Every finding on record at Colonial Care Center

Based on observation, interview, and record review, the facility failed to maintain a debris-free dumpster area when trash was not properly contained, covered, and free from overflowing for three of three trash dumpsters.This failure had the potential to result in pests (an organism that causes harm to humans such as flies, cockroaches, and rodents) entering the facility and spreading diseases to the residents.Findings:During an observation on 2/9/2026 at 8:45 a.m. in the outdoor garbage area, there were three dumpsters. The three trash dumpsters were open and overflowing with garbage. There were folded brown boxes and trash bags filled with used personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) overflowing from the three trash dumpsters onto the lid of two trash bins.During a concurrent observation and interview on 2/10/2026 at 8:20 a.m. in the outdoor garbage area, with the Dietary Services Supervisor (DSS), two of three trash dumpster lids were not completely closed. DSS stated trash dumpsters should not be overfilled. DSS stated garbage containers should be kept closed when not in use to prevent pests from getting inside. DSS stated residents could get sick from diseases that pests spread.During a review of the facility's policy and procedure (P&P) titled, Waste Control and Disposal, undated, the P&P indicated, Outside garbage bin should be kept closed at all times and surrounding areas must be kept clean. Dispose garbage in a timely manner to prevent build up.

Based on interview, and record review, the facility failed to Identify and to intervene in two of three sampled residents (Resident 17 and Resident 156)' history of trauma and triggers which may cause re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again) as evidenced by:A. Failing to assess and identify the trauma and triggers for Resident 17 related to natural/human caused disaster.B. Failing to assess and identify the trauma and triggers for Resident 156 related to homelessness. This failure had the potential to result in Resident 17 and Resident 156 experiencing re-traumatization and further psychosocial decline.Findings:A. During a review of Resident 17's admission record, the admission record indicated Resident 17 was admitted initially to the facility on [DATE] and last readmission was on [DATE] with diagnoses including post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), schizophrenia (a mental illness that is characterized by disturbances in thought), and dementia (a progressive state of decline in mental abilities).During a review of Resident 17's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 17 was able to make decisions for activities of daily living.During a review of Resident 17's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 17 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for hygiene, bed mobility, transfer, dressing, bathing, and eating.During a concurrent interview and record review on [DATE], at 9:48 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 17's Care Plan Report (CPR) titled, Trauma Informed Care: ineffective coping related to past traumatic incident -Large scale natural and/or human caused disaster survivor, and adjusting to new place, revised on [DATE] was reviewed. The CPR Goal indicated, Resident 17 will have reduced episodes of behavior daily until [DATE]. The CPR Interventions indicated, implement useful interventions to reduce stress, monitor behavior episodes, and provide a safe environment and atmosphere of acceptance. RNS 1 stated, Resident 17's CPR did not indicate what the nature of the trauma was and what triggers Resident 17 had. RNS 1 stated, the CPR interventions were not individualized without identifying what might trigger Resident 17 to experience re-traumatization. RNS 1 stated, it was important to identify the triggers and implement interventions that were individualized according to Resident 17's needs to prevent re-traumatization.During a concurrent interview and record review on [DATE], at 10:41 a.m., with Social Service Assistant (SSA) 1, Resident 17's Trauma Care Evaluation (TCE), dated [DATE] was reviewed. The TCE was done and signed by SSA 1. The TCE indicated, there was no trauma and triggers identified. SSA 1 stated, the staff should have assessed and identified the triggers of PTSD and the severity of possible re-traumatization from the triggers to prevent recurrent events. SSA 1 stated, she could not get much information regarding trauma and its triggers from Resident 17. SSA 1 stated, she should have contacted Resident 17's psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) and public guardian (a court-appointed public official or agency that acts as the legally authorized guardian or conservator for individuals unable to care for themselves or manage their own finances, usually due to physical or mental disability) to obtain information regarding his PTSD.B. During a review of Resident 156's admission record, the admission record indicated Resident 156 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 156's H&P, dated [DATE], the H&P indicated, Resident 156 was able to make decisions for activities of daily living.During a review of Resident 156's MDS, dated [DATE], the MDS indicated Resident 156 required supervision or touching assistance from one staff for hygiene, bed mobility, transfer, dressing, bathing, and eating.During a review of the Resident 156's Order Summary Report (OSR), dated [DATE], the OSR indicated, give Melatonin (medication to help with sleep) 3 milligram (mg) 2 tablets by mouth at bedtime was ordered on [DATE].During an interview on [DATE], at 11:03 a.m., with Resident 156 in his room, Resident 156 stated, he was diagnosed with PTSD. Resident 156 stated, while he was homeless and someone attacked him suddenly. Resident 156 stated, he was left unconscious and was treated at General Acute Care Hospital (GACH). Resident 156 stated, when someone gets close to him without letting him know first, he gets retraumatized. Resident 156 stated, one of the night nurses came in and fixed his blanket, and it triggered him a few weeks ago. Resident 156 stated, he was having difficulty with sleeping and having nightmares since that incident and has had to take a sleeping pill.During a concurrent interview and record review on [DATE], at 9:53 a.m., with RNS 1, Resident 156's Care Plan Report (CPR) titled, Trauma Informed Care: ineffective coping related to past traumatic incident diagnosis of PTSD, revised on [DATE] was reviewed. The CPR Goal indicated, Resident 156 will have reduced episodes of behavior daily until [DATE]. The CPR Interventions indicated, implement useful interventions to reduce stress, monitor behavior episodes, and provide a safe environment and atmosphere of acceptance. RNS 1 stated, Resident 156's Care Plan was not person centered and there was no individualized and specific interventions.During a concurrent interview and record review on [DATE], at 10:48 a.m., with SSA1, Resident 156's Trauma Care Evaluation (TCE), dated [DATE] was reviewed. The TCE was done and signed by SSA 1. The TCE indicated, there was no trauma and triggers identified. SSA 1 stated, completing the trauma assessment was important, because the resident's care would be different according to the needs from the assessment. SSA 1 stated, she would refer the resident to proper services according to the trauma assessment to prevent re-traumatization. SSA 1 stated, Resident 156's care plan was not person centered because there was no assessment done for the trauma.During an interview on [DATE], at 2:09 p.m., with the DON, the DON stated, when Resident 156 who has PTSD as a diagnosis was admitted to the facility, Resident 156 should be assessed for its triggers, and past history to prevent re-traumatization. The DON stated, the care plan could not be resident centered, and resident focused if the trauma assessment was not done correctly. The DON stated, the facility has many residents who were veterans. The DON stated, staff should have assessed the residents' PTSD and made the plan of care according to the findings. The DON stated re-traumatization would harm Residents' psychosocial well-being.During a review of the facility's Policy and Procedure (P&P) titled, Trauma Informed and Culturally Competent Care, revised on 8/2022, the P&P indicated, Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Preparation: 2. Nursing staff are trained on trauma screening and assessment tools. 3. All staff are guided in evidence-based organizational and interpersonal strategies that support trauma-informed and culturally competent care. 4. All staff receive orientation and in-service training regarding cultural competency as an aspect of resident centered care . 3. For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. 4. Triggers are highly individualized. Some common triggers may include a. experiencing a lack of privacy or confinement in a crowded or small space, b. exposure to loud noises, or bright/flashing lights; c. certain sights, such as objects; and/or d. sounds, smells, and physical touch .Resident Assessment: 1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. 2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments .Resident Care Planning: 1. Develop individualized care plans that address past trauma 2. Identify and decrease exposure to triggers that may re-traumatize the residents. 3. Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety and depression). 4. Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values.

Based on observation, interview, and record review, the facility failed to implement infection control measures by failing to:1. Ensure Certified Nurse Assistant (CNA) 2 did not pick up Resident 186's contaminated cloth from hallway floor and place in the resident's closet without washing.2. Follow Enhanced Barrier Precaution [EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent multidrug-resistant organism (MDRO) spread where direct contact is likely] while handling dirty bed linens for Resident 175.These failures had the potential to result in compromised infection control measures to prevent the spread of infection among residents, staff, and visitors. Findings: 1. During a review of Resident 186's admission record, the admission record indicated Resident 186 was initially admitted to the facility on [DATE] and last re-admission was on 4/2/2025 with dementia (a progressive state of decline in mental abilities), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and paranoid schizophrenia (a complex psychiatric disorder characterized by distorted thinking and awareness). During a review of Resident 186's History and Physical (H&P), dated 4/7/2025, the H&P indicated, Resident 186 had no capacity (ability) to understand and make decisions. During a review of Resident 186's Minimum Data Set (MDS-a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 186 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, maximal assistance ( Helper does more than half the effort) from one staff for hygiene, dressing, bed mobility, transfer, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating. During an observation on 2/11/2026, at 11:01 a.m., in a hallway near Resident 182's room, CNA 2 was walking toward Resident 182's room with a light brown hoodie and a white sweatshirt in her hands. CNA 2 dropped the light brown hoodie on the hallway floor near Resident 182's room. CNA 2 picked up the brown hoodie from the floor and went inside Resident 182's room. CNA 2 came out of Resident 182's room without any clothes in her hands. During a concurrent observation and interview on 2/11/2026, at 11:06 a.m., with CNA 2 in Resident 182's room, CNA 2 opened Resident 182's closet door, the light brown hoodie that CNA 2 dropped on the hallway floor and picked up was hanging right next to Resident 182's clean clothes. CNA 2 stated, she should have put the light brown hoodie in the dirty linen hamper or took it back to the laundry for rewashing instead of placing it in the closet next to the clean clothes. CNA 2 stated, the hoodie got contaminated when she dropped it on the floor. CNA 2 stated, she had to take all of Resident 182's clothes from the closet to wash to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). During an interview on 2/12/2026, at 11:17 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated, CNA 2 should have taken the contaminated clothes to the laundry room right after picking it up from the floor instead of hanging the hoodie in the closet where the clean clothes were hung to prevent cross contamination. During an interview on 2/12/2026, at 2:02 p.m., with the Director of Nursing (DON), the DON stated, the staff should be mindful with surrounding and infection prevention measures to protect themselves and vulnerable residents from spreading infection. During a review of the facility's Policy and Procedure (P&P) titled, Standard Precautions, revised 4/2023, the P&P indicated, Policy and Procedure Implementation .Linen: a. Linen are handled and processed in a manner that prevent contamination of clothing and avoid transfer of microorganisms to other residents and environments. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program, revised 4/2023, the P&P indicated, Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation: 11. Prevention of Infection -a. Important facets of infection prevention include: (3) educating staff and ensuring that they adhere to proper techniques and procedure. During a review of the facility's Policy and Procedure (P&P) titled, Laundry and Bedding, Soiled, revised 9/2022, the P&P indicated, Policy Interpretation and Implementation: Handling .Contaminated laundry is bagged or contained at the point of collection. Storage . Clean linen is stored separately, away from soiled linens, at all times. Clean linen is kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination . Personal Clothing: Personal clothing that becomes soiled with blood or body fluids is covered or removed and immediate laundered before leaving the work area. 2. During a review of Resident 175's admission Record, the record indicated the facility admitted the resident on 8/3/2023, with diagnoses including but not limited to diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), seizures, and dysphagia (difficulty swallowing). During a review of Resident 175's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 11/5/2025, the MDS indicated the resident is dependent (relies on someone else) in completing activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 175's care plan, dated 8/6/2025, the care plan indicated the resident is on EBP for high-risk infections associated with feeding tubes (a soft flexible tube that allows liquid food to enter the stomach or intestine). During an observation on 2/9/2026 at 10:20 a.m. in Resident 175's room, an EBP sign was posted on the resident's headboard. A box of open medium and large gloves was accessible on the left-hand side upon entering the room. Blue disposable gowns were stored outside to the right of Resident 175's room. During a concurrent observation and interview on 2/9/2026 at 10:23 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 was changing Resident 175's used bed linens. CNA 1 did not wear a gown or gloves while handling the used bed linens. CNA 1 stated that she saw the EBP sign but forgot to wear PPE. CNA 1 stated she should have worn gloves and a gown while changing Resident 175's dirty linens. During an interview on 2/11/2026 at 10:50 a.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated staff should wear a gown and gloves when providing high contact care for residents on EBP. LVN 6 stated high contact care activities include medication administration, changing dirty bed linens, and wound care. During an interview on 2/11/2026 at 11:13 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated it is important to follow the posted transmission-based precautions (TBP, used to help stop the spread of germs from one person to another) to protect against the spread of infection. During a concurrent interview and record review on 2/12/2026 at 1:58 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated June 2024 was reviewed. The P&P indicated, wear gloves and gown prior to performing high contact resident care activities such as transferring and changing linens. The DON stated staff did not follow the EBP policy while providing care for Resident 175.

Based on observation, interview and record review the facility failed to ensure residents, who were identified at risk for fall, did not fall and sustained injury for one of three sample residents (Resident 8 and Resident 44). The facility failed to: 1. Ensure Change of Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition), care plan, Interdisciplinary Team (IDT team members from different departments working together with a common purpose to set goals and make decisions ensure residents receive the best care), Medical Doctor (MD) notification was initiated for Resident 8 after Rehabilitation staff (group of healthcare professionals who work together with a patient and their family to achieve maximum physical, cognitive, and functional independence) initiated a post fall assessment (evaluation performed by staff to check for injuries and identify the cause of a fall) dated 12/3/2025 .2.Ensure the licensed nurses evaluated the effectiveness of interventions of Residents 8's care plan titled, Resident has impaired vision related to Cataract (the lens of the eye becomes progressively opaque, resulting in blurred vision) initiated on 7/15/2024, after Resident 8 fell on 9/29/25, to develop new interventions to prevent the resident's fall on 12/3/2025 with injuries. 3. Ensure staff followed the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised 3/2018 the P &P indicated, If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 4. Ensure Resident 8 who was visual impaired (restricted vision, partial or complete blindness) was supervised and assisted to the bathroom (staff member actively monitoring a person during the process of using the restroom ) as indicated in the minimum data set (MDS) assessment. These failures resulted in: Resident 8 falling while in the restroom on 12/3/2025 around 1:30 p.m., sustaining a right superior (above) pubic rami (located at the front of each side of the pelvis) fracture (broken bone) of unknown age which required hospitalization in a General Acute Care Hospital (GACH) for treatment and evaluation. On 1/23/2025 Resident 8 fell down on the floor complained of (C/O) headache mostly occipital region rates her pain 8/10with bump at the back of the head. Findings: During a review of Residents 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), cataract (a progressive condition makes vision blurry and cloudy), and history of falling. During a review of Resident 8's Minimum Data Set [MDS- resident assessment tool) dated 12/18/2025, the MDS indicated Resident 8 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making and needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance) when toileting and with personal hygiene. During a review of Resident 8's care plan, titled, Bowel and Bladder Retraining related to alteration in elimination pattern, dated 4/22/2024, the care plan interventions included; assist Resident 8 to the toilet, the bedside commode or offer a bedpan as indicated, before breakfast, before lunch, before dinner and as needed. During a review of Resident 8's care plan titled, Resident 8 has impaired visual functioning related to cataracts, initiated on 7/15/2024, the care plan goal for Resident 8 was to minimize the risk of injury related to visual impairment. The care plan indicated to provide a safe environment free of hazards, maintain adequate room lighting, ophthalmologist (medical specialty in diagnosing and treating the eyes) consult as needed and observe for decrease in vision and blurring. During a review of Resident 8's Social Service Note, dated 3/27/2025 timed at 10:06 a.m., the Social Service Note indicated Resident 8 had a hard time seeing and did not move her pupils (center of the eye allows light to enter so one can see) when being tested (no reaction to light indicates severe vision impairment). During a review of Resident 8's COC dated 3/31/2025 timed at 2:00 p.m., the COC indicated Resident 8 was observed with loss of vision in her right eye. The COC indicated Resident 8 also verbalized she was losing vision in her left eye. The COC indicated when Resident 8 heads to the bathroom she guides herself by holding onto furniture along the path or the wall to the bathroom. During a review of Residents 8's Social Service Note dated 4/3/2025 timed at 12:29 p.m., the Social Service Note indicated the Social Worker (SW) found an ophthalmologists office takes Resident 8's insurance and the ophthalmologist's office requested Resident 8's identification card and insurance card for the referral packet and order to be sent to the office. The Social Service Note indicated Resident 8 had destroyed all of the requested documents and Resident 8's Responsible Party did not have any copies of Resident 8's insurance information. During a review of Resident 8's Care Plan titled, Risk for Falls, initiated on 7/4/2025, the Care Plan indicated the goal for Resident 8 was Resident 8 would be free from falls. The Care Plan interventions included assist resident with ambulation and transfers. During a review of Resident 8's Physician Orders dated 10/20/2025, the Physician Order indicated, Rescheduled appointment with ophthalmologist for cataract surgery on 10/21/2025 at 11:30 a.m., until 3:30 p.m. During a review of Resident 8's Eye Examination Report dated 10/21/2025, the Eye Examination Report indicated Resident 8 reported blurry vision in both eyes and it was worsening for the past 6 months, and the blurred vision was making activities of daily living more difficult. The Eye Examination Report indicated Cataract surgery was recommended as a means of improving Resident 8's visual function. During a review of Resident 8's Optometry (medical specialty testing and treating vision) report dated 11/25/2025, the Optometry Report indicated recommendations indicated further testing and evaluation with ophthalmology. During a review of Resident 8's Social Service Note dated 11/25/2025 timed at 4:24 p.m., the Social Service Note indicated ophthalmology referral from optometry was acknowledged. During a review of Resident 8's COC form dated 12/3/2025 and timed at 5:56 p.m., the COC form indicated, Resident 8 complained of right hip and leg pain. The COC form indicated Resident 8 had pain when attempting active range of motion (AROM- movement a person can produce at a joint using their own muscle power, without any outside assistance or aids). During a review of Resident 8's Rehabilitation Fall Risk Assessment form dated 12/5/2025 and timed 10:35 a.m., the Fall Risk Assessment form indicated date of incident 12/3/2025 (unknown time) unwitnessed fall, per Resident 8, Resident 8 fell in the bathroom. During a review of Resident 8's COC form dated 12/5/2025 timed at 1:30 p.m., the COC form indicated while charge nurse was making rounds, LVN 2 saw Resident 8 walking by herself to the bathroom and bumping into the bathroom door The COC form indicated LVN 2 assisted Resident 8 back to bed. The COC form indicated Resident 8 limped when she walked, complained of 5/10 right groin pain. The COC form indicated Resident 8's Medical Doctor (MD) ordered to transfer Resident 8 to the GACH for further evaluation. During a review of Resident 8's Nursing Progress notes dated 12/6/2025 timed at 12:59 a.m., the Nursing Progress notes indicated the GACH gave report Resident 8 had fracture of superior ramus of pubis (top front portion of the hip bones). During a review of Resident 8's Interdisciplinary Team (IDT team members from different departments working together with a common purpose to set goals and make decisions ensure residents receive the best care) note dated 12/8/2025 timed at 1:35 p.m., the IDT note indicated Resident 8 had a fall on 12/5/2025 and Resident 8 needed limited to maximum assistance with activities of daily living (ADL's). The IDT note indicated Resident 8 returned to facility and has fracture of superior ramus of pubis.no treatment required. it will heal itself. During a review of Resident 8's COC form dated 1/23/2026 timed 1:27 a.m., the COC form indicated at 12:24 a.m. a loud bang was heard coming from the Resident 8's room. The COC indicated Certified Nurse Assistant (unknown CNA) immediately entered the room and found Resident 8 lying on the floor near the bathroom door. The COC indicated emergency services were contacted and Resident 8 was transferred to GACH. During a review of Resident 8's Nursing Progress notes dated 1/23/2026 timed at 9:37 a.m., the Nursing Progress notes indicated Resident 8 was transferred back from the GACH emergency department with a diagnosis of, scalp hematoma (a solid swelling of clotted blood within the tissues usually due to trauma) During an observation on 2/10/2026 at 12:45 p.m., outside of Resident 8's room, Resident 8 was seen sitting at the edge of the bed trying to get up from the bed by holding onto the wall. Resident 8 started to ambulate towards the restroom without assistance. During an interview on 2/12/2026 at 7:13 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 8 informed her she had unwitnessed fall in the bathroom back in 12/2025. LVN 2 stated if there is a report from any Residents they fell on the ground Licensed staff initiate a COC, an incident report to investigate the incident and the Licensed staff update the care plan. LVN 2 stated there was no COC initiated for the unwitnessed fall Resident 8 reported that Resident 8's MD was not notified. LVN 2 stated the care plan for Resident 8 was not updated to meet Resident 8's needs to prevent the fall on 1/23/2026. LVN 2 stated Resident 8 should always be supervised when ambulating to the restroom due to her worsening vision. During a concurrent interview and record review on 2/12/2026 at 8:06 a.m., with LVN 3, Resident 8's GACH x-ray report and physicians' orders from facility for the month of December 2025. LVN 3 stated Resident 8 came back from the GACH on 12/6/2025 with x-ray results indicating a fracture of the right superior pubic ramus, of unknown age. LVN 3 stated Resident 8 was not referred to an orthopedic (medical specialty treating conditions affecting the bones or muscles) doctor. LVN 3 stated Resident 8 should have been assessed by an orthopedic physician to clear Resident 8 for physical therapy. LVN 3 stated Resident 8 continued to have falls due to her vision problems. LVN 3 stated Resident 8 is completely blind (severe visual impairment) in the right eye and has poor vision on the left eye due to cataracts. LVN 3 stated Resident 8's ophthalmologist recommended a referral for further testing and evaluation. During a review of Resident 8's -Physical Therapy (PT- a person qualified to treat disease, injury, or physical conditions by methods such as massage, heat treatment, and exercise rather than by drugs or surgery) Progress Notes dated 12/5/2025 (unknown date), the Progress Notes indicated Due to Resident 8's diagnosis of a fracture, weight-bearing and standing activities will remain on hold until further MD order for weight bearing precaution. During a review of Resident 8's PT progress notes dated 12/31/2025 (unknown time), the PT progress notes indicated weight bearing activities remain on hold until further MD order for weight bearing precautions. During an interview and concurrent record review on 12/12/2026 at 10:45 a.m., with the Assistant Director of Nursing (ADON), Resident 8's COC report for the month of December. The ADON stated staff did not complete a COC for Resident 8's unwitnessed fall on 12/3/2025 and did not notify the physician. The ADON further stated Resident 8 was readmitted on [DATE] from a GACH with a fracture of the right rami of unknown age. The ADON explained the IDT decided no intervention or follow-up was needed, due to the fracture of unknown age. During an interview on 2/12/2026 at 2:34 p.m., with the Director of Nursing (DON), the DON stated she did not know about Resident 8's unwitnessed fall. The DON stated no investigation was conducted and Resident 8's MD was not notified. The DON stated Resident 8 returned from GACH on 12/6/2025 with an old fracture, which did not require an orthopedic follow-up as it would heal naturally. The DON stated the GACH said no treatment required we did not do anything else to monitor Resident 8's fracture. The facility didn't report the fracture to our agency because they knew the cause of the fracture. During a review of the facility's policy and procedure titled Falls and Fall Risk, managing revised on 3/2018, indicated staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 9), who was receiving hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) :Physician orders for specific fluid allowed in 24 hours were placed.Fluid intake was being measured.These deficient practices had the potential to place residents at risk for fluid retention and overload.Findings:a. During a review of Resident 9's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 3/1/2022 and was readmitted on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing).During a review of Resident 9's History and Physical (H&P) dated 3/3/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS- a resident assessment tool), the MDS indicated Resident 9 had no issues with thinking or memory. The MDS indicated Resident 9 required maximal assistance from staff for toileting and bathing and supervision for eating.During a concurrent interview and record review on 2/10/2026 at 11:33 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 9's physician orders dated 4/1/2024 was reviewed. The physician orders indicated Fluid restriction; limited to no water pitcher at bedside. LVN 2 stated the physician order was unclear and should have the amount of fluid the resident can have in a 24 hour period. LVN 2 stated not having a clear fluid restriction order places dialysis residents at risk for fluid overload.During an interview on 2/12/2026 at 9:58 a.m. with Registered Dietician (RD), the RD stated not having a clear fluid restriction order places dialysis residents at risk for fluid overload due to impaired kidney (organ responsible for filtering blood to remove waste products and excess water) function.During a concurrent interview and record review on 2/12/2026 at 8:47 a.m. with Registered Nurse (RN) 1, Resident 9's physician orders were reviewed. RN 1 stated physician orders indicated Fluid restriction; limited to no water pitcher at bedside. RN 1 stated Resident 9's fluid restriction order was incomplete and should have the amount of fluid resident can have each day. Resident 9's Nutrition Dietary Note dated 1/30/2026 was reviewed. RN 1 stated Resident 9's fluid restriction was limited to no water pitcher at bedside. Resident 9's hemodialysis care plan report was reviewed. RN 1 stated Resident 9's fluid restriction was not documented on any interventions. RN 1 stated not having orders that specify amount of fluid Resident 9 can have in a day places resident at risk for fluid retention and overload.During a review of facility policy and procedure titled, Care of Resident Receiving Renal Dialysis undated, the P&P indicated, Fluid Restriction followed: a. MD orders for specific fluid allowed in 24 hours.b. During a concurrent interview and record review on 2/10/2026 at 11:33 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 9's physician orders were reviewed. LVN 2 stated Resident 9 did not have any physician orders for intake measurements. LVN 2 stated monitoring fluid intake was important for residents on dialysis because they are at risk for fluid overload.During a concurrent interview and record review on 2/12/2026 at 8:47 a.m. with Registered Nurse (RN) 1, Resident 9's physician orders were reviewed. RN 1 stated Resident 9 did not have any physician orders for intake measurements. RN 1 stated if nurses were documenting the resident's fluid intake, nurses would document in progress notes. Resident 9's nursing progress notes were reviewed. RN 1 stated there was no documentation of Resident 9's fluid intake. Resident 9's Administration Report for fluid restriction, limited to no water pitcher at bedside was reviewed. RN 1 stated nurses document task completed to verify there was no water pitcher at Resident 9's bedside. RN 1 stated there was no documentation of amount of fluid Resident 9 consumed throughout the day. RN 1 stated there should be documentation of Resident 9's fluid intake. RN 1 stated not monitoring or documenting Resident 9's fluid intake places resident at risk of fluid overload.During a concurrent interview and record review on 2/12/2026 at 1:20 p.m. with the Director of Nursing (DON), the DON stated Resident 9 was only given fluids by the kitchen with meals. Resident 9's diet orders were reviewed. The DON stated the diet order does not indicate amount of fluid Resident 9 was being served with each meal. The DON stated monitoring fluid intake is important for dialysis residents because they are at risk for fluid overload.During a review of facility policy and procedure (P&P) undated, indicated, Fluid restriction followed: Intake measured and recorded each shift, if ordered.

Based on observation, interview, and record review, the facility failed to ensure two of five sample residents (Resident 73 and Resident 99): Obtained consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) that explains the risk and benefits of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) with the resident representative prior to installation. was offered other alternative attempts prior to installing side rails. These failures had the potential to result in compromised resident safety associated with unassessed bed rail use. Findings: A.)During a record review of Resident 73's admission record indicated Resident 73 was admitted on [DATE] with a diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a record review of Resident73's Minimum Data set (MDS- resident assessment tool), dated 1/26/2026 indicated that Residents cognitive was impaired. The MDS indicated that Resident 73's needs maximal assistance (helper does more than half the effort)with showers, resident needs moderate assistance with toileting, upper body dressing, lower body dressing, putting on/taking off footwear and with personal hygiene. During a review of Resident 73's admission orders dated 11/18/2025 indicated Support & Safety Device Low bed with bilateral quarter rails in bed as an enabler for bed mobility, repositioning and other Activities of daily living (ADL's) (not considered a restraint- any manual method, physical or mechanical device, equipment, or material that cannot be removed easily by the resident). Padded siderails to decrease potential injury. During an observation on 2/10/2026 at 8:50 a.m. in Resident 73's room, Resident 73 was lying in bed on her back with bilateral side rails up. During a concurrent observation and interview on 2/9/2026 at 11:56 a.m. in Residents 73's room with Licensed Vocational Nurse (LVN 3), LVN 3 stated that Resident 73 should not have bilateral padded side rails because Resident 73 does not have a diagnosis of seizures. LVN 3 stated that usually bilateral side rails are implemented for residents with seizures for safety reasons. LVN 3 stated that the bilateral padded siderails should be removed for Resident 73. During a review of Interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their resident) - Madwords assessment dated [DATE] indicated that no physical restraints used and recommended at this time. The assessment did not indicate that bilateral rails were in use for support and safety. The IDT note did not indicate that alternative attempts were used prior to installing bilateral rails. During a concurrent interview and record review on 2/10/2026 at 1:09 p.m. with Registered Nurse (RN 1), RN 1 stated that Resident 73 informed consent is incomplete because it is missing padded bilateral quarter rails and the consent was not verified by a second licensed nurse since it was obtained via telephone. RN 1 stated that it is important to include the complete physician order on the consent and for a second nurse to verify the consent for it to be accurate and valid before initiating the side rails. During an interview and record review on 2/12/2026 at 10:45 a.m. with Assistant Director of Nursing (ADON), ADON stated that alternative attempts were not implemented to Resident 73 prior to installing the bilateral rails because it was not documented in the side rail assessment dated [DATE] or on IDT note dated 11/24/2025. ADON stated that it was important to use alternatives before installing bed rails to avoid using modalities and do nursing interventions first to determine if safe for Resident 73. B). During a record review of Resident 99's admission record indicated Resident 99 was admitted on [DATE] with a diagnoses dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and history of falling. During a record review of Resident 99's MDS dated [DATE] indicated that residents cognitive was impaired. The MDS indicated that Resident 99 needs maximal assistance with toileting, shower, lower body dressing and putting on/taking off footwear. During an observation on 2/9/2026 at 9:49 a.m. in Resident 99's room, Resident 99 was lying in bed facing the door with bilateral side rails up and call light within reach. During an interview and record review on 2/11/2026 at 12:45 p.m. with LVN 4, LVN 4 stated that Resident 99 has a low bed with bilateral quarter rails for mobility. LVN 4 mentioned that staff must obtain consent, implement alternative interventions, and complete an assessment before installing side rails LVN 4 stated that Resident 99's consent form was incomplete because it lacked the date and nurse's signature. LVN 4 emphasized the importance of obtaining a second nurse's signature to verify accuracy. The side rail assessment dated [DATE] indicated that staff implemented visual monitoring before installing the side rails. During an interview, Maintenance Staff 1 (MS 1) said he was responsible for measuring bed rails for Resident 99. The side rail/entrapment assessment(a safety check to make sure a person (usually a patient or resident) cannot get stuck or caught in dangerous gaps between their bed, mattress, and side rails from 11/24/2025 showed all zones were within guidelines (less than 4 3/4 inches). However, MS 1 admitted he did not measure all zones because he was unsure of their locations. MS 1 mentioned the measurements focus on gaps between the rail and mattress to prevent resident's hands from getting stuck. During a review of the facility's policy and procedure titled, Bed Safety and Bed Rails dated 8/2022 indicated the use of bed rails or side rails is prohibited unless the criteria for bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment and informed consent. During a review of the facility's policy and procedure titled, Informed Consent dated 12/2024 indicated that a licensed nurse will verify the informed consent information and sign it to confirm its accuracy and completeness.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Three errors out of 29 opportunities contributed to an overall error rate of 10.34 % affecting two of five residents observed for medication administration (Residents 92 and 97). The errors noted were as follows:Incorrect strength of ferrous sulfate (an iron supplement) administered to Resident 97Incorrect formulation of multivitamins (a vitamin supplement) administered to Resident 97Incorrect strength of ferrous sulfate administered to Resident 92 The deficient practice of failing to administer medications in accordance with the physician's orders or professional standards increased the risk that Residents 92 and 97 may have experienced medical complications possibly resulting in hospitalization.Findings: During an observation of medication administration on 2/10/26 at 8:07 AM with the Licensed Vocational Nurse (LVN 4), LVN 4 was observed administering the following medications to Resident 92 by mouth:7.5 milliliters (ml - a unit of measurement for volume) of ferrous sulfate 220 milligrams (mg - a unit of measurement for mass) per 5 ml. During an observation of medication administration on 2/10/26 at 9:14 AM with the LVN 4, LVN 4 was observed administering the following medications to Resident 97 via gastrostomy tube (g-tube - a tube surgically implanted into the stomach for the administration of medication and nutrition):7.5 ml of ferrous sulfate 220 mg/ 5 ml.One tablet of a multivitamin with minerals supplement. A review of Resident 92's admission Record (a document containing diagnostic and demographic information), dated 2/11/26, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including dementia (a decline in mental abilities including memory, thinking, language and reasoning severe enough to interfere with daily life.)A review of Resident 92's History and Physical (a record of a physician's comprehensive medical assessment), dated 7/5/25, indicated Resident 92 did not have the capacity to understand and make decisions.A review of the physician's order, dated 2/5/26, indicated Resident 92's attending physician prescribed ferrous sulfate 5 mg/ 20 ml to take 7.5 ml by mouth once daily. A review of Resident 97's admission Record (a document containing diagnostic and demographic information), dated 2/11/26, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including cerebral infarction (stroke.)A review of Resident 97's History and Physical, dated 10/12/25, did not indicate whether Resident 97 had the capacity to understand and make decisions.A review of the physician's order, dated 2/5/26, indicated Resident 97's attending physician prescribed ferrous sulfate 5 mg/ 20 ml to take 7.5 ml by mouth twice daily via g-tube.A review of the physician's order, dated 10/12/25, indicated Resident 97's attending physician prescribed one tablet of multivitamins (without minerals) to be given once daily via g-tube.During an interview on 2/10/2026 at 10:23 AM with LVN 4, LVN 4 stated he administered the wrong dose of ferrous sulfate to Residents 92 and 97. LVN 4 stated the order was for the ferrous sulfate 5 mg/20 ml formulation and he administered 220 mg/5 ml. LVN 4 stated he failed to check that the strength of the formulation he had did not match the formulation in the physician's order prior to administering the medication. The LVN 4 stated he should have contacted the physician to clarify the order once he noted that the strength of the order did not match the product on hand. LVN 4 stated giving an incorrect dosage of any medication to a resident could result in the resident experiencing medical complications. LVN 4 stated he also administered the incorrect formulation of multivitamins to Resident 97. LVN 4 stated the order was for the regular multivitamin and he administered the multivitamin with minerals formulation. LVN 4 stated he does not have the formulation without minerals and should have called the physician to clarify prior to administering the other form. LVN 4 stated administering the wrong medications or the wrong formulations of medications to the residents could result in medical complications which could lead to harm. A review of the facility's policy Medication Administration - General Guidelines, dated October 2017, indicated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications.Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.

