12/20/2023 and revised on 6/17/2024, indicated goals that included the resident not having injuries from smoking and for the resident to inform nursing staff to remove oxygen tank prior to smoking. On 7/22/2024, an intervention was added for the resident to seek assistance and supervision from facility staff for when the resident wants to smoke. The care plan interventions included encouraging the resident to seek assistance/supervision and removing oxygen tank prior to smoking, encouraging the use of smoking apron, and respecting the resident's rights. During a review of Resident 1's care plan titled [Resident 1] is non-compliant with smoking schedule, smoking policies, and keeping his own cigarette dated 3/6/2024 and revised on 6/17/2024, indicated goals that included for the resident to not smoke without supervision, resident would participate in decisions relating to smoking schedules and policies, and the resident would not suffer injuries from unsafe smoking practices. The care plan interventions included instructing Resident 1 about smoking risks and hazards, notifying charge nurse immediately if it is suspected the resident had violated the facility's smoking policy, observing clothing and skin for signs of cigarette burns, and instructing Resident 1 about facility policy on smoking, and locations. During a review of Resident 1's care plan titled [Resident 1] is a smoker revised on 6/18/2024, indicated goals that Resident 1 would not smoke without supervision and would not suffer injury from unsafe smoking practices. The care plan interventions included information that Resident 1 required supervision while smoking, instructing Resident 1 about facility policy on smoking, locations, times, safety concerns, notifying charge nurse immediately if it was suspected that Resident 1 has violated the facility smoking policy. During a review of facility records titled Smoking Safety - initial assessment, dated 5/9/2023, 6/5/2024, and 6/22/2024, indicated Resident 1's risk factors included impaired gait (walking) and balance. The facility records indicated the same recommendations for 5/9/2023, 6/5/2024, and 6/22/2024 Smoking Safety- V2 initial assessments, that indicated discussion of smoking cessation plan and resident smoking with staff supervision. During a review of Resident 1's care plan titled Resident is at risk for injury due to non-compliance with smoking policy creating/making his own cigarette dated 7/22/2024, indicated goals that included the resident will not cause injury to himself or to others and the resident will ask staff when he needs to smoke. The care plan interventions included to continue teaching/reminding the resident with his risk factors, frequent monitoring of resident's behavior, encourage verbalization of feelings and concerns, and for the IDT to review the resident's behavior regarding smoking needs, and informing the resident of the consequences for non-compliant behavior. During a review of Resident 1's Progress Notes dated 7/23/2024 timed at 4:02 PM, indicated an incident that occurred on 7/20/2024 during the night shift (11 PM to 7 AM), when Licensed Vocational Nurse (LVN 3) would not allow Resident 1 to go outside the outdoor patio to smoke. During a review of LVN 3's written statement dated 7/25/2024 timed at 10:41 AM, indicated the incident that occurred on 7/20/2024, during the start of the night shift (11PM-7AM) when Resident 1 requested to smoke. LVN 3 informed Resident 1 that he cannot go outside because it was past the facility's Smoking Scheduled times and the resident got upset. The written statement indicated Resident 1 still went out the outdoor patio smoking area while the resident's oxygen tank was on and attached to the resident's wheelchair while the resident attempted to light a cigarette. The written statement further indicated LVN 3 was able to remove the oxygen tank before Resident 1 was able to light the cigarette. During a review of Resident 1's record titled Change of Condition [COC] dated 7/31/2024 timed at 3 PM, indicated another incident that occurred on 7/31/2024, when Resident 1 was heard calling for help from the facility's outdoor patio. The resident was discovered to have sustained second degree burns on the resident's nose, mouth, and hands. The COC indicated Resident 1 reported having severe pain, rating it at10 out of 10 pain [numerical pain rating scale with 10 being the highest level of pain and 0 for no pain). The COC indicated that emergency services (911) where contacted, and the resident was transferred to the acute hospital (GACH 1). During a review of Resident 1's GACH 1 record titled Trauma Surgery History & Physical dated 7/31/2024 timed at 4:55 PM, indicated Resident 1 had a primary medical history of status post (medical or clinical shorthand that refers to a state after an event or intervention) explosive accident in the facility. The GACH 1 record indicated [Resident 1] was sitting in a chair, smoking cigarette with his NC oxygen, (the resident) has second degree bilateral (both) burns of the hands, singed facial hairs, second degree burns of bilateral cheeks, carbonaceous sputum (upper airway injury), with 10/10 pain. The GACH 1 record indicated Resident 1 received treatments for the burns and bilateral dressings to both hands. The GACH 1 record indicated Resident 1 would be transferred for further treatment to GACH 2 Burn Center. During a review of Resident 1's GACH 2 Burn Center records titled Inpatient Progress Note dated 7/31/2024 timed 9:50 PM, indicated the resident had deep partial thickness burns with necrotic (dead body tissues) tissues on upper and lower lips. In addition, the resident had left hand with partial thickness burn to left [NAME] (the inside) hand involving the fourth (ring finger) to the fifth digits (little finger) and right hand with partial thickness burn to right [NAME] hand at base of second digit (forefinger) to the fifth digits. Treatment plan of Santyl (ointment that removes dead infected skin) and Vashe (skin and wound cleansing solution) to hands and Bactroban (antibiotic [stops growth of bacteria] ointment) topically (applied to the skin)to the resident's face. The GACH 2 records indicated an order to give the resident Tylenol (over the counter pain medication), Gabapentin (medication for nerve pain) and oxycodone (a strong narcotic medicine used to treat severe pain) for pain as needed. During a review of Resident 1's GACH 2 Burn Center records titled Patient Discharge Instructions dated 8/2/2024 timed at 5:40 PM, indicated the resident was discharged back to the facility on [DATE] with discharge diagnoses including, second degree burns of back of the right hand, back of the left hand, head, face, and neck, and wound pain. During the facility's initial tour and observation, in the presence of the DON, on 8/1/2024 at 10:16 AM, there were warning signs observed posted at the facility's double door exit to the outdoor patio Smoking Area that indicated No oxygen is allowed beyond that point. During an interview with the DON on 8/1/2024 at 10:16 AM, the DON stated if a resident smoker was using oxygen, the facility staff would remove the resident's oxygen prior to going to the outdoor patio Smoking Area. The DON stated the warning signs had been posted on the double door exit to the outdoor patio prior to Resident 1's smoking accident on 7/31/2024. During an interview on 8/1/2024 at 10:20 AM with the DON, the DON stated the facility's process for smoking supervision was for residents who smoke to go to the Nursing Station during the Scheduled Smoking times and notify the nursing staff if they wish to smoke and then nursing staff would notify the Activity Department to supervise the residents in the outdoor smoking patio. The DON stated the facility did not have a system to monitor residents who exit the double doors to smoke in the patio outside the Smoking Schedule (9 AM, 11 AM, 1 PM, 3:30 PM, and 6:30 PM). During an interview on 8/1/2024 at 10:50 AM with the DON, the DON stated that according to her investigation, the facility staff (Nursing and Activity staff) did not know that Resident 1 went outside to smoke on 7/31/2024. The DON stated she was uncertain how Resident 1 obtained his cigarettes and lighter. The DON stated that during her investigation, she found out that Resident 1 hid the cigarettes and lighter in his room. During a concurrent interview on 8/1/2024 at 11 AM, and record review of Resident 1's Progress Notes dated 7/23/2024 timed at 4:02 PM, the Progress Notes indicated the incident that happened with Resident 1 on 7/20/2024, when LVN 3 would not allow Resident 1 to go outside the patio to smoke on 7/20/2024, during the night shift. The DON stated that on 7/20/2024, during the night shift, Resident 1 wanted to go outside, but LVN 3 blocked the outdoor patio exit to prevent Resident 1 from smoking when the resident was on oxygen. The DON stated LVN 3 did not report the incident (7/20/2023) to the DON until after a few days when Resident 1 notified her (DON) that LVN 3 blocked the outdoor patio. The DON stated LVN 3 did not complete a Change in Condition documentation or revise the resident's care plan that addressed the Resident 1 attempting to go to the patio while on oxygen. During an interview on 8/1/2024 at 12:03 PM with LVN 1, LVN 1 stated he heard Resident 1 yelling for help on 7/31/2024 at around 3 PM, which prompted him (LVN 1) to rush to the facility's outdoor patio. LVN 1 stated when he went out to the patio, he observed Resident 1 with black discoloration around the lower part of the face, nostrils, and both hands. LVN 1 stated he did not know where Resident 1 got his cigarettes and lighter or how the resident was able to go out to the facility's patio without staff supervising resident while smoking. During an interview on 8/1/2024 at 12:30 PM with LVN 2, LVN 2 stated in the afternoon of 7/31/2024, he observed Resident 1 go out to the facility's outdoor patio (Smoking Area). Shortly thereafter, LVN 2 stated he heard Resident 1 yelling for help outside the facility's outdoor patio smoking area. LVN 2 stated he went outside and removed the resident's oxygen tank. LVN 2 stated he observed black and red discoloration on Resident 1's nose, lips and both hands. LVN 2 stated he did not know how Resident 1 obtained cigarettes and lighter. Resident 1 was not allowed to keep smoking materials in his room or maintain in his possession. During an interview on 8/1/2024 at 12:46 PM with Resident 2, Resident 2 stated he was outside in the facility's outdoor smoking area patio on 7/31/2024, around 3 PM, when he observed Resident 1 removed a cigarette and a lighter from beneath his gown. Resident 2 stated when Resident 1 attempted to light the cigarette, he witnessed flames igniting and coming from the lower part of Resident 1's face. Resident 2 stated Resident 1 tried to put out the fire with his own hands. During a concurrent interview and record review of Resident 1's care plan titled [Resident 1] is non-compliant with smoking schedule, smoking policies, and keeping his own cigarette revised on 6/17/2024, on 8/1/2024 at 1 PM, Registered Nurse (RN) 1 stated the care plan indicated Resident 1 was non-compliant with smoking protocols and schedule. RN 1 stated Resident 1 was instructed to inform nursing staff to remove his oxygen tank prior to smoking in the facility's outdoor patio and seek supervision. RN 1 stated, Resident 1 was known to be non-compliant with the facility's smoking policy and keeps his cigarettes on his own. RN 1 stated that even if Resident 1's care plan indicated education was provided to Resident 1 about the Smoking Policy, the facility staff should have done more interventions, that included one-to-one supervision every shift, to ensure Resident 1's safety since he continued to be non-compliant with the smoking policy. During an interview on 8/1/2024 at 3:59 PM with Treatment Nurse [TX] 1, TX1 stated LVN 1 had called for assistance for Resident 1 on 7/31/2024 around 3 PM, TX 1 stated on 7/31/2024 upon responding to Resident 1's call for help resident 1 refused to have facial burns cleansed with saline solution (a mixture of water and salt) and requested A&D ointment (first aid salve used on burns) be applied on 7/31/2024 at the facility's outdoor smoking patio. TX 1 stated Resident 1 had a history of being non-compliant with the facility's smoking policy to seek staff supervision prior to smoking during the designated smoking times, despite being provided with education. During an interview on 8/2/2024 at 12:31 PM with the Activity Director [AD], the AD stated there had been a lack of communication between the Activity Department and Nursing Department on who is assigned to supervise the resident smokers during smoking times. The AD stated that residents are supervised during smoking by anyone who is available. The AD stated that Resident 1 sometimes hide from facility staff when he goes outside the patio to smoke. The AD stated that on 7/31/2024, during the afternoon shift [3 PM to 11 PM] she did not verbally notify the nursing staff that there was no available Activity Assistants to help supervise smoking. During an interview on 8/2/2024 at 12:45 PM, the DON stated the facility's Activity Department and overseen by the AD who had two Activity Assistants (AA) was in charge of supervising and monitoring resident smokers during smoking schedule for 9 AM, 11 AM, 1 PM, and 3:30 PM. The DON stated that the 6:30 PM smoking schedule was the last time for residents to smoke for the day. The DON stated that the Nursing Department should be assigned to supervise resident smokers at 6:30 PM. The DON stated that there was no specified facility staff from the Activity Department and Nursing Department assigned for each schedule indicated in the facility's Smoking Schedule and staffing assignments and/or the resident's care plans, as a means to communicate to all facility staff. The DON stated the staff assignments was based on verbal communication by the AD to either of the two AAs or the charge nurses to any of the nursing staff available during the morning [7 AM to 3 PM] and [3 PM to 11 PM] evening shifts. The DON stated that Nursing staff was to cover the Activity Staff (AD and AAs) in supervising resident smokers if the AD and the AAs were not available to supervise residents during the smoking schedule or outside the smoking scheduled times. During a concurrent interview and review of the facility's undated policy and procedures (P&P) titled, Resident Smoking, on 8/2/2024 at 2:18 PM, the DON stated that the P&P did not indicate what the facility's actions for residents who continued to be non-compliant with the facility's smoking policy, that included additional safety measures to protect residents who uses oxygen and who consistently do not adhere to the policy. During the same interview on 8/2/2024 at 2:18 PM, the DON stated that all resident smokers' care plans about smoking, including Resident 1 did not have the specific smoking measures designed for each resident's concerns, including communication of these safety measures to all facility staff, especially those who will be the staff responsible in supervising the residents while smoking. The DON stated that nursing staff should have added and