Every finding on record at Community Hospital Of San Bernardino D/P SNF

Based on observation, interview, and record review, the facility failed to ensure staff followed safe infection control practices when: 1. One Licensed Vocational Nurse (LVN 3) dropped a Multivitamin/Multimineral Liquid Supplement (a multidose bottle, containing drinkable mix of vitamins and minerals that helps people get important nutrients when they don't get enough from food) lid on the floor, attached the lid back on to the multidose bottle, and returned the medication bottle to the medication cart. 2. LVN 3 did not wash hands, after reaching under the gown for glasses, and don/doff (put on and take off) appropriate PPE (Personal Protective Equipment) after the administration of medications via gastrostomy tube (g-tube- medical device designed to deliver nutrition, fluids, or medications directly into the stomach through a small opening in the abdominal wall), prior to exiting and re-entering Resident 83's room and before performing Resident 83's oral care. 3. Dirty soiled linens and clothing were found on the floor in the laundry room. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 82 highly vulnerable residents whose health conditions are already compromised. 1.During a review of Resident 83's History and Physical (medical record summarizing a patient's past health information and current physical examination findings), indicated Resident 83 was admitted to the facility on [DATE], with diagnoses which included a brain aneurysm (balloon-like bulge in a brain blood vessel), respiratory failure (the lungs cannot get enough oxygen into the blood), and hypertension (high blood pressure). During an observation on September 2, 2026, at 8:14 AM, outside Resident 83's room, Licensed Vocational Nurse (LVN 3) dropped the lid to Multivitamin/Multimineral Liquid Supplement onto the floor. LVN 3 picked up the lid from the floor, placed the lid back onto the bottle of medication, and returned it to the medication cart. During an interview on September 2, 2026, at 8:47 AM with LVN 3, LVN 3 stated that when he dropped the medication lid onto the ground, the lid should have been discarded and not returned back onto the bottle and medication cart to be used for future medication administration. LVN 3 acknowledged and further stated he did not discard the lid and medication, and he should have done so for infection prevention. During an interview on September 3, 2026, at 8:27 AM with the Infection Preventionist Nurse (IP), the IP stated when the medication lid was dropped on the floor, it should have been cleaned to prevent the spread of infection. The IP further stated this was not done, creating an opportunity for cross-contamination from germs on the floor to the residents. During a concurrent interview and record review on September 3, 2026, at 3:18 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Medication Administration, dated February 2024 was reviewed. The P&P indicated, These policies and procedures are established to assure. administration of drugs in an accurate, safe, timely and sanitary manner.Medication should be removed from the container in a sanitary manner to prevent contamination of the remainder of the contents. The DON stated the policy was not followed. The DON further stated the policy should be followed to minimize the exposure of infection. 2.During an observation on September 2, 2026, at 8:38 AM, in Resident 83's room, LVN 3 administered Resident 83's medication via g-tube wearing a disposable gown and gloves. Using the same gloves, LVN 3 reached underneath his gown to retrieve a pair of glasses and put them on his face. LVN 3 poured oral solution into a medication cup and placed an oral swab into the solution. Then LVN 3 left the room to gather oral suctioning supplies from the medication cart in the hallway, outside Resident 83's room, wearing the same gloves and gown. LVN 3 re-entered Resident 83's room and proceeded to open the oral suctioning equipment and provided oral care to Resident 83. During a subsequent interview on September 2, 2026, at 8:42 AM outside Resident 83's room with LVN 3, LVN 3 stated that he should have changed gloves and performed hand hygiene after he reached underneath his gown and applied his glasses. LVN 3 further stated he should have removed gloves, gown, and performed hand hygiene prior to leaving resident's room and prior to entering the room, and before touching the medication cart for supplies. LVN 3 further stated that these steps were not followed and they should have been for proper infection control. During an interview on September 3, 2026, at 8:26 AM with the IP, the IP stated LVN 3 should have performed hand hygiene and changed gloves before and after reaching under his gown and applying his glasses. The IP stated LVN 3 should have removed the PPE and performed hand hygiene when leaving a resident's room. The IP further stated LVN 3 should have performed hand hygiene and donned a gown and gloves prior to providing oral care to Resident 83. During a concurrent interview and record review on September 3, 2026, at 3:19 PM with the DON, the facility's P&P titled, Standard Precautions, dated February 2024 was reviewed. The P&P indicated, Before leaving the patient's room or cubical, remove and discard PPE.remove gloves after contact with patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. The DON stated the policy was not followed. The DON further stated it should be followed to minimize the exposure of infection. 3. During a concurrent observation and interview on September 2, 2026, at 12:55 PM with the Infection Preventionist (IP) in the laundry room there were soiled linens, gowns, clothing, an opened cloth laundry bag filled with soiled linen sitting directly on the floor. The IP stated the soiled linens should not have been left on the floor and the linens should have been placed inside the bag off the floor. The IP stated she was not sure why it was on the floor. During an interview on September 2, 2026 at 1:10 PM, with the Infection Prevention/Infection Control Manager (IP Manager), the IP Manager stated soiled laundry needs to be contained in a closed bag and transported in laundry containers. The IP Manager stated that at no time should soiled linens be left on the floor. The IP Manager further stated that her expectation is for staff to follow and handle soiled linen properly. During an interview on September 2,2026, at 13:22 PM, with the Environmental service Director (EVS Director), the EVS Director stated dirty linens are transported in bags with closed containers and taken to the designated area to be picked up by the contracted laundry services company. The EVS Director stated that soiled linens or any patients/residents clothing should not be left on the floor. During a concurrent interview and record review on September 2, 2026, at 2:55 PM with the IP, the facility policy and procedures (P&P) titled, Cleaning of Patient/ Resident Personal Linen, Clothing, or Other Washable items dated May 2000 was reviewed. The P&P indicated, .1.1. Any soiled patient linens, clothes, or personal washable items will be transported to the laundry area in a covered, leak proof container.1.3 Open bagged soiled linens. Empty linens into a cart or basket . The IP acknowledged the policy was not followed and that it should have been.

Based on observation, interview, and record review, the facility failed to ensure their policy and procedure (P&P) for Restraints or Seclusion was followed for one of two sampled residents (Resident 7) when Resident 7 was not assessed every two hours while using a right-hand mitten (soft mittens placed over a resident's hands to stop them from pulling at medical equipment) restraint. This failure had the potential for Resident 7 to be at risk for severe physical and psychological harm (mental distress), including suffocation (not being able to breathe), nerve and skin damage, blocked blood flow, stiff joints, and extreme distress.During the review of Resident 7 admission Record(clinical record with demographic information), the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnosis which included acute chronic respiratory (ongoing breathing trouble suddenly got much worse) with hypoxia (dangerously low oxygen levels in their blood), anoxic brain injury (brain is completely cut off from its oxygen supply, causing brain to die), and cerebral palsy (a lifelong brain condition that affects a person's ability to move, control their muscles, and maintain balance and posture).During a review of Resident 7's Active Orders (orders given by a doctor to follow), dated April 11, 2024, the Active Orders indicated, Restraint and Monitoring LTC (Long Term Care) Mitten to R (right) hand q (every) 2 hr. (hours).During an observation on August 31, 2026 at 12:20 PM in Resident 7's room, Resident 7 was lying in bed in a semi upright position on a ventilator, tube feeding running, and with a hand mitten to the right hand. During a concurrent interview and record review on September 3, 2026 at 12:55 PM with the Director of Nursing (DON), Resident 7's Restraint Monitoring, dated August 20, 2026, to September 2, 2026 was reviewed. There was missing documentation on the Restraint Monitoring on the following dates and times: August 20, 2026- missing 6:00 PMAugust 22, 2026- missing 8:00 AMAugust 22, 2026- missing 10:00 AMAugust 22, 2026- missing 12:00 PMAugust 22, 2026- missing 2:00 PMAugust 22, 2026- missing 4:00 PMAugust 22, 2026- missing 6:00 PMAugust 23, 2026- missing 10:00 AMAugust 23, 2026- missing 12:00 PMAugust 23, 2026- missing 4:00 PMAugust 24, 2026- missing 8:00 AMAugust 24, 2026- missing 10:00 AMAugust 24, 2026- missing 12:00 PMAugust 24, 2026- missing 2:00 PMAugust 24, 2026- missing 4:00 PMAugust 24, 2026- missing 6:00 PMAugust 25, 2026- missing 8:00 AMAugust 25, 2026- missing 10:00 AMAugust 25, 2026- missing 12:00 PMAugust 25, 2026- missing 2:00 PMAugust 25, 2026- missing 4:00 PMAugust 25, 2026- missing 6:00 PMAugust 29, 2026- missing 4:00 AMAugust 29, 2026- missing 6:00 AMDuring a concurrent interview and record review on September 3, 2026 at 1:04 PM with the DON, the facility's (P&P) titled, Restraint or Seclusion, dated October 2024 was reviewed. The P&P indicated, .6.4 Other monitoring- Other monitoring activities will be completed every two hours, including but not limited to.6.4.4 Circulation Motion Sensation (CMS) and reference to systematic release of the restraint with completion of range of motion. The DON stated the policy was not followed. The DON further stated her expectation is that nurses are to follow physician orders for restraint monitoring.

Based on interview and record review, the facility failed to ensure the allegation of neglect for one of one sample resident (Resident 35) was reported in a timely manner to the appropriate authorities in accordance with the California Reporting Requirements (result in serious bodily injury is reported immediately and no later than 2 hours, if no injury it is reported no later than 24 hours).This failure had the potential to delay appropriate interventions and protective measures for Resident 35 and place the resident at risk for further harm.During the review of Resident 35 admission Record (clinical record with demographic information), the admission Record indicated, Resident 35 was admitted on [DATE] with diagnoses which included chronic respiratory failure (long term breathing problems) with hypoxia (dangerously low oxygen levels in their blood), anoxic brain injury (brain is completely cut off from its oxygen supply, causing brain to die),and cerebral palsy (a lifelong brain condition that affects a person's ability to move, control their muscles, and maintain balance and posture).During an interview on August 31, 2026 at 4:55 PM with the Administrator (Admin), the Admin stated she needed to report a neglect allegation involving Resident 35. The allegation was made by the resident's family member, who stated a nurse had been mean to Resident 35 by refusing to assist her by saying she did not have time to listen and to not use the call light anymore. During a follow up interview on September 3, 2026 at 12:05 PM, with the Admin, the Admin confirmed she did not report the allegation to CDPH (California Department of Public Health). The Admin stated she was told not to report it. When asked when she should have reported the incident, the Admin stated allegations of abuse are required to be reported within 2 hours, and all other reportable incidents must be reported within 24 hours.During a concurrent interview and record review on September 3, 2026, at 1:04 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Abuse, Neglect, and Violence- Patient Identification, Intervention, and Mandated Reporting, dated May 9, 2022, was reviewed. The P&P indicated, . Attachment C. California Reporting Requirements. A Quick Reference Guide to Assault and Abuse Reporting Requirements . Elder/Dependent Adult Abuse. 1. Immediate report by telephone or confidential Internet reporting toll (if available) .2. If initially reported by phone, follow up with written report or Internet report within two working days. NOTE: If the abuse occurred in a long term care facility, quicker reporting is required (sometimes within two hours of learning of the incident). The DON stated the P&P was not followed. The DON further stated that abuse incidents should be reported within two hours, and if not abuse, within 24 hours.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review Level II (PASRR Level II - a special evaluation that helps decide what extra support or care a person needs for residents who are identified to have a serious mental illness [SMI-mental health condition that makes it hard for a person to do everyday things like going to school, working, or taking care of themselves] or an intellectual/developmental disability [I/DD-significant limitations in both thinking and every day functioning]) was completed for one of two sampled residents (Resident 61) when Resident 61 PASRR Level I Screening ( initial assessment to see if a person going into a nursing home might have a serious mental illness or an intellectual/developmental disability) was positive for SMI and was not resubmitted to the Department of Mental Health Office within 5 days of admission for a Level II Mental Health Evaluation.This failure had the potential for Resident 61's needs for treatment and services not being accurately assessed, placing them at risk of inadequate care and placement.Findings:During a review of Resident 61's History and Physical (medical record summarizing a patient's past health information and current physical examination findings), the H&P indicated Resident 61 was admitted to the facility on [DATE] with diagnoses which included respiratory failure (the lungs cannot get enough oxygen into the blood), bipolar disorder (mental health condition where a person has changes in mood and energy), and acute encephalopathy (brain disorder that causes quick changes in thinking, behavior, or alertness, usually due to illness, toxins, or chemical imbalances in the body). During a review of Resident 61's Notice of PASRR Level I Screening Results, dated December 9, 2025, it indicated, Your Level I Screening indicates that a SMI Level II Mental Health Evaluation is required. Level II Mental Health Evaluation Referral: Required for SMI.During an interview on September 2, 2026 at 1:50 PM with the Case Manager (CM), the CM stated Resident 61's PASRR, dated December 9,2025, indicated that a Level II Mental Health Evaluation was required. On the resident's admission to the facility on December 30, 2025, it was the responsibility of the facility to set up a Level II Mental Health Evaluation as indicated but it was not done. The CM further stated it was important to have an accurate PASRR assessment to ensure the facility was able to provide the required services to meet the residents' needs.During a concurrent interview and record review on September 3, 2026, at 6:47 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, PAS/PASARR (Preadmission Screening and Resident Review), dated March 2024, was reviewed. The P&P indicated, .If a level II screen is triggered on the PAS/PASRR, the case manager must fax it to the Department of Mental Health office within 5 days of admission and retain the faxed copy and receipt. The DON stated that a follow up should have been completed because of patient safety and compliance. The DON further stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for splint (medical device used to support, protect, and immobilize an injured bone, joint, or soft tissue) application and use for one of six sampled residents (Resident 58) when there was no evidence to show the application, removal, and assessment of Resident 58's splints.This failure had the potential for Resident 58 to develop joint stiffness, compartment syndrome (swelling that can occur and cause nerve problems and muscle damage), skin breakdown, and pressure injuries (localized area of damage to the skin and tissue).Findings:During a review of Resident 58's History and Physical (medical record summarizing a patient's past health information and current physical examination findings), the H&P indicated Resident 58 was admitted to the facility on [DATE] with diagnoses which included respiratory failure (the lungs cannot get enough oxygen into the blood), diffuse axonal injury (nerve damage that affects the brains ability to communicate to the body), and tracheostomy (breathing tube placed through a surgical opening into the neck). During an observation on August 31, 2026 at 11:45 AM in Resident 58's room, Resident 58 was lying in bed. On the nightstand, there were two arm braces and two leg braces next to the resident's bed. During an observation and interview on August 31, 2026, at 12:03 PM with a certified nursing assistant (CNA 1) in Resident 58's room, CNA 1 confirmed the two elbow splints, and two leg splints were not applied. CNA 1 stated those should have been on Resident 58, but she began charting and forgot to apply the medical splints. CNA 1 further stated it was important to apply the splints to prevent contractures and maintain resident's mobility.During a review of Resident 58's Active Order Summary (list of all active physician orders to carry out for a resident), an order for Orthotic Devic LTC (long term care), dated August 25, 2025, was reviewed. The Orthotic Device LTC indicated, .Q [every]Day, Place B [bilateral' knee ext [extender] splints daily for 6 hours; check skin integrity every 2 hours .Site: Hand R [right]| Hand L [left]. q Day, [NAME] [apply] B hand roll splints 6 hours/ [per] day with skin integrity checks every 2 hours .Elbow R | Elbow L q Day. [NAME] B. Elbow splits 6 hrs/ per day with skin integrity checks every 2 hours.During a concurrent interview and record review on September 3, 2026, at 3:12 PM with a Registered Nurse (RN 1), RN 1 reviewed Resident 58's System Evaluation LTC Ortho GIP (location in the electronic medical record for evaluation of orthopedic splints) and medical records, RN 1 confirmed there was no documentation for the application, removal, and assessment of the splints in Resident 58's medical record and further stated there should have been.During a concurrent interview and record review on September 3, 2026, at 3:15 PM with the Director of Nursing (DON), the facility's P&P titled, Splint Application and Use, dated February 19, 2024, was reviewed. The P&P indicated, Splints are to be worn according to the schedule determined by written order of the MD. the skin will be checked for redness, irritation or pressure marks every 2 hours. The DON confirmed there was no documentation regarding the application, removal and assessment and stated, if it is not documented, it was not done. The DON further stated the policy, and it should be followed to ensure proper delivery of care and resident safety.