Based on observation, interview, and record review, the facility failed to ensure food safety, sanitary food storage and food preparation practices.These failures have the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for the residents.Findings:During an observation on 2/9/2026 at 8:45 a.m. in the kitchen with the Dietary Services Supervisor (DSS), In Refrigerator 2 there were two open corn tortilla packages on the top shelf. One corn tortilla package with an open date of 2/7/2026 was in its original plastic packaging and open-to-air. One open corn tortilla package was stored in plastic wrap with no open date.During an observation on 2/9/2026 at 9:13 a.m. in the kitchen with the DSS, In the dry storage room there was one dented pineapple can on the same shelf as non-dented food cans. One open dried tri-colored pasta was stored in its original packaging and open-to-air.During a concurrent observation and interview on 2/10/2026 at 8:27 a.m. with the DSS in the kitchen, there was a black trash bin with a broken lid that did not close. There was a brown trash bin with no lid in the handwashing area. The DSS stated the trash bins were actively used by kitchen staff. The DSS stated uncovered trash cans are not sanitary because they attract pests by providing readily accessible food.During an interview on 2/10/2026 at 8:40 a.m. with the DSS, the DSS stated a can is dented if the surface or seam of the body is not smooth. The DSS stated there is a separate area to store dented cans to prevent kitchen staff from using them. The DSS stated dented canned foods pose a risk for botulism (a serious illness caused by a toxin that attacks the body's nerves) because air and moisture can enter the container, allowing bacteria to grow and spoil the food.During a concurrent observation and interview on 2/10/2026 at 8:51 a.m. with the DSS in the kitchen, there were three cutting boards (yellow, blue, and brown) with visible cut marks. The DSS stated that cutting boards with visible cut marks and scratches should be replaced. The DSS stated harmful bacteria can grow in the grooves of scratched cutting boards and can cause cross contamination when food product is placed on the cutting board.During an interview on 2/10/2026 at 9:01 a.m. with the DSS, DSS stated open refrigerated food products should be labeled with an open date and stored in a covered container to limit exposure to contaminants. DSS stated open dates prevent staff from using potentially expired food items that can be unsafe for residents to eat. The DSS stated pests can infest open dry goods that are not properly stored. The DSS stated residents could potentially get foodborne illness from contaminated food.During a concurrent observation and interview on 2/10/2026 at 9:32 a.m. with the DSS in the kitchen, four wet pans were stacked on top of each other. The DSS stated pots and pans should be completely air-dried before stacking them and putting them away. The DSS stated wet nesting (when wet dishes, utensils, or cookware are stacked, trapping moisture and creating ideal conditions for bacteria to grow) can occur.During a review of the facility's Dry Goods Storage Guidelines, dated 2018, the recommended storage length for opened refrigerated corn tortillas is one week.During a review of the facility's policy and procedure (P&P) titled, Dating and Labeling, undated, the P&P indicated, loose food items should be placed in containers or bins. The P&P indicated, containers or bins will be dated, labeled, and covered. The P&P indicated, food items should have an open date.During a review of the facility's P&P titled, Storage of Canned and Dry Goods, undated, the P&P indicated, containers with tight fitting lids or re-sealable plastic bags will be used for opened packages like pasta, rice, cereal, and flour.During a review of the facility's P&P titled, Storage of Canned and Dry Goods, undated, the P&P indicated, dented, leaking or bulging cans will be stored separately in a designated area.During a review of the facility's P&P titled, Waste Control and Disposal, undated, the P&P indicated, Trash bins should be covered at all times.During a review of the facility's P&P titled, Cutting Board Cleaning, undated, the P&P indicated, Dietary staff to ensure all cutting boards are in good condition.During a review of the facility's P&P titled, Dish Washing Procedures - Dish Machine, undated, the P&P indicated, Dishes and utensils will be air dried before storage.

Based on interview and record review, the facility failed to follow the care plan and implement nonpharmacological interventions (any healthcare intervention not involving medications) for pain for one of eight sampled residents (Resident 20).This deficient practice had the potential to place the resident at risk for ineffective pain management and untreated pain.Findings:During a review of Resident 20's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 11/15/2021 with diagnoses including hypertension (HTN- high blood pressure), schizophrenia (a mental illness that is characterized by disturbances in thought) and low back pain.During a review of Resident 20's History and Physical (H&P) dated 12/21/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 20 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 20 was dependent on staff for toileting and bathing and required maximal assistance with dressing and personal hygiene.During an interview on 2/11/2026 at 9:41 a.m. with Resident 20, Resident 20 stated pain medications sometimes help with the recurrent pain he had in his right shoulder. Resident 20 stated he had never been offered anything besides pain medications for the pain. Resident 20 stated a hot pack might help with the pain and he was interested in trying alternative interventions.During a concurrent interview and record review on 02/11/2026 at 9:46 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 20's care plan titled Actual Pain: Right Shoulder Pain indicated nonpharmacological interventions including hot pack, cold pack, massage and distraction. LVN 2 stated he had never offered Resident 20 a hot pack for pain because Resident 20 usually had a lidocaine patch (a topical medication applied to the skin to relieve localized pain) on his right shoulder. LVN 2 stated care plan interventions should have been followed to better manage Resident 20's pain. LVN 2 stated care plans should have been followed to address Resident 20's pain. LVN 2 stated not implementing care plan interventions places residents at risk for ineffective pain management and untreated pain.During a concurrent interview and record review on 2/12/2026 at 8:47 a.m. with Registered Nurse (RN) 1, Resident 20's nurses progress notes were reviewed. RN 1 stated if nonpharmacological interventions for pain were implemented, documentation would be present in nurses progress notes. RN 1 stated there was no documentation of nonpharmacological interventions implemented to address Resident 20's pain. RN 1 stated following care plans were important because goals and interventions address resident specific needs. RN 1 stated not implementing care plan interventions for pain places residents at risk for untreated painDuring a review of facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated March 2023, the P&P indicated, The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: provided by qualified persons.

Based on observation, interview, and record review, the facility failed to obtain a complete a written informed consent (voluntary agreements to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of physical restraints (devices that limit a resident's movement) prior to the use of padded bilateral upper side rails for one of one sampled resident (Resident 196).This failure resulted in a violation of Resident 196's right to be informed and participate in treatment decisions. Findings:During a review of Resident 196's admission Record, the record indicated the facility admitted the resident on 1/22/2026, with diagnoses including but not limited to tracheostomy (a surgical procedure to create an opening through the neck into the windpipe to provide an alternative airway), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 196's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 1/29/2026, the MDS indicated the resident is severely cognitively impaired (inability to carry out regular tasks and apply judgement).During a review of Resident 196's physician order, dated 1/31/2026, the order indicated, obtain informed consent from the resident representative (a designated individual authorized to act on behalf of another person) after explanation of risks and benefits for the use of padded bilateral upper side rails when the resident is in bed.During a review of Resident 196's care plan, dated 1/31/2026, the care plan indicated, Low bed with padded bilateral upper half side rails up and locked when in bed for safety and positioning.During a review of Resident 196's informed consent for low bed with bilateral upper half side rails, undated, the consent indicated documentation is to be completed before treatment is initiated for use of a restraint.During an observation on 2/9/2026 at 9:46 a.m. in Resident 196's room, Resident 196's bilateral upper side rails were padded and locked in position.During a concurrent interview and record review on 2/11/2026 at 1:18 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 196's informed consent for low bed with bilateral upper half side rails was reviewed. The consent did not indicate a signature from the prescribing physician, resident representative, or nurse verifying the consent. LVN 3 stated she inputted the physician order into the system and forgot to ensure the informed consent form was completed.During a concurrent interview and record review on 2/16/2026 at 1:53 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, dated August 2022 was reviewed. The P&P indicated, the use of bed rails or side rails is prohibited unless the criteria for the use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The DON stated padded side rails are a safety device and require informed consent prior to use. The DON stated staff did not follow the facility's P&P.During a review of the facility's P&P titled, Informed Consent, dated December 2024, the P&P indicated, the prescribing physician, resident or resident representative, and verifying nurse must sign the informed consent form to ensure completeness.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 18) who was under hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) was visited by hospice licensed nurses weekly per hospice care agreement.This failure had the potential to result in Resident 18 not having their hospice needs met, as they agreed upon.Findings:During a review of Resident 18's admission Record, the admission Record indicated, Resident 18 was initially admitted to the facility on [DATE] and last re-admission was on 10/3/2025 with diagnoses including senile degeneration of brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and encephalopathy (a disturbance of brain function).During a review of Resident 18's History and Physical H&P, dated 10/4/2025, the H&P indicated, Resident did not have the capacity (ability) to understand and make decisions.During a review of Resident 18's Minimum Data Set (MDS-a resident assessment tool), dated 1/19/2026, the MDS indicated Resident 18 was dependent on staff and required assistance (Helper does all of the effort) from two or more staff for eating, hygiene, shower/bath, dressing, bed mobility, and transfer.During a concurrent interview and record review on 2/11/2026, at 9:59 a.m., with Registered Nurse Supervisor (RNS)1, Resident 18's Patient Calendar, dated 2/2026 was reviewed. The Patient Calendar indicated, there was no initial on 2/10/2026 for Hospice Registered Nurse (RN). RNS 1 stated, the hospice RN should have put her initials when she came to see Resident 18 and documented assessment in communication note. RNS 1 stated, there was no sign-in sheet for the hospice staff. RNS 1 stated, RN or Licensed Nurses should have visited Resident 18 once a week (every Tuesday) per hospice agreement. RNS 1 stated, the facility staff did not follow up with the hospice staff, regarding the missing visit on 2/10/2026. RNS 1 stated, Hospice nurses visits should be done weekly according to the hospice agreement, and Resident 18 would not receive specialty care and assessment if the hospice nurses' visits were not ensured as agreed. During an interview on 2/12/2026, at 2:15 p.m., with the Director of Nursing (DON), the DON stated, the staff should have followed up with weekly hospice licensed nurses' visit to ensure Resident 18 received the care agreed upon. The DON stated, the facility staff had the responsibility for ensuring Resident 18 who was under hospice care received the best care, especially specialty care such as hospice assessment and palliative care (a medicine or form of medical care that relieves symptoms without dealing with the cause of the condition) as agreed.During a review of Resident 18's Hospice Communication Update, dated from 1/2026 to 2/2026, the Hospice Communication Update indicated, there was no assessment and documentation on 2/10/2026 from RN or Licensed Nurse.During a review of Resident 18's Hospice Certification of Terminal Illness, dated1/8/2026, the Hospice Certification of Terminal Illness indicated, Hospice would provide Skilled Nursing Service from RN or Licensed Nurse once a week for 13 weeks and Aide Service twice a week for 13 weeks.During a review of Resident 18's Care Plan Report titled, Resident 18 was at risk for unavoidable declines, revised 2/4/2025 and 11/13/2025, the Care Plan Interventions indicated, provide Resident 18 to have comfortable and dignified dying process and refer to Hospice services as ordered.During a review of Resident 18's Order Summary Report (OSR), dated 2/11/2026, the OSR indicated, admit to the hospice care on routine level of care with diagnosis of senile degeneration of the brain was ordered on 10/13/2025.During a review of the facility's Policy and Procedure (P&P) titled, Hospice Program, revised 7/2017, the P&P indicated, Policy Interpretation and Implementation: 5. Hospice providers who contract with this facility: a. must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency; and b. are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. 9. (in general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: a.Determining the appropriate hospice plan of care; b. Changing the level of services provided when it is deemed appropriate; c. Providing medical direction, nursing and clinical management of the terminal illness; d. Providing spiritual, bereavement and/or psychosocial counseling and social services as needed; and e. Providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs.

Based on observation, interview, and record review the facility failed to store two unopened Humalog insulin pens (a medication used to treat high blood sugar) in the refrigerator per the manufacturer's requirements affecting Residents 160 and 207 in one of five inspected medication carts (Station 3 Cart A.)The deficient practices of failing to store unopened insulin pens in the refrigerator per the manufacturer's requirements increased the risk that Residents 160 and 207 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.Findings: During a concurrent observation and interview on [DATE] at 1:25 PM of Station 3 Medication Cart A with the Licensed Vocational Nurse (LVN 5), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:Two unopened Humalog insulin pens were found stored in the medication cart at room temperature. According to the product labeling, unopened Humalog insulin pens should be stored in the refrigerator. During a concurrent interview, LVN 5 stated the Humalog insulin pens for Residents 160 and 270 are stored at room temperature and not labeled with an open date. LVN 5 stated unopened insulin should be stored in the refrigerator because once stored at room temperature it is only good for 28 days. LVN 5 stated if insulin in the medication cart does not have an open date on it, we won't be able to know accurately when it expires. LVN 5 stated giving expired insulin to residents could cause poor blood sugar control possibly leading to medical complications.A review of the facility's policy titled Storage of Medications, revised [DATE], indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. medications requiring refrigeration. are kept in a refrigerator with a thermometer to allow temperature monitoring.

Based on observation, interview, and record review, the facility failed to ensure the tube feeding (a method of delivering liquid nutrients, fluids, and medications directly into the stomach or small intestine via a flexible tube) machine was on and functioning properly to administer the feeding for one of three sample residents (Resident 5) when the tube feeding machine was on but not administering the feeding to Resident 5 for over three hours.This deficient practice placed Resident 5 at risk for weight loss and nutritional deficit. Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE], readmitted on [DATE]. Resident 5's diagnoses included acute respiratory failure (a life-threatening, sudden-onset condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and persistent vegetative state (a disorder of consciousness following severe brain injury where the patient is awake but completely unaware of themselves or their environment).During a review of Resident 5's Minimum Data Set (MDS], a resident assessment tool), dated 12/22/2025, the MDS indicated Resident 5 was rarely/never understood. The MDS indicated Resident 5 was dependent (helper does all the effort to complete the task while resident does none) on mobility (ability to move freely and easily) with transfers and self-care abilities such as eating, hygiene and dressing.During a review of Resident 5's Order Summary Report dated 2/9/2026, the Order Summary Report indicated Jevity 1.5 (a type of tube feeding brand) at 60 milliliter per hour (mL/hr, a units of measurement used to calculate how much fluids an individual receives) for 20 hours via (by) pump to provide 1200 milliliter (mL, unit of measurement) or 1800 kcal (measure nutritional energy) per day, start enteral feeding at 12:00 p.m. and stop at 8:00 a.m.During a review of Resident 5's Order Summary Report dated 12/4/2025, the Order Summary Report indicated turn pump on at 12 p.m. and turn off at 8 a.m. the following day or until dose is completed.During an observation on 2/9/2026 at 11:06 a.m., in Resident 5's room, Resident 5 was resting in bed with eyes closed. The tube feeding machine with the tube feeding formula bottle was near the resident. The tube feeding tubing was connected to the resident but was not on. The formula bottle was full at 1500 mL of formula in the bottle.During an observation on 2/9/2026 at 3:16 p.m., in Resident 5's room, Resident 5 was lying in bed. The tube feeding machine next to the resident was connected to the resident and the machine was on but the feeding in the tube was not moving into the resident. The tube feeding machine was on but the tube feeding machine was not moving the tube feeding formula into Resident 5's abdomen for feedings. During a concurrent observation and interview on 2/9/2026 at 3:38 p.m., with Licensed Vocational Nurse (LVN) 1 in Resident 5's room, LVN 1 stated LVN 1 turned on the tube feeding at 12:00 p.m. today. LVN 1 stated there was about 1500 mL left in formula bottle. LVN 1 stated LVN 1 does not know why the tube feeding was not infusing the feedings into Resident 5 and started to troubleshoot the cause of the delay. LVN 1 was able to start the tube feeding after troubleshooting the machine and tube feeding formula started moving along the tube into the resident. During an interview on 2/12/2026 at 10:10 a.m., with Registered Dietician (RD), the RD stated Resident 5's order was for Jevity 1.5 @ 60 mL/hr for 20 hours. The RD stated Resident 5 was in a vegetative state (a person is awake but not aware of themselves or their surroundings because the thinking part of their brain is severely damaged) and unable to communicate his needs. The RD stated if the tube feeding was started at 12:00 p.m. and at 3:38 p.m. and there was still 1500 mL of formula feeding in the bottle, it means that Resident 5 did not receive any tube feeding. The RD stated negative outcome of not receiving the tube feeding was potential weight loss, and the resident's recovery would be affected.During an interview on 2/12/2026 at 1:33 p.m., with the Director of Nursing (DON), the DON stated the tube feeding was not given to the resident if the tube feeding was started at 12:00 p.m., and formula bottle was still full at 1500 mL at 3:38 p.m. on same day. The DON stated that it was over three hours of no tube feeding given. The DON stated she would expect the formula bottle to be less than full if the tube feeding was started at 12:00 p.m. and by 3:38 p.m., the formula bottle would reflect amount given since the time it started. The DON stated it was the expectation for the nursing staff to assess the resident, make a change in condition assessment, notify primary physician, and start the tube feeding right away. The DON stated the negative outcome of residents not receiving the tube feeding as ordered was weight loss, skin issues can develop or become worse, and the residents were not getting the nutrients needed.During a review of the facility's policy and procedure (P&P) titled Enteral Nutrition, revised November 2018, indicated adequate nutritional support through enteral nutrition is provided to residents as ordered. some examples of potential benefits of using a feeding tube include addressing malnutrition and dehydration; and promoting wound healing. the nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo- or hyperglycemia, and altered electrolytes. The nursing staff and provider also monitor the residents for worsening of conditions that place the residents at risk for the above.During a review of the facility's P&P titled Enteral Feedings-Safety Precautions, revised November 2018, indicated to ensure the safe administration of enteral nutrition. all personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 15) received Restorative Nursing Assistant ([RNA], a certified nursing assistant who works with patients in skilled nursing facilities to help them regain their ability to perform daily tasks) services ordered for the resident.This deficient practice had the potential to negatively have a decline in range of motion and mobility leading to contractures. Findings:During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 15's history and physical (H&P) dated 7/5/2025, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set ([MDS], a resident assessment tool) dated 12/31/2025, the MDS indicated Resident 15 had intact cognitive (thinking process) skills. The MDS indicated Resident 15 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with self-care abilities such as eating, hygiene, and dressing. The MDS indicated Resident 15 was dependent with mobility abilities such as sitting to lying position, and transfers. During a review of Resident 15's Order Summary Report, the Order Summary Report indicated an order dated 1/14/2025 RNA to perform passive range of motion ([PROM], a movement of a joint through its available range by an external force without the patient using their own muscles) to bilateral lower extremities ([BLE], both legs) every day five times a week or as tolerated. The Order Summary Report indicated an order dated 10/10/2024 RNA to perform PROM to bilateral upper extremities ([BUE], both arms) every day five times a week or as tolerated. The Order Summary Report indicated an order dated 10/10/2024 RNA to apply soft hand rolls (soft, cushioned, or inflatable orthotic devices designed to manage hand dysfunction, specifically finger flexion contractures) to bilateral hands up to four hours every day five times a week or as tolerated. During a review of Resident 15's Documentation Survey Report for December 2025, the Documentation Survey Report for December 2025 indicated RNA to perform PROM to BLE every day, five times a week or as tolerated was completed five days a week but there was documentation of NA on 12/30/2025 and 12/31/2025. The Documentation Survey Report for December 2025 indicated RNA to perform PROM to BUE every day five times a week or as tolerated was completed five days a week but there was documentation of NA on 12/30/2025 and 12/31/2025. The Documentation Survey Report for December 2025 indicated that RNA to apply soft hand rolls to bilateral hands up to four hours every day five times a week or as tolerated was completed five days a week but there was documentation of NA on 12/25/2025, 12/30/2025 and 12/31/2025. During an observation and interview on 2/9/2026 at 10:31 a.m., with Resident 15 in his room, Resident 15 was resting on his left side and turned to his back when surveyor greeted Resident 15. Resident 15 stated he can't use his hands which also meant he (Resident 15) was not able to use his wheelchair as before. Resident 15 stated he was not getting any physical therapy right now and was not sure about getting any RNA services.During a concurrent interview with record review on 2/12/2025 at 12:13 p.m. with RNA 1, the Documentation Survey Report for December 2025 was reviewed. RNA 1 stated Resident 15 has orders for RNA services five times a week as ordered. RNA 1 stated RNA services could possibly be provided for the dates that indicated NA and the nursing staff might have input the information incorrectly but if it was not documented, the services were not provided. RNA 1 stated the importance of residents getting RNA services every day was so staff are providing the services to the residents based on the orders. RNA 1 stated the staff do RNA services to prevent the residents from getting worse. During an interview on 2/7/25 at 4:44 p.m. with Director of Nursing (DON), the DON stated residents who are in the RNA program should be getting the services provided to them as ordered by the physician. The DON stated the importance of accurate documentation was if the residents were getting the services, the documentation should reflect the services provided to the residents. The DON stated that if it was not documented that the services were provided, it means the services were not provided as ordered. The DON stated residents can have a decline with their movement and mobility if RNA services were not provided to the residents. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised July 2017, indicated, residents will not experience an avoidable reduction in range of motion (ROM). residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts.During a review of the facility's P&P titled Job Title: Restorative Nursing Aid (RNA), revised 11/13/2025, indicated restorative nursing approaches on residents to assist the residents in reaching their maximum potential mobility assists in providing a clean, safe, dignified, happy and healthy environment for residents by performing the duties as described below.assists residents with range of motion exercises (passive/active), other general strengthening exercises, and ambulation/transfer exercises per physician's orders to improve or maintain mobility and independence in the resident. provides daily and weekly documentation for each resident in the restorative program, including weekly progress summaries for each resident. provides residents with routine restorative nursing care and services in accordance with the resident's assessment, care plan and as directed by supervisors. does required daily documentation as required by policy and procedure.

Based on interview and record review, the facility failed to ensure nursing staff used behavioral signs of pain (observable non-verbal actions that indicate distress such as facial grimacing, moaning, irritability) to assess pain for one of eight sampled residents (Resident 20).This deficient practice had the potential to result in inaccurate pain assessments and untreated pain.Findings:During a review of Resident 20's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 11/15/2021 with diagnoses including hypertension (HTN- high blood pressure), schizophrenia (a mental illness that is characterized by disturbances in thought) and low back pain.During a review of Resident 20's History and Physical (H&P) dated 12/21/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 20 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 20 was dependent on staff for toileting and bathing and required maximal assistance with dressing and personal hygiene.During an interview on 2/11/2026 at 9:41 a.m. with Resident 20, Resident 20 stated he had recurrent pain in his right shoulder and his current pain level was a six out of ten on a numeric pain scale (self-report tool used to quantify pain intensity utilizing a numeric scale of zero to ten, zero indicating no pain and ten as severe pain). Resident 20 stated he had pain in right shoulder in the morning and Licensed Vocational Nurse (LVN) 2 administered pain medication to treat the pain. Resident 20 stated pain remained unrelieved after taking pain medication.During a concurrent interview and record review on 2/11/2026 at 9:46 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 20's Pain Level Summary, dated 2/11/2026 was reviewed. Resident 20's Pain Level Summary indicated, pain level on 2/11/2026 at 8:45 a.m. was zero out of ten on a numeric scale. LVN 2 stated when he assessed Resident 20's pain level, Resident 20 yelled he was in pain but refused to state his pain level on a numeric scale. LVN 2 stated he administered Resident 20's scheduled pain medication, but documented pain level as zero out of ten. LVN 2 stated his documentation of Resident 20's pain of zero out of ten was inaccurate and he should have assessed Resident 20's pain using behavioral signs of pain (observable non-verbal actions that indicate distress such as facial grimacing, moaning, irritability). LVN 2 stated inaccurate pain assessments place residents at risk of prolonged discomfort and untreated pain.During an interview on 2/12/2026 at 1:20 p.m. with the Director of Nursing (DON), the DON stated licensed nurses are expected to assess the pain of residents each shift and as needed. The DON stated when residents are unable to verbalize pain level using a numeric scale, licensed nurses should assess residents' behavioral signs of pain. The DON stated not assessing residents' behavioral signs of pain places residents at risk of inaccurate pain assessments. The DON stated inaccurate pain assessments place residents at risk for untreated pain.During a review of facility policy and procedure (P&P) titled, Pain Assessment and Management dated March 2020, the P&P indicated, Recognizing pain: Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain .Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program.

Based on observation, interview and record review, the facility failed to implement the nursing interventions according to the care plan for one of three sampled residents (Resident 99). This deficient practice had the potential for Resident 99 needs not being met. Findings: During a record review of Resident 99's admission record indicated Resident 99 was admitted on [DATE] with a diagnoses dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and history of falling. During a record review of Resident 99's MDS dated [DATE] indicated that residents cognitive was impaired. The MDS indicated that Resident 99 needs maximal assistance with toileting, shower, lower body dressing and putting on/taking off footwear. During an observation on 02/09/2026 at 9:49 a.m. in Resident 99's room, Resident 99 was lying in bed facing the door with bilateral siderails up and call light within reach. Resident 99 did not have any floor mats or bed alarm in room. During a review of the care plan initiated on 5/6/2021 indicated Resident 99's care plan titled Falling Star Program. The Care plan goal indicated will reduce risk for falls and/or injury through appropriate interventions daily. The care plan interventions indicated floor mats, bed/chair alarm and IDT conferences for falls. During an interview and record review on 2/11/2026 at 12:45 p.m., Licensed Vocational Nurse (LVN) 4 stated that Resident 99's care plan was not updated to reflect the resident's current needs. LVN 4 reported that the facility does not follow the care plan regarding Resident 99's floor mat and bed alarm. LVN 4 further stated that Resident 99 has never had a bed alarm. During a review of the facility's policy and procedure titled, care plans, comprehensive-person centered dated 3/2023 indicated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes.