implemented additional safety measures especially when Resident 1 was on oxygen and continued to be noncompliant of smoking safety such as removing oxygen tank before smoking. The DON stated the additional safety measure should had been a one-to-one staff supervision when the resident continued to show non-compliance to safety while smoking. The DON stated that Resident 1 had an interdisciplinary team (IDT) discussion about his care and including smoking compliance on 3/14/2024, 6/6/2024, and 7/24/2024, indicating the same information such as reeducation of facility smoking, and oxygen policies and procedures and that resident will not smoke without supervision. The DON stated Resident 1's smoking care plans were not specific to increase observation/supervision. The DON stated the facility staff should have been more attentive to Resident 1's issues and concerns and could have added a one-to one sitter, increase monitoring, remove the oxygen tank prior to resident going to the outdoor smoking area patio. The DON stated Resident 1's care plans was not specific to Resident 1's main issues and concerns. During a concurrent observation and interview on 8/3/2024 at 11:05 AM, in Resident 1's room, Resident 1 was lying in bed, with oxygen delivering 5 liters/min humidified via NC. Resident 1's bilateral hands were wrapped with gauze [a very thin, light cloth, used to cover cuts] dressing. During the observation, Resident 1 was observed with second degree burns on the lower part of the face, from the tip of the nose to both lower cheeks, down to the chin. Resident 1's lips were dark in color. Resident 1 complained of 10/10 (severe) pain. Resident 1 stated that on 7/31/2024, he lit a cigarette while on NC with oxygen flowing at 5 liters/min and the cigarette blew up in his face. During the same interview, on 8/3/2024 at 11:05 AM, Resident 1 stated Normally, [facility] staff catches me before I go outside. Normally they see me coming before going outside, and normally they [facility staff] say wait, let me take off your oxygen. Resident 1 stated that on 7/31/2024, during that time (3 PM) the facility staff did not remind him. Resident 1 stated Resident 1 forgot that he had his oxygen on when he lit up his cigarette. Resident 1 stated when he put the cigarette in his mouth and lit it with his lighter, the cigarette exploded. Resident 1 stated that the plastic part of the NC and his face caught on fire and burnt his mustache. Resident 1 stated he tried to put the fire out by using his hands. Resident 1 stated he yelled for help and it took forever for nurses to come. Resident 1 stated he did not remember how long it took for staff to come help him. Resident 1 stated he puts his cigarettes and lighter inside his drawer in his room. Resident 1 stated he orders his smoking materials online (an activity or service available on or performed using the internet or other computer network) and stores them in his drawer. During a review of the facility's undated policy and procedures (P&P) titled, Resident Smoking, the P&P indicated the following: 1. The facility was to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. 2. Safety measures included the prohibition of oxygen use in the smoking area. 3. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. 4. Any resident who was deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. 5. All smoking measures will be documented in each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible supervising residents while smoking. 6. If a resident or family does not abide by the smoking policy or care plan, the plan of care may be revised to include additional safety measures. During a review of the facility's policy and procedure titled Accidents and Supervision revised on 12/19/2022, indicated The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accident, to include 1. Id [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 41) was immediately provided CPR (cardiopulmonary resuscitation a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse] consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) prior to the arrival of emergency medical personnel in accordance with the standard of practice and the facility's policy and procedure titled Medical Emergency Response and Cardiopulmonary Resuscitation (CPR) by failing to: 1. Ensure Licensed Vocational Nurse (LVN 1) immediately initiated CPR to Resident 41 when found unresponsive, without pulse and not breathing rather than checking the code status (a resident's record that describes the type of life saving procedures (if any) the resident or their representative would the health care team to conduct if your heart stopped beating and/or stopped breathing to keep him/her alive) of Resident 41 and calling for assistance. 2. Ensure Resident 41's Advance Directives (document signed by the resident or representative indicating the care treatments that the resident wished in an event of emergency) and or POLST (a Portable Orders for Life Sustaining Treatment- is a record singed by the resident/representative and the physician that indicates the resident's medical treatment wishes so that emergency personnel know what treatments the resident wants during medical emergency) and/or code status was known to the facility staffs and available to the staffs for review in an event of a code. 3. Ensure the Emergency Cart (EC, a storage cart that contains equipment necessary to perform life-saving procedures on residents experiencing a medical emergency) is maintained containing contents, devices/equipment that are accessible and used during CPR such as Ambu-bag (a type of device known as a bag valve mask, which is commonly used to provide respiratory support to patients who are not breathing or not breathing adequately),Glucometer (device used to check blood sugar levels), pulse oximeter (device used to check oxygen saturation levels in the blood), 20 gauge (inner size) Intravenous Catheter (IV catheter is a thin plastic tube that is inserted into the vein for the purpose of giving medications, blood, etc.), kerlix (a type of gauze), nebulizer kit (device used to provide treatment to the lungs), First Aid kit (a kit used for emergency). As a result of these deficient practices, the initiation of CPR was not initiated immediately, for Resident 41 with a full code status (resident wishes to be revived when breathing and/or heart stopped). Resident 41 was transferred to the General Acute Care Hospital (GACH) 1 Emergency Department (ED) on [DATE], after being found unresponsive, without pulse and not breathing. The GACH 1 ED Report indicated 911 (an emergency call system) and paramedics were called by the facility at approximately 5:52 AM. Resident 1 expired at the GACH 1 on [DATE] at 6:50 AM with the diagnosis of cardiac arrest. On [DATE] at 11:47 AM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the failure to ensure CPR was immediately performed on Resident 41. The survey team notified the Director of Nursing (DON), the Administrator (ADM) and the Regional Consultant (RC) of the IJ situation. On [DATE] at 6:03 PM, the IJ was removed in the presence of the ADM, and the DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE] at 6:03 PM, included the following: 1. On [DATE], (DON) had a 1:1 (one on one) in-service with the licensed nurse assigned to Resident 41 regarding Medical Emergency Response. Disciplinary action was taken with licensed nurse who delayed the CPR on the full code resident and was suspended pending investigation. 2. On [DATE], the Medical Records Director (MRD) or designee completed a chart audit on every resident and compared the Advance Directive/Physician Orders for Life Sustaining Treatment (POLST) to the physician order for accuracy. 3. On [DATE] the facility emergency cart checklist was revised by the DON. The glucometer, glucose strips, lancets, nebulizer, and nebulizer kit were added on [DATE]. The updated form will be utilized by licensed nurses starting [DATE]. The emergency cart was checked by the DON on [DATE] for appropriate supplies and equipment. No issues were identified. 4. On [DATE], the Resource Nurse Consultant (RNC) and Respiratory Therapy Consultant designee educated licensed nurses and certified nurse assistance (CNAs) on the facility's policy and procedure for Medical Emergency Response and location of code status for each resident. Licensed nurses and CNAs were not permitted to work a shift until education was completed. Nurses on leave will receive education prior to their next scheduled shift. 5. On [DATE], the RNC and Respiratory Therapy Consultant initiated Code Blue (a code called out by the facility to alert other staffs about residents that needed emergency care) drill to be completed on all shifts randomly by using the facility landline's paging system located at the nurse's station, hallway outside room [ROOM NUMBER], between rooms [ROOM NUMBERS], activity room, rehabilitation room and office rooms (Administrator, DON, Dietary, SSD office), and announcing Code Blue to room. Licensed nurses and CNAs were in-serviced by the RNC regarding the paging system on [DATE]. The licensed nursing and CNAs staffs who were not scheduled to work on [DATE] will participate in the Code Blue drill during their scheduled shift. 6. On [DATE] the RNC, (Director of Nursing) DON and (Director of Staff Development) DSD conducted an audit of licensed nurses and certified nurse assistants (CNAs) CPR certification. No issues were identified. 7. Starting [DATE], newly hired licensed nurses and CNAs will have their CPR certification card on file and have competency prior to their scheduled shift. 8. Starting [DATE], DON or designee will audit new admissions chart to compare the resident's Advance Directives/ POLST to the physician orders for accuracy. This audit will continue for three months. Findings will be reviewed at the monthly QA (Quality Assurance) Committee meeting for discussion and recommendations. 9. Starting [DATE], ,d+[DATE] licensed nurse will print the daily code status from PCC orders and will place it in the binder labeled Code Status located at the nurse's station. The SSD will oversee that the code status is available and updated daily. In the absence of SSD, the license nurse working will verify that the code status is updated. 10. Starting [DATE], the POLST will be reviewed and verified by the DON and SSD immediately after admission of the resident to the facility. The RN Sup will oversee the POLST in the A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented on [DATE]. DON or designee to complete weekly mock (fake) code drills on all shifts and monitor code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Any trends will be discussed during monthly Quality Assurance meeting which will be held scheduled monthly. The DON will conduct compliance audits weekly for three months. Findings will be reported at monthly QA Committee meeting for discussion and recommendations. 11. Starting [DATE], the DON will randomly audit the emergency cart on a weekly basis in addition to the daily checks from ,d+[DATE] licensed nurse to ensure that the equipment and supplies are stocked as indicated on the emergency cart checklist. This audit will continue for three months. Findings will be reviewed at the monthly QAA (Quality Assurance) Committee meeting for discussion and recommendations. Cross reference to F695 and F726 Findings: 1. A review of Resident 41's Admission Record indicated the facility originally admitted the resident on [DATE], and was readmitted on [DATE], with diagnoses that included congestive heart failure (failure of the heart to meet the body's demand), acute respiratory failure with hypoxia (a condition where a person do not have enough oxygen in the tissues of the body), chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 41's Clinical Admission record, dated [DATE] timed at 3:18 PM, indicated Resident 41 was receiving oxygen at 3 liters per minute. The Clinical Admission indicated Resident 41's pulse oximetry (pulse oximetry is a painless, noninvasive method of measuring the saturation of oxygen in a person's blood) reading during admission to the facility was at 95% (a resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person) using oxygen administered via nasal cannula (a long plastic hose used to deliver oxygen into the nares). The Clinical Admission indicated Resident 41's discharge goal was to return home. A review of Resident 41's History and Physical (H&P) dated [DATE], indicated the resident had the capacity to understand and make decisions. The H&P indicated one of Resident 1's diagnosis included Pneumonia (severe lung infection) treated. A review of Resident 41's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment reference date of [DATE], indicated the resident had moderate cognitive (thought process) impairment. The MDS indicated Resident 41 required partial/moderate assistance (helper does less than half the effort) in walking up to 10 feet and was not attempted to be assessed if she could walk 50 feet or more. The MDS indicated Resident 41 required supervision (helper provides verbal cues) on task such as oral hygiene, upper body dressing, sit to stand and bed mobility. The MDS indicated Resident 41 required partial/moderate assistance with toileting, shower and lower body dressing. A review of Resident 41's POLST signed by Resident 41 on [DATE], and signed and dated by Physician 1 on [DATE], indicated to attempt CPR to Resident 41 to restore breathing and heart circulation and beat. During the review of Resident 41's Progress Notes dated [DATE] timed at 5:30 AM, authored by Licensed Vocational Nurse (LVN) 1 indicated Resident 41 approached LVN 1 at the Nursing Station asking for another oxygen tank (a container with oxygen inside it, used for helping people to breathe). The Progress Notes indicated LVN 1 advised Resident 41 that Resident 41 still had half a tank left and will change (the oxygen tank) when it is lower. The Progress Notes indicated Resident 41 understood and just waited outside Nursing Station until staff finished with rounds. During the same review of Resident 41's Progress Notes dated [DATE] timed at 5:30 AM, the Notes indicated Noted Resident 41's oxygen tank outside Nursing Station. The Progress Notes indicated LVN 1 went inside Resident 41's room to ask if the resident still wanted her oxygen tank. The Progress Notes indicated Resident 41 was found unresponsive in bed with eyes slightly open, no pulse, no rise of chest (an indication that the resident was not breathing). [Resident 41] was still warm, blood sugar 301, unable to get blood pressure. The Progress Notes indicated 911 [paramedics] was called while staff (unknown) did CPR The Progress Notes indicated Resident 41 was transferred to the GACH on [DATE] at 6:25 AM, and family and Physician 1 was notified. A review of Resident 41's Change of Condition (COC) note dated [DATE] timed at 6:23 AM, indicated Found [Resident 41] unresponsive lying in bed with eyes slightly open. Called code blue and started CPR. 911 was called and noted patient (Resident 41) was full code, did CPR for 10 minutes before paramedics arrived and took over patient care. No pulse, after 25 minutes of CPR patient was transferred to GACH. The COC