Based on observation, interview, and record review, the facility failed to ensure medications were properly secured for one of three (3) medication carts (Medication Cart 1- used to transport medication between resident-to-resident rooms) when one Licensed Vocational Nurse (LVN 1) left Medication Cart 1 key unattended, inside a disposable cup on top of the medication cart.This failure had the potential to result in medications being accessible by unauthorized individuals and medications being used inappropriately by unauthorized individuals.During a concurrent observation and interview on September 2, 2026 at 6:04 AM, LVN 1 was outside room [ROOM NUMBER] documenting on the computer. Medication Cart 1 was positioned outside of room [ROOM NUMBER] with the cart key placed inside a disposable cup on top of the cart. LVN 1 verified the key had been left unattended and stated the keys should not have been left there in the cup.During an interview on September 3, 2026 at 7:10 AM, with a Charge Nurse (CN1), CN1 stated the medication key must not be left unattended and should be carried by the assigned nurse at all times. CN1 further stated if the medication key is left accessible, anyone could potentially access the medication cart and obtain medications.During a concurrent interview and record review on September 3, 2026, at 9:05 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Safe Storage of Medication, dated June 74, was reviewed. The P&P indicated, .2.0. Medication storage areas must be secured at all times so that unauthorized persons cannot obtain access to them. The DON stated the policy was not followed. The DON further stated it was important for staff to keep the medication cart key to themselves to prevent unassigned personnel and residents from gaining access to the medications.

Based on interview and record review, the facility failed to implement a fall care plan intervention for one of four sampled residents (Resident 1).This failure resulted in Resident 1 falling off the bed, placing his safety at risk.Findings:During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included respiratory failure (life-threatening condition which causes shortness of breath) and cardiac arrest (medical emergency where the heart suddenly stops beating).During a review of the Resident 1's Fall Care Plan, initiated on June 14, 2024, it indicated an intervention of Assess for need for side rails or any.During a review of Resident 1's Minimum Data Set (MDS - a standardized clinical assessment tool), under Section GG (Functional Abilities - focuses on a resident's functional abilities and goals, specifically assessing self-care and mobility performance to capture the level of assistance needed), dated April 2, 2026, the MDS Section GG indicated, Resident 1 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity: Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for Toileting Hygiene Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring: in/out of tub/shower.During a review of Resident 1's Nurse's Notes, dated April 20, 2026, at 10:28 AM, it indicated LVN [Licensed Vocational Nurse] reported pt [resident] had unwitnessed fall on 4/20/2026 @ [at] 9:30 AM, went to room, found pt[resident] lying on floor facing up next to his bed, head on top of IV (Intravenous) - pole side (right side side-rail down) .During an interview on May 4, 2026, at 10:25 AM, with Certified Nursing Assistant (CNA), CNA stated she was responsible for Resident 1 when he fell on April 20, 2026. She stated it occurred while she was preparing Resident 1 for a shower. CNA stated she forgot to lock or secure Resident 1's bedside rails when she went out to get the shower bed. CNA further stated she was only gone for a few seconds, but when she returned, she saw Resident 1 had already fallen on the floor.During a concurrent interview and record review on May 4, 2026, at 10:45 AM, with the Facility Administrator (Admin), the Admin reviewed and acknowledged the facility's policy and procedures (P&P) titled, Fall Prevention Program dated April 2005, which indicated .An individualized interdisciplinary fall prevention/reduction plan of care will be developed and implemented for each resident identified as a fall risk. The Admin stated it was not followed.

Based on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was safely reconnected to the ventilator (a machine that supports or controls a person's breathing when they cannot breathe adequately on their own) following a shower. This failure resulted in an avoidable interruption in Resident 1's life supporting respiratory assistance and requiring a code blue response (an emergency code indicating a patient needs immediate medical attention), which had the potential to cause brain damage from lack of oxygen, and lead up to death. Resident 1 was subsequently transferred to Intensive Care Unit (ICU) for close observation and treatment.Findings: A review of Resident 1's face sheet (contain demographic and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including sepsis (a life threating medical emergency that happens when the body's extreme response to an infection causes widespread inflammation and tissue damage) and respiratory failure ( a condition where the lungs does not have enough oxygen in the blood). A review of Resident 1's Physician Notes, dated [DATE], indicated, Resident 1 is Ventilator dependent, on Ventilator support attached via a tracheostomy ( a surgical procedure to create an opening to create an opening in the neck into the windpipe, called trachea, to establish a direct airway for breathing), with anoxic brain injury (occurs when the brain is completely deprived of oxygen, leading to brain damage), encephalopathy ( any disorder that affects the brain function or structure) and chronic respiratory failure (a long term condition where the lungs cannot supply enough oxygen to the blood or remove enough carbon dioxide). A review of Resident 1's Nursing Progress Note, dated [DATE], indicated, approximately around 1:40 PM Respiratory Therapist (RT 1) came to charge nurse and says that patient unresponsive. A review of the facility's document for Resident 1 titled, CODE BLUE RECORD, dated [DATE], indicated that CPR (cardiopulmonary resuscitation-an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) initiated at 1:45 PM. During a concurrent interview, and record review on [DATE], at 4:50 PM, with the Director of Cardiopulmonary (related to heart and lungs) Services (DCPS), the facility's policy and procedure (P&P), titled, Manual ventilation [technique to provide assisted breathing by a staff] of Residents During Shower Procedure in NCU [Neurological Care Unit-area for patient with brain condition], dated [DATE], was reviewed. The P&P stated .7.0 The RCP (Respiratory Care Practitioner) is responsible for powering on the ventilator, confirming proper ventilator function and reconnecting the resident. The DCPS stated looking at the incident it appears that RT 1 reconnected Resident 1 to the ventilator following shower; however, RT 1 did not resume ventilation from standby mode (device is not active to save power). During an interview on [DATE], at 1:30 PM, with Registered Nurse (RN 1), RN 1, stated on [DATE], she oversaw 28 residents in the unit, including 15 who were on ventilators. The last time she checked Resident 1 was at approximately 12:00 PM. RN 1 further stated at the time Resident 1 had returned from shower room, she does not recall checking the ventilator or its setting. At approximately 1:45 PM, RT1 came and told her that Resident 1 was unresponsive, so RN 1 immediately went to Resident 1's room and code blue was initiated. During an interview on [DATE], at 1:45 PM, with Certified Nursing Assistant (CNA 1), CNA 1 stated that she took Resident 1 to shower room with CNA 2 and RT 1 on [DATE], at 10:30 AM. CNA 1 saw RT 1 disconnected Resident 1 from ventilator and attached it to Ambu bag (a device used to provide positive pressure ventilation to patients who are not breathing or have difficulty breathing). Upon returning from the shower RT 1 disconnected Ambu bag and reconnected Resident 1 back to the ventilator. CNA 1 further stated she did not see the ventilator being turned on. During an interview on [DATE], at 2:00 PM, with RT 1, RT 1 stated that on [DATE], he assisted with Resident 1's shower. RT 1 reported shower took approximately 30 minutes, from 10:30 AM to 11:00 AM. RT 1 stated, he disconnected Resident 1 from the vent and connected to Ambu bag to 10 liters per minute (L/min) of oxygen cylinder for transfer to shower gurney (hospital stretcher or transport bed). Upon returning from the shower, RT 1 stated he reconnected Resident 1 to the ventilator, resumed ventilation from standby mode, and performed dressing change on tracheostomy. RT 1 further stated during routine rounds at 1:35 PM, RT 1 found Resident 1 was lying in bed, pale, eyes closed, unresponsive, no pulse or respirations, and the ventilator was on standby mode. RT 1 notified charge nurse and code blue started immediately. During an interview on [DATE], at 2:25 PM, with CNA 2, CNA 2 stated that she was working with CNA 1 on [DATE], and helped with showering Resident 1. which took 30 minutes to complete the task. CNA 2 further stated RT1 connected Resident 1 back to the ventilator and changed tracheostomy dressing, but CNA 2 does not remember looking at the ventilator. During a concurrent interview and record review on [DATE], at 2:25 PM, with Bio Med Technician (BMT), the facility's document titled, [Brand name] Ventilator [Serial number], Export timestamp: 2025-11-19_09-57-00, dated from [DATE], at 8:04 AM through [DATE], 1:55 PM, was reviewed. The document indicated that the ventilator was on standby mode. BMT verified and confirmed that the ventilator was on Standby mode from 10:35 AM to 1:39 PM (3 hours and 4 minutes). A follow-up concurrent interview and record review on [DATE], at 2:35 PM, with BMT, the facility's document titled, OEM [Original Equipment Manufacturer] -Scheduled Preventative Maintenance, dated [DATE], was reviewed. The document indicated that the scheduled preventative maintenance for [Brand name] Ventilator [Serial number], was conducted on [DATE]. BMT stated that there was nothing wrong with the ventilator. A review of Resident 1's Nursing Progress Note, dated [DATE], indicated, Resident 1 was transferred after the emergency response to ICU on [DATE], at 2:18 PM, for close observation and treatment. During an observation of Resident 1 in ICU, on [DATE], at 2:45 PM, Resident 1 was observed lying in bed attached to ventilator, with FiO2 (the percentage of oxygen a person inhales with each breath with the maximum of 100 percent) set at 30 percent. During a concurrent interview and record review on [DATE], at 3:10 PM, with the DCPS, the facility's document titled, [Brand name] Ventilator [Serial number], Export timestamp: 2025-11-19_09-57-00, dated from [DATE], at 8:04 AM, through [DATE], at 1:55 PM, was reviewed. The document indicated that the ventilator was on standby mode. The DCPS verified and confirmed RT 1 did not resume ventilation from standby mode. As a result, Resident 1 experienced respiratory arrest (a person has stopped breathing or is breathing so weakly that is not sustainable for life), which led to initiation of code blue and transferred to ICU for closed observation and treatment.

Based on observation, interview, and record review, the facility failed to ensure residents are free of accidents for one of three residents (Resident 1) when Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 1) did not ensure the attachment holding the bar and scale of the Hoyer lift (a mechanical device used to transfer people from one surface to another) was properly secure prior to Resident 1's transfer. This failure resulted in the attachment holding the bar and scale of the Hoyer lift became disconnected which caused Resident 1 falling from the Hoyer lift, sustaining a head laceration (cut), and requiring suture and closed observation in the Intensive Care Unit (ICU).Findings: A review of Resident 1's face sheet (contains demographic and medical information), indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including anemia (insufficient red blood cells), chronic respiratory failure (when lungs are too weak to keep oxygen in and carbon dioxide out of the body for a long time), and cerebrovascular accident (CVA - when blood cannot get to a part of the brain and causes it to die from lack of oxygen). A review of Resident 1's clinical record, Physical Therapy Progress Summary, dated August 29, 2025, indicated, Resident 1 was dependent, total assistance. Impaired RLE (right lower extremity), impaired LLE (left lower extremity). Impaired attention and concentration, impaired orientation, impaired memory/learning. A review of Resident 1's clinical record, Physician Note, dated October 2, 2025, indicated, Resident 1 .presents from the NCU [neuro care unit] after a fall. The patient [Resident 1] developed a laceration on the back of her head. The patient [Resident 1] was admitted to the hospital for a head CT [computed tomography - x-ray that takes detailed pictures of brain and skull]. The head CT was negative for intracranial [inside skull] hemorrhage [bleeding]. The patient [Resident 1] had a 4 cm [centimeter-unit of measurement] laceration on the back of her head. Laceration sutured in the ICU [Intensive Care Unit]. The patient [Resident 1] will be transferred back to the floor. A review of Resident 1's clinical record, Change of Condition (details significant deviations from a resident's baseline status, including physical, cognitive, behavioral, or functional changes), dated October 2, 2025, indicated, Upon arrival in room found patient [Resident 1] laying on ground with head on side of Hoyer lift and ventilator's (machine that assists in breathing when lungs cannot on their own) still connected to patient and left-hand mitten in place. Full body assessment done and noted laceration to back of head around 2 inches in length small amount of blood and pressure applied to stop bleeding. A review of Resident 1's clinical record, RRT [Rapid Response Team-a group of health care profession who are called to bedside to assist in a sudden critical intervention] Activation and Response - Text, dated October 2, 2025, indicated, .Primary Call Reason: Other: Fall. RRT called had a fall from Hoyer lift, Per NCU staff patient [Resident 1] was lifted above the level of the bed when she [Resident 1] fell from the Hoyer lift.Patient [Resident 1] taken to CT then to ICU bed 10.Interventions: Other: Cleansed wound on head. and Outcome: Transferred to ICU. During an interview on October 9, 2025, at 11:42 AM, with the Unit Manager (UM), the UM stated, Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 1) used the Hoyer lift to weigh Resident 1. A sling was used and in the process of lifting, the attachment holding the sling and scale was disengaged and Resident 1 fell to the floor. During a concurrent observation and interview on October 9, 2025, at 11:50 AM, with the UM and Maintenance Staff (MS 1), in the maintenance room, both acknowledged the lift equipment present in the room was the lift equipment used to lift Resident 1. MS 1 demonstrated the attachment hook that would hold the scale and bar. The scale and bar had interlocking hooks that go on top of each other and had a red safety latch to ensure them from being disengaging. MS 1 stated, It would take a lot to actually get the attachment to disconnect all of a sudden. You would need to hold down the safety latch to get the hook out or have it sway enough where the hook is angled to where it can disconnect MS 1 further stated, When we took it [the lift] out of the floor and assessed it, we didn't see any physical problems, or anything fault about it. There's no physical wear or anything. During an interview on October 9, 2025, at 12:00 AM, with the UM, the UM stated, Staff are trained on proper use of the lift equipment. The UM further stated all new employees are provided with orientation and yearly competency checks to ensure proper training with the lift equipment. During a concurrent interview and record review on October 9, 2025, at 12:03 PM, with the UM, the facility's document titled, Clinical Engineering Request: 696164 (Work Order), dated October 2, 2025, was reviewed. The Work Order indicated biomed inspection was completed for [name of lift equipment] scale #132309953, confirming no mechanical defect. The UM stated, based on the work order, there was no issue with the machine or the strap at the time of the fall. A review of the facility's document, Unusual Occurrence - Resident Fall with Laceration, dated October 7, 2025, indicated, .the investigation concluded that the primary cause of the incident was the separation of the attaching C clasp on the scale portion of the hoyer lift from the C clasp of the lifting strap. This separation resulted in [Resident 1] dropping from the lift. She [Resident 1] landed on the floor where her head made contact with the leg of the lift, causing the laceration .evaluation found no problems, defects, or broken parts that might have contributed to the C clasp separating from each other .immediate education of proper hoyer lift usage was provided to the LVN and CNA . During a phone interview on October 9, 2025, at 1:57 PM, with CNA 1, CNA 1 stated, the attachment holding the bar and scale were secured and CNA 1 checked before lifting Resident 1 out of bed. CNA 1 further stated, once Resident 1 started to lift, CNA 1 suggested to bring Resident 1 away from the bed as Resident 1's body was still slightly touching the bed. CNA 1 added, as Resident 1 was being moved away from the bed, the attachment holding the bar and scale suddenly disconnected and Resident 1 fell to the floor. During a phone interview on October 9, 2025, at 3:26 PM, with LVN 1, LVN 1 stated, LVN 1 was standing on the right-hand side of Resident 1's bed and CNA 1 was on the left. LVN 1 further stated, Resident 1's feet were dangling on the bed after being lifted by the Hoyer lift, so CNA 1 said to move Resident 1 away from the bed to get an accurate weight reading. CNA 1 started moving the Hoyer lift away from the bed as soon as Resident 1 was not hovering over the bed, the attachment holding the scale and bar disconnected. Resident 1 fell and hit Resident 1's head. Additionally, a Registered Nurse (RN) came into Resident 1's room to assess wounds and found a bleeding laceration on the back of Resident 1's head. LVN 1 confirmed LVN 1 was unsure about the safety and secureness of the attachment. LVN 1 further stated, LVN 1 observed CNA 1 verify the attachment. During an observation on October 10, 2025, at 2:24 PM, in Resident 1's room, Resident 1 was observed to be resting in bed, positioned by pillows on the right side. Mitten was observed on left hand. Laceration on head did not have sutures and appeared dry. During a review of the [name brand of lift] Instruction Guide, revised May 31, 2012, the instruction guide indicated, .Safety Instructions: .Before lifting always make certain that: .the lifting accessories is selected appropriately in terms of type, size, material and design with regard to the patient's needs; lifting accessories are not damaged; the lifting accessory is correctly applied to the lifting equipment; the lifting accessory is correctly and securely applied to the patient, so that no personal injury can occur. During a concurrent interview and record review on October 10, 2025, at 3:00 PM, with the Clinical Director (CD), the facility's policy and procedure (P&P) titled, Safe Patient Handling and Mobility Program, revised July 2023, was reviewed. The P&P stated, .Supporting a culture of safety and accountability by setting expectations for the utilization of safe patient handling and mobility techniques and technology by staff. The CD stated, the facility did not follow the P&P. During a phone interview on October 16, 2025, at 1:12 PM, with the Administrator (Admin), the Admin stated that there were no issues with the Hoyer lift machine, and it was in working condition prior to Resident 1's fall incident. The Admin further stated, the nursing staff were at fault and should have been more careful regarding proper Hoyer lift usage and safety to prevent similar errors in the future. During a phone interview on October 17, 2025, at 12:57 PM, with MS 2, MS 2 stated, the Hoyer lift was last inspected in October 2024, it was scheduled for annually (once a year) inspection, so it would be due for maintenance again by the end of October 2025. MS 2 further stated that the separation of the attaching C clasp on the scale portion of the Hoyer lift from the C clasp of the lifting strap was probably caused by whoever did it [secure the attachment] didn't hook it up properly. They probably didn't notice it [C clasp] wasn't seated properly. I don't know how else it would fall like that. It doesn't make sense .