Based on observation, interview and record review the facility failed to ensure Minimum Data Set (MDS- a resident assessment tool) accurately reflects resident status for two of five sampled residents (Resident 73 and Resident 99). This failure had the potential to result in inaccurate assessment of the resident's condition, leading to inappropriate care planning, monitoring and interventions. Findings: A. During a record review of Resident 73's admission record, it indicated Resident 73 was admitted on [DATE] with a diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a record review of Resident73's Minimum Data set (MDS- resident assessment tool), dated 1/26/2026 , the MDS indicated that Residents 73 cognition was impaired. The MDS indicated that Resident 73's needs maximal assistance (helper does more than half the effort) with showers, resident needs moderate assistance with toileting, upper body dressing, lower body dressing, putting on/taking off footwear and with personal hygiene. During an observation on 2/10/2026 at 8:50 a.m. in Resident 73's room, Resident 73 was lying in bed on her back with padded bilateral side rails up. During a concurrent observation and interview on 2/9/2026 at 11:56 a.m. in Resident 73's room with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that Resident 73 should not have padded side rails because Resident 73 does not have a diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 73's order summary report dated 2/12/2026, the summary report indicated physician's order Support & Safety Device low bed with bilateral quarter rails in bed as enabler for bed mobility, repositioning and other activity of daily living (ADL's) not considered a restraint. Padded siderails to decrease potential injury. During a concurrent interview and record review with MDS Nurse on 2/12/2026 at 1:15 p.m., the was reviewed. The MDS Nurse stated that Resident 73's assessment was not completed accurately. The assessment section P of the MDS titled, Restraints and Alarms incorrectly addressing the question asking whether Resident 73 use bed rails in bed and padded side rails. MDSNurse stated that bilateral side rail was not captured on the MDS because it is not considered a restraint. During a Review of Resident 73's care plan initiated on 12/4/2024 titled Resident is low bed with bilateral quarter rails in bed as enabler for bed mobility, repositioning and other ADLs. (not considered a restraint). B. During a record review of Resident 99's admission record, the admission record indicated Resident 99 was admitted on [DATE] with a diagnoses dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and history of falling. During a record review of Resident 99's MDS dated [DATE] , the MDS indicated that Resident's 99 cognition was impaired. The MDS indicated that Resident 99 needs maximal assistance with toileting, shower, lower body dressing and putting on/taking off footwear. During an observation on 02/09/2026 at 9:49 a.m. in Resident 99's room, Resident 99 was lying in bed facing the door with bilateral siderails up. During a review of Resident 99's order summary Report dated 2/12/2026 the order summary report indicated physician's order Support & Safety Device low bed with bilateral quarter rails in bed as enabler for bed mobility, repositioning and other activity of daily living (ADL's) not considered a restraint. During an interview and record review on 2/12/2026 at 10:45 a.m. with Assistant Director of Nursing (ADON), ADON stated that the MDS nurse should have captured the use of bed rails in Resident 99's annual assessment and Resident 73's quarterly assessment . It is important to accurately complete the assessment to create a care plan that meets Resident 99's and 73's needs.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse when Resident 96 pushed Resident 44, causing Resident 44 to fall to the ground. This deficient practice resulted in Resident 44 falling and sustaining a traumatic skin tear measuring 1 centimeter (cm unit of measure of length) long by x 0.1 cm wide on the right eyebrow, requiring an emergency visit to a General Acute Care Hospital (GACH) for treatment and management. Findings: During a review of Resident 44's admission record, the admission record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), depression (constant feelings of sadness, and irritability that lasts more than two weeks) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Residents 44's Minimum Data [MDS)] resident assessment tool), dated 12/26/2025, the MDS indicated Resident 44 cognitive (ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 44 needed partial assistance with personal hygiene, putting on/taking off footwear, lower body dressing, shower, toileting, and oral hygiene. During a review of Resident 96's admission record, the admission record indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), restlessness and agitation. During a review of Resident 96's care plan titled, Ineffective coping as evidenced by episodes of anger or hostility towards other residents, initiated on 10/01/2025, the care plan goals for Resident 96 included, resident needs to be met until the next assessment. The care plan intervention was to respect resident's preferences. During an observation on 2/09/2026 at 9:25 a.m., in the hallway Resident 44 was walking in the hallway and using paper towels to clean the handrails adjacent to room [ROOM NUMBER]. During an observation on 2/09/2026 at 9:27 a.m., Resident 96 was lying in bed with bilateral (both) side rails up, and call light within reach. The door of the closet in Resident 96's room was slightly ajar. During a review of Resident 44's COC assessment form dated 2/11/2026 and timed 5:45 a.m., the COC assessment form indicated Resident 44 had a cut on the right side of her forehead. The COC assessment form indicated on 2/11/2026 5:45 a.m. Resident 44 was found on the floor, bleeding from a cut on right side of her forehead. The COC assessment form indicated (LVN 6) (unknown staff) applied pressure to Resident 44's cut to minimize bleeding. The COC assessment form indicated Resident 44 was transferred to GACH emergency department. During a review of Resident 96's Change of Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition) assessment dated [DATE] and timed at 7:19 a.m., the COC assessment form indicated on 2/11/2026 at 5:45 a.m., Resident 96 stated she pushed her roommate (Resident 44) for being in her closet. During a concurrent observation and interview on 2/10/2026 at 12:54 p.m., with Certified Nurse Assistance (CNA) 1 in room [ROOM NUMBER], CNA 1 stated that the closets in the room were not locked because the locks did not work. CNA 1 stated that the closets in the residents' rooms must remained locked at all times. CNA 1 stated they would notify the maintenance department about the broken lock. During an observation on 2/11/2026 at 4:08 p.m. in room [ROOM NUMBER] Resident 44 was lying in bed with bilateral side rails up, wearing nonskid socks facing the window. the closet doors in Resident 44's room remained open, and accessible to all residents. During an interview on 02/11/2026 at 10:31 a.m., with Resident 96, Resident 96 stated earlier that morning (prior to the altercation with Resident 44), there was urine on the floor in their room. Resident 96 stated facility staff (unknown) instructed her (Resident 96) to return to bed. Resident 96 stated the urine was still on the floor. Resident 96 stated she went to bed, but later around 3:00 a.m., Resident 44 got out of bed and began cleaning (what) and looking at things inside her (Resident 96's) unlocked closet. Resident 96 reported Resident 44 searched through her (Resident 96)'s closet and was speaking in Spanish. Resident 96 stated she did not understand Spanish. Resident 96 stated she observed Resident 44 going through her belongings in her closet. Resident 96 stated she got out of bed and pushed Resident 44 away from the closet, but Resident 44 attempted to continue to look through the closet again. Resident 96 stated she pushed Resident 44 a second time, causing Resident 44 to fall to the floor. Resident 96 stated that staff (unknown) were aware of Resident 44's behavior and that both residents had been arguing since early morning. During an interview on 02/11/2026 at 10:13 a.m., with CNA 2, CNA 2 stated that Resident 44 often wandered into other residents' rooms and attempted to clean. CNA 2 stated that it was important to keep closets locked to prevent residents from accessing each other's belongings. CNA 2 stated that Resident 96 always wanted her closet locked at all times. During an interview and record review on 2/11/2026 at 12:14 p.m., with LVN 4 of Resident 44's care plan report and active physician orders for 02/2026 . LVN 4 stated that Resident 44 likes to clean and fix things in her and other residents' rooms. LVN 4 stated that staff had consistently observed Resident 44's behavior of cleaning and fixing things in other residents' room, since Resident 44 was admitted . LVN 4 stated facility staff did not monitor this behavior and there was no care plan for this behavior. LVN 4 stated the facility did not consider Resident 44's behavior of going into other residents' rooms cleaning and fixing things as a problem behavior. LVN 4 stated that Resident 44's care plan should have included monitoring this behavior of cleaning / fixing other resident's belongings. LVN 4 stated staff should have been monitoring Residents 44 behavior and potentially prevented the altercation with Resident 96 on 2/11/2026 at 5:45 a.m During an interview on 2/11/2026 at 3:56 p.m. with Social Worker (SW) 1, SW 1 stated that all the closets must be locked because residents in this unit are confused and can grab belongings from other residents since the residents wandering into other's rooms. SW 1 stated that CNAs are aware that all the closets must be locked to prevent items from going missing. SW stated that the altercation between Resident 44 and Resident 96 could have been avoided if the closet in Resident 96's room was locked. During an record review of Resident 44's tiled Licensed Nursing Note dated on 2:05 p.m indicated that Resident 44 came back from GACH, was assessed by treatment nurse and noted right eyebrow skin tear with discoloration measuring 1 cm long by x 0.1 cm wide.During an interview on 2/12/2026 at 7:13 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that approximately around 3:00 a.m., Resident 44 and Resident 96 were yelling at each other over water on the floor, which Resident 96 mistook for urine from Resident 44. LVN 2 stated unknown CNA and herself cleaned the floor and reassured Resident 96 that it was water. LVN 2 stated she put Resident 44 back to bed and did not notice whether the closet was unlocked. LVN 2 stated that she left Resident 44 and Resident 96 in the same room. During a subsequent interview on 2/12/2026 at 7:15 a.m., with LVN 2, LVN 2 stated at approximately around 5:00 a.m. while she was standing between rooms [ROOM NUMBERS], LVN 2 heard a loud noise, turned around and found Resident 44 on the floor bleeding from her head. LVN 2 stated she separated Resident 44 and Resident 96. LVN 2 stated Resident 96's closet remaining open was a major factor in the altercation. LVN 2 stated Resident 96 pushed Resident 44, because Resident 44 went into her closet. LVN 2 stated it was preventable if Resident 96's closet would have been closed and locked. During an interview on 02/12/2026 at 10:45 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that residents must be free from physical abuse because they are frail and rely on staff for safety. The ADON explained that closet locks should always be used, especially in secured units (exit and entrance to the unit are managed by facility staff), since residents wander and open closets. During interview on 2/12/2026 at 1:48 p.m. with the Administrator(Admin), the Admin stated that Resident 44 and Resident 96 should have been separated when the first altercation occurred regarding the water on the floor. Admin stated that it could have been prevented since there is already a verbal altercation prior before the physical altercation about the closet. Admin stated that this would be intentional for Resident 96 since it was triggered with the water droppings on the floor prior to the closet incident. During a review of Resident 44's GACH Emergency Documentation (ED) titled ED physician notes dated 2/11/2026 timed at 6:23 a.m. indicated complaint of head pain with laceration to frontal head and left knee pain after assaulted by another resident. The ED notes indicated that Resident 44 laceration to right eyebrow was closed using dermabond (surgical glue). Resident 44 was discharge with diagnosis of assault (physical attack) and facial laceration. During a record review of the facility's policy and procedure (P&P) titled, Abuse & Mistreatment of Residents revised on 5/3/2023 indicated involved resident(s) shall be removed from the environment that threatens residents' health or safety if the suspect is another resident the residents shall be separated to avoid any further contact. During a record review of the facility's policy and procedures (P&P) titled, Abuse & Mistreatment of Residents revised on 5/3/2023 indicated resident with possible needs and potential for behavioral symptoms and manifestation that may lead to conflict, and anger shall be identified through comprehensive assessment, initially upon resident admission and continually thereafter. During a record review of the facility's P&P titled, Secured Unit revised (unknown date) indicated may keep resident closets locked unless resident/responsible party prefers otherwise.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff notified the physician in a timely manner when one out of three residents (Resident 122) refused tube feeding (a method of delivering liquid nutrients, fluids, and medications directly into the stomach or small intestine via a flexible tube) for the day. This deficient practice placed Resident 122 at risk for potential weight loss and malnutrition. Findings:During a review of Resident 122's admission Record, the admission Record indicated Resident 122 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 122's diagnoses included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), acute respiratory failure (a life-threatening, sudden-onset condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 122's Minimum Data Set ([MDS], a resident assessment tool), dated 1/29/2026, the MDS indicated Resident 122 had intact cognitive (thought process) skills for daily decision-making. Resident 122 was dependent (helper does all the effort to complete the task while resident does none) on mobility (ability to move freely and easily) with transfers and self-care abilities such as eating, hygiene and dressing.During a review of Resident 122's Order Summary Report dated 11/26/2025, the Order Summary Report indicated Jevity 1.5 (a type of tube feeding brand) at 60 milliliter per hour ([mL/hr], a volume flow rate unit of measurement commonly used to define the rate at which fluids are given over a specific time) for 20 hours via (by) pump to provide 1200 mL or 1800 kilocalorie ([kcal], measure nutritional energy) per day.During a review of Resident 122's Order Summary Report dated 2/2/2025, the Order Summary Report indicated to turn feeding pump on at 12:00 p.m. and to turn feeding pump off at 8:00 a.m. the following day or when dose is completed. During an observation on 2/9/2026 at 12:06 p.m., of Resident 122 in his room, Resident 122 was awake and resting in bed. The tube feeding machine with the tube feeding formula bottle was near the resident. The tube feeding machine was connected to the resident, but the machine was off with about 1400 milli liters (mL - a unit of measure of volume) of tube feeding left in the formula bottle.During an observation on 2/9/2026 at 3:30 p.m., in Resident 122's room, Resident 122 was in bed. The tube feeding machine next to the resident was still connected to the resident but the tube feeding machine was still off with about 1400 mL of tube feeding left in the formula bottle. During a concurrent observation and interview on 2/9/2026 at 3:45 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the tube feeding machine was running around 10:00 a.m. today. LVN 1 stated Resident 122 did not want the tube feeding to continue at that time, so LVN 1 turned the tube feeding machine off and flushed Resident 122's tube feeding tube. LVN 1 stated if a resident refused the tube feeding, the primary physician should have been notified. LVN 1 stated he did not notify Resident 122's primary physician about Resident 122's refusal for tube-feeding. During an interview on 2/12/2026 at 10:10 a.m., with Registered Dietician (RD), the RD stated Resident 122's order was for Jevity 1.5 at 60 mL/hr for 20 hours for total of 1200 mL and 1800 calories daily. The RD stated the nursing staff should report Resident 122's refusal of tube feeding to the primary physician and/or the RD, and document that the physician and the RD were made aware. The RD stated residents have the right to refuse, but stated the RD needed to be made aware of the resident refusing the feeding so the RD can talk to the resident and inform them of benefits of the feeding and the risks of not receiving the feeding such as weight loss, and delay in recovery. During an interview on 2/12/2026 at 1:33 p.m. with the Director of Nursing (DON), the DON stated residents have the right to refuse feeding, but nursing staff should document the refusal in the residents' chart, call the primary physician, and inform the residents about risks and benefits of the refusal. The DON stated the outcome of residents when they continue to refuse tube feeding was weight loss, skin issues, and the residents not getting the nutrients needed to sustain life.During a review of the facility's policy and procedure (P&P) titled Requesting, Refusing and/or Discontinuing Care or Treatment, the P&P indicated residents, and resident representatives have the right to request, refuse and/or discontinue treatment. Treatment refers to medical care, nursing care, and interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms. detailed information relating to the request, refusal or discontinuation of treatment are documented in the resident's medical record.documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following such as the date and time the care or treatment was attempted; the type of care or treatment; the resident's response and stated reason(s) for request, discontinuation or refusal; the name of the person who attempted to administer the care or treatment; that the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the medication/or treatment; the resident's condition and any adverse effects due to the request; the date and time the practitioner was notified as well as the practitioner's response; all other pertinent observations; and the signature and title of the person recording the data.the healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request.

Based on interview and record review, the facility failed to ensure Advance Directives ([AD]-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information was provided to the residents and/or responsible parties and had a completed Physician Orders for Life-Sustaining Treatment ([POLST]- a medical order that helps give people with serious illness more control over their care during a medical emergency) for one of three sampled residents (Resident 18) in the medical records.These failures had the potential for delay of care and treatment and/ or inadvertently missed health care wishes/ decisions of the residents during emergencies, end of life, and changes in condition.Findings:During a review of Resident 18's admission Record, the admission Record indicated, Resident 18 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with diagnosis including senile degeneration of brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and encephalopathy (a disturbance of brain function).During a review of Resident 18's History and Physical (H&P), dated [DATE], the H&P indicated, Resident did not have the capacity (ability) to understand and make decisions.During a review of Resident 18's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 18 required dependent assistance (Helper does all of the effort) from two or more staff for eating, hygiene, shower/bath, dressing, bed mobility, and transfer.During a concurrent interview and record review on [DATE], at 9:59 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 18's Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE] was reviewed. The POLST indicated, Resident 18 had order for Do Not Attempt Resuscitation (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). The POLST indicated, Section D for AD was left blank and it was not completed. RNS 1 stated, the POLST was not completed because there was missing information. RNS 1 stated, if the POLST was not completed, the resident would be treated as full code and all life sustaining measures would be done during the emergency per policy. RNS 1 stated, the resident would be treated against his/her wish.During a concurrent interview and record review on [DATE], at 10:36 a.m., with Social Service Assistant (SSA) 1, Resident 18's Advance Healthcare Directive Acknowledgement (AHDA), dated [DATE] was reviewed. The AHDA indicated, the written materials regarding right to formulate/ accept or refuse AD were given to Resident 18's Responsible Party (RP) via telephone. The AHDA indicated, SSA 1 completed POLST and had telephone consent from RP without other witnesses. SSA 1 stated, she did not provide written materials regarding AD. SSA 1 stated, she did not complete and update the POLST. SSA 1 stated, she should have a witness while she was getting verbal consent via telephone. SSA 1 stated, there should be two witnesses when obtaining verbal or telephone consent including herself. SSA 1 stated, Resident 18's RP stated, she did not want to formulate AD and stayed on DNR status. SSA 1 stated, it was her responsibility to ensure documenting the availability of AD and discussion regarding AD with the resident or decision maker on POLST to honor the resident's wishes regarding care and treatment.During an interview on [DATE], 2:21 p.m., with the Director of Nursing (DON), the DON stated, AD and POLST should be available for all residents regardless. The DON stated, SSA 1 and staff should have ensured the completion of POLST and provided written information regarding AD. The DON stated, AD and POLST were important to honor residents' wishes and the guideline for how to treat residents in emergency situation.During a review of Resident 18's Social Service Note (SSN), dated, [DATE], the SSN indicated, SSA 1 reviewed Resident 18's POLST with RP and RP agreed to remain DNR, selective treatment, no artificial means of nutrition, including feeding tubes and no advance directive.During a review of Resident 18's Order Summary Report (OSR), dated [DATE], the OSR indicated, DNR was ordered on [DATE].During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised 9/2022, the P&P indicated, Policy Statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Policy Interpretation and Implementation . 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3.Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative. 5. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the residents' legal representative.During a review of the facility's Policy and Procedure (P&P) titled, POLST, revised 5/2024, the P&P indicated, Policy Interpretation and Implementation: 1. By signing POLST, which becomes a medical order, the physician, nurse practitioner or physician assistant certifies that the orders on the form are consistent with the resident's medical condition and preferences . 5. The POLST Allows both the doctor and patient (or their representative) to specify the types of medical treatment that the patient wishes to receive at the end of life.

Based on interview and record review, Licensed Vocational Nurse (LVN) 1 failed to assess the mobility limitations and take precautions before moving one of three sampled residents (Resident 1), who was dependent on staff to roll from the left to the right side. The facility failed to ensure: LVN 1 requested assistance from another staff member before repositioning Resident 1, who per the Minimum Data Set ([MDS] a resident assessment tool), was dependent on staff to roll from the left side to the right and or the assistance of two or more helpers was required for Resident 1 to roll from the left to the right side. This deficient practice resulted in LVN 1 repositioning Resident 1 without assistance and hitting Resident 1's right knee on the resident's bed frame. Resident 1 experience pain, swelling and tenderness to the right knee, and was subsequently diagnosed with an acute (sudden-onset) right distal femur fracture (a break of the knee). Resident 1 was transferred to a General Acute Care Hospital (GACH) where the fractured knee was immobilized (to prevent from moving), she was treated for pain and monitored for bleeding and a thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included a closed fracture (broken bone that does not penetrate the skin) of lower end of right femur, dementia (a progressive state of decline in mental abilities), and Alzheimer's (disease characterized by a progressive decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 1's cognition (the ability to think and reason) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort, resident did none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on staff for rolling left to right. The MDS indicated Resident 1 had a functional limitation in range of motion ([ROM] the full, functional measurement of the distance and direction a joint can move, stretching from maximum bending to full straightening) to both of her upper (arms) and lower (legs) extremities. During a review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 1/2/2026, and timed at 9:30 p.m., the SBAR indicated during rounds LVN 1 observed Resident 1 at the edge of her bed, upon repositioning the resident, she (LVN 1) accidentally bumped Resident 1's knee against the resident's bed frame. The SBAR indicated Resident 1's knee was slightly swollen, tender to touch and Resident 1 was moaning with facial grimacing.During a review of Resident 1's Physician's Orders, dated 1/2/2026, and timed at 11:50 p.m., the Physician's Order indicated a STAT (immediate) radiology ([X-ray] a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) to Resident 1's bilateral (both sides) hips, right femur and right knee due to pain. During a review of Resident 1's X-ray Report, dated 1/3/2026 and timed at 12:01 p.m., the X-ray report indicated Resident 1 had a fracture of the right distal femur. During a review of Resident 1's Licensed Nurses Note, dated 1/3/2026 and timed at 3:43 p.m., the note indicated Resident 1 was transferred to a GACH due to a fracture. During a review of the GACH's Emergency Department's History of Present Illness (HPI), dated 1/3/2026, the HPI indicated Resident 1 present to the emergency room with swelling and deformity of the right distal thigh, an X-ray indicated an acute distal femur fracture. The HPI indicated Resident 1 was admitted to the GACH for pain control, immobilization, an orthopedic (a medical specialist focusing on the muscles and bones) surgical evaluation, monitoring for complications including bleeding, thromboembolism and skin breakdown. During a review of the GACH's Orthopedic Consultation report, dated 1/5/2026, and timed at 9:37 a.m., the Orthopedic Consultation indicated Resident 1's injury was likely due to malunion (a broken bone that healed in an abnormal, misaligned position) and surgery was not recommended due to Resident 1's dementia and non-ambulatory status. The report indicated Resident 1 was stable for discharge from an orthopedic standpoint. During an interview on 1/28/2026 at 4:40 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 required a two-person assist for care. On 1/2/2026 she and CNA 2 provided care to Resident 1 during the 3 p.m. to 11 p.m., shift. CNA 1 stated sometime during the evening (time unknown), she and CNA 2 noticed Resident 1's right knee was bending weirdly. CNA 1 stated they (CNA 1 and CNA 2) informed LVN 1, LVN 1 repositioned Resident 1 and accidentally bumped the resident's right knee on bed frame. During an interview on 1/29/2026 at 10:13 a.m., LVN 1 stated on 1/2/2026, at around 9:30 p.m., while making rounds, she found Resident 1 at the edge of the right side of her bed, with her right foot hitting the bed's footboard. LVN 1 stated she knew Resident 1 was a two-person assist but everyone was busy caring for other residents', to prevent Resident 1 from falling she decided to reposition Resident 1 without assistance. LVN 1 stated she used a draw sheet (a small, folded bed sheet or specialized fabric placed across the middle of a mattress, covering the area between a patient's upper back and thighs. Primarily used to reposition, lift, or transfer patients) to pull Resident 1 up while Resident 1's right leg was crossed over the left leg; both legs were straight. LVN 1 stated Resident 1 was centered in the middle of the bed and as she proceeded to turn Resident 1 toward the left side of the bed, Resident 1 moved her legs, and her right knee hit the bed frame on the bottom of her bed that was exposed because the mattress did not cover the bed frame completely. LVN 1 stated she noticed Resident 1 was grimacing, moaning, and she observed redness and swelling on the resident's her right knee. During an interview on 1/29/2026 at 11:54 a.m., the Director of Nursing (DON) stated LVN 1 should have called for help if Resident 1 required a two-person assist. During a review of the facility's undated P/P, titled, Positioning & Moving Residents the P/P indicated before moving or lifting a resident, staff members were to assess the resident's physical abilities, mobility limitation in joints and muscles, strength, awareness of surroundings, and ability to follow directions. Staff members will use maximum precautions when moving or lifting residents, obtain assistance from other professional as needed.

Based on observation, interviews and record reviews, the facility did not provide timely medical intervention and transferred to a general acute care hospital (GACH) for one of three sampled residents (Resident 1) who experienced a significant change in condition related to unmanaged pain and delayed treatment. The facility failed to: 1. Notify Resident 1's physician promptly after receiving an order for right hip and right femur (the bone of the thigh or upper hind limb, articulating at the hip and the knee) x-ray (images of the inside of the body) result on 10/22/2025 at 1:22 a.m. indicating an acute (a condition that sudden) proximal (point of attachment) femoral (hip) fracture (broken bone) with soft tissue swelling (accumulation of fluid in the body's muscles and is a sign of inflammation caused by injury). The physician was not notified until 8:35 a.m., over seven hours later. 2.The facility failed to follow Resident 1's care plan titled, Resident 1 has the potential for alteration in comfort due to pain related to proximal femoral fracture, soft tissue swelling dated 10/22/25, which required staff to assess for pain, notify the physician of abnormal x-ray findings, administer pain medications as ordered, and notify the physician of any change in condition. 3.The facility failed to implement its policy and procedure titled Change in a Resident's Condition or Status (dated 2/2021), which requires prompt notification of the attending physician and resident representative upon significant changes in the resident's medical condition. These failures resulted in Resident 1 experiencing unmanaged right hip pain (documented up to 9/10 { 7 to 9-severe pain on a non-verbal pain scale [tools used to assess pain in residents who cannot verbally communicate]) and increased swelling. The resident was ultimately transferred to a GACH, approximately 10 hours after the initial signs of injury, and underwent a [NAME] (removal or resection of the head and neck of the femur. [NAME] is usually performed when the patient has a severely painful hip, and a total hip replacement [surgical procedure to replace a damaged hip] cannot be done) procedure with hip disarticulation (a surgical procedure where the entire leg is removed through the hip joint) on 10/24/2025. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses include chronic respiratory failure (a condition where there is not enough oxygen in your body) dependence on ventilator (a machine or device used to support or replace the breathing of a person ) age-related osteoporosis (a disease that makes bones weak, thin, and more likely to break) with current pathological fractures ( a condition where bones naturally become weaker and more fragile as people get older),quadriplegia, ( paralysis of both arms, and both legs), and contracture (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). During a review of Resident 1's Minimum Data Set (MDS- a resident's assessment tool) dated 8/19/2025, the MDS indicated Resident 1 had severe impairment in cognitive (ability to understand and be understood by others) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all the effort. Residents make none of the effort to complete the activity) with bed mobility, oral hygiene, toileting hygiene, personal hygiene, shower and upper/lower body dressing. The MDS indicated no indicators of pain or possible pain in the last five days of assessment (8/19/2025). During a review of Resident 1's Physician's Order dated 10/21/2025 at 3:30 p.m., the Physician's Order indicated to have a Stat (immediately) X-ray of Resident 1's right hip and right femur. During an observation on 11/5/2025 at 10:55a.m., Resident 1 was observed lying down on a low bed. Resident 1 was observed with both legs contracted (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) drawn toward the chest. The right hip area was observed with multiple stitches (piece of special thread used to hold the edges of a wound together to promote healing) due to [NAME] surgery done on 10/24/2025. During a concurrent observation and interview on 11/5/2025 at 11:00 a.m., with Licensed Vocational Nurse (LVN 1) in Resident 1's room, LVN 1 stated Certified Nursing Assistant (CNA) 1 observed Resident 1 on 10/21/2025 at approximately 1:45 p.m. making facial grimaces, (strong emotions suggestive of pain), and noted Resident 1's right hip appeared unstable wobbling, indicating an abnormal range of motion (ROM- the full movement potential of a joint or series of joints in a specific direction) compared to the resident's usual contracted position. LVN 1 stated CNA 1 immediately reported to her (LVN 1) and she informed Registered Nurse (RN) 1. LVN 1 stated RN 1 assessed Resident 1 but opted not to perform a more extensive physical assessment to avoid more complication. LVN 1 stated RN 1 noted the resident's right hip area was hot to touch. During a telephone interview on 11/5/25 at 11:34 a.m., with CNA 1, CNA 1 stated she was not certain of what happened to Resident 1's right hip. CNA 1 stated the splint (a supporting device made of hard material to protect a body part) applied on both lower extremities around the knees may have been too tight or pulled. CNA 1 stated that she began caring for Resident 1 on 10/21/2025 at the start of her shift (7:00 a.m. to 3:00 p.m.). CNA 1 stated she did not observe abnormalities during routine morning care on 10/21/2025 at approximately 10 a.m. CNA 1 stated on 10/21/2025 around 1:45 p.m., when she checked Resident 1, she observed the resident making facial grimaces. CNA 1 stated she noted Resident 1's right leg appeared loose and the right hip unstable. CNA 1 stated she immediately notified the charge nurse (LVN 1). CNA 1 stated Resident 1 wears a splint, with her legs typically positioned together, ankles overlapping, and drawn toward the chest. CNA 1 stated the Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) worked with the resident on 10/21/2025 at approximately 10:45 a.m. During the interview on 11/5/25 at 11:40 a.m., with RNA 1, RNA 1 stated she provides residents with ROM and splinting. RNA 1 stated Resident 1 had an order for knee splints for both lower extremities. RNA 1 stated she spread apart both Resident 1's knees and apply splints on 10/21/2025. RNA 1 stated Resident 1 was very contracted on both lower extremities and fragile. RNA 1 stated on 10/21/2025, she performed ROM to Resident 1 after Resident 1 was pre medicated with Tylenol (pain medication) and cleaned by CNA 1. RNA 1 stated when she performed ROM and applied knee splints to Resident 1 at 10:45 a.m., the resident was fine and tolerated the treatment. RNA 1 stated at approximately 2:45 p.m., RN 1 asked her why Resident 1's legs were loose. RNA 1 stated she does not know what happened to Resident 1's leg as it was okay when she did ROM and applied knee splints on 10/21/2025 at 10:45 a.m. During an interview on 11/5/25 at 1:05 p.m., with RN 1, RN 1 stated LVN 1 reported to her regarding Resident 1's wobbly leg. RN 1 stated when she assessed Resident 1's leg, she did not observe any swelling, but the right hip area was hot to touch. RN 1 stated she called Resident 1's medical doctor (MD) 1 and received an order on 10/21/2025 at 3:30 p.m., for stat x-ray to right hip and right femur. RN 1 stated LVN 1 gave Resident 1 Tylenol (pain medication) 500 milligrams (mg-unit of measurement) two tablets for pain scale pain scale rating of 7/10 ( zero to ten pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). During an interview on 11/5/2025, at 2:55 p.m., with LVN 1, LVN 1 stated pain assessment was based on Resident 1's facial expression, which was the reason the resident was medicated with Tylenol (pain medication). LVN 1 stated Resident 1 received Tylenol 500 mg (2 tablets) on 10/21/2025, at 2:14 p.m. and at 4:17 p.m. LVN 1 stated during the night shift ( 11 p.m. to 6 a.m.) Resident 1 received Norco ( narcotic pain medication used to manage moderate to severe pain) 5/325 mg one tablet on 10/22/2025 at 5:12 a.m., and 9:11 a.m. LVN 1 stated Resident 1 was transferred to GACH on 10/22/2025 approximately 11 a.m. LVN 1 stated Resident 1 hip and femur x-ray result was received on 10/22/2025 at 1:22 a.m. LVN 1 stated Resident 1's x-ray result was faxed to MD 1 at that time (1:22 a.m.). LVN 1 stated MD 1 was notified of Resident 1's x-ray result on 10/22/2025 at 8:35 a.m., and an order was received to transfer Resident 1 to the GACH. During an interview on 11/5/2025 at 3:10 p.m., with LVN 2, LVN 2 stated he received orders from Resident 1's physicians on 10/22/2025 approximately 9 a.m., to transfer Resident 1 to GACH. LVN 2 stated RN 3 called the ambulance, and the ambulance arrived around 11 a.m. During a telephone interview on 11/6/25 at 10:50 a.m., with RN 2, RN 2 stated she received the faxed x-ray results indicating Resident 1 had femoral fracture on 10/22/2025 at 1:22 a.m. RN 2 stated she immediately faxed the results to Resident 1's MD and informed the Assistant Director of Nursing (ADON). RN 2 stated she called Resident 1's MD on 10/22/2025 at 6:00 a.m. and spoke with the receptionist. RN 2 stated she did not receive an order to transfer Resident 1 to GACH until the end of her shift (11 p.m. to 7 a.m. shift). RN 2 stated during her initial rounds on 10/21/2025 at approximately 11:30 p.m., she observed the resident sleeping. RN 2 stated at around 12:30 a.m., Resident 1 opened her eyes and was noted to have swelling of the right hip. RN 2 stated she did not contact the medical director when she received the x-ray result because she received an order from MD 2 to wait until a.m. RN 2 stated she assumed a.m. means 6 a.m. since there was no specific instruction to call at a particular time in the morning and her understandings that morning referred to 6:00 a.m. RN 2 stated she typically expects a physician to call-back within 15 to 20 minutes, but with Resident 1' s positive x-ray result for fracture she was unable to follow up with the MD.During a review of Resident 1's Medication Administration Record (MAR) dated 10/21/25 at 2 p.m., the MAR indicated Tylenol Extra strength 500 mg two tablets were given to Resident 1 for pain level of 7/10, and Tylenol 500 mg two tablets were given to Resident 1 on 10/21/25 at 4:17 p.m. for pain level of 5/10 rated by facial grimacing. During a review of Resident 1's Nursing Progress Note dated 10/21/2025 at 2:20 p.m., the Nursing Progress Notes indicated at 2 p.m., LVN 1 informed RN 1 regarding Resident 1's right leg ( appeared wobbly and loose with swelling). The Nursing Progress Notes indicated Resident 1 was observed with facial grimacing indicating the resident had 4/10 pain on a facial expressions pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). The Nursing Progress Notes indicated Resident 1 administered Tylenol 500 mg two tablets via gastrostomy tube (GT- a medical device [used to prevent or treat a disease] used for feeding, hydration, and medication). During a review of Resident 1's Nursing Progress Note dated 10/21/2025 at 3:17 p.m., the Nursing Progress Notes indicated CNA 1 reported Resident 1 was observed with increased facial grimacing during resident care while repositioning. The Nursing Progress Notes indicated Resident 1 had an increase in pain each time Resident 1 was repositioned. During a review of Resident 1's Physician Order dated 10/21/2025 at 8:56 p.m., the Physician Order indicated an order for Norco oral tablet 5-325mg one tablet to be given through G-Tube every four hours as needed for severe pain ranging (6 to 9 out of ten) on a pain rating scale. During a review of Resident 1's Nursing Progress Note dated 10/21/2025 at 9:21p.m., the Nursing Progress Notes indicated that on 3 p.m., to 11 p.m., shift Resident 1 was observed restless with facial grimacing. Resident 1was in severe pain with swelling on right thigh, warm and tender to touch with redness, abnormal rotation of right thigh extending to the femur/knee. The Nursing Progress Note indicated Resident 1 was given Tylenol extra strength two tablets for moderate to severe pain. The Progress Notes indicated RN 1 received an order from Resident 1's physician on 10/21/2025 at 3:30p.m., to do x-ray of the right hip and right femur. The Progress Notes indicated RN 2, paged Resident 1's MD for an order for strong pain medication. The Progress Notes indicated on 10/21/2025 at 8:56 p.m., received MD order for Norco (pain medication used to manage moderate to severe pain) 5/325 mg every four hours as necessary (PRN) for seven days. The Progress Notes indicated Resident 1 received Norco 5/325 mg on 10/21/2025 at 10 p.m. The Progress Notes indicated MD 2 ordered to call MD 1 in a.m., if x-ray result was positive for fracture to get order to transfer Resident 1 out to the hospital. During a review of Resident 1's Nursing Progress Note dated 10/22/2025 at 12:10 a.m., the Nursing Progress Notes indicated Resident 1 was observed with minimal to moderate swelling to the right leg and right knee, and it was very warm to touch. The Nursing Progress Notes indicated Resident 1 had increased facial grimacing with beads of sweat (small, round droplets of perspiration on the skin, which can be caused by physical exertion, heat, or stress). The Nursing Progress Notes indicated Resident 1's right leg swelling has doubled in size. During a review of Resident 1's Radiology (a medical document that describes the results of an imaging test, such as an x-ray) Report dated 10/21/2025, the Radiology Report indicated right femoral fracture with soft tissue swelling. The Radiology Report was electronically signed by the radiologist (a medical doctor who specializes in diagnosing and treating diseases and injuries using medical imaging techniques like x-rays) on 10/22/2025 at 12:31 a.m. During a review of Resident 1' s MAR dated 10/22/25 at 5:12 a.m. Norco one tablet 5-325mg was given to Resident 1 for severe pain of 6/10 rated by facial grimacing and moaning/groaning. Norco one tablet 5-325mg was administered to Resident 1 on 10/22/25 at 9:17 a.m. for severe pain level of 9/10 rated by facial grimacing and crying. During a review of Resident 1's Nursing Progress Note dated 10/22/2025 at 5:29 a.m., the Nursing Progress Notes indicated Resident 1 had a swelling on the right thigh with facial grimacing when touch. During a review of Resident 1' s Nursing Progress Note dated 10/22/2025 at 8:15a.m., the Nursing Progress Note indicated Resident 1 was monitored for status post-acute right proximal femoral fracture. The Nursing Progress Note indicated Resident 1 was observed awake and alert resting in bed with episodes of facial grimacing. The Nursing Progress Notes indicated a pain assessment of 7/10 based on non-verbal scale. The Nursing Progress Note indicated Resident 1 had short period of hyperventilation (breathing too fast or too deeply), ventilator alarming, occasional moaning/groaning, facial grimacing, rigidity and clenched fists. The Nursing Progress Note indicated Resident 1's right leg appeared with moderate swelling, slight yellow tinged discoloration, and flaccidity ( part of the body that is hanging loosely) with increased ROM. During a review of Resident 1's Care Plan titled Resident 1 has the potential for alteration in comfort due to pain related to proximal femoral fracture, soft tissue swelling dated 10/22/25, the Care Plan intervention indicated to monitor signs and symptoms of pain, flinching, moaning, crying, grimaced facial expression and inform physician promptly, provide nursing comfort measures, assess characteristics of pain, location, duration, quality, aggravating and alleviating factors, radiation (pain that begins in one area and spread to another), intensity and document, administer medication as ordered, monitor effect of medication, provide pain medication prior to planned expected activities. During a review of Resident 1's Nursing Progress Notes dated 10/22/2025, at 9:05 a.m., the Nursing Progress Notes indicated Resident 1 was resting in bed with facial grimacing. Resident 1's non-verbal pain scale score was documented as 9/10. Resident 1 exhibited a short period of hyperventilation, ventilator alarms, crying, facial grimacing, rigidity, clenched fists, and was unable to be consoled by voice or touch. Resident 1 was given Norco 5/325 mg on 10/22/2025 at 9:11 a.m. The Nursing Progress Notes indicated, during a room check at 10:00 a.m., Resident 1 continued to display signs of distress, including hyperventilation, facial grimacing, rigidity, and clenched fists. The Nursing Progress Notes indicated at 10:30 a.m., a pain reassessment was conducted, with a non-verbal pain scale score of 5/10. Resident 1 continued to exhibit occasional moaning/groaning, facial grimacing, and a tense effect. The Nursing Progress Notes indicated at 12:19 p.m. Resident 1 was transported out of the facility. During a review of Resident 1's Pain Assessment, the Pain Assessment indicated the following:1. On 10/21/25 at 2 p.m. Resident 1 pain level was 7/10 and reassessed at 2:30p.m. with pain level of 3/10 rated by facial grimacing.2. On 10/21/25 at 4:13 p.m. and 4:17p.m., Resident 1 pain level was 5/10 rated by facial grimacing. 3. On 10/21/25 at 11:10 p.m. and 11:15 p.m., Resident 1 pain level was 6/10 rated by facial grimacing. 4. On 10/22/25 at 5:12 a.m., Resident 1 pain level was 6/10 rated by facial grimacing and crying.5. On 10/22/25 at 8:15 a.m., Resident 1 pain level was 7/10 rated by facial grimacing and crying, rigid, fist clenched. 6. On 10/22/25 at 9:11 a.m., Resident 1 pain level was 9/10 rated by facial grimacing, crying, rigid, fist clenched. 7. On 10/22/25 at 10:30 a.m., Resident 1 pain level was 5/10 rated by facial grimacing, groaning/moaning. During a review of Resident 1' s GACH Record titled Consultation Report dated 10/24/2025 , the Consultation Report indicated Resident 1 was admitted to the hospital on [DATE] for pain in the right hip, probably due to a pathological fracture from severe osteoporosis. The GACH Record indicated Resident 1 had a surgical procedure [NAME] procedure with left hip disarticulation (removing the entire left leg by detaching it at the hip joint) done on 10/24/2025 at 12:31 p.m. During a review of Resident 1's Emergency Department (ED) Report dated 10/22/2025, the ED Report indicated Resident 1 arrived at the ED from nursing home because staff noticed swelling and redness to Resident 1's right thigh and x-ray found possible femur fracture. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or status dated 2/2021, indicated the facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition.The nurse will notify residents attending physicians on call when there has been a/ an:An accident or incident involving the residenta. Discovery of injuries of an unknown sourceb. Significant change in the residents' physical/emotional/ mental conditionc. Need to transfer the resident to a hospital/treatment centerd. Specific instructions to notify the physician of changes in resident's condition. e. In addition to notifying the residents and /or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition or status. During a review of the facility's policy and procedure (P&P) titled, Transfer or discharge dated 8/2018, indicated transfers or discharges may be necessary to protect the health and well-being of the residents:a. If the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. The facility will notify the resident's attending physician for transfer to the hospital for treatmentc. Notify the receiving facility that the transfer is being maded. Notify the representative or family member.