indicated Physician 1 was notified on [DATE] at 6:42 AM and the vital signs (measurement of the heart rate, breathing and blood pressure) were documented as follows: a. Blood pressure-,d+[DATE] (normal ranges between ,d+[DATE] to ,d+[DATE]) b. Respirations indicated 0-(number of breaths per minute normal range is between 12 to 20) c. Pulse-indicated-0 (heart rate per minute, normal range is 60 to 100) d. Apical pulse indicated 0 (number of times the heart beats per minute, normal range is 60 to 100) e. Temperature-97.5 F (Fahrenheit, a unit of measuring temperature [normal range 97 F to 99 F]) f. Oxygen Saturation 65% (low) (oxygen level in the blood-normal range ,d+[DATE]%) g. Blood sugar- 301 mg/dL (high) (milligrams per deciliter- normal range ,d+[DATE] mg/dL) A review of Resident 41's Emergency Department Report from GACH 1, dated [DATE], indicated the paramedics (an emergency personnel who performs CPR and other emergency care) was called by the facility staff on [DATE] at approximately 5:52 AM. The report indicated Resident 41 died on [DATE] at 6:50 AM. A review of Resident 41's GACH 1 Emergency Department (ED) Reports dated [DATE] timed at 7:14 PM, indicated Resident 41 was brought in by ambulance from the facility and found pulseless and not responsive. The GACH 1 ED report indicated the paramedics were called by the facility at approximately 5:52 AM and Resident 41 was last seen in her usual state of health 10 minutes prior. The GACH ED 1 report indicated paramedics were unable to obtain any return of spontaneous circulation in the field and were directed by base station to be transported. The report indicated Resident 41 arrived to GACH 1 ED with CPR in progress and Advanced Cardiac Life Support (ACLS, a set of clinical guidelines for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, using advanced medical procedures, medications, and techniques) in excess of 50 minutes, an additional dose of epinephrine (primary drug used in cardiac arrest, to increase cardiac output), sodium bicarbonate (medication used to treat metabolic acidosis [when acids build up in your body]), and calcium gluconate (medication used to manage cardiac arrest) were administered. The GACH 1 ED report indicated chest compressions continued with assisted ventilation (the movement of gas into and out of the lung by an external source connected directly to the patient) through endotracheal tube (a tube placed between the vocal cords through the airway to provide oxygen and inhaled gases to the lungs). The report indicated Resident 41 remained pulseless without cardiac activity on ultrasound and died on [DATE] at 6:50 AM. During an interview on [DATE] at 5:33 PM, the DON stated, there was no physician's order that indicated the code status for Resident 41. During a telephone interview on [DATE] at 6:04 PM, with the primary physician (Physician 1), Physician 1 stated he was notified by LVN 1 on [DATE] after Resident 41 was transferred to GACH 1. Physician 1 stated he could not recall the exact details of LVN 1's telephone notification on [DATE]. During a telephone interview with LVN 1 on [DATE] at 6:28 PM, LVN 1 stated on [DATE], at around 5:30 AM, while LVN 1 was putting away medications, (Resident 41) approached him and asked if LVN 1 could change her portable oxygen tank because Resident 41 believed her oxygen tank was empty. LVN 1 stated he observed Resident 41's oxygen tank gauge (a medical device designed to display the pressure level in an oxygen tank) and saw that the oxygen tank gauge was still half full. LVN 1 stated he checked Resident 41's oxygen saturation and vital signs but could not recall and did not document the oxygen saturation level and vital signs results on [DATE]. LVN 1 stated that he did not do any other assessments (respiratory) because he needed to finish his medication pass and go home. LVN 1 stated he left Resident 41 sitting in a chair by the Nursing Station and proceeded to finish putting away medication in Medication Cart 1. LVN 1 stated after leaving Resident 41 in the Nursing Station, he continued to administer medications to the residents in seven rooms before going to another Nursing Station by Medication Cart 2 to retrieve Resident 41's medications which were kept in Medication Cart 2. LVN 1 stated as he was approaching Medication Cart 2, he observed Resident 41 was not at the Nursing Station anymore but Resident 41's oxygen tank was left sitting by the Nursing Station. LVN 1 stated he proceeded to go to Medication Cart 2 to remove Resident 41's medications before he decided to go to Resident 41's room. During the same telephone interview, on 5 /,d+[DATE] at 6:28 PM, LVN 1 stated as he entered Resident 41's room, LVN 1 observed Resident 41 lying in bed and not breathing. LVN 1 stated he went outside Resident 41's room to call for help and returned to Resident 41's bedside. LVN 1 stated when CNA 1 went to Resident 41's room, LVN 1 instructed CNA 1 to wait in the room, until he was able to review Resident 41's code status in the electronic medical records. LVN 1 stated he went outside Resident 41's room and went back to the Nursing Station and Medication Cart 2. LVN 1 stated he logged into the electronic medical records, but the electronic records did not indicate Resident 41's code status. LVN 1 stated he had to go to Nursing Station 1 to get Resident 41's paper chart to look for the POLST. LVN 1 stated Resident 41's POLST indicated Resident 41 was a full code (full support which includes cardiopulmonary resuscitation (CPR) if the patient has no heartbeat and is not breathing). LVN 1 stated after reviewing Resident 41's paper chart, LVN 1 returned to Resident 41's room to initiate CPR. LVN 1 stated that after completing about two full sets (consisting of 2 rescue breaths and 15 chest compressions) of CPR, LVN 1 instructed CNA 1 and CNA 2 to take over CPR, as he went outside Resident 41's room to the Nursing Station to call 911. LVN 1 stated he was the only licensed nurse during the shift (11 Pm to 7 AM) for the entire facility on [DATE]. During an interview on [DATE] at 7:31 PM with CNA 1, CNA 1 stated on [DATE] she was working inside another resident's room when she heard LVN 1 calling for help. CNA 1 stated LVN 1 initiated the CPR to Resident 41 after checking the code status of Resident 1. During a telephone interview on [DATE] at 7:58 PM with CNA 3, CNA 3 stated she did not hear LVN 1 called for Code Blue while she was in the restroom. CNA 3 stated when she got out of the restroom, she went to Resident 41's room and saw CNA 1, CNA 2, and CNA 7 performing CPR while LVN 1 was on the phone in the Nursing Station, calling 911. CNA 3 stated she touched Resident 41's hand and felt that Resident 41 was still warm. During a second telephone interview on [DATE] at 2:01 PM with Physician 1, Physician 1 stated facility staff should immediately initiate CPR when a resident is found to be unresponsive and without a pulse. Physician 1 stated a resident's code status should be entered into the resident's records upon admission. Physician 1 stated Resident 41 was under his care and was very frail. During another interview on [DATE] at 1:56 PM with LVN 1, LVN 1 stated on [DATE] he saw CNA 1 in the hallway when he came out of Resident 41's room after finding Resident 41 unresponsive and not breathing. LVN 1 stated he instructed CNA 1 don't start anything because he stated he needed to find out Resident 41's code status first. LVN 1 stated he went to the medication cart and logged into the electronic records but was not able to find Resident 1's code status in the electronic records. Then LVN 1 stated he went to the Nursing Station and looked through Resident 41's paper chart to look for the resident's code status. LVN 1 stated he found Resident 1's POLST that indicated Resident 1 was a Full Code (attempt to provide CPR). LVN 1 stated when he learned of Resident 1's code status, he went back to the resident's room and initiated CPR. LVN 1 stated everyone was on standby and did not perform CPR until he found out the resident's code status. During a second interview on [DATE] at 4:07 PM with CNA 1, CNA 1 stated CNA 2 and CNA 7 were in the room when she arrived in Resident 1's room. CNA 1 stated CNA 3 arrived in the room sometime after. CNA 1 stated when she went into the room, she helped CNA 2 and CNA 7 place the backboard (a flat piece of platform that is placed under a person's body for the purpose of providing effective CPR) under Resident 1's body. CNA 1 stated LVN 1 started CPR after they put the backboard (a board designed to provide rigid support during movement of a person during CPR and to provide support to residents with suspected spinal or limb injuries). During a telephone interview on [DATE] at 2:06 PM with Resident 41's Family Member (FM 1), FM 1 stated the resident was in good spirits on [DATE]. FM 1 stated Resident 1 was planning on going home on [DATE]. FM 1 stated she talked to Resident 41 on [DATE], then on [DATE] at around 7 AM, she was informed by GACH 1 physician that Resident 41 passed away. During a concurrent interview and record review of the facility's policy and procedure (P&P) titled, Medical Emergency Response, revised on [DATE], on [DATE] at 6:11 PM, the DON stated the staff who first witnessed a medical emergency, such as finding an unresponsive and pulseless resident, should initiate immediate action, including CPR and calling for assistance. The DON stated the P&P indicated the CPR will only be stopped if a Do Not Resuscitate (DNR, instruction to not perform CPR on a resident) order is found to be in place in the resident's record. The DON stated staff should initiate CPR then have someone else verify the resident's code status. The DON stated delaying the CPR could result in a resident's death. During the same interview and record review on [DATE] at 6:11 PM with the DON, the facility's P&P titled, Cardiopulmonary Resuscitation (CPR), revised [DATE], the DON stated the P&P indicated facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and in the absence of advance directives or a Do Not Resuscitate order. DON stated staff should initiate CPR right away even without knowing the resident's code status. DON stated staff should perform CPR right away and should not delay CPR by searching for the code status. DON stated CPR can always be stopped if staff eventually find the code status as DNR. During a telephone interview on [DATE] at 6:15 PM with CNA 2, CNA 2 stated she saw Resident 41 near the Nursing Station on [DATE] at around 5:30 AM. CNA 2 stated she went to another resident's room and sometime later, she heard LVN 1 call for code blue. CNA 2 stated as she was going into Resident 1's room, LVN 1 was coming of the room to check for the code status. CNA 2 stated that CNA 2, CNA 1 and CNA 4 did not start CPR as instructed by LVN 1. CNA 2 stated that when LVN 1 came back to the room, that was when LVN 1 started CPR. CNA 2 stated she does not remember how long it took LVN 1 to find Resident 41's code status in the resident's records. 2. During a concurrent observation of the completeness of the emergency cart and interview with the DON on [DATE] at 10:57 AM, the DON stated the following were missing from the facility's emergency cart: a. Ambu-bag (a type of device known as a bag valve mask, which is commonly used to provide respiratory support to patients who are not breathing or not breathing adequately) b. Glucometer (device used to check blood sugar levels) c. Pulse Oximeter (device used to check oxygen saturation levels in the blood) d. 20 Gauge Intravenous Catheter (IV, a thin plastic tube that is inserted to a person's vein for the purpose of giving medications, blood, etc.) e. Kerlix (a type of gauze) f. Nebulizer kit (device used to provide treatment to the lungs) g. First Aid Kit that had missing items. On [DATE] at 10:57 AM, the facility's document titled, Emergency Cart Checklist, revised ,d+[DATE], was reviewed with the DON. The DON stated the Emergency Cart Checklist was the current checklist used by the facility staff to check the completeness of the Emergency Cart. The DON stated the form was completed by the LVN (LVN 4) from the 11 PM to 7 AM shift on [DATE]. The DON stated she did not know why the checklist was checked off if some items are missing. During a concurrent interview and record review of Emergency Cart Checklist on [DATE] at 5:03 PM with LVN 4, dated ,d+[DATE], LVN 4 stated he completed the checklist on the night of [DATE]. LVN 4 stated he knew that there were missing supplies in the EC. LVN 4 stated he used to write an X if a supply was missing but was instructed by a former staff member of the facility to put a check instead. LVN 4 stated he was also instructed to report the missing items using a group chat in his cellphone. LVN 4 stated the group chat members included the facility Administrator, DON, Director of Staffing Development (DSD), and nurses from the 11:00 PM to 7:00 AM shift. During an interview on [DATE] at 5:45 PM with the DSD, the DSD stated licensed nurses were tasked and were trained to complete the Emergency Cart Checklist. The DSD stated the nurses were instructed to write an 'X' if an item is missing or write a line or check when the item is in the EC. The DSD stated staff are expected to notify the DSD via phone call or text message if an item or items are missing. The DSD stated nurses are also able to refill the EC and do not have to wait for the DSD's reply. The DSD further stated none of the nurses have informed him of any of the missing items in the EC. During an interview on [DATE] at 6:11 PM with the DON, the DON stated the EC is used in the case of an emergency such as a code blue. The DON stated the EC should be always restocked after use and ready for use. The DON stated not having the proper equipment in the EC could result in the delay of care, such as CPR, to residents that are experiencing a medical emergency. The DON stated Ambu-bags are used during a CPR procedure and should always be stocked in the EC. A review of the facility's Emergency Cart Checklist, unidentifiable, revision date, indicated the following must be present in the EC: a. First Drawer: Oxygen Sign and Gloves b. Second Drawer: Glucometer, Glucose Strips (a small piece of plastic that is used with a glucometer), thermometer (device used to check body temperature, pulse oximeter, lancets (a device used to prick a person's finger with an enclosed needle for the purpose of withdrawing a small amount of blood), alcohol pads, blood pressure cuff (device used to check blood pressure), and stethoscope (device used to listen to a person's heart, lungs, etc.) c. Third Drawer: Insulin syringe (a small cylindrical tube that is connected to a needle and a plunger), IV Catheter, Normal Saline (a liquid solution), Tapes, torniquet (an elastic band that is usually tied to a person's limb to facilitate insertion of an IV catheter), scissors, gauze, and kerlix. d. Fourth Drawer: [Nasal Cannula], non-rebreather mask (a mask that is connectable to an oxygen-delivery source to provide supplemental oxygen to a patient), oxygen tubing, Nebulizer, and Nebulizer kit. e. Fifth Drawer: Isolation gown (disposable gown that is worn to protect a person's clothing), face mask (a small piece of paper-like material that is worn to cover a person's nose and mouth), zip locks, trash bag, infectious waste bag, Ambu-bag, first aid kit, flashlight, and extension cord. A review of the facility's P&P titled, Medical Emergency Response, revised [DATE], indicated the employee who first witness or is first on site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance. The P&P also indicated a nurse will stay with the resident and designate a staff member to announce a Code Blue, if necessary, notify the physician and call 911 as needed. The P&P indicated Night shift supervisor or nurse will ensure that all emergency carts and equipment are inventoried and ready to use. The P&P also indicated staff will ensure emergency medications and equipment are inventoried and restocked. A review of Basic Life Support Provider Manual by American Heart Association, dated 2020, indicated: High-quality CPR (proper hand position and depth of chest compression) with minimal interruptions and early defibrillation (administering a controlled electric shock to allow restoration of the normal rhythm) are the actions most closely related to good resuscitation outcomes. High quality CPR if started immediately after cardiac arrest combined with early defibrillation can double or triple the chances of survival. These time-sensitive interventions can be provided both by members of the public and by healthcare providers. By standers who are not trained in CPR should at least provide chest compressions. Even without training, bystanders can perform chest compressions with guidance from emergency telecommunicators over the phone.