Based on observation, interview, and record review the facility failed to maintain an infection control program for 14 of 85 sampled residents (Resident 16, 18, 22, 24, 33, 41, 43, 52, 63, 68, 77, 82 and 83) when: 1. For one resident (Resident 41), there was no date or staff initial on Resident 41's gastro enteral tube (G tube- a feeding tube inserted through abdomen into the stomach to provide nutrition, fluids, and medication directly to the digestive system) and water flush bag (a bag with water administered to residents through G tube). 2. For 10 residents (Resident 83, 82, 63, 77, 52, 68, 22, 60, 24, and 41), suction tubes( a plastic tube used to remove bodily fluids and secretions, or foreign materials from a body cavity or passage by creating vacuum) were not used according to the policy and procedures (P&P) for disposable equipment change associated with artificial airway(a medical device such as a tube or other devices inserted into a patient's respiratory track to maintain and open airway) and mechanical ventilators (a medical procedure where a machine is used to assist or replace a person's breathing ). 3. For four resident (Resident 83, 33, 43 and 18 ), the facility staff did not use appropriate proper personal protective equipment (PPE- equipment used to minimize injuries and illness) during medication administration. 4. For one resident ( Resident 16) the facility staff did not wear appropriate PPE during transfer of a resident from shower. These failures had the potential to place residents at a greater risk for spreading infection from cross-contamination (the transfer of harmful bacteria) causing a preventable infection and negative impact on residents' health and safety.Findings: 1. During a review of Resident 41’s “Record of Admission” (demographic data), undated, the “Record of Admission” indicated, Resident 41 was admitted to the facility on [DATE], with the diagnosis of respiratory failure (a medical condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide father in the body). During a review of Resident 41’s “Orders”, dated August 7, 2025, the “Orders” indicated, Resident 41 was ordered to be on continuous GT feeding with [Formula Name] with the rate to be given at 55 milliliters [ml—unit measurement] per hour. During a concurrent observation and interview on August 24, 2025, at 10:40 AM, with Licensed Vocational Nurse (LVN 4), in Resident 41’s room, Resident 41’s G tube feeding bottle and water flash bag were observed with no date and initials on label. LVN 4 acknowledged that label did not have date and initials. LVN 4 stated that the nursing staff was expected to date and initial on the label for the G tube feeding bottle and water flush. LVN 4 further stated that G tube feeding bottle and water flush were scheduled to be changed every 24 hours, as this label did not have the date and initials it would be hard to say when it was hung. During a concurrent observation and interview on August 24, 2025, at 10:45 AM, with the Infection Preventionist (IP) nurse, Resident 41’s G tube feeding bottle and water flush bag were observed with no date and initials on the label. The IP nurse confirmed that G tube feeding and water flush bag has no date and initials on the label. The IP nurse stated the nursing staff were expected to complete the label with the details including date, time and initials when the G tube feeding was hung. The IP nurse further stated it was an infection control concern when the nursing staff did not know when the G tube feeding was hanged. During a concurrent observation and interview on August 24, 2025, at 11:10 AM, with Registered Nurse 2 (RN 2), Resident 41’s G tube feeding bottle and water flush bag were observed with no date and initials on the label. RN 2 acknowledged that the label has no date and initials. RN2 stated that the nursing staff was expected to complete the label with date and initials to know when the G tube feeding was hung. RN 2 further stated, it was a concern for infection control since the bag should be changed every 24 hours as per policy. During a concurrent interview and record review on August 27, 2025, at 2:50 PM, with the IP, the facility’s policy and procedure (P&P) titled, “Administration of formula via feeding tube, gravity, bolus, pump”, dated March 2024, was reviewed. The P&P indicated, “…. Pump or infusion control method . 17.0 pump bags, syringes and tubing are to be changed every 24 hours and properly labeled with date, time and nurses initials”. The IP stated, the policy was not followed. 2a. During a review of Resident 83’s “Face sheet” (demographic data), undated, the “Face sheet” indicated, Resident 83 was admitted to the facility on [DATE], with the diagnosis of respiratory failure. During a review of Resident 83’s “Order”, dated May 17, 2023, the “Orders” indicated, Resident 83 needed suction twice daily. 2b. During a review of Resident 82’s “Face sheet”, undated, the “Face sheet” indicated, Resident 82 was admitted to the facility on [DATE], with the diagnosis of chronic respiratory failure. During a review of Resident 82’s “Orders”, dated January 18, 2017, the “Orders” indicated, Resident 82 needed to be evaluated for suction at least every two hours and as needed. 2c. During a review of Resident 63’s “Face sheet”, undated, the “Face sheet” indicated, Resident 63 was admitted to the facility on [DATE], with the diagnoses of respiratory failure and cardiac arrest (a condition in which the heart suddenly stops beating effectively). During a review of Resident 63’s “Orders”, dated November 22, 2023, the “Orders” indicated, Resident 63 needed to be evaluated for suction at least every two hours and as needed. 2d. During a review of Resident 77’s “Face sheet”, undated, the “Face sheet” indicated, Resident 77 was admitted to the facility on [DATE], with the diagnosis of chronic respiratory failure. During a review of Resident 77’s “Orders”, dated January 18,2017, the “Orders” indicated, Resident 77 needed to be evaluated for suction at least every two hours and as needed. 2e. During a review of Resident 52’s “Face sheet”, undated, the “Face sheet” indicated, Resident 52 was admitted to the facility on [DATE], with the diagnoses of chronic respiratory failure and anoxic brain (a condition in which brain does not receive enough oxygen even when blood flow is adequate). During a review of Resident 52’s “Orders”, dated July 11, 2025, the “Orders” indicated, Resident 52 needed to be evaluated for suction at least every two hours and as needed. 2f. During a review of Resident 68’s “Face sheet”, undated, the “Face sheet” indicated, Resident 68 was admitted to the facility on [DATE], with diagnosis of respiratory failure. During a review of Resident 68’s “Orders”, dated April 18, 2024, the “Orders” indicated, Resident 68 needed to be evaluated for suction at least every two hours and as needed. 2g. During a review of Resident 22’s “Face sheet”, undated, the “Face sheet” indicated, Resident 22 was admitted to the facility on [DATE], with the diagnoses of bronchial asthma (a condition in which persons airway becomes inflamed narrow and swollen and produce mucus which makes difficulty to breathe), and cerebral palsy (a continental disorder of movement muscle tone and posture). During a review of Resident 22’s “Orders”, dated January 30, 2025, the “Orders” indicated, Resident 22 needed to be evaluated for suction at least every two hours and as needed. 2h. During a review of Resident 60’s “Face sheet”, undated, the “Face sheet” indicated, Resident 60 was admitted to the facility on [DATE], with the diagnosis of respiratory failure. During a review of Resident 60’s “Orders”, dated November 29, 2021, the “Orders” indicated, Resident 60 needed to be evaluated for suction at least every two hours and as needed. 2i. During a review of Resident 24’s “Record of “Face sheet”, undated, the “Face sheet” indicated, Resident 24 was admitted to the facility on [DATE], with a diagnosis of respiratory failure. During a review of Resident 24’s “Orders”, dated May 24, 2023, the “Orders” indicated, Resident 24 needed to be suctioned twice daily. 2j. During a review of Resident 41’s “Face sheet”, undated, the “Face sheet” indicated, Resident 41 was admitted to the facility on [DATE], with the diagnosis of Respiratory Failure. During a review of Resident 41’s “Orders”, dated January 16, 2017, the “Orders” indicated, Resident 41 needed to be evaluated for suction at least every two hours and as needed. During an observation on August 24, 2025, from 10:00 AM through 11:00 AM, Resident’s 83, 82, 63, 77, 52, 68, 22, 60, 24, and 41 was observed to have suction tube (a medical tube that connect to a machine to get rid of patient’s fluid) with no labels connected to suction canister (a container used to store body fluids, such as mucus, blood, secretions using a negative pressure suction) by their bedside. During a concurrent observation and interview on August 24, 2025, at 11:15 AM, with Respiratory Therapist (RT1), the suction tubings with no labels were observed. RT1 acknowledged and confirmed that the suction tubings did not have labels. RT1 stated suction tubings were a shared responsibility between respiratory therapists and nursing staff. RT1 further stated, the section tube should be labeled with date and initials so that staff would know when the tubing must be changed. During a concurrent observation and interview on August 24, 2025, at 11:20 AM, with the IP, the suction tubing with no labels were observed. The IP confirmed that the suction tubing was missing labels. The IP stated staff were expected to place a label with date and initials according to the policy. The IP further stated, it is a concern for infection control as staff would not know when the suction tubing was placed and needed to be changed. During a concurrent interview and record review on August 27, 2025, at 2:55 PM, with the IP nurse, the facility’s P&P titled, “disposable equipment change associated with artificial airway and mechanical ventilators”, dated March 2023, was reviewed. The P&P indicated, “… purpose: to define the frequency at which disposable supplies associated with mechanical ventilation are changed… Procedures: all disposable equipment used in the provision of care to the patient with an artificial airway, including mechanical ventilation and aerosol therapy, is changed according to the frequency identified for each respective device. The Inline suction catheter is changed every 24 hours and as needed.1.4.2 a sticker, indicating the day the unit is to be changed”. The IP stated the policy was not followed. 3a. During an observation on August 26, 2025, at 8:03 AM, in Resident 83’s room, LVN 1 was observed to administer medication to Resident 83 through G tube by wearing gloves. During an interview on August 27, 2025, at 8:40 AM, with LVN 2, LVN 2 stated that it was not necessary to wear gown while passing medications. LVN 2 further stated, some staff preferred to use gown while passing medications to prevent spilling off medications to their scrub. During an interview on August 27, 2025, at 8:48 AM, with Registered Nurse 1 (RN 1), RN 1 stated, staff were expected to wear gown and gloves while passing medications. RN 1 further stated, staff were expected to follow enhanced barrier precautions during the care provided for residents to prevent infections. 3b. A review of Resident 33’s “Record of Admission”, indicated, Resident 33 was admitted to the facility on [DATE]. A review of Resident 33’s “History and Physical (H&P - Contains medical history, diagnoses and assessments), dated April 28, 2025, indicated, Resident 33 has medical history of tracheostomy dependent, gastrostomy dependent, cerebral palsy, and epilepsy (seizures or a sudden burst of abnormal brain activity that causes temporary changes in movement, behavior, or awareness). During a medication administration observation on August 26, 2025, at 8:15 AM, with LVN 6, LVN 6 did not wear a gown despite having to give medication to Resident 33, through G-tube 3c. A review of Resident’s 43 “Record of admission” indicated, Resident 43 was admitted to the facility on [DATE]. A review of Resident 43’s H&P, dated February 11, 2025, indicated Resident 43 has medical history of Tracheostomy dependent, G-tube dependent, cerebral palsy, epilepsy and shaken baby syndrome (a serious brain injury caused by violently shaking an infant leading to bleeding, swelling or even death.) During a medical administration observation on August 27, 2025, at 8:15 AM, with LVN 7, LVN 7 did not wear a gown despite having to give medications to Resident 43 through G-tube. During an interview on August 27, 2025, at 8:18 AM, with LVN 7, LVN 7 stated, Resident 43 was not on any type of precautions such as droplet (keeping germs from spreading though cough sneezes or talking by using a mask, gown, gloves, and proper hand hygiene), contact precautions ( keeping germs from spreading through touch by wearing a gown, gloves, and proper hand hygiene), or enhanced barrier precautions. LVN 7 stated that she was not wearing an isolation gown because she did not have a chance to grab it prior to administering medication. LVN 7 stated she puts on a gown when administering medications because of personal preference but indicated that the staff did not have to gown up unless they are on contact, droplet, or EBP precautions. 3d. During a review of Resident 18’s “Record of Admission”, undated, the “Record of Admission” indicated, Resident 18 was admitted to the facility on [DATE]. During a review of Resident 18’s H&P, dated July 10, 2025, the H&P indicated Resident 18 was admitted to the facility with diagnoses which included chronic respiratory failure with hypoxia (a long-term condition where the lungs and respiratory system cannot get enough oxygen into the blood, resulting in dangerously low blood oxygen levels (hypoxemia) over time), and anoxic brain injury (a condition where the brain does not receive enough oxygen for an extended period, leading to damage or death of brain cells). During an observation on August 26, 2025, at 8:51 AM, with LVN 5, LVN 5 was preparing to administer medications to Resident 18 who was lying in his bed. Resident 18 had a tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide an artificial airway) and a gastric feeding tube (a thin, flexible tube inserted into the stomach through the abdominal wall to provide nutrition when a person cannot eat adequately by mouth). Without wearing a PPE gown (protective garment worn in healthcare which provide a physical barrier that covers the torso and arms, helping to prevent the transmission of microorganisms by acting as a barrier between healthcare workers and patients), LVN 5 accessed Resident 18’s gastric feeding tube with a 60 cubic centimeter (cc – unit of measure) syringe, checked gastric residual (volume of stomach contents), and verified correct placement (ensured the feeding tube was positioned in the stomach). LVN 5, while still not wearing a PPE gown, then administered 10 medications to Resident 18 through the residents gastric feeding tube. During an interview on August 26, 2025, at 2:38 PM, with LVN 5, LVN 5 stated when she administered medications to Resident 18, she did not have on a gown because a gown was optional and not required since Resident 18 was not in an isolation room (a room designated specifically with transmission based isolation precautions) because Resident 18’s room did not have an isolation sign posted outside the doorway and therefore it was not a requirement to wear a gown during patient care activities. During an interview on August 27, 2025, at 2:05 PM, with the IP, the IP stated all three of the skilled nursing facility units required EBP during high contact care activities. The IP further stated all residents in the skilled nursing facility were under EBP because they all either had a tracheostomy, required mechanical ventilation (the use of a machine that helps you to breathe or breathes for you), or had gastric feeding tubes and staff were supposed to wear a gown and gloves during the “six moments of care” which included: morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatments, wound care, mobility assistance and preparing to leave a room, and cleaning and disinfecting the environment. During an interview on August 27, 2025, at 2:14 PM, with the DON, the DON stated staff were supposed to be following EBP and wear a gown and gloves when administering medications to residents who had a feeding tube. During a review of the facility’s P&P titled, “Enhanced Barrier Precautions,” dated March 2025, the P&P indicated, “The purpose of Enhanced Barrier Precautions (EBP) is to reduce the spread of multidrug-resistant organisms (MDROs) in the nursing homes…EBP Guidelines…1.5 EBP are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized…Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-contact resident activities include: -Dressing – Bathing/showering – Transferring – Providing hygiene – Changing linens – Changing briefs or assisting with toileting – Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator – Wound care: any skin opening requiring a dressing…Indwelling medical Devices: include, but are not limited to, central vascular lines (including hemodialysis catheters), indwelling urinary catheters, feeding tubes, and tracheostomy tubes…” 4. During a review of Resident 16’s “Record of Admission”, undated, the “Record of Admission” indicated Resident 16 was admitted on [DATE]. During a review of Resident 16’s H&P, dated May 17, 2025, the H&P indicated Resident 16 was in a vegetative state (a condition in which a person is awake but unaware of their surroundings or themselves) and had diagnoses which included chronic respiratory failure with hypoxia, and anoxic encephalopathy (a condition where the brain experiences a deprivation of oxygen which leads to widespread damage to brain cells), and was status post (previously had surgery for) tracheostomy and gastric feeding tube. During an observation on August 26, 2025, at 2:45 PM, in Resident 16’s room, Certified Nursing Assistant 2 (CNA 2) was returning from the shower with Resident 16. Resident 16 was dripping water, had towels draped over him and was lying in a shower bed (a mobile, water-resistant bed/gurney used to wash people with limited mobility) and had a tracheostomy and a feeding tube. CNA 2 stated the facility’s staff had just showered Resident 16 and were going to transfer him back to bed. CNA 2 was wearing a gown which was tied in the back, the head loop was around her neck, but the arm sleeves were not used and were instead tucked into the front of the gown similarly to how one would wear an apron. CNA 2 then transferred Resident 16 from shower bed to his regular bed while wearing her gown without the use of the sleeves. During an observation on August 26, 2025, at 3:03 PM, with CNA 2, CNA 2 retrieved linen from a linen cart which was outside Resident 16’s room. CNA 2 was still wearing her PPE gown like an apron and was not using the sleeves of the gown. During a concurrent observation and interview on August 26, 2025, at 3:07 PM, with CNA 2, CNA 2 was still wearing her PPE gown like an apron and stated she had just transferred Resident 16 to bed and changed his linens. When asked why she was wearing a PPE gown like an apron without the use of the arm sleeves, CNA 2 stated it was because she often would get too hot when she used the arm sleeves of the gowns so she would not use the sleeves, so she stays cooler. During an interview on August 27, 2025, at 2:05 PM, with the IP, the IP stated EBP were supposed to be used during the “6 moments of care” which included morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatments, wound care, mobility assistance and preparing to leave a room, and cleaning and disinfecting the environment. The IP further stated as a part of EBP, staff were supposed to wear a gown and gloves when performing any of the “6 moments of care.” During a follow-up interview on August 27, 2025, at 2:08 PM, with IP, the IP stated, all residents in skilled nursing facility were required to be on EBP since all residents either had a tracheostomy, or a feeding tube. During a follow up interview on August 27, 2025, at 2:12 PM, with the IP, the IP stated, it was not appropriate for any staff member to wear a PPE gown without putting their arms in the sleeves. The IP further stated it was important to wear PPE appropriately to help prevent the spread of infection. During a review of the facility’s P&P titled, “Enhanced Barrier Precautions,” dated March 2025, the P&P indicated, “…1.7 EBP will be followed when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility…Definitions…Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes… High-contact resident activities include: -Dressing – Bathing/showering – Transferring – Providing hygiene – Changing linens – Changing briefs or assisting with toileting – Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator – Wound care: any skin opening requiring a dressing…”

