Every finding on record at Coral Cove Post Acute

Based on observation, interview, and record review the facility failed to ensure two of three sample resident's (Resident 1 and Resident 2) rooms had safe temperature levels not to exceed above 81-degree Fahrenheit ( F, a unit of measure for temperature).This failure made Resident 1 and Resident 2 feel uncomfortable in the rooms and had the potential to be at risk for dehydration (a condition that occurs when your body loses more fluids than it takes in) that leads to heat stress (the overall physical burden and strain your body experiences when working or resting in hot environments) and heat exhaustion (a more advanced moderate illness caused by a heavy loss of water and salt through excessive sweating).Findings:During a review of Resident 1's admission Record, the admission indicated Resident 1 was admitted at the facility on 6/14/2024 with a diagnoses including atrial fibrillation (irregular heart rate that can cause poor blood flow), diabetes mellitus ([DM], a chronic disease that affects how the body processes sugar), and congestive heart failure ([CHF], weakness of the heart that leads to buildup of fluid in the lungs and other parts of the body).During a review of Resident 1's History and Physical (H&P), dated 12/17/2024, the H&P indicated Resident 1 could make his needs known.During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 7/17/2026, the MDS indicated Resident 1 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment) and needed assistance from staff with set up or clean up (helper sets up or cleans up while resident completes activity) for self-care activities such as eating, hygiene, bathing, dressing and putting on footwear. The MDS indicated Resident 1 needed set up or clean up assistance for mobility, transfers and ambulation. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted at the facility on 6/17/2026 with a diagnoses including hypertension ([HTN], high blood pressure), benign prostatic hyperplasia ([BPH], age-associated prostate gland enlargement that can cause urination difficulty) and cerebral infarction ([stroke], blockage of the flow of blood brain, causing or resulting in brain tissue death).During a review of Resident 2's H&P, dated 6/17/2026, the H&P indicated Resident 2 could make his needs known.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was cognitively intact and needed maximal assistance (helper does more than half the effort) to supervision (helper provides verbal cues as resident completes activity) with self-care activities such as eating, hygiene, bathing and dressing. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort) to supervision with mobility, transfers and ambulation. During a concurrent observation and interview on 8/26/2026 at 9:13 a.m. with the Maintenance Supervisor (MS), the MS was checking the temperatures of all the rooms in the facility with surveyor. The MS stated the temperature of room [ROOM NUMBER] was 83 degrees, room [ROOM NUMBER] was 83 degrees, room [ROOM NUMBER] was 85 degrees, room [ROOM NUMBER] was 79 degrees. MS stated the last time he checked the temperature of the room was on 8/21/2026. The MS stated he did not check the temperature of the rooms this week because he got too busy. The MS stated he did not check the temperature of the rooms again until this surveyor asked to check the temperature of the rooms. The MS stated he did not think the rooms would be too hot because fans were provided to the residents in the room. During a concurrent observation and interview on 8/26/2026 at 11:30 a.m. with Resident 1 in room [ROOM NUMBER], Resident 1 was sitting in his rollator walker (a type of mobility aid with wheels on all its legs, handlebars, hand brakes, and usually a built-in seat). Resident 1 stated the air conditioner in his room had not worked for two years now. Resident 1 stated the room gets warm during midday (the exact middle of the day or twelve o'clock in the afternoon). Resident 1 stated the air conditioner worked in the hallway so that was where he spent most of his time because the air conditioner in his room did not work, and his room got to hot. Resident 1 stated during the heat wave last week, his room was hot and he had to open the patio door to get the air in from outside.During a concurrent observation and interview on 8/26/2026 at 4:00 p.m. with Resident 2 in room [ROOM NUMBER], Resident 2 was sitting at the edge of the bed. Resident 2 stated the room feels hot. Resident 23 asked when the air conditioner was going to get fixed so it can cool the room down. During an interview on 8/26/2026 at 4:12 p.m. with the MS, the MS stated, the weather was too hot, and he should be checking the temperatures daily. The MS stated the residents could get dehydrated leading to heat stroke (a serious medical condition that happens when the body becomes dangerously overheated, causing a very high body temperature and leading to symptoms like exhaustion, confusion, loss of consciousness, and the inability to cool down through sweating) . The MS stated the room temperatures need to be at 65 to 70 degrees due to the extreme heat that we have had recently.During an interview on 8/26/2026 at 5:09 p.m. with the Director of Nursing (DON), the DON stated the residents that are staying in hot rooms can get dehydrated. The DON stated older residents are more prone to getting dehydrated quickly, losing more fluids in the body and prone to getting heat stress and heat strokes. During a review of the facility's policy and procedures (P&P) titled Maintenance Service, dated 1/1/2012, indicated, the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.During a review of the facility's P&P titled Extreme Weather, dated 1/1/2012, indicated, to provide residents, visitors, and staff with a comfortable and safe environment during extreme weather. the facility staff will assess residents for comfort and take additional measures to promote a comfortable environment as necessary.the Maintenance Department maintains a log of facility temperatures. If the temperature is above or below standard, the Maintenance Department takes and documents measures to remedy the situation.During a review of the facility's P&P titled Resident Rooms and Environment, dated 1/1/2012, indicted, to provide residents with a safe, clean, comfortable and homelike environment. the facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences.facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following such comfortable temperatures.

Based on interview and record review, the facility failed to develop and implement a comprehensive person center care plan for one of three sampled residents (Resident 1) by failing to: 1.Develop a comprehensive person-centered care plan to address Resident 1's wandering (walk around without any clear purpose or direction). This failure had the potential to negatively affect the delivery of care and services to Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and hypertension (HTN- high blood pressure).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/31/2026, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 1 requiring touching assistance (helper provides verbal cues and/or touching and/or contact guard assistance) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including anxiety (emotion characterized by feelings of tension, worried thoughts) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 was dependent (helper does all the effort) with ADLs.During an interview on 8/21/2026 at 11:50 a.m., with Resident 2, Resident 2 in the hallway, Resident 2 stated Resident 1 came into her room while her Family Member (FM) 1 was visiting and it made her feel uncomfortable. Resident 2 stated Resident 1 wanders into her room every night and just stands there and stares.During a phone interview on 8/21/2026 at 2:05 p.m., with Registered Nurse Supervisor (RNS) 1, RNS stated Resident 1 likes to wander into other resident rooms and needs to be redirected.During a concurrent interview and record review on 8/21/2026 at 2:35 p.m., with Licensed Vocational Nurse 1 (LVN) 1, reviewed Resident 1's care plan. LVN 1 stated there was no care plan addressing Resident 1's wandering, but there should have been one. LVN 1 stated a care plan should have been developed with interventions outlining how to care for the resident, and for Resident 1, it would have included strategies to manage and monitor the resident's wandering.During an interview on 8/25/2026 at 2:59 p.m., with the Director of Nursing (DON), the DON stated Resident 1 should have a care plan for wandering. The DON stated a care plan was a guide for the resident's care with interventions and was communication tool, so the staff know how to care for the residents.During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the residents rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure the staff monitored and supervised one of three sampled residents (Resident 1) after Resident 1 was observed wandering (walk around without any clear purpose or direction) into Resident 2's room.This failure resulted in Resident 1 wandering into Resident 2's room, causing Resident 2 to feel uncomfortable.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and hypertension (HTN- high blood pressure).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/31/2026, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 1 requiring touching assistance (helper provides verbal cues and/or touching and/or contact guard assistance) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including anxiety (emotion characterized by feelings of tension, worried thoughts) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 was dependent (helper does all the effort) with ADLs.During an interview on 8/21/2026 at 11:50 a.m., with Resident 2, Resident 2 was sitting in the hallway, Resident 2 stated Resident 1 came into her room while her Family Member (FM) 1 was visiting and it made her uncomfortable. Resident 2 stated Resident 1 wanders into her room every night and just stands in her doorway and stares.During a phone interview on 8/21/2026 at 12:36 p.m., with Family Member (FM) 1, FM 1 stated Resident 1 wandered into Resident 2's room and just stood there. FM 1 stated when Resident 1 wandered into Resident 2's room, it made herself and Resident 2 feel uncomfortable and felt Resident 1 was harassing them because they told him to leave and Resident 1 just stood there. FM 1 stated there was no one with Resident 1, and FM 1 stated she did not know why the facility allows him to wander around into other resident rooms.During a phone interview on 8/21/2026 at 2:05 p.m., with Registered Nurse Supervisor (RNS) 1, RNS stated Resident 1 likes to wander into other resident rooms and requires redirection. RNS 1 stated that on the night of 8/20/2026, Resident 1 wandered into Resident 2's room and did not have a sitter at that time but was assigned one after Resident 2 told her that Resident 1 wandered into her room.During an interview on 8/21/2026 at 2:35 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 tends to wander into other resident rooms. LVN 1 stated Resident 1 had a sitter at the beginning of the month and was assigned another sitter earlier this week. LVN 1 stated Resident 1 can be confused at times and requires redirection but he all he wants to do is talk to women.During an interview on 8/25/2026 at 2:59 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was a wanderer and should have a sitter at all times. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, dated 2/10/2023, the P&P indicated, Purpose- to enhance the safety of residents of the facility.During a review of the facility's P&P titled, Resident Safety, dated 4/15/2021, the P&P indicated, Residents will be evaluated on admission, quarterly, and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the Resident. During the comprehensive assessment period the interdisciplinary (IDT) members will assess the resident's safety risk (e.g., wandering) as well as other resident specific safety risks.

Based on observation, interview and record review, the facility failed to follow appropriate infection prevention and control practices for six of 30 sampled residents (Resident 4, 50, 58, 92, 116, and 117) by failing to:a. Ensure a visitor was wearing personal protective equipment (PPE) when touching Resident 4 who was on enhanced barrier precautions (EBP - special safety rules where health workers wear gloves and gowns to stop the spread of tough germs).b. Perform hand hygiene prior to providing feeding assistance to Resident 50.c. Implement appropriate Transmission-Based Precaution (TBP, additional precautions to decrease spread of germs from one person to another) for Resident 58 and Resident 92 with suspected Scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate skin causing intense itching, inflammation, and red patches).d. Implement appropriate TBP for Resident 116 with clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) and Resident 117.These failures had potential to increase the risk of infection transmission among facility residents, staff and visitors. Findings: A. During an observation on 8/10/2026 at 10:55 a.m. observed EBP sign outside of Resident 4's room and a visitor in Resident 4's room was oral suctioning (a medical cleanup process that uses a small vacuum machine and a plastic tube to clear spit, mucus, or throw-up out of a person's mouth so they can breathe easily) to Resident 4 and was not wearing PPE. During a review of Resident 4's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 8/11/2026, the Face Sheet indicated the facility admitted Resident 4 on 5/22/2026 with diagnosis including acute respiratory failure (a serious medical emergency where the lungs suddenly cannot get enough oxygen into the blood or get rid of enough carbon dioxide), gastrostomy (G-Tube - a minor surgery that creates a small opening through the abdomen into the stomach for placement of a feeding tube), tracheostomy (a surgical procedure of cutting an opening into the windpipe through the neck for placement of a tube to assist breathing), and history of methicillin resistant staphylococcus aureus infection (MRSA – a type of bacteria that cannot be killed by many common antibiotics). During a review of Resident 4's History and Physical (H&P) dated 5/23/2026, the H&P indicated Resident 4 had mild impairment of the ability to think or make decisions. During a review of Resident 4's Minimum Data Set (MDS – a resident assessment tool) dated 5/29/2026, the MDS indicated Resident 4 was dependent on staff with oral hygiene, toileting hygiene, showering or bathing, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. The MDS indicated Resident 4 had active diagnoses including multidrug-resistant organism (MDRO – a bacteria resistant to several antibiotics). During a review of Resident 4's Order Summary Report (a list of active physician orders) dated 8/11/2026, the Order Summary Report indicated Resident 4 was on EBP for G-Tube status and tracheostomy. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 on 8/10/2026 at 10:57 a.m. in Resident 4's room, Resident 4's visitor was observed performing oral suctioning to Resident 4. LVN 1 stated Resident 4's visitor was not wearing PPE and should be wearing PPE when in Resident 4's room especially when touching Resident 4. LVN 1 stated the importance of wearing PPE when entering an EBP room, was to prevent the spread of infection from visitors or residents or residents to visitors. LVN 1 stated there would be potential for an increased risk of infection. During an interview on 8/13/2026 at 2:47 p.m. with the Director of Nursing (DON), the DON stated the importance of visitors wearing PPE when entering residents' room who are on EBP was to ensure residents will not be exposed to potential infections visitors were carrying. The DON stated there would be increased risk for residents to be exposed to infections visitors may be carrying. During a review of the facility's Policy and Procedure (P&P) titled IPC303 Enhanced Barrier Precautions revised 10/15/2024, the P&P indicated, 2. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of MDROs: . g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. The P&P indicated, Use of Gown and Gloves by Family Members or Other Visitors of a Resident on EBP 22. Visitors and family members need to wear gowns and gloves only when they are participating in high-contact care activities for a resident on EBP. a. such as morning and evening care (the same practices as HCP providing such care). b. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 10/31/2023, and readmitted on [DATE] with diagnoses including epilepsy (disorder that causes episodes of seizures or altered consciousness) , gastrostomy status (a gastrostomy tube placed in their stomach through a small opening in the abdomen), cardiac arrhythmia (when your heat does not beat in a normal way, too fast, too slow, or in an irregular pattern). During a review of Resident 50's MDS, dated [DATE], the MDS indicated the resident's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was severely impaired. The MDS indicated Resident 50 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, showering and personal hygiene. During a concurrent observation and interview on 8/10/2026 at 12:48 p.m. with Certified Nursing Assistant (CNA) 3, in Resident 50's room, CNA 3 was observed standing on the left side of the resident, handing the call light and bedside rail, adjusting the head of bed, and moving the resident's meal tray closer to the resident. CNA 3 then began feeding the resident without performing hand hygiene. CNA 3 acknowledged he did not perform hand hygiene prior to feeding the resident. During an interview on 8/13/2026 at 3:54 p.m. with the Director of Nursing (DON), the DON stated staff should perform hand hygiene before feeding residents to prevent contamination and reduce the risk of infection transmission. During a review of the facility's P&P titled Hand Hygiene, revised 9/1/2020, the P&P indicated staff should perform hand hygiene before and after assisting a Resident with dining if direct contact with food is anticipated or occurs. c. During a review of Resident 58's admission Record, the admission Record indicated the facility admitted the resident on 12/4/2023 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain), adult failure to thrive (when an older adult's health, body, and mood start to decline in a noticeable way, often because of a mix of physical, emotional, and stoical problems) and malnutrition (when your body doesn't get enough food energy). During a review of Resident 58's H&P, dated 8/11/2026, the H&P indicated the resident could make needs known but could not make medical decisions. During a review of Resident 58's MDS, dated [DATE], the MDS indicated the resident's cognition was severely impaired. The MDS indicated Resident 58 required setup assistance (helper sets up or clean up) with eating oral hygiene, supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with toileting, showering and personal hygiene. During a review of Resident 92's admission Record, the admission Record indicated the facility admitted the resident on 8/10/2025 and readmitted on [DATE] with diagnoses including cellulitis (infection of the skin) of left lower limb, muscle weakness, and type 2 diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 92's History and Physical (H&P), dated 8/11/2026, the H&P indicated, the resident could make needs known but could not make medical decisions. During a review of Resident 92's Minimum Data Set, dated [DATE], the MDS indicated the resident's cognitive was intact. The MDS also indicated Resident 92 required setup assistance (helper sets up or clean up) with eating, oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 92's Order Summary Report, as of 8/11/2026, the Order Summary Report indicated following order: Starting 8/5/2026, administer 6 tablets of Ivermectin (a medicine that helps get rid of certain parasites in the body, like worms or tiny insects) 3milligram (mg- a unit of mass) everyday by mouth for dermatitis. Starting 8/5/2026, apply Permethrin topical cram 5 % (a medicine used to kill tiny mites that cause scabies) to general body topically every day for dermatitis. Starting 8/11/2026, follow the contact isolation. During a concurrent interview and record review on 8/11/2026 at 1:11 p.m. with the IPN, Resident 92's Order Summary Report, as of 8/11/2026 was reviewed. The IPN stated Resident 92 developed a rash and the physician ordered ivermectin and permethrin for dermatitis (skin irritation that causes redness, soreness, and rash) on 8/5/2026. The IPN stated the medications were not typically indicated for dermatitis and staff should have clarified the indication with the physician. The IPN stated staff (unknown) obtained a skin scraping (medical test to determine presence of scabies) on 8/10/2026, did not initiate contact precautions (procedures to reduce risk of spread of infections through direct or indirect contact) while awaiting confirmation, placing Resident 58, the roommate, at potential risk for exposure to scabies. The IPN stated staff should have initiated contact precautions until scabies were ruled out and acknowledged being unsure of the facility's protocol for suspected scabies. During an interview on 8/13/2026 at 3:54 p.m. with the DON, the DON stated the medications (ivermectin and permethrin) were used to treat scabies and when scabies was suspected staff should initiate contact precautions until the resident was cleared. The DON stated staff should clarify the diagnosis with the physician, appropriately manage linens, avoid placing the resident with a roommate at risk for exposure, and immediately post precaution signage to communicate the required precautions to staff and visitors. During a review of the facility's P&P titled Resident Isolation-Categories of Transmission-Based Precautions, revised 1/1/2012, the P&P indicated contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment, examples of infections requiring contact precautions included scabies. The P&P also indicated the facility alerts staff to the type of precaution a resident requires and may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room. During a review of the facility's P&P titled Resident Isolation-Initiating Transmission-Based Precautions, revised 4/22/2016, the P&P indicated When a resident is suspected of, or is identified as, having a communicable infectious disease, the Charge Nurse notifies the Infection Control Coordinator and the resident's Attending Physician for appropriate transmission-based precautions. Transmission-based precautions remain in effect until the Attending Physician or Medical Director discontinues them, which occt1rs after requirements for discontinuation are met. d. During a review of Resident 116's admission Record, the admission Record indicated the facility admitted the resident on 8/7/2026 with diagnoses including osteomyelitis (when bacteria or germs infect your bone, making it painful, swollen, and sometimes a causing fever) of right shoulder, C-difficile and Type 2 Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 116's H&P dated 8/10/2026, the H&P indicated the resident had the ability to make medical decisions. During a review of Resident 116's Order Summary Report, as of 8/11/2026, the Order Summary Report indicated an order starting 8/8/2026, put on contact isolation due to C. difficile. During a review of Resident 117's admission Record, the admission Record indicated the facility admitted the resident on 8/10/2026 with diagnoses including pneumonia (an infection that makes your lungs swell and fill with fluid, making it hard to breathe), respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and Asthma (condition in which your airways narrow and swell making breathing difficult). During an observation on 8/10/2026 at 11:50 a.m. in Resident 116's room, the resident's room was observed without signage to indicate Resident 116 was on TBP isolation nor TBP supplies. During a concurrent interview and record review on 8/11/2026 at 1:11 p.m. with the IPN, Resident 116's Order Summary Report, dated 8/8/2026 was reviewed. The IPN stated staff should have initiated contact isolation for Resident 116 upon admission due to C. difficile with diarrhea, staff did not initiate contact isolation until the afternoon of 8/10/2026, two days after admission, and placed Resident 117 in the same room with Resident 116, who did not require contact isolation. The IPN stated staff should not have placed the two residents in the same room and should have implemented contact isolation upon admission to prevent the potential spread of C. difficile to other residents and staff. During an interview on 8/13/2026 at 3:54 p.m. with the DON, the DON stated the facility should have implemented appropriate TBP, including contact insolation, for Resident 116 when the order was initiated on 8/8/2026 due to C-difficile. The resident should not have been placed in the same room with a resident who did not require contact isolation to prevent the potential spread of infection. During a review of the facility's P&P titled Resident Isolation-Categories of Transmission-Based Precautions, revised 1/1/2012, the P&P indicated contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment, examples of infections requiring contact precautions included diarrhea associated with Clostridium difficile. The P&P also indicated the facility alerts staff to the type of precaution a resident requires and may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room. During a review of the facility's P&P titled Resident Isolation-Initiating Transmission-Based Precautions, revised 4/22/2016, the P&P indicated when transmission-based precautions are implemented, the Infection Control Coordinator (or designee): Ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need Posts the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel are aware of precautions, or aware that they must first see a nurse to obtain additional information about the situation before entering the room. Explains to the resident (or representative) the reason(s) for the precautions.