Based on observation, interview, and record review, the facility failed to ensure a resident, who was receiving feeding through a gastrostomy tube ([GT] a soft tube surgically placed into the stomach to provide nutrition and medications), did not have a severe weight loss (a weight loss greater than five percent (%) in one month, or greater than 7.5% in three months, and greater than 10% in six months) for one of 48 residents receiving GT feeding (Resident 188). The facility failed to ensure: 1.The licensed nurses conducted a change of condition (COC) assessment and monitored Resident 188 closely including weekly weights, signs and symptoms of malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function), and dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake), when the resident had A.Significant weight loss of (nine pounds ([lbs.] a unit of weight measurement) in one month (12/6/2024 [119 lbs.]-1/3/2024 [110lbs]) which was 7.6 % of Resident 188's admission body weight of 119 lbs., B.Weight loss of 24 lbs. in two months (12/6/2024 [119 lbs.]-1/31/2025 [95 lbs.]) on 1/31/2025 which was 20.1% of Resident 188's admission body weight of 119 lbs. C.Weight loss of 25.8 lbs. on 2/6/2025 (12/6/2024 [119 lbs.] - 2/6/2025 93.2 lbs.]) which was 21.6% of Resident 188's admission body weight of 119 lbs. 2. The licensed nurses notified Resident 188's physician and responsible party (RP) of Resident 188's 7.6% significant weight loss identified on 1/3/2025 and 20.1% weight loss in two months identified on 1/31/2025 in accordance with Resident 188's untitled care plan dated 12/23/2024. 3. Resident 188's assigned nurse (unknown) notified the Registered Dietician (RD) to evaluate Resident 1 when the resident had a nine lbs. weight loss on 1/3/2025. 4. Registered Nurse (RN) 3 notified the RD on 1/31/2025 for the RD to evaluate Resident 188's 20.1% weight loss, in accordance with the untitled care plan dated 12/23/2024 when Resident 188 was noted to have continued weight loss. 5. The Interdisciplinary Team ([IDT] a team of different health care professionals working together to develop care interventions for a resident), including the RD met after Resident 188's significant weight loss was first identified on 1/3/2025, and then on 1/31/2025, to develop interventions to prevent further weight loss. 6. The IDT developed an individualized care plan with measurable goals to address Resident 188's weight loss identified on 1/3/2025 and 1/31/2025. 7. Restorative Nursing Assistant ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) 1 documented Resident 188's weight right after weighing Resident 188 on 1/31/2025 on the RNA Monthly Weight Report. 8. The RD did not wait until 2/6/2025 (30 days later) to reassess the effectiveness of Resident 188's nutritional interventions recommended on 1/7/2025, including increasing Resident 188's GT feeding 10 additional cubic centimeter ([cc], a unit of measurement) per hour (hr.) to 55 cc/hr, once his diarrhea (loose stool) subsided, per IDT/ care plan review, continue to monitor weight trends (unknown frequency), and reassess as needed (unknown frequency) the interventions recommended (on 1/7/2025). As a result of these deficient practices, Resident 188 had severe weight loss of 25.8 lbs. equal to 21.6% in 60 days. These deficient practices placed Resident 188 and 48 facility residents recieving enteral feeding at risk for malnutrition, dehydration, and possible death. On 2/8/2025 at 4:44 p.m., an Immediate Jeopardy ([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 to a resident) was called in the presence of the facility's Director of Nursing (DON) and the administrator (ADM) due to the facility's failure to implement interventions to prevent Resident 188's severe weight loss, and placed 48 residents recieving enteral feeding at risk for malnutrition, dehydration, and possible death. On 2/9/2025 at 1:13 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 2/9/2025 at 3:10 p.m., in the presence of the DON and ADM. The IJRP included the following immediate actions: a. A change of condition assessment, Situation Background Assessment Recommendation ([SBAR] a communication tool used to share information in a structured way) for severe weight loss was completed on 2/6/2025, which included vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's basic body functions), pain, laboratory (medical procedure that involves testing a sample of blood, urine, or other substance from the body) results reviewed and obtained new physician orders on 2/6/2025 for adding Liquacel (protein supplement) and to increase GT feeding to 55cc/hr. b. On 2/8/2025, the assistant director of nursing (ADON) conducted another assessment, indicating the Resident 188 remained at his baseline (starting point used for comparisons) condition with normal vital signs, and without any sign of distress. c. On 2/8/2025, the IDT members, including the RD, conducted an IDT care plan meeting. During the meeting, the IDT members addressed Resident 188's overall condition with severe weight loss of 12/6/2024 119Ibs, 1/3/2025 ll0lbs (-9 lbs.), 2/6/2025 93.2Ibs. (25.8 lbs.) The physician instructed to start weekly weight for four weeks and repeat the comprehensive metabolic panel ([CMP] a blood test to check liver, kidney, and metabolic health) on 2/10/2025. d. RNA 1 will receive a performance correction notice, and a one-on-one in-service by the DON regarding weight documentation, emphasizing the importance of recording the weight on the same day it was measured. e. On 2/8/2025, the weights management in-service was initiated until all licensed nurses, including part-time and night ([NOC] 11 p.m. to 7 a.m. shift) will be completed. In-service will be expected to be completed by 2/10/2025. Any licensed nurse unable to attend the in-service due to part time status, emergency or leave of absence has been removed from the schedule and must be given an in-service prior to returning to work. Weight Management in-service includes: e1. Conducting a change of condition assessment for significant or severe weight change: loss or gain of 3 lbs. within a month, 5% a loss or gain of at least 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. e2. Licensed nurses will notify RD and physician of the significant or severe weight changes. e3. Conduct significant weight loss IDT care plan to include useful interventions based on assessment. f. The DON and ADON initiated review of all residents' weight records (180 residents) for the past 30 days to ensure that all significant or severe weight changes had proper assessments, RD recommendations, MD notifications, and updated plan of care. All reviews will be completed by 2/10/2025. g. The DON and the ADON will conduct monthly in-services to licensed nurses regarding weight management for 3-months, covering the following details: Conducting a change of condition assessment for significant or severe weight change: loss or gain of 3 lbs. within a month, 5% a loss or gain of at least 5% in 30 days, 7 .5% in 90 days, or 10% in 180 days. DON and/or designee will notify RD and physician of the significant or severe weight changes. Conduct significant or severe weight loss IDT care plan to include useful interventions based on assessment. Note that education on oral gratification is not considered a useful intervention for promoting weight gain. h. The DON and/or designee will repeat a monthly in-service for three months to RNA responsible for weights documentation, to ensure all weights are recorded on the same day it is measured. i. On 2/8/2025, the DON created a weight management monitoring log, including significant or severe weight loss. j. The DON/ADON will meet with the RNA weekly for four weeks, then monthly for three months to ensure timely weight documentation. k. The DON/ADON will participate in weekly weight management meeting and document the findings with corrective actions in the monitoring log. L. The DON/ADON will monitor weight variance through weekly weight meeting to ensure all residents with weight variance (significant or severe) will be addressed. The DON will discuss weight management related findings during the monthly QA meeting for three months to ensure ongoing compliance with the state and federal regulations. (cross reference: F553, F580, F656, and F865) Findings: During a review of Resident 188's Admission Record, the Admission Record indicated Resident 188 was admitted to the facility 12/6/2024 with diagnoses including muscle wasting (the shrinking and weakening of muscles), non-Hodgkin lymphoma (cancer [invasive growth of disease causing organisms]), tracheostomy tube (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and multiple pressure ulcers (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) and had a GT. During a review of Resident 188's Minimum Data Set ([MDS] a resident assessment tool) dated 12/13/2024, the MDS indicated Resident 188 had severe cognitive impairment (a significant decline in cognitive abilities that significantly impact daily functioning and independence) for daily decision making. The MDS indicated Resident 188's current weight as of 12/6/2024 was 119 lbs. The MDS indicated Resident 188 was receiving a therapeutic (a meal plan that controls the intake of certain foods or nutrients) diet and was receiving 51% or more of his total calories through a feeding tube. During a review of Resident 188's untitled Care Plan initiated on 12/23/2024, the Care Plan indicated Resident 188 had cancer with an increased risk for weight loss secondary to non-Hodgkin's lymphoma. The untitled Care Plan indicated Resident 188's goal was not to have a weight loss exceeding 5% per month. The Care Plan interventions included RD evaluations and to notify the physician and Resident 188's responsible party of any change of conditions. During a review of a document titled, Weekly-Weights- Station Subacute (a level of care needed by a patient who does not require hospital level acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) Summary dated 12/2024, the document indicated Resident 188's admitting weight was 119 lbs. and was weighed weekly after admission on 12/6/2024. Resident 188's weight was as follows: 1. On 12/11/2024 Resident 188's weight was 115 lbs. There was four lbs. weight loss in five days since admission on12/6/2024. 2. On 12/18/2024 Resident 188's weight was 112 lbs. There was another three lbs. weight loss in a week from 12/11/2024. 3. On 12/27/2024 Resident 188's weight was 110 lbs. There was another two lbs. weight loss in a week from 12/28/2024. 4. On 1/3/2025 Resident 188's weight was 110 lbs. The Weekly Weights and Vitals Summary did not indicate the aforementioned weekly weights were recorded and addressed in Resident 188's electronic medical record (EMR) and the resident's weekly weight loss was addressed. During a review of Resident 188's Weights and Vitals Summary, dated 12/6/2024, the Weekly Weights and Vitals Summary indicated Resident 188 weighed 119 lbs. The Weights and Vitals Summary dated 1/3/2025 indicated Resident 188's weight was 110 lbs., a nine lbs. (7.6%) weight loss since admission. The Weights and Vitals Summary did not indicate Resident 188's weekly weight measurements were continued when the weight loss was identified on 1/3/2025. During a review of Resident 188's Weights and Vitals Summary dated 2/6/2025, the Weights and Vitals Summary indicated Resident 188 weighed 93.2 lbs., which was a 25.8 lb. (21.7%) weight loss since admission. During a review of Resident 188's Order Summary Report (physician's orders), the Order Summary Report indicated an order was placed on 12/6/2024 to monitor Resident 188's weight weekly for four weeks and then monthly. The Order Summary Report indicated an order for monthly weights was placed on 12/6/2024. The Order Summary Report indicated there was an order placed on 12/6/2024 for GT feeding with Glucerna (diabetes-specific nutritional formula) 1.5 calorie ([cal] a unit of energy derived from nutrition) at 45 cubic centimeters (cc) per hour (hr) for 20 hours via GT pump (device to administer feeding formula) to provide 900 cc equal to1350 kilocalories (kcals) per day and discontinued on 1/7/2025. During a review of Resident 188's change of condition (COC)- Licensed Nurse Note dated 12/14/2024, the note indicated Resident 188 was having frequent loose stools (diarrhea). During review of Resident 188's Order Summary Report the Order Summary Report indicated on 1/7/2025, an order was placed for Imodium A-D (antidiarrhea medication) 2 milligrams (mg) via GT every four hours as needed for loose stool for seven days. During a review of Resident 188's Nutrition/ Dietary Note dated 1/7/2025 at 10:56 a.m., the Nutrition/Dietary Note indicated the RD documented Resident 188's weight was 110 lbs. with a nine lbs. weight loss in one month. The RD documented Resident 188's ideal body weight ([IBW] the healthiest weight per height) range was 117 lbs. to 143 lbs., and Resident 188's nine lbs. weight loss was significant. The Nutrition/Dietary Note indicated the RD recommended to increase the Glucerna 1.5 from 45 cc/hr to 55 cc/hr to provide 1100cc/1650 kcal per day. The Nutrition/Dietary Note indicated the RD recommended to monitor the resident's weight trends (frequency not specified) and she (RD) documented she would reassess the resident's nutritional needs as needed. There was an addendum (additional information) added on 1/7/2025 to the Nutrition/ Dietary Note indicating Resident 188 was able to tolerate the GT feeding well and had no nausea (feeling sick to your stomach), vomiting (throwing-up forces the contents of the stomach up through the food pipe) or diarrhea. During a review of Resident 188's Nutrition/ Dietary Note dated 1/7/2025 at 1:13 p.m., the Nutrition/ Dietary Note indicated the RD discussed Resident 188's frequent loose stools with a nurse (unknown) and to hold the order to increase the GT feeding to 55 cc/hr due to Resident 188's diarrhea. The Nutrition/ Dietary Note indicated the GT feeding would be increased once the diarrhea resolved. During a review of Resident 188's Medication Administration Record (MAR) for January 2025, the MAR indicated Imodium A-D was last given to the resident on 1/13/2025 for loose stool. During a review of Resident 188's Order Summary Report for January 2024, the Order Summary Report indicated an order dated 1/7/2025 to increase Glucerna 1.5 to 55 cc/hr. to administer for 20 hours via GT pump to provide 900 cc/1350 kcal per day. This order was discontinued three days later on 1/10/2025. The Order Summary Report indicated on 1/10/2025 an order was placed to decrease the Glucerna 1.5 back down to 45 cc/hr to administer for 20 hours to provide 900 cc/1350 kcal per day. The Order Summary Report indicated there were no new orders placed until 2/7/2025. On 2/7/2025 there was a new order to increase the GT feeding with Glucerna 1.5 at 55 cc per hour for 20 hours via GT pump to provide 1100 cc/1650 kcal per day. During a review of Resident 188's Licensed Nurses Progress Notes dated 1/7/2025, the Licensed Nurses Progress Notes indicated Resident 188's physician (MD 1) was informed Resident 188 was having loose stool and the RD recommended to increase Resident 188's GT water flush (water given through the GT for hydration) to 50cc/hr related to elevated (no result specified) blood urea nitrogen ([BUN] a kidney function laboratory test). The Licensed Nurses Progress Notes did not indicate MD 1 was informed of Resident 188's nine lbs. weight loss. During a review of Resident 188's Care Plan (untitled) initiated on 1/7/2025, the Care Plan indicated Resident 188 was identified to be at risk for dehydration secondary to diarrhea. The Care Plan indicated the goal for Resident 188 was to reduce the risk of unplanned weight changes. The Care Plan interventions included monitoring Resident 188's weight (frequency not identified) and report (unspecified to whom) any change of plus or minus (+/-) of three pounds per week or +/- five pounds per month per policy (policy not identified). This Care Plan did not include Resident 188's actual weight loss of 7.5% (nine lbs.) that had been identified on 1/3/2025 or the interventions to reduce the risk of continued weight loss from occurring. During a concurrent observation and interview on 2/5/2025 at 12 p.m., with Resident 188, in Resident 188's room, the resident was observed receiving Glucerna 1.5 through GT at rate of 45 cc/hr. Resident 188 stated he had been losing weight recently but was hopeful he would gain some weight back because he passed his swallow evaluation (checks how well a resident swallows) on 2/4/2025 and was now able to eat a little food along with his tube feeding for oral gratification (the pleasure derived from oral activities such as eating). Resident 188 stated he hoped to gain some weight because his legs looked like bones. Resident 188 was observed pulling his bed sheets away from his legs. Resident 188 legs were observed being very thin with prominent bones. Resident 188 stated he wanted to be stronger to participate in therapy. During an interview on 2/5/2025 at 12:03 p.m., Licensed Vocational Nurse (LVN) 6 stated RNA 1 was responsible for measuring and recording weights. LVN 6 stated RNA 1 had not reported any recent weight changes for Resident 188. During an interview on 2/5/2025 at 2:49 p.m., Registered Nurse (RN) 2 stated as of 2/5/2025, the last weight recorded for Resident 188 was on 1/3/2025. RN 2 stated RNA 1 was supposed to turn monthly weights in by the fifth day of every month but they were not yet completed. RN 2 stated the facility usually did not complete a COC for weight loss unless it was a lot of weight, like a 40 lbs. weight loss. RN 2 agreed that a nine lbs. (7.6%) weight loss was a lot of weight to lose in one month. RN 2 stated that a COC did not need to be completed for a 7.5% weight loss. RN 2 stated if Resident 188 had been weighed weekly for four weeks after he was admitted on [DATE], per physician's order, the RD could have assessed Resident 188 sooner than 1/7/2025 and identified the gradual weight decrease. RN 2 stated she reviewed Resident 188's electronic medical record and could not find any documentation that Resident 188 was weighed weekly as RD recommended. During an interview on 2/6/2025 at 10:22 a.m., RNA 1 stated she weighed Resident 188 on Friday 1/31/2025 and the resident weighed 95 lbs. RNA 1 stated she did not document the weight for 1/31/2025 in Resident 188's chart but I knew Resident 188 had lost a lot of weight so she (RNA 1) verbally informed RN 3 about the weight loss on 1/31/2025. RNA 1 stated RN 3 stated that the weight loss identified on 1/31/2025 was okay, and that Resident 188 would start gaining weight because he passed his swallow evaluation and was able to eat (for oral gratification) as well as receive tube feedings. RNA 1 could not produce any documentation that the resident's weight of 95 lbs. on 1/31/2025 was documented. RNA 1 pointed to her head and stated, it is all in here. RNA 1 stated the residents' monthly weights on the sub-acute unit were not entered into the computer yet because she had yet to complete taking all the weights for the month and would finish by 2/7/2025. During an interview on 2/6/2025 at 11:48 a.m., RN 3 stated on 1/31/2025, RNA 1 did inform her Resident 188 lost a lot of weight (did not know exact amount). RN 3 stated she did not inform the physician because she was admitting another resident at the time. RN 3 stated she assumed Resident 188 would start gaining weight now that he was able to eat by mouth and was continuing to receive tube feeding. RN 3 stated Resident 188's diarrhea had stopped sometime mid-January 2025 (exact date unknown). During an observation on 2/6/2025 at 12:02 p.m., RNA 1 and LVN 3 were observed weighing Resident 188 using a mechanical lift (device used to assist with transfers [from one surface to another] and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) containing a scale. Resident 188 weighed 93.2 lbs. (total of 25.8 lbs. weight loss from admission weight of 119 lbs. on 12/6/2024). During an interview on 2/6/2025 at 12:21 p.m., the RD stated the nursing staff did not notify her of Resident 188's identified weight loss on 1/3/2025. The RD stated residents' monthly weights were documented in the residents' medical records and were printed out for her review every Monday or Thursday (in general). The RD stated on 1/7/2025, she reviewed Resident 188's weight report dated 1/3/2025 which indicated the resident weighed 110 lbs. and had a weight loss of nine lbs. The RD stated she assessed Resident 188 on 1/7/2025. The RD stated she had not reassessed Resident 188 since 1/7/2025 (30 days ago) when she evaluated him for significant weight loss and did not implement any interventions such as measuring his weight weekly because she (RD) did not feel Resident 188 required weekly weights for close monitoring. The RD stated she was unable to increase Resident 188's GT feeding on 1/7/2025 because Resident 188 had diarrhea. The RD stated she did not reassess Resident 188 after the diarrhea subsided on 1/13/2025. The RD stated she did not feel it was necessary to monitor Resident 188's significant weight loss of 7.6% more frequently than monthly. The RD stated it was important to monitor severe weight loss closely to ensure the residents health status did not decline. The RD stated the potential outcome of severe weight loss was malnutrition. During an interview on 2/6/2025 at 2:04 p.m., MD 1 stated he should have been notified as soon as possible of Resident 188's severe weight loss. MD 1 stated it was important he was notified so he could decide on new interventions and ensure the RD was assessing the resident's nutritional needs. During a review of Resident 188's Nutrition/ Dietary Note dated 2/6/2025, the Nutrition/ Dietary Note indicated Resident 188 weighed 93 lbs., and had a 17 lbs. (15%) weight loss in one month from 1/3/2025 to 2/6/2025 and had 26 lbs. weight loss in three months from 12/6/2025 to 2/6/2025. The Nutrition/ Dietary Note indicated the weight loss was significant and was likely related to pressure ulcer healing, diarrhea, and respiratory failure (a serious condition that makes it difficult to breathe on your own). The Nutrition/ Dietary Note indicated Resident 188 was tolerating GT feeding well and was not experiencing diarrhea at the time on 2/6/2025. The Nutrition/ Dietary Note indicated the RD recommended to increase the GT feeding to Glucerna 1.5 at 55cc/hr for 20 hrs. to provide 1100 cc/1650 kcal daily. During a review of Resident 188's COC/ Interact Assessment form (SBAR) dated 2/7/2024, the COC indicated Resident 188 had a 26 lbs. weight loss. The COC indicated MD 1 was notified of the weight loss. During a review of Resident 188's COC/ Interact Assessment forms (SBAR), the COC/Interact Assessment forms did not indicate there were any other COCs from admission (on 12/6/2024) to 2/7/2025 in Resident 188's chart regarding weight loss or that MD 1 or Resident 188's responsible party (RP), family member (FM)1were informed of the resident's severe weight loss. During an interview on 2/7/2025 at 12:41 p.m., Resident 188's FM 1 stated nursing staff (unknown) told her in passing Resident 188 was losing weight, but no one informed her how much weight. FM 1 stated on 2/7/2025, the morning nurse (unknown) called her about Resident 188's weight loss and informed her that Resident 188 had lost weight. FM 1 stated they did not inform her of the actual amount of weight he lost but now she was feeling worried about Resident 188's health. During an interview on 2/8/2025 at 1:23 p.m., the ADON stated a COC was important documentation including monitoring when an issue outside of the resident's baseline occurred. The ADON stated a significant weight loss was outside of Resident 188's baseline and a COC should have been initiated. The ADON stated he reviewed Resident 188's medical record and did not find a COC completed for weight loss or any documentation indicating the physician or FM 1 was notified of the weight loss. The ADON stated the RD needed to be made aware of significant weight loss but so did the physician because the physician had more options for addressing the weight loss, more interventions, and modalities to address the weight loss. The ADON stated a care plan should have been created for the weight loss as a change of condition. The ADON stated it was important to create a care plan, so all staff involved knew the new interventions, new goals, and the problem the resident was having. The ADON stated he reviewed Resident 188's medical record and did not find a care plan for the resident's severe weight loss. The ADON stated it was important to monitor interventions for a COC to see if interventions were effective. The ADON stated the IDT should have met and discussed Resident 188's weight loss so that they could collaborate and come up with new solutions for the weight loss and recommend them to the physician. The ADON stated the IDT was to be done as soon as the RP and resident were available to be involved in the care planning. The ADON stated as soon as Resident 188's diarrhea subsided on 1/13/2025 the RD should have reassessed the resident and the physician should have been notified so they could decide if GT feeding could have been increased. The ADON stated the potential outcome of not monitoring severe weight loss or reassessing the resident's interventions was further weight loss. The ADON stated based on Resident 188's current weight of 93.2 lbs., the interventions were not working and the IDT meeting should have been conducted to address the resident's progressive weight loss. During an interview on 2/8/2025 at 1:57 p.m., the RD stated she did not attend IDT meetings for weight loss. The RD stated the IDT discussed Resident 188's case but the notes of the IDT discussion were not written down. The RD stated if it was not documented, it was not done. The RD stated RNA 1 did not write down any weights on 1/31/2025, she (RNA 1) just told her (RD) the weight verbally on 2/6/2025. The RD stated the potential outcome of not being notified right away of weight loss was a delay of interventions to prevent further weight loss. The RD stated she based her assessment of Resident 188's chart and information obtained from nurses but did not assess or speak to the resident himself. During an interview on 2/8/2025 at 2:33 p.m., the DON stated facility staff cannot assume a weight loss was expected based on the resident's diagnosis. The DON stated they must closely monitor the resident's weight trends (via weekly weights) to see if any other interventions could be implemented for the resident. The DON stated she was not made aware Resident 188 had severe weight loss and that his weight loss was not discussed during an IDT meeting. The DON stated communication among the care team was important so weights can be addressed appropriately. The DON stated it was important to reassess the interventions to see if the interventions were working and revise and add new interventions as needed. During an interview on 2/8/2025 at 3:02 p.m., the director of staff development (DSD) stated the weights should be documented in the resident's chart right away after obtaining the weight. The DSD stated, we are all human and the RNAs could forget a weight or mix up the weights of different residents if they did not write them down right away. The DSD stated accurate weights were important so an accurate nutritional assessment could be done, and weights could be accurately monitored. During an interview on 2/8/2025 at 3:26 p.m., the medical director (MD 2) stated the physician needed to be informed as soon as weight loss was identified. MD 2 stated any significant weight fluctuations needed to be addressed. MD 2 stated continued weight loss was not good and affected a resident's well-being, could lead to malnutrition and slow pressure sore healing. During a review of the facility's policy and procedure (P/P) titled Nutritional assessment dated ,d+[DATE], the P/P indicated as part of the comprehensive assessment, the nutritional assessment was to be a systematic, multidisciplinary process that included gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk of impaired nutrition. During a review of the facility's P/P titled Weight Assessment and Intervention dated 3/2022, the P/P indicated weights were to be recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since last weight assessment was retaken the next day for confirmation and if the weight is verified, the nursing team was to immediately notify the RD in writing. Residents were to be weighed at an interval determined by the IDT. The threshold for significant unplanned and undesired weight loss was to be based on the following criteria [ where percentage of body weight loss = (usual weight - actual weight)/ (usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate (RP). Individualized care plans shall address to the extent possible: the identified causes of weight loss; goals and benchmarks for improvement; and time frames and parameters for monitoring and reassessment. During a review of the facility's P/P titled Change in Resident's Condition or Status dated 3/2022, the P/P indicated the nurse was to notify the physician and RP when there has been a significant change in the resident's physical condition. Notifications were to be made within 24 hours. The nurse was to record information relative to changes in the resident's record. During a review of the facility's Registered Dietician (RD) Consultant job description dated 4/2022, the job description indicated the RD was to work with the ADM, nursing, and other department heads on planning resident care issues, and quality assessment monitoring and reporting. The RD was responsible for evaluating the nutritional needs of the residents and documenting in the nutritional record.