Based on observation, interview, and record review, the facility failed to ensure staff implemented appropriate interventions and oversight of restraints for two of eight sampled residents (Resident 38 and Resident 45) when: 1. Resident 38's mitten restraint (soft hand cover used to prevent a person from scratching or removing medical devices) was not properly worn or secured to Resident 38's right hand. 2. Resident 45's restraint was not reassessed monthly as required by the facility's policy and procedures (P&P) for Restraint, Physical Guidelines for Use and Assessment. These failures had the potential to result in unsafe restraint use, decreased resident safety and violation of residents' rights. Findings: 1. A review of resident 38's Face sheet (FS-Document containing resident demographics), indicated, Resident 38 was admitted to the facility on [DATE]. A review of Resident 38's History and Physical (H&P- a document containing demographic information), dated January 9, 2025, indicated, Resident 38 had a history of tracheostomy (trach-a small surgical hole made in the front of the neck into the windpipe to help a person breath) dependent, gastrostomy (G tube-a small tube placed through the skin into the stomach to give foods, liquids, and medicine) dependent, spastic quadriplegic cerebral palsy (a condition that makes all four limbs stiff and hard to control), and intractable epilepsy (seizures or a sudden burst of abnormal brain activity that causes temporary changes in movement, behavior, or awareness) that are very hard to control with medication). During an observation on August 24, 2025, at 2:07 PM, in room [ROOM NUMBER], Resident 38 was observed with right hand mitten restraint completely off, laying on stomach, and was lifting right arm near the trach. No staff or family members were present in the room. During a concurrent observation and interview on August 24, 2025, at 2:11 PM, with Licensed Vocational Nurse (LVN 3), in room [ROOM NUMBER], Resident 38 was observed to have mitten restraint completely off. LVN 3 verified and stated that Resident 38 should have mitten restraint to the right hand. LVN 3 stated it is important for the mitten restraint to be reapplied because Resident 38 tends to grab on things. A review of Resident 38's orders, dated April 11, 2024, indicated, Resident 38 had an order for Mitten to R [Right] Hand. indication for restraints: Pulling at Lines, Tubes, or Dressing. During an interview on August 24, 2025, at 4:54 PM, with Resident 38's father, he stated, the reason that Resident 38 was on restraint's because she puts her hands in her mouth, makes herself gag and pulls on things. During an interview on August 24, 2025, at 5:02 PM, with LVN 3, LVN 3 stated, it was a shared responsibility between Certified Nurse Assistant (CNAs) and LVNs for monitoring residents' restraints. LVN 3 further stated that improper restraint application can lead to pulling and dislodging devices. During a concurrent interview and record review on August 27, 2025, at 12:07 PM, with the Director of Nursing (DON) and the administrator (Admin), the facility's P&P titled, Restraint, Physical Guidelines for Use and Assessment, dated September 2020, was reviewed. The P&P indicated .Padded Hand mittens.to keep the resident's movements from pulling out tubes. tracheostomy tubes.wrap webbing around the resident's wrist and secure webbing with the slider buckle.tighten webbing sufficiently to prevent from removing mittens. The DON stated that the policy was not followed since Resident 38 was able to get out of the restraint. The DON further stated it is important to follow the policy to keep the residents from harming themselves. 2. A review of Resident 45's FS, indicated, Resident 45 was admitted to the facility on [DATE]. A review of Resident 45's H&P, dated May 8, 2025, indicated that Resident 45 had a history of agitation and restlessness with potential to harm self, intracranial hemorrhage (bleed inside the brain), trach dependent, and G-tube dependent. During an observation on August 24, 2025, at 10:15 AM, Resident 45 had a mitten restraint to right arm. During an interview on August 24, 2025, at 10:18 AM, with Charge Nurse (CN 1), CN 1 stated, the facility will reassess the need for restraints every month, the interdisciplinary team (IDT- a group of healthcare professional who work together to plan and coordinate a resident's care) will discontinue the restraint if the resident passes a 72-hour trial without needing the restraint. A concurrent interview and record review on August 24, 2025, at 3:10 PM, with CN 1, Resident 45's physical restraint medical symptom summary sheet, dated from January 1, 2025, through, August 2025, was reviewed. CN 1 confirmed, Resident 45's restraint was last reviewed on June 30, 2025 (55 days from last assessed). CN 1 stated sometimes they are a little late documenting it into the chart. CN 1 verified that the month of July was missing. CN1 stated, the person who updated the form was Minimum Data Set Nurse (MDSN). During a concurrent interview and record review on August 24, 2025, at 3:38 PM, with the MDSN, Resident 45's physical restraint medical symptom summary sheet, dated January 1, 2025, through, August 2025, document, was reviewed. The physical restraint medical symptom summary sheet indicated, Resident 45's restraint was last reviewed on July 31, 2025. The MDSN verified and confirmed that Resident 45's July restraint assessment was updated today, August 24, 2025 (24 days late). The MDSN stated that the document should have been updated sooner since it is important to do the monthly reassessment to ensure whether the resident still needed the restraints. During an interview on August 27, 2025, at 12:04 PM, with CN 2 and the DON, CN 2 stated that restraints are assessed every month. CN 2 stated that based on the physical restraint medical symptom summary sheet nursing staff will report in the IDT meetings. CN 2 further stated that if physical restraint medical symptom summary sheet was missing a month, then it was not reported in the IDT meetings because IDT team based off the physical restraint medical symptom summary sheet. During a concurrent interview and record review on August 27, 2025, at 12:10 PM, with the DON and Admin, the facility's P&P titled, Restraint, Physical Guidelines for Use and Assessment, dated September 2020, was reviewed. The P&P indicated .the duration of use, not to exceed thirty (30) days.monthly reassessments; the interdisciplinary team will reassess the use of the restraint, the effectiveness of the action plan, less restrictive measures and their effectiveness, progress of the restraint reduction plan and further actions to be taken. The DON confirmed that the policy was not followed since the facility was missing the documentation for July. The DON stated it is important to follow the policy to ensure safe and quality care for the residents and to be restraint free as much as possible.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatments and services to promote wound healing and prevent pressure ulcer (PU- a sore that develops on the skin when there is too much pressure on one area for a long time) development for two of 12 sampled residents (Resident 7 and Resident 37) when: 1. For two residents (Resident 7 and Resident 37), who were at risk for PU development, the repositioning was not documented every two hours. 2. For Resident 37, low air mattress was programmed with the incorrect resident weight. These failures may have contributed to the development of pressure ulcers in Resident 7 and Resident 37, potentially exposing them to harm and resulting in prolonged hospitalization. Findings: 1a. A review of Resident 7’s “admission Record (contains medical and resident demographics), undated, indicated, Resident 7 was admitted to the facility on [DATE]. A review of Resident 7’s “History & Physical” (H&P- a document containing demographic information), dated September 8, 2024, indicated, Resident 7 has a history of decubitus ulcer (a sore on the skin from lying in one spot for too long) of coccyx (the small tailbone at the bottom of the spine), tracheostomy (trach- a small surgical hole made in the front of the neck into the windpipe to help a person breath) dependent, gastrostomy (G-tube-a small tube placed through the skin into the stomach to give foods, liquids, and medicine) dependent, and anoxic encephalopathy (brain damage caused by lack of oxygen). A review of Resident 7’s “Pressure Ulcer Treatment Care plan,” dated March 14, 2025, through August 23, 2025, indicated “turn and reposition at least q [every] 2 hours.” A review of Resident 7’s “Wound Care Note,” dated May 16, 2023, indicated, Resident 7 had a wound to the “Sacro coccyx [ the lower end of the spine where the sacrum and tailbone meet] .type…partial thickness… Measurements (length/width/depth): 1 X [BY] 1 CM [Centimeter-unit of measurement] …. Right ischial tuberosity [the bones that support your weight when you sit down] …type: …partial thickness… measurements (length/width/depth) 2 x 3 cm…Braden score [BS-a tool used to assess a patient's risk for developing pressure injury. Score of 15-18 at risk, score 13-14 moderate risk, 10-12 high risk, 9 or below indicates very high risk] 10…turn q2h [every 2 hours].” A review of Resident 7’s “Wound Care note,” dated June 24, 2025, indicated Resident 7 had a wound to “Location: Sacro coccyx…type: Reopened Stage 4 [full thickness skin and tissue loss, muscle, tendons, ligaments cartilage or even bone is visible.] Pressure Injury [PI- a sore that develops on the skin when there is too much pressure on one area for a long time]…Measurements (length/width/depth): 1.8 cm X 2.5 cm X 1.2 cm…tunneling…1.8 cm… Location: Right ischial tuberosity…type: stage 3{full-thickness skin loss where subcutaneous fat is visible, but bone, tendon, or muscle is not exposed] pressure injury…measurements (length/width/depth): 1.5 cm x 0.5 cm x 1.7 cm…Braden score: 10… reposition: turn q2h…” A concurrent interview and record review on August 27, 2025, at 12:29 PM, with the Director of Nursing (DON) and Administrator (Admin), Resident 7’s “ADLS [activity of daily living, including turns]”, dated August 1, 2025, through August 26, 2025, was reviewed. The “ADLS” for repositioning was completed as follows: On August 19, 2025, at 10:00 PM: position supine (on the back) On August 19, 2025, at 1:36 AM: position supine (3.5 hours without turn) On August 25, 2025, at 12:40 AM: position “head of the bed elevated” On August 25, 2025, at 10:02 AM: position “head of the bed elevated” (9 hours and 22 minutes without turn) The DON verified and confirmed that the nursing staff did not document repositioning every two hours and should have. The DON further stated that “head of the bed elevated” did not count as a turn. A follow-up concurrent interview and record review on August 27, 2025, at 12:32 AM, with the DON and Admin, the facility’s policy and procedure (P&P) titled, “Skin Care, prevention,” dated February 2024, was reviewed. The P&P indicated, “…Turn and reposition the dependent resident at least every two hours, and as needed…” The DON stated that the expectation for the staff was to turn the residents at least every two hours. The DON further stated that nursing staff did not follow the policy and should have to promote healing and to maintain the quality of life for the residents. 1b. A review of Resident 37’s “admission Record, undated, the “admission Record” indicated Resident 37 was admitted to the facility on [DATE]. During a review of Resident 37’s “History & Physical, dated August 25, 2025, the H&P indicated Resident 37 had diagnoses which included obesity (a chronic condition characterized by excessive body fat accumulation that poses a risk to health), encephalopathy (a broad term for any diffuse brain disease altering brain function), tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide an artificial airway) and a gastric feeding tube (a thin, flexible tube inserted into the stomach through the abdominal wall to provide nutrition when a person cannot eat adequately by mouth). During an observation on August 26, 2025, at 5:45 AM, in Resident 37’s room, Resident 37 was lying on a low air loss mattress (a specialized mattress used to help treat and prevent pressure ulcers) and was turned to her left side. A sign titled, “turn clock” (schedule indicating at what times residents are supposed to be turned and in what direction) posted above the head of Resident 37’s bed indicated the resident was supposed to be turned to her left from two to four, and to her right from four to six. During a concurrent observation and interview on August 26, 2025, at 5:54 AM, with Certified Nursing Assistant 3 (CNA 3), in Resident 37’s room, CNA 3 acknowledged Resident 37 was turned to the left side despite the “turn clock” indicating the resident was supposed to be on her right side from four to six. CNA 3 further stated Resident 37 had been turned to her left side since 4:45 AM. CNA 3 stated residents were supposed to be turned every 2 hours. During further interview on August 26, 2025, at 6:04 AM, with CNA 3, CNA 3 stated at 4:45 AM she (CNA 3) had to change Resident 37’s brief and when she was done, she did not turn Resident 37 to the right side (as indicated on the turning schedule) because by the time 6:00 AM would have come around, she would not have had enough time to return back to Resident 37 to turn her because she knew she would have been busy changing all the other residents on the unit before shift change. CNA 3 then stated she wanted Resident 37 to be on the left side so she was turned to the correct side as indicated by the turning schedule at the time shift change occurred at 7:00 AM. During continued observation on August 26, 2025, at 6:50 AM, Resident 37 was still turned to her left side and no staff had turned Resident 37 from the time Resident 37 was initially observed to be turned to the left side at the 5:45 AM observation. During continued observation on August 26, 2025, at 7:13 AM, Resident 37 was still turned to her left side and no staff had turned Resident 37 from the time Resident 37 was initially observed to be turned to the left side at the 5:45 AM observation. During continued observation on August 26, 2025, at 7:48 AM, Resident 37 was still turned to her left side and no staff had turned Resident 37 from the time Resident 37 was initially observed to be turned to the left side at the 5:45 AM observation. During continued observation on August 26, 2025, at 8:15 AM, CNA 4 entered Resident 37’s room and turned Resident 37 from her left to her right side (Three hours and thirty minutes had passed since 4:45 AM). During an interview on August 26, 2025, at 2:09 PM, with Registered Nurse 3 (RN 3), RN 3 stated all residents were supposed to be turned every two hours for the prevention of pressure ulcers. During an interview on August 27, 2025, at 2:20 PM, with the DON, the DON stated residents were supposed to be turned every two hours as indicated on their turning schedule. During a review of Resident 37’s Minimum Data Set Assessment (MDS assessment – a comprehensive assessment of the resident), dated July 24, 2025, the MDS assessment indicated in section M0150 “Risk of Pressure Ulcers/injuries,” that Resident 37 was at risk for development of pressure ulcers/injuries. During a review of Resident 37’s care plan titled, “Pressure Ulcer Risk Care Plan,” dated February 15, 2025, the care plan indicated, “…At risk for further pressure ulcer related to: -history of resolved pressure ulcer; presence of compromised scarred tissue, -Immobility, -incontinent bowel…Interventions…Turn and reposition at least every 2 hours…” During a review of the facility’s P&P titled, “Skin Care, Turning,” dated February 2024, the P&P indicated, “…It is the policy of this facility to turn and re-position all dependent residents a minimum of every two hours routinely, and as needed. It is the policy of this facility to provide skin care to dependent residents every two hours at the time of turning and as needed…” 2. A review of Resident 37’s “admission Record,” undated, the “admission Record” indicated Resident 37 was admitted to the facility on [DATE]. During a review of Resident 37’s H&P, dated August 25, 2025, the H&P indicated Resident 37 had diagnoses which included obesity, tracheostomy, and a gastric feeding tube. During an observation on August 24, 2025, at 12:11 PM, in Resident 37’s room, Resident 37 was lying on a low air loss mattress. The programmable setting of the low air loss mattress was set to 350 – (to) 500 pounds (lbs—unit of weight). During a concurrent observation and interview on August 24, 2025, at 12:23 PM, with Licensed Vocational Nurse 8 (LVN 8), LVN 8 stated she was the nurse assigned to Resident 37 and confirmed Resident 37’s low air loss mattress was set to 350 – 500 lbs. LVN 8 stated the weight setting was incorrect. LVN 8 then looked up Resident 37’s weight in the electronic health record and stated Resident 37 weighed 133 lbs. LVN 8 stated she was not aware the low air loss mattress was set for the incorrect weight and stated the programmed weight should have been 100 – 165 lbs. LVN 8 further stated it was important that the low air loss mattress was programmed accurately for the residents weight because it changed the way the air mattress worked and it was most beneficial to the residents if it was programmed to the residents correct weight. During a review of Resident 37’s physician’s orders, dated January 28, 2025, the physician’s orders indicated, “Low air loss overlay…Citadel 200 bed for wound management.” During a review of Resident 37’s care plan titled, “Pressure Ulcer Risk Care Plan,” dated February 15, 2025, the care plan indicated, “…At risk for further pressure ulcer related to: -history of resolved pressure ulcer; presence of compromised scarred tissue, -Immobility, -incontinent bowel…Interventions…Pressure redistribution mattress as needed…” During an interview on August 26, 2025, at 2:09 PM, with RN 3, RN 3 stated the Citadel 200 bed was supposed to be set specifically for the residents’ weight range. RN 3 further stated it was important to ensure the low air loss mattress was set appropriately because depending on the residents’ weight, the bed would adjust its settings. During an interview on August 27, 2025, at 2:20 PM, with the DON, the DON stated the Citadel bed was a low air loss mattress and staff were expected to ensure the bed setting was set to match the residents’ weight. The DON stated the bed used the programmed weight range to change the air flow in the mattress. During a review of the facility’s P&P titled, “Skin Care, Prevention,” dated February 2024, the P&P indicated, “Policy: To maintain skin integrity; to prevent skin and tissue breakdown and the development of pressure sores…8.5 Consistently use pressure reducing devices such as pressure relief mattresses, static air, alternating air, gel, or water type mattresses or overlays as ordered…”