Based on interview and record review, the facility failed to ensure proper influenza vaccination (a vaccine that helps protect you from getting sick with the flu and makes illness less severe if you do catch it) practices by failing to provide the required education, obtain and document informed consent or refusal, and maintain accurate vaccination records for two of five sampled residents (Residents 50 and 59).This failure had the potential to affect residents' ability to make informed vaccination decisions and increase the risk of vaccine-preventable illness.Findings:During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 10/31/2023, and readmitted on [DATE] with diagnoses including epilepsy (disorder that causes episodes of seizures or altered consciousness), gastrostomy status (a gastrostomy tube placed in their stomach through a small opening in the abdomen), cardiac arrhythmia (when your heat does not beat in a normal way, too fast, too slow, or in an irregular pattern).During a review of Resident 50's Minimum Data Set (MDS- a resident assessment tool), dated 5/25/2026, the MDS indicated the resident's cognition (functions your brain uses to think, pay attention, process information, and remember things) was severely impaired. The MDS indicated Resident 50 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, showering and personal hygiene.During a review of Resident 59's admission Record, the admission Record indicated the facility admitted the resident on 5/8/2026 with diagnoses including benign paroxysmal vertigo (most common causes of vertigo-sudden feeling of spinning or moving), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain).During a review of Resident 59's History and Physical (H&P), dated 5/9/2026, the H&P indicated the resident did not have the ability to make own medical decisions but could make needs known.During a review of Resident 59's Minimum Data Set (MDS- a resident assessment tool), dated 5/15/2026, the MDS indicated the resident's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 59 required setup assistance (helper sets up or clean up) with eating, moderate assistance (helper does less than half the effort to complete the task) with eating, supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with oral hygiene, toileting hygiene, showering and personal hygiene.During a concurrent interview and record review on 8/11/2026 at 2:47 p.m. with the Infection Preventionist Nurse (IPN), Resident 50's immunization record, dated 10/18/2025, and Resident 59's immunization record, dated 10/20/2025 were reviewed. The IPN stated Resident 50's influenza vaccine was documented as refused on 10/18/2025 and the IPN could not identify what education was provided, who received the education, or who declined the vaccine. The IPN stated Resident lacked capacity and there was no documented consent supporting the refusal. The IPN also stated Resident 59 received an influenza vaccine on 10/20/2025 without documented consent, and the only consent in the record was obtained on 5/8/2026 for the upcoming influenza season. The IPN stated vaccination should include appropriate education regarding risks and benefits, informed consent, timely administration, and complete documentation to ensure accurate tracking and protect residents from illness.During an interview on 8/13/2026 at 3:54 p.m. with the Director of Nursing (DON), the DON stated facility should ensure providing influenza appropriately by providing proper education, vaccination, receiving consent properly to residents and documented and remained accordingly.During a review of the facility's Policy and Procedure (P&P) titled Influenza Prevention and Control, revised 9/10/2020, the P&P indicated,Before offering the influenza vaccine, each Resident or the Resident's representative will be given education regarding the risk and benefits and potential side effects of the immunization.The Resident or representative must give consent prior to receiving the vaccine. They can refuse immunization - with such refusal being noted in the Resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure that nursing staff had specific competencies and skill sets necessary to care for residents' needs by failing to: a. Ensure Restorative Nursing Assistant (RNA) 1 knew what a fortified diet was when feeding Resident 107 and Resident 54. b. Ensure Licensed Vocational Nurse (LVN) 3 knew the item on the tray was considered a fortified item. This deficient practice had the potential to compromise resident care and nutritional support due to adequate training and competency among nursing staffFindings: During a concurrent observation and interview on 8/12/2026 at 12:34 p.m. with Resident 107, Resident 107 stated he does not know what the food was on his plate and did not know what the sour cream in the container was for. a. During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), parkinsonism (any condition that causes slowed movement, tremors), and metabolic encephalopathy (brain malfunction caused by chemical imbalance or toxins in the blood when other parts of the body liver [large, reddish-brown organ in the upper right belly that cleans blood, produce digestive juices, and store energy] or kidney [(bean-shaped organ located in the back below the rib cage to filter blood, remove waste, and balance body fluids] was not working properly) During a review of Resident 107's history and physical (H&P) dated 9/18/2025, the H&P indicated Resident 107 had fluctuating capacity to understand and make decisions. During a review of Resident 107's Minimum Data Set (MDS, a resident assessment tool), dated 8/3/2026, the MDS indicated Resident 107 had moderate cognitive (ability to think and make decisions) impairment. The MDS indicated Resident 107 was dependent on facility staff for toileting hygiene, bathing, chair/bed-to-chair transfer, shower transfer, required substantial assistance (helper does more than half the effort) on facility staff for sit to lying, lying to sitting on side of bed, required supervision for upper (above waist) and lower (below waist) dressing, personal hygiene, roll left and right, and required setup for eating and oral hygiene. During a concurrent observation and interview on 8/12/2026 at 12:39 p.m. with RNA 1 was feeding Resident 54 did not know what the sour cream, on Resident 107's meal tray was for. b. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus (medical condition where a physical blockage traps fluid inside the brain) anoxic (condition where there were no oxygen) brain damage, and dysphagia. During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54 had moderate cognitive impairment. The MDS indicated Resident 54 was dependent on facility staff for all aspects of activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 54's H&P dated 7/31/2026, the H&P indicated Resident 54 could make needs known but cannot make medical decisions. During a review of the fortified lunch for Wednesday 8/12/2026, the taco casserole indicated to add additional one to two tablespoon (tbs, standard unit of volume in cooking) additional shredded cheese or one tbs sour cream and put half an ounce (oz, unit of weight) of melted margarine on the zucchini. During a concurrent observation and interview on 8/12/2026 at 12:41 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated it depends on the residents if they like sour cream or not when asked why some residents have sour cream and some do not. During a concurrent observation and interview on 8/12/2026 at 12:43 p.m. with RNA 1 and CNA 4, RNA 1 stated she does not know what a fortified diet was and CNA 4 was observed asking other residents if they wanted sour cream with their lunch. During an interview on 8/12/2026 at 12:44 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated he did not know what a fortified diet was. During an interview on 8/12/2026 at 2:46 p.m. with RNA 1, RNA 1 stated a fortified diet was used to make residents stronger and indicated she did not know why some residents had sour cream and some did not and thought it was a garnish. RNA 1 stated residents that were on fortified diets were on a special diet based on their condition and indicated if they do not know what a fortified diet was (or provide the items that make the diet a fortified diet), the resident could decline and lose more weight. During an interview on 8/12/2026 at 3:53 p.m. with LVN 3, was unable to verbalize if sour cream was considered a fortification. LVN 3 stated fortified. During an interview on 8/13/2026 at 1:51 p.m. with the Dietary Supervisor (DS), the DS stated it was important to ensure the residents fortified meals included the ingredients that make it a fortified meal, so the residents gain more calories and indicated the residents would continue to lose weight. During an interview on 8/13/2026 at 3:09 p.m. with the Director of Nursing (DON), the DON stated that a fortified diet was a nutritiously enhanced diet for residents who were experiencing weight loss or who had sepsis (a life-threatening blood infection) to help increase their caloric intake. The DON stated if the resident was not getting their fortified diet, the residents would not be getting their required nutrition and would continue to lost weight. The DON stated the staff would need to be educated that the added items (butter, milk) on the trays were a part of the fortified diet. During a review of the facility's policy and procedures (P&P) titled, Therapeutic Diets dated 6/1/2014, the P&P indicated the purpose is to ensure that the Facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders. During a review of the facility's policy and procedures (P&P) titled, Fortification of Food: Increasing Calories And/or Protein in the Diet dated 2023, the P&P indicated Food & Nutrition Services staff will be familiar with the fortification process for each item chosen to be used at the facility. During a review of the facility's P&P titled, Staff Competency Validation dated 6/4/2024, the P&P indicated the purpose is to protect the health, safety, and well-being of residents. The policy did not indicate procedures to help staff identify items that are considered fortified items.

Based on interview and record review, the facility failed to ensure a qualified infection preventionist (IP) was designated and consistently provided oversite of the facility's infection Prevention and Control Program (IPCP).This failure had potential to compromise the identification, prevention, and control of infections and place resident at increased risk for the spread of infection.Findings:During a review of Previous Infection Preventionist Nurse (PIPN) 1, 2 and 3's employee files, undated, the employee files indicated the facility hadhired PIPN 1 on 2/3/2025 and demoted on 5/1/2026hired PIPN 2 on 4/20/2026 and terminated on 6/15/2026hired PIPN 3 on 6/29/2026 and terminated on 7/15/2026 During an interview on 8/11/2026 at 8:38 a.m. with the Administrator (ADMIN), the ADMIN stated the most recent PIPN 3 worked for approximately 20 days and then resigned. The ADMIN stated after the PIPN 3 resigned, the Director of Staff Development (DSD) and Infection Preventionist Nurse (IPN) served as interim IPs and performed the IP duties. The ADMIN stated unable to explain how the IP duties and responsibilities were divided between the DSD and the IPN.During an interview on 8/11/2026 at 9:40 a.m. with the IPN, the IPN stated during the period when the facility did not have a formally designated IP, the IPN and the DSD covered the IP role. The IPN stated the IPN only assisted as needed and did not perform the primary IP duties. The IPN stated the DSD was responsible for the facility's Infection Prevention and Control Program (IPCP) including monitoring infections, antibiotic use, tracking vaccinations, and ensuring appropriate infection-control precautions. The IPN stated the IPN's primary role during this period was as a Treatment Nurse and the IPN was officially appointed as the facility's IP the day before the interview.During a concurrent interview and record review on 8/11/2026 at 1:11 p.m. with the IPN, the DSD's qualification as IP, undated, was reviewed. The IPN stated no documentation was available to verify the DSD's qualifications to serve as the IP. The IPN stated the facility should have verified and maintained the documentation of the DSD's qualifications before assigning the DSD to perform the IP role. The IPN stated there was no documentation demonstrating the IPCP had been reviewed at least annually; infection surveillance logs, line lists, and infection maps were not consistently reviewed or kept current and lacked evidence of ongoing tracking, analysis, and interventions; and the IPN was unable to explain how infection trends and finding were reported to Quality Assessment and Assurance/Quality Assurance and Performance improvement program (QAA/QAPI -a data driven proactive approach to improvement used to ensure services are meeting quality standards). The IPN stated the IP responsibilities had not been consistently carried out due to frequent changes in management.During an interview on 8/13/2026 at 3:54 p.m. with the Director of Nursing (DON), the DON stated having a qualified infection preventionist (IP) was important to ensure proper oversite of the facility's Infection Prevention and Control Program (IPCP), prevent and control the spread of infection, and protect the facility's vulnerable and immunocompromised resident population.During a review of the facility's Job Description (JD) of the Infection Preventionist (IP), undated, the Job description indicated the IP serves as the facility's Infection Prevention and Control Officer, with oversight of the facility Infection Prevention and Control program. The JD also indicated the IP's specific education/Vocational requirements:The Infection Preventionist must be qualified by education, training, clinical or healthcare experience, or infection prevention and control certification.The IP must have completed Specialized Training in Infection Prevention and ControlThe IP must complete 10 Infection Prevention and Control CEUs annually to maintain knowledge, proficiency, and competency in the field after completing initial training.The IP must be employed full-time in the facilityThe JD indicated the IP's role included;providing oversight of the facility Infection Prevention and Control program activities with the goals of the program being: Monitor for evidence of infection /communicable disease implement appropriate control measures and identify and correct problems related to infection prevention and control practices.Providing ongoing monitoring to identify possible communicable diseases/infections before they can spread to others in the facility and to whom they should be reported.Maintaining records per regulatory requirements.Performing surveillance.Analyzing, identifying, and presenting facility trends/variances and developing plans in conjunction with the center QAPI process.Reporting Infections and Communicable Diseases as appropriate to local and/or state health department.

Based on observation, interview and record review the facility failed to ensure three of five sampled residents (Resident 107, 80, and 11) were provided with a therapeutic diet (a customized meal plan that controls the intake of specific foods or nutrients to treat, manage, or prevent a medical condition) as ordered by failing to ensure: 1. Resident 107 and Resident 80 were provided pureed broccoli with cheese per fortified diet (foods that have extra vitamins and minerals added to them to make them healthier) order.2. Resident 11 received minced and moist (soft, tender, and moist pieces) lunch as prescribed by physician. This deficient practice had the potential to prevent the residents from receiving the benefits of the therapeutic diet.Findings: a. During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), parkinsonism (any condition that causes slowed movement, tremors), and metabolic encephalopathy (brain malfunction caused by chemical imbalance or toxins in the blood when other parts of the body liver [large, reddish-brown organ in the upper right belly that cleans blood, produce digestive juices, and store energy] or kidney [(bean-shaped organ located in the back below the rib cage to filter blood, remove waste, and balance body fluids] was not working properly) During a review of Resident 107's history and physical (H&P) dated 9/18/2025, the H&P indicated Resident 107 had fluctuating capacity to understand and make decisions. During a review of Resident 107's Minimum Data Set (MDS, a resident assessment tool), dated 8/3/2026, the MDS indicated Resident 107 had moderate cognitive (ability to think and make decisions) impairment. The MDS indicated Resident 107 was dependent on facility staff for toileting hygiene, bathing, chair/bed-to-chair transfer, shower transfer, required substantial assistance (helper does more than half the effort) on facility staff for sit to lying, lying to sitting on side of bed, required supervision for upper (above waist) and lower (below waist) dressing, personal hygiene, roll left and right, and required setup for eating and oral hygiene. During a review of Resident 107's order summary dated 8/13/2026, the order summary indicated an order for a fortified diet, level four pureed (smooth, uniform texture requiring no chewing) texture dated 3/11/2026. During a review of the fortified lunch recipe and instructions for 8/13/2026, the instructions indicated to add an additional two teaspoons (tsp, unit of volume in cooking) shredded cheese to the broccoli. During a review for 8/13/2026's menu, the menu indicated glazed ham, potato medley, broccoli with tarragon, cornbread, and frosty sherbet square. During a concurrent observation and interview on 8/13/2026 at 11:28 a.m. with the Dietary Supervisor (DS), the DS stated Resident 107 was supposed to and did not have cheese in the pureed broccoli. b. During a review of Resident 80's admission Record, the admission Record indicated Resident 80 was admitted to the facility on [DATE] with diagnoses including dysphagia, dementia (a progressive state of decline in mental abilities), and malnutrition. During a review of Resident 80's H&P dated 6/27/2026, the H&P indicated Resident 80 lacked the capacity to make medical decisions. During a review of Resident 80's MDS, dated [DATE], the MDS indicated Resident 80 had moderate cognitive impairment. The MDS indicated Resident 80 was dependent on facility staff for the majority of activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and required substantial assistance on facility staff for upper body dressing, chair/bed-to-chair transfer, and sit to stand. During a review of Resident 80's order summary dated 8/13/2026, the order summary indicated an order for a regular standard portion diet, level four pureed texture, level two mildly thick consistency (thickened liquid that flows slower than regular liquids to help adults swallow safely), fortified dated 8/1/2026. During a concurrent observation and interview on 8/13/2026 at 11:30 a.m. with the DS, the DS stated Resident 80 was supposed to have cheese in the pureed broccoli for the fortified diet. During an observation on 8/13/2026 at 11:35 a.m., the fortified broccoli with cheese pureed was a light green color and did not appear to have cheese in or on it. c. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dysphagia, dementia, and encephalopathy (any damage or disease that affects the brain). During a review of Resident 11's H&P dated 12/5/2025, the H&P indicated Resident 11 did not have the capacity to understand and make decisions. During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 had moderate cognitive impairment. The MDS indicated Resident 11 was toileting hygiene, bathing, sit to lying, required substantial assistance on facility staff for oral hygiene, lower body dressing, personal hygiene, roll left and right, required partial assistance (helper does less than half the effort) on facility staff for upper body dressing, and supervision for eating. During a review of Resident 11's order summary dated 8/13/2026, the order summary indicated an order for a level five minced and moist, texture level zero, thin consistency (unthicken liquids that flow quickly and freely like water) dated 4/1/2026. During a concurrent observation and interview on 8/13/2026 at 12:42 p.m. with the DS, the DS stated Resident 11 was on a minced and moist diet. The DS stated aside from the glazed ham, the vegetables, mashed potatoes, and the corn bread on his plate were pureed. During an interview on 8/13/2026 at 1:00 p.m. with the DS, the DS stated residents that were on fortified diets did not get the pureed broccoli with cheese. The DS stated it was important to provide the residents with their fortified items to help them gain more calories or the residents would continue to lose weight. The DS stated for Resident 11's plate, three of the four textures were wrong and indicated Resident 11 should have gotten a minced and moist tray. The DS stated the specific textures were for the resident's safety to ensure they were able to swallow and chew to prevent choking from occurring. During an interview on 8/13/2026 at 3:09 p.m. with the Director of Nursing (DON), the DON stated that a fortified diet is a nutritiously enhanced diet for residents who are experiencing weight loss or who had sepsis (a life-threatening blood infection) to help increase their caloric intake. The DON stated if the resident is not getting their fortified diet, the residents will not be getting their required nutrition and would continue to lost weight. The DON stated giving a resident that has an order for a minced and moist but received a pureed diet is a downgrade and the doctor should be notified that they were given the wrong diet. During a review of the facility's policy and procedures (P&P) titled, Therapeutic Diets dated 6/1/2014, the P&P indicated the purpose is to ensure that the Facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders. Therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the Dietitian. The therapeutic diet will be reflected on the resident's tray card. The Dietary Manager and Dietitian will observe meal preparation and serving to ensure that: each food item, served separately in the regular diet, is pureed and served separately for a pureed diet according to the menu spreadsheet and puree recipes. During a review of the facility's policy and procedures (P&P) titled, Fortification of Food: Increasing Calories And/or Protein in the Diet dated 2023, the P&P indicated the enrichment of foods will be done on an individual basis for the residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. The goal is to increase the calorie and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutrition status. Identification of the residents in need of fortification will be done by the Facility Registered Dietician or the Food and Nutrition Services (FNS) Director. Residents considered will have demonstrated an inability to consume the amounts of foods required to prevent significant weight loss, skin breakdown, and/or loss of muscle mass. Calories and/or protein will be added to selected foods. Food & Nutrition Services staff will be familiar with the fortification process for each item chosen to be used at the facility. Residents usually eat the same amount of food whether it is fortified or not. Therefore, fortification should increase nutrient density without increasing the amount of food sent.