Based on interview and record review, the facility failed to ensure that a resident with a Full Code status (resident wants all life saving measures in case of life threatening emergencies) and in distress, received Cardiopulmonary Resuscitation (CPR-an emergency procedure to restart a person's heart, chest compressions) immediately, reducing the residents chances of survival and adverse health outcomes for one of 145 residents with Full Code status (Resident 44). The facility failed to: 1.Ensure Registered Nurse (RN) 2 announced a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) when Resident 44 had no palpable (rhythmic beat of a blood vessel indicating a heartbeat, that can be felt by touch) heartbeat. 2.Ensure RN 2 provided resuscitation and basic life support such as CPR immediately without loss of critical time to Resident 44, when Resident 44 no longer had a palpable pulse on [DATE]. 3.Ensure RN 2 was knowledgeable of the facility's policies and procedures regarding initiating CPR when a full code resident is unresponsive. 4.Ensure RN 2 implemented the facility's policy and procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation, revised February 2018, which indicated if an individual was found unresponsive and not breathing normally, a licensed staff, certified in CPR/BLS shall initiate CPR and the American Heart Association ([AHA] the leader in resuscitation science, education, and training, and publisher of the official Guidelines for CPR) guidelines which indicated First responder will call for help, send available staff to call a Code Blue, retrieve emergency medical equipment, assess the residents' level of consciousness, circulation, airway, and breathing and begin CPR, call 911, CPR will continue until the paramedics arrive and assume responsibility. These deficient practices delayed life-saving resuscitation attempts, such as CPR to ensure Resident 44's body had uninterrupted blood, and oxygen circulation, to prevent irreversible damage such as brain damage and or death. The facility had 145 residents, with a Full Code status and at risk of not receiving CPR in case of cardiopulmonary arrest. On [DATE] at 4:43 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and the Director of Nursing(DON) due to the facility's failure to identify the need for and initiate basic life support to Resident 44, including CPR immediately upon discovering the resident was unresponsive. On [DATE] at 1:34 p.m., the Facility submitted an acceptable IJ removal plan (IJRP- an intervention to immediately correct the deficient practices). After verification the IJRP was implemented through observation, interview, and record review, the IJ was removed while onsite on [DATE] at 4:44 p.m., in the presence of the ADM and the DON. The IJRP included the following: 1.Resident 44 was transferred to the general acute care hospital (GACH) on [DATE] and currently remains hospitalized . 2.On [DATE], the Administrator (ADM) and the Director of Nursing (DON) notified the facility Medical Director of the findings outlined in the IJ removal plan and developed an IJ removal plan. 3.On [DATE] and [DATE], two American Heart Association ([AHA] the leader in resuscitation science, education, and training, and publisher of the official Guidelines for CPR) Instructors provided in-services to nurses on the facility's CPR policy and procedure. The training covered the following: a.Assessment and activation for CPR iUnconsciousness with absence of life ii.Gasping or no observable chest movements (rise and fall) iii.No palpable carotid pulse (the rhythmic beat of a blood vessel that can be felt on either side of the neck), do not use a pulse oximeter (a device that measures how much oxygen is in the blood) to assess for pulse. b.Code for cardiac/respiratory arrest-Code Blue c.CPR Procedures 4.All nursing including part time and overnight shift who was unable to attend the Inservice must be given an in-service prior to returning to work. 5.The DON and Registered Nurse (RN) supervisor reviewed residents who required CPR within the past 30 days and identified one resident aside from Resident 44 with an incident of code blue with not the same deficient practice 6.The AHA instructors will repeat the in services to nursing staff, regarding CPR policy and procedure, every month for 3 months to ensure compliance. 7.The DON and/or designee will review residents who have a change in condition weekly for 4 weeks and monthly thereafter, to ensure that any resident requiring CPR has received the CPR timely, and continually until the paramedics (emergency response team) arrive or there are obvious sign of life. 8.The DON and/or designee will review residents who have change in condition weekly for 4 weeks and monthly thereafter, to ensure that any resident required. Findings: During a review of Resident 44's Admission Record, the Admission Record indicated Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Type II Diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), Sepsis (blood infection), and Urinary Tract Infection (UTI- disease causing bacteria in the urinary tract). During a review of Resident 44's Nursing Admission Assessment, dated [DATE], the Nursing Admission Assessment indicated Resident 44 had an admitting diagnosis of pneumonia (a lung infection that make it difficult to breath). The Nursing Admission Assessment indicated Resident 44 had completed antibiotics (medicines that treat bacterial infections by killing bacteria or stopping them from growing) at the GACH prior to admission. During a review of Resident 44's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 44 did not have the capacity to understand and make decisions. During a review of Resident 44's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 44 had severely impaired cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 44 had functional limitation in range of motion (the distance and direction a joint can move) on upper extremity (your arm, including your shoulder, elbow, wrist, and hand) and lower extremity (your leg, including your hip, thigh, knee, shin, ankle, and foot), The MDS indicated Resident 44 needed assistance from two or more helpers for the resident to transfer to and from a bed to a wheelchair. During a review of Resident 44's Order Summary Report, as of [DATE], the Order Summary Report indicated there was an order on [DATE] to provide CPR. During a review of Resident 44's Life-Sustaining Treatment (POLST-resident's preferences for medical treatment), dated [DATE], the POLST indicated that facility must attempt CPR if Resident 44 had no pulse and was not breathing. During a review of Resident 44's care plan for Advance Directive (a document that expresses the resident's health care wishes should they be unable to speak for themselves), revised [DATE], the care plan indicated that CPR was to be performed, with interventions including respecting Resident 44's or family's wishes regarding resuscitation efforts. During a review of Resident 44's Change of Condition (COC)/Interact Assessment Form (situation, background, assessment, and recommendation [SBAR] a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations), dated [DATE] at 11p.m., the COC indicated Resident 44's oxygen saturation (amount of oxygen in blood) level was between 88 to 90 percent (%) on room air (RA) (oxygen saturation reference range 95%-100%). The COC indicated facility staff placed Resident 44 on oxygen at 2 Liters (L)/ minute (min) nasal canula (NC) and Resident 44's oxygen saturation went up to ,d+[DATE]%. The COC indicated Resident 44 was placed on 72-hour monitoring, and her Medical Doctor (MD) was notified on [DATE] at 11:30 p.m. During a review of Resident 44's COC dated [DATE], the COC indicated at 7:30 a.m. on [DATE] Resident 44 was up in her wheelchair. The COC indicated Resident 44's vital signs (VS) were: Blood Pressure ,d+[DATE] millimeters of mercury (mmHg- unit of measure. Reference range ,d+[DATE] mmHg), Heart Rate 84 (beats) /(per) minute (min-reference range 60 to 100), Oxygen saturation 93% with oxygen 2L/min via NC, Temperature (measure how well the body can make and get rid of heat) 97.9 degree (Reference range 96.8 degree to 98.6 degree) and Respiration Rate 16 (breaths)/min (Reference range 12 to 20 /min) prior to the incident. The COC indicated at 8:40 a.m., Resident 44 was up in her wheelchair, diaphoretic (sweating heavily), eyes closed with VS: HR ,d+[DATE]/min, oxygen saturation 88% with oxygen at 2L/min via NC. The COC indicated Resident 44 had a palpable (detectable by touch) pulse (heartbeat) of 50 beats/min then Resident 44 was transferred to her bed. The COC indicated Resident 44's heart rate started to fluctuate (vary) from ,d+[DATE]/min and her oxygen level dropped to 80%. The COC indicated staff did not observe Resident 44's chest rise and fall (indicating breathing), so staff grabbed the Ambu-bag (a handheld device that helps patients' breath when they aren't breathing well or at all) and started providing breaths until the paramedics arrived at 8:45 a.m., and initiated CPR. The COC indicated RN 1 and RN 2 were aware that Resident 44 was full code before calling the paramedics at 8:41 a.m. During a review of the Paramedics Report, dated [DATE], the Paramedics Report indicated Resident 44 had a cardiac arrest (when the heart suddenly stops beating, preventing blood and oxygen from being pumped to the body's organs) on [DATE] at 8:30 a.m., witnessed by staff. The Paramedics Report indicated the emergency medical staff (EMS - Paramedics) arrived at resident's room at.8:44 a.m. and found Resident 44 lying in bed pulseless, apneic (an involuntary pause in breathing), with fixed and dilated pupils (a person's pupils are wide open and do not respond to light, indicating a serious medical condition, often associated with brain damage or severe head injury). The Paramedics Report indicated facility staff noticed Resident 44 was breathing with increased effort, so they began ambuing (the act of using an Ambu-bag) the resident. The Paramedics Report indicated facility staff never initiated chest compressions, even though Resident 44 was observed to be in full cardiac arrest. The Paramedics Report indicated the paramedics immediately initiated CPR on Resident 44 and achieved Resident 44's return to spontaneous circulation (ROSC - when heartbeat and breathing return to normal. During a review of Resident 44's Emergency Documentation-MD notes, from the GACH, dated [DATE], the Emergency Documentation-MD notes indicated EMS brought Resident 44 to the GACH's Emergency Department (ED) from the facility after EMS provided emergency services including CPR at the facility (where Resident 44 resided). The Emergency Documentation-MD notes indicated according to EMS, upon EMS's arrival, Resident 44 was pulseless. The Emergency Documentation-MD note indicated EMS initiated CPR, provided emergency services and Resident 44's ROSC was achieved. The Emergency Documentation-MD note indicated Resident 44's diagnoses at the ED included cardiopulmonary arrest. The note indicated Resident 44 was admitted to the intensive care unit (ICU GACH Unit that cares for seriously ill patients that need constant observation). During an interview on [DATE], at 9:38 a.m., with CNA 1, CNA 1 stated on [DATE] at approximately 8:30 a.m., she entered Resident 44's room to assist Resident 44 with her breakfast and observed Resident 44 sitting in her wheelchair sweating. CNA 1 stated she called CNA 2 to check on Resident 44. CNA 1 stated CNA 2 entered the room, assessed Resident 44, and told her (CNA 1) not to feed Resident 44 her breakfast. CNA 1 stated she stayed with Resident 44 while CNA 2 went to get help. During an interview on [DATE] at 10:17 a.m., with RN 2, RN 2 stated on [DATE] at approximately 8:35 a.m., when she entered Resident 44's room, she observed Resident 44 was lying down, appeared sweaty, and pale. RN 2 stated she checked Resident 44's pulse manually and felt Resident 44's pulse. RN 2 stated the oximeter readings of heartbeat on Resident 44's finger fluctuated between 36 beats/min, to 46 beats/min, and Resident 44's oxygen saturation dropped from 88% to 70%. RN 2 stated she left Resident 44's room and returned with a crash cart (cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest). RN 2 stated she suctioned (to suck out or remove something, like thick liquids using a force created by a vacuum) her Resident 44's mouth to remove secretions. RN 2 stated after suctioning Resident 44, she manually checked Resident 44's pulse and it went up to 50/min. RN 2 stated, when Resident 44's pulse was no longer detectable manually, she relied on the oximeter readings of Resident 44's pulse, which still indicated a pulse at 32/min. RN 2 stated she (RN 2) did not initiate CPR because the oximeter indicated Resident 44 had a pulse, although she could not obtain Resident 44's pulse manually. During an interview on [DATE] at 10:14 a.m., with Treatment Nurse (TXN) 1 stated, she was aware Resident 44 was a full code. TXN 1 stated staff should have initiated chest compressions when Resident 44 stopped breathing and had no pulse. During an interview on [DATE] at 10:52 a.m., with RN 2, RN 2 stated she did not initiate chest compressions when she (RN 2) could no longer detect Resident 44's pulse from the resident's carotid artery (the main blood vessels that supply blood to the brain face, and neck). RN 2 stated the oximeter still displayed a pulse reading. RN 2 stated, if the heart rate was not palpable manually, but the oximeter showed numeric values of 30's/min, 40/min and 50/min, it indicated a regular rhythm. RN 2 stated she did not initiate chest compressions when she (RN 2) could no longer detect Resident 44's pulse from the resident's carotid artery (the main blood vessels that supply blood to the brain face, and neck). RN 2 stated she did not announce a Code Blue, because she believed Resident 44 still had a heart rate based on the oximeter reading. During an interview on [DATE] at 12:15 p.m., the Director of Nursing (DON), stated if the COC involved a Resident's unresponsiveness, staff must assess the Resident's lung function and pulse immediately. The DON stated if the resident did not have a detectable pulse staff must start chest compressions immediately, provide breathing support, and call a Code Blue for emergency intervention. The DON stated if an oximeter indicated numbers like 30's/min, 45/min, 50/min without a palpable pulse, it could be an indication that the resident was not okay, and it was important to provide timely CPR. During an interview on [DATE] at 4:17 p.m., Resident 44's primary doctor stated Resident 44 was a full code, and the staff should have provided CPR when Resident 44 experienced a cardiac arrest. During a review of the facility's P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation, revised February 2018, indicated Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. The P&P indicated sudden cardiac arrest (SCA) was a loss of heart function due to abnormal heart rhythms (arrhythmias). 1. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentations of SCA. 2. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 3. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival. 4. If an individual (resident, visitor, or staff member) was found unresponsive and not breathing normally, a licensed staff certified in CPR/BLS will initiate CPR unless the person had a do not resuscitate (DNR) order, or obvious signs of irreversible death (e.g., rigor mortis). The P&P indicated, if the resident's NR status was unclear, CPR will be initiated until it was determined that there was a DNR or a physician's order not to administer CPR. According to the P&P, if the first responder was not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrived. The P&P indicated Preparation for Cardiopulmonary Resuscitation was as follows: 1. The facility's procedure for administering CPR would incorporate the steps covered in the 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care. 2. Select and identify a CPR team for each shift in the case of an actual cardiac arrest, with a designated team leader who would be responsible for coordinating the CPR. The team The P&P also indicated Preparation for Cardiopulmonary Resuscitation was as follows : 1. If an individual was found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: Instruct a staff member to activate Code Blue and call 911. Verify or instruct a staff member to verify the code status of the individual. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: a Following initial assessment, begin CPR with chest compressions; b Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; c Allow full chest recoil after each compression; and d Minimize interruptions in chest compressions. 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide 2 breaths via ambu-bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. Continue with CPR/BLS until emergency medical personnel arrive. During a review of AHA's article titled 11 things to know to save a life with CPR, published [DATE], the article indicated according to research, each minute of delayed CPR, there was a decreased chance of survival by about 10%.

Based on observation, interview, and record review, the facility failed to ensure the resident, who had no impairments in the right hand and arm range of motion ([ROM], full movement potential of a joint [where two bones meet]) did not acquire an avoidable decline (reduction) in ROM and did not develop a contracture (loss of motion associated with stiffness and joint deformity) of the right wrist and right hand for one of seven sampled residents (Resident 59). The facility failed to: 1.Accurately assess and code the Minimum Data Set ([MDS], a comprehensive assessment and care screening tool) dated 12/28/2023, to indicate ROM limitations in Resident 59's right arm. 2. Assess Resident 59's ROM of both arms for any changes or decline in ROM on the quarterly Joint Mobility Screens ([JMS] a brief assessment of a resident's ROM in both arms and both legs), dated 11/21/2023 and 12/28/2023. 3. Ensure Resident 59 was provided with a Restorative Nursing Aide program ([RNA] a nursing program that uses restorative nursing aides RNAs to help residents maintain their function and mobility) treatment in accordance with the Occupational Therapy ([OT] a profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities), Rehabilitation Screening ([Rehab Screen] a quarterly evaluation of a resident's need for skilled therapy [services that require specialized training and experience of a licensed therapist or therapy assistant] or an RNA program) recommendations on 9/28/2023 to prevent a decline in Resident 59's right arm ROM and in accordance with the facility's P&P titled, Restorative Nursing Program. These deficient practices, from 9/28/2023 to 2/23/2024 (approximately five months), resulted in Resident 59 developing a severe contracture (>50% loss of motion) of the right wrist and right hand. Findings: During a review of Resident 59's Admission Record, the Admission Record indicated Resident 59 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right sided hemiplegia (weakness to the right side of the body), osteoarthritis (loss of protective cartilage that cushions the ends of your bones), and anoxic brain damage (injury to the brain caused by lack of oxygen). During a review of Resident 59's MDS, dated [DATE], the MDS indicated Resident 59 had clear speech and severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making and required extensive assistance (resident involved in activity while staff provided support) for bed mobility, transfers between surfaces, dressing, toilet use, and personal hygiene. The MDS indicated Resident 59 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) and had no ROM limitations in both arms but had ROM limitations in both legs. During a review of Resident 59's Physician's Orders, the Physician's Orders indicated an order dated 2/28/2020 for RNA to provide passive range of motion ([PROM] a movement at a given joint with full assistance from another person) exercises to Resident 59's right arm followed by the application of a right-hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for four to six hours, five times a week as tolerated. The Physician Orders indicated order for RNA was discontinued on 2/28/2020 timed at 3:02 p.m. During a review of Resident 59's care plan titled ROM Limitations Related to Right Hemiplegia and Arthritis, revised 1/1/2024, the care plan indicated the goal was for Resident 59 to avoid complications related to contractures and would not experience a ROM decline. The care plan interventions to prevent ROM decline included for RNA to provide PROM exercises to the right arm followed by the application of a right-hand splint, for four to six hours, five times a week as tolerated. During a review of Resident 59's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment dated 6/8/2023, the PT Evaluation and Plan of Treatment indicated Resident 59's ROM in both arms was within functional limits ([WFL] a sufficient movement without limitation). During a review of Resident 59's Physician's Orders, the physician's order indicated for OT to provide OT evaluation and treatment for Resident 59. The Physician Order indicated order for RNA was discontinued on 6/9/2023 timed at 11:46 a.m. During a review of Resident 59's Occupational Therapy Re-admission Joint Mobility Screening (OT JMS), dated 6/14/2023, the OT JMS indicated Resident 59's had full PROM in both wrists, hands, fingers, elbows, and shoulders. During a review of Resident 59's PT Discharge Summary, dated 7/27/2023, indicated Resident 59 RNA Program was not applicable (did not apply) because Resident 59 refused. During a review of Resident 59's Physician's Orders, the Physician's Orders indicated an order dated 7/27/2023 at 9:05 p.m., for RNA to provide PROM exercises to Resident 59's both legs, five times a week as tolerated. During a review of Resident 59's Occupational Therapy Rehabilitation Screening (OT Rehab Screen), dated 9/28/2023, the OT Rehab Screen indicated an RNA Program was recommended for Resident 59. During a review of Resident 59's Nursing Quarterly Joint Mobility Screen, dated 11/21/2023, the JMS indicated for Resident 59 to continue PROM exercises with RNA to both legs and no evaluation or recommendations for Resident 59's arm was documented. During a review of Resident 59's MDS, dated [DATE], the MDS indicated Resident 59 had clear speech and severely impaired cognitive skills for daily decision making. The MDS indicated Resident 59 required substantial/maximal assistance (helper does more than half the effort to complete the task) for hygiene and lying to sitting on the side of the bed, partial/moderate assistance (helper does less than half the effort to complete the task) for dressing, and supervision/touching assistance (helper provides verbal cues or steadying assistance for activity) for eating and rolling to both sides. The MDS indicated Resident 59 had no ROM limitations in both arms and had ROM limitations in one leg. During a review of Resident 59's Nursing Quarterly Joint Mobility Screen, dated 12/28/2023, the JMS indicated for Resident 59 to continue PROM exercises with RNA to both legs and no evaluation or recommendations for Resident 59's arm was documented. During a review of Resident 59's OT Rehab Screen, dated 12/28/2023, the OT Rehab Screen indicated an RNA Program was recommended for Resident 59. During a concurrent observation and interview on 2/20/2024 at 2:33 p.m., in Resident 59's room, Resident 59 was observed sitting upright in the bed with the left ankle crossed over the right knee. Resident 59's right elbow was bent, the right wrist was bent downwards, the fingers of the hand were bent into a fist, and the right thumb was fully straight. Resident 59 attempted to straighten the right wrist and open the right hand using her left arm but was unable to do so. Resident 59 stated that she previously had full range of motion in her right arm, but currently she had difficulty moving it due to her right wrist and right hand were stuck (unable to move from a particular position). Resident 59 stated facility staff assisted her with exercises to both legs but did not provide exercises for her arms and hands. During an interview on 2/21/2024 at 3:15 p.m., Certified Nursing Assistant (CNA 8) stated Resident 59's does not use her right arm to assist with care during activities of daily living ([ADLs], basic activities such as eating, dressing, and toileting) and mobility (ability to move). During an interview on 2/21/2024 at 3:19 p.m., RNA 1 stated she assisted Resident 59's with legs PROM exercises because there was no order for ROM for the resident 's arms. RNA 1 stated she does not recall ever performing ROM exercises to Resident 59's arms throughout the entirety of Resident 59's stay at the facility. (Resident 59 was admitted on [DATE] and readmitted on [DATE]). During an interview on 2/21/2024 at 3:47 p.m., RNA 2 stated he assisted Resident 59 with PROM exercises to both legs only because there was no order to provide exercises for Resident 59's arms. RNA 2 stated, in the past, there was an order for RNA to assist with exercises to the right arm and apply a right-hand splint, but does not know why the order was discontinued. During a concurrent interview and record review on 2/22/2024 at 10:27 a.m. with Physical Therapist (PT 1), PT 1 stated the Rehabilitation Department (rehab department) performed JMS for all the residents in the facility upon admission, re-admission, annually, and upon notification by staff of a resident change of condition to monitor for changes in joint ROM. PT 1 stated the OT JMS assessed ROM of the resident's arms and the PT JMS assessed ROM of the resident's legs. PT 1 stated the nursing department performs quarterly JMS and should notify the rehab department if any changes or declines noted in a resident's ROM. PT 1 stated the rehab department also performed Rehab Screens quarterly. PT 1 stated the OT Rehab Screen assessed the resident's overall level of function related to ADLs and ROM of the arms. PT 1 stated the PT Rehab Screen assessed the resident's overall level of function related to mobility and ROM of the legs. PT 1 stated the results of the Rehab Screen and JMS indicates if a resident required skilled therapy services or an RNA Program. Resident 59's PT Evaluation was reviewed; PT 1 stated Resident 59 was evaluated by PT on 6/8/2023 and indicated ROM of both arms were WFL. PT 1 stated he did not recommend an RNA Program upon discharge from PT treatment on 7/27/2023 due to multiple resident's refusals with mobility. PT 1 stated he wrote an RNA order for RNA to perform PROM to Resident 59's both legs due to Resident 59 high risk for developing a contracture without RNA intervention. PT 1 stated Resident 59 had fluctuating (changing frequently) cooperation levels with mobility but did not refuse to participate in ROM exercises. During a concurrent interview and record review on 2/22/2024 at 10:40 a.m. with Occupational Therapist (OT 1), Resident 59's entire medical therapy record, physician's orders (dated 2/28/2020), and OT Annual JMS (dated 6/14/2023) were reviewed. OT 1 stated the purpose of the JMS was to monitor if resident's joint ROM had maintained, improved, or declined. OT 1 stated it was important to regularly monitor for changes in joint ROM to ensure the proper RNA services were provided to the resident if needed to prevent a decline in ROM and or development of contractures. OT 1 stated she performed an OT JMS on 6/14/2023 with Resident 59, which indicated Resident 59 had full ROM of both wrists, hands, fingers, elbows, and shoulders. OT 1 stated the physician ordered and discontinued RNA to perform PROM exercises to Resident 59's right arm followed by the application of a right-hand splint order on 2/28/2020. OT 1 stated she did not know the reason Resident 59's RNA order was discontinued and was unable to find documentation to indicate the reason of discontinuance of the order for PROM exercises and right-hand splint on 2/28/2020. OT 1 stated Resident 59 did not receive any RNA services for the arms while in the facility since the RNA order, dated 2/28/2020, was discontinued and no other RNA orders addressing Resident 59's arms were found in the clinical record. OT 1 stated Resident 59 was at high risk for contracture development due to Resident 59's diagnosis of right hemiplegia and could have benefitted from OT and/or an RNA program while in the facility to maintain and prevent a decline of ROM of the arms. During a concurrent observation and interview on 2/22/2024 at 11:15 a.m., while in Resident 59's room, OT 1 was observed performing an OT JMS and re-assessed Resident 59's ROM of both arms. Resident 59 stated she was unable to straighten her right wrist and open her right hand. Resident 59 screamed when OT 1 attempted to straighten Resident 59's right wrist and fingers on the right hand. OT 1 stated Resident 59's had severe contractures of the right wrist and fingers of the right hand and recommended skilled OT services for management of the right-hand contracture. OT 1 stated Resident 59 was at high risk for contracture development due to the diagnosis of hemiplegia and failed to receive treatment and services while in the facility to maintain arm ROM and prevent a decline. OT 1 stated Resident 59's right hand and right wrist contractures could have been prevented if OT evaluated Resident 59 earlier and established an RNA program for right arm ROM exercises. During a review of Resident 59's OT JMS, dated 2/22/2024, the JMS indicated Resident 59 had severe (>50% ROM loss) ROM limitations in the right wrist, right hand, and right fingers. The JMS indicated Resident 59 had minimal (<25% loss) ROM limitations in the right elbow and right shoulder. The JMS indicated Resident 59 had severe contractures of the right wrist, hand, and fingers and recommended a skilled OT therapy evaluation. During a review of Resident 59's OT Rehab Screen, dated 2/22/2024, the OT Rehab Screen indicated Resident 59 had contractures to the right wrist and right hand and recommended skilled OT services to provide evaluation and treatment of Resident 59's contractures. During an interview on 2/22/2024 at 12:45 p.m., the Minimum Data Set Nurse (MDSN) stated the facility monitored any changes in joint ROM by the MDS and JMS performed by the Rehab Department and nursing. The MDSN stated the Rehab Department performed a detailed JMS annually, upon admission, and upon change of condition. The MDSN stated nursing monitors for changes in a resident's ROM through the completion of the MDS and quarterly JMS screen performed by a licensed nurse or MDSN. The MDSN stated the licensed nurse JMS assessed the resident's general ROM as it relates to resident ability to complete ADLs such as eating and dressing. The MDSN stated nursing observed the resident active movement of the arms and legs during ADLs but did not perform ROM to physically assess the joint ROM of the arms. During a concurrent interview and record review on 2/22/2024 at 1:01 p.m. with the MDS Assistant (MDSA), Resident 59's quarterly MDS, dated [DATE] and 12/28/2023 were reviewed. The MDSA stated the MDS was a comprehensive (complete) assessment of the resident and was used to create a plan of care. The MDSA stated the facility monitored for changes in a resident's joint mobility by assessment entered in the MDS, nursing quarterly JMS, and PT and OT JMS. The MDSA stated nursing performed JMS by observing a resident actively move his or her arms and legs to perform ADLs and compared the results with therapy notes. The MDSA stated Resident 59's MDS assessment, dated 9/28/2023 and 12/29/2023 indicated Resident 59 was scored a zero which indicated Resident 59 had no ROM limitations in both arms. During a concurrent observation and interview on 2/22/2024 at 11:15 a.m., while in Resident 59's room, the MDSA was observed re-assessing Resident 59's ROM of both arms. Resident 59 was observed sitting in a wheelchair with the right elbow, right wrist, and fingers of the right hand in a bent position. The MDSA was observed unable to straighten Resident 59's right wrist and right hand. Resident 59 stated she was unable to straighten her right wrist and fingers of the right hand because they were stuck and asked MDSA for a splint to help straighten her wrist and keep her hand open. The MDSA asked Resident 59 if she can use her right arm for ADL's such combing the hair and eating but Resident 59 was unable to use the right arm. The MDSA stated he clearly remembered recently evaluating Resident 59's right arm when completing the MDS on 12/28/2023 and stated the MDS was coded incorrectly. The MDSA stated Resident 59's right arm ROM looked the same on 12/28/2023 when the MDS was coded and should have been coded a one instead of a zero to indicate Resident 59 had ROM impairments in one arm since Resident 59 was unable to use the right arm for ADLs due to joint limitations. The MDSA stated the facility was unable to identify Resident 59's decline in right arm ROM because the MDS was coded incorrectly. The MDSA stated that if MDS dated [DATE] was coded correctly, the facility could have identified Resident 59's right arm ROM decline since the previous MDS assessment dated [DATE] indicated no arm ROM limitations and could have provided services to prevent a further decline. During a concurrent interview and record review on 2/22/2024 at 1:49 p.m. reviewed with MDSN Resident 59's MDS assessments dated 9/28/2023 and 12/28/2023 were reviewed. The MDNS stated it was important for the MDS to be coded accurately because it was a comprehensive assessment of a resident's current level of function used to create the plan of care. The MDNS stated if Resident 59's MDS dated [DATE] was coded correctly, the facility could have identified Resident 59's decline in right arm ROM earlier and provided the proper services such as skilled OT therapy or RNA services to prevent a further decline in ROM and contracture. During a concurrent interview and record review on 2/22/2024 at 4:20 p.m., with MDSN Resident 59's nursing JMS dated 11/21/2023 and 12/28/2023 were reviewed. The MDSN stated nursing did not assess Resident 59's ROM of both arms. The MDSN stated nursing assessed the ROM of Resident 59's both legs but did not assess ROM of Resident 59's both arms on 11/21/2023 and 12/28/2023 JMS. The MDNS stated the facility could have identify the decline in Resident 59's right arm ROM if the ROM of Resident 59's arms were assessed during the 11/21/2023 and 12/28/2023 JMS. The MDNS stated the rehab department should have notified to provide skilled OT therapy or establish an RNA program. During a concurrent interview and record review on 2/23/2023 at 2:47 p.m., with the Director of Rehabilitation (DOR) Resident 59's clinical therapy records and OT Rehab Screens dated 9/28/2023 and 12/28/2023, were reviewed. The DOR stated the facility monitored for changes in residents' joint ROM by OT and PT JMS, quarterly nursing JMS, and quarterly Rehab Screens. The DOR stated the OT and PT JMS were completed annually, upon admission, upon re-admission, and upon notification of a resident's change of condition. The DOR stated the rehab department was never notified from nursing or other staff of a decline in Resident 59's right arm ROM. The DOR stated the OT and PT JMS involved the licensed therapist moving the resident's joints through his or her available ROM to provide a more accurate and measurable (something that could be quantified) way of identifying any ROM changes. The DOR stated the OT Rehab Screens were completed quarterly by a licensed therapist to identify any changes in a resident's ADL performance, provided a general assessment of a resident's ROM of both arms, and determined if skilled therapy services or an RNA program were recommended based on the results. The DOR reviewed Resident 59's OT Rehab Screens, dated 9/28/2023 and 12/28/2023, and stated the OT recommended an RNA program for Resident 59 based on the results of the screening. The DOR stated that if an RNA program was recommended on the Rehab Screen, the therapist should have checked the clinical record to ensure the resident was on an RNA program or request an OT evaluation to start an RNA program if needed. The DOR stated the OT Rehab Screen recommendations for an RNA program for Resident 59 on 9/28/2023 and 12/28/2023 were not carried out. The DOR stated Resident 59 was not on an RNA program for arm exercises on 9/2023 and OT was never ordered to evaluate Resident 59 to start an RNA program. During a concurrent interview and record review on 2/23/2024 at 3:51 p.m. Resident 59's OT Rehab Screens dated 9/28/2023 was reviewed. PT 1 stated he conducted the OT Rehab Screen on 9/28/2023 and recommended an RNA program for Resident 59's arm. PT 1 stated he assumed Resident 59 was already on an RNA program for the arms since Resident 59 was receiving RNA services for leg exercises but did not check to confirm and did not ask for an OT evaluation to start an RNA program if needed. PT 1 stated the recommendation for an RNA program for Resident 59's arms on 9/28/2023 was not carried out resulting in Resident 59 not receiving treatment and services to prevent a decline in Resident 59's right arm ROM and contracture. PT 1 stated that if the Rehab Screen recommendations were not carried out, residents in the facility could develop contractures and a functional decline in ROM. PT 1 stated Resident 59's right wrist and right-hand contractures could have been prevented if the OT Rehab Screen recommendations of RNA program for the arm were carried out on 9/28/2023. During a concurrent interview and record review on 2/23/2024 at 7:18 p.m. with the Director of Nursing (DON), Resident 59's clinical record was reviewed. The DON reviewed Resident 59's OT JMS, dated 6/14/2023, and stated Resident 59 had full ROM of the right shoulder, elbow, wrist, hand, and fingers. The DON reviewed Resident 59's physician's order, dated 2/28/2020, for RNA to perform PROM to Resident 59's right arm and apply a right-hand splint. The DON stated the RNA order was ordered on 2/28/2023 and discontinued on 2/28/2020 but did not know why. The DON reviewed Resident 59's order, dated 6/9/2023, for OT to provide evaluation and treatment to Resident 59. The DON stated the physician's order for an OT evaluation and treatment on 6/9/2023 and was discontinued on the same day (6/9/2023) but did not know why. The DON reviewed Resident 59's quarterly nursing JMS dated 11/21/2023 and 12/28/2023 and stated the licensed nurses did not assess Resident 59's ROM of both arms. The DON reviewed Resident 59's OT Rehab Screens, dated 9/28/2023 and 12/28/2023, and stated the licensed OT recommended an RNA program for Resident 59's arms on OT Rehab Screen. The DON stated there was no documentation Resident 59 received RNA services for the arms and OT services while in the facility. The DON reviewed Resident 59's OT JMS and OT Rehab Screen, dated 2/22/2024, and stated Resident 59 had severe contractures of the right wrist and right hand and required skilled OT services. The DON reviewed Resident 59's care plan, revised 1/1/2024, and stated the care plan indicated Resident 59 had ROM limitations with a goal to avoid complications related to contractures and would not experience a ROM decline. The DON stated the care plan interventions included PROM exercises to Resident 59's right arm followed by the application of a right-hand splint. The DON stated the care plan intervention was inaccurate, not up to date, and was not implemented since Resident 59's RNA order for PROM of the right arm and right-hand splint was discontinued on 2/28/2020. The DON stated there were no RNA orders for the right arm after it was discontinued on 2/28/2020. The DON stated that if Resident 59's care plan intervention was to receive right arm ROM exercises and a splint, it should have been implemented because it indicated Resident 59 required ROM maintenance services but was not done. The DON stated Resident 59 had right hemiplegia, did not move without encouragement, and was at high risk for contracture development. The DON stated Resident 59 did not receive treatment and services to maintain and prevent a decline in the Resident 59's right wrist and right hand. The DON stated the tools the facility had in place to identify and monitor for joint ROM changes were ineffective. The DON stated Resident 59's right wrist and right-hand contractures could have been prevented if Resident 59 MDS reflects the correct ROM of right arm, licensed staff assessed Resident 59's arm ROM during JMS, OT recommendations were carried out and Resident 59 received RNA program for her arm. During a review of the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, revised July 2017, indicated residents would not experience an avoidable reduction in ROM and residents with limited ROM would receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated nursing would identify the resident's current ROM of his or her joints and limitations in movement as part of the comprehensive assessment and develop a plan of care to include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve ROM. During a review of the facility's P&P undated titled, Restorative Nursing Program indicated the purpose of the RNA program was to maintain the resident's functional ability and reduce further declines. The P&P indicated the RNA program was to be provided under the direction of the Rehab Team, physician, DON, and other disciplines as needed and would include residents with limited mobility due to physical impairments, muscular deterioration (decrease in muscle size and tissue), contractures, and other physical and cognitive limitations. The policy indicated each resident shall be given care to reduce the risk of contractures, deformities, and decline in functional activities that included ROM exercises. CROSS REFERENCE TO F641