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 5) received necessary treatment and services to maintain, increase range of motion (ROM- moving the joints to keep them flexible and prevent stiffness) or prevent further decline when nursing staff did not perform ROM as ordered by physician and specified in the care plan (a guide for nurses to follow regarding the plan of care). This failure had the potential to result in decreased mobility and pain and increased the risk of further contractures (muscles and tendons have tightened and shortened).Findings: A review of Resident 5's Face sheet (FS-Document containing resident demographics), indicated, Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's History & Physical (H&P- a document containing demographic information), dated May 6, 2025, indicated, Resident 5 has a history of cerebral palsy (CP-a condition that affects movement, balance, and muscle control), tracheostomy (trach- a small surgical hole made in the front of the neck into the windpipe to help a person breath) dependent, gastrostomy (G-tube-a small tube placed through the skin into the stomach to give foods, liquids, and medicine) dependent, severely contracted, and epilepsy (seizures or a sudden burst of abnormal brain activity that causes temporary changes in movement, behavior, or awareness). A review of Resident 5's Active orders, dated January 19, 2023, indicated Range of motion LTC [long term care] BID [ 2 times a day] provide PROM [Passive range of motion- a health care provider moves resident's joints for them like bending an arm or leg] exercises to BUE [both arms] q [every] AM shift [7:30 AM to 7:00 PM] and BLE [both legs] q night shift [7:30 PM to 7:00 AM] as tolerated. A review of Resident 5's ROM Care Plan, dated April 2025, through October 2025, indicated, PROM exercises to BUE Q AM shift, BLE Q NOC [night] shift as tolerated. A concurrent interview and record review on August 26, 2025, at 1:45 PM, with Certified Nursing Assistant (CNA 1), Resident 5's Restorative Activity Prom, dated from July 31, 2025, through August 26, 2025, was review. The Restorative Activity Prom for repositioning was not completed every shift as follows: July 31, 2025: AM shift: no documentationAugust 1, 2025: AM and PM shift: no documentationAugust 2, 2025: AM and PM shift: no documentationAugust 3, 2025: AM and PM shift: no documentationAugust 11, 2025: AM and PM shift: no documentationAugust 12, 2025: AM and PM shift: no documentationAugust 13, 2025: AM and PM shift: no documentationAugust 14, 2025: PM shift: no documentationAugust 15, 2025: AM and PM shift: no documentationAugust 16, 2025: AM shift: no documentation CNA 1 verified and confirmed the missing ROM. CNA 1 stated, she was unable to provide other documented evidence to show Resident 5 received ROM every shift. CNA 1 stated it was important to complete the ROM as ordered to prevent residents from getting further contracted. CNA 1 stated that the CNAs were responsible for providing the ROM. During a concurrent interview and record review on August 27, 2025, at 11:27 AM, with the Director of Nursing (DON) and Administrator (Admin), the facility's policy and procedure (P&P) titled, Nursing care, restorative & supportive, dated February 2024, was reviewed. The P&P indicated, Restorative and supportive care shall include: .Providing range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited range of motion. The DON stated the policy was not followed, and the nursing staff was expected to follow the physician orders and complete documentation. The DON further stated that it was important to provide ROM as ordered for patient safety.

Based on observation, interview, and record review, the facility failed to ensure the safety and security of medications when Licensed Vocational Nurse 5 (LVN 5) left 12 medications on a computer desk unattended, and unsecured in a resident's room. This failure had the potential to place all 87 residents living on the unit at risk of harm due to increased risk for medication diversion (when a medication is taken for use by someone other than whom it was prescribed.)Findings: During a concurrent observation and interview on August 26, 2025, at 8:46 AM, with LVN 5, in Resident 18's room, LVN 5 placed 12 medications on a portable computer desk located at the bedside of Resident 18. The 12 medications included:-Glycopyrrolate (a medication commonly used to treat stomach ulcers or to inhibit respiratory secretions) 1 milligram (mg - unit of measure) tablet crushed-Vitamin C 500 mg tablet crushed-baclofen (a muscle relaxant) 10 mg tablet crushed-sennosides/docusate/sodium (a combination medication used to treat constipation) 8.6 mg /(per) 50 mg tablet crushed-amlodipine besylate (medication used to treat high blood pressure) 5 mg tablet crushed-vitamin D3 10 micrograms (mcg - unit of measure) 400 international units (iu - unit of measure) tablet crushed-Famotidine (medication used to treat stomach ulcers) 20 mg tablet crushed-carmex ointment (lip moisturizer) 10 mg topical (applied to the skin)-calcium carbonate (an antacid commonly used to treat heartburn or upset stomach) 500 mg tablet crushed-mineral oil USP (commonly used to treat dandruff) 30 milliliters (ml - unit of measure) topical-polyethelene glycol powder (laxative used to treat constipation) 3350 17 grams (gm - unit of measure)-multivitamin w/minerals liquid 15 mls LVN 5, then left Resident 18's room to retrieve a blood pressure cuff and left the 12 medications on the computer table at the bedside of Resident 18 who was lying in bed. LVN 5 returned a few minutes later and stated the unit only had three blood pressure cuffs and she had to go find one. LVN 5 then administered all 12 medications to Resident 18. During an interview on August 26, 2025, at 9:00 AM, with LVN 5, LVN 5 stated she needed to get a blood pressure cuff so she had to leave Resident 18's room. LVN 5 further stated that she should not have left medications unattended, especially with the behavioral health unit (a hospital-based unit or standalone facility that provides intensive, structured care for individuals experiencing a mental health crisis or substance abuse issues) right next door. 5 acknowledged the increased risk of someone coming into the room and consuming or taking the medications when they were not supposed to. During an interview on August 27, 2025, at 2:20 PM, with the Director of Nursing (DON), the DON stated staff should never leave medications unattended if they were not locked in a drawer or locked in a medication cart. During a review of the facility's policy and procedure (P&P) titled, Safe Storage of Medications, dated January 2023, the P&P indicated, Purpose: To outline procedures for safe storage of medications. Policy: Medications will be stored under appropriate conditions to maintain medication integrity, promote the availability of medications when needed, minimize the risk of medication diversion, and reduce potential dispensing errors.All medications dispensed from the pharmacy and not immediately administered to the patient must be secured in an approved medication storage area, including locked medication carts, treatment carts, medication rooms, medication refrigerators, or automated dispensing machines.2.0 Medication storage areas must be secured at all times so that unauthorized persons cannot obtain access to them. 2.1 Medication carts and treatment carts containing medications must be locked unless under the direct supervision of the nurse or other licensed/registered personnel.

Based on observation, interviews, and record review, the facility failed to provide full visual privacy for two of 28 sampled residents (Resident 59 and Resident 70) when there was no curtain between Resident 59's and Resident 70's bed. This failure had the potential to compromise resident 59's and Resident 70's dignity and right to full visual privacy.Findings: A review of Resident 59's Face sheet (FS-Document containing resident demographics), indicated, resident 59 was admitted to the facility on [DATE]. A review of Resident 59's History & Physical (H&P- a document containing demographic information), dated February 11, 2025, indicated, Resident 59 has a history of cerebral palsy (CP-a condition that affects movement, balance, and muscle control), tracheostomy (trach- a small surgical hole made in the front of the neck into the windpipe to help a person breath) dependent, gastrostomy (G-tube-a small tube placed through the skin into the stomach to give foods, liquids, and medicine) dependent, and seizures (a sudden burst of abnormal brain activity that causes temporary changes in movement, behavior, or awareness.) A review of Resident 70's FS, indicated, Resident 70 was admitted to the facility on [DATE]. A review of Resident 70's H&P, dated June 23, 2025, indicated that Resident 70 has a history of down syndrome (a condition present at birth caused by an extra chromosome, leading to developmental and physical differences), trach dependent, G-tube dependent, and seizures. During an observation on August 24, 2025, at 12:10 PM, in room [ROOM NUMBER], there was no curtain dividing Resident 59 and Resident 70. During an interview on August 24, 2025, at 12:14 PM, with Charge Nurse (CN 1), CN 1 stated that the way the facility staff ensure privacy was having a curtain between residents. During a concurrent observation and interview on August 24, 2025, at 12:16 PM, with CN 1 in room [ROOM NUMBER], the room was observed without a curtain between Resident 59 and Resident 70. CN1 verified and stated she was unsure of how long or the reason of missing the curtain in the room. CN 1 further stated that Environmental Services (EVS) takes care of hanging curtains. CN 1 confirmed there should have been a curtain to provide privacy for both residents. During an interview on August 24, 2025, at 12:31 PM, with EVS Staff (EVSS1), EVSS 1 stated that she was unsure of why there was no curtain or who took off the curtain. During a concurrent interview and record review on August 24, 2025, at 11:39 AM, with the Director of Nursing (DON) and the Administrator (Admin), the facility's policy and procedures (P&P) titled, Resident Privacy and confidentiality, dated February 2024, was reviewed. The P&P indicated, . to assure the resident's right to personal privacy and confidentiality .Nursing staff will use curtain to provide full visual privacy during resident care, toileting, treatments and issues of dignity and other requested times . The DON indicated that the facility's P&P was not followed since there was no curtain in the room. The DON further stated it is important to follow the policy to provide each resident their right to be treated with dignity and respect.

Based on observation, interview, and record review, the facility failed to ensure the Centers for Disease Control and Prevention (CDC-a service organization that protects the public's health's) guideline was followed appropriately for two (2) of four sampled residents (Resident 57 and Resident 85) when the Infection Preventionist (IP) did not assess, monitor, and manage the transmission-based precaution (methods that are used to help stop the spread of germs from person to another) appropriately. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to all residents and staff in the facility. Findings: During a review of Resident 85's History and Physical (H&P-contain diagnoses information), indicated, Resident 85 was admitted on [DATE], with diagnoses which included respiratory failure (a condition when lungs cannot get enough oxygen into the blood) with tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck), cerebellar hemorrhage (bleeding in the small space in the brain), hypertension (high blood pressure), and diabetes mellitus (characterized by high blood sugar). A review of Resident 85's Order Sheet, dated August 14, 2024, indicated, resident was ordered to be on droplet isolation (an infection control practice used to prevent the spread of infection that are transmitted through respiratory droplets), for Extended-Spectrum Beta-Lactamase (ESBL-a type of infection that is difficult to be treated). During a review of Resident 57's H&P, H&P indicated, Resident 57 was admitted to the facility on [DATE], with diagnosis which included anoxic encephalopathy (when the brain loses oxygen supply), cardiac arrest (when the heart suddenly and unexpectedly stops pumping), seizure (a sudden, uncontrolled burst of electrical activity in the brain), chronic hypoxemic respiratory failure (prolong lack of oxygen in the blood)and diabetes (a chronic disease that affects how your body turns food into energy). There was no indication that Resident 57 was on any transmission-based precaution. During a concurrent observation and interview on August 16,2024, at 8:15 AM, with the Infection Preventionist (IP), in Resident 85 and 57's shared room, a droplet precaution sign was on the wall outside the room. Residents 85 and 57 were lying in bed with the ceiling suspended; curtain between the two residents, were drawn open. The IP confirmed and stated Resident 57 is not on isolation (needs to be separated from others), but Resident 85 was on droplet precautions. During a concurrent interview and record review on August 16, 2024, at 9:17 AM, with the IP, the facility's policy and procedure (P&P) titled, Transmission-Based Precautions, dated May 1997, and the federal regulations for cohorting [placing together] isolation and non-isolated patients regarding droplet precautions, were reviewed. The P&P indicated, .If a private room is not available and cohorting with a like illness is not feasible, the patient shall be separated at all times by at least three feet from other patients . The federal regulations for cohorting isolation and non-isolated patients regarding droplet precautions indicated, .if it becomes necessary for a resident who requires droplet precaution to share a room with resident who does not have the same infection, the facility should make decisions regarding resident placement on a case-by-case basis after considering infection risks to other resident in the room and available alternatives. Spatial separation and drawing curtain between resident bed is especially important for residents in multi-bedrooms with infections transmitted by the droplet route . The IP acknowledged and stated the facility's policy was missing the drawing of the curtain between resident beds and further stated it should have been in their policy. The IP further stated, she did not know the curtains should be pulled forward when cohorting with a droplet precaution resident. During a concurrent interview and record review on August 16, 2024, at 9:19 AM, with the Neuro Care Unit Manager (NM), the facility's P&P titled, Transmission-Based Precautions, dated May 1997, was reviewed. The P&P indicated, .If a private room is not available and cohorting with a like illness is not feasible, the patient shall be separated at all times by at least three feet from other patients . During a follow-up interview and record review on August 16, 2024, at 9:20 AM, with the NM, the federal regulations and the CDC guidelines for droplet precautions, were reviewed. The CDC guidelines for droplet precautions indicated, .Spatial separation of greater than or equal to 3 feet and drawing the curtain between patient beds is especially important for patients in multi-bedrooms with infections transmitted by the droplet route . The NM acknowledged the federal regulations and the CDC guidelines for the drawing of the curtains for droplet precautions were not accurately reflected in the facility's policy. The NM stated it is important for the policy to reflect the standard of practices for the protection of residents from being exposed to infections. During a review of the facility's job description titled, Infection Preventionist, dated November 30, 2021, indicated, .responsibilities, Job details 1.1 Responsible for assisting the department to ensure compliance program in sub-acute services, State and CMS regulations.