Based on interview, and record review, the facility failed to ensure the comprehensive care plans were implemented for three off four sampled residents when: A. Resident 2 was prescribed an anticoagulant (a medicine that slows down your body's process of making blood clots) and labs were not done prior to starting the medication or just after the medication was started to have baseline labs for blood thinning medications. B. Resident 4 had a physician order for a 1:1 sitter (staff assigned to provide continuous, direct, and uninterrupted supervision to a single resident who requires close monitoring for safety)at bedside to provide one on one observation. Resident 4 did not have a 1:1 sitter. C. Resident 12 had an intervention to administer an appetite stimulant to prevent further weight loss on 5/26/26.This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 2, Resident 4, and Resident 12.Findings: A.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including traumatic (caused by exterior blunt force) hemorrhage (bleeding) of left brain, gastrostomy tube (G-tube- a tube placed directly into the stomach for long-term feeding), tracheostomy (a tube placed into a surgically created hole through the front of the neck and into the windpipe-trachea), and anxiety (constantly feeling worried and nervous). During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool) dated 7/17/2026, the MDS indicated Resident 2 had severe cognitive (thinking process) impairment and was dependent (helper does all of the effort to complete the task) with self-care abilities such as hygiene, showers and dressing. The MDS indicated Resident 2 was dependent on mobility such as rolling and shower transfers. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated heparin sodium injection solution (a prescription anticoagulant blood thinner medication used to prevent and treat dangerous blood clots in veins, arteries, or the lungs) 5000 units/milliliter (u/mL, a units of measurement) inject 1 mL subcutaneously (medication introduced under the skin) three times a day for deep vein thrombosis ([DVT], a serious condition where a blood clot forms in a deep vein in the body, most often in the lower leg, thigh, or pelvis) prophylaxis rotate injection sites ordered on 7/16/2026. During a review of Resident 2's care plan titled, Resident was on anticoagulant therapy for DVT prophylaxis dated 7/11/2026, the care plan indicated a focus that resident at risk for bleeding with goal to be free from discomfort or adverse reactions related to anticoagulant use through the review date and interventions of laboratory tests as ordered and report any abnormal lab results to medical doctor (MD). During a review of Resident 2's Lab Results Report, the Lab Results Report did not indicate a lab testing to check if the blood levels were within normal range before starting one on blood thinning medication such as platelets ([PLT], measures the number of tiny cell fragments in your blood that help form clots to stop bleeding), prothrombin time test ([PT], a blood test that measures how many seconds it takes for your blood to form a clot), a partial thromboplastin time test ([PTT], a blood test measures the time in seconds it takes for your blood to form a clot), and international normalized ratio test ([INR], a blood test that measures how long it takes your blood to form a clot). During a concurrent interview and record review on 8/13/2026 at 2:12 p.m. with the MDS Registered Nurse (MDSRN), the care plan dated 7/11/2026 and lab results report were reviewed. The MDSRN stated for heparin medication, there should be a PT/PTT/INR lab done prior to starting the medication because if the resident gets injured, the resident can experience uncontrolled bleeding. The MDSRN stated a care plan was the basis for the plan of care for residents and how the care was provided for the residents. The MDSRN stated the care plan was developed but not all of the interventions were implemented. The MDSRN stated labs were not done as indicated in the interventions and that the facility just continued heparin injection from the general acute care hospital (GACH) when she was admitted to the facility. The MDSRN stated the facility continued orders for heparin from GACH but stated the facility should have labs done for residents so the facility can get a baseline labs to make sure PT/PTT/INR are normal and if there are any changes, the facility are aware. During a concurrent interview and record review on 8/13/2026 at 2:37 p.m. with the Director of Nursing (DON), the care plan dated 7/11/2026 and lab results report were reviewed. The DON stated a care plan was important because it was for facility staff to individualize the residents' care because not all residents are the same. The DON stated the care plan should have been implemented and the labs should have been done. The DON stated no labs were done when heparin was continued in the facility from the GACH. The DON stated the labs were important when an individual was started on heparin medication because the labs will indicate the possibility of bleeding if the levels were below a certain number. The DON stated the facility needed baseline labs to see where the residents were at in their blood levels and if there were any changes from the baseline, it can be addressed. During a review of the facility's policy and procedures (P&P) titled Person-Centered Care Planning, dated 5/22/2025, indicated the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well­being. comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment. B. During a review of Resident 4's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 8/11/2026, the Face Sheet indicated the facility admitted Resident 4 on 5/22/2026 with diagnoses including acute respiratory failure (a serious medical emergency where the lungs suddenly cannot get enough oxygen into the blood or get rid of enough carbon dioxide), gastrostomy (G-Tube - a minor surgery that creates a small opening through the abdomen into the stomach for placement of a feeding tube), tracheostomy (a surgical procedure of cutting an opening into the windpipe through the neck for placement of a tube to assist breathing), and history of methicillin resistant staphylococcus aureus infection (MRSA – a type of bacteria that cannot be killed by many common antibiotics). During a review of Resident 4's History and Physical (H&P) dated 5/23/2026, the H&P indicated Resident 4's ability to think or make decisions was mildly impaired. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was dependent on staff with oral hygiene, toileting hygiene, showering or bathing, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. During a review of Resident 4's Order Summary Report (a list of active physician orders) dated 8/11/2026, the Order Summary Report indicated a physician's order for a 1:1 sitter at bedside to provide one-on-one observation for the resident. During a review of Resident 4's Care Plan Report revised on 6/10/2026, the Care Plan Report indicated Resident 4 was at risk for falls related to confusion, gait or balance problems, hypotension, incontinence (loss of voluntary control of urination and bowel movements), poor communication or comprehension, unaware of safety needs, shaking and tremors, at risk for harm or injury. The Care Plan Report indicated 1:1 sitter at bedside to provide one on one observation for the resident. During a concurrent observation, interview and record review on 8/11/2026 at 12:56 p.m. with Infection Preventionist Nurse (IPN), Resident 4's room was observed and Resident 4's physician order dated 5/22/2026 and care plan revised 6/10/2026 were reviewed. The IPN stated there was no sitter at Resident 4's bedside. The IPN stated Resident 4's physician order dated 5/22/2026 indicated 1:1 sitter at bedside to provide one-on-one observation for the resident. The IPN stated Resident 4's care plan indicated 1:1 sitter at bedside to provide one on one observation for the resident. The IPN stated the importance of having a sitter at bedside as indicated in Resident 4's care plan was to ensure Resident 4's safety. The IPN stated not having a sitter at bedside would increase Resident 4's risk for potential fall and injury. During an interview on 8/13/2026 at 2:42 p.m. with the DON, the DON stated the importance of following Resident 4's care plan for providing a 1:1 sitter at bedside was to ensure Resident 4's safety. The DON stated if Resident 4's care plan was not followed and Resident 4 was not provided a sitter at bedside, Resident 4 was at an increased risk for falls, injuries, and accidental dislodgement of medical devices. During a review of the facility's P&P titled P-NP04 Person-Centered Care Planning revised 4/24/2025, the P&P indicated interventions are actions, treatments, procedures, or activities designed to meet an objective. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. C. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including moderate protein-calorie malnutrition (insufficient nutrients to sustain normal body functions), and noninfective gastroenteritis and colitis (when the stomach and intestines get red, swollen, and sore due to certain allergies, foods, and medications). During a review of Resident 12's Nutritional Risk assessment dated [DATE], the nutritional risk assessment indicated interventions for Resident 12 as follow: continue food preference accommodation to improve intake, consider appetite stimulant if oral (PO) intake remains poor. During a review of Resident 12's H&P dated 6/2/2026, the H&P indicated Resident 12 could make decisions for activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 was cognitively intact. The MDS indicated Resident 12 was dependent on staff for toileting hygiene, bathing, lower body (below waist) dressing, shower transfer, required substantial assistance (helper does more than half the effort) for rolling left and right, sit to lying, required partial assistance (helper does less than half the effort) for upper body (above waist) dressing, and required supervision for eating, oral hygiene, and personal hygiene. During a review of Resident 12's care plan, titled, Resident continues to trigger for significant weight loss related to decreased oral (PO) intake, ongoing acute and chronic illness burden, fluctuating appetite, and resident being a very selective eater with limited food acceptance, resulting in increased risk for nutritional decline, weakness, dehydration, and further weight loss, dated 5/26/2026. The care plan interventions indicated to administer appetite stimulants and other medications as ordered, dated 5/26/2026. During a concurrent interview and record review on 8/13/2026 at 9:54 a.m. with the Minimum Data Set Registered Nurse (MDSRN), the MDSRN stated there were no orders placed for appetite stimulates for the appetite stimulant intervention on the care plan dated 5/26/2026. The MDSRN stated interventions are placed for the problems identified and indicated if it was on the care plan, it should be implemented and followed. The MDSRN stated if the care plan was not followed, the facility would not be able to provide the proper care to address the concern. During an interview on 8/13/2026 at 3:24 p.m. with the DON, the DON stated a care plan was a continuation of care and must be followed. The DON stated if there was an intervention that was not followed, then it should be updated and the rational for not carrying out the intervention should be documented. The DON stated not following the care plan would result in further weight loss. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning dated 9/7/2023, the P&P indicated the Facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. During a review of the facility's P&P titled, Person-Centered Care Planning dated 5/22/2025, the P&P indicated interventions are actions, treatments, procedures, or activities designed to meet an objective. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to store and handle food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 107 out of the 117 residents in the facility by failing to 1. Ensure food items in the freezer were dated.2. Ensure damaged items were discarded and food items were dated in the dry storage.3. Ensure the food temperature was within the recommended temperatures during tray line.This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and could lead to other serious medical complications and hospitalization. Findings:During a concurrent observation on 8/10/2026 at 8:20 a.m. with Dietary Aid (DA) 1, DA 1 stated in the three door freezer, there were frozen broccoli that were not labeled.During a concurrent observation on 8/10/2026 at 8:42 a.m. with the Dietary Supervisor (DS), there was a dry milk bag sitting on top of a tray that had a hole on the left side of the bottom corner with the contents spilled out into the dry storage room.During a concurrent observation on 8/10/2026 at 8:45 a.m. with the DS, there was a container of reduced calorie chocolate instant pudding mix with no dates (received date, use by date) labeled in the dry storage room.During a concurrent observation and interview on 8/10/2026 at 8:47 a.m. with the DS, there were three boxes of baking soda that were damaged and had water stains in the dry storage room. The DS stated it was important to date and label food items to ensure the kitchen does not provide the residents with spoiled and expired items. The DS stated if there were no labels, the kitchen won't know when the food items were received, providing residents with food that had expired, which could cause food borne illness to the residents. The DS stated they remove damaged items from the storage as it carries bacteria, was a physical contaminant, and opened items could attract rodents and pests. During a review of the facility's policy and procedures (P&P) titled, Food Storage and Handling, effective date 6/4/2024, the P&P indicated Dry Storage Area: label and date all storage products. The P&P did not indicate frozen vegetable storage should be labeled and to discard items that are damaged and unlabeled. During a review of the facility's P&P titled, Dietary Department-Infection Control, effective date 6/4/2024, the P&P indicated the purpose of the policy is to ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for one of five sampled residents by failing to identify and remove a lighter from Resident 20, who required supervised smoking.This failure had the potential to result in accidents or injury to Resident 20, as well as all residents, staff and visitors in the facility. Findings:During a review of Resident 20's admission Record, the admission Record indicated the facility admitted the resident on 10/7/2024 with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), interstitial pulmonary disease (a group of lung conditions that cause inflammation and scarring of the thin tissue between the air sacs in your lungs) and multiple fractures (broken bone) of ribs.During a review of Resident 20's History and Physical (H&P), dated 10/28/2025, the H&P indicated the resident had fluctuating capacity to understand and make decisions.During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated 6/30/2026, the MDS indicated the resident's cognition (to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 20 required setup assistance (helper sets up or clean up) with eating, oral hygiene, personal hygiene, supervision assistance (helper provides verbal cues and/ or touching/ steadying and/or contact guard assistance as resident completes activity) with toileting hygiene, and showering.During a review of Resident 20's Care Plan titled, At risk for injury/harm, revised 12/30/2025, the Care Plan's intervention included the resident's smoking supplies were stored in the activity department.During a concurrent observation and interview on 8/10/2026 at 12:17 p.m. with Resident 20 in the patio, a yellow lighter was observed on the resident's wheelchair while the resident was resting in a chair on the patio. Resident 20 stated the resident kept his cigarettes in the room, used the lighter to light a cigarette and smoked in the resident's room. Resident 20 stated he has had this lighter in his possession possessed since admission.During a concurrent observation and interview on 8/10/2026 at 12:29 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 observed Resident 20's wheelchair and noted the yellow lighter on the wheelchair. During a concurrent interview and record review on 8/12/2026 at 9:15 a.m. with the Activity Director (AD), Resident 20's Smoking and Safety, dated 7/10/2025 was reviewed. The AD stated Resident 20 was assessed as needing supervision when smoking the IDT recommended supervised smoking for safety. The AD stated facility stored smoking supplies in the activity department and required Resident 20 to surrender smoking supplies. The AD stated facility did not permit Resident 20 to keep a lighter in his possession.During an interview on 8/13/26 at 3:54 p.m. with the Director of Nursing (DON), the DON stated the facility should remove the resident's lighter and ensure proper supervision during smoking. The DON stated staff should screen the resident's belongings for hazardous items that could cause injury or accidents and maintain a safe environment.During a review of the facility's policy and procedure (P&P) titled Smoking Residents, revised 7/27/2023, the P&P indicated the facilities that accommodate residents who smoke will take reasonable precautions by providing a safe environment and protecting the non-smoking residents to provide a safe environment for residents, staff, and visitors.