Based on interview and record review, the facility failed to assess, identify interventions, and services for Resident 41, who had diagnoses of respiratory failure with hypoxia (condition in which tissues of the body are starved of oxygen), pneumonia (lung inflammation) and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and who was receiving continuous oxygen therapy by failing to: 1. Monitor and conduct respiratory assessment for complications associated with the use of oxygen and notify the primary physician (Physician 1). On [DATE] at 5:30 AM, Resident 41 verbalized not feeling well and asked the Licensed Vocational Nurse (LVN) 1 for her oxygen tank to be replaced because the resident, felt it was empty. 2. Evaluate and assess the need to obtain a physician's order for the use of oxygen therapy from the date of admission to the facility on [DATE], for Resident 41 who had a diagnosis of COPD and respiratory failure with hypoxia. 3. Notify and obtain a physician's order to administer Resident 41's oxygen at 3 liters per minute, via nasal cannula (NC-a medical device that consists of a small, flexible tube with two prongs that sit inside a patient's nostrils) and titrate (continuously measure and adjust the balance) to keep oxygen saturation (measures the percentage of oxygen in the blood) equal to or above 92% on [DATE] (3 days after admission to the facility). LVN 2 stated he did not obtain and clarify Resident 41's oxygen therapy orders from Physician 1 on [DATE]. 4. Develop and implement a resident- centered care plan (a formal process that correctly identifies existing needs and recognizes resident's potential needs or risks) to address and identify interventions based upon the resident's assessment and orders, for resident's history of respiratory distress (a serious lung condition that causes low blood oxygen) with hypoxia and need for oxygen therapy, as indicated in the facility's policy and procedures on Oxygen Administration and Comprehensive Care Plans. 5. Notify the physician of any changes in the resident's respiratory condition, including changes in vital signs (blood pressure, temperature, pulse, heart rate), oxygen concentrations, or evidence of complications associated with the use of oxygen, in accordance with the facility's policy and procedures on Oxygen Administration. 6. Ensure LVN 1 initiated immediate action, and performed cardiopulmonary resuscitation (CPR- involves chest compressions and mouth to mouth [rescue breaths with the aim to circulate blood and oxygen in the body), after finding Resident 41, unresponsive and not breathing, on [DATE], as indicated in the facility's policy and procedure titled Medical Emergency Response and Resident 41's Portable Orders for Life Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency). These failures resulted in the delay in assessment, care, and physician notification of Resident 41's respiratory condition when the resident verbalized her concern to LVN 1 that the resident felt her oxygen tank being empty and not feeling well, on [DATE] around 5:30 AM. As a result, Resident 41 was transferred to the General Acute Care Hospital (GACH) 1 Emergency Department (ED) on [DATE]. The GACH 1 ED report indicated Resident 41 was brought in by ambulance from the facility and found pulseless and not responsive. The GACH 1 ED report indicated 911 paramedics were called by the facility at approximately 5:52 AM. Resident 41 passed away at GACH 1 on [DATE] at 6:50 AM with a diagnosis of cardiac arrest. On [DATE] at 11:44 AM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to conduct respiratory assessment, identify interventions, and services for Resident 41, who had diagnoses of respiratory failure with hypoxia, pneumonia and COPD, and who was receiving continuous oxygen therapy. The survey team notified the Director of Nursing (DON), the Administrator (ADM) and the Regional Consultant (RC) of the IJ situation due to the facility's failure to ensure Resident 41 received respiratory assessment, treatments, and services when Resident 41 verbalized to LVN 1 the resident was not feeling well and asked for her oxygen tank to be replaced because the resident felt it was empty. On [DATE] at 6:13 PM, while onsite at the facility, the survey team removed the IJ, in the presence of the ADM, and the DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE] at 6:03 PM, included the following: 1. Administrator notified the facility Medical Director of Immediate Jeopardy incident on [DATE]. 2. On [DATE], licensed nurses identified was in-serviced by the DON regarding Physician notification when there is a change of condition focusing on respiratory system, respiratory assessment, and management of disease such as COPD, respiratory failure with hypoxia and oxygen therapy. Identified license nurse was suspended on [DATE] pending investigation. 3. On [DATE], the DON and Registered Nurse (RN) Supervisor reviewed the 13 residents with oxygen therapy orders, COPD diagnosis and respiratory distress with hypoxia for signs of respiratory distress or change of condition. 4. On [DATE], the Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) nurse reviewed in-house residents with diagnosis of COPD and respiratory failure with hypoxia for the implementation of resident centered care plans. 5. Starting [DATE], licensed nurses will check that residents are receiving the appropriate oxygen therapy as ordered at the start of their shift. When placing residents from oxygen concentrators to oxygen tanks, licensed nurses will verify the oxygen order to ensure that the liters per minute being administered matches the order. Cross reference F678 Findings: During review of GACH 1 Pulmonology (a branch of medicine that specializes in diagnosing and treating diseases of the lungs and other parts of the respiratory system) Progress Notes dated [DATE] timed at 12:14 PM, indicated Resident 41 was previously admitted to GACH 1 on [DATE], with diagnoses including acute on chronic systolic heart failure (one or two main types of heart failure), severe aortic stenosis, end stage renal disease (final, permanent stage of kidney disease) on dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to), dyspnea (shortness of breath), and hypoxia. The GACH 1 Pulmonology Progress Notes indicated Resident 41 felt weak and tired and was receiving 4 Liters (L, unit of measure) of Oxygen via Nasal Cannula (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils to deliver supplemental oxygen). The progress note indicated Resident 41's chest x-ray results indicated small bilateral pleural effusions (buildup of excess fluid between the layers of the pleura [part of the respiratory tract that cushions the lung and reduces any friction that may develop between the lung, rib cage, chest cavity] outside the lungs). A review of GACH 1 Cardiology Progress Notes dated [DATE] timed at 8:21 AM, indicated Resident 41 was on 4 liters per minute of oxygen therapy during that time ([DATE]) and Resident 41 stated that breathing was stable at this level of oxygen. A review of Resident 41's Admission Record indicated the facility originally admitted the resident on [DATE], and was readmitted back to the facility on [DATE], with diagnoses that included acute on chronic systolic heart failure, acute respiratory failure with hypoxia, and COPD. A review of Resident 41's Clinical admitted d [DATE] timed at 3:18 PM, indicated Resident 41 was on Oxygen at 3 liters per minute. The Clinical Admission indicated Resident 41's pulse oximetry (pulse oximetry is a painless, noninvasive method of measuring the saturation of oxygen in a person's blood) reading during admission to the facility was at 95% (a resting oxygen saturation level between 95% and 100% is regarded as normal for a healthy person) using oxygen administered via nasal cannula. The Clinical Admission indicated Resident 41's discharge goal was to return home. A review of Resident 41's History and Physical (H&P) dated [DATE], indicated the resident had the capacity to understand and make decisions. The H&P indicated one of Resident 41's diagnosis included pneumonia. A review of Resident 41's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment reference date of [DATE], indicated the resident had moderate cognitive (thought process) impairment. The MDS indicated Resident 41 required partial/moderate assistance (helper does less than half the effort) in walking up to 10 feet. The MDS indicated Resident 41 required supervision (helper provides verbal cues) on task such as oral hygiene, upper body dressing, sit to stand and bed mobility. The MDS indicated Resident 41 required partial/moderate assistance with toileting, shower and lower body dressing. A review of Resident 41's POLST signed and dated by Physician 1 on [DATE], indicated to attempt and perform CPR, if the resident was found with no pulse and is not breathing. A review of Resident 41's physician's order dated [DATE], authored by LVN 2, indicated to administer oxygen via NC at 3 liters (unit of measurement) per minute, may titrate oxygen to maintain oxygen saturation greater or equal to 92% every shift for shortness of breath. A review of Resident 41's care plan dated [DATE], indicated the resident was at risk for rehospitalization due to COPD . and hypertension (high blood pressure). The care plan interventions included to notify the physician if resident presents with signs and symptoms of respiratory distress . such as adventitious lung sounds (any sounds that occur in addition to normal breathing sounds), shortness of breath . A review of Resident 41's care plan dated [DATE], indicated the resident has pneumonia. The care plan interventions included to auscultate (listening to the sounds of the body during a physical examination) lung sounds, listen for crackles and diminished breath sounds due to atelectasis (the collapse of part or all of a lung, is caused by a blockage of the air passages). During the review of Resident 41's Progress Notes dated [DATE] timed at 5:30 AM, authored by Licensed Vocational Nurse (LVN) 1 indicated Resident 41 approached LVN 1 at the Nursing Station asking for another oxygen tank (a container with oxygen inside it, used for helping people to breathe). The Progress Notes indicated LVN 1 advised Resident 41 that Resident 41 still had half a tank left and will change (the oxygen tank) when it is lower. The Progress Notes indicated Resident 41 understood and just waited outside Nursing Station until staff finished with rounds. During the same review of Resident 41's Progress Notes dated [DATE] timed at 5:30 AM, the Notes indicated Noted Resident 41's oxygen tank outside Nursing Station. The Progress Notes indicated LVN 1 went inside Resident 41's room to ask if the resident still wanted her oxygen tank. The Progress Notes indicated Resident 41 was found unresponsive in bed with eyes slightly open, no pulse, no rise of chest, [Resident 41] was still warm, blood sugar 301, unable to get blood pressure. The Progress Notes indicated 911 [paramedics] was called while staff (unknown) did CPR The Progress Notes indicated Resident 41 was transferred to the GACH on [DATE] at 6:25 AM, and family and Physician 1 was notified. A review of Resident 41's Change of Condition (COC) note dated [DATE] timed at 6:23 AM, indicated Found [Resident 41] unresponsive lying in bed with eyes slightly open. Called code blue (a declaration of or a state of medical emergency and call for medical personnel and equipment to attempt to resuscitate a patient) and started CPR. 911 was called and noted patient was full code, did CPR for 10 minutes before paramedics arrived and took over patient care. No pulse, and after 25 minutes of CPR and resident was transferred to GACH. The COC indicated Resident 41's oxygen saturation was 65% and blood sugar of 301. The COC indicated Physician 1 was notified on [DATE] at 6:42 AM. A review of Resident 41's Medication Administration from [DATE] to [DATE] indicated an order to administer ipatropium-albuterol (made up of two different bronchodilators (a drug that relaxes and opens the airways, used to treat COPD) inhalation solution 0.5 - 2.5 milligrams (mg) / 3 milliliters (ml). Inhale 3 ml orally, every 6 hours as needed for shortness of breath. The MAR indicated X marks from [DATE] to [DATE], indicating no inhalation solution was signed out and provided to Resident 41. A review of Resident 41's GACH 1 Emergency Department (ED) Reports dated [DATE] timed at 7:14 PM, indicated Resident 41 was brought in by ambulance from the facility and found pulseless and not responsive. The GACH 1 ED report indicated the paramedics were called by the facility at approximately 5:52 AM and Resident 41 was last seen by facility staff (LVN 1) in her usual state of health 10 minutes prior. The GACH 1 ED report indicated paramedics were unable to obtain any return of spontaneous circulation in the field and were directed by base station to be transported. The report indicated Resident 41 arrived to GACH 1 ED with CPR in progress and Advanced Cardiac Life Support (ACLS, a set of clinical guidelines for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, using advanced medical procedures, medications, and techniques) in excess of 50 minutes, an additional dose of epinephrine (primary drug used in cardiac arrest, to increase cardiac output), sodium bicarbonate (medication used to treat metabolic acidosis [when acids build up in your body]), and calcium gluconate (medication used to manage cardiac arrest) were administered. The GACH 1 ED report indicated chest compressions continued with assisted ventilation (the movement of gas into and out of the lung