Based on observation, interview, and record review, the facility failed to maintain infection control practices for four (4) of seven (7) sampled residents (Resident 51, Resident 69, Resident 57, and Resident 85) when: 1. Resident 51, who was not on transmission-based precaution (methods that are used to help stop the spread of germs from person to another), was observed less than three (3) feet (unit of measurement) apart from Resident 69 who was on transmission-based precautions. 2. The visitor of Resident 85, who was on droplet isolation (an infection control practice uses to prevent the spread of infection that are transmitted through respiratory droplets), was not educated about the proper use of Personal Protective Equipment (PPE-such as mask, gown and gloves worn to minimize exposure to illnesses) and was seen walking out of the isolation room without taking off the PPE. 3. Resident 57, who was not on transmission-based precautions was observed in the same room with Resident 85, who was on transmission-based precautions, with the ceiling suspended curtains drawn opened between the residents. These failures had the potential to put all residents, visitors, and staff at risk to be exposed to a contagious disease (illness caused by spread of germs) that could compromise residents' health and may lead to actual harm from preventable diseases. Findings: 1. A review of Resident 69's History and Physical (H&P-contains the overall condition of the resident), indicated, Resident 69 was admitted to the facility on [DATE], with diagnoses which included respiratory failure encephalopathy (a condition when lungs cannot get enough oxygen into the blood which cause disturbance of brain function) with tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck), and subarachnoid hemorrhage (bleeding in the brain and surrounding tissues) from ruptured aneurysm (when a weakened area in a blood vessel wall burst, leading to bleeding). A review of Resident 69's Order Sheet, dated August 19, 2024, indicated, Resident 69 was ordered to be on droplet and contact isolation (a type of transmission-based precaution that is used to prevent the spread of diseases that can be transmitted through direct or indirect contact with an infected person or contaminated surfaces) for Extended-Spectrum Beta-Lactamase (ESBL-a type of infection that is difficult to be treated). A review of Resident 51's H&P, indicated, Resident 51 was admitted on [DATE], with diagnoses which included chronic respiratory failure (long term condition when lungs can't get enough oxygen into the blood) with tracheostomy, and diabetes (disorder characterized by high blood sugar). There was no indication that Resident 51 was on any transmission-based precaution. During a concurrent observation and interview on August 12, 2024, at 10:15 AM, with License Vocational Nurse 1 (LVN1), Resident 51 and Resident 69 were observed in room [ROOM NUMBER]. room [ROOM NUMBER]'s door was open, with a sign taped to it, which stated, stop and report to nurse's station before entering room. The back of the sign stated, Droplet and Contact Precaution Isolation, and indicated that an isolation mask, gown, and gloves were the required PPE that needed to be worn by any person when entering the room. Resident 51 was seen on a geriatric chair (a specialized recliner-like chair designed to provide comfort and support for elderly or disabled individuals who may have limited mobility) and Resident 69, who was seen in his bed. There was no cubicle curtain drawn between Resident 51 and Resident 69. LVN 1 stated that Resident 51 and Resident 69 should be kept at least three (3) feet apart. LVN 1 verified and confirmed Resident 51 and Resident 69 were separated only one and a half (1.5) feet apart. During a concurrent interview, on August 12, 2024, at 10:25 AM, with the Infection Preventionist (IP) and LVN 1, IP stated that the facility's policy and procedure (P&P) indicated, it is feasible, residents with and without transmission-based precaution can be in the same room. IP further explained Resident 51, who was not on transmission-based precaution, could share room with Resident 69, who was on droplet and contact isolation, but they must be at least three (3) feet apart. LVN 1 confirmed and stated, Resident 51 and Resident 69 were seen only 1.5 feet apart. IP responded by saying, Since they are not 3 feet apart, they are not following the policy. A review of facility's P&P titled, Transmission-based precaution, dated May 1997, indicated, . 2.2.1 If a private room is not available and cohorting [divide people into groups] with a like illness is not feasible, the patient shall be separated at all times by at least three feet from other patient .3.2.2 Ensure that patients are physically separated from each other by at least 3 feet. Draw the cubicle curtain closed between beds to minimize opportunity for direct contact . 2. A review of Resident 85's H&P, indicated, Resident 85 was admitted on [DATE], with diagnoses which included respiratory failure (ability to maintain adequate gas exchange in the lung) with tracheostomy, cerebellar hemorrhage (bleeding in the small space in brain), hypertension (high blood pressure), and diabetes mellitus. A review of Resident 85's Order Sheet, dated August 14, 2024, indicated, resident was ordered to be on droplet isolation for ESBL. During a concurrent observation and interview on August 15, 2024, at 1:52 PM, Resident 85 was observed in room [ROOM NUMBER]. room [ROOM NUMBER]'s door was open, with a sign taped to it, which stated, stop and report to nurse's station before entering room. The back of the sign stated, Droplet Precaution Isolation, and indicated that an isolation mask, gown, and gloves were the required PPE that needed to be worn by any person when entering the room. One visitor was seen inside the room, with PPE on. The visitor was observed walking out of the room wearing PPE. The visitor stated he visited Resident 85 and had never been informed by staff that he needed to remove the PPE before leaving the room. During an interview on August 15, 2024, at 1:57 PM, with LVN 2, LVN 2 stated she has not educated Resident 85's visitor to remove PPE before leaving isolation room. During an interview on [NAME] 15, 2024, at 2:09 PM, with Registered Nurse 1 (RN 1), RN 1 stated that she educated family members to wear PPE when entering isolation room but did not educate the family members to remove the PPE before leaving the room. RN 1 further stated, according to the facility's P&P, the family members should remove PPE before leaving the isolation room. During an interview on August 15, 2024, at 2:14 PM, with the Director of Nursing (DON), the DON stated, per policy, staff and resident's family should wear PPE when entering isolation room and should remove PPE when leaving the isolation room. A review of facility policy and procedure (P&P) titled, Transmission-based precaution, dated May 1997, indicated, .The gown will be removed before leaving the room and discarded into the regular trash unless it heavily soiled with blood, body fluids, or other potentially infectious materials . 50575 3. During a review of Resident 85's H&P, indicated, Resident 85 was admitted on [DATE], with diagnoses which included respiratory failure with tracheostomy, cerebellar hemorrhage, hypertension, and diabetes mellitus. A review of Resident 85's Order Sheet, dated August 14, 2024, indicated, resident was ordered to be on droplet isolation for ESBL. During a review of Resident 57's H&P, H&P indicated, Resident 57 was admitted to the facility on [DATE], with diagnoses which included anoxic encephalopathy (when your brain loses oxygen supply), cardiac arrest (when the heart suddenly and unexpectedly stops pumping), seizure (a sudden, uncontrolled burst of electrical activity in the brain), chronic hypoxemic respiratory failure and diabetes (a chronic disease that affects how your body turns food into energy). There was no indication that Resident 57 was on any transmission-based precautions. During a concurrent observation and interview on August 16,2024, at 8:15 AM, with the Infection Preventionist (IP) in Resident 85 and 57's shared room, a droplet precaution sign was on the wall outside the room. Residents 85 and 57 were lying in bed with the ceiling suspended curtains, between the two residents, drawn open. The IP stated Resident 57 is not on isolation but Resident 85 was on droplet precautions. During a concurrent interview and record review on August 16, 2024, at 9:17 AM, with the IP, the federal regulations for droplet precautions was reviewed. The federal regulations for droplet precautions indicated, .If it becomes necessary for a resident who requires droplet precaution to share a room with resident who does not have the same infection, the facility should make decisions regarding resident placement on a case-by-case basis after considering infection risks to other resident in the room and available alternatives. Spatial separation and drawing curtain between resident bed is especially important in multi-bedrooms with infections transmitted by the droplet route . The IP acknowledged and stated the federal regulation for droplet precautions were not followed. During a subsequent concurrent interview and record review on August 16, 2024, at 9:20 AM, with the Neuro Care Unit Manager (NM), the federal regulations and the CDC guidelines for droplet precautions were reviewed. The CDC guidelines for droplet precautions indicated, .Spatial separation of greater than or equal to 3 feet and drawing the curtain between patient beds is especially important for patients in multi-bedrooms with infections transmitted by the droplet route . The NM acknowledged the federal regulations, and the CDC guidelines were not followed and further stated that those were important to follow for the protection of the other residents from being exposed.

Based on observation, interview, and record review, the facility failed to ensure resident's right were followed for one of four sample residents (Resident 81), when Resident 81 was placed on a left soft wrist restraint (device to prevent excessive movement of a body part to which they are attached) without an Informed Consent. This failure resulted in Resident 81 and Resident 81's Representative not being fully informed about the care and treatment provided. Findings: During a review of Resident 81's clinical record, the Record of Admission (contains demographic and medical information), indicated Resident 81 was admitted to the facility on [DATE]. A review of the Resident 81's History and Physical (H&P-contains information of health issues), dated July 28, 2024, indicated, admission diagnoses which include Cerebral Palsy (disorder that permanently affect a person's movement and muscle coordination), Tracheostomy status (an opening through the neck into the windpipe to allow air to fill the lungs and help a person breathe), and Gastrostomy status (a tube inserted through the abdomen to deliver fluids, nutrition, and medications directly to the stomach). During an observation on August 12, 2024, at 3:22 PM, in Resident 81's room, Resident 81 was resting in a bed with a soft wrist restraint on his left wrist, tied to the bed. During a concurrent interview and record review on August 15, 2024, at 2:18 PM, with the Neuro Care Unit Manager (NM), Resident 81's Order Summary Report, dated July 5, 2024, was reviewed. The Order Summary Report indicated, Left wrist restraint to prevent pulling at lines, tubes, and dressings. The NM acknowledged and stated there should have been a consent for the soft wrist restraint but could not find one. During a concurrent interview and record review on August 16, 2024, at 9:16 AM, with the NM, the facility's Policy and Procedure (P&P) titled, Restraints, Physical Guidelines for Use and Assessment, dated September 2001, was reviewed. The P&P indicated, .Complete the consent for use of the ordered physical restraint .the physician will discuss with the resident/representative the risk for injury based on individual resident factors and the potential risks and benefits of all options under consideration including using or not using a restraint. Additionally, the resident/representative will be informed of the right to refuse or revoke consent for the use of restraint. The physician will obtain informed consent from the resident/representative. The NM stated the policy was not followed and further stated the physician should have obtained informed consent prior to the application of the soft wrist restraint because it is our policy.

Based on observation, interview and record review, the facility failed to ensure the enteral nutrition (liquid nutrition administered via feeding tube) was administered as ordered for one of 88 residents (Resident 60) when the feeding pump (a device used to deliver food to patient via feeding tube) was not stopped as ordered for Resident 60, causing Resident 60 to receive excessive feeding. This failure had the potential to increase the risk for aspiration (when food or liquids enter the lungs) and compromise the health of Resident 60. Findings: During a review of Resident 60's clinical record, the Record of Admission (contains demographic and medical information), the Record of Admission indicated, Resident 60 was admitted to the facility on [DATE]. A review of Resident 60's History and Physical (H&P-contain diagnoses information), dated November 26, 2023, indicated, the resident was admitted with diagnoses which included Gastrostomy status (a tube inserted through the abdomen that delivers nutrition and hydration directly to the stomach), Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should), and Tracheostomy (an opening in the neck and into the windpipe to help someone breathe). During a review of Resident 60's Order Summary Report, dated August 7, 2024, the Order Summary Report indicated, The resident is to receive [Name of tube feeding] at 52 ml (milliliter- a unit of measurement) per hour or until 1040ml/1560 kcal (kilocalorie - the amount of energy in food) is infused via pump daily; feeding to start at noon (12:00 PM). During a concurrent observation and interview on [DATE], at 10:01 AM, with Licensed Vocational Nurse (LVN 4), in Resident 60's room, Resident 60 was resting in bed with the feeding pump infusing [Name of tube feeding] at a rate of 52 ml per hour. The total amount infused noted on the pump screen indicated 1512ml. LVN 4 confirmed and stated the feeding pump should not be running at this time and should have been stopped when the 1040ml (an excess of 472ml) infusion was completed, per the physician order. During a concurrent interview and record review on August 15, 2024, at 9:33 AM, with the Neuro Care Unit Manager (NM), the facility's Policy and Procedure (P&P) titled Closed System Ready-to-hang Containers of formula Procedure for dated April 1994, was reviewed. The P&P indicated, .to accurately administer the amount of formula ordered by the physician . The NM acknowledged and stated the policy was not followed. The NM further stated it is important to follow the policy because the amount of feeding ordered is calculated by the nutritionist based on the calorie needs for each resident.