Based on the interview and record review, the facility failed to ensure blood pressure was not obtained from the arm with an arteriovenous shunt (AV shunt, a surgically created connection between blood vessels to facilitate hemodialysis [a medical treatment that filters waste and excess fluids from the blood when the kidneys can no longer perform this function effectively]) for one of two sampled residents (Resident 83).This failure had the potential to compromise the access of the AV shunt and result in injury or complications to the resident.Findings:During a review of Resident 83's admission Record, the admission Record indicated the facility admitted the resident on 3/22/2017 and readmitted on [DATE] with diagnoses including chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood), severe obesity (having an unusually high amount of body fat), and gout (a common and complex form of arthritis characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in one or more joints).During a review of Resident 83's History and Physical (H&P), dated 7/11/2022, the H&P indicated, the resident did not have the ability to understand and make decisions.During a review of Resident 83's Minimum Data Set (MDS- a resident assessment tool), dated 7/23/2026, the MDS indicated Resident 83 required setup assistance (helper sets up or clean up) with eating, oral hygiene, personal hygiene, maximal assistance (helper does more than half the effort to complete task) with toileting hygiene, and showering.During a review of Resident 83's Order Summary Report, orders as of 8/14/2026, the Order Summary Report indicated not to take blood pressure, no injections, no constrictive clothing to left upper extremity due to left upper arm AV shunt since 3/9/2026.During a review of Resident 83's Care Plan titled Dialysis Therapy, revised 2/25/2026, the care plan's interventions included not to take blood pressure on Resident 83's left arm due to the AV shunt on left upper arm.During a concurrent interview and record review on 8/13/2026 at 9:25 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 83's Weights and Vitals Summary, for the month of August 2026 was reviewed. LVN 2 stated staff obtained blood pressure measurements multiple times from the arm with the AV shunt on 8/1/2026 at 4:24 a.m., 8/2/2026 at 9:47 a.m., 8/3/2026 at 7:00 a.m., 8/3/2026 at 5:45 p.m., 8/4/2026 at 7:36 a.m., 8/4/2026 at 6:23 p.m., 8/5/2026 5:14 p.m., 8/9/2026 at 5:14 p.m., 8/11/2026 at 9:39 a.m., and 8/12/2026 at 10:33 a.m., despite the physician's order and care plan indicating blood pressure measurements were contraindicated on that arm. LVN 2 stated obtaining blood pressure from the affected arm could damage and compromise the AV shunt.During an interview on 8/13/2026 at 3:54 p.m. with the Director of Nursing (DON), the DON stated staff should not obtain blood pressure measurements from the arm with the AV shunt to prevent injury to the AV shunt.During a review of the facility's Policy and Procedure (P&P) titled Dialysis Management, revised 1/25/2024, the P&P indicated no blood pressure, phlebotomy, or other pressure inducing procedures on the arm with an AV shunt.

Based on interview and record review the facility failed to maintain complete and accurate Medication Administration Records (MAR) for one of eight sampled residents (Resident 11) when multiple entries observed as blank were subsequently completed after the initial record review.This failure had the potential to result in inaccurate clinical information and affect the accuracy and continuity of care.Findings:During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 4/14/2015, and readmitted on [DATE] with diagnoses including encephalopathy (any damage or disease that affects the brain), altered mental status (any change in a person's normal cognitive function, awareness, or behavior, ranging from mild confusion to complete unresponsiveness) and unspecified psychosis (a mental condition where a person has trouble telling what is real from what is not).During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool), dated 7/1/2026, the MDS indicated Resident 11's cognition (to think, pay attention, process information, and remember things) was severely impaired. The MDS indicated Resident 11 required Supervision assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance) with eating, maximal assistance (helper does more than half the effort to complete task) with oral hygiene, personal hygiene and dependent (helper does all effort) with toileting hygiene, and showering.During a review of Resident 11's MAR on 8/12/2026 at 10:54 a.m., the following multiple entries were observed to be blank indicating the tasks were not completed:Monitor for pain and chart intensity of pain using 1-10 numeric pain scales (tool to gauge level of pain, 0-no pain to 10 unbearable pain) scheduled on 8/8/2026 at 3 p.m. Monitor for side effects of mirtazapine (antidepressant medication): dry mouth, blurred vision (eyes can't see things clearly), constipation (hard to poop), urinary retention (can't empty your bladder completely when you go to the toilet), hypotension (a condition where blood pressure is abnormally low), appetite changes, headache, insomnia (difficulty getting enough sleep or trouble sleeping without interruption), dyspepsia (indigestion), weight changes, scheduled on 8/8/2026 at 3 p.m.Monitor for side effects of risperidone (antipsychotic medication): stiffness of neck, confusion, muscle rigidity (stiff, firm, or unyielding), involuntary movements (a body movement that happens without thinking about it or deciding to do it), drooling (salivating), tremors (a shaking or trembling movement), restlessness (uneasy), sleep disturbance, dry mouth, blurred vision (your eyes can't focus sharply, so things look fuzzy or out of focus), constipation (infrequent bowel movements and difficulty passing stools), and sedation (when someone feels calm, relaxed, or sleepy because of a medicine called a sedative), scheduled on 8/8/2026 at 3 p.m.Monitor behavior: episode of schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by resistance to care, indicate the number of behavior occurrences, scheduled on 8/8/2026 at 3 p.m. During a concurrent interview and record review on 8/12/2026 at 12:05 p.m. with Registered Nurse Supervisor (RNS) 2, Resident 11's MAR, dated 8/8/2026 was reviewed. RNS 2 stated the previously blank MAR, now had information documented in it indicating those tasks were carried out. During a review of Medication Admin Audit Report on 8/12/2026 at 1:50 p.m. the Audit Report indicated Licensed Vocational Nurse (LVN) 9 entered the entries for 8/8/2026 at 3 p.m. on 8/12/2026 at 11:27 a.m. after the initial record review on 8/12/2026 at 10:54 a.m. There was no documentation indicating these were late entries.During an interview on 8/12/2026 at 2:01 p.m. with LVN 9, LVN 9 stated she completed the previously blank MAR monitoring entries five days later and was unable to independently recall the specific monitoring findings documented. LVN 9 stated the monitoring should have been documented at the time it was performed to ensure accuracy of the resident's clinical record.During a concurrent interview and record review on 8/12/2026 at 3:01 p.m. with RNS 4, Resident 11's MAR, dated 8/8/2026 and Progress Notes, dated 8/12/2026 were reviewed. RNS 4 stated the subsequently entered information was not identified as a late entry or addendum in the MAR or progress notes. RNS 4 stated timely and accurate documentation of medication-related monitoring, including target behaviors, adverse effects, and effectiveness, was important, particularly for antidepressant and antipsychotic medications. RNS 2 stated monitoring should be documented immediately after it is performed, and any laten entry or addendum should be clearly identified as such in the MAR or progress notes to maintain the accuracy and reliability of the resident's record.During an interview on 8/13/2026 at 3:54 p.m. with the Director of Nursing (DON), the DON stated documentation should be completed immediately after performing the task, especially when licensed staff were monitoring behaviors, adverse reactions, or side effects. The DON stated Documentation entered five days later was not considered timely or reliable. The DON stated if documentation must be added later, it should be clearly identified as a late entry. During a review of the facility's Policy and Procedure(P&P) titled Completion and Correction, dated 3/25/2026, the P&P indicatedAny person(s) making observations or rendering direct services to the resident will document in the medical record.Entries will be recorded in a timely manner and will be complete, legible, and accurate.Entries will be recorded in chronological sequence. When adding an entry at a later date, the entry is to be clearly identified as a late entry, using the appropriate date and time.Late entries should be documented as soon as possible.Any addendum or clarification entered into the medical record after the original documentation shall include the current date and time, be clearly designated as an addendum or clarification, reference the original entry, state the reason for the late entry, and identify any sources of information used to support the additional documentation.

Based on observation, interview and record review, the facility failed to ensure resident was treated with dignity and respect for one of four sample residents (Resident 50) bya. failing to maintain the resident's privacy and dignity when the resident was observed with the privacy curtain open and the private area exposed.b. failing to provide feeding assistance at the resident's eye level.This failure had the potential to negatively affect residents' dignity, privacy, and quality of life.Findings:During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 10/31/2023, and readmitted on [DATE] with diagnoses including epilepsy (disorder that causes episodes of seizures or altered consciousness), gastrostomy status (a gastrostomy tube placed in their stomach through a small opening in the abdomen), cardiac arrhythmia (when your heat does not beat in a normal way, too fast, too slow, or in an irregular pattern).During a review of Resident 50's Minimum Data Set (MDS- a resident assessment tool), dated 5/25/2026, the MDS indicated the resident's cognition (functions your brain uses to think, pay attention, process information, and remember things) was severely impaired. The MDS indicated Resident 50 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, showering and personal hygiene.a. During a concurrent observation and interview on 8/10/2026 at 12:05 p.m. with Licensed Vocational Nurse (LVN) 10, from the hallway in front of Resident 50's room, the resident's privacy curtain was observed open while the resident was lying in bed. Resident 50's adult briefs was partially open, exposing the left leg, a portion of the private area, and abdomen. There were multiple staff (unknown) passing through the hallway at the time. LVN 6 stated the resident was known to remove their adult briefs at times. LVN 6 acknowledged staff should have maintained the resident's privacy, including keeping the curtain closed, when necessary, to prevent exposure of Resident 50's private area and protect the resident's dignity.During a concurrent interview and record review on 8/12/2026 at 10:39 a.m. with Registered Nurse Supervisor (RNS) 2, Resident 50's Progress notes, for month of August 2026 and Care plan, as of 8/12/2026 were reviewed. RNS 2 stated there was no documentation indicating the resident removed the brief. RNS 2 stated staff should maintain the resident's privacy, including ensuring she wears pants or a brief, closing the curtain, and performing frequent checks to prevent exposure.During an interview on 8/13/2026 at 3:54 p.m. with the Director of Nursing, the DON stated the facility should maintain the resident's privacy and dignity when the resident was observed with the curtain open and the private area exposed and visible from the hallway. The facility should always honor and respect dignity and privacy.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 1/1/2012, the P&P indicated employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. The H&P also state and federal laws guarantee certain basic rights to all residents of the Facility. These rights include Privacy and confidentiality. b. During a concurrent observation and interview on 8/10/2026 at 12:48 p.m. with Certified Nursing Assistant (CNA) 3, in Resident 50's room, CNA 3 was observed standing at the resident's bedside while assisting the resident with drinking water. CNA 3 acknowledged staff should be seated while providing feeding assistance to maintain eye level.During an interview on 8/13/2026 at 3:54 p.m. with the DON, the DON stated staff should maintain eye level while assisting residents with feeding to promote dignity and comfort and to avoid making residents feel rushed during meals.During a review of the facility's P&P titled Resident Rights-Accommodation of Needs, revised 1/1/2012, the P&P indicated staff interacts with the residents in a way that accommodates the physical or sensory limitations of the residents, maintains each resident's dignity.During a review of the facility's P&P titled Feeding Assistance, dated 6/9/2026, the P&P indicated feeding will be provided in a respectful manner.

Based on interview and record review, the facility failed to ensure one of 13 sampled residents (Resident 54) had a completed Advance Directives ([AD]-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) correctly by failing to ensure Resident 54 had an AD acknowledgement form. These failures had the potential to result in care being provided that was inconsistent with the residents' wishes and could compromise the residents' rights to make decisions regarding their medical care during emergencies, end of life, and changes in condition.Findings: During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus (medical condition where a physical blockage traps fluid inside the brain) anoxic (condition where there are no oxygen) brain damage, and cognitive communication deficit. During a review of Resident 54's Minimum Data Set (MDS, a resident assessment tool), dated 7/10/2026, the MDS indicated Resident 54 had moderate cognitive (ability to think and make decisions) impairment. The MDS indicated Resident 54 was dependent on facility staff for all aspects of activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 54's history and physical (H&P) dated 7/31/2026, the H&P indicated Resident 54 could make needs known but cannot make medical decisions. During a review of the Interdisciplinary (IDT resident's health care team consisting of various specialties) Care Conference notes dated 7/9/2026 at 9:00 a.m., the IDT Care Conference notes indicated Resident 54's representative was on the phone during the care meeting, and was available to make a decision regarding Resident 54's AD. The IDT Care Conference notes indicated the AD was offered to Resident 54. The IDT Care Conference notes indicated Resident 54 was unable to formulate an AD due to cognitive impairment. During a review of the Social Service Progress Note dated 7/10/2026 at 11:20 a.m., the social service progress note indicated Resident 54 was provided education on their right to formulate an AD (brochure provided), and the resident does not have an AD and is unable to formulate due to impaired cognition. During a concurrent interview and record review on 8/13/2026 at 3:04 p.m. with the Director of Nursing (DON), the Social Service Progress Note dated 7/10/2026 at 11:20 a.m. was reviewed. The DON stated the social service progress note for Resident 54 dated 7/10/2026 indicated Resident 54 that had impaired cognition was educated was educated about formulating an AD. The DON stated it was important to educate the correct individual (Resident 54's representative) to ensure the plan of care being presented was understood. The DON stated if the resident's representative was not educated, the facility may not be able to meet their AD needs. The DON stated if a resident/representative does not formulate an AD after being educated, it should be documented that they refused on the progress note or on the IDT meeting notes. During a review of the facility's policy and procedures (P&P) titled, Advance Directive, effective date 7/31/2024, the P&P indicated upon admission, the Admissions Staff or Designee will provide written information to the resident concerning his or her right to make decisions concerning medical care; including the right to accept of refuse medical or surgical treatment, and the right to formulate advance directives. The Interdisciplinary Team will periodically review the Advance Directive, if applicable, with the resident or resident representative, to ensure that it still reflects the resident's wishes. The P&P did not indicate procedures for how the facility will obtain Advance Directives for residents who do not have the capacity to make decisions for themselves.

Based on observation, interview, and record review the facility failed to ensure one of one resident observed for privacy (Resident 91)'s electronic medical record was secured and was not easily accessible to unauthorized individuals.This deficient practice had the potential to compromise Resident 91's privacy and confidentiality by allowing unauthorized individuals access to Resident 91's protected health information.Findings:During an observation on 8/11/2026 at 2:24 p.m. near room [ROOM NUMBER], a medication cart with a laptop computer displaying Resident 91's Medication Administration Record (MAR) was left unattended.During a review of Resident 91's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 8/11/2026, the Face Sheet indicated the facility admitted Resident 91 on 6/23/2026 with diagnosis including urinary tract infection (infection occurring within the urinary system), chronic obstructive pulmonary disease (COPD - a long-term medical condition making it harder to get air out of the lungs), and muscle weakness.During a review of Resident 91's History and Physical (H&P) dated 6/24/2026, the H&P indicated Resident 91 had fluctuating capacity to understand and make decisions.During a review of Resident 91's Minimum Data Set (MDS - a resident assessment tool) dated 7/11/2026, the MDS indicated Resident 91 was dependent on staff with toileting hygiene, showering or bathing, lower body dressing, and putting on or taking off footwear. The MDS indicated Resident 91 needed maximum (helper does more than half the effort to complete the activity) staff assistance with upper body dressing. The MDS indicated Resident 91 needed moderate (helper does less than half the effort to complete the activity) staff assistance with oral hygiene and personal hygiene. The MDS indicated Resident 91 needed set-up assistance from staff with eating.During a concurrent observation and interview on 8/11/2026 at 2:25 p.m. with the Staffing Coordinator (SC), the medication cart with the unattended laptop computer was observed. The SC stated the laptop computer displayed Resident 91's MAR. The SC stated laptop computers should be closed or logged off to protect residents' privacy. The SC stated if laptop computers were not closed or logged off, there would be potential for residents' health information to be exposed to unauthorized individuals.During an interview on 8/11/2026 at 2:50 p.m. with Licensed Vocational Nurse (LVN) 10, LVN 10 stated she should not have left the laptop computer with Resident 91's MAR open and unattended. LVN 10 stated it was important for the laptop computers to be logged off or closed to protect Resident 91's health information. LVN 10 stated there would be potential for Resident 91's health information to be exposed and easily accessible to unauthorized individuals.During a review of the facility's policy and procedures (P&P) titled Electronic Protected Health Information Security dated 12/1/2012, the P&P indicated II. Physical Safeguards A. The facility will work to locate terminals for access to ePHI in secure locations to prevent unauthorized access. i. Computers or other electronic devices will be located in areas that limit access to residents and visitors. ii. When possible, monitors should face away from public view. C. When not in use, laptops or other mobile electronic devices should be stored in a physically secure location.

Based on observation, interview, and record review the facility failed to ensure one of one resident observed for homelike environment (Resident 99) when Resident 99's wall molding panel located on the head of the bed was not broken and was securely attached to the wall.This deficient practice had the potential to affect Resident 99's safety and comfort and result in an environment that was not homelike.Findings:During an observation on 8/10/2026 at 10:20 a.m. in Resident 99's room, the wall near Resident 99's head of bed was observed. The wall molding was broken, loose, and had a nail protruding.During a review of Resident 99's Face Sheet (front page of the chart that contains a summary of basic information about the resident) dated 8/11/2026, the Face Sheet indicated the facility admitted Resident 99 on 7/17/2019 with diagnoses including muscle weakness, cerebral infarction (stroke - where a part of the brain dies due to a blood clot or blocked blood vessel which stops blood, oxygen, and food from circulating to the affected area), and dysphagia (difficulty swallowing)During a review of Resident 99's History and Physical (H&P) dated 4/2026, the H&P indicated Resident 99 did not have the capacity to understand or make decisions.During a review of Resident 99's Minimum Data Set (MDS - a resident assessment tool) dated 7/27/2026, the MDS indicated Resident 99's ability to think or make decisions was severely impaired. The MDS indicated Resident 99 needed maximum (helper does more than half the effort to complete the activity) assistance from staff with toileting hygiene, showering or bathing, lower body dressing and putting on or taking off footwear. The MDS indicated Resident 99 needed set-up or clean-up assistance from staff with eating, oral hygiene, upper body dressing, and personal hygiene.During a concurrent observation and interview on 8/10/2026 at 1:02 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 99's room, the wall molding by Resident 99's head of bed was observed. LVN 1 stated the molding was broken and was coming off the wall with a nail sticking out. LVN 1 stated the importance of maintaining Resident 99's room and environment was to ensure safety and for Resident 99 to have a homelike environment. LVN 1 stated if the room was not maintained, Resident 99 would feel like his room was not his home. LVN 1 stated the wall molding needed to be secured to ensure Resident 99's safety.During a concurrent observation on 8/11/2026 at 1:21 p.m. with the Director of Nursing (DON) in Resident 99's room, the wall molding panel by the head of the bed was observed. The DON stated the wall molding panel was broken and had a nail sticking out. The DON stated it was important to maintain Resident 99's room because the room was his home and the facility would want Resident 99 to feel safe and he was in his own home. The DON stated if Resident 99's room was not well maintained there would be potential for Resident 99 to feel as if he was living in an institution and he would not feel safe and comfortable.During a review of the facility's policy and procedures (P&P) titled Maintenance Service revised 1/1/2012, the P&P indicated II. Functions of the maintenance department may include, but are not limited to: . B. Maintaining the building in good repair and free from hazards.During a review of the facility's P&P titled Resident Rooms and Environment dated 1/1/2012, the P&P indicated The facility provides residents with a safe, clean, comfortable, and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences.