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and mechanical sling lift device was used in transferring one of three sampled residents (Resident 1) to ensure the resident was free of falls and injuries by failing to: 1.Use an appropriate lifting device (a mechanical sling lift [resident sits in the sling to transfer]) for Resident 1, who had a high risk for falls due to lower extremity paralysis (inability to move the legs and lower body, typically caused by spinal injury or disease), and was unable to stand. 2.Use a two-person or more trained Certified Nursing Assistant (CNA) to physical assist in transferring Resident 1 from the bed to the chair. These failures resulted in Resident 1 falling and sustaining multiple lower leg fractures (broken bones) with pain and cellulitis (an infection of the deep tissue) from an open traumatic wound (injury to the skin, blisters) and requiring a transfer to a general acute care hospital (GACH) for treatment and remained for three days. Findings: During a review of Resident 1 ' s Admission Record (A/R) dated 1/6/2023, the A/R indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. According to the AR, Resident 1 ' s diagnosis included paraplegia (paralysis [loss of ability to move] of legs and lower body), Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar; elevated blood sugar) receiving insulin (a hormone used to control blood sugar), peripheral vascular disease ([PVD] a disease that prevents normal blood flow to the legs), and hypertension (high blood pressure). During a review of Resident 1 ' s Minimum Data Set (MDS), an assessment and care-screening tool, dated 11/9/2022, the MDS indicated Resident 1 was non-ambulatory and used a wheelchair for mobility. According to the MDS, Resident 1 was totally dependent upon staff for care and required a 2 or more-person physical assist for transferring. During a review of Resident 1 ' s care plan titled, To prevent or reduce incident of injury/fall . dated 11/19/2022, the care plan indicated the staff ' s interventions indicated to keep the bed in low position and place bilateral floor mats on the floor to decrease potential injury. During a review of Resident 1 ' s care plan, dated 11/19/2022 and titled, ADL, (activities of daily living [mobility, grooming, toileting, and hygiene]) the care plan indicated Resident 1 required total assistance with ADLs. The staff ' s interventions included notifying the physician and /or responsible party of any change of condition and provide a safe environment. During a review of Resident 1 ' s history and physical (H/P), dated 11/29/2022, the H/P indicated Resident 1 ' s diagnosis included paraplegia and PVD. During a review of the facility ' s Situation Background Assessment and Recommendations ([SBAR] an internal facility communication document), dated 12/30/2022 and timed at 5:23 p.m., the SBAR indicated RN 1 went to assess Resident 1 after CNA 2 reported the resident ' s skin changes. RN 1 indicated upon assessment, Resident 1 had blisters (a small bubble on the skin filled with serum [body fluid/blood plasma] and usually caused by friction, burning and other damage) and discoloration on the left lower leg, both knees were swollen, and an abrasion (a superficial scraping off the skin) and redness was observed on the right knee. According to the SBAR, RN 1 reported it to the physician (Physician 1), who ordered Bactrim (an antibiotic to treat infection) for cellulitis (bacterial infection the causes redness, swelling and pain) and a stat (immediate) x-ray (a diagnostic test to determine extent of injury). The x-ray indicated Resident 1 had multiple fractures on both legs. Resident 1 was transferred to the GACH by ambulance on 12/31/2022 at 1:30 a.m. During a review of Resident 1 ' s GACH H/P, dated 12/31/2022, the H/P indicated Resident 1 was paraplegic and unable to stand or walk. The H/P indicated Resident 1 sustained fractures to both legs/knees from a traumatic injury with unspecified fractures of lower end of femur (thigh bone), left tibia (the larger of the two lower leg bones), upper end of right tibia, and upper and lower end of right fibula (the smaller of the two leg bones). According to the GACH H/P, Resident 1 ' s legs were immobilized with splints (hard material used to immobilize body parts) and pain management was the care provided with an orthopedic (a physician who specializes in the care and treatment of bones, joints, and other structures involved in movement of the body) referral. Resident 1 was transferred back to the Skilled Nursing Facility (SNF) 1/3/2023 (three days after admission to the GACH). During an observation on 1/6/2023 at 12:02 p.m., while in Resident 1 ' s room, the resident ' s bed was not in the lowest position and there were no floor mats in place on the floor next to the bed. During an interview with Resident 1 (Spanish speaking only) on 1/6/2023 at approximately 12:05 p.m., with Restorative Nurse Assistant (RNA) 1 as a Spanish to English translator, Resident 1 stated he recalls having a fall to his knees with a lot of pain but does not remember when. According to RNA 1, Resident 1 stated he remembered right before the fall he felt dizzy and had aching knees. During an interview with RNA 1 on 1/6/2023 at approximately 12:10 p.m., RNA 1 stated she performs passive range of motion exercises (exercises done by another person, when the person was unable to participate in any motion) on Resident 1 ' s legs. RNA 1 stated Resident 1 was bed-bound (unable to get out of bed without full assistance). During an interview with CNA 1 on 1/6/2023 at 12:19 p.m., CNA 1 stated she was Resident 1 ' s nurse on 12/29/2022, the day of the fall incident. CNA 1 stated on 12/29/2022, the day Resident 1 fell , she and two untrained nursing students (UNS 1 and 2) were transferring Resident 1 out of the bed (OOB) into a chair. CNA 1 stated she used a stand-up lift (Vera lift) to get Resident 1 OOB instead of a mechanical sling lift when Resident 1 fell . CNA 1 stated she and UNS 1 and 2 lost their grip on Resident 1 during the transfer and guided the resident to the floor where he laid on his buttocks. CNA 1 stated she reported the fall incident to the charge nurse, Licensed Vocational Nurse (LVN) 1. During a review of the stand/sit lift manufacture guidelines (Vera Lift), the guidelines indicated the following residents were not suited to use the stand/sit lift: 1. Residents with unpredictable behavior. 2. Resident unable to follow instructions. 3. Residents who cannot bear weight. 4. Resident who are paraplegic or quadriplegic (all limbs paralyzed). During a review of the facility ' s in-service, dated 10/17/2022 and titled, Lifting/Transferring/Mechanical Lifts/Slings/Gait Belt, CNA 1 was not listed as one of the employees who attended the training. During an interview with LVN 2, on 1/6/2023 at 12:34 p.m., LVN 2 stated she was Resident 1 ' s nurse on 12/30/2022 for the 3:00 p.m. to 11:00 p.m. shift, when Resident 1 ' s bilateral leg injuries were discovered by CNA 2 at 4:30 p.m. LVN 2 stated she did not receive any endorsement or report of any incident including falls with Resident 1 during the change of shift that day between 2:30-3:00 p.m. LVN 2 stated she found out from CNA 2 and RN 1 that Resident 1 had swelling and discoloration on both knees. During an interview with the administrator (ADM) on 1/6/2023 at 1:53 p.m., the ADM stated CNA 1 told him she had UNS 1 and 2 assisting her in transferring Resident 1, on 12/29/2022, the day the resident fell . The ADM stated CNA 1 told him she did not think Resident 1 fell since there was no injury. The ADM stated, My staff need further education and training regarding falls. During a concurrent observation and interview on 1/6/2023 at 2:58 p.m., while inside Resident 1 ' s room, Resident 1 ' s bed was observed not in a low position. RNA 1 stated Resident 1 ' s bed was not in a low position and should have been. During an interview with LVN 2 on 1/6/2023 at 3:01 p.m., LVN 2 stated if a resident had a fall risk, the staff ' s interventions would typically be to have the bed in low position. LVN 2 stated Resident 1 ' s bed was not in a low position and there were no floor mats on the floor. During an interview with the Minimum Data Set Nurse (MDSN) 1 and the ADM, on 1/6/2023 at 3:07 p.m., the ADM and MDSN 1 both stated they could not find any notes or documentation regarding Resident 1 ' s fall on 12/29/2022. During a telephone interview with LVN 1 on 1/9/2023 at 1:30 p.m., LVN 1 stated on 12/29/2022 at approximately 10 a.m., LVN 3 reported to her Resident 1 was on the floor. LVN 1 stated at approximately 10:30 a.m. on 12/29/2022 she went to check on Resident 1 and saw CNA 1 tending to Resident 1 at that time. LVN 1 stated upon assessment of Resident 1, she did not find any injuries on Resident 1 ' s body and notified the supervisor, and Registered Nurse (RN) 2. LVN 1 stated she got busy during the shift change (2:30 p.m.-3 p.m.) on 12/29/2022 and forgot to endorse Resident 1 ' s fall incident to the in-coming nurse and she did not complete an incident report and/or document the resident ' s fall. LVN 1 stated she was a new nurse and thought RN 2 would document the incident and endorse Resident 1 ' s fall information to the oncoming shift. LVN 1 stated reporting and documenting incidents should occur within 72 hours. LVN 1 stated Resident 1 was a high fall risk. During a telephone interview on 1/12/2023 at 9:15 a.m., with RN 3, RN 3 stated she was the charge nurse on 12/30/2022, for the 7:00 a.m. to 3:00 p.m. shift, but was not notified of any injuries or incidents regarding Resident 1 in the report. RN 3 stated she made quick rounds on 12/30/2022 and would only do assessments when a nurse notifies her of a concern. RN 3 stated she received a telephone call the same day 12/30/2022 from RN 1 after her shift was over (after 3 p.m.) who asked her if she knew about the bruising and swelling on Resident 1 ' s leg. RN 3 stated she informed RN 1 she had no idea what happened and does not know if it happened on her shift or not. During a telephone interview on 1/12/2023 at 9:25 a.m. with CNA 3, CNA 3 stated on 12/29/2022, during the 11 p.m. to 7 a.m. shift, Resident 1 was not able to turn in bed and she reported the resident had pain in his leg and there were bruises (blood or bleeding under the skin) and scratches (sore or mark on the surface with a sharp or pointed object) on the resident ' s legs. CNA 3 stated she then notified the charge nurse (LVN 5). During an interview with on 2/14/2023 at 11:10 a.m. with RN 2, RN 2 stated on 12/29/2022, she was very busy and does not remember anyone reporting to her about Resident 1 having a fall. RN 2 stated if she had known about Resident 1 ' s fall, she would have called the physician and wrote a Change of Condition (COC) note as per protocol. During an interview on 2/14/2023 at 11:31 a.m. with LVN 3, LVN 3 stated on 12/29/2022 she witnessed Resident 1 on the floor as she walked by the resident ' s room and CNA 1 with UNS 1 and 2. LVN 3 stated she told CNA 1 not to touch Resident 1 until she called the nurse to come and assess the resident. LVN 3 stated she reported Resident 1 ' s fall to LVN 1 and RN 2 at the nursing station. During an interview on 2/14/2023 at 12:04 p.m., with the Director of Rehab ([DOR] supervises all Rehab staff, who was a physical therapist {PT} healthcare professional who helps injured or ill people to improve movement and manage pain]), the DOR stated the last time he evaluated Resident 1 for physical therapy was in 2020, and at that time Resident 1 was not ambulating (walking). The DOR stated according to the resident ' s status then and now (as the DOR was currently seeing Resident 1 after the fall incident), a sling lift (a device used to transfer residents from bed to chair using a sling attached to a lifting machine) was the most appropriate lifting device to use when transferring Resident 1 from bed to chair since the resident was unable to stand. During an interview with an Occupational Therapist ([OT] a healthcare professional who treats and helps residents to improve and perform daily tasks) 1, on 2/14/2023 at 12:10 p.m., OT 1 stated she last worked with Resident 1 in 2020. OT 1 stated Resident 1 was totally dependent and could not stand. OT 1 stated when a resident was totally dependent, the caregiver must do all the work for the resident during the care activities. During review of an email from the ADM, dated 2/15/2023 and timed at 5:01 p.m., after several attempts were made to interview the two student CNAs regarding Resident 1 ' s fall to no avail, the ADM indicated he was not able to find the instructor or the students to obtain the names who were assisting CNA 1 when Resident 1 fell on [DATE]. During a review of the facility ' s undated policy and procedure (P/P) titled, Mechanical Lifts/Slings: Monitoring Functions, the P/P indicated mechanical lifts will be used in a safe, non-hazard areas and the resident ' s safety and privacy would always be provided. During a review of the facility ' s undated policy and procedure (P/P) titled, Positioning and Moving Residents, the P/P indicated before moving a resident, the staff should assess the resident ' s physical abilities, ability to balance, sit, and stand. The P/P also indicated when using a mechanical lift, a two-person assist must always be used.

Based on interview and record review, the facility failed to ensure when one of three sampled residents (Resident 1) had a change of condition (COC): 1. Resident 1 ' s physician (Physician 1) and responsible party (RP) were notified timely after the resident fell on [DATE] and sustained injuries. Physician 1 was not notified of Resident 1 ' s fall on 12/29/2022 and injuries until 12/30/2022. 2. Adhere to the facility ' s policy and procedure (P/P) titled, COC, which indicated the physician would be notified promptly and a 72-hour COC assessment would be documented. 3. Implement Resident 1 ' s care plan titled, ADLs which indicated if Resident 1 had any change of condition, the physician/responsible party would be notified immediately. These failures resulted in Resident 1 receiving a delay in diagnosis, care, and treatment for multiple lower leg fractures (broken bones), cellulitis (an infection of the deep tissue) from an open traumatic wound (an opened wound that occurs because of injury or accident), resulting in a transfer to a general acute care hospital (GACH) and being admitted for three days. Findings: During a review of Resident 1 ' s Admission Record (A/R) dated 1/6/2023, the A/R indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. According to the AR, Resident 1 ' s diagnosis included paraplegia (paralysis [loss of ability to move] of legs and lower body), Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar; elevated blood sugar) receiving insulin (a hormone used to control blood sugar), peripheral vascular disease ([PVD] a disease that prevents normal blood flow to the legs), and hypertension (high blood pressure). During a review of Resident 1 ' s Minimum Data Set (MDS), an assessment and care-screening tool, dated 11/9/2022, the MDS indicated Resident 1 was non-ambulatory and used a wheelchair for mobility. According to the MDS, Resident 1 was totally dependent upon staff for care and required a 2 or more-person physical assist for transferring. During a review of Resident 1 ' s care plan, dated 11/19/2022 and titled, ADL, (activities of daily living [mobility, grooming, toileting, and hygiene]) the care plan indicated Resident 1 required total assistance with ADLs. The staff ' s interventions included notifying the physician and /or responsible party of any change of condition and provide a safe environment. During a review of Resident 1 ' s history and physical (H/P), dated 11/29/2022, the H/P indicated Resident 1 ' s diagnosis included paraplegia and PVD. During a review of the facility ' s Situation Background Assessment and Recommendations ([SBAR] an internal facility communication document), dated 12/30/2022 and timed at 5:23 p.m., the SBAR indicated RN 1 went to assess Resident 1 after Certified Nursing Assistant 2 (CNA 2) reported the resident ' s skin changes. Registered Nurse 1 (RN 1) indicated upon assessment, Resident 1 had blisters (a small bubble on the skin filled with serum [body fluid/blood plasma; {colorless fluid part of blood} and usually caused by friction, burning and other damage) and discoloration on the left lower leg, both knees were swollen, and an abrasion (a superficial scraping off the skin) and redness was observed on the right knee. According to the SBAR, RN 1 reported the resident ' s change of condition to the physician (Physician 1), who ordered Bactrim (an antibiotic to treat infection) for cellulitis (bacterial infection the causes redness, swelling and pain) and a stat (immediate) x-ray (a diagnostic test to determine extent of injury). The x-ray indicated Resident 1 had multiple fractures on both legs. Resident 1 was transferred to the GACH by ambulance on 12/31/2022 at 1:30 a.m. During a review of Resident 1 ' s GACH H/P, dated 12/31/2022, the H/P indicated Resident 1 was paraplegic and unable to stand or walk. The H/P indicated Resident 1 sustained fractures to both legs/knees from a traumatic injury with unspecified fractures of lower end of femur (thigh bone), left tibia (the larger of the two lower leg bones), upper end of right tibia, and upper and lower end of right fibula (the smaller of the two leg bones). According to the GACH H/P, Resident 1 ' s legs were immobilized with splints (hard material used to immobilize body parts) and pain management was the care provided with an orthopedic (a physician who specializes in the care and treatment of bones, joints, and other structures involved in movement of the body) referral. Resident 1 was transferred back to the Skilled Nursing Facility (SNF) 1/3/2023 (three days after admission to the GACH). During an interview with Resident 1 (Spanish speaking only) on 1/6/2023 at approximately 12:05 p.m., with Restorative Nurse Assistant 1 (RNA 1) as a Spanish to English translator, RNA 1 stated Resident 1 stated he recalls having a fall to his knees with a lot of pain but does not remember when. According to RNA 1, Resident 1 stated he remembered right before the fall he felt dizzy and had aching knees. During an interview with CNA 1 on 1/6/2023 at 12:19 p.m., CNA 1 stated she was Resident 1 ' s CNA on 12/29/2022, the day of the fall incident. CNA 1 stated on 12/29/2022, the day Resident 1 fell , she and two untrained CNA students (Untrained CNAs 1 and 2) were transferring Resident 1 out of the bed (OOB) into a chair. CNA 1 stated she used a stand-up lift (Vera lift) to get Resident 1 OOB instead of a mechanical sling lift (a lift with a sling; resident sits in the sling) when Resident 1 fell . CNA 1 stated she and UNS 1 and 2 lost their grip on Resident 1 during the transfer and guided the resident to the floor where he laid on his buttocks. CNA 1 stated she reported the fall incident to the charge nurse, Licensed Vocational Nurse (LVN) 1. During an interview with LVN 2, on 1/6/2023 at 12:34 p.m., LVN 2 stated she was Resident 1 ' s nurse on 12/30/2022 when Resident 1 ' s bilateral leg injuries were discovered by Certified Nursing Assistant 2 (CNA 2) at 4:30 p.m. LVN 2 stated she did not receive any endorsement or report of any incident or fall with Resident 1 during the change of shift that day between 2:30-3 p.m. LVN 2 stated she found out from CNA 2 and RN 1 Resident 1 had swelling and discoloration on both of knees. During an interview with the administrator (ADM) on 1/6/2023 at 1:53 p.m., the ADM stated CNA 1 told him she had two CNA students assisting her in transferring Resident 1, on 12/29/2022, the day the resident fell . The ADM stated CNA 1 told him she did not think Resident 1 fell since there was no injury. The ADM stated, My staff need further education and training regarding falls. During an interview with the Minimum Data Set Nurse 1 (MDSN 1) and the ADM, on 1/6/2023 at 3:07 p.m., they both stated they could not find any notes or documentation regarding Resident 1 ' s fall on 12/29/2022. The ADM stated there were no notes or change of condition (COC) report regarding any notification to the resident ' s physician and/or family regarding the fall incident on 12/29/2022. During a telephone interview with LVN 1 on 1/9/2023 at 1:30 p.m., LVN 1 stated on 12/29/2022 at approximately 10 a.m., LVN 3 reported to her Resident 1 was on the floor. LVN 1 stated, at approximately 10:30 a.m. on 12/29/2022 she went to check on Resident 1 and saw CNA 1 tending to Resident 1 at that time. LVN 1 stated upon assessment of Resident 1, she did not find any injuries on Resident 1 ' s body and notified the supervisor, Registered Nurse 2 (RN 2). LVN 1 stated she got busy during the shift change (2:30 p.m.-3 p.m.) on 12/29/2022 and forgot to endorse Resident 1 ' s fall incident to the in-coming nurse and she did not complete an incident report and/or document the resident ' s fall. LVN 1 stated she was a new nurse and thought RN 2 would document the incident and endorse Resident 1 ' s fall information to the oncoming shift. LVN 1 stated reporting and documenting incidents should occur within 72 hours. LVN 1 stated Resident 1 was a high fall risk. During a telephone interview on 1/12/2023 at 9:15 a.m., Registered Nurse 3 (RN 3), RN 3 stated she was in charge on 12/30/2022, for the 7 a.m. to 3 p.m. shift, but was not notified of any injuries or incidents regarding Resident 1 in the report. RN 3 stated she made quick rounds on 12/30/2022 and would only do assessments when a nurse notifies her of a concern. RN 3 stated she received a telephone call the same day 12/30/2022 from RN 1 after her shift was over (after 3 p.m.) who asked her if she knew about the bruising and swelling on Resident 1 ' s leg. RN 3 stated she informed RN 1 she had no idea what happened and does not know if it happened on her shift or not. During an interview with RN 2 on 2/14/2023 at 11:10 a.m., RN 2 stated on 12/29/2022, she was very busy and does not remember anyone reporting to her about Resident 1 having a fall. RN 2 stated if she had known about Resident 1 ' s fall, she would have called the physician and wrote a Change of Condition (COC) note as per protocol. During an interview with LVN 3 on 2/14/2023 at 11:31 a.m., LVN 3 stated on 12/29/2022 she witnessed Resident 1 on the floor as she walked by the resident ' s room and CNA 1 with two student CNAs. LVN 3 stated she told CNA 1 not to touch Resident 1 until she called the nurse to come and assess the resident. LVN 3 stated she reported Resident 1 ' s fall to LVN 1 and RN 2 at the nursing station. During a review of the facility ' s undated P/P titled, Change of Condition indicated: 1. The definition of a change of condition is a sudden or marked difference in resident, including but not limited to injuries from a fall, skin breakdown (any opening of the skin), swelling. 2. The physician shall be notified promptly. During a review of the facility ' s undated P/P titled, Notification of Physician the P/P indicated the physician would be notified if there was a change in condition (deterioration of, or suspicion of deterioration of the patients ' health which deviates what is normal for them) of the resident, and that this call/notification will be documented in the nurses ' notes.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program for three of 29 residents (Residents 1, 2, and 3) with suspected scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate your skin by intense itching, inflammation, and red patches) or suspicious rash by failing to: 1. Ensure Residents 1, 2, and 3 who were exhibiting symptoms of suspected scabies were placed on isolation and ensure the facility protocol for scabies was followed. 2. Conduct an infection surveillance (close observation or monitoring) by completing a line listing (a table that contains key information about each case in an outbreak) of residents with a suspicious rash in the sub-acute unit. 3. Provide the necessary care and treatment to Resident 1, who had a severe itchy rash and was suspected to have scabies on 4/29/2022, and for Resident 2 and 3 who was suspected to have scabies on 5/2/2022. Facility did not obtain skin scraping (a test to confirm or rule out scabies) for scabies before administering [medication(s)] Permethrin cream 5% ([Elimite] a medication applied to the entire body to treat scabies) to the resident's skin per manufacturer's guidelines. Residents 1, 2 and 3 were not placed on contact isolation precaution on the day the cream was applied. 4. Ensure showers were provided for Residents 1, 2, and 3, eight to twelve hours after the application of the medicated cream, and the shower rooms were disinfected after suspected residents have used them. 5. Perform disinfection of the mattress, pillows, bedside equipment, and floors after treatment for Residents 1, 2 and 3. 6. Report an outbreak of scabies to the local health Department after 3 residents (Residents 1, 2 and 3,) had rashes with severe itching, which affected their quality of life, while being treated for suspected scabies. These deficient practices placed all residents, staff, vendors, and visitors at risk to acquire and be exposed to the scabies infection. On 5/7/2022 at 6:30 p.m., the Department identified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident and the situation created a need for an immediate corrective action). The administrator (ADM), Infection Preventionist (I/P) and the Assistant Director of Nursing (ADON) were notified at this time of the immediate actions that needed to be taken and the seriousness of the residents' health and safety threatened due to the facility's failure to prevent and maintain an infection control program. On 5/9/2022 at 12:12 p.m., the ADM provided an acceptable removal plan for correction of the IJ. The IJ removal plan included the following: 1. Line listing monitoring was created for all residents and staff in the sub-acute unit on 5/7/22. This will be used daily to monitor signs and symptoms of scabies and efficacy of prophylactic treatment provided. This will be done until two to six weeks after the second prophylactic treatment is completed to ensure treatment provided is effective. Any identified change in skin condition will be addressed immediately, and plan of care including monitoring of residents will be updated as needed. 2. All 29 residents in the subacute unit were placed on contact isolation precaution on 5/7/22 until 5/9/22, after shower is provided, 12 hours after application of elimite (prescription medication used to treat scabies) cream. 3. The facility reported to the Department on 5/7/22, the scabies prophylactic treatment was provided to three residents, Resident 1 on 4/29/22, and Residents 2 and 3 on 5/2/22. 4. Long Beach Department of Health and Human Services was notified via email on 5/7/22 of the residents provided with scabies prophylactic treatment and residents identified with rashes. 5. Skin sweeps were performed on 5/8/22 to all sub-acute residents. 15 subacute residents identified with rashes were seen by the Dermatologist on 5/8/22. Any new physician orders were carried out by the Licensed Staff. 6. The Dermatologist ordered skin scraping on 15 out of 15 subacute residents identified with rashes, which were performed 5/8/22. 7. Prophylactic treatment provided to all residents in the sub-acute unit on 5/8/22. Residents will be showered on 5/9/22, 12 hours after the application of prophylactic treatment. 8. Deep cleaning and disinfection of all subacute rooms were scheduled on 5/9/22, when residents were scheduled to be showered after application of the scabies prophylactic treatment. 9. Subacute Staff were provided an in-service on the facility's policy and procedures on scabies. This was started on 5/7/22 and will be on-going until all subacute staff are given the in-service education. Staff on vacation or not scheduled will be provided an in-service on the day they return to work before the beginning of their shift. The in-service education included, but not limited to, the following topics: 1. Conducting body check when providing care to residents and any change of condition should be reported immediately to the Charge Nurse and/or RN Supervisor. 2. How to identify signs and symptoms of scabies. 3. Cause of scabies. 4. Prevention of scabies. 5. Treatment of scabies. 6. Ensuring skin plan of care of residents are implemented and updated as needed. 10. The Treatment Nurse and/or Charge Nurse will conduct a daily body check on the residents identified with rashes until the rashes are resolved and/or six weeks after the second prophylactic treatment is provided, whichever is longer. A weekly body check will be conducted on all residents to identify any skin change of condition. Any findings will be reported to the Director of Nursing and will be addressed immediately. On 5/9/22 at 12:12 p.m., while onsite, after verifying the implementation of the facility's removal plan through observation, interview, and record review, the ADM, DON, and IP Nurse were notified the IJ was removed. Findings: a. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re admitted on [DATE]. Resident 1's diagnoses included heart failure (when the heart does not pump blood as well as it should), diabetes mellitus (high blood sugar), chronic respiratory failure (condition that results in the inability to effectively exchange carbon dioxide and oxygen). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/2/2022, the MDS indicated Resident 1 rarely or never understood and/or never understand others. The MDS indicated Resident 1 had severely impaired cognitive skills (ability to learn, remember, understand, and make decision) for daily decision making. The MDS indicated Resident 1 required total assistance with eating, bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. During a record review of Residents 1's Order Summary Report, for the month of May 2022, the report indicated to apply Permethrin Cream (Elimite) 5% from the head to toe topically, one time a day, every Monday for four weeks for dermatitis (condition of the skin in which it becomes red, swollen, and sore, sometimes with small blisters). During a record review of Resident 1's Treatment Administration Record (TAR), for the month of May 2022, the TAR indicated at 9 a.m. on 5/2/2022, cream was applied from head to toe for dermatitis. During a record review of Resident's 1 Non-pressure Sore Skin Problem, dated 3/25/2022, the report indicated Resident 1 had multiple redness, varied in size and shape, some flat and rash elevated with dry scaly skin to the trunk. During a record review of the Resident's 1 Telephone Order, dated 4/29/2022 and timed 3:21 p.m., the order indicated Ivermectin (used to treat infections) Tablet 3 milligrams ([mg] unit of measurement) every Monday for dermatitis, Permethrin cream 5 % apply from head to toe topically, one time a day, every Monday for 4 weeks, Prednisone (used to treat conditions such as skin diseases) 20 mg two times a day for dermatitis for 5 days, and generalized unspecified dermatitis wash with soap and water pat dry, apply clobetasol propionate (used on the skin to treat swelling, itching, and irritation) 0.05% cream to affected area for 4 weeks. During an interview with LVN 3 on 5/7/2022 at 4:10 p.m., LVN 3 stated Resident 1 was on contact isolation for Carbapenem-Resistant Enterobacteriaceae ([CRE] bacteria which is resistant to a specific class of antibiotics) of the sputum (mucus material). LVN 3 stated that there was no other isolation that she was aware of other than CRE for Resident 1. b. During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and re admitted on [DATE]. Resident 2's diagnoses included heart failure, chronic respiratory failure, and hyperlipidemia (high levels of lipids [fat] in the blood). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was usually able to understand others and had unclear speech. The MDS indicated Resident 2 required supervision with set up help with bed mobility, locomotion off unit and on unit, and dressing; and limited assistance with transfer, walking in the room and in corridor, toilet use, personal hygiene, and extensive assistance in bathing. During a record review of Resident 2's Nursing Progress Note, dated 4/29/2022, indicated that Resident 1 was seen and examined by the Dermatologist with an order of Ivermectin 3mg tablet every Monday and permethrin cream 5 % apply from head to toe every Monday for 4 weeks and Prednisone tablet 20mg two times a day for Dermatitis. During a record review of Resident 2's Order Summary Report, for the month of May 2022, the report indicated a dermatology consult dated 3/30/2022, Permethrin cream 5% apply from head to toe topically one time a day every Monday for dermatitis, unspecified for four weeks. During a record review of Resident 2's Nursing Progress Note dated 5/2/2022 at 10:20 p.m., the note indicated Resident 2 was being monitored for a body rash at the trunk anterior (front) and posterior (back), including upper extremities (arms). The note indicated applied Elimite cream from the neck to the toes for prophylaxis then shower in the morning. During a record review of Resident 2's Non-pressure sore skin problem report date identified 5/2/2022, the report indicated Resident 2 had spotty, elevated redness, varied in size and shape to the posterior and anterior trunk. During a concurrent observation and interview with Resident 2 on 5/7/2022 at 3:05 p.m., Resident 2 was observed to have a red, small blister and bumps on the skin, and rashes to the abdomen, back, arm and legs. Resident 2 stated that his roommate and the room across his room has rashes too. Resident 2 stated that there were a lot of residents that have rashes, and the residents were the reason of his itchiness right now. Resident 2 stated that cream was applied but did not help, and he did not take a shower after applying the cream. Resident 2 stated that he wheels himself outside and stays in the front lobby during the daytime. During an interview with LVN 1 on 5/7/2022 at 3:24 p.m., LVN 1 stated the Dermatologist came and did not order skin scraping. LVN 1 stated skin scraping was important to rule out scabies and properly treat the residents and isolate as needed. LVN 1 stated when the Dermatologist visited, residents with rashes were evaluated and only three residents were treated with Permethrin cream as a prophylaxis treatment. LVN 1 stated Resident 2 was noted scratching a lot lately. c. During a review of Resident 3's Admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included acute respiratory failure (condition that results in the inability to effectively exchange carbon dioxide and oxygen), anemia (lack of healthy red blood cells), and anoxic brain damage (harm to the brain due to a lack of oxygen). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severely impaired cognitive skills for daily decision making, and rarely or never understood and/or never understand others. The MDS indicated Resident 3 required total assistance with eating bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. During a record review of Resident 3's Treatment Administration Record (TAR), for the month of April 2022, the TAR indicated on 4/29/2022, Resident 3 had left upper extremity, back and abdomen unspecified dermatitis. The TAR indicated to wash with soap and water, pat dry, and apply clobetasol propionate 0.05% cream to the affected area every day for 4 weeks. During a record review of Resident 3's Licensed Nursing Note, dated 4/29/2022, orders of Ivermectin 3 mg once a day, every Monday, for 4 weeks, and Permethrin cream 5% apply from head to toe every Monday for 4 weeks for unspecified dermatitis. During an interview with Licensed Vocational Nurse (LVN) 1 on 5/7/2022, at 12:02 p.m., LVN 1 stated the facility had residents with rashes and itchiness beginning April 2022. LVN 1 stated the rashes started with Resident 1 and spread throughout the other residents in the sub-acute unit. LVN 1 stated when the IP and LVN 1 did a skin sweep on 5/5/2022, there were more than half of the residents in the sub-acute unit identified with rashes. LVN 1 confirmed residents who were exhibiting symptoms of scabies (rash and itchiness) were currently not being isolated from others. LVN 1 stated the facility's contracted dermatologist visited seven residents with rashes and prescribed cream for three of the residents. LVN 1 stated the cream was used to treat dermatitis and Ivermectin (treatment for scabies infection, including [Norwegian] scabies) 3 mg to be given for 4 weeks. LVN 1 stated that he did not remember having to isolate the residents identified with rashes, even before or during application of the permethrin cream. LVN 1 stated no one was isolated. LVN 1 stated there was no skin scraping were performed prior to the application of permethrin or a deep cleaning of the resident's rooms. During an interview with IP on 5/7/2022 at 1:10 p.m., IP stated that she was the one who assisted LVN 1 with the skin sweeps in the sub-acute unit on 5/5/2022. IP stated staff found more residents in the sub-acute unit with suspicious rashes and the residents were currently being treated. IP stated two of the residents was treated prophylactically with permethrin. IP stated Resident 1 was the first one to get treated on 4/29/2022. During an interview with IP on 5/7/2922 at 1:35 p.m. IP stated that she was not aware that there were total of three residents who was provided with prophylactic cream for scabies because of their rashes. IP stated after 4/29/2022, Residents 2 and 3 were both treated on 5/2/2022. IP stated Resident 1 was the first one to get treated on 4/29/2022, then Residents 2 and 3 were treated on 5/2/2022. IP stated the rashes were not reported to the Public Health local office nor the Department of Public Health. IP stated that she does not know why it was not reported. During a concurrent observation and interview with the IP on 5/7/2022, at 1:37 p.m., the IP confirmed the facility currently had one room designated for contact isolation due to CRE of the sputum. During an interview with LVN 2 on 5/7/2022 at 1:45 p.m., LVN 2 stated the residents in the sub-acute unit were being monitored because of rashes. LVN 2 stated the residents' physicians were aware, and a plan of care was initiated because of the rashes. LVN 2 stated the treatment nurse was responsible for treating and providing updates on the residents with skin conditions. During a telephone interview with the Director of Nursing (DON) on 5/7/2022 at 2 p.m., the DON stated that she was aware that there were residents in the sub-acute unit that developed rashes and itchiness. The DON stated that the Dermatologist came to the facility and prescribed prophylactic cream for scabies and diagnosed the residents with dermatitis. The DON stated residents that were treated were not isolated, and housekeeping did not deep clean the rooms. The DON stated none of the residents were ordered for skin scraping prior to being prophylactically treated. The DON stated she did not report the residents' rashes or suspicion of a scabies outbreak in the facility. During a telephone interview with the DON and IP on 5/7/2022 at 2:15 p.m., IP stated there were no dermatologist notes in the medical chart of the three residents that were treated. The DON stated there should be progress notes stating the purpose of the dermatologist's visit and new treatment orders for residents with skin issues. The DON stated she was not aware there were no progress notes from the Dermatologist. IP stated there was no specific care plan initiated for the resident's rashes. During an interview with Certified Nursing Assistant 1 (CNA 1) on 5/7/2022 at 2:37 p.m., CNA 1 stated he noticed Residents 2 and 3 were scratching and their rashes have been multiplying, starting from the fingers to the back and was now generalized or almost over the whole body. CNA 1 stated that he has been asking the LVNs if he needed to wear a gown, gloves, or full PPE because he just wears gloves when providing care. CNA 1 stated he reported the resident's worsening rashes to the License Nurses on duty at that time. During an observation on 5/7/2022 at 3:40 p.m., Residents 1 and 2 were both observed to have a red rash in between their fingers, abdomen, arms, back, neck and hip area. During an interview with LVN 1 on 5/7/2022 at 3:45 p.m., LVN 1 stated that Residents 1 and 2 were treated with cream and an oral pill for their rash. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 5/7/2022 at 3:58 p.m., the ADON stated he received the order for permethrin cream and the physician diagnosed Resident 2 with dermatitis. The ADON stated that he was aware it was prophylactic treatment for scabies, but he did not verify with the physician. During an interview with the IP on 5/7/2022 at 4:05 p.m., IP stated that skin scraping was not done prior to application of the cream. IP stated it was important to do skin scraping to make sure the rashes were not scabies and to treat properly if it was dermatitis or scabies. During an interview on 5/7/2022 at 4:15 p.m. with Laundry Staff 1 (Staff 1), Staff 1 stated that she washed the clothes of the residents in the sub-acute unit altogether first, then she washed their linen, towels and personal clothes or hospital gowns. Staff 1 stated she was unaware of any special protocols when doing the laundry for the residents in the sub-acute unit. Staff 1 stated the CNAs would put the linen and clothes in a separate bag if the residents were on isolation. Staff 1 stated she did not see any isolation bags in the laundry area the prior week. During an interview on 5/7/2022 at 4:35 p.m. with Housekeeping supervisor (HS), HS stated she was the one who made the assignment for deep cleaning or terminal cleaning in the room if instructed to do so. HS stated she received no instruction from the nursing department or the administrator that she needed to deep clean the rooms in the sub-acute unit. HS stated there was no deep cleaning in the subacute unit except for the regular monthly scheduled deep cleaning. During a record review of the Deep Cleaning Calendar Schedule, for the month of May 2022, the schedule indicated Residents 1, 2 and 3 rooms were not scheduled for deep cleaning 12 hours after applying the cream. During an interview with IP on 5/7/2022 at 4:45 p.m., IP stated no line listing of the residents identified with rashes was completed. IP stated that she did not start any line listing as well for the staff because no one really complained about being itchy or no one reported that someone developed a rash. During a record review of the facility's Activities of Daily Living (ADL) sheet, for the month of May 2022, the sheet indicated Residents 2 and 3 were not given showers 12 hours after the cream was applied. During a concurrent interview with the ADON and IP and record review on 5/7/2022 at 5:10 p.m., ADON and IP both confirmed and verified that Residents 1, 2 and 3 were not provided showers 12 hours after the application of the cream. IP stated that showers should have been given to all three residents to remove the cream or any lice (tiny, wingless, parasitic insects that feed on human blood) on the skin during the treatment. IP stated that if showers were not provided, it meant the medicine was still on the residents' skin which could cause toxicity as well. ADON stated that if showers were not provided after the application, treatment would not be complete. During an interview with the IP on 5/7/2022 at 5:20 p.m., IP stated the facility did not follow their P/P. IP stated no skin scrapings were performed prior to the application of treatment, terminal cleaning of the sub-acute unit, and no showers were provided after the treatment. IP stated Residents 1, 2 and 3 were not placed on isolation. During an interview with the Administrator (ADM) on 5/7/2022 at 5:36 p.m., ADM stated she did not report the outbreak to the DPH or to Public Health. ADM stated she was not aware there were three residents who received the prophylactic treatment. ADM stated the facility staff did not follow the facility's P/P. ADM stated the rooms in the sub-acute unit were not terminally cleaned nor were any of the residents placed on isolation. During a record review of the facility's undated policy and procedure (P/P) titled, Scabies- Prevention and Control, the P/P indicated that as soon as a case of scabies is confirmed or suspected, the following precautions should be implemented: 1. Place symptomatic resident on contact isolation precautions. 2. Restrict resident to his/her room for the duration of the first treatment period, usually eight to twelve hours. 3. Patients with signs and symptoms suggestive of scabies will be placed in contact isolation until the infestation has been ruled out or treated. 4. Personal protective clothing that includes gloves and long-sleeved gowns when direct contact with a patient with signs and symptoms of scabies will be worn. 5. Skin scrapings will be performed for suspected cases. 6. Reporting to Licensing and Certification and local Public Health Nurse when two or more suspected cases of scabies are identified within a 14-day period regardless of whether confirmed cases are identified. 7. Developing and instituting use of surveillance data collection form. 8. Treating possible contacts, essentially all residents, healthcare workers, volunteers, and visitors (mass prophylaxis). 9. Bathe or shower resident prior to applying scabicide if not bathed within the last 24 hours. 10. Place all non-washable personal clothes in plastic bag and keep sealed for seven days. All other items should be dry cleaned or washed in washing machine and then machine dried in a hot dryer for 20 minutes. 11. Change all bed linens following the application of scabicide. Remove all used towels, wash cloths, bed clothes. Place in plastic bag and send to laundry for washing/drying. 12. Instruct laundry personnel not to sort these items; they must be washed separately from other facility laundry. 13. Change bed linens, towels and clothing after the scabicide has been washed off. 14. Disinfect the mattress, pillow covers, bedside equipment and floors after scabicide has been washed off. 15. Disinfect multiple use equipment. Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program for three of 29 residents (Residents 1, 2, and 3) with suspected scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate your skin by intense itching, inflammation, and red patches) or suspicious rash by failing to: 1. Ensure Residents 1, 2, and 3 who were exhibiting symptoms of suspected scabies were placed on isolation and ensure the facility protocol for scabies was followed. 2. Conduct an infection surveillance (close observation or monitoring) by completing a line listing (a table that contains key information about each case in an outbreak) of residents with a suspicious rash in the sub-acute unit. 3. Provide the necessary care and treatment to Resident 1, who had a severe itchy rash and was suspected to have scabies on 4/29/2022, and for Resident 2 and 3 who was suspected to have scabies on 5/2/2022. Facility did not obtain skin scraping (a test to confirm or rule out scabies) for scabies before administering [medication(s)] Permethrin cream 5% ([Elimite] a medication applied to the entire body to treat scabies) to the resident's skin per manufacturer's guidelines. Residents 1, 2 and 3 were not placed on contact isolation precaution on the day the cream was applied. 4. Ensure showers were provided for Residents 1, 2, and 3, eight to twelve hours after the application of the medicated cream, and the shower rooms were disinfected after suspected residents have used them. 5. Perform disinfection of the mattress, pillows, bedside equipment, and floors after treatment for Residents 1, 2 and 3. 6. Report an outbreak of scabies to the local health Department after 3 residents (Residents 1, 2 and 3,) had rashes with severe itching, which affected their quality of life, while being treated for suspected scabies. These deficient practices placed all residents, staff, vendors, and visitors at risk to acquire and be exposed to the scabies infection. On 5/7/2022 at 6:30 p.m., the Department identified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident and the situation created a need for an immediate corrective action). The administrator (ADM), Infection Preventionist (I/P) and the Assistant Director of Nursing (ADON) were notified at this time of the immediate actions that needed to be taken and the seriousness of the residents' health and safety threatened due to the facility's failure to prevent and maintain an infection control program. On 5/9/2022 at 12:12 p.m., the ADM provided an acceptable removal plan for correction of the IJ. The IJ removal plan included the following: 1. Line listing monitoring was created for all residents and staff in the sub-acute unit on 5/7/22. This will be used daily to monitor signs and symptoms of scabies and efficacy of prophylactic treatment provided. This will be done until two to six weeks after the second prophylactic treatment is completed to ensure treatment provided is effective. Any identified change in skin condition will be addressed immediately, and plan of care including monitoring of residents will be updated as needed. 2. All 29 residents in the subacute unit were placed on contact isolation precaution on 5/7/22 until 5/9/22, after shower is provided, 12 hours after application of elimite (prescription medication used to treat scabies) cream. 3. The facility reported to the Department on 5/7/22, the scabies prophylactic treatment was provided to three residents, Resident 1 on 4/29/22, and Residents 2 and 3 on 5/2/22. 4. Long Beach Department of Health and Human Services was notified via email on 5/7/22 of the residents provided with scabies prophylactic treatment and residents identified with rashes. 5. Skin sweeps were performed on 5/8/22 to all sub-acute residents. 15 subacute residents identified with rashes were seen by the Dermatologist on 5/8/22. Any new physician orders were carried out by the Licensed Staff. 6. The Dermatologist ordered skin scraping on 15 out of 15 subacute residents identified with rashes, which were performed 5/8/22. 7. Prophylactic treatment provided to all residents in the sub-acute unit on 5/8/22. Residents will be showered on 5/9/22, 12 hours after the application of prophylactic treatment. 8. Deep cleaning and disinfection of all subacute rooms were scheduled on 5/9/22, when residents were scheduled to be showered after application of the scabies prophylactic treatment. 9. Subacute Staff were provided an in-service on the facility's policy and procedures on scabies. This was started on 5/7/22 and will be on-going until all subacute staff are given the in-service education. Staff on vacation or not scheduled will be provided an in-service on the day they return to work before the beginning of their shift. The in-service education included, but not limited to, the following topics: 1. Conducting body check when providing care to residents and any change of condition should be reported immediately to the Charge Nurse and/or RN Supervisor. 2. How to identify signs and symptoms of scabies. 3. Cause of scabies. 4. Prevention of scabies. 5. Treatment of scabies. 6. Ensuring skin plan of care of residents are implemented and updated as needed. 10. The Treatment Nurse and/or Charge Nurse will conduct a daily body check on the residents identified with rashes until the rashes are resolved and/or six weeks after the second prophylactic treatment is provided, whichever is longer. A weekly body check will be conducted on all residents to identify any skin change of condition. Any findings will be reported to the Director of Nursing and will be addressed immediately. On 5/9/22 at 12:12 p.m., while onsite, after verifying the implementation of the facility's removal plan through observation, interview, and record review, the ADM, DON, and IP Nurse were notified the IJ was removed. Findings: a. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re admitted on [DATE]. Resident 1's diagnoses included heart failure (when the heart does not pump blood as well as it should), diabetes mellitus (high blood sugar), chronic respiratory failure (condition that results in the inability to effectively exchange carbon dioxide and oxygen). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/2/2022, the MDS indicated Resident 1 rarely or never understood and/or never understand others. The MDS indicated Resident 1 had severely impaired cognitive skills (ability to learn, remember, understand, and make decision) for daily decision making. The MDS indicated Resident 1 required total assistance with eating, bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. During a record review of Residents 1's Order Summary Report, for the month of May 2022, the report indicated to apply Permethrin Cream (Elimite) 5% from the head to toe topically, one time a day, every Monday for four weeks for dermatitis (condition of the skin in which it becomes red, swollen, and sore, sometimes with small blisters). During a record review of Resident 1's Treatment Administration Record (TAR), for the month of May 2022, the TAR indicated at 9 a.m. on 5/2/2022, cream was applied from head to toe for dermatitis. During a record review of Resident's 1 Non-pressure Sore Skin Problem, dated 3/25/2022, the report indicated Resident 1 had multiple redness, varied in size and shape, some flat and rash elevated with dry scaly skin to the trunk. During a record review of the Resident's 1 Telephone Order, dated 4/29/2022 and timed 3:21 p.m., the order indicated Ivermectin (used to treat infections) Tablet 3 milligrams ([mg] unit of measurement) every Monday for dermatitis, Permethrin cream 5 % apply from head to toe topically, one time a day, every Monday for 4 weeks, Prednisone (used to treat conditions such as skin diseases) 20 [TRUNCATED]