Based on observations, interviews, and record review, the facility failed to ensure secure storage of medications for one of 15 medication carts (a mobile cart used by licensed nurses to store and transport medication to resident rooms) when Medication Cart #1 was left unlocked and unattended by a licensed nurse in North wing. This failure had the potential to cause unsafe access from unauthorized personnel to medications which could potentially cause harms and injuries from misuse of medication. Findings: During an observation on August 15, 2024, at 5:33 AM, Licensed Vocation Nurse (LVN 6) was observed utilizing Medication Cart #1 prior to entering inside room [ROOM NUMBER] and closed the door without locking the cart. Medication Cart #1 was parked in the hallway, by room [ROOM NUMBER] in the North wing, and was left unlocked and unattended by LVN 6. During an interview on August 15, 2024, at 5:40 AM, LVN 6 acknowledged and stated she did not lock the medication cart and should have locked it after she removed the medication. LVN 6 further stated it is important to lock the medication cart to keep the medication safe and to follow facility's policy. During a concurrent interview and record review on August 15, 2024, at 9:22 AM, with the NeuroCare Unit Manager (NM), the facility's Policy and Procedure (P&P) titled Safe Storage of Medication dated June 1974, was reviewed. The P&P indicated, .Medication carts and treatment carts containing medications must be locked unless under the direct supervision of the nurse or other licensed/registered personnel . The NM stated the policy was not followed and the nurse should have locked the medication cart before entering the room. The NCUM further stated it is important to keep all medications locked to make sure the medications are kept safe and only licensed and authorized personnel have access to the medications.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff were trained to use transfer equipment properly in accordance with the manufacturer's recommendations and followed a safe lifting technique during a sling scale lift (SSL- a mechanical device used to assist residents and staff during transfers) for one out of three sampled residents (Resident 1) on August 9, 2022. This failure resulted in Resident 1's falling, sustaining a laceration (a deep cut or tear in the skin) on the back of her head, and scalp. Resident 1 was required to be transferred to the general acute care hospital (GACH). Resident 1 received staples to the back of her head and was subsequently admitted to the Intensive Care Unit (ICU) for a higher level of care. Findings: During a review of Resident 1's facility's Admission Record (a clinical record with demographic information), it indicated, Resident 1 was admitted to the facility on [DATE], with an admission diagnosis of respiratory failure. During a review of Resident 1's clinical record, Fall Risk, (Facility's)tdated August 1, 2022, it indicated, Fall Risk Scale Type, John Hopkinsa Eurot and a Euro oeFall Risk Score 6 .moderate risk.t During a review of Resident 1's facility's clinical record, Change of Condition (COC),t dated August 9, 2022, the COC indicated, Resident 1 fell on the floor during weighing when the scale leg strap was accidentally disconnected from Resident 1 .Resident 1 landed on her buttocks then her head . medical emergency team (MET) was called due to bleeding noted on the back of Resident 1's head . During a review of Resident 1's clinical record, Rapid Response Team Activation and Response (RRT AR),tat the facility, dated August 9, 2022, the RRT AR indicated, .Team called for accidental fall. Upon arrival Resident 1 was found in supine (lying face upward) position on floor .bleeding noted on floor from back of head . and Outcome: Transferred to ICU. Follow up: MD 1 placed 5 staples to scalp laceration. t During a review of Resident 1's clinical record, History and Physical (H&P - from GACH), dated August 9, 2022, the H&P indicated, resident had a diagnoses which included pseudomonas pneumonia (a type of germ causes inflammation of the lungs) and [CONDITION(S)] (diffuse disease of the brain that alters brain function or structure). A further review of the H&P indicated, Resident 1 fell and suffered injury to the back of her head and Resident 1 started to bleed from the scalp .Resident 1 has hematoma (bleeding usually caused by an injury) and scalp was stapled, blood pressure dropped . During an interview on August 11, 2022, at 2:45 PM, with the Clinical Director (CD), the CD stated, Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 1) used the [Name of lift equipment company] lift equipment to weigh Resident 1. A sling was used and in the process of lifting, both stated they heard a snap, then the leg strap disconnected, and Resident 1 fell on the floor. During a concurrent observation and interview on August 11, 2022, at 2:55 PM, in the maintenance room with the Clinical Manager (CM) and the CD, both stated This was the lift equipment used to lift Resident 1. The [Name of lift equipment company] lift equipment was observed to have a missing safety latch clip (SLC) from the sling bar. The CD further stated, SLC prevents the sling from accidentally slipping from the sling arm. During an interview on August 11, 2022, at 3:05 PM, with the Director of Staff Development (DSD), the DSD stated, All staff are trained on proper use of the lift equipment.tThe DSD further stated all new employees are provided orientation and yearly training with the lift equipment. Staff are trained and are validated with successful return demonstration. During a review of the facility's record [Name of the lift equipment company] Demonstration Checklist (DS),tundated, the DS indicated, Slowly lifts the patient so that the patient is off the bed surface (does not lock wheels when lifting). During an observation on August 11, 2022, at 3:40 PM, Resident 1 was observed at GACH in the ICU bed. Resident 1 was awake,nonverbal, unable to follow commands and was observed to have staples on the back of her head. During a phone interview on August 11, 2022, at 10:05PM, with LVN 1, LVN 1 stated she was called in the room to assist CNA 1 to weigh Resident 1. The lift equipment was used to weigh Resident 1 and while lifting the resident they heard a snap, the sling came unhooked, and Resident 1 slipped down on the floor. During a phone interview on August 11, 2022, at 10:35 PM, with CNA 1, CNA 1 stated he heard a snap while lifting Resident 1 with the lift equipment. CNA 1 further stated the sling came unhooked and Resident 1 slipped out and landed on her bottom. During a follow up phone interview on August 17, 2022, at 12:06 PM, with CNA 1, CNA 1 stated while lifting Resident 1 with the SSL, the lift equipment's wheels were locked and that's how he was trained upon hire and orientation. During a follow up phone interview on August 17, 2022, at 2:42 PM, with LVN 1, LVN 1 stated she pressed the button to lift Resident 1 and the lift equipment's wheels were locked. LVN 1 further stated she gets the lift equipment training yearly. During a phone interview on August 17, 2022, at 2:47 PM, with CNA 2, CNA 2 stated when using the lift equipment, the wheels are to be locked when lifting the resident. CNA 2 further stated that's what she remembers during training. During a phone interview on August 17, 2022, at 2:55 PM, with CNA 3, CNA 3 stated when she uses the lift equipment, the wheels are to be locked when lifting the resident, to stop it from moving. During a review of the facility's record Investigation Summary (IS), dated August 17, 2022, the IS indicated, Conclusion: .our investigation concludes the fall was the result of human error specifically staff failing to follow the policies and instructions for safe lifting techniques . During a review of the facility's policy and procedure (P&P) titled, Safe Patient Handling and Mobility,teffective date: December 13, 2017, the P&P indicated, Policy: It is the policy of [NAME] Health that health care workers (HCW) who provide patient care are responsible for working in a safe manner when performing vertical lifts, lateral lifts, repositioning, and management of bariatric patients. Purpose: To establish guidelines for consistent safe patient handling and mobility (SPHM) practices. t During a concurrent phone interview and record review on August 17, 2022, at 3:40PM, with the CM, the facility's record, [Name of lift equipment company] Instruction Guide (IG),t undated, was reviewed. The IG indicated, .during lifting, wheels should remain unlocked so that the lift may shift to the patient's center of gravity. The CM stated, If wheels are locked during the process of lifting, manufacturer's instructions are not being followed. The CM further stated, Staff are trained to use that equipment and are expected to follow the policy for safe lifting techniques.

Based on observation, interview, and record review, the facility failed to ensure that staff were trained to use transfer equipment properly in accordance with the manufacturer's recommendations during a sling scale lift (a mechanical device used to assist residents and staff during transfers) transfer affecting one of three sampled residents (Resident 1). This failure resulted in a fall that caused a fracture to Resident 1's left lower leg. Findings: During an observation on (MONTH) 20, (YEAR), at 2:14 PM, with Registered Nurse 2 (RN 2) Resident 1 was lying on the bed, connected to a ventilator (a device used to help with breathing). During a concurrent interview with RN 2, she stated Resident 1 did not have the ability to communicate or to move. A review of Resident 1's Face Sheet (a record that provides the demographic data of the Patient) indicated, Resident 1 was readmitted to the facility on (MONTH) 30, 2005. She was admitted with [DIAGNOSES REDACTED]. A review of Resident 1's Change of Condition (C[NAME]) dated (MONTH) 16, (YEAR), written by Registered Nurse 1 (RN 1) titled, Change of Condition indicated while weighing the patient (Resident 1) using the sling scale by two staffs (Certified Nurse's Aide 1, {CNA 1} and Licensed Vocational Nurse 1{ LVN 1) pt's (patients) sliding out of sling and LVN 1 assisted patient to the floor. A record review of Resident 1's CT (Computed Tomography, a form X' ray) of the pelvis report dated, (MONTH) 16, (YEAR), at 10:04 PM, indicated an acute intertrochanteric fracture (a [MEDICAL CONDITION]).The anatomic (body parts) site of this type of [MEDICAL CONDITION] is the proximal or upper part of the femur (thigh bone) of the left femur with fracture involvement of the greater & lesser trochanter (parts of the thigh bones) approximately 5 mm (millimeter, a unit of measurement) of displacement is noted. A review of the facility's Incident /Accident Investigation Report dated (MONTH) 16, (YEAR), indicated Interviewed CNA 1/LVN 1, stated that sling scale was not applied properly (was not crisscross) to the hooks. A review of manufacturer's recommendations provided by the facility for Liko Sling, indicated that the sling sleeves had to be crisscross and attached to the sling bar securely while lifting the resident. A review of Registered Nurse 1's (RN 1) Investigation Statement dated (MONTH) 16, (YEAR), indicated that .I asked CNA (CNA 1) if he applied the sling scale correctly, and told me, he did not apply sling scale properly as how it should be, it was not crisscross to the lower part of the sling to the hook . A Review of the POS [REDACTED]. (Resident 1) using sling scale, pt's (patients)sliding out of sling. LVN (LVN 1) assisted pt. to the floor. While interviewing CNA (CNA 1) and LVN (LVN 1), they stated they did not apply sling scale properly. They did not crisscross the sling scale to the hook This document was signed by Manager 1. During a telephone interview with CNA 1, on (MONTH) 22, (YEAR), at 4:26 PM, he stated that during the process of weighing Resident 1, on (MONTH) 16, 1028, around 12:30 AM, he stated, while transferring Resident 1, using the sling scale, he did not make sure the proper application of sling (crisscross the slings). He stated that made the Resident 1 to fall. A review of the facility policy and procedure titled Safe Patient Handling revised September, (YEAR), indicated .As assessed and appropriate to patient's (Resident) condition, handling equipment and patient assist device will be used to ensure safety .

Based on interview and record review, the facility failed to ensure that oxygen titration (to adjust the amount of the oxygen the person is receiving to keep the level in the blood above 92%) was completed by a qualified licensed health practitioner for 3 of 18 sampled residents (Resident 2, 11, and 18). These failures had the potential to result in respiratory distress and respiratory arrest for residents receiving oxygen therapy. These findings placed all residents of the facility receiving oxygen therapy (87 residents) at risk for respiratory distress, [MEDICAL CONDITION], serious harm, or death in a universe of 87 residents. Immediate Jeopardy was called on February 26, 2014 at 11:15 AM in the presence of the Vice President of Sub Acute and Behavioral Health (via telephone call) and the Director of Nursing. Findings: 1. During a review of the clinical record for Resident 11, on February 24, 2014 at 8:30 AM, the record documented that Resident 11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During a review of Residents 11's Medication Administration Record, [REDACTED]. A review of Resident 11 nurses' notes dated January 31, 2014, did not show any documented interventions for the oxygen saturation of 74 percent. A review of the physicians order on February 24, 2014 at 8:30 AM for Resident 11, dated May 24, 2013 reflected, "Check O2 (oxygen) saturation every shift and PRN (as need), titrate (to adjust the amount of the oxygen the person is receiving to keep the level in the blood above 92%) O2 to maintain saturation above 92 percent." During an interview with registered nurse (RN) 1 on February 24, 2014 at 9:00 AM she confirmed the documented oxygen saturation for Resident 11, on January 31, 2014 was 74 percent, and there was no documentation in the nurse's notes regarding the oxygen saturation of 74. RN 1 stated the nurse who wrote that was not on duty today. When asked about the procedure for titration of oxygen, she stated she was not sure of a procedure or policy on titrating oxygen. She would raise the oxygen liters until it (oxygen titration) goes to 92 percent, and assess vital signs (a resident temperature, pulse, respiration, and blood pressure). She continued to state, "sometimes they (residents) have accompanying symptoms of hypo or hyperventilation (to slow breathing which does not meet the need of the body or over breathing) not enough volume, I would leave the respiratory therapist (RT) there (with the resident) and call the doctor." During an interview with the Director of Nurses, on February 24, 2014, at 9:30 AM she reviewed the clinical record of Resident 11, and was unable to find documentation of interventions for the oxygen saturation of 74 percent. She stated, "I don't know why she (the licensed vocational nurse) wrote that but it looks like she made a mistake. We would call the MD (physician) to titrate oxygen, we do not just titrate it on our own, and we would write in the nurses notes and on the back of the MAR indicated [REDACTED]. During an interview with licensed vocational nurse (LVN) 2, on February 24, 2014, at 11:00 AM, she stated, "It is human to error, it's (oxygen saturation) 94 cause if its 74, I would have to do something. I need to titrate the oxygen to 100 percent; I would turn the oxygen to 8 or 9 liters of oxygen. I would call the RN supervisor and call the MET (Medical Emergency Team) team, and monitor and stay with the patient, the doctor would get called." She stated it is a nursing intervention for her to titrate oxygen, and she had an in-service with the RT. During an interview with the respiratory care practitioner (RCP), on February 24, 2014, at 11:10 AM, he stated, if they (nurses) have saturation problems they usually call the RCP, but they (nurses) will "Bump two (increase the oxygen administration by two liters) they will not slowly crawl up (slowly increase the oxygen flow), you want to give them (residents) oxygen if their sats (oxygen saturation) are down." He also stated, "They have had in services on this, they call us." During an interview with LVN 5 on February 24, 2014 at 11:15 AM she stated, if the oxygen saturation rate for the resident was below 92 percent, "I would suction (the resident's airway), and check it again, if it is still below 92 percent I would change the regulator. I would then increase the oxygen by 2 liters, if I just increased the oxygen and didn't change the regulator (the meter that adjusts the amount of oxygen) it is not going to give the same amount of oxygen. I would keep the oxygen at that amount about an hour then come back and check again (the oxygen saturation). If the saturation level is not increased I will call my charge nurse and then RT." 2. During a review of the clinical record for Resident 18, on February 24, 2014 at 12:10 PM, the record documented that Resident 18 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During a review of Resident 18's MAR, on February 24, 2014 at 12:10 PM for the month of January 2014, showed that on January 31, 2014, the nurse documented that the resident's oxygen saturation (the amount of oxygen available in the blood for use by the body, normal is above 92%) was 74 percent. A review of Resident 18's nurses' notes dated January 31, 2014 did not show any documented interventions for the oxygen saturation of 74 percent. A review of the recapitualtion (a summary of all the phsycian's current orders for the Residnet) of the physicians orders for February 2014, showed an order originally dated, November 11, 2011, stated, "Check O2 saturation every shift and PRN titrate (to adjust the amount of the oxygen the person is receiving to keep the level in the blood above 92%) oxygen to maintain saturation above 92 percent." During an interview with RN 1 on February 24, 2014, at 12:20 PM, she confirmed the documented oxygen saturation for Resident 18, on January 31, 2014 was 74 percent, and there was no documentation in the nurse's notes regarding the oxygen saturation of 74. During an interview with the Director of Education on February 24, 2014, at 1:25 PM, she stated, "l do annual competency, but the nurses are not trained in Oxygen titration." During review of the training calendar for nursing staff (Registered Nurses and Licensed Vocational Nurses) on February 24, 2014, at 1:25 PM, for the year of 2013 and 2014, there was no scheduled training on oxygen titration or oxygen therapy. During an interview with the Director of Education on February 24, 2014, at 4:45 PM, she stated for titration of oxygen "we call the MET (Medical Emergency Team) team. The RT's do that, we don't. When resident's de-sat (a decrease amount of oxygen in the blood) we call the MET team, we call the experts. One hundred percent honest, we have protocols in place; it is not for nursing staff. We need to fix it, we have opportunities there. NCU (neurological care unit) is recent for me taking care of; I did education for the hospital." During an interview with Physician 1, on February 25, 2014 at 9:05 AM he stated, "the pulse oximetry (the method for monitoring a patient's oxygen levels in the blood) should be between 90 to 92 percent. If it drops below that they should call me, there is no protocol. Call me and I will give them orders." During an interview with Physician 2, on February 25, 2014 at 10:10 AM, he stated, "if the resident de sats, then suction (the resident's airway) to keep his sats (oxygen saturation) greater. Elevate the oxygen, whatever it takes for sats to get back to 98 percent. The nurse and the RT should do this then call me." When asked what nurse he was referring to he stated, "The RN charge nurse." During an interview with LVN 5 on February 24, 2014 at 1:05 PM, the LVN stated that to titrate oxygen she would set the oxygen at 5-6 liters to keep the oxygen saturation (the amount of oxygen in the blood stream for use by the body) above 92%. She stated that if the saturation were to go down she would assess the resident and could increase the oxygen to 8 liters and then slowly decrease it to keep the saturation above 92%. She further stated that she could call the RN (Registered Nurse) or RCP (Respiratory Care Practitioner) if the saturation did not increase. 3. On February 19, 2014 a review of the clinical record for Resident 2 was conducted. Resident 2 was admitted to the facility with [DIAGNOSES REDACTED]. During a review of the physician's order January 23, 2014, documented that Resident 2 had an order for [REDACTED]." During an interview with LVN 3 on February 24, 2014 at 3:02 PM, she stated that to titrate oxygen she would take the oxygen saturation to see if it is at least 92%. If it wasn't she would call the RN and the RT. She would then see what they determined and then could suction the resident or turn up the oxygen. She reviewed the order for Resident 2 and confirmed that there were no parameters for administering oxygen, only the order to titrate it to keep the saturation above 92%. Review of the facilities policy and procedure titled, "Oximetry, Pulse" dated April 2013, reflected the following, " Notify the physician and obtain treatment orders if the O2 saturation is 90% or below. Document this condition change and notification in the resident record." Review of the facility policy and procedure titled, " Oxygen Titration Protocol" for the cardiopulmonary department, dated effective January 1993, reflected, "Contact physician with final FIO2 (fraction of inspired oxygen, percentage of oxygen in the space being measured) to obtain order for specific liter flow/FIO2 and enter specific order in physician orders." Review of the "Licensed Vocational Nurse Scope of Practice Standards" reflected the following, "The LVN may not independently determine that an oxygen deficit exists and proceed to administer oxygen when specific conditions and parameters for oxygen administration are not given by the physician." Due to the facility's failure to: -Ensure that LVN's did not work outside of their scope of practice -Ensure there was a policy and procedure for nursing staff regarding titration of oxygen -Ensure all nursing staff were trained regarding oxygen titration and saturation levels, residents of the facility were at risk of serious harm, or death for a universe of 87 residents. Immediate Jeopardy was called on February 26, 2014 at 11:15 AM with the Vice President of Sub Acute and Behavioral Health (via telephone call) and the DON. On February 26, 2014 at 5:15 PM, the DON presented a plan of corrective action to the survey team. The plan of correction included the following elements: A. Oxygen Therapy Policy #R20 Revised Date: 2/26/14 to included changes: Only RN or RCP may titrate oxygen to maintain physician ordered O2 saturation. LVN's may administer oxygen at a physician ordered set rate or set percentage of delivery. Titration will not be done by LVN. B. All LVNs, RNs, and RCPs will be in-serviced on changes to the policy. C. Physician order updated for all residents to state, "Check O2 Saturation Q (every) shift and PRN (as needed). Titrate O2 to maintain saturation at or above 90% or as specified by MD (physician)." D. Change of condition log for documentation of any O2 saturation events reviewed by the NCU (Neurological Care Unit) director or designee. E. Review of Change of Condition Log of any O2 saturation events. Random review of 10 events per week, or 100% if less than 10 events. Audit to include: Oxygen titration only performed by RN and RCP and Notification to the RN and physician of resident change of condition. F. Findings reported to the Quality Improvement Council (QIC), Medical Executive Committee (MEC), and Governing Body until 100% compliance is sustained for 4 months. G. Changes to the LVN job description to include "...Recognizes the change in patient status and reports changes to immediate supervisor and initiate appropriate treatment within the LVN Scope of Practice." The corrective action was accepted on February 26, 2014 at 5:25 PM. On February 26, 2014 at 5:25 PM, the survey team met with the facility DON, consultant, QA nurse, and Clinical Manager, and informed them that the team abated the Immediate Jeopardy.