Based on observation, interview, and record review, the facility failed to ensure Resident 2, who had a left-hand mitten restraint (a large, padded glove placed on a patient's hand to prevent them from pulling out medical lines, tubes, or self-harming), had a physical restraint assessment done and signed informed consent prior to the implementation of the left-hand mitten restraint.This deficient practice had the potential to place Resident 2 at risk for decline in physical functioning, reduced hand mobility and loss of hand grip.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including traumatic (caused by external blunt force trauma) hemorrhage (uncontrolled bleeding) of left cerebrum (left side of the brain tissue), gastrostomy tube ([G-tube], a tube placed directly into the stomach for long-term feeding), tracheostomy ([trach], a tube placed into a surgically created hole through the front of the neck and into the windpipe, the trachea), and anxiety (constantly feeling worried and nervous).During a review of Resident 2's History and Physical (H&P), dated 7/15/2025, the H&P indicated Resident 2 lacked capacity to make medical decisions.During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool) dated 7/17/2026, the MDS indicated Resident 25's cognition (thinking process) was severely impaired and was dependent (helper does all the effort to complete the task) with self-care abilities such as hygiene, showers and dressing. The MDS indicated Resident 2 was dependent on facility staff for mobility such as rolling from side to side and shower transfers. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated to apply a left hand mitten to prevent manipulation of medical devices (G-tube and trach), may remove mitten during activities of daily living ([ADL], the fundamental self-care tasks that people do every day to live and care for themselves every two hours for fifteen minutes, assess skin integrity (the health, wholeness, and structural completeness of the skin) and circulation (the continuous movement of blood through a closed system or from place to place) changes, then re-apply, monitor for redness, skin breakdown, swelling or irritation and report to medical doctor (MD) for any abnormalities every two hours ordered on 7/11/2026.During a review of Resident 2's assessment documentation, it was noted that the facility did not conduct a physical restraint assessment prior to the application of the left-hand mitten restraint. There was no evidence that the facility evaluated the appropriateness of the restraint, considered less restrictive alternatives, or established protocols for monitoring the effectiveness and continued necessity of the restraint.During a review of Resident 2's Informed Consent Documentation, dated 8/12/2026 (32 days after the restraint had been applied), the informed consent documentation, indicated apply left hand mitten to prevent manipulation of medical device, may remove mittens during ADL's every two hours for fifteen minutes, assess for skin integrity and circulation changes, then reapply and monitor for redness, skin breakdown, swelling or irritation and report to medical doctor for any abnormalities every two hours. During an observation on 8/10/2026 at 11:16 a.m. in Resident 2's room, Resident 2 was resting in bed facing the window, her body was facing the window away from the door. Resident 2 had a left hand mitten on and was trying to touch the medical device she had on her neck. During a concurrent interview and record review on 8/12/2026 at 10:41 a.m. with the MDS Registered Nurse (MDSRN), the order summary report, restraint assessment documentation and informed consent were reviewed. The MDSRN stated the left-hand mitten restraint was started on Resident 2 because Resident 2 was trying to pull out her trach and G-tube. The MDSRN stated the physical restraint assessment was a form that indicated what the resident's orientation was, what are the physical functioning and behaviors were, why the physical restraint was needed, if least restrictive measures were implemented first to keep the resident safe prior to the implementation of a physical restraint. The MDSRN stated the physical restraint assessment was not done prior to the implementation of the soft hand mitten restraint. The MDSRN stated applying physical restraints on a resident prior to evaluation and assessment was taking away the resident's freedom of movement. The MDSRN stated informed consent was obtained on 8/12/2026. The MDSRN stated informed consent should have been obtained prior to implementation of the hand mittens. The MDSRN stated it was a violation of resident rights to apply hand mittens without getting informed consent. The MDSRN stated informed consent was obtained prior to providing services and devices that are not normal for an individual. The MDSRN stated all residents should be free from physical restraints unless deemed necessary.During a concurrent interview and record review on 8/13/2026 at 2:49 p.m. with the Director of Nursing (DON), the assessment documentation and informed consent dated 8/12/2026 were reviewed. The DON stated the hand mitten was initiated for safety of Resident 2 but that the facility should have done an initial physical restraint assessment to make sure it was appropriate for Resident 2. The DON stated applying a restraint without an assessment and informed consent prior was a violation of Resident 2's freedom and rights. The DON stated the facility should have gotten informed consent prior to continuing the use of the restraints from the GACH and to do an restraint assessment to make sure Resident 2 still needed the left-hand mitten. During a review of the facility's policy and procedures (P&P) titled Informed Consent, dated 1/3/2024, indicated informed consent must be obtained prior to the proposed treatment or procedure, where possible, consent should be obtained sufficiently in advance to allow the resident or their surrogate decision-maker time to consider and make an informed decision.During a review of the facility's P&P titled Restraints, dated 3/27/2024 indicated before any type of restraint is used, the Licensed Nurse will verify that the prescribing healthcare practitioner obtained informed consent from the resident/resident representative and has been documented in the resident's medical record. Once decision has been reached to use a restraint, a Licensed Nurse will complete the Physical Restraint Assessment, the Physical Restraint Assessment will be included in the resident's medical record.

Based on interview and record reviewed, the facility failed to ensure appropriate psychotropic (affects the mind, or mood) medication use by failing to identify a specific indication, monitoring target behaviors and adverse effects, and obtain informed consent for one of five sampled residents (Resident 11) prior to the renewal of a physicians order for risperidone (antipsychotic medication).This failure had the potential to result in unnecessary psychotropic medication use, unidentified adverse effects, and treatment without informed consent.Findings:During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 4/14/2015, and readmitted on [DATE] with diagnoses including encephalopathy (any damage or disease that affects the brain), altered mental status (any change in a person's normal awareness, or behavior, ranging from mild confusion to complete unresponsiveness) and unspecified psychosis (a mental condition where a person has trouble telling what is real from what is not).During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool), dated 7/1/2026, the MDS indicated Resident 11's cognition (think, pay attention, process information, and remember things) was severely impaired. The MDS indicated Resident 11 required Supervision assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance) with eating, maximal assistance (helper does more than half the effort to complete task) with oral hygiene, personal hygiene and dependent (helper does all effort) with toileting hygiene, and showering.During a review of Resident 11's Order Summary Report, orders as of 8/12/2026, the Order Summary Report indicatedStarting 3/24/2026, administer risperidone tablet 0.25miligrm (mg, a unit for weight) by mouth two times a day for schizophrenia (a brain condition that affects how a person thinks, feels, and behaves) manifested by resistance to care.Starting 4/30/2026, monitor behavior every shift: episode of schizophrenia manifested by resistance to care, indicate the number of behavior occurrences.Starting 4/30/2026, monitor for side effects of antipsychotic medication every shift; stiffness of neck, confusion, muscle rigidity (stiff, firm, or unyielding), involuntary movements (a body movement that happens without you thinking about it or deciding to do it), drooling (salivating), tremors (a shaking or trembling movement), restlessness (uneasy), sleep disturbance, dry mouth, blurred vision (your eyes can't see things clearly), constipation, and sedation, due to use of risperidone.During a concurrent interview and record review on 8/12/2026 at 12:05 p.m. with Registered Nurse Supervisor (RNS) 2, Resident 11's Order Summary Report, as of 8/12/2026, informed consent for the use of risperidone, undated, and Medication Administration Record (MAR), dated 8/8/2026 were reviewed. RNS 2 stated the indication for the use of risperidone (resistance to care) was not specific, and an informed consent was not obtained prior to renewing the medication. RNS 2 stated the medication order also required monitoring of the resident's target behaviors and any adverse effects from taking the medication was not documented on 8/8/2026 until 8/12/2026. RNS 2 stated the medication order should have been clarified, informed consent obtained prior to renewal, and the resident's behaviors and adverse effects monitored every day to ensure appropriate medication and resident safety.During an interview on 8/13/2026 at 3:54 p.m. with the interim Director of Nursing (DON), the DON stated, the facility should ensure psychotropic medications have a specific clinical indication, informed consent upon renewal, and appropriate monitoring of target behaviors and adverse effects. The DON stated this documentation is necessary to justify continued use of the medication and prevent unnecessary psychotropic medication use.During the review of the facility's policy and procedure (P&P) titled Informed Consent, revised 12/21/2023, the P&P indicated Except in emergencies, informed consent must be obtained prior to the proposed treatment or procedure.During the review of the facility's P&P titled Behavior/Psychoactive Medication Management, dated 1/30/2026, the P&P indicated any order for psychoactive medications must include a specific behavior manifestation. The residents will be observed and/or monitored for side effects, and adverse consequences, including sedation. All complications and side effects should be reported to the healthcare practitioner.

Based on interview and record review, the facility failed to ensure laboratory orders were carried out for the month of February and May 2026 for one out of five sampled residents (Resident 58). These deficient practices had the potential to prevent the resident from receiving safe and effective treatment and create complications related to their medications. Findings: During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that could affect thoughts, mood, and behavior), dementia (a progressive state of decline in mental abilities), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 58's Minimum Data Set (MDS, a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 58 had moderate cognitive (ability to think and make decisions) impairment. The MDS indicated Resident 58 required supervision for most activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and required set up for eating and oral hygiene. During a review of Resident 58's history and physical (H&P) dated 8/11/2026, the H&P indicated Resident 58 could make needs known but could not make medical decisions. During a review of Resident 58's order summary report, dated 8/13/2026, the order summary report indicated Resident 58's medications included Divalproex Sodium (brand name Depakote, medication that helps calm down overactive signals in the brain that were both a mood stabilizer and an anticonvulsant [prevent seizures]) oral tablet delayed release 250 milligram (mg, unit of mass) one tablet by mouth two times a day for bipolar disorder manifested by sudden outbursts of anger/irritability) dated 7/1/2025, and laboratory orders included complete blood count (CBC, routine lab test that measures the core types of cells in the blood: red blood cells [disk-shaped cells in your blood that carry oxygen from your lungs to the rest of your body], white blood cells [tiny body guards in blood that fight off germs like bacteria and viruses], and platelets [pieces of cells that stick together to stop you from bleeding), comprehensive metabolic panel (CMP, routine blood test that measures different values to check the body's fluid balance, blood sugar), Valproic Acid (checks how much of a specific medication was in a person's blood), Vitamin B 12 (measures how much of this vitamin was in the blood to build healthy red blood cells), Vitamin D (measures how much nutrient was in the body to keep the bones strong and healthy), folate level (measures how much this vitamin was in the blood to make healthy red blood cells) every second Tuesday of November, February, May, August ordered 11/10/2025. During a review of Resident 58's lab results report dated 11/12/2025, the labs indicated the valproic avid levels were low with 21.2 micrograms (mcg, tiny unit of weight) per milliliter (mL, unit of volume) with reference range of 50-100 mcg/mL. During a concurrent interview and record review on 8/13/2026 at 11:35 a.m. with the Minimum Data Set Registered Nurse (MDSRN), the MDSRN stated the order for the CBC, CMP, Valproic Acid, Vitamin B 12, Vitamin D, and Folate Level were standing orders and should have been done in February and May. During an interview on 8/13/2026 at 2:09 p.m. with the MDSRN, the MDSRN stated the last labs that were drawn for Resident 58 was in November 2025 and did not have any labs for February and May 2026. The MDSRN stated there was no documentation that indicated Resident 58 had refused labs for February and May. The MDSRN stated if a resident refuses labs, they would have to reoffer the labs the following day. The MDSRN stated labs were important to ensure the medication was working and indicated without labs, they would not know if the medication was being absorbed properly and was at a therapeutic level. The MDSRN stated they should follow doctors orders to know if those medications were appropriate for the resident or not and indicated orders were not carried out. The MDSRN stated not following doctors orders could put the resident at risk for side effects of the medication. During an interview on 8/13/2026 at 3:29 p.m. with the Director of Nursing (DON), the DON stated when there was an order for labs, it would be triggered on the Medication Administration Record (MAR, document used to track every medication administered) for residents who were on seizure medications (Depakote). The DON stated that without laboratory tests, staff cannot determine what was occurring within the resident and indicated medications were being administered without any evaluation of their effectiveness. The DON stated labs provide a picture of the residents health and indicated they would not know if the medication was at a therapeutic or toxic level for residents who were on these medications for behavioral management. During a review of the facility's policy and procedures (P&P) titled, Laboratory Services, revised date 1/1/2012, the P&P indicated the purpose was to ensure the provision of laboratory services as required for residents at the Facility. The Facility will provide laboratory services in an accurate and timely manner to meet the needs of residents per Attending Physician orders. Laboratory services will be provided when ordered by the Attending Physician.