Based on interview, and record review the facility failed to implement their abuse policy to ensure one of 1 resident (1) was free from willful infliction of injury, and confinement resulting in physical abuse, which caused the resident physical harm. Resident 1, who was diagnosed as having dementia with behavioral disturbance (are often globally described as agitation including verbal and physical aggression, wandering, and hoarding which create distress), cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), problems communicating, and needing assistance with activities of daily living (a term used to collectively describe fundamental skills that are required to independently care for oneself such as eating, bathing, and mobility) hit the Certified Nursing Attendant (CNA 1) in the head. During the altercation CNA 2 witnessed CNA 1 yelling at Resident 1 saying Don't F-king hit me, while holding the resident's forearm across his chest tightly and forcefully. CNA 2 told CNA 1 three times to let go of Resident 1 but CNA 1 did not. Resident 1 sustained a skin tear to the left forearm and a fist size redness to the sternum (breast bone). This deficient practice resulted in Resident 1 sustaining a skin tear to the left forearm and a fist size redness to the sternum, hearing threats of harm, disparaging words, which also put other residents in the facility at risk for harm. Findings: On 9/3/20 at 4:30 p.m., an Facility Reported Incident was initiated for violation of residents rights and safety. The allegations indicated Resident 1 was not treated with respect and dignity by the CNA 1. During review of Resident 1's Face Sheet (Admission Record) on 9/3/20 at 4:30 pm, it indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. The Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the care plan dated 3/24/20 for Resident 1 it indicated the resident exhibited self care deficit, and needed total assistance from staff for activities of daily living due to dementia with behavioral disturbance, [CONDITION(S)], cognitive, and communication deficit. The interventions indicated if the resident was resistive to care the staff had to try again later or have another person approach the resident. The care plan dated 3/24/20 indicated Resident 1 had cognitive and communication deficit as manifested by short, and long term memory problems, severely impaired with daily decision making, problem understanding others, problem being understood, and did not speak the dominant language of the facility. The interventions indicated to speak clearly and slowly, encourage the resident to make choices in care, and to acknowledge, and support non-verbal expressions. During a review of the Minimum Data Set (MDS) a standardized assessment and care screening tool dated 6/22/20 indicated Resident 1 was severely impaired with cognitive skills for daily decision making, rarely made self- understood, and rarely understood others. The MDS assessment indicated Resident 1 required extensive assistance from staff for activities of daily living. During an interview through CNA 2 translating in Spanish on 9/3/2020 at 10:02 a.m., Resident 1 was asked regarding CNA 1 or someone forcefully pushing/holding him down in the bed. However, Resident 1 turned his head toward the window and did not answer. During interview and review of Background Screening Result form on 9/3/2020 at 3:51 p.m., the Administrator acknowledged and stated CNA 1, who was sent from a registry (agency that provides temporary nurse staffing) dated 7/06/20 was involved in a physical altercation with Resident 1. The Administrator stated the incident and CNA 1 were reported to the police department, Licensing and Certification Program Aide and Technician Certification section, long term care Ombudsman (patient advocate), and the nursing agency registry. The Administrator stated Resident 1's family member was also informed of the incident. During an interview on 9/3/20 at 6:01 p.m., CNA 2 stated on 7/06/20 at around 5:30 p.m., heard yelling coming from Resident 1's room but the resident's door was closed. CNA 2 stated when entering the room she witnessed CNA 1 yelling at Resident 1. CNA 2 stated during the verbal altercation CNA 1 told Resident 1 Don't F-king hit me, while holding Resident 1's forearm across his chest very hard, tightly, and forcefully. CNA 2 stated telling CNA 1 to let go of Resident 1's arm immediately. However, CNA 1 continued holding Resident 1's arms across his chest using force. CNA 2 stated repeating three times for CNA 1 to let go of Resident 1, but CNA 1 yelled and threatened by saying I (CNA 2) was going to be sorry and he was not going to forget this. CNA 2 stated telling CNA 1 to stop threatening the resident and herself because he was one phone call away from contacting the administration. During interview CNA 2 stated CNA 1 continued yelling and saying That nobody hits me I have a concussion. CNA 2 stated she told CNA 1 that if he was hurt he should let the charge nurse know how he was feeling. CNA 2 stated Resident 1 sustained a skin tear to the forearm that was bleeding. During a review of the facility's Incident Interview Record form dated 7/06/20, indicated Licensed Vocational Nurse (LVN 1) was informed about the abuse that took place on 7/06/20 between Resident 1 and CNA 1, which had been witnessed by CNA 2. According to the report LVN 1 instructed CNA 1 to leave Resident 1's room by going to the nursing station. LVN 1 stated when assessing Resident 1 there was 2 centimeter (cm) by 1 cm skin tear to the right forearm and a fist size redness noted on the sternum. LVN 1 stated CNA 1 explained that Resident 1 struck him with a closed fist on the side of his face. LVN 1 stated CNA 1 stated that was why he held Resident 1's forearm to prevent further assault from the resident. LVN 1 stated CNA 1 acknowledged that losing his composure resulted in the insults towards Resident 1. During a review of the facility's Incident Interview Record form dated 7/06/20 indicated Registered Nurse (RN 1) that on 7/06/20 at 5:30 p.m., while CNA 1 was giving care to Resident 1 suddenly Resident 1 hit CNA 1 in the head. During interview RN 1 stated CNA 1 informed RN 1 as to why he held Resident 1's right arm tightly across the resident's chest was to avoid the resident from hitting him again. RN 1 stated CNA 1 explained that was how Resident 1 sustained a skin tear over the right forearm. According to the facility's undated policy and procedure titled Abuse and Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy indicated abuse is defined as the willful infliction of injury, unreasonable confinement, or punishment with resulting physical harm or pain or mental anguish, or deprivation by a individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. During a review of the facility's undated policy and procedure titled Care of Physically/Verbally Abusive Residents indicated when the resident exhibits aggressive behavior stop, provide safety, and notify the charge nurse. The policy indicated to speak to the resident in a calm voice and when the resident is demonstrating an abusive outburst, and not responding to interventions, stop and monitor the resident safety, and well-being.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent and eradicate (destroy) cockroach infestation (presence of an unusually large number of cockroaches (small insect that can carry and spread infectious diseases)) and mice dropping (black granular in shape feces) throughout the facility for 164 of 164 residents who were eating food and drinking in their room. The deficient practice resulted in the presence multiple cockroaches observed in the residents' room including three (3) small nymphs (baby cockroach) one (1) medium cockroach, one (1) large German cockroach (a small species of cockroach that have the ability to access food items and carry serious disease) in residents' room [ROOM NUMBER], next to the residents' blanket and under the beds. There was one (1) nymph cockroach at the nurses' station (3) on the counter. Two nymph and two (2) medium cockroach in the employee's breakroom by the water dispenser and refrigerator. In the laundry room three (3) medium size cockroaches were observed on the floor. In the facility's equipment supply for respiratory therapy room mice droppings were observed. The cockroach infestation and mice droppings placed all 164 residents at risk of vector-borne diseases (Illnesses that results from infections transmitted to humans by insects, such as cockroaches). On 9/1/2020 at 11:05 a.m., an Immediate Jeopardy (IJ is a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents.) was declared and the facility's administrator (ADM) and Director of Nursing (DON) were notified of the findings. On 9/4/2020 at 2:48 p.m., the IJ was removed in the presence of the administrator after implementation of the acceptable plan of action (POA, interventions to correct the deficient practice) was verified and confirmed on an onsite visit via observation, interview and record review. The acceptable POA included the following actions: 1. room [ROOM NUMBER], 202, 313, employees' breakroom and laundry room were deep cleaned, beds and bed side tables of residents were changed. The pest control company inspected and provided treatment as needed on 9/1/2020. 2. The Storage Room was deep cleaned. The pest control company inspected for signs and sources of roaches and rodents, and provided treatment as needed on 9/1/2020. 3. All areas of the facility will be cleaned. This will be completed on 09/04/2020. 4. The pest control company inspected the facility, all rooms and outside, for any signs and sources of cockroaches and rodents. Inspection was completed 9/1/2020. Treatment was completed on all areas of the facility on 09/02/2020. 5. The pest control company representative will provide an in-service to the Maintenance Team, Administrator, Director of Staff Development (DSD), DON and Infection Control Preventionist Nurse (ICPN) on identification of pests and tracking possible sources of pests. This will be completed on 9/3/2020. 6. The Facility's administrative staff will provide an in-service to the housekeeping and dietary department on how to identify different kinds of pest specifically roaches and rodents, and procedure on reporting identified areas with pest/s to their immediate supervisor. This will be completed on 9/3/2020. The Department Managers will assist on in-servicing the staff. The facility's staff will provide an in-service to employees returning from vacation or time off request on the day they return prior to the beginning of their shift. 7. The Certified Nurse Assistants (CNAs) will check the residents' rooms after meals and snacks to ensure there are no food residues left on the bed, floor, overbed tables and bedside table. 8. The staff will be given an in-service on making sure personal food and/or drinks are not left on top of any surfaces at the nursing stations and break rooms, personal food items cannot be stored in the breakroom and kitchen. 9. Lockers, and staff refrigerators will be cleared of old food items every Friday. Staff must wipe any surfaces with juice and/or food remnants immediately. Scheduled staff members will be in- serviced by 9/3/2020. The facility's staff will provide an in-service to employees returning from vacation or time off request on the day they return, prior to the beginning of their shift. 10. The nursing staff will be given an in-service on identification of common kinds of pests, such as roaches and rodents, causes and how to prevent pest infestation. Nursing staff will immediately report any signs of roaches and rodents to the Maintenance Department. The Maintenance team will immediately inspect identified area/s and treatment will be provided per direction of the pest control company. The pest control company will be notified and will be asked to come in to inspect affected areas within 48 hours. This will be completed on 9/3/2020. The facility's staff will provide an in-service to employees returning from vacation or time off request on the day they return, prior to the beginning of their shift. 11. The Maintenance Supervisor (MS) and/or designee will check the residents' rooms and all areas of the facility for any signs of roaches and rodents weekly for 90 days and monthly thereafter. Any areas identified to be affected will be addressed immediately, identified area/s will be cleaned and treatment will be provided per direction of the pest control company. The pest control company will be notified and will be asked to come in to inspect affected area within 48 hours. The Maintenance Supervisor will maintain a log of weekly pest control inspection. 12. The Administrator will monitor by reviewing the pest control maintenance log weekly for 90 days and monthly thereafter. Any concerns identified will be addressed immediately. This plan of correction has been integrated into the quality assurance system and will be reviewed quarterly by the quality assurance committee for its effectiveness and to ensure compliance. Findings: A review of the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation (retrieved on July 16, 2020, from publichealth.alcounty.gov/eh/docs/specializedvencor_management) indicated that cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. When cockroaches that live outdoors and come into contact with human excrement in sewers or with animal fecal matter, they have the potential to transmit bacteria that cause food poisoning if they enter the structures. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated July 1, 2019 (retrieved on July 16, 2020, from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html) indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens from one living organism to other living organisms). A review of the facility's census report, dated 9/1/2020, indicated there were 164 residents residing in the facility. A review of the Pest Management Sanitation Report dated 6/12/2020, 7/6/2020, 8/6/2020 and 8/13/2020 indicated pest activity was found, and control measures were initiated. The Pest Management Sanitation Report indicated the kitchen, laundry, employee lounge room, patios and outside was treated. The report dated 8/28/2020 indicated there was no pest found during their monitoring. On 9/1/2020 at 2:55 a.m., during an observation of room [ROOM NUMBER] and interview, CNA 1 and Licensed Vocational Nurse 1 (LVN 1) confirmed seen the cockroaches in room [ROOM NUMBER]. LVN 1 stated the facility's MS was aware the cockroach problem. LVN 1 stated she has seen cockroaches in different areas of the facility. On 9/1/2020 at 3 a.m., during an interview, Resident 1 stated the facility had cockroaches everywhere and it was not the first time that he had seen them. Resident 1 stated, It is nasty. On 9/1/2020 at 3:10 a.m., during a concurrent observation and interview of room [ROOM NUMBER], the DON confirmed the room had cockroaches. The DON stated the pest exterminator had been coming to the facility often. On 9/1/2020 at 4:01a.m., during a concurrent observation and interview, LVN 1 confirmed a nymph crawling on the nurses' station (3) counter near the medication cart. On 9/1/2020 at 5:06 a.m., during an interview, LVN 2 stated the facility had an ongoing problem of cockroaches for a while and management was aware but seemed to not care. LVN 2 stated it was disgusting to see the cockroaches running around in residents' nightstand, crawling on their food and beds. LVN 2 stated the cockroaches could be observed by turning the residents' lights, You could see them running. On 9/1/2020 at 5:14 a.m., during an interview, Resident 2 stated he has seen cockroaches crawling on the wall of his room, on top of the bedside rails and on his bed. Resident 2 stated it was disgusting to see cockroaches while eating and it made him feel sad because he had been asking to have his room sanitized but no one seemed to listen. Resident 2 stated he did not want to get sick because of a cockroach. On 9/1/2020 at 6:31 a.m., during concurrent observation and interview of the staff lunchroom and the laundry room, the Assistant Director of Nursing (ADON) confirm cockroaches in the lunchroom and laundry room. The ADON stated the facility had a cockroach problem since last month. The ADON confirmed the mice dropping found on the storage room. The ADON stated the storage room contained supplies for the residents. On 9/1/2020 at 9:40 a.m., during an interview, Housekeepers 1 and 2 (HK 1 and 2) stated the facility has been having problems with cockroaches for a while (approximately 1 month). HKs 1 and 2 stated the cockroaches are outside by the garbage cans and inside resident's rooms. HKs 1 and 2 stated the supervisor was aware of the problem. On 9/1/2020 at 10 a.m., during an interview, in the presence of the Assistant Administrator, the Administrator (ADM) stated he was not aware the facility had cockroach problem but did have the pest control come in every month and three times the month of August 2020 for follow-ups (sic). On 9/1/2020 at 10:22 a.m., during an interview, the MS stated he was made aware by the staff of the cockroach problem. The MS stated he treats the facility with a treatment provided by the pest company, and he treats the facility when needed. He further stated once a month the pest control company comes in and verifies if the treatment was effective or not. On 9/1/2020 at 10:57 a.m., during an interview, in the presence of the DON, the ADM confirmed she had the pest control company come in three (3) times in the month of August 2020 because the facility did have a problem with cockroaches. A review of the facility's undated policy and procedures (P/P) titled, Housekeeping-Pest Control, indicated the ADM arranges for a pest control company to visit and inspect the facility at least once a month for insects, termites, rodents, and any other pest that may cause damage to the facility. The P/P indicated immediate action was taken and once exterminated or sprayed by the pest control company would inspect the facility to ensure that all environment pest were removed from the premises and issue the ADM an additional report that verifies all pest was removed.