Based on observation, interview and record review, the facility failed to accurately assess, care plan, evaluate treatment and revise the approaches to prevent the deterioration of a pressure ulcer and the formation of new pressure ulcers for 2 of 17 sampled residents (Resident 6 and Resident 17). This failure caused Resident 6 to experience a deterioration in a stage II pressure ulcer to a stage IV and allowed the formation of a stage II pressure ulcer to her left ear. The failure allowed the formation of a pressure ulcer on the back of Resident 6's head that is unstageable due to the presence of dead tissue. The failure also allowed Resident 17 to acquire an open wound on the back of the neck. Findings: 1. During A tour of the facility on 6/6/11 at 7:00 AM, Resident 6 was observed lying on her back in her bed. During a concurrent interview with RN 2, she stated that Resident 6 was on bedrest because of pressure ulcer development. Pressure ulcers are described as an area of skin, usually over a boney area, that deteriorates when you stay in one position for too long without shifting your weight. Pressure ulcers are staged in the following way per the National Pressure Ulcer Advisory Panel: Stage I - A reddened area on the skin that, when pressed, does not turn white Stage II - The epidermis or topmost layer of the skin is broken, creating a shallow open sore. Drainage may or may not be present. Stage III - The break in the skin extends through the dermis (second skin layer) into the subcutaneous and fat tissue. The wound is deeper than in Stage Two. Stage IV - The breakdown extends into the muscle and can extend as far down as the bone. Usually lots of dead tissue and drainage are present. A review of Resident 6's medical record was initiated on 6/6/11. Resident 6, age 26, was admitted to the facility on [DATE] and readmitted on [DATE] following an acute care hospitalization . Her [DIAGNOSES REDACTED]. A review of the annual MDS dated [DATE] and the quarterly review MDS dated [DATE] reflects that Resident 6 had no pressure ulcers at that time. A review of Resident 6's medical record reflects she is being treated for [REDACTED]. On 2/4/11 Resident 6 was readmitted to the facility following a stay at an acute care facility. Review of the admission assessment identified Resident 6 had a white scab on her sacrum measuring approximately 0.5 inches in diameter. The surrounding tissue in the available photographs was pink. The wound photograph is dated 2/4/11. There is no time on the photograph. On 2/16/11 the facility documented with an untimed photograph the sacral wound was 1.5 cm x 1.5 cm with no tunneling (a wound having channels that extend into and through subcutaneous tissue or muscle) or undermining (a pocket under the edges of a wound). The photographic wound documentation reflects there was no exudate present and the wound bed is pink/beefy red tissue. Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect the resident is to be turned every 2 hours. On 3/4/11 the untimed photographic wound documentation reflects the sacral wound was unstageable and is 3.3 cm x 2.5 cm. The sacral wound was draining serosanguineous (composed of serum and blood) fluid and the wound bed was slough pink/beefy red tissue and black/brown eschar (dead tissue). Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect the resident is to be turned every 2 hours. On 3/18/11 the photographic wound documentation reflects the sacral wound was a stage IV measuring 2.9 cm x 2.6 cm x 0.5 cm. The drainage has an odor and is serosanguineous (composed of serum and blood) and the wound bed has beefy red tissue, slough and black/brown eschar (dead tissue). Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect the resident is to be turned every 2 hours. On 3/25/11 the photographic wound documentation reflects Resident 6's stage 4 sacral wound now measuring 3.0 cm x 3.8 cm. Documentation reflects Resident 6 refuses to be turned and the facility will continue to educate her on the importance of turning. Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect resident is to be turned every 2 hours. On 4/3/11 the photographic wound documentation for Resident 6's sacral wound shows measurements of 4.3 cm x 3.9 cm. No other documentation was available in the medical record for this date. On 4/8/11 Resident 6's sacral wound shows measurement of 3.5 cm x 3.6 cm with a depth of 0.7 cm. The licensed nurse documented there was undermining from 4-9 with deepest area at 7 o'clock. Bone exposed to center of wound bed. Continue with current treatment and monitor daily. On 2/22/11 a second stage II pressure ulcer was identified on Resident 6's left ear measuring 0.3 cm x 0.2 cm Treatment orders were received for [MEDICATION NAME] Ointment (ointment used to prevent minor skin injuries such as cuts, scrapes, [MEDICAL CONDITION] becoming infected). Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect the resident is to be turned every 2 hours. On 3/4/11 the wound to her left ear measured 1.0 cm x 0.7 cm and is documented as unstageable. The notes on the treatment records show that the current treatment is to continue and that Resident 6 is not allowing the staff to position her head in such a way that the pressure on her ear is relieved. Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect the resident is to be turned every 2 hours. There is no care plan in the medical record to address this pressure ulcer other than the treatment plans. On 3/18/11 the documentation for Resident 6's left ear shows the wound is a stage II measuring 1.0 cm x 0.1 cm with a depth of 0.1 cm. Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect the resident is to be turned every 2 hours with the addition of an accuair bed. On 3/25/11 the documentation shows improvement in Resident 6's left ear wound measuring 1.0 cm x 0.1 cm x .01 cm Treatments are to continue as ordered. Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect the resident is to be turned every 2 hours. On 4/3/11 Resident 6's left ear wound measured 1.8 cm x 0.3 cm. Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect resident is to be turned every 2 hours. On 4/18/11 a third wound was identified on the back of Resident 6's head measuring 0.4 cm x 0.7 cm with a red wound bed. Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect resident is to be turned every 2 hours. On 4/29/11 Resident 6's head wound measured 1.4 cm x 1.1 cm. Documentation reflects to continue with current treatment and monitor daily. Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect resident is to be turned every 2 hours. On 5/6/11 Resident 6's head wound measured 1.5 cm x 1.9 cm with a wound bed of eschar (dead tissue). Documentation reflects that the physician was notified. [MEDICATION NAME] ointment was discontinued and an order for [REDACTED]. On 5/13/11 Resident 6's head wound measured 2.5 cm x 2.5 cm with a wound bed of eschar. The licensed nurse documented that Santyl ointment is to continue. Documentation reflects that Resident 6 refuses to use neck pillow to reduce pressure to the back of her head. Preventative measures on the "Weekly Pressure Ulcer Assessment Form" reflect resident is to be turned every 2 hours. During an interview with Resident 6 on 6/7/11 at 11:20 AM she stated she used to have an air cushion in her wheelchair when she was at home that prevented her from getting sores. She stated the facility told her she got her wounds because she was not eating good. She stated she does not like to be turned because when she is on her side she cannot breathe and it scares her. She stated she did not like the supplemental tube feedings and usually refused them because it made her stomach hurt. When Resident 6 was asked if she had complained of her stomach hurting to the facility staff, she stated that she had. During an interview with Resident 6 on 6/7/11 at 2:30 PM she stated she is mad about being made to stay in her bed because of her bed sore. During an interview with RN 4 on 6/7/11 at 3:50 PM she stated that it is the treatment nurses responsibility to evaluate the wound weekly and notify the charge nurse on duty of any changes or the need for additional treatment. She stated she has not seen Resident 6's wounds. She stated that she was not the person that had been notified of any changes to Resident 6's wounds. During an interview with LVN 5 on 6/7/11 at 2:20 PM she stated that Resident 6 usually refuses her [MEDICATION NAME] feedings. Because it happens all the time, I no longer make a note when she refuses, I just circle it. Resident 6 has never told me that the feedings make her stomach hurt. She stated she had not done any investigation into why Resident 6 refuses her supplemental feedings. During an interview with LVN 4, the primary treatment nurse for the facility, on 6/7/11 at 4:00 PM, she stated that Resident 6's physician was made aware of the deterioration of her wounds. When she was asked, she stated Resident 6's physician had not ever been present during a dressing change but he had seen the pictures. She stated that she has done the best she can do with the products that are available to her. LVN 4 stated that it is her responsibility to assess the wounds and determine the appropriate treatment for [REDACTED]. When LVN 4 was asked about any investigation done by the facility or staff regarding her refusal to be turned and her refusal to use the neck pillow recommended to her, she stated that Resident 6 has a right to refuse to be turned. She stated no additional investigations had been done regarding Resident 6's refusal of care. During this interview, LVN 4 stated that Resident 6 used to have another kind of pressure relieving mattress but it was a long time ago. LVN 4 stated those beds are very expensive and it would still require Resident 6 to be turned. When LVN 4 was asked about additional equipment or beds that might benefit Resident 6 due to her refusal to be turned, she stated that the wound to her head developed while the accuair bed was in use. She stated she just has to ask the DON for additional equipment if she feels it is needed by a resident and the DON either approves or denies her request. She stated she had not requested any additional equipment for Resident 6. During an interview with LVN 4, the treatment nurse, on 6/8/11 at 9:00 AM she stated she was unable to find documentation of the treatments for her sacral wound until 2/16/11. LVN 4 was able to provide copies of the photographs that were taken during the various stages of wound development but written treatment records were unavailable for the period when the wound was first identified on 2/4/11. During an interview with CNA 1 on 6/8/11 at 3:11 PM she stated that Resident 6 usually does not allow the CNA's to turn her because she says she can't breathe. CNA 1 stated Resident 6 sometimes lets her put a pillow under her hip but when she cries because she can't breathe, "I feel bad and always put her back on her back". There is no care plan available in Resident 6's medical record to address her inability to breathe comfortably on her side. Review of the Interdisciplinary Plan of Care Conference Records dated 5/4/11 and 6/8/11 show Resident 6 is on psychoactive medication for a history of depression. The Skin Condition assessment shows Resident 6 has three pressure ulcers receiving treatment. Under the section for Psychosocial Concerns, the IDT documented there are no changes noted. There are no notes regarding non-compliant behavior. There are no notes regarding Resident 6 refusing her supplemental tube feedings. A care plan dated 5/4/11 identifies Resident 6 is non-compliant with her treatment plan. Resident 6 refuses to turn and reposition and wants to be out of bed even with a bedrest order for wound healing. Interventions listed for this problem include; one on one interaction to encourage verbalization and to determine the underlying cause of non-compliant behavior. Be firm and concise when interacting with resident. Psychology follow up. During an interview with the Registered Dietician (RD) on 6/8/11, at 4:15 PM, she stated Resident 6 used to be very active in her wheelchair throughout the unit. The RD stated that she is "starting to feel there is a psychological component to her not eating". She stated that Resident 6 had an order for [REDACTED]. She stated Resident 6 usually would refuse the formula feedings because it upset her stomach. The RD stated she recommended that Resident 6's physician order a medication ([MEDICATION NAME], to increase the ability to digest food quickly) that would help with Resident 6's feelings of discomfort from the tube feeding. During this interview with the RD, she stated that she had received an order that day from Resident 6's physician that her tube feedings following meals were no longer based on her percentage of each meal consumed and she is required to have a 100 ml [MEDICATION NAME] of formula following all of her meals. She stated she was uncomfortable with the nurses having to decide if Resident 6 had eaten 50% and then offering the tube feeding. She stated she had changed Resident 6's formula, based on Resident 6's report of a stomach ache, 3 times during the past month with no improvement and she was hoping that the addition of the medication [MEDICATION NAME] would help. A care plan dated 5/4/11 in Resident 6's medical record reflects Altered Nutritional Status secondary to Resident 6 refusing night gastrostomy tube feedings and delayed wound healing. Interventions include: 1. Give diet as ordered 2. Document food intake with meals 3. Offer substitute as appropriate 4. Weigh monthly and as needed 5. Inform doctor of low oral intake. The care plan dated 5/4/11 titled At Risk for unavoidable/further unavoidable lists no individualized interventions for Resident 6 refusing to be turned. It lists interventions to continue to assess for circulatory impairment and treatments as ordered. There was no additional care plan available in the medical record and the facility was unable to provide an earlier care plan to address Resident 6's pressure ulcers. The care plans dated 2/16/11 titled Impaired Skin Integrity, for Resident 6's sacral pressure ulcers lists only the ordered medical treatments for the care of the existing wounds with updates for new orders noted. There are no other individualized interventions for the treatment of [REDACTED]. Review of the facility policy titled Assessment, Pressure Ulcer Risk dated 5/09 reflects that a licensed nurse is to assess all residents for their pressure ulcer risk and then decide whether and to what extent the factors that put each resident at risk can be modified, stabilized or removed. There is no documentation provided by the facility to reflect that Resident 6's risk factors for pressure ulcer development were modified or stabilized or that there was any investigation into the reasons for her refusing to be turned. The psychosocial affects of her depression were not addressed with individualized interventions to allow her access to her wheelchair. 2. Resident 17 was a [AGE] year old male, who was admitted to the facility on [DATE] and discharged on [DATE], with the following [DIAGNOSES REDACTED]. On 6/13/11, a review of Resident 17's closed clinical record was conducted. A review of the document titled " Wound Documentation " dated 2/5/11, indicated an open area on the back of the neck under the [MEDICAL CONDITION] ( a surgical opening through the neck into the trachea) tie. The picture of the wound revealed a 7.5 cm x 0.5 cm red open wound. No previous documentation or assessment of the wound was in the clinical record. A review of the care plan dated 2/22/11, for Resident 17 indicated a reopen area on the back of the neck. On 6/8/11, at 3:30 PM while observing the Respiratory Therapist (RT), an observation was made of the [MEDICAL CONDITION] (trach) care and dressing change for sampled resident 8. During the changing of [MEDICAL CONDITION] the RT did not assess the back of the resident ' s neck area under [MEDICAL CONDITION]. On 6/13/11 at 2:30 PM, a record review was conducted with the RT supervisor, when asked who was responsible for the skin assessment [MEDICAL CONDITION]; she stated that both Nursing and the Respiratory department are responsible for daily assessment [MEDICAL CONDITION]. After reviewing the picture of the wound she stated " I guess it wasn't done, but it should have been " . A review of the facility ' s Policy and Procedure titled, "[MEDICAL CONDITION] Site Care": identified that [MEDICAL CONDITION] site care will be performed every shift, and as needed.(5) Assess the site for evidence or signs of skin breakdown or infection.(11) [MEDICAL CONDITION] if soiled. Ties should fit snugly against skin, but loose enough to allow 1-2 fingers to slip beneath them