Based on interview, and record review, the facility failed to ensure: 1. A ventilator assisted individual ([[NAME]] a person who relies on a medical device to completely or partially assist with their breathing) received appropriate airway management by ensuring the ventilator (a medical machine that helps or fully takes over the breathing process for a patient) was turned on after one of five sampled residents (Resident 1) was transported to her room following a shower. 2. A Respiratory Therapist ([RT] a specialized health professional who diagnoses, treats, and manages patients with breathing and cardiopulmonary disorders) was available to monitor and manage Resident 1's airway. As a result, Resident 1 was connected to a portable ventilator (Vent 2) on [DATE] at 8:53 a.m., and Vent 1 was powered down (turned off) at 8:55 a.m. While powered down, Vent 1 was not able to alert staff, via alarms, that Resident 1 was not being ventilated. From 10:37 a.m., through 11:08 a.m., both RTs (RT 1 and RT 2) were on meal breaks and not monitoring Resident 1. At 11:08 a.m., Resident 1 was found with an odd skin tone (orange), unresponsive (a patient who fails to react or respond to external stimuli, such as voice, touch, or pain), without pulses, or an oxygen saturation level ([O2 sat] a measurement of how much oxygen the blood is carrying as a percentage normal range from 92% to 100%), and was subsequently pronounced deceased at 11:45 a.m., by paramedics. These deficient practices resulted in Resident 1's death and placed seven other [NAME] at risk for inadequate airway support that could result in serious medical complications, including death. On [DATE] at 5:39 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM), the Director of Nursing (DON), the Regional Quality Management Consultant (RQMC), [NAME] President of Operations (VPO) 1, and VPO 2 due to the facility's failure to ensure Resident 1's airway was managed appropriately. An IJ Removal Plan ([IJRP] a plan to immediately correct the deficient practices) was immediately requested. On [DATE] the facility submitted an acceptable IJRP. After onsite verification of the IJRP's implementation through observation, interview, and record review, the IJ was removed on [DATE] at 3:09 p.m., in the presence of the ADM, the DON, the RQMC, and a Registered Nurse Consultant (RNC). Non-compliance of F695 remained at the scope and severity of G actual harm that is not Immediate Jeopardy. The IJRP included the following: Effective 7/7/ 2026, the facility implemented a standardized Shower/Disconnection Verification Log to ensure safe ventilator disconnect/reconnect practices for all ventilator-dependent residents requiring transport, showering, or any other clinically necessary ventilator transition. Upon completion of the shower or transport and immediately following reconnection to the resident's prescribed ventilator, the RT will complete the Shower/Disconnection Verification Log. As part of this process, the RT will perform and documents a standardized verification to confirm: a. The resident is connected to the prescribed ventilator. b. The ventilator is powered on and functioning properly. c. Prescribed ventilator settings are verified against the physician's orders. d. Ventilator tubing and all connections are secure. e. Ventilator alarms are active, functioning appropriately, and audible. f. The resident demonstrates appropriate chest rise, satisfactory oxygenation, and no signs of respiratory distress. Any concerns identified will be addressed immediately before the RT leaves the resident. The Shower/Disconnection Verification Logs will be reviewed daily for completeness and accuracy by the RT and/or RN Supervisor. Any identified omissions or deviations from the established process will be addressed immediately through corrective coaching, re-education, and competency validation as appropriate. Compliance trends and audit findings will also be reviewed during the facility's interdisciplinary clinical meetings with the DON and the Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) to identify opportunities for improvement, implement additional corrective actions as needed, and ensure sustained compliance with the revised ventilator disconnect/reconnect process. Effective [DATE], the facility implemented a new protocol requiring ventilator-dependent residents to remain connected to their assigned bedside ventilator during transport and showering using a dedicated rolling ventilator stand. The practice of transferring residents to a separate shower ventilator has been discontinued, reducing the risk associated with ventilator disconnects and reconnects. In addition, the facility implemented mandatory visual verification by the RT and nursing to confirm the resident remains connected to the prescribed ventilator, the ventilator is powered on and functioning properly, prescribed settings are verified, and the required Observation Log During Resident Showers and/or other transport is completed.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses including anoxic brain damage (an injury to the brain tissue caused by a complete lack of oxygen reaching the brain), tracheostomy (a surgically created opening in front of the neck leading directly into the windpipe to help a person breath), and was dependent on a respiratory ventilator. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had severe cognitive (a person's brain function, memory, and orientation) impairment. The MDS indicated Resident 1 was dependent on staff for activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician Orders dated [DATE], the Physician Orders indicated the following settings for Vent 1: 1. Synchronized Intermittent Mandatory Ventilation ([SIMV] a mode that delivers mandatory breaths per minute but synchronizes with the patient's breathing efforts, allowing them to take extra, pressure-supported breaths on their own) 16 mandatory breaths per minute by the machine, 2. Tidal Volume ([TV] amount of air delivered per an adult respiratory cycle) of 450 milliliters ([ml] a unit of measurement) 3. Positive End-Expiratory Pressure ([PEEP] the amount of positive pressure maintained in the lungs at the end of a breath) +5 4. Pressure Support ([PS] delivery of a fixed amount of positive pressure to augment the patient's own respiratory effort) 15. During a review of Resident 1's Respiratory Equipment Log (a tracking document to record critical data regarding the usage, maintenance, and clinical performance of a mechanical ventilator) dated 6/2026, the Respiratory Equipment log indicated on [DATE] Resident 1 was assigned Vent 1. During a review of Resident 1's Ventilator Usage Report (a summary generated by or for a mechanical ventilator that details how long, how often, and under what settings the machine was used) dated [DATE], the Ventilator Usage Report indicated Vent 2 was powered on at 8:53 a.m., and powered off at 9:08 a.m. During a review of Resident 1's Ventilator Usage Report dated [DATE], the Ventilator Usage Report indicated Vent 1 was powered off at 8:55 a.m., and was not powered on until 11:09 a.m. During a review of Resident 1's Alert Compliance Monitoring Report (a clinical or operational document that tracks how often and how quickly healthcare staff respond to critical mechanical ventilator alarms), dated [DATE], the Alert Compliance Monitoring Report indicated there were no activity alerts on Vent 1 for Resident 1 on [DATE] between 9:02 a.m. and 11:10 a.m. During a review of RT 1's Timecard Report dated [DATE], the Timecard Report indicated RT 1 went on meal break from 10:37 a.m., to 11:07 a.m. During a review of RT 2's Timecard Report dated [DATE], the Timecard Report indicated RT 2 went on meal break from 10:30 a.m., to 11 a.m. During a review of Resident 1's RT Progress Note, dated [DATE] and timed at 1:28 p.m., the RT Progress Note indicated at 11:09 a.m., RT 1 entered Resident 1's room to administer a breathing treatment when Resident 1 was noted with a change in skin color. RT 1 checked Resident 1's O2 sat (there was no O2 sat level), suctioned Resident 1's airway (via her tracheostomy), and found Resident 1 with no pulse. During a review of Resident 1's Ventilator Operation Verification Report (a document verifying a mechanical ventilator has passed its pre-use, diagnostic, or maintenance tests), dated [DATE], the Ventilator Operation Verification Report indicated Vent 1 successfully passed its mechanical operation, functionality, and internal event history. There were no mechanical defects or operational malfunctions identified. Vent 1 successfully passed all required operational tests and was functioning within the manufacture's specifications at the time of inspection. Vent 1's internal event lots and trend data were retrieved and reviewed and indicated the software maintained an internal record of operational events, alarms, setting changes, and system activity. Vent 1's records were automatically generated by the device and were designed to provide an accurate historical account of the ventilator's operation in accordance with the manufacturer's software design and applicable Functional Difficulties Questionnaire ([FDQ] regulatory requirements for event logging and data retention. The Ventilator Operation Verification Report indicated Vent 1 was powered off on [DATE] from 8:55 a.m., until 11:08 a.m. Vent 1's trend data was consistent with the ventilator being powered off and not actively providing mechanical ventilation to Resident 1. During a review of the Paramedics Run Sheet (a legal and medical document used by emergency medical services to record all details of a prehospital emergency response. It tracks the patient's condition, treatments administered, and incident timelines from dispatch through hospital transfer), dated [DATE], the Paramedic Run Sheet indicated Resident 1 was pronounced dead on [DATE] at 11:45 a.m. During an interview on [DATE] at 9:20 a.m., RT 1 stated on [DATE] in the morning (time unknown) she and Certified Nursing Assistant (CNA) 1 transported Resident 1 to the facility's shower room using Vent 2. After the shower, CNA 1 and CNA 2 put Resident 1 in her bed and she (RT 1) reconnected Resident 1 to Vent 1. RT 1 stated she went to lunch at approximately 10:40 a.m., and after lunch, she entered Resident 1's room to administer Resident 1's breathing treatment at approximately 11:08 a.m. RT 1 stated she noticed Resident 1 looked discolored (orange) and when she looked at Vent 1 everything was running OK, but she observed Resident 1's eyes were not moving, so she suctioned her but Resident 1 had no gag reflex (an involuntary muscle contraction of the back of the throat). She then checked Resident 1's O2 sat and received an error reading, then noted Resident 1 was unresponsive and without a pulse. During an interview on [DATE] at 10:11 a.m., and a subsequent interview at 4:38 p.m., the DON stated ventilator alarms would not go off if the ventilator was not turned on. The DON stated after a resident was brought back from a shower the RT should have ensured the vent (Vent 1) was on and plugged in, the resident was connected to Vent 1, all settings were as ordered, and the resident was not in distress prior to leaving the resident. The DON stated if Vent 1 was not turned on, Resident 1 was not being ventilated and could die because Resident 1 was dependent on the ventilator to assist with her breathing. During an interview on [DATE] at 5:11 p.m., RT 2 stated on [DATE] when RT 1 went to lunch at approximately 10:47 a.m., she (RT 1) did not tell her (RT 2) she was leaving the floor and did not endorse Resident 1's care to her. RT 2 stated she did not see Resident 1 between 10:40 a.m. and 11:07 a.m. During a review of facility's Policy and Procedure (P/P) titled Ventilator Assessment and Management dated [DATE], the P/P indicated the Respiratory Care Practitioner or Registered Nurse assigned to the Resident must perform Visual ventilator checks every 2 hours, and perform the following: a. Assess the Resident for the need for oral or tracheal suctioning b. Assess the Resident's tolerance of the set (programmed) ventilator settings, c. Ensure proper and function and audibility of the ventilator alarms and eternal ventilator alarm, and d. Any ventilator set parameter changes, respiratory interventions, and outcome of performed interventions, e. Inspect ventilator tubing, humidification, and circuit connections for secure placement, kinks, or excess condensate.

Based on observations, interviews, and record reviews, the facility failed to ensure two out of five sampled residents (Resident 62 ,Resident 101 and Resident 80) received care and services to promote wound healing and to prevent new pressure injuries (PI: localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from occurring by: 1. Failing to initiate a wound treatment for Resident 62 when a change of condition (COC) was identified as a Stage III pressure injury (injury that extends through the skin into deeper tissue and fat)on 6/26/2025. 2. Failing to follow and implement the plan of care for repositioning every two (2) hours for Resident 62, Resident 101 and Resident 80. 3. Failing to provide offloading measures (refer to strategies used to reduce or redistribute pressure on specific parts of the body to prevent pressure injuries), such as a low air loss mattress (LAL- minimizing or removing weight to help prevent and heal ulcer) upon identification of the pressure ulcer in Resident 62 and Resident 101. 4. Failing to ensure the Registered Dietitian ([RD] nutrition specialist) reassessed and implemented nutritional interventions for Resident 62 and Resident 101. 5. Failing to ensure the interdisciplinary team (IDT: group of healthcare teams consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) met to discuss and develop appropriate wound healing interventions for Resident 62 and Resident 101. These deficient practices resulted in Resident 62, Resident 101's and Resident 80 preventable PI. Resident 62's right buttock redness progressed to a Stage III PI on 6/26/2025 with measurements of 2 centimeter (cm: unit of length) by (x) 2 cm (width) x 0.2 cm (depth). Resident 101 skin redness on the coccyx ( tailbone area) identified on 6/25/2025 progressed to an unstageable PI (base of the wound is unable to be determined due to the base of the wound covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) on 6/26/2025, measuring 0.5 cm long x 0.5cm width x 0 cm depth. Resident 101's PI was reclassified as a stage III PI, measuring 1 cm length x 1 cm width x 0.1 cm depth with 100 percent (%) granulation (new, red, bumpy, and moist connective tissue fills the wound bed).Findings: a. During a review of Resident 62's admission Record (Face Sheet), the admission Record indicated Resident 62 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), type II diabetes mellitus (DM: a chronic disease that affects how the body processes sugar), and dementia (a progressive state of decline in mental abilities). During a review of Resident 62's Minimum Data Set (MDS: a resident assessment tool), dated 6/25/2025, the MDS indicated Resident 62 was cognitively (mental action or process of acquiring knowledge and understanding ability) severely impaired. The MDS indicated Resident 62 was dependent on staff for chair/bed-to-chair transfer, shower transfer, toileting hygiene, bathing, upper (waist above) and lower (waist below) body dress, required moderate assistance (provides less than half the effort) for oral hygiene, and required supervision for eating. The MDS indicated Resident 62 was at risk for developing pressure ulcers/injuries with no indication of an active pressure ulcer/injury. The MDS indicated Resident 62 had other skin issues of Moisture Associated Skin Damage (MASD: moisture associated skin damage caused from prolonged exposure to moisture) and had skin and ulcer/injury treatments to provide nutrition or hydration intervention to manage skin problems and applications of ointments/medications other than to feet. During a record review of Resident 62's COC dated 6/25/2025 at 1:11 p.m., the COC indicated a Certified Nursing Assistant (CNA) was changing and cleaning Resident 62 when there was redness on the right buttocks and reported to Treatment Nurse 2 (TXN 2) The recommendation was to follow the facility protocol treatment for redness. During a record review of Resident 62's Braden Scale for Predicting Pressure Ulcer Risk evaluation (a tool designed to help healthcare providers assess the resident's risk for developing pressure injury), dated 6/25/2025 timed 3:08 pm, the Braden Scale indicated Resident 62 was at high risk (score range 10 to 12) for developing pressure ulcers with a score of 12. During a record review of Resident 62's wound assessment and plan visit dated 6/26/2025 indicated as Stage III pressure injury measured 2.0 cm length x 2.5 cm width x 0.2 cm depth. During a review of Resident 62's progress note dated 6/26/2025 timed 3:09 pm, the progress note indicated Resident 62's right buttock redness was re-classified to Stage III PI. The wound was acquired in-house (within the facility) on 6/26/2025 and the PI was staged by the Physician Assistant (PA) with measurements of 2 cm x 2 cm x 0.2 cm. The primary dressing is MediHoney gel with secondary dressing to offload pressure. During a record review of Resident 62's Treatment Administration Record (TAR: document that indicates the administration of treatments for residents) for 6/2025, the TAR indicated starting on 6/28/2025, for Right buttock PI: cleanse with NS (normal saline solution-a mixture of water and salt concentrate of 0.9 percent [%]), pat dry, apply Medical Honey (MediHoney: promote healing in wounds by creating a moist environment offering antimicrobial and anti-inflammatory effect) gel, cover with specialized foam dressing, every day shift for 30 days. During a review of Resident 62's care plan (CP) untitled dated 6/30/2025, the CP indicated stage III right buttocks PI with interventions to keep skin clean and dry, and moisturized, turn/reposition resident every 2 hours, and administer treatment per Medical Doctor (MD )order initiated on 6/30/2025. During a record review of the Nutrition/Dietary Note dated 7/22/2025 at 10:34 am, the nutrition/dietary note indicated Resident 62 had a Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) PI on the right buttocks with measurements of 1 cm x 1 cm x 0.1 cm. During an observation on 8/14/2025 at 8:52 am, Resident 62 was observed lying on her left side on a low air loss mattress (LAL) with a position pillow to her mid-back and buttocks area. Three linen sheets were placed under Resident 62's buttocks reducing air circulation. During an observation on 8/14/2025 at 9:50 am, Resident 62 was observed lying on her left side in the same position with the position pillow to the right buttock and three sheets underneath resident's buttocks. During a concurrent observation, interview and record review on 8/14/2025 at 3:49 pm, Resident 62's progress notes authored by LVN 5 were reviewed with Licensed Vocational Nurse (LVN) 4. LVN 4 stated, Resident 62's right buttock had been re-classified as a Stage III pressure ulcer on 6/25/2025. LVN 4 stated treatment was not implemented on the day the facility identified the acquired PI (on 6/25/2025). LVN 4 stated there was a change of condition (COC) on 6/25/2025, where redness to right buttock was identified, LVN 4 stated it was important to notify the wound doctor and Registered Dietitian (RD). LVN 4 stated that staff should reposition residents every 2 hours to relieve pressure from the affected areas. LVN 4 stated CNA's documentation of Resident 62's repositioning could not be locate in the Point of Care ([POC] section in the electronic medical records) . During the interview on 8/14/2024 at 3:49 pm, LVN 4 stated a Registered Dietitian did not address or re-assess Resident 62 until 7/22/2025 for the specified PI. LVN 4 stated the importance of RD nutritional assessment in addressing the nutritional or hydration needs of Resident 62. LVN 4 stated Resident 62 should be on low air loss mattress and it was not implemented when Stage III was identified. LVN 4 stated that staff should have used a low air loss mattress for Resident 62 immediately after identifying the Stage III pressure injury, but the facility did not provide the LAL until 23 days later. During the interview on 8/14/2024 at 3:49 pm, LVN 4 stated one sheet of linen should be used, and not 3 linens, as ample amounts of linen wound interfere with air circulation. LVN 4 stated there were 3 sheets under Resident 62's buttocks when she was pulled up (repositioned) in the morning. LVN 4 stated it is beneficial for residents to have low air mattresses and indicated it was not implemented as Resident 62 was combative and the facility should not have waited to provide the low air mattress despite Resident 62 being combative. During the interview on 8/14/2024 at 3:49 pm, LVN 4 stated the IDT did not evaluate Resident 62's PI until 7/20/2025, nearly a month after the PI was identified. LVN 4 stated IDT meetings are attended by the Director of Nursing (DON), TXN, Assistant Director of Nursing (ADON), and Social Service (SS), and the IDT meeting for Resident 62 should have been done within 48 hours of the identification of a new PI. LVN 4 stated a Braden Scale reassessment was not completed for Resident 62 when the PI was identified on 6/26/2025. During a concurrent interview and record review on 8/15/2025 at 8:21 am, Certified Nursing Assistant 4 (CNA 4) stated staff should reposition residents every 2 hours. CNA 4 mentioned that there was no documentation of repositioning on paper or in the POC. During an interview and record review on 8/15/2025 at 12:53 pm, with RD , RD stated Resident 62 was at nutritional risk and the resident's psychotropic medications (drugs that affect mental processes) could affect the weight and increased the risk of skin breakdown., RD stated almost a month after the PI was identified (on 6/26/2025) when RD assessed Resident 62 (on 7/22/2025). On 6/2025/25, RD stated there was no mention of specific PI treatments in the care plan. RD stated her involvement in Resident 62's care was important to promote faster wound healing. RD stated evaluation of the residents with PI should be conducted within 48 hours after the identification of a new PI for nutrition and hydration interventions. During a concurrent interview and record review on 8/15/2025 at 2:12 pm, the DON stated that care plans should be individualized for each resident. The DON said they (the facility in general) informed the family and involved them (the family) in the IDT, and the IDT team created the plan of care. The DON stted that the RD should be involved within 48 hours, and the care plan should be initiated and reflect the intended care. DON stated the IDT should meet with the residents within 72 hours if there is a COC. The DON stated care plan interventions should include repositioning the resident every 2 hours, providing low air loss(LAL) mattress, and avoiding putting on multiple sheets to the mattress, as it defeats the purpose of the airflow mattress. During the interview on 8/15/2025 at 2:12 pm, the DON stated a pressure injury is preventable if the residents care plans and assessments are done accordingly. The DON stated the facility cannot prove that Resident 62 was being repositioned since they do not document repositioning in the POC. The DON stated Resident 62 does not have a reassessment Braden Scale when it should have been done the day the pressure injury was discovered (on 6/26/2025). The DON stated when a pressure injury was identified on 6/26/2025 . The DON stated the low air loss mattress was ordered on 7/22/2025, almost a month after the identification of pressure injury. During a review of the facility's Policy & Procedure (P&P) titled, Skin Integrity Management revised on 6/27/2024, the P&P indicated facility will identify, evaluate, and intervene to prevent further pressure injury and/or heal pressure ulcers and any other skin integrity conditions. B. During a review of Resident 101's Face Sheet, the Face Sheet indicated Resident 101 was initially admitted to the facility 4/7/2020 and was readmitted on [DATE] with diagnoses of hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infection (stroke-blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left dominant side, g-tube, and type II DM. During a review of Resident 101's History and Physical (H&P), dated 12/22/2024, the H&P indicated Resident 101 does not have the capacity to understand and make decisions. During a review of Resident 101's MDS dated [DATE], the MDS indicated Resident 101's cognition was severely impaired. The MDS indicated Resident 101 is dependent on all aspects of performing activities of daily living (ADLs: activities such as bathing, dressing, personal/oral hygiene, and toileting). The MDS indicated Resident 101 has impairment on both sides of the upper and lower extremity. The MDS indicated Resident 101 had a Stage III PI with skin and ulcer/injury treatments of pressure reducing devices for bed, nutrition or hydration intervention to manage skin problems, and pressure ulcer/injury care. During a record review of Resident 101's COC dated 6/25/2025 at 11 am, the COC indicated TXN noted redness on Resident 101's coccyx. (commonly referred to as the tailbone) initial treatment was rendered, and the Nurse Practitioner (NP) was notified. During a review of Resident 101's COC dated 6/26/2025, the COC indicated upon reassessment with the wound care team and PA, the previously classified Stage I (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness)PI (appears as redness caused by prolonged pressure, often on a bony area) on the coccyx was classified as unstageable PI on 6/26/2025. During a review of Resident 101's CP titled Unstageable Pressure Injury dated 6/29/2025, the CP indicated repositioned Resident 101 every two hours. During a review of Resident 101's Wound Assessment and Plan dated 6/26/2025, the wound assessment and plan indicated it was an initial assessment, wound location: coccyx, unstageable PI (identified as Stage I in the COC) onset date 6/26/2025 with measurements of 0.5 cm x 0.5cm x 0 cm. The treatment order indicated to apply Medical Honey Gel-cleanse wound with normal saline or sterile water, apply to wound bed, and cover with dry clean dressing as instructed. During a review of Resident 101's Wound Assessment and Plan dated 7/2/2025 and 7/9/2025, the wound assessment and plan indicated wound location: sacrum (triangular bone at the base of the spine, just above the coccyx) and coccyx area, Stage III PI, onset date 9/11/2024, healing with measurements of 1 cm x 1 cm x 0.1 cm. The comment section indicated the wound was a re-ulceration (re-opening) of a previously healed Stage III PI. During a review of Nutritional Risk assessment dated [DATE] timed at 4:06 pm, the quarterly nutritional risk assessment indicated Resident 101 wound condition was reviewed with the wound IDT, the wound is a healing Stage III sacrum/coccyx PI, measuring 0.5 cm x 0.5 cm x 0.1 cm. During a concurrent interview and record review on 8/15/2025 at 9:10 a.m. with LVN 4, Resident 101's Braden Scale for 4/10/2025 and 7/15/2025 were reviewed. LVN stated Resident 101 was high risk for developing PI, LVN 4 stated Resident 101 score was 9 on 7/15/2025 and 13 on 4/10/2025. LVN 4 stated the Braden scale assessment should have been completed again upon the identification of the unstageable PI on 6/26/2025. During the interview and record review on 8/15/2025 at 9:10 am with LVN 4, Resident 101's Activities of daily living (ADL's-activities such as bathing, dressing and toileting a person performs daily ) , CP and COC were reviewed. LVN 4 stated the care plan dated 6/25/2025 indicated unstageable and redness at the coccyx. LVN 4 stated on 6/26/2025, the resident's Stage I PI was reclassified as an unstageable PI and is currently ongoing. LVN 4 stated on the CNA POC notes, there were no notes of repositioning. LVN 4 stated Resident 101's treatment started on 6/28/2025. LVN 4 stated an unstageable is defined as not knowing if the PI is Stage III or Stage IV (tissue loss exposing underlying structures such as muscle, bone, tendon, and cartilage) and an unstageable PI would warrant, at a minimum, a low air mattress, supplement, wound MD consultation, RD evaluation, lab, and regimented turning/repositioning at least every 2 hours. LVN 4 stated on 7/2/2025, Resident 101's PI was reclassified as Stage III, measuring 1 cm in length, 1cm in width, and 0.1 cm in depth, and the wound was noted to have 100% granulation. LVN 4 stated all PI were preventable if the residents were being turned. During the interview and record review on 8/15/2025 at 9:10 a.m. with LVN 4, Resident 101's ADL's, CP and COC was reviewed. LVN 4 stated the LAL was ordered on 7/18/2025, 22 days after Resident 101 PI was first identified. During the continued interview and record review on 8/15/2025 at 9:10 a.m. with LVN 4, Resident 101's labs (laboratory test) were reviewed and showed labs were done 5/2025. LVN 4 stated labs should have been ordered when the unstageable wound was identified on 6/26/2025, in order to identify nutritional needs and support wound healing. LVN 4 stated the albumin (protein in the blood) on 7/21/2025 was low 3.4 grams per deciliter (while 3.4 [g/dL, a unit of measurement]is within the lower end of the normal range [3.5 g/dl to 5.7 g/dl, it is a significant finding because low albumin is associated with poor wound healing, an increased risk of pressure ulcer development, and longer healing times. This suggests a need for careful assessment and potential nutritional interventions to support wound repair.). LVN 4 stated labs should have been ordered when the unstageable wound was identified on 6/26/2025. During the interview and record review on 8/15/2025 at 9:10 a.m. with LVN 4, Resident 101's IDT notes dated 7/20/2025 and 7/24/2025 and Resident 101's Nutritional Risk Assessment, 7/30/2025 were reviewed. The IDT notes indicated RD was not consulted in the IDT meetings for Resident 101. LVN 4 stated the RD evaluated Resident 101 on 7/30/2025, thirty-four days from the date the PI was identified. LVN 4 stated the RD documented Resident 101 was noted with increased wound healing needs and was currently on tube feeding (a medical method of delivering liquid nutrition directly into the stomach through a flexible tube) and supplements; and the current regimen only meet 91% of Resident 101's nutritional needs and 89% of fluid needs. The RD recommended increasing the tube feeding volume and water flushes to meet the needs and support wound healing. Jevity 1.5 (a calorically dense, fiber-fortified therapeutic nutritional formula designed for individuals who require tube feeding) was increased to 55 milliliters per hour (ml/hr, a unit of measurement) for 20 hours daily and free water was increased to 826 milliliters. The RD recommended to monitor labs until the levels become normal. During a concurrent interview and record review on 8/15/2025 at 9:10 a.m. with LVN 4, Resident 101's treatment records werereviewed. LVN 4 stated the treatments for Resident 101 were delayed. LVN 4 stated providing treatment to Resident 101 was important, to facilitate wound healing and to prevent complications. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning effective date 5/22/2025, the P&P indicated The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. During a review of the facility's P&P titled, Skin Integrity Management effective date 7/31/2024, the P&P indicated the facility will identify, evaluate, and intervene to prevent further pressure injury and/or heal pressure ulcers and any other skin integrity conditions. A plan of care will be developed to provide guidelines for the treatment of skin integrity conditions to facilitate healing. A licensed nurse will complete a skin evaluation when there is a change in skin integrity. A licensed nurse will complete the skin evaluation weekly. The physician and responsible party will be notified when there is a change in condition of the pressure injury or skin integrity condition. The dietary needs of the Resident will be evaluated by the registered dietitian upon any significant change in skin condition and any recommendations will be reviewed by the physician and orders obtained if appropriate. Interdisciplinary Team (IDT)/skin Committee will document discussion and recommendations for ski integrity issue. Review the residents' care plan and update as necessary. During a review of the facility's P&P titled, Evaluation of Weight and Nutritional Status effective date 2/20/2025, the P&P indicated the facility will maintain an acceptable nutritional status for residents per professional standards by analyzing the assessment information to identify the medical conditions, causes and/or problems related to the resident's condition and needs. Implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice. Developing interventions involving the resident and/or the resident representative to ensure the resident's needs, preferences and goals are accommodated. Monitoring and evaluating the resident's response, or the lack of response to interventions. In connection with the assessments mentioned above, IDT will further assess nutritional needs and goals of the resident within the context of his/her overall condition, including the following: mental health disorders, relevant conditions and diagnosis, and overall prognosis/condition. C. During a review of Resident 80's admission record, the admission record indicated Resident 80 was initially admitted to the facility on [DATE] with diagnoses including contractures (stiffening/shortening at any joint, that reduces the joint's range of motion) of the right and left elbow, myocardial infarction (MI-heart attack), and dementia (a progressive state of decline in mental abilities). During a review of Resident 80's History and Physical (H&P), dated 7/1/2025, the H&P indicated Resident 80 did not have the capacity to understand and make decisions. During a review of Resident 80's MDS, dated [DATE], the MDS indicated Resident 80 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment and was dependent on eating, toileting, bathing, and dressing. During a concurrent interview and record review with Treatment Nurse (TXN) 1 on 8/15/2025 7:19 a.m., Resident 80's medical record was reviewed. TXN 1 stated Resident 80 developed right buttock redness on 6/17/2025 which progressed to a stage 2 pressure injury (partial-thickness loss of skin, presenting as a shallow open sore or wound) on 6/29/2025. Resident 80's care plans indicated care plans were not revised until 6/27/2025. The care plan initiated for right buttock pressure injury initiated on 6/27/2025 indicated an intervention to reposition Resident 80 every two hours. TXN 1 stated a new care plan should have been initiated when Resident 80 developed the right buttock redness on 6/17/2025. TXN 1 stated there was no documentation indicating Resident 80 was repositioned every two hours. TXN 1 stated, if it is not charted that Resident 80 was repositioned every two hours, we do not know if the intervention was performed. During an interview with the DON on 8/15/2025 at 4 p.m., the DON stated the staff should update the care plan if there are changes and interventions should be documented. The DON stated repositioning a resident with a pressure injury every two hours could prevent the residents' wounds from declining. During a review of the facility's policy and procedure (P&P) Skin integrity Management, revised 6/8/2024, the P&P indicated the facility will identify, evaluate, and intervene to prevent further pressure injury and or heal pressure ulcers and any other skin integrity conditions and to review the resident's care plan and update as necessary.

Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who had an unwitnessed fall on 1/11/2025 with injuries, was provided appropriate care by the nursing staff. The facility failed to: 1. Ensure Resident 1 ' s physician was notified following Resident 1 ' s unwitnessed fall to obtain instructions for care and monitoring. 2. Ensure Resident 1 ' s Responsible Party (RP 1) was notified following Resident 1 ' s unwitnessed fall and subsequent injuries. 3. Ensure Resident 1 was assessed, monitored with documentation of Resident 1 ' s incident, and continued health status following his unwitnessed fall in order to update the physician of the resident status. 4. Ensure Resident 1 ' s incident and care were endorsed to the oncoming shift (7 a.m. - 3 p.m.) following his unwitnessed fall and injuries on 1/11/2025 during the 11 p.m. - 7 a.m. shift. This deficient practice resulted in a delay in Resident 1 ' s care following his unwitnessed fall with injuries on 1/11/20225, due to Licensed Vocational Nurse 2 ' s (LVN 2) failure to assess and monitor the resident, to document and report that Resident 1 had an unwitnessed fall. Resident 1 was subsequently transferred to an General Acute Care Hospital (GACH) on 1/13/2025, were he was assessed with multiple bruises in different healing stages to both his arms, swelling to the right foot, skin abrasion (a skin injury when the skin rubs off) with bruising and coagulated blood (a process that prevents excessive bleeding when a blood vessel is injured) to this right shoulder, the right bicep (a large muscle in the upper arm), right elbow and right knee. This deficient practice had the potential for serious injuries to be unknown by the resident ' s physician resulting in possible death. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including atrial fibrillation ([Afib] a heart condition that causes an irregular heartbeat), cirrhosis of the liver (a type of liver damage where the healthy cells are replaced by scar tissue and the liver is not able to perform its vital functions for the body to function normally), right lung malignant neoplasm (a form of cancer that spreads into or invades nearby tissues) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot. During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 12/30/2024, the MDS indicated Resident 1 had periods of disorientation and was not able to make consistent and reasonable decisions and required a two-person assist to complete his activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and was incontinent (loss of control) of bladder and bowel functions. During a review of Resident 1 ' s History and Physical (H&P) dated 11/4/2024, the H&P indicated Resident 1 was able to make his needs known but could not make medical decisions. During a review of Resident 1 ' s Order Summary Report (Physician ' s orders), the Order Summary Report indicated Resident 1 had the following orders: 1. On 11/7/2024 - Apixaban (a medication used to treat blood clots and prevent stroke with side effects of bleeding) 5.0 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) one tablet two times a day for Afib. 2. On 11/7/2024 - Aspirin (a medication used as to provide relief from pain and swelling and prevention of blood clots in the body with side effects of bleeding ) 81 mg chewable one tablet daily for cerebrovascular accident prophylaxis (stroke prevention). During a review of Resident 1 ' s Care Plan related to the potential/actual impairment to skin integrity due to fragile skin, incontinence and limited mobility, dated 11/2/2023, the Care Plan indicated Resident 1 was to have no complications related to skin injury with interventions including following the facility protocols for treatment of injury and to monitor/document location, size and treatment of skin injury and report abnormalities to the primary care physician. During a review of Resident 1 ' s Care Plan on anticoagulant (drugs used to reduce the body ' s ability to form blood clots such as apixaban)/anti platelet (drugs such as aspirin which stop the blood cells from sticking together to form a clot ) therapy related to Afib, and at risk for bleeding dated 6/14/2024. The goal of the Care Plan was for Resident 1 to be free from discomfort or adverse reactions to the anticoagulant ' use with interventions including inspecting Resident 1 ' s skin and report abnormalities to the nurse. During a review of Resident 1 ' s SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) and Change of Condition (COC) Charting and Skilled Documentation dated 1/11/2025 and timed at 8:10 a.m., the SBAR and COC indicated Resident 1 was found with skin tears to the following areas of his body: 1. Right elbow 0.5 centimeters ([cm] metric unit of measurement, used for medication dosage and/or amount) by 0.5 cm. 2. Right thigh 1.0 cm by 1.0 cm. 3. Left lower leg 0.5 cm by 0.5 cm. 4. Right shoulder 0.5 cm by 0.5 cm. During a review of Resident 1 ' s Health Status Note dated 1/11/2025 and timed at 8:10 a.m., the Health Status Note indicated Resident 1 was observed with skin tears on his right shoulder measuring 0.5 by 0.5 cm, his right elbow measuring 0.5 by 0.5 cm, right leg/thigh measuring 1 cm by 1 cm, and his left below the knee measuring 0.5 cm by 0.5 cm. The Health Status Noted indicated Resident 1 reported the towel used by the certified nursing assistant (CNA 2) to clean him during the night shift was rough and caused his bleeding. During a review of Resident 1 ' s SBAR dated 1/13/2025 and timed at 12:13 p.m., the SBAR indicated Resident 1 had a fall incident and on 1/13/2025 the primary care physician recommended Resident 1 be sent to a GACH for a computerized tomography scan ([CT] a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) of the head. During a review of Resident 1 ' s Health Status Note dated 1/13/2025 and timed at 12:13 p.m., the Health Status Note indicated Resident 1 had an alleged fall on 1/11/20205 at 5 a.m., based in a written statement by the Certified Nursing Assistant (CNA 2) assigned to care for Resident 1 on that shift (11 p.m. - 7 a.m.). The Health Status Note indicated Resident 1 sustained multiple discolorations and skin tears to his right shoulder measuring 0.5 by 0.5 cm, his right elbow measuring 0.5 by 0.5 cm, his right leg/thigh measuring 1 cm by 1 cm, and his left below the knee measuring 0.5 cm by 0.5 cm. During a review of Resident 1 ' s Order Summary Report date 1/13/2025, the Order Summary Report indicated to transfer Resident 1 to a GACH after an alleged unwitnessed fall. During a review of GACH ' s Emergency Department (ED) Documentation dated 1/14/2025 and timed at 4:12 a.m., the ED Documentation indicated Resident 1 presented to the GACH lethargic (a state of being drowsy and dull, listless, and unenergetic, indifferent and lazy, sluggish and inactive), with multiple bruises in different healing stages to both his arms, swelling to the right foot, skin abrasion with bruising and coagulated blood to the right shoulder, the right bicep, right elbow and right knee after an unwitnessed fall. During a telephone interview on 1/13/2025 at 3:26 p.m., Resident 1 ' s RP 1 stated on 1/11/2025 at 11 a.m., he visited Resident 1 at the facility and was told by LVN 3 that Resident 1 was bleeding from multiple skin tears on his body. RP 1 stated LVN 3 did not know how Resident 1 sustained the skin tears and she did not receive a report from the nurses on 11 p.m. to 7 a.m. shift that Resident 1 had a COC. RP 1 stated Resident 1 told him and LVN 3 that the towel used on him was hard and rough and caused burning to his skin. RP 1 stated on 1/13/2025 at 11 a.m., he visited Resident 1 again and was told Resident 1 had an alleged fall on 1/11/2025 at 5 a.m., and he (Resident 1) would be transferred to a GACH for further evaluation and tests. RP 1 stated he was not informed by staff of Resident 1 ' s injury or fall that occurred on 1/11/2025 at 5 a.m., until he arrived at the facility (1/11/2025 at 11 a.m.). During an interview on 1/14/2025 at 11:10 p.m., Certified Nursing Assistant 2 (CNA 2) stated on 1/10/2025 during the 11 p.m. to 7 a.m. shift, she noticed Resident 1 was moving a lot in bed at the beginning of the shift and she informed LVN 2 about Resident 1 ' s restlessness. CNA 2 stated Resident 1 ' s legs were dangling off the side of the bed, and she had to reposition him several times. CNA 2 stated around 5 a.m., on 1/11/2024, she was passing by Resident 1 ' s room and saw Resident 1 lying on floor face up by the right side of his bed. CNA 2 stated Resident 1 had a bowel movement on the floor, and she informed LVN 2 of Resident 1 ' s situation. CNA 2 stated she and LVN 2 placed Resident 1 back in bed, she cleaned him up but and did not notice any wounds on Resident 1 but stated she did see a minimal amount of blood on the floor. CNA 2 stated LVN 2 took over Resident 1 ' s care after she (CNA 2) was finished cleaning Resident 1 up and since LVN 2 was aware of Resident 1 ' s incident, she left at the end of her shift and did not inform the incoming nurses of Resident 1 ' s fall incident because she thought LVN 2 would report what happened. During a telephone interview on 1/15/2025 at 11:55 a.m., LVN 2 stated on 1/10/2025 during the early part of the 11 p.m. to 7 a.m. shift she was informed by CNA 2 that Resident 1 was restless in bed. LVN 2 stated when she checked on Resident 1, he was pulling off his oxygen tubing. LVN 2 stated she assisted Resident 1 to reposition in bed and reminded him to keep his oxygen tubing in place. LVN 2 stated at 5 a.m. on 1/11/2025, she was informed by CNA 2 that Resident 1 was lying on the floor on the right side of his bed. LVN 2 stated Resident 1 did not look like he was in distress or pain, therefore she did not check his vital signs ([v/s] the measurements of the body ' s essential functions, such as temperature, breathing rate, pulse, blood pressure and level of pain) nor did she do a full assessment including a neuro check on Resident 1. LVN 2 stated she assessed Resident 1 ' s skin after CNA 2 completed Resident 1 ' s incontinence care and stated she observed a small amount of bleeding to Resident 1 ' s right upper arm and left it open to air, because the area looked like an old wound that possibly reopened after the fall. LVN 2 stated she did not feel like Resident 1 had fallen since Resident 1 was always on a low bed, so she did not call Resident 1 ' s physician or RP 1 regarding the incident, she did not document the incident or Resident 1 ' s status in his medical record and she did not endorse anything to the oncoming shift (7 a.m. -3 p.m.) because she did not feel like Resident 1 had a COC. LVN 2 stated she should have called Resident 1 ' s physician and RP 1 so the physician could decide on what interventions the resident needed, and transfer Resident 1 to the GACH for further care and evaluation as necessary. LVN 2 stated documenting in the resident ' s medical record during a COC was important to ensure the resident ' s health progress and assessments were recorded and the resident ' s condition was communicated to the healthcare team. During a telephone interview on 1/15/2025 at 12:32 p.m., LVN 3 stated during her initial resident rounds on 1/11/2025 at 8 a.m., and upon assessment of Resident 1, she noted Resident 1 had multiple skin tears on his body. LVN 3 stated she was not informed by the previous shift of Resident 1 ' s skin tears or possible COC and there was no documentation in Resident 1 ' s medical record to reflect that anything had occurred during the previous shift. LVN 3 stated on 1/13/2024 during the 7 a.m. to 3 p.m. shift, she was informed that Resident 1 had an alleged fall on 1/11/2025 at 5 a.m. LVN 3 stated Resident 1 was on medications with side effects of bleeding, and he should have been assessed at the time of the fall with documentation in his medical record as well as a report to the oncoming nurses, Resident 1 ' s physician and his RP. During an interview on 1/14/2025 at 10:10 p.m., the Director of Nursing (DON) stated Resident 1 ' s alleged fall was discovered on 1/13/2025 after the facility investigated Resident 1 ' s skin injuries. The DON stated the nurses are expected to assess and monitor any resident when there is a COC to determine the residents ' condition and progress in order to identify continued changes. The DON stated the licensed nursing staff should have informed Resident 1 ' s physician, to obtain instructions for care to prevent a delay in treatment and any complications. During a telephone interview on 1/15/2025 at 5:42 p.m., Resident 1 ' s Physician stated she was made aware of Resident 1 ' s multiple skin tears and alleged fall on 1/13/2025 and ordered that Resident 1 be transferred to a GACH for further evaluation. Resident 1 ' s physician stated the facility nursing staff should have called her immediately after Resident 1 was found on the floor so she could have ordered a Stat (immediate) Xray to determine if Resident 1 was injured and to instruct the nursing staff to monitor Resident 1 because he was at risk for bleeding due to medications that he was taking. Resident 1 ' s physician stated Resident 1 should have been assessed including a neuro check to identify and keep track of the resident ' s progress and response to treatment. During a review of the facility ' s Policy and Procedure (P/P) titled, Change of Condition Notification revised 4/1/2015, the P/P indicated the resident ' s change of condition is defined when any sudden and marked change in the residents ' condition which is manifested by signs and symptoms different than usual denote a problem, complication or permanent change in the residents ' status and require medical assessment, coordination and consultation with the attending physician and a change in the treatment plan. The P/P indicated the licensed nurse will notify the resident ' s attending physician and legal representative or an appropriate family member when there is an: a. Incident/ accident involving the resident, b. An accident involving the resident which results in an injury and has the potential for requiring physician intervention. c. Significant change in the residents ' physical, mental or psychosocial status such as deterioration of health, mental or psychosocial status, life threatening conditions and/or clinical complications. The Licensed Nurse will notify the family/surrogate decision makers of any changes in the residents ' condition as soon as possible. The Licensed Nurse will document the time the attending physician was notified and the method by which physician was contacted, the response time, and whether or not orders were received, the time the family/responsible person was notified