Based on observation, interview and record review, the facility failed to follow and implement its abuse policy titled, Abuse Allegation Reporting, which indicated that a thorough investigation would be conducted after an allegation of abuse and to ensure protection for one of three sampled residents (Resident 1). Resident 1 alleged he was abused by a facility's staff that resulted in injuries. Resident 1 alleged that he was punched in the face by a facility's staff after a metal hanger was removed from his hand. This deficient practice resulted in Resident 1 being abused and the facility's inability to identify the alleged perpetrator that punched Resident 1 in the face, due to its failure to investigate Resident 1's allegation. These failures resulted in Resident 1 requiring a transfer to the general acute care hospital (GACH) for treatment of [REDACTED]. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 3/13/19, indicated the resident had severe impairment in cognition (thought process)) and delusions (condition in which a person cannot tell what is real from what is imagined). The MDS indicated Resident 1 required oversight supervision of locomotion (ability to move from one place to another) on and off unit. A review of Resident 1's care plan, revised on 9/14/17 and titled, Resident and/or Responsible Party Have Been Made Aware that the Facility has Stable Systems to Prevent not only Abuse, but also those Practices and Omissions, Neglect and Misappropriation of Property that is Left Unchecked, Lead to Abuse. The goal indicated that Resident 1 would be free from abuse. The staff interventions indicated that a form would be completed and reported when abuse was suspected. A review of Resident 1's unsigned Physician 1's (Physician 1) telephone orders, dated 5/25/19 and timed at 12:25 p.m., indicated to transfer Resident 1 to the GACH for evaluation due to increase agitation (feeling or appearing troubled). A review of a Situation Background Assessment and Recommendation ((SBAR) an internal communication tool), dated 5/25/19 and timed at 11:40 a.m., indicated Certified Nurse Assistant 1 (CNA 1) witnessed Resident 1 holding a hanger and waving it attempting to attack staff members. The SBAR indicated that the facility transferred Resident 1 via a non-emergency ambulance to the GACH for evaluation after the incident. A review of Resident 1's transfer form, dated 5/25/19 and timed at 11:55 a.m., indicated Resident 1 transfer [DIAGNOSES REDACTED]. The transfer form indicated that Resident 1 refused a body assessment. A review of a GACH's Emergency Documentation (ED), dated 5/25/19 and timed at 3:23 p.m., indicated that Resident 1 alleged that a tall guy who works at the facility punched him in the face after taking a wire hanger from his hand. The ED note indicated Resident 1's left cheek was observed swollen. A review of Resident 1's pictures obtained from the GACH, dated 5/25/19 and timed at 9:40 p.m., indicated that Resident 1 had bruises (discolored skin on the body, caused by a blow or impact) on the left side of the face, left lower leg, and left shoulder. A review of a Police Department's (PD) report, dated 5/28/19 and timed at 7:24 p.m., indicated Resident 1 had a left eye bruise. The report indicated that Resident 1 was unable to provide the name or title of the staff, but the resident described the staff as tall and muscular man. A review of a Resident 1's Readmission Assessment, dated 5/29/19, indicated Resident 1 refused assessment. The Readmission Assessment on 5/30/19 indicated Resident 1 had discoloration to the left periorbital (tissue surrounding the orbit of the eye) area measuring two (2) centimeters (cm) by (x) 3cm purplish/greenish in color. A review of Resident 1's physician's (Physician 1) orders, dated 5/30/19, indicated to monitor Resident 1's left lower periorbital area discoloration for 21 days. A review of the facility's investigation report, dated 6/5/19, 11 days after the incident, and signed by the facility's Administrator (ADM) on 6/8/19, indicated that the facility was not able to substantiate (to find true) any abuse allegations. The report indicated that on 5/25/19, Resident 1 was agitated and swinging around a wire hanger and that multiple attempts were made to remove the hanger, but the staff were unsuccessful. The facility's staff interviews indicated that Resident 1 was severely agitated and hit himself while CNA 1 and the Social Service Designee 1 (SSD 1) attempted to remove the hanger from Resident 1. On 6/5/19 at 12:20 p.m., during an interview, Resident 1 stated that a tall, black muscular man and a skinny little man wearing glasses came into his room to argue with him and then punched him in the face and the tall muscular man threw him off the bed. Resident 1 stated that he has not seen the tall man again in the facility. Resident 1 stated he was scared of the tall man punching him again and needed to defend himself, but didn't know how. Resident 1 stated that on the day he was punched, he notified all the nurses were in his room, but nothing was done. On 6/5/19 at 2:21 p.m., during an interview, the Director of Nursing (DON) stated that Resident 1 was aggressive and the care plans interventions were to allow him time to calm down and approach him in a calmly manner. The DON stated that there was no investigation of Resident 1's injury conducted because she thought the injuries were from Resident 1 hitting himself on 5/25/19 prior to the GACH's transfer. On 6/5/19 at 2:45 p.m., during an interview and review of Resident 1's pictures, the ADM stated that on 5/29/19 upon Resident 1's return to the facility, she noticed a slight discoloration to the left eye and cheekbone. The ADM stated that no investigation was conducted to investigate how Resident 1 sustained the injuries. The ADM stated that Resident 1 probably hit himself when the staff attempted to remove the hanger from his hand. On 7/8/19 at 1:31 p.m., during a telephone interview, SSD 1 stated that on 5/25/19, he was called by the staff to assist with Resident 1's aggressive behaviors. SSD 1 stated that upon entering Resident 1's room with CNA 1, Resident 1 was swinging a metal hanger at them. SSD 1 stated that he removed the hanger from Resident 1's hands while CNA 1 distracted him. SSD 1 stated that they noticed that Resident 1 hit his face multiple times after the removal of the hanger. At 1:44 p.m., on 7/8/19, during a telephone interview, CNA 1 stated that approximately at 11:30 a.m., on 5/25/19, he was called by the nurses to assist with Resident 1's aggressive behavior. CNA 1 stated that upon entering the resident's room, SSD 1 took the hanger away, while he (CNA 1) was talking to the resident trying to calm him down. CNA 1 stated that Resident 1 began to hit himself all over his body like if he was [NAME]-Kong acting as if he was the king. CNA 1 stated that they have received in-service trainings by the facility and that was the way aggressive situations were to be handled. On 7/9/19 at 7:56 a.m., during an interview and concurrent observation of the facility's surveillance video footage, dated 5/25/19, in the presence of the ADM, two staff with the description that Resident 1 gave, were observed walking into Resident 1's room at the time of the incident. During the video surveillance observation, Licensed Vocational Nurse 2 (LVN 2) was observed looking into Resident 1's room after CNA 1 and SSD 1 walked into Resident 1's room and a few seconds later covering her face and turning around abruptly and walking away from the room, and then turned again towards the room still covering part of her face and laughing. The administrator stated she did not understand why LVN 2 reacted in that manner. The ADM stated that none of the staff were suspended during the investigation because none of the staff injured the resident. On 7/9/19 at 8:10 a.m., during the continuous video observation and concurrent interview, CNA 1 was observed sweating profusely during the interview. CNA 1 stated that he did not hit Resident 1, that he just went into the room to distract him while SSD 1 removed the hanger from his hand. CNA 1 stated he was aware why LVN 2 flinched (sudden movement of the body) during the time of the incident. On 7/11/19 at 9:13 a.m., during a concurrent interview and record review, LVN 3 stated that on 5/30/19, she conducted a body readmission assessment on Resident 1. LVN 3 stated that upon the body assessment, Resident 1's left eye had discoloration and pictures were taken, and the DON, Physician 1 and the resident's Responsible Party (RP) were notified of the findings. LVN 3 stated that she did not ask Resident 1 how he sustained the injury, but she made the DON aware so that an investigation could be conducted according to their policy. On 7/20/19 at 12:10 p.m., during a concurrent interview and record review, Resident 1 stated that he was afraid of the tall man, and that he had seen him and the skinny guy walking around the unit again. Resident 1 was able to point at CNA 1's picture and stated that he was the one that hit him in the face. On 7/26/19 at 3:25 p.m., during a telephone interview, SSD 2 stated that she was made aware of Resident 1's discoloration upon his return on 5/30/19, but did not follow-up with the resident because she thought the nursing staff was following-up with Resident 1's injury. SSD 2 stated that her role was to follow-up with the residents to identify and address their concerns, but she did not do it for Resident 1. SSD 2 stated that the ADM, DON, RN 1 were aware of Resident 1's left eye discoloration upon his return from the GACH, but the SSD stated she was unaware why no investigation was conducted. A review of the facility's undated policy and procedure (P/P) titled, Abuse Allegation Reporting, indicated that injuries of unknown source should be reported to the administrator/abuse coordinator immediately. The DON and the ADM would suspend the employee to prevent further potential abuse while the investigation is in progress. The investigation will identify events that may constitute abuse and determine the direction of the investigation.

Based on observation, interview, and record review, the facility failed to follow its policy and a resident's plan of care to ensure when a resident had a change of condition (C[NAME]), that a physician and family member were immediately notified for one of three sampled residents (Resident 1). Resident 1, who had a [DIAGNOSES REDACTED]. member (FM 1), but was not reported to the physician and/or family prior to FM 1 identifying it. This deficient practice resulted in a delay of diagnosis, care and treatment for [REDACTED]. Resident 1 was given two tablets of Tylenol (a medication used for pain relief) 650 milligrams (mg) via a gastrostomy-tube ((GT tube) a tube surgically placed in the stomach to provide nutrition/hydration) for pain management. Findings: A review of Resident 1's Admission Record (Face sheet) indicated the resident was initially admitted to the facility on [DATE] and was last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/12/19, indicated Resident 1 was non-ambulatory, non-verbal, and had cognitive impairment (lack ability to make decisions, understand, and learn). According to the MDS, Resident 1 was totally dependent on the staff for all activities of daily living ((ADL), bed mobility, and transfer, locomotion on unit and off unit, dressing, eating, toilet use, and personal hygiene). Resident 1 scored 0 on brief interview of mental status (BIMS). (A score of zero means the resident lack the ability to make decisions, understand and learn). A review of a document, dated 10/5/18 and titled, Side Rail Safety Assessment, indicated Resident 1 had an altered mental status. The staff's interventions included frequent and scheduled monitoring, pain assessment and managed a reassessment done regularly and modify accordingly. A review of a History and Physical (H/P), dated 10/8/18, indicated Resident 1 did not have the capacity to understand and make decisions. A review of an Admission Nursing Assessment, dated 10/8/18, did not indicate that Resident 1 had a [MEDICAL CONDITION] arm on admission to the facility, which was verified by the Director of Nursing (DON). On 3/5/19 at 4:33 p.m., the DON stated the resident was not admitted to the facility with a fracture, but had generalized body swelling and was receiving [MEDICATION NAME] 20 milligram (mg) ((antidiuretic) used to treat excessive fluid accumulation and swelling). A review of a Care plan, dated 10/22/18 and titled, Fall Risk/Injury, indicated Resident 1 had a risk for falls/injury due to poor safety awareness and judgement. The goal indicated there would be a reduced risk of falls and injury daily for the resident. The staff's intervention included to visibly observe the resident frequently, have physical therapy ((PT) highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility ) assess the resident quarterly and PRN (whenever necessary) for safety of gait, transferring, sitting, and the need for safety devices. The care plan also indicated the resident would have a safe and clutter-free environment and the staff would notify the physician as indicated. A review of an untitled Care Plan, dated 10/22/18, indicated Resident 1 was at risk for spontaneous pathological stress fractures (fractures that occur as the result of repeatedly making the same movement in a specific region) related to [MEDICAL CONDITION]. The staff's intervention included to observe for sudden acute pain, redness, discoloration, swelling, tenderness with guarded movement of extremities and inform physician promptly. The plan of care also indicated for the staff to handle the resident gently and carefully during care. A review of the Multidisciplinary Progress Record, dated between 2/8/19 and 2/11/19, indicated that there was no documentation the nursing staff observed Resident 1 for pain, redness, swelling, and tenderness to the resident's left arm and that the physician was notified promptly as indicated in the resident's care plan. A review of an Interdisciplinary Team (a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) Conference Record, dated 2/18/19 indicated Resident 1's family member (FM 1) visited the resident at the facility on 2/14/19 and expressed concerns about the resident's left upper extremity being swollen. FM 1 notified the nursing staff because the swelling was unusual compared to the resident's previous body swelling on admission. A review of a Nurses Progress Note, dated 2/14/19 and timed 12:30 p.m., indicated Resident 1's primary physician was made aware of the resident's swollen arm by FM 1 and ordered a STAT (Immediate) x-ray of the resident's left shoulder and upper arm. A review of Nurses Progress Note, dated 2/14/19 and timed at 4:20 p.m., indicated the results of Resident 1's x-ray were received and the primary physician was notified with an order to transfer the resident to the GACH for further evaluation. According to the progress note, Resident 1 returned to facility on 2/15/19 at 6:30 a.m. with an order for [REDACTED]. A review of a Licensed Vocational Nurse (LVN) note, dated 2/14/19 and timed during the 7 a.m. to 3 p.m. shift, indicated Resident 1 was unable to verbalize needs. The note indicated, at 12:30 p.m. on 2/14/19, FM 1 approached the nursing station and stated, The resident's (Resident 1) generalized swelling had worsened compared to the last time I saw her. According to the note, FM 1 insisted on speaking to the resident's doctor (Physician 1) regarding the increase in swelling and requested the telephone number. The note indicated FM 1 called Physician 1 and the physician called the facility and ordered for Resident 1 to be transferred to the GACH due to the excessive swelling. A review of the STAT x-ray report, dated 2/14/19, indicated there was a minimally displaced/non-displaced [MEDICAL CONDITION] neck (attachment of a ligament to the shoulder joint). A review of (MONTH) 2019's Medication Administration Record [REDACTED]. A review of Resident 1's Pain Risk Assessments, dated 10/5/18, 10/18/18, and 1/10/19, indicated Resident 1 scored 20, 14, and 14 respectively during each assessment date above. The scoring indicated Resident 1 was already experiencing pain and had an order for [REDACTED]. A review of a physician's orders [REDACTED]. a.m., indicated to apply arm sling to Resident 1's upper extremity 24 hours a day for six weeks for left arm neck fracture. A review of the GACH's emergency room 's (ER) note, dated 2/15/19 and timed at 3:05.a.m. indicated a discharge [DIAGNOSES REDACTED]. According to the note, Resident 1 was discharged from the ER with a referral to the orthopedic doctor and social services. The note indicated a sling (flexible strap or belt used in the form of a loop to support weight) was provided to Resident 1 at the time of discharge to the facility. On 3/5/19 at 3:39. p.m., during an observation, Resident 1 was observed lying in bed asleep and was non-verbal with a left arm elbow sling intact. At 3:40 p.m., on 3/5/19, during an interview, LVN 1 stated Resident 1 was transferred to the GACH for a [MEDICAL CONDITION] arm on 2/14/19. During an interview on 3/5/19 at 4:02 p.m., the Director of Nursing (DON) stated, I did a full investigation on the resident's (Resident 1) fracture after the family member (FM1) had come in to visit the resident and identified the swelling. The DON stated on 2/14/19, FM 1 reported to Registered Nurse 1 (RN 1) that he had noticed an unusual swelling on Resident 1's left arm and shoulder and insisted on speaking to the resident's primary physician. The DON stated FM 1 insisted that Resident 1 be transferred out to the GACH. DON, stated resident was already swollen on admission to the facility and was been treated with [MEDICATION NAME]. My staff did not know about the unusual swelling on resident's left arm until the family member came into the facility to visit resident. On 3/28/19 at 9:38 a.m., during an interview, RN 1 stated, I was the supervisor on call when the resident's (Resident 1) family member (FM 1) came to visit. The family member came to the nursing station and stated that the resident's left arm was swollen more than usual and requested for the resident to be transferred to the hospital and to speak to the primary physician. At 10:01 a.m. on 3/28/19, during an interview, Certified Nurse Assistant 2 (CNA 2), stated, I take care of the resident (Resident 1) twice a week and she requires a two-person assist during transfer. I am the nurse assigned for resident's care today. I just received an in-service on transferring residents last week after incident occurred. On 4/15/19 at 2:25 p.m., during a telephone interview, CNA 1 stated, I do take care of the resident every other week two days in a row. I took care of the resident on 2/14/19, the day the family member reported swelling on the resident's left arm. CNA 1 stated that during care if there was any discoloration or swelling, she would report to the charge nurse. CNA 1 stated Resident 1's left arm was big and swollen on 2/14/19, when she gave the resident a bed bath. CNA 1 stated that on the previous days prior to 2/14/19 she took care of Resident 1 and she did not know the swelling had increased. On 3/28/19 at 11:15 a.m., during a conference with the DON and the Administrator, the Administrator stated, I would have done the same thing as the family member, if my family member was found in that condition. On 4/2/19 at 1:15 p.m., during a telephone interview, FM 1 stated that he had gone to the facility on [DATE] to visit Resident 1. FM 1 stated he noticed that Resident 1's left arm was unusually swollen with discoloration. FM 1 stated, I went to the nursing station and reported it to the nurse and she told me she was okay and there was nothing wrong with her. I told her no, she is not okay and requested for her to be transferred to the hospital and have an x-ray done. FM 1 stated he spoke to Physician 1 and he agreed for an x-ray to be done and the resident to be transferred to the GACH. FM 1 stated, I asked her (Resident 1) to squeeze my hand, but she could not, and I knew that something was definitely wrong. A review of the facility's undated policy and procedure, titled Change of Condition (C[NAME]), with no revised date, defined a change of condition as a sudden difference in a resident's movements (example, limited range, pain when moving, unsteady gait), skin condition such as swelling, or discoloration, injuries (example from falls or altercation. The policy indicated upon a change of condition for any reason, nursing staff members were to notify the physician promptly. Daily assessment of condition changes shall be handled by the Nurse Supervisor under the DON, with follow up provided immediately. Certified Nursing Assistants (CNAs) provide daily care to residents and usually notice changes in overall resident condition. The policy indicated CNAs would report changes in condition of residents for whom they provide care to the Charge Nurse as soon as possible. According to the policy, a change of condition included, but not limited to; skin breakdown, swelling, bruising, nausea, and pain etc. A review of another undated policy and procedure, titled 'Monitoring Residents, indicated residents with special care needs and potential for neglect shall likewise be monitored in accordance with their plans of care, and at a minimum, included in the regular monitoring of Charge Nurses during endorsements of care to nurse's aides. Facility monitoring programs included daily care by nursing staff, daily rounds, incontinent care rounds, and RNA programs etc.

Based on observation, interview, and record review, the facility evaluated and identified smoking hazards for five of 29 sampled residents, but failed to implement the identified interventions and provide adequate supervision to those residents (Res 4, 17, 24, 25 and 26) with a known smoking safety risk. The facility's smoking policy did not indicate the methods by which the residents were assessed as being safe to smoke without supervision and no information was provided in regards to the frequency at which the residents who smoked were reassessed. This deficient practice had the potential to result in fire, resident sustaining burn-related injuries due to smoking or death. On 9/30/15 at 5:15 p.m., an immediate jeopardy (IJ) was declared with the facility's administrator, in the presence of the director of nurses (DON). The administrator and DON were given specific details that justified the IJ including individuals at risk. The facility submitted an immediate plan of correction (POC) for the IJ removal. The POC included: 1. Belongings of residents, who smoke in Stations 1 and 2 (open units), and Station 3 (locked unit), were searched for cigarettes and lighters in their possession on 9/30/15. 2. The facility revised the Smoking Policy and Procedure on 9/30/15 to reflect specific smoking schedule and supervision assignments. The facility established a specific procedure for residents who required supervised smoking, and a systemic procedure for residents who were non-compliant with the smoking policy. 3. The facility's IDT (Interdisciplinary Team) discussed the new Smoking Policy and Procedure with Residents 24 and 25 on 9/30/15. Both residents agreed to comply with the facility's new smoking policy. 4. The new Smoking Policy and Procedure was discussed with all residents identified to be smokers in the facility on 9/30/15 and 10/1/15. These residents were reassessed using the facility's Smoker Risk Assessment. The residents' care plans were updated to reflect their current status based on the reassessments that included the provision of safety devices such as smoking aprons and cigarette extenders. 5. The Quality Assurance Committee reviewed and approved the revised Smoking Policy and Procedure on 10/1/15 and reviewed the plan of care for all residents who smoke. 6. The facility had 19 smoking aprons and ordered additional 15 smoking aprons on 10/1/15. 7. The facility conducted an in-service for all staff regarding the facility's new Smoking Policy and Procedures on 10/1/15. 8. The facility's smoking schedule was revised. A new smoking time and designated staff-smoke supervisors were created for Stations 1and 2. (This was separate from the smoking schedule for the locked unit in Station 3) 9. The Daily Staffing Assignment Sheet was revised to include the smoking supervisor, who will utilize a sign in and out log sheet when monitoring the residents. The smoking supervisor will ensure a staff member is assigned on each designated smoking time. 10. The staff assigned to supervise smoking in Stations 1 and 2 will keep all cigarettes and lighters in a locked box which will be stored in Nursing Station 2 when not in use. The staff assigned to supervise smoking in Station 3 will keep all cigarettes and lighters in a locked box which will be stored in Nursing Station 3 when not in use. 11. For residents who do not need supervision when smoking will be provided locks for the bedside drawers to store cigarettes and lighter when not in used and the keys will be kept at the Nursing Station. The charge nurse will be in charge for monitoring the keys. 12. The facility created a Smokers Checklist to be posted in Stations 1, 2, and 3. The checklist indicated the supervision status of each resident who smoke and if apron is required or not. 13. Residents identified to be smokers and who go out on pass will be searched by the charge nurse when they come back to the facility to ensure that they will not have any cigarettes or lighters in their possession. 14. Belongings of residents who smoke will be searched for cigarettes and lighters by the social service designee during shower days, twice a week, and monthly during room deep cleaning with residents' permission. On 10/2/15, at 10 a.m., the IJ was abated after the administrator and director of nursing presented an acceptable immediate plan of correction. Findings: On 9/29/15, at 3:45 p.m., during the initial tour of the facility, with the licensed vocational nurse (LVN 1), three residents were observed smoking outside in the general smoking patio unsupervised by a facility staff. On 9/30/15, at 2:03 p.m., in the presence of the activity director (AD) who stated she was the secondary person responsible in facilitating the assessments and supervision of residents who smoked together with the assistant director of nurses (ADON), an interview was conducted with a certified nurse assistant (CNA1) and LVN 1, both who were permanently assigned at the facility's locked unit (Station 3). The AD stated the facility had 5 scheduled smoking hours at 9 a.m., 11:30 a.m., 1:30 p.m., 4 p.m., and 6:30 p.m. The AD further stated that the activity assistants were only assigned during their designated times at 9 a.m., 4 p.m., and 6:30 p.m. to supervise the residents in the general smoking patio. The AD also stated that during 11:30 p.m., and 1:30 p.m., CNA 1 is assigned to supervise smoking. CNA 1 stated he was assigned to supervise the residents in Station 3 locked unit, and he would take the residents out in the general smoking patio. CNA1 was asked in the presence of the AD, if CNA1 was at the smoking patio at 1:30 pm to supervise the residents in the smoking patio. CNA1 stated he was there with the residents of Station 3 locked unit. CNA1 stated maybe he came with the residents of Station 3 locked unit right after the evaluator and AD left the smoking patio at 1:35 p.m. LVN 1 was asked as to who was assigned to the residents who smoke in Stations 1 and 2 (open unit) and residents who wanted to smoke outside the facility's scheduled smoking hours. LVN 1 pointed at the AD. AD stated, I thought it was nursing, and pointed back to LVN 1. Both the AD and LVN 1 suggested asking the charge nurses in Stations 1 and 2 who were usually assigned to supervise the residents in Stations 1 and 2 and those residents who smoke outside the facility's scheduled hours because neither did AD nor the LVN knew who was responsible for the supervision for the residents in Stations 1 and 2. On 9/30/15, at 2:10 p.m., during an interview, Activity Assistants (AA) 1 and 2 both stated they were only assigned to supervise residents who smoked in the locked unit of the facility (Station 3) only at 9 a.m. and 4 p.m. (not as previously stated by the AD which was 11:30 a.m., and 1:30 p.m.) Both AA 1 and 2 stated that residents in Station 3 smoking scheduled hours were 5 times a day at 9 a.m., 11:30 a.m., 1:30 p.m., 4 p.m., and 6:30 p.m. but for residents in Stations 1 and 2, they smoke A bunch of times, because they carry their own cigarettes. On 9/30/15, at 3:35 p.m., a concurrent interview and record review was conducted with the ADON, with regard to the undated facility's policy and procedure titled, Smoking Policy and Procedure indicated the facility's Designated smoking area will be under supervision, as needed per smoking assessment by facility staff . Repeat IDT's (Interdisciplinary Conference) for non-compliance will be provided as needed . Care plans will be completed related to smoking, based on smoking assessment and IDT conference. The Smoking Policy and Procedure did not stipulate the methods by which the residents were assessed as being safe to smoke without supervision and the frequency of reassessments to determine if any change had occurred to residents including who was to supervise the residents in Stations 1 and 2 and Station 3. a. On 9/30/15, at 1:35 p.m., during an observation of the general smoking patio, in the presence of the AD, Resident 24 was observed smoking unsupervised outside in the general smoking patio. Resident 24 was observed with a lighted cigarette in his hand and another unlit cigarette on the table. Resident 24 was not wearing a smoking apron. During a concurrent interview, the activity director stated Resident 24 had always been non-compliant with the facility's smoking policy and procedure and did not follow the smoking scheduled times. The AD stated the facility staff supervised residents who smoked in the general smoking patio during the facility's smoking schedules but Resident 24 was used to smoking outside the smoking scheduled times when facility staff are not there to supervise. The AD stated, He usually smokes whenever time he wants, and usually gets upset when facility reminds him that the resident needed supervision with smoking. The AD stated they give residents, one cigarette at a time and did not know why Resident 24 had two cigarettes in his possession at that time. A review of Resident 24's Admission Record indicated the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Psychiatric Evaluation Note, dated 4/4/15, 7/25/15, and 8/29/15, indicated Resident 24 had impaired mood, poor cognition, confused, and had poor insight and judgement. On 9/30/15 at 2:15 p.m., a concurrent interview and record review was conducted with the ADON. The facility's Smoker Risk Assessment for Resident 24, dated 9/10/15, indicated the resident had intermittent confusion, had limited use of upper body for activities of daily living, and needed redirection for safety awareness. Resident 24 scored 4 (scoring guideline indicated score of 1 and above requires supervision during smoking) in the assessment. The facility's Smoker Risk Assessment form did not indicate what specifically the smoking scales indicate for each score number. There was only a definition of 0 = Requires no supervision (Independent Smoker), and 1 and above = requires supervision (Non-independent Smoker). A review of the Care Plan for Smoking, dated 6/7/14, indicated Resident 24 required supervision while smoking, should have no access to lighters, and needed to use a smoking apron. The ADON acknowledged with what the care plan indicated. On 9/30/15, at 2:15 p.m., during an interview and after record review, the ADON acknowledged that Resident 24's Interdisciplinary Team Conference Record, dated 9/22/15, indicated to review Smoking Policy and Smoker Risk Assessment for Resident 24 failed to specify that the resident required supervision while smoking and address resident's non-compliance with the smoking policy. The ADON also stated, Resident 24 gets to keep his own cigarettes and lighter but per smoking assessment he is not allowed to smoke unsupervised. The ADON stated Resident 24 was non-compliant with the facility's smoking policy. When asked about if Resident 24 was allowed to keep his own cigarettes and lighter the ADON stated Resident 24 is not allowed to smoke unsupervised and keep his own cigarettes because the resident goes out of the facility and buys his own cigarettes when out on pass. The ADON further stated it's difficult to track the resident's possession of smoking supplies when they go out on pass. b. On 9/30/15, at 1:35 p.m., in the presence of the AD, Resident 25 was observed wheeling himself towards the patio with a pack of cigarette and a lighter in his hand and another pack of cigarette was observed showing in his shirt pocket. Resident 25 stopped and spoke with the AD to assist him in making his lighter work and clicked (activated) on his lighter while still inside the facility, three times. The AD did not intervene or stop Resident 25 and the resident proceeded to go outside the patio to smoke. The AD stated Resident 25 was another resident who was non-compliant with the scheduled smoking time and was getting his cigarettes and lighter outside the facility when he was out on pass. The AD stated Resident 25 was alert and oriented and could smoke without supervision. A review of Resident 25's Admission Record indicated the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED].). On 9/30/15 at 2:17 p.m., a concurrent interview and record review was conducted with the ADON. The facility's Smoker Risk Assessment for Resident 25, dated 7/28/15 a review of a Smoker Risk Assessment, dated 7/28/15, indicated Resident 25 had limited use of upper body for activities of daily living. Resident 25 scored 1 in the assessment, which indicated that the resident required supervision during smoking. The facility's Smoker Risk Assessment form did not indicate what specifically the smoking scale indicate for each score number. There was only a definition of 0 = requires no supervision (Independent Smoker), and 1 and above = requires supervision (Non-independent Smoker). A review of the Psychiatric Evaluation Note, dated 8/31/15, indicated Resident 25's thought content/process was disorganized was paranoid, incoherent, illogical, and had auditory hallucinations (something the resident hears but that does not exist in reality). A review of a Care Plan, revised on 8/5/15, indicated Resident 25 had cognitive (mental) and communication deficits as manifested by fluctuation in cognitive functioning with short and long term memory problems, had moderately impaired decision making. Another Care Plan for Smoking, dated 2/5/15, indicated Resident 25 required supervision while smoking and should have no access to matches and lighters. There was no care plan addressing Resident 25's continued non-compliance with the facility's smoking policy. The ADON acknowledged with what the care plans indicated and that there was no care plan developed for Resident 25's non-compliance with the smoking policy. On 9/30/15, at 2:17 p.m., during an interview and after record review, the ADON acknowledged that Resident 25's Interdisciplinary Team Conference Record, dated 9/25/15, indicated to review Smoking Policy and Smoker Risk Assessment for Resident 25 failed to specify that the resident required supervision while smoking and address resident's non-compliance with the smoking policy. On 9/30/15, at 2:25 p.m., the ADON stated she asked the staff at Station 2 as to who gave and lit the cigarettes for Resident 25. The staff could not state where Resident 25 got the cigarettes earlier that day. c. On 9/30/15, at 11:40 a.m., Resident 4's room was observed to have an oxygen machine at the bedside. Resident 4 was seen sitting in his wheelchair by the facility's lobby. During a concurrent interview, Resident 4 stated he smoked one to two cigarettes a day and bought the cigarettes on his own at the liquor store across the street from the facility. Resident 4 stated he kept his own cigarettes and lighter and hid it at the side corner of his wheelchair. A review of Resident 4's Admission Record indicated that the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. On 9/30/15 at 3:20 p.m., a concurrent interview and record review was conducted with the ADON. The facility's Smoker Risk Assessment for Resident 4, dated 8/7/15 indicated Resident 4 had very limited mobility requiring extensive (weight bearing support) to total assistance with upper body for activities of daily living. Resident 4 scored 2 in the assessment which indicated that the resident required supervision during smoking. The facility's Smoker Risk Assessment form did not indicate what specifically the smoking scale indicated for each score number. There was only a definition of 0 = Requires no supervision (Independent Smoker), and 1 and above = requires supervision (Non-independent Smoker). A Care Plan initiated on 11/11/14 and revised on 8/10/15 indicated Resident 4 required supervision with smoking and should have no access to matches and lighter. The ADON acknowledged with what the care plan had indicated. On 9/30/15, at 3:20 p.m., during an interview, the ADON stated the last Interdisciplinary Team Conference Record for Resident 4 was dated 5/27/15 and the IDT had not met with Resident 4 to discuss the changes to his smoking supervision last 8/7/15. The ADON stated the IDT had not informed Resident 4 that he now required supervision while smoking. The ADON acknowledged during record review that there was no documented evidence of an on-going interdisciplinary team (IDT) conference completed for Resident 4 to review the Smoking Policy and Smoker Risk Assessment. d. A review of Resident 17's Admission Record indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Psychiatric Evaluation Note, dated 7/25/15, indicated Resident 17 had poor cognition, impaired mood and incoherent thought process, and had poor insight and judgement. On 9/30/15 at 3:30 p.m., a concurrent interview and record review was conducted with the ADON. The facility's Smoker Risk Assessment for Resident 17, dated 9/21/15, indicated Resident 17 scored 2, which indicated that the resident required supervision during smoking. The facility's Smoker Risk Assessment form did not indicate what specifically the smoking scale indicated for each score number. There was only a definition of 0 = requires no supervision (Independent Smoker), and 1 and above = requires supervision (Non-independent Smoker). A review of Resident 17's care plan for smoking developed on 9/22/14 indicated Resident 17 required supervision while smoking and should have no access to matches and lighters. The ADON acknowledged with what the care plan had indicated. On 9/30/15, at 5:05 p.m., during an interview, Resident 17 stated he bought his cigarettes and lighter outside the facility and kept his cigarette and lighter with him. The resident further stated that the AD sometimes bought them for him. Resident 17 stated he did not wear smoking apron and did not follow the facility's smoking scheduled times. Resident 17 stated the facility did not do anything even if a resident smoked outside the schedule time. Resident 17 stated sometimes a facility staff (CNA) was there to supervise and sometimes not. Resident 17 stated there had been some residents who had been caught smoking outside the designated smoking area of the facility. On 9/30/15, at 3:30 p.m., during an interview, the ADON stated she knew that Resident 17 was non-compliant with the facility's smoking policy. The ADON stated the resident's family would come and give the resident cigarettes. When asked, the ADON stated the family had not been included in the IDT Conference because they were unreachable. During record review, there was no documented evidence in the clinical record that Resident 17's family was contacted to reinforce the facility's smoking policy. e. A review of Resident 26's Admission Record indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 9/30/15 at 3:38 p.m., a concurrent interview and record review was conducted with the ADON. The facility's Smoker Risk Assessment for Resident 26, dated 11/22/14, 2/23/15, 5/26/15, and 8/25/15, indicated Resident 26 required assistance with upper body ADLs, was non-compliant and unaware of safety and scored 3, which indicated that the resident required supervision during smoking. The facility's Smoker Risk Assessment form did not indicate what specifically the smoking scale indicated for each score number. There was only a definition of 0 = Requires no supervision (Independent Smoker), and 1 and above = requires supervision (Non-independent Smoker). The Interdisciplinary Team Conference Record, dated 8/6/14 and updated 5/25/15, to review Smoking Policy and Smoker Risk Assessment for Resident 26 indicated that the resident required supervision while smoking and needed to use smoking apron. A handwritten note on the IDT Conference Record indicated that the resident stated she will keep her cigarettes and she was able to smoke independently at the smoking patio. There was no documented evidence of a follow up on Resident 26's non-compliance of the facility's smoking policy. The ADON stated the IDT just documented what Resident 26 told them during the conference. On 9/30/15, at 3:38 p.m., during an interview with the ADON who acknowledged that she was the primary person responsible in facilitating the assessments and supervision of residents who smoked, she stated when asked if there was a system in place for residents who continued to be non-compliant with the facility's smoking policy. The ADON stated there was no system in place because even if the facility tried to talk to the residents to comply with the smoking policy, I can't really take away their rights to smoke. A review of the IDT Conference Record form that stipulated the facility ' s Smoking Policy and Resident ' s responsibility related to smoking indicated that non-compliance may lead to unexpected burns, property damage and/or death.