by an external source connected directly to the patient) through endotracheal tube (a tube placed between the vocal cords through the airway to provide oxygen and inhaled gases to the lungs). The report indicated Resident 41 remained pulseless without cardiac activity on ultrasound (an imaging test that uses sound waves to make pictures of organs) and died on [DATE] at 6:50 AM. During an interview and concurrent record review of Resident 41's Clinical Admission notes and Physician Orders with the DON on [DATE] at 5:33 PM, the DON stated Resident 41 was admitted to the facility on [DATE] with oxygen being administered via NC. The DON stated Resident 41's Oxygen therapy order was initiated on [DATE]. The DON stated after reviewing all of Resident 41's care plans developed from [DATE] to [DATE], the resident's care plans did not indicate care plans were developed for Resident 41's use of oxygen, history of hypoxia, and shortness of breath. During the same concurrent interview and record review of Resident 41's COC notes, Progress Notes, vital signs records, and assessment notes from [DATE] to [DATE] with the DON, on [DATE] at 5:33 PM, the DON stated there was no documented evidence found indicating a respiratory assessment and treatment was performed on [DATE], by LVN 1, when Resident 41 verbalized to LVN 1 that Resident 41 was not feeling well and felt her oxygen tank was empty. During a telephone interview on [DATE] at 6:04 PM, with Physician 1, Physician 1 stated Resident 41 was on continuous oxygen therapy due to her medical condition of cancer, systolic heart failure and pneumonia. Physician 1 stated he would expect the licensed nurse assigned to care for Resident 41, to conduct a respiratory assessment of Resident 41 when she verbalized to LVN 1 on [DATE] that Resident 41 felt like her oxygen tank was empty, because Resident 41 might not be feeling well. Physician 1 stated that LVN 1 should have checked Resident 41's vital signs and respiratory assessment because of Resident 41's respiratory diagnoses (pneumonia, COPD, hypoxia) and notified Physician 1 immediately. Physician 1 stated he was notified by LVN 1 on [DATE] after Resident 41 was transferred to GACH 1. Physician 1 stated he could not recall the exact details of LVN 1's telephone notification on [DATE]. During a telephone interview with LVN 1 on 5 /,d+[DATE] at 6:28 PM, LVN 1 stated on [DATE], at around 5:30 AM, while LVN 1 was putting away medications, Resident 41 came up to LVN 1 and asked if LVN 1 could change her portable oxygen tank because Resident 41 believed her oxygen tank was empty. LVN 1 stated he observed Resident 41's oxygen tank gauge (a medical device designed to display the pressure level in an oxygen tank) and saw that the oxygen tank gauge was still half full. LVN 1 stated he checked Resident 41's oxygen saturation and vital signs but could not recall and did not document the oxygen saturation level and vital signs results on [DATE]. LVN 1 stated that he did not do any other assessments (respiratory) or treatment to Resident 41, because he needed to finish his medication pass on [DATE] and go home. LVN 1 stated he left Resident 41 sitting in a chair by the Nursing Station and preceded to finish putting away medications in Medication Cart 1. LVN 1 stated after leaving Resident 41 in the Nursing Station, he continued to administer medications to other residents in seven rooms before going to another Nursing Station by Medication Cart 2, to retrieve Resident 41's medications which were kept in Medication Cart 2. LVN 1 stated as he was approaching Medication Cart 2, he observed Resident 41 was not at the Nursing Station anymore but Resident 41's oxygen tank was left by the Nursing Station. LVN 1 stated he proceeded to go to Medication Cart 2 to remove Resident 41's routine medications before he decided to go to Resident 41's room. During the same telephone interview, on 5 /,d+[DATE] at 6:28 PM, LVN 1 stated as he entered Resident 41's room on [DATE], LVN 1 observed Resident 41 lying in bed and not breathing. LVN 1 stated he went outside Resident 41's room to call for help and return to Resident 41's bedside. LVN 1 stated when Certified Nurse Assistant (CNA) 1 came to Resident 41's room, LVN 1 instructed CNA 1 to wait in the room, until he was able to review Resident 41's code status in the electronic medical records. LVN 1 stated he went outside Resident 41's room back to the Nursing Station and Medication Cart 2. LVN 1 stated he logged into the electronic medical records, but the electronic records did not indicate Resident 41's code status. LVN 1 stated he had to go to Nursing Station 1 to get Resident 41's paper chart to look for the POLST. LVN 1 stated Resident 41's POLST indicated Resident 41 was a full code (full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and is not breathing). LVN 1 stated after reviewing Resident 41's paper chart, LVN 1 returned to Resident 41's room to initiate CPR. LVN 1 stated that after completing about two full sets (consisting of 2 rescue breaths and 15 chest compressions) of CPR, LVN 1 instructed CNA 1 and CNA 2 to take over CPR, as he went outside Resident 41's room to the Nursing Station to call 911. LVN 1 stated he was the only licensed nurse during the shift (11 PM to 7 AM) for the entire facility on [DATE]. During an interview on [DATE] at 7:31 PM, with CNA 1, CNA 1 stated that in the morning of [DATE], between 5:30 AM to 6 AM, CNA 1 stated she was sitting by the Nursing Station and recalled observing Resident 41 walking up to the Nursing Station and verbalized not feeling well to LVN 1. CNA 1 stated seeing LVN 1 leaving the Nursing Station after talking to Resident 41 and LVN 1 continued passing medications on his assigned residents. CNA 1 stated that on [DATE], she heard LVN 1 shouting for help. CNA 1 stated she went to Resident 41's room, where she found LVN 1 standing right by the resident. CNA 1 stated LVN 1 instructed her to wait and remain at Resident 41's bedside, while LVN 1 went out to check Resident 41's code status. During the same interview on [DATE] at 7:31 PM, with CNA 1, CNA 1 stated LVN 1 returned to Resident 41's bedside and initiated chest compressions while CNA 2 used the Ambu bag (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing) to give Resident 41 two rescue breaths. CNA 1 stated LVN 1 instructed to check for Resident 41's vital signs. CNA 1 stated she remembered the pulse oximeter (an electronic device that measures the saturation of oxygen in the blood) not reading and the blood pressure machine showing an error result. CNA 1 stated LVN 1 instructed CNA 1 to take over the chest compressions while LVN 1 went back to the Nursing Station to call 911. CNA 1 stated she recalled LVN 1 returning to Resident 41's room and continued to perform CPR to Resident 41, until the paramedics arrived and took over the CPR. During a telephone interview on [DATE] at 7:49 PM with LVN 2, LVN 2 stated that on [DATE], she noted in Resident 41's previous ([DATE] to [DATE]) GACH 1 records that the resident should be on oxygen therapy. LVN 2 stated that on [DATE], LVN 2 entered the physician order for oxygen at 3 liters per minute via NC in Resident 41's electronic records but did not inform or verify the oxygen orders with Physican 1. LVN 1 stated she assumed that the admitting licensed nurse just forgot to put in the oxygen orders for Resident 41 upon admission to the facility on [DATE]. During another interview on [DATE] at 1:56 PM with LVN 1, LVN 1 stated he saw CNA 1 on [DATE] upon finding Resident 41 unresponsive and not breathing. LVN 1 stated he instructed CNA 1 and stated, don't start anything because LVN 1 needed to find out Resident 41's code status first. LVN 1 stated he went to the medication cart and logged into the electronic records but was not able to find Resident 41's code status. LVN 1 stated he went to the Nursing Station and looked through Resident 41's paper chart to look for the resident's code status. LVN 1 stated he found Resident 41's POLST that indicated Resident 41 was a Full Code (attempt to provide CPR). LVN 1 stated when he learned of Resident 41's code status, he went back to the resident's room and initiated CPR. LVN 1 stated that on [DATE], everyone was standing by for CPR because we did not know the code status yet. During a concurrent interview and record review of the facility's policy and procedure (P&P) titled, Medical Emergency Response, revised on [DATE], on [DATE] at 6:11 PM, the DON stated the staff who first witnessed a medical emergency, such as finding an unresponsive and pulseless resident, should initiate immediate action, including CPR and calling for assistance. The DON stated the P&P indicated the CPR will only be stopped if a Do Not Resuscitate (DNR, instruction to not perform CPR on a resident) order is found to be in place in the resident's record. The DON stated staff should initiate CPR then have someone else verify the resident's code status. The DON stated delaying the CPR could result in a resident's death. During a telephone interview on [DATE] at 2:06 PM with Resident 41's Family Member (FM 1), FM 1 stated the resident was in good spirits on [DATE]. FM 1 stated Resident 41 was planning on going home on [DATE]. FM 1 stated she talked to Resident 41 on [DATE], then on [DATE] at around 7 AM, she was informed by GACH 1 physician that Resident 41 passed away. During a telephone interview on [DATE] at 6:15 PM with CNA 2, CNA 2 stated she saw Resident 41 near the nursing station on [DATE] at around 5:30 AM. CNA 2 stated she went to another resident's room and sometime later, she heard LVN 1 call for code blue. CNA 2 stated as she was going into Resident 41's room, LVN 1 was coming of the room to check for the code status. CNA 2 stated that CNA 2, CNA 1 and CNA 4 did not start CPR as instructed by LVN 1. CNA 2 stated that when LVN 1 came back to the room, that was when LVN 1 started CPR. CNA 2 stated she does not remember how long it took LVN 1 to find Resident 41's code status in the resident's records. A review of the facility's policy and procedure titled Notification of Changes, with a revision date of [DATE], indicated the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident representative when there is a change of condition requiring notification. A review of the policy and procedure titled Oxygen Administration dated [DATE] indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy indicated the resident's care plan shall identify interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: the type of oxygen delivery system, when to administer, such as continuous or intermittent and /or when to discontinue, equipment setting for the prescribed flow rates, monitoring of oxygen saturation levels and/or vital signs as ordered, and monitoring for complications associated with the use of oxygen. The policy indicated staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. A review of the facility's policy and procedure titled Comprehensive Care Plans, dated [DATE], indicated the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. A review of the facility's policy and procedure titled, Medical Emergency Response, revised on [DATE], indicated The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid . The policy indicated, a nurse will assess the situation and determine the severity of the emergency, stay with the resident, designate a staff member to announce a Code Blue, if necessary, and call 911 as needed. The policy further indicated, CPR will continue unless there is a DNR (do not resuscitate) order in place .

Based on observation, interviews, and record review, the facility failed to ensure a resident receiving enteral feeding (delivery of nutrients through a feeding tube directly into the stomach, duodenum [first part of small intestine], or jejunum [middle part of the small intestine]) received appropriate care and services, according to current standards of practice in maintaining and verifying tube placement to prevent tube feeding complications, to the extent possible, for two of two sampled residents (Resident 1 and 2) including: 1. For Resident 1, failure to assess and identify the swelling in Resident 1's left lower abdominal (stomach) area as a change of condition during the assessment of the gastrostomy tube (GT- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) site by the licensed nurses every shift (7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM shift) from [DATE] to [DATE]. 2. For Resident 1, failure to implement interventions to address Resident 1's redness and swollen left lower abdominal area which included monitoring the skin and GT site for irritation, infection such as redness and swelling, and notifying the physician. 3. For Resident 2, failure to ensure that Licensed Nurse (LVN) 4 verified GT placement and checked gastric residual volume (GRV, the amount of liquid drained from a stomach following administration of enteral feed) during an observation of Resident 2's GT feeding on [DATE] at 12:55 PM, prior to starting the tube feeding via a continuous feeding (is the uninterrupted administration of enteral formula over extended periods of time) pump. 4. For Residents 1 and 2, failure to implement an updated policy and procedure titled Confirming Placement of Feeding Tubes, revised in [DATE], with current interventions according to the professional standards of practice for checking and maintain GT placement and assessments of Resident 1 during feedings. The facility did not update the policy and procedure for confirming placement of feeding tubes since [DATE] up to the present ([AGE] years), to ensure the safe practice of checking and maintain GT placement and assessments. As a result, Resident 1 was transferred to the general acute care hospital (GACH) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 received multiple antibiotics (medicines that fight bacterial infections in people), undergone surgical procedure for g-tube dislodgment and [CONDITION(S)], and to remove the large amount of tube feeds found in the abdominal wall. Resident 1 was placed in the GACH Intensive Care Unit (ICU; a unit in the acute hospital in which patients who are dangerously ill) for 25 days. On [DATE], Resident 1 was admitted to a long-term acute care (LTAC; a specialty care hospital designed for patients with serious medical problems that required intense, special treatment) hospital Intensive Care Unit (ICU, a unit that provide intensive medical care) from GACH and died at the LTAC on [DATE] with final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Coli., bacteria found in the environment, foods, and intestines of people and animals that can cause infection), aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs that can cause severe complications), acute respiratory failure, abdominal wall [CONDITION(S)], and [CONDITION(S)] infected with E. Coli. For Resident 2, this deficient practice had the potential to cause GT complications to Resident 2 such as tube dislodgement causing aspiration pneumonia, tube leakage outside the stomach. Findings: 1. A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Non-Pressure Sore Skin Problem Report, dated [DATE], indicated Resident 1 had a GT site located at the left abdomen (stomach area). The Non-Pressure Sore Skin Problem Report indicated monitoring (on the GT site at the abdomen) was conducted from [DATE] up to on [DATE] and indicated no significant changes and no signs and symptoms of infection were noted. A review of Resident 1's care plan dated [DATE], indicated the resident had concerns/problems that included altered nutrition, on GT feeding related to dysphagia (difficulty swallowing), risk for aspiration related to the presence of tube feeding and dysphagia, and risk for GT site infection. The care plan goals indicated Resident 1 would be free from signs and symptoms of aspiration daily and would be free from signs and symptoms of GT site infection daily. The care plan interventions included monitoring tolerance to feeding like presence of abdominal distention (bloating or swelling) and notify physician, monitoring and reporting signs and symptoms of redness, swelling, and pain to physician promptly. A review of Resident 1's care plan dated [DATE], indicated the resident had alteration in skin integrity with a goal that included wounds not developing secondary infection (an infection that occurs during or after treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] ., and monitoring skin and report red/discolored skin. A review of Resident 1's Admission Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated [DATE], indicated Resident 1 was usually understood and usually understand others. The MDS indicated Resident 1 was severely impaired of cognition (thought process). The MDS indicated Resident 1 was totally dependent and required one-person physical assistance for bed mobility, dressing, and eating. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident 1 received Diabetisource AD (a GT feeding formula) at 60 millimeters (ml, a volume measurement) for 20 hours via a tube feeding pump from [DATE] to [DATE]. 2. Resident 1's GT feeding order to decrease the tube feeding rate of Diabeticsource AD from 60 ml to 45 ml for 20 hours via a tube feeding pump on [DATE] during the 7 AM to 3 PM shift. 3. Resident 1's GT residuals (volume of fluid remaining in the stomach at a point of time during the enteral nutrition feeding) were checked every shift (eight hours). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Resident 1's GT placement were checked every shift, from [DATE] to [DATE]. 5. Resident 1 received 2.5 ml of [MEDICATION(S)] 10 mg/5 ml routinely, daily via GT during the 7 AM to 3 PM shift, 30 minutes before treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 had pressure injuries to the sacrococcyx (tailbone), right hip and left hip. A review of Resident 1's [DATE] to [DATE] Nurses Notes indicated the following information: a. On [DATE] timed at 10:45 AM, indicated Resident 1's vital signs (a person's signs of life; specifically : the pulse rate, respiratory rate, body temperature, and blood pressure) were: temperature 97.0 (in older adults, the average body temperature is lower than 98.6) degrees Fahrenheit ([°F] a measure of temperature where 30 degrees is very cold and 100 degrees is very hot), heart rate was 110 beats per minute (normal range for adults age 18 and over is 60 - 100 beats per minute), respirations was 19 breaths per minutes, blood pressure (normal blood pressure in adults is below ,d+[DATE]) was ,d+[DATE] millimeter per mercury (mm/Hg, unit of measurement for blood pressures), and a pain level 0 out of 10 (pain scale of 0 means no pain and 10 is severe/worst pain). The Nurses Notes indicated Resident 1 did not have any cardiac or respiratory distress, tolerated the GT feeding and the GT site did not have signs and symptoms of infection. b. On [DATE] timed at 11:10 AM, indicated Resident 1's vital signs were: temperature 97.5 °F, heart rate was 108, respiration was 17, blood pressure was ,d+[DATE] mm/Hg, and pain level of 0 out of 10. The Nurses Notes indicated Resident 1 did not have any cardiac or respiratory distress, tolerated the GT feeding and the GT site was dry and intact. c. On [DATE] timed at 1 PM, indicated LVN 7 noted Resident 1 with minimal cough and received a breathing treatment. The Nurses Notes indicated Resident 1's vital signs were: blood pressure of ,d+[DATE] mm/Hg, heart rate was 70, respiration was 19, temperature 98.1, pain level of 0 out of 10, and the oxygen saturation was 98% (indicates that amount of oxygen traveling through your body. Normal oxygen saturation is usually between 95% and 100%). d. On [DATE] timed at 6:45 PM, indicated RN 1 wrote, Physician 1 evaluated Resident 1 and was notified about chest x-ray results. The Nurses Notes indicated Physician 1 ordered to decrease Resident 1's GT feeding rate to 45 ml per hour (from 60 ml per hour). e. On [DATE] timed at 3 AM, indicated LVN 3 wrote, Resident 1 was on monitoring for congestion. Resident 1's breathing was even, unlabored, did not have shortness of breath, and was not in any acute distress. The Nurses Notes indicated Resident 1's vital signs were: blood pressure was ,d+[DATE] mm/Hg, heart rate was 87, temperature 97.8, and respiration was 19. f. On [DATE] timed at 8:30 AM, indicated Director of Nurses (DON) 1 wrote received new orders (CBC [Complete Blood Count] a group of tests that evaluate that cells that circulate in the blood) stat (immediately), CMP ([Comprehensive Metabolic Panel] blood test that measures your sugar level, electrolyte [essential minerals] and fluid balance, kidney function, and liver function) stat. UA ([urinalysis] test of urine to diagnose or monitor several diseases and conditions) from Physician 1 and carried it out. g. On [DATE] timed at 1:40 PM, indicated LVN 7 wrote, Resident 1's breathing was Even, unlabored, did not have shortness of breath, and was not in any acute distress. The Nurses Notes indicated Resident 1 did not have a fever or was not congested. The Nurses Notes indicated Resident 1's GT feeding was tolerated well and was flushed with water as per Physician 1's orders. The Nurses Notes indicated Resident 1's vital signs were: blood pressure was ,d+[DATE] mm/Hg, heart rate was 105 beats per minute, temperature was 99.8° F, the oxygen saturation was 92%, and pain level 0 out of 10. h. On [DATE] timed at 4 PM, indicated that during nursing rounds Registered Nurse (RN) 1 noticed Resident 1's breathing fast and appeared to look weak. Resident 1's vital signs were: blood pressure ,d+[DATE] mm/Hg, heart rate was 143, temperature of 99.9 °F, respirations was 30, and oxygen saturation was 94%. The Nurses Notes indicated Resident 1 was able to respond, but in a very soft voice and chest congestion was noted. The Nurses Notes indicated Resident 1's GT feeding was held, and Physician 1 was notified and ordered to transfer Resident 1 to the GACH. The Nurses Notes indicated Resident 1's family member (FM 1) was at bedside and RN 1 called paramedics via [DATE] (emergency services). i. On [DATE] timed at 4:12 PM, the Nurses Notes indicated paramedics arrived at the facility and at 4:20 PM, Resident 1 was transferred to GACH. A review of Resident 1's OT (Occupational Therapy) Daily Treatment Note, dated [DATE], indicated Resident 1 verbalized to Occupational Therapist Assistant (OTA) 1 that he did not feel well and declined to transfer out of bed for therapy. The OT Daily Treatment Note indicated; OTA 1 notified the nursing staff (unknown). A review of Resident 1's Final Chest X-ray result dated [DATE] for congestion indicated an enlarged heart and congestive heart failure. The x-ray result indicated there was a small left pleural effusion (an unusual amount of fluid in the lung) and a clinical correlation (a medical process physician use to make a diagnosis) follow up was suggested. A review of Physician 1's Progress Notes dated [DATE] timed at 6:45 PM indicated a pre-typed progress notes indicated AVSS (abbreviation for Afebrile, Vital Signs Stable). The Progress Note indicated a handwritten note indicating the tube feeding was decreased to 45 ml per hour for 20 hours (from 60 ml per hour). The Progress Note indicated Resident 1's oral diet was between 40% to 60%. The Progress Note indicated under gastrointestinal (GI) physical assessment indicated soft, nondistended, no hepatosplenomegaly (enlargement of the liver and spleen), and no hernia (an obvious swelling beneath the skin of the abdomen or the groin), no masses (a lump in the body that can be caused by the abnormal growth of cells). A review of Resident 1's CNA Skin Detail Report (per facility policy and procedure Skin Inspection [Form C]) for ,d+[DATE] indicated CNA 3 wrote there were no new skin problems observed from [DATE] timed at 2:09 AM. The Report indicated that CNA 4 wrote there were no new skin problems observed on ,d+[DATE] 19 timed at 11:22 AM. A review of the Ambulance Report - Prehospital Care report Summary dated [DATE] indicated the local Fire Department emergency services arrived at the facility on [DATE] at 4:12 PM and left the facility with Resident 1 at 4:27 PM. The Ambulance Report indicated the dispatch reason was hypotensive (relating to or suffering from abnormally low blood pressure) of less than 90 mm/Hg of systolic blood pressure (the top number indicated the pressure when your heart pushes blood out) and chief complaint of congestion. The ambulance report indicated rhonchi (type of lung sounds often caused by secretions in larger airways or obstructions and can be heard in patients with pneumonia) was heard to the left and right lungs. The ambulance report indicated Resident 1's vital signs timed at 4:21 PM were ,d+[DATE] mm/Hg, pulse of 168, and echocardiogram (a noninvasive [the skin is not pierced] procedure used to assess the heart's function and structures) rhythm of [CONDITION(S)]/flutter (abnormal heart rhythm). A review of the GACH's Emergency Department (ED) Reports dated [DATE] timed at 4:42 PM indicated Resident 1 was sent from a nursing home for worsening [CONDITION(S)] (very fast heart rate), fever, and cough for three days. The ED report's Physical Examination indicated findings of [CONDITION(S)] (superficial reddening of the skin, usually in patches, because of injury or irritation) to the left lower abdominal wall with induration (an area of hardness in the skin) extending into the groin (the area between the abdomen and the thigh) and scrotum (pouch of skin located behind the penis). Resident 1 was lethargic (sleepy or fatigued) but arousable. The ED report indicated medical interventions such as fluid boluses (a defined fluid administered over a defined time) and antibiotics (a medication that fight bacterial infection) were started for Resident 1 and (a surgeon a medical specialist who performs surgery) was consulted for possible [CONDITION(S)]. The Impression and Plan indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The report indicated Resident 1's condition was critical, and Resident 1 was admitted to the ICU. A review of Resident 1's GACH Computed Tomography ([CT] internal images of the body) Abdomen/Pelvis (lower part of the trunk, between the abdomen and the thigh) with contrast (a special dye to highlight areas of the body being examined) report, dated [DATE] and timed at 5:55 pm, indicated a displaced percutaneous (through the skin) g-tube in the left upper abdominal wall adjacent to a large collection of abscess (a localized collection of pus surrounded by inflamed tissue) involving the left abdominal wall with extension into the left pelvic wall (part of the body between the hips) and the left scrotal (a sac of skin that hangs below the penis) region. The CT indicated there was consolidation pneumonia (the lungs filled with liquid instead of air) or pattern of the right lower lobe. A review of Resident 1's Surgery and Procedure Report, dated [DATE] timed at 2:17 pm, indicated Resident 1's surgery took place on [DATE] and the postoperative (after surgery) diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Report indicated Resident 1 had a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) placed in recently (date not mentioned) and was complaining of increasing abdominal pain. The Report indicated the CT showed dislodgment of the g-tube with a large collection of tube feeds (a liquid form of nourishment) in the subcutaneous (under the skin) tissue. The Surgery and Procedure Report indicated large amounts of tube feeds were removed from the external oblique fascia (one of the muscles that forms the anterior [front side] abdominal wall) and the internal oblique muscle (a muscle found on the lateral side of the abdomen). The Surgery and Procedure Report indicated the internal and the posterior (back side) external oblique fascia were completely necrotic (death of cells or tissue through disease or injury). The Surgery and Procedure Report indicated some of the muscle and some of the subcutaneous tissue was debrided (removal of dead, damaged, or infected tissue). A review of Resident 1's GACH Discharge Summaries, dated [DATE], indicated Resident 1 had a prolonged course in the GACH ICU and was placed on vasopressors (group of medications that contract blood vessels and raise blood pressure) and multiple antibiotics. Resident 1 was stable to transfer to an LTAC on tube feeding via the new access GT. A review of Resident 1's LTAC Death Summary, transcribed on [DATE] indicated Resident 1 was admitted to the LTAC ICU on [DATE] and expired at the LTAC on [DATE]. Resident 1 was admitted to the LTAC ICU with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . coli, aspiration pneumonia, pneumonia due to E. coli, acute respiratory failure with [CONDITION(S)] (low oxygen levels), severe [CONDITION(S)] with septic shock (life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection), abdominal wall [CONDITION(S)], [CONDITION(S)] infected with extended-spectrum beta-lactamases ([ESBL] an enzyme found in some strains of bacteria that is resistant to several antibiotics) E. coli and enterococcus (a type of bacteria in gastrointestinal [stomach and intestines] system), abdominal abscess infected with beta-lactamase (ESBL), and unspecified [CONDITION(S)]. A review of Resident 1's Death Certificate, dated [DATE] and timed at 10:20 am, indicated the immediate cause of Resident 1's death was due to cardiopulmonary arrest (sudden loss of heart function, breathing, and consciousness). The Death Certificate indicated other significant conditions that contributed to Resident 1's death included pneumonia, [CONDITION(S)], and heart failure. During a telephone interview, on [DATE] at 8 AM, FM 2 stated that on [DATE], at around 3 PM, she followed FM 1 who was already in the facility that day ([DATE]) to visit Resident 1. FM 2 stated she noticed that Resident 1 looked lethargic. FM 2 stated that she was a practicing physician and would carry her stethoscope (a medical instrument for listening to the action of someone's heart or breathing) with her all the time. FM 2 stated she listened to Resident 1's heart rate and the resident was [CONDITION(S)] with a heart rate of around 150 to 160 beats per minute and Resident 1 was breathing really fast. FM 2 stated Resident 1's consciousness was in and out and FM 2 stated she heard Resident 1 stated Take me to the hospital. FM 2 stated she asked a licensed nurse (unknown) to check Resident 1's blood pressure and oxygen saturation. FM 2 stated that Resident 1's blood pressure was ,d+[DATE] mm/Hg and the oxygen saturation was 88 % on room air. FM 2 stated the licensed nurse (unknown) placed Resident 1 on oxygen via nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils) and the oxygen saturation went up to 92%. FM 2 stated FM 1 had to go to the facility's Nursing Station and told RN 1 to call [DATE] emergency medical services. FM 2 stated when they reached the GACH ED, Resident 1's gown was lifted and the resident's Entire left side of his body was swollen and red. It was from his torso (trunk) down to his scrotum. During a telephone interview with FM 1 on [DATE] at 11:31 AM, FM 1 stated that FM 1 was at the facility on [DATE] for approximately five hours before Resident 1 was transferred to the GACH via [DATE] emergency services. FM 1 stated that RN 1 did not do nursing rounds on [DATE] prior to Resident 1's GACH transfer. FM 1 stated RN 1 and the other licensed nurses did not go to Resident 1's room on [DATE] until they had to notify the licensed nurses to check on Resident 1 and instruct the licensed nurses to call [DATE]. FM 1 stated Resident 1's stomach area and groin were completely exposed, and the licensed nurses should have seen the swollen abdomen and groin. FM 1 stated that he always visited Resident 1 and stay at Resident 1's bedside six days a week for six hours and he had only seen a licensed nurse check Resident 1's abdomen using the stethoscope prior to starting the GT feeding or administering medications via the GT one time, when the facility staff was replacing the GT feeding. FM 1 stated It was shocking that no one noticed this (swollen abdomen) from his therapist to his nurses, or when they were bathing him. During the telephone interview with FM 1 on [DATE] at 11:31 AM, FM 1 stated he observed Resident 1's swollen abdomen when FM 2 came to the facility and examined Resident 1 on [DATE] and lifted his gown. FM 1 stated Resident 1's groin and stomach area were red and swollen and looked like there were two big 2-liter soda (soft drink) bottles inside the resident's abdomen. During a telephone interview with RN 1 on [DATE] at 11:22 AM, RN 1 stated she was no longer employed in the facility but remember being the RN supervisor in the facility when Resident 1 was transferred to GACH on [DATE]. During the telephone interview, RN 1 stated GT placement for residents in the facility were checked every start of the shift. RN 1 stated Resident 1's GT feeding via pump was on continuous infusion and the GT placement and patency were verified by the licensed nurses through auscultation (the action of listening to sounds from organs, typically with a stethoscope [an instrument used to hear and amplify the sounds produced by the internal organs), every start of the shift (7 AM, 3 PM, and 11 PM). RN 1 stated she remembered FM 1 and 2 called her attention while in the facility, on [DATE] and asked her to call [DATE] emergency services for Resident 1. RN 1 stated she remembered stopping the GT feeding of Resident 1 during that time, prior to calling [DATE], because Resident 1's breathing was faster. RN 1 could not remember the rate of Resident 1's breathing during that time. RN 1 stated she could not remember anything else, or any other assessments she performed prior to calling [DATE] because it's been a long time. During a telephone interview on [DATE] at 12:57 PM, CNA 4 stated could not remember Resident 1's condition or skin assessments on [DATE]. On [DATE], [DATE], [DATE] and [DATE], a telephone interview with Certified Nurse Assistant (CNA) 3 was attempted but CNA 3 was not available for interview. CNA 3 was assigned to Resident 1 on [DATE] for 11 PM- 7 AM shift. On [DATE], [DATE], [DATE] and [DATE], a telephone interview with LVN 3 was attempted but LVN 3 was not available for interview. LVN 3 was assigned to Resident 1 on [DATE] for 11 PM- 7 AM shift. During a telephone interview with LVN 7 on [DATE] at 1:21 PM, LVN 7 stated she remembered taking care of Resident 1 on GT feeding. LVN 7 stated when she administered Resident 1's GT feeding, she would verify GT placement prior to administering GT feeding. LVN 7 stated she used a stethoscope and flushed the GT with air, to listen to a gurgling sound or swooshing sound. LVN 7 stated she did not do anything else to check for GT placement. LVN 7 stated if something was wrong with the GT, it can be verified it with an x-ray. When asked if licensed nurses perform abdominal assessments for residents on GT feeding, LVN 7 stated You can also check the abdomen if it is hard . As long as there is a sound, it should be fine. During a concurrent interview and review of Resident 1's Nurses Notes from [DATE] to [DATE], on [DATE] at 3:30 PM, LVN 2 stated (LVN 2 was assigned to Resident 1 on [DATE] for 3 PM to 11 PM shift) he could not find documented evidence of any assessments or notes he wrote on [DATE] during the 3 PM to 11 PM shift. LVN 2 stated it was RN 1 who documented during the 3 PM to 11 PM shift. LVN 2 stated he could not recall that day, on [DATE], that Resident 1 was seen by Physician 1. LVN 2 stated he could not find documented and measured vital signs on the Nurses Note and Physician 1's Progress Notes dated [DATE] at 6:45 PM during the 3 PM to 11 PM shift. LVN 2 stated Physician 1 indicated AVSS in his Progress Notes on [DATE] at 6:45 PM indicating the resident was Afebrile, Vital Signs Stable. LVN 2 stated the Nurses Notes indicated Resident 1's GT Dressing site was dry and intact. LVN 2 stated that licensed nurses would check if the GT site dressing was soaked with drainage and would look on top of the GT dressing. LVN 2 stated licensed nurses would only document if they have observed any abnormalities in the abdominal area. LVN 2 stated he could not find documented evidence that the licensed nurses documented on the Nurses Notes and included an assessment of Resident 1's entire abdominal area when the GT dressing was checked every shift. During a telephone interview, on [DATE] at 1:27 PM, Physician 2 (GACH Surgeon) stated he was the general surgeon (a surgical specialty that focuses on abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, etc.) at the GACH and operated on Resident 1 on [DATE]. Physician 2 stated he examined Resident 1 in the GACH ED on [DATE] and Resident 1 was in a lot of pain, the abdomen was somewhat distended, tender, and had induration that clearly indicated something was not right. Physician 2 stated the CT of the abdomen results on [DATE] was a complication of the GT feeding because all the tube feeds went lateral (toward the side of the abdomen). Physician 2 stated, You thought it would have gone medial (middle) and lateral (side), it just went lateral. Physician 2 stated Resident 1 had to go to the operating room right away on [DATE] because the tube feeds are hyperosmolar (high concentration of a substance), a lot of sugar. It is going to kill all the tissue around it and draw all the fluid into it as well. Physician 2 stated he took over two liters (a unit of volume or measurement) of tube feeds from Resident 1. During the telephone interview, on [DATE] at 1:27 PM, Physician 2 stated This has clearly been going on for a few days. That is the reason why this caused the necrosis, [CONDITION(S)] and that was why he (Resident 1) was in so much pain. Physician 2 stated Resident 1 would have died in a few hours on [DATE], if he had not performed the emergency surgery. Physician 2 stated This was a delayed diagnosis. I would estimate this was going on for a couple of days. When Physician 2 was asked his expert opinion on how the tube feeds ended up in Resident 1's abdominal wall, Physician 2 stated Obviously, the feeding tube was pulled out to some degree . Usually they (GT) pops out completely .He (Resident 1) was confused . He was demented (driven to behave irrationally due to anger, distress). Physician 2 stated that Physician 1's physical examination (on [DATE] at 6:45 PM) was not thorough, he (Resident 1) would have been in pain. Physician 2 stated the chest x-ray performed to Resident 1 on [DATE] at the facility had nothing to do with Resident 1's issues with the tube feeding. During another telephone interview, on the same day, at [DATE] at 2:32 PM, Physician 2 stated that nurses required some discipline to make sure they see the resident (Resident 1). Physician 2 stated that Resident 1 must have been complaining of severe abdominal pain and Resident 1 was grimacing like crazy when he saw resident in the ED on [DATE]. Physician 2 stated that any amount of tube feed leaking into the muscles would have caused pain immediately. Physician 2 stated that Resident 1's condition had been going on for a couple of days and there was a lot of opportunity for the facility staff to notice Resident 1. Physician 2 stated that the [CONDITION(S)] caused Resident 1's continued decline that led to his death. Physician 2 stated The mortality (the state of being subjected to death) of [CONDITION(S)] is relatively high. During a telephone interview, on [DATE] at 12:16 PM, DON 2 stated the facility's licensed nurses were expected to monitor and care for all residents on GT feeding residing in the facility by checking the GT placement every shift by auscultation, using a stethoscope, check the GT dressing if dry or leaking. DON 2 stated the facility's licensed nurses performs head to toe skin and body assessment weekly for all residents, including residents on GT feeding, and document their findings on the Weekly Summary. DON 2 stated the CNAs were responsible in reporting any skin issues found during body checks conducted by CNAs on resident shower days (once a week) and every morning and evening care daily. DON 2 stated the CNA would have to look at the skin and report any changes to the licensed nurses. During the telephone interview, on [DATE] at 12:16 PM, DON 2 stated that the facility practice was licensed nurses were required to perform an abdominal assessment of resident on GT feeding when they perform verification of GT placement and checking of gastric (stomach) residuals. DON 2 stated licensed nurses should check the resident's bowel sounds in all four quadrants, lift the resident's gown to visualize the abdomen and check for any swelling. DON 2 stated it was not indicated in the facility's policy because it was a basic standard of nursing practice. DON 2 stated that it was important for licensed nurses to perform abdominal assessments every shift for residents on tube feeding to ensure that any abnormal changes and gastrointestinal complications would be reported to the physician right away. DON 2 stated that the facility's current practice is to check placement of GT by auscultation. DON 2 stated she did not know what the other ways were to check for GT placement according to current professional standards of practice. DON 2 stated the facility had a recent competency checks, a few months ago, for the licensed nurses and verified auscultation as the way to check for G [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure the residents were free from physical restraints (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) for one of three sampled residents (Resident 1). Certified Nursing Assistants (CNA) 2 and 3 tied Resident 1 with a cloth gown and/or a bed sheet to the waist and around the wheelchair to prevent Resident 1's freedom of movement when agitated and prevent a fall for about one year (exact date unknown) since CNA 1 and 3 first reported (7/29/20) the improper us of restraint on to the facility administrator. This deficient practice resulted in Resident 1's rights being violated, abused, and held against her will. Findings: A review of Resident 1's face sheet (Admission Record) indicated the facility initially admitted Resident 1 to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 9/06/20, indicated Resident 1 was severely impaired in cognitive skills (thought process) for daily decision-making. The MDS indicated Resident 1 required one-person limited physical assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) for bed mobility, transfer, walk in room, walk in corridor, dressing, eating, toilet use and personal hygiene. A review of a facility document, titled Interview Record: Allegation of Improper use of Resident Restraints dated 7/29/20, indicated CNA 1 reported she had allegedly witnessed Resident 1 being restrained to a wheelchair. The document indicated CNA 1 stating that this incident had been going on since CNA 1 started at the facility over a year ago (5/20/2019). The document indicated everyone knows about it particularly Licensed Vocational Nurse (LVN) 1 and CNA 2. The document indicated CNA 1 had seen Resident 1 restrained when combative or agitated at the Nursing Station, hallway, and resident's room. A review of a facility document titled Interview Record: Allegation of Improper use of Resident Restraints, dated 7/29/20, indicated CNA 2 was questioned by the facility administrator on whether she had ever restrained Resident 1 while in the wheelchair. The document indicated CNA 2 responded yes she had, however, CNA 2 added that the resident had occasional behavior issues that increased her risk for fall and CNA 2 want to keep Resident 1 safe. The document indicated CNA 1 reported that LVN 1 and other CNAs were aware of this practice (restraining Resident 1). The document indicated a follow-up interview on 7/30/20, indicated CNA 2 stated she would occasionally wrap a bed sheet around Resident 1's waist as a way to pull the resident up in the chair or transfer to bed or wheelchair with safety, on days that Resident 1 was more agitated or more likely to fall. A review of a facility document titled Interview Record: Allegation of Improper use of Resident Restraints, dated 7/29/20, indicated CNA 3's allegations to CNA 2 of restraining Resident 1 for a long time, perhaps more than a year. The document indicated CNA 3 stating she believed that the restraints was done for Resident 1's safety since the resident had occasional behavioral outbursts that increased her risk of falling. A review of another document Interview Record: Allegation of Improper use of Resident Restraints, dated 8/10/20 from CNA 3 indicated admitting that CNA 3 had also restrained Resident 1 previously, but only to keep Resident 1 safe. A review of a facility document, titled Interview Record: Allegation of Improper use of Resident Restraints, dated 7/29/20, indicated CNA 4 reported allegedly witnessing Resident 1 restrained to the wheelchair on three separate days, about a month ago (from the interview date), but did not witness who restrained Resident 1. A review of a facility document, titled Interview Record: Allegation of Improper use of Resident Restraints, dated 7/29/20, indicated CNA 5 reported witnessing Resident 1 allegedly being restrained around the waist to the wheelchair, twice, approximately a month ago (from the interview date). A review of a facility document, titled Complaint Regarding Professional Behavior of Colleagues, dated 8/10/20, indicated CNA 6 recalled that approximately a month ago (from the date of interview), CNA 6 had challenges with the care of Resident 1 and CNA 3 approached CNA 6 about restraining Resident 1 to the wheelchair to keep the resident safe. The document stated CNA 3 proceeded to tie the bedsheet around Resident 1. During an observation on 2/03/21 at 6:37 a.m., Resident 1 was observed in bed, awake and calm. During an attempt to interview, Resident 1 stared blankly and did not respond to questions. During an observation on 2/03/21 at 6:45 a.m., LVN 3 was observed entering the room of Resident 1. Resident 1 became attentive and communicated with LVN 3 in the Armenian language. During a subsequent interview of LVN 3, LVN 3 stated Resident 1 responds well when staff speak to her in Armenian. LVN 3 stated that Resident 1 understands English and most of the time would not answer when spoken in English. During an interview with Resident 1 on 2/03/21 at 6:50 am, LVN 3 translated in Armenian that Resident 1 did not respond directly to questioning regarding being tied up in the wheelchair. LVN 3 stated Resident 1 responded to basic questions of how her day had been. During an interview, on 2/03/21 at 7:27 a.m., the administrator stated he initially could not substantiate the investigation but when a previous employee spoke up, he was able to substantiate the allegation. The administrator stated multiple night shift employees were terminated or resigned (CNAs 1, 2, 3, 5, and LVN 1 and 2) from the facility due to the incident (including the staff that had knowledge of Resident 1 being restrained and did not report). During a concurrent interview and review of two photographs provided by the administrator, on 2/03/21 at 10:30 a.m., one photograph showed a resident from a front view, sitting on a wheelchair with a white and blue cloth patient gown tied to the waist around the wheelchair. The administrator stated that the resident tied in the wheelchair in the photograph was Resident 1. The photograph showed Resident 1 with arm extended, reaching forward, and mouth opened wide. The second photograph showed Resident 1's back of the wheelchair with the same white and blue patient gown tied in a knot at waist level. The administrator stated he received the photographs from CNA 1 via text message on 7/29/20. During a telephone interview, on 2/09/21 at 12:14 p.m., CNA 5 stated she witnessed Resident 1 tied to her wheelchair but did not know who tied Resident 1. CNA 5 stated CNA 3 was Resident 1's regular CNA, and CNA 3 would tie Resident 1 to her wheelchair with a cloth gown around the waist tied at the back of the wheelchair like a seat belt so Resident 1 would not fall. CNA 5 stated that since she started to work at the facility, she would always see Resident 1 being tied to her wheelchair. During a telephone interview, on 2/09/21 at 12:48 p.m., LVN 1 stated she was not employed with the facility anymore. LVN 1 stated she did not want to be involved with the incident anymore. During a telephone interview on 02/09/21 at 12:58 p.m., CNA 6 stated she did not work full time at the facility but recalled CNA 3 telling her to tie Resident 1 down (CNA 6 unable to recall date). CNA 6 stated she told CNA 3 that she could not do that. CNA 6 stated that CNA 3 explained to her it was for Resident 1's safety since Resident 1 would get agitated. CNA 6 stated she did not report what CNA 3 told her because she had not actually seen Resident 1 tied up, so she did not know if it was something CNA 3 had been doing before. During a concurrent review of Resident 1's records with the director of nursing (DON), on 2/22/21 at 1:05 p.m., the DON stated there was no documented physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan dated 11/13/19 and reevaluated dated 5/2020, indicated the resident randomly screams without purpose which affects other residents. The care plan interventions indicated Resident 1 would be monitored closely by staff members and had a caregiver during the day to monitor the resident one-on-one. A review of Resident 1's care plan, titled Behavior dated 2/1/20 and reevaluated dated 5/1/2020, indicated Resident 1 had episodes of going out to the patio unassisted. The care plan indicated Resident 1 had episodes of being aggressive when staff would try to assist, high risk for fall and injury, and elopement (to escape or run away). The care plan interventions included assessing what may cause Resident 1's behavior and what may trigger behavior and attempt to reduce/eliminate those triggers if possible. The interventions indicated to respect Resident 1's rights to refuse treatment and care. During a telephone interview on 2/22/20 at 1:05 p.m., the DON stated the use of physical restraint was not a facility practice. The DON stated that restraining Resident 1 physically was a form of abuse. The DON stated nurses should always assess the residents for behavior and should try to figure out the cause of the behavior if it was associated to pain. The DON stated the nurses should try to figure out if the resident needed one-to-one monitoring and should not restrain the resident. During a concurrent review of Resident 1's care plans titled Behavior, the DON stated Resident 1 used to have a one-on-one caregiver (Caregiver 1) during the day provided and hired by Resident 1's family. The DON stated Caregiver 1 would come during the day and stay with Resident 1. The DON stated it had been a while that Caregiver 1 was in the facility to stay with Resident 1 (since November 2019). The DON could not provide documented evidence from Resident 1's medical records of nursing interventions provided by the licensed nurses and CNAs to manage Resident 1's behavior during the night shift. During a telephone interview, on 3/23/21 at 2:20 p.m., the administrator stated that Caregiver 1 was a companion for Resident 1 during daytime unlike what the care plan indicated. The administrator stated Resident 1 would have occasional behavioral outbursts and that was when CNAs would stay with her during the day. The administrator stated the CNAs would sit in with Resident 1 for a few hours. The administrator stated Resident 1 did not require constant one-on-one care. A review of the facility's policy and procedure titled, Use of Restraints, revised on September 2013 indicated restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline or staff convenience, or for the prevention of falls.

Based on observation, interview, and record review, the facility failed to anticipate and provide necessary care and services to effectively manage pain for two of 12 sample residents (Residents 1 and Resident 6) who are cognitively impaired, for by failing to: 1. Assess the need for pain medication before treatment and dressing change of a wound on the left foot (foot ulcer) and stage 3 pressure ulcers (an injury to the skin and underlying tissue from prolonged pressure on the skin) one on the left ischium (buttock) and one on the right ischium (Resident 1). 2. Follow the physician's orders [REDACTED]. 3. Ensure Resident 6 received pain medication as a comfort measure prior to range of motion (ROM - the extent of movement of a joint), exercise as indicated in the care plan. These deficient practices resulted in Resident 1 and Resident 6 experiencing unnecessary discomfort and can lead to a diminished quality of life and quality of care. Findings: a. A review of the admission record (Face Sheet) indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated January 27, 2017, indicated Resident 1's cognitive skills (the act or process of knowing, perceiving) were severely impaired and was totally dependent with one person assisting for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Pain Assessment form dated May 6, 2017, indicated the resident had pain or had the potential for pain. The pain or potential pain was due to status [REDACTED]. The assessment indicated Resident 1 was non-verbal and was unable to answer for determining pain intensity. A review of Resident 1's care plan dated May 7, 2017, indicated the resident is prone for alteration in comfort and at risk for pain associated with immobility, pressure ulcer, and movement. The goal of the care plan was to relieve Resident 1 of pain or discomfort after nursing and or pharmacologic (drugs, including their composition, uses, and effects) interventions. The interventions included observing the resident for verbal or non-verbal complaints (such as moaning, crying, restlessness, etc.) of pain and report to the attending physician; assess for cause/s, site, location, duration and frequency of pain; pain medication; and monitor for need of routine pain management. A review of Resident 1's physician orders [REDACTED]. 1. Tylenol (a pain reliever and fever reducer medication) 500 milligrams (mg) by gastrostomy tube (GT- a tube surgically inserted through the abdomen for nutrition and medication) thirty minutes prior to wound treatments. 2. [MEDICATION NAME] (a strong pain medication indicated for the relief of moderate to moderately severe pain) 5/325 mg by GT as needed every six hours for moderate pain. On May 20, 2017 at 7:15 p.m., during an observation of Resident 1's pressure ulcer treatment of [REDACTED]. Licensed Vocational Nurse 2 (LVN 2) continued the treatment to the right ischium and then proceeded to provide wound treatment to the left foot ulcer. The resident was observed grimacing, groaning and flinching when LVN 2 was measuring the left foot wound. LVN 2 continued with the treatment and dressing change and did not stop to assess the resident for pain. Resident 1 was observed groaning and grimacing intermittently during the duration of the treatment. During an interview with LVN 2 at the time of the observation, LVN 2 stated he did not give Resident 1 pain medication prior to the wound treatment. LVN 2 stated Resident 1 was given Tylenol during the 7 a.m.-3 p.m. shift, at an unspecified time. On May 21, 2017 at 4:53 p.m., LVN 2 was interviewed. LVN 2 stated during the pressure ulcer and wound treatment (observation of May 20, 2017 at 7:15 p.m.,) he observed Resident 1 flinching and guarding the left foot when he (LVN 2) was patting the area with medicine. LVN 2 stated he was not familiar with the schedule of the resident's pain medication. LVN 2 stated Had I known, I would have medicated her. A review of May 2017 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of the May 2017 MAR Pain Scale Monitoring for every shift from May 7, 2017, to May 20, 2017, indicated Resident 1 had no pain on each shift. On May 21, 2017 at 7:00 a.m., during an interview, Certified Nursing Assistant 4 (CNA 4) stated he had observed Resident 1 with discomfort in the face and groaning when the resident was being turned in bed. On May 21, 2017 at 9:00 a.m., Resident 1 was observed on her back in bed with her eyes close. At 9:10 a.m., during a treatment observation of Resident 1's left foot wound, the resident started groaning and grimacing when Registered Nurse 2 (RN 2) held the resident's foot to remove the gauze dressing. Resident 1 continued to groan, grimace and flinch while RN 2 was cleaning the resident's foot wound with normal saline (solution of salt and water). RN 2 continued with the treatment and did not stop to assess Resident 1 for pain. During an interview at the time of the observation, RN 2 stated he did not give Resident 1 pain medication prior to the treatment of [REDACTED]. During a follow up interview on May 21, 2017 at 9:35 a.m. with RN 2 in the presence of the Director of Nurses (DON), RN 2 stated It was a mistake. I should have stopped the treatment. A review of the May 2017 MAR for May 21, 2017, prior to Resident 1's treatment, indicated the resident was not given Tylenol 500 mg. via GT before the treatment was performed, as the physician ordered, to ensure comfort for Resident 1. On May 21, 2017 at 4:35 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated he gave Resident 1 [MEDICATION NAME] after the treatment was initiated (on May 21, 2017 at 9:00 a.m.). LVN 3 stated he observed Resident 1 grimaced while he was giving the pain medication, also. LVN 3 stated he assessed the pain as a level 7 (using a pain scale of 0-10, zero being no pain and 10 being the worst possible pain), indicating the resident had moderate pain. LVN 3 stated RN 2 did not inform him, RN 2 was going to do wound treatment. LVN 3 stated Resident 1 was supposed to get Tylenol thirty minutes before the wound treatment. A review of the facility's policy titled Medication Administration, with a revised date of February 2013, indicated Medications are administered in accordance with written orders of the prescriber and obtain and record any vital signs as necessary prior to medication administration. A review of an undated facility policy titled Pain Management, indicated if there is a new onset of pain, worsening of pain, new pain medication, pain medication change and or other, the Licensed Nurse will complete the pain assessment and notify the Attending Physician and IDT (Interdisciplinary) for further recommendations. b. A review of the admission record (face sheet) indicated Resident 6 was originally admitted to the facility March 12, 2014 and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated February 15, 2017, indicated Resident 6 rarely or never makes self-understood, rarely or never had the ability to understand others, cognitive skills were severely impaired and the resident was non-verbal. The MDS indicated Resident 6 was totally dependent on the staff for bed mobility, dressing, and personal hygiene. A review of Resident 6's Physician order [REDACTED]. Tylenol 50 mg every six hours as needed for slight pain. A review of Resident 6's Physician order [REDACTED]. part toward the middle of the body) for ten repetitions, one set as tolerated. A review of Resident 6's care plan for pain dated November 15, 2016, indicated the resident will show relief of pain or discomfort after administration of medication for the next 90 days. The interventions include monitor for signs and symptoms of pain like flinching, moaning, crying, grimaced facial expression, provide pain medication prior to planned expected activities like RNA, and administer medication as ordered. On May 22, 2017 at 11:30 a.m., during range of motion (ROM) exercise observation, Resident 6 was sitting in the wheelchair in her room. Restorative Nursing Assistant 1 (RNA 1) provided ROM exercises to Resident 6 starting from the right lower extremity. Resident 6 was observed with facial grimacing after three repetitions of knee flexion and extension. RNA 1 stated he had to stop the exercise because the resident could not tolerate the exercise. RNA 1 was observed to perform three repetitions of flexion and extension exercises of the knees and hips on both sides. RNA 1 was observed to perform upper extremities exercises only three repetitions, because Resident 6 had tears in her eyes. RNA 1 stated the resident had pain, so he needs to stop the treatment and ask the licensed nurse to give the resident pain medication. RNA 1 stated he was not sure if Resident 6 received pain medication prior to the RNA treatment. On May 22, 2017 at 11:55 a.m., during a record review and interview with Director of Nursing (DON), the Medication Administration Record [REDACTED]. The DON stated the Licensed Nurses should have given pain medication at 30 minutes prior to treatment. The DON stated she will tell the nurse to give pain medication to Resident 6.