Based on interview and record review, the facility failed to ensure that a care plan with a goal to minimize falls and to decrease significant injuries as a result of any the falls by placing a bed at the lowest position with floor mats on both sides of the bed, for one of three sampled residents (Resident 1) was followed. Resident 1 was found kneeling on the floor by the left side of her bed, holding onto the bed's siderail with the bed in a high position and no floor mats on the floor beside Resident 1's bed. The facility failed to: Ensure Resident 1 had her bed in the lowest position with floor mat on the left side of Resident 1's bed, based on Resident 1's Care Plan dated 3/20/2022. This deficient practice resulted in Resident 1 sustaining a fracture (a break in the bone) to her T11 and T12 thoracic bones (the part of the spine between the neck and the abdomen that make up vertebrae [a series of small bones forming the backbone] from T1 through T12 and mostly protect the heart and lungs), and fractures of her right tibia ([shin] the inner and usually larger of the two bones between the knee and the ankle) and fibula ([calf bone] the outer and usually smaller of the two bones between the knee and the ankle). Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including glaucoma (an eye disease that can cause vision loss and blindness), legal blindness, and dementia (a progressive state of decline in mental abilities), During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 1 was able to make decisions that were reasonable and consistent. The MDS indicated Resident 1's vision was severely impaired. During a review of Resident 1's History and Physical (H&P) dated 9/2/2024, the H&P indicated Resident 1 also had diagnoses that included osteoarthritis (a degenerative joint disease in which the tissue in the joint break down over time), and encephalopathy (a change in how the brain works due to an underlying condition and causes confusion, memory loss and loss of consciousness). During a review of Resident 1's Fall Risk Assessment, dated on 9/2/2024 and timed at 10:23 a.m., the Fall Risk Assessment indicated a score of 15. A score of 10 or more indicated a high risk for falls. During a review of Resident 1's Order Summary Report (Physician's Order), dated 10/2024, the Physician's Order indicated the following orders: 1. On 3/20/2022 Resident 1 may have bilateral (both) floor mats (a cushioned floor pad designed to help prevent injury should a person fall) every shift. 2. On 3/20/2022 keep Resident 1's bed at the lowest position every shift. During a review of Resident 1's untitled Care Plan, dated 3/20/2022, the Care Plan indicated Resident 1 was at risk for falls/injury related to her cognitive impairment (a condition where there are problems of the person's ability to think, learn, remember, use judgement, and make decisions), encephalopathy, chronic obstructive pulmonary disease ([COPD] a lung disease that causes breathing problems and restricted airflow), legal blindness, dementia, fibromyalgia (a chronic condition that causes widespread pain and tenderness in the body), and age-related debility (a state of general weakness or feebleness that may be a result or an outcome of one or more medical conditions). The Care Plan indicated a goal to minimize Resident 1's risk of falls and decrease significant injuries as a result of the falls. The Care Plan's interventions included ensuring Resident 1's bed was kept at the lowest position with floor mats on both sides of Resident 1's bed. During a review of Resident 1's Change in Condition (COC) form, dated 10/10/2024 and timed at 2:24 a.m., the COC form indicated Resident 1 had a fall incident with left leg pain (later determined at the GACH to be the right leg/knee) level rated 10 out of 10 on a pain scale of zero to 10 (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain), blood pressure (BP) of 230/159 millimeters of mercury (mmHg, normal BP is 120/80), heart rate (HR) of 129 beats per minute (bpm, normal HR is 60-100 bpm), and respiratory rate (RR) of 22 breaths per minute (normal range is 12-18 breaths per minute). During a review of Resident 1's Nursing Progress Notes dated 10/10/2024 and timed at 4:22 a.m., the Nursing Progress Note indicated Resident 1 was found kneeling on the floor, holding the siderail of her bed. The Nursing Progress Note indicated Resident 1 complained of a pain rated 10 out of 10 to her left leg (later determined at the GACH to be the right leg/knee) and the same day (10/10/2024) was transferred to a General Acute Hospital (GACH) at 2:30 a.m. During a review of Resident 1's Order Summary report (Physician's Order), dated 10/10/2024, the Physician's Order indicated to transfer Resident to a GACH for further evaluation due to a fall. During a review of the GACH's Emergency Department (ED) documentation dated 10/10/2024 and timed at 2:45 a.m., the ED documentation indicated Resident 1 presented with a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) and deformity (a part of someone's body which is not the normal shape because of injury or illness, or because they were born that way) with loss of sensation (ability to feel) to the area below her right knee after a non-syncopal (not cause by fainting) fall out of bed in the skilled nursing facility (SNF). The ED documentation indicated Resident 1 complained of a pain level of 10 out of 10 to the lower area of her right knee and was administered Morphine (a medication used to treat pain) for pain. The ED documentation indicated on 10/10/2024 at 4:11 a.m., Resident 1 had an Xray (special pictures of the inside of the body) of the right hip, pelvis, right knee, right tibia, and fibula, and the right femur (the thigh bone). The ED documentation indicated Resident 1 sustained an acute (severe and sudden in onset) minimally displaced (the break in the bone does not go all the way through) fracture of the right knee, tibia, and fibula. The ED documentation indicated on 10/10/2024 at 4:16 a.m., Resident 1 underwent a CT scan (a diagnostic imaging [picture] procedure that uses a combination of Xrays and computer technology to produce images of the inside of the body) of her abdomen and pelvis with contrast (a solution given to a patient before a CT scan to help make certain parts of the body appear more clearly in the images). The ED documentation indicated Resident 1 sustained a new compression fracture (a type of broken bone that can cause the vertebrae to collapse, making them shorter) of the T11 and T12 thoracic bones, as compared to a previous CT scan done on 3/14/2024. During a review of GACH's Orthopedic (a branch of medicine that focuses on the care of the bones, muscles and joints) Surgery Consultation notes dated 10/10/2024 and timed at 9:25 a.m., the Orthopedic Surgery Consultation notes indicated Resident 1's fractures could be treated with weight bearing restrictions (limitations placed on a patient's ability to bear weight on a specific part of their body, typically due to an injury or surgery) and a knee immobilizer (a removable device that maintains the stability of the knee). During a telephone interview on 10/25/2024 at 4:05 a.m., Resident 1's Responsible Party (RP) 1 stated over the past few months every time she visited Resident 1, she noticed Resident 1's bed was always in a high position and there was never a floor mat on the floor next to the Resident 1's bed. RP 1 stated she kept reminding nurses about her concerns. RP 1 stated the staff were aware that Resident 1 was legally blind and could get disoriented at times. RP 1 stated Resident 1 had a fall in the past at the facility and needed frequent supervision and a lot of reminders not to get up unassisted. RP 1 stated Resident 1 told her that she (Resident 1) was calling for assistance the night she fell (10/9/2024) because her pillow fell on the floor, no one came to help her get her pillow, so she (Resident 1) tried to get up to get the pillow herself and she rolled out of the bed. RP 1 stated she felt the facility was negligent because the fall precautions (a low bed and floor mats) the facility was supposed to provide, were not implemented all the time. RP 1 stated after Resident 1 fell and broke her backbones and her right knee, her pain become more difficult to control, and there were days she could not participate with the physical therapy ([PT] a health profession that uses physical activities and treatments to help people improve their movement and physical function) provided in the facility. RP 1 stated she was concerned that Resident 1's condition would get worse. During an interview on 10/28/2024 at 6:14 a.m., Certified Nursing Assistant 2 (CNA 2) stated Resident 1 could be forgetful at times and needed supervision and frequent reminders to call for assistance. CNA 2 stated Resident 1 had a fall in the past and had floor mats in place on each side of her bed, but for the past couple of months (not sure how long) there had been no floor mats at Resident 1's bedside and she was not sure why. CNA 2 stated the floor mats could have helped lessen the impact when Resident 1 fell (10/10/2024) and might have helped prevent Resident 1's injuries. During an interview on 10/28/2024 at 6:39 a.m., CNA 4 stated Resident 1 had a floor mat in place on the right side of her bed only because Resident 1 had a tendency to lean on that side of the bed. CNA 4 stated she did not expect Resident 1 to fall off the left side of her bed. During a telephone interview on 10/28/2024 at 9:59 a.m., Licensed Vocational Nurse (LVN ) 4 stated she found Resident 1 kneeling on the bare floor, on the left side of her bed while holding onto the bed's siderail. LVN 4 stated she had to lower Resident 1's bed when she assisted Resident 4 during the fall incident. LVN 4 stated Resident 1's injuries might have been prevented or minimized if there had been floor mats in place and her bed was in a low position, per her care plan. During an interview on 10/28/2024 at 12:43 p.m., the Assistant Director of Nursing Services stated the nursing staff were expected to implement fall precautions intervention as indicated in the resident's care plan and as ordered by the doctor. During a review of the facility's Policy and Procedure (P/P) titled NP04 Comprehensive Person-Centered Care Planning revised 8/24/2023, the P/P indicated the facility provides a person-centered, comprehensive, and interdisciplinary care that reflects the best practice standards for meeting the health, safety, psychosocial, behavioral, environmental needs of the residents in order to obtain or maintain their highest physical, mental, and psychosocial well-being. The P/P indicated the residents' care plan must be developed and implemented based on the residents' goals and objectives. During a review of the facility's Policy and Procedure (p/p) titled Resident Safety revised 4/15/2021, the P/P indicated the facility shall provide the residents a safe environment.

Based on observation, interview, and record review, the facility failed to ensure, the resident who had intact ( not impaired) right eyesight did not lose eyesight and became blind, for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses acted upon and carried out the optometrist ' s (specialized health care profession that involves examining the eyes and related structures for defects or abnormalities) [OPT 1]) recommendations made on 3/22/2024 for Resident 1 to see a retina (the light sensitive lining of the eye) specialist (medical doctor who specialized in disease of the retina) and a glaucoma specialist (medical doctor who specialized in glaucoma [eye disease that can cause vision {state of being able to see} loss and blindness]). Resident 1 was not seen by retina specialist (MD 2) until 8/1/2024 (132 days later) and was seen by the glaucoma specialist (MD 3) on 8/27/2024 (158 days later). 2. Ensure Social Services Director (SSD 1), Case Management (CM 1), and licensed nurses informed Resident 1 ' s primary physician (MD 1) of OPT 1 ' s recommendations to see retina and glaucoma specialists for the right eye blurred vision, obtained MD 1 ' s order and followed through with scheduling and arranging Resident 1 ' s appointment to see retina and glaucoma specialist to prevent the resident ' s right eye vision loss. 3. Ensure Resident 1, who was admitted to the facility on [DATE] with an intact (not impaired) right eye vision, had a comprehensive plan of care for the potential of impaired vision in the right eye due to diagnosis of advanced diabetic retinopathy (complications of diabetes [a condition in which the body fails to process glucose (sugar) correctly ] that affects patient ' s eye that can lead to blindness) with interventions to prevent vision loss. These deficient practices resulted in Resident 1 ' s decreased vision in the right eye leading to right eye vision loss and blindness. Resident 1 developed depression (a mood disorder that can cause a persistent feeling of sadness and loss of interest in activities) requiring medical treatment, became isolated (having minimal contact from his family and lost his independence in activities of daily living ([ADLs] activities related to personal care). On 9/6/2024 at 1:59 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider ' s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called due to the facility ' s failure to prevent a decline in Resident 1 ' s right eye vision in the presence of the Director of Nursing (DON), Director of Staffing (DSD), and the facility ' s Regional Nurse Consultant (RNC). On 9/7/2024 at 11:40 a.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility ' s IJRP ' s implementation through observation, interview, and record review, the IJ was removed on 9/7/2024 at 4:50 p.m., in the presence of the DON and RNC. The IJRP included the following immediate actions: 1. On 8/27/2024, Resident 1 was seen and evaluated by Ophthalmologist (eye care specialist) and recommendations for follow-up appointments/treatments have been carried out as indicated. A follow up appointment was scheduled for 9/19/2024. 2. On 8/1/2024 and 8/26/2024, Resident 1 was seen and evaluated by Retina Specialist and recommendations for follow-up appointments/treatments have been carried out as indicated. A follow up appointment was scheduled for 9/30/2024. 3. On 9/6/2024, Resident 1 ' s plan of care related to vision was reviewed by the interdisciplinary team ([IDT] a team that provides integrated care) and was updated accordingly. 4. On 9/6/2024, the DON/Designee provided an in-service (training done during your time at work, to learn new skills) education to the infection preventionist nurse (IP), SSD 1, CM 1 and the licensed nurses on duty regarding the policy and procedures for Ancillary Services (diagnostic and supportive measures that help healthcare providers treat residents) , with emphasis on the importance of reviewing recommendations from ancillary services and ensure physician was notified and recommendations are carried out and followed through. The in-service will be completed by 9/11/2024. Licensed Nurses on leave or unscheduled will receive education upon return to work. SSD 1 is responsible for locating agencies and programs that meet the needs of residents, facilitating the execution of service provider contracts, and referring residents to existing contracted providers. For clinical services, a nursing designee will assist SSD 1 in locating a provider. Referrals for medical services are only made pursuant to an Attending Physician ' s order. 5. The Director of Social Services or his or her designee will coordinate with Nursing Staff to ensure that the Attending Physician ' s order and referral to outside provider is documented in the resident ' s medical record. 6. Facility Process related to Ancillary Services: a. Upon licensed nurse ' s receipt of new ancillary service referral orders from the attending physician, the licensed nurse will print a copy of the referral order and place the copy in the Referrals/Appointments Binder located in each nurse ' s station. b. For outside Ancillary Services appointments already scheduled by the licensed nurse as ordered by the attending physician, a copy of the appointment order will be placed in the Referrals/Appointments Binder. c. Social Services and Case Manager will review the Referrals/Appointments Binder every morning on weekdays for any new referral orders. d. Social Services will arrange for in-house ancillary visits and/or outside ancillary appointments as indicated. e. For any outside ancillary appointments requiring prior authorization (process that health insurance companies use to determine if a medical treatment or service is medically necessary before it can be provided) from the insurance, the Case Manager will submit the request for prior authorization. f. Upon resident ' s return from outside ancillary appointment, the licensed nurse will review the ancillary service progress notes written by the specialist for any recommendations. g. New recommendations from the ancillary service will be relayed by the licensed nurse to the resident ' s attending physician for further orders. h. New orders from the attending physician will be carried out by the licensed nurse. i. Upon completion of in-house ancillary visit, the specialist progress report(s) will be gathered by the Social Services and a copy will be provided to the licensed nurse to ensure that any recommendations are relayed to the resident ' s attending physician. 7. During Daily Clinical Meetings on Mondays to Fridays, the DON, Social Services, and Case Manager will review the following: a. New Ancillary Services progress notes to ensure that all recommendations from the ancillary services are relayed to the attending physicians and are followed through in a timely manner; and b. Referrals/Appointments Binder for new referrals to Ancillary Services to ensure that the referrals are followed through. c. Any appointments or other recommendations pending completion will continue to be reviewed during these meetings by the DON, and Social Services, and Case Manager. All actions/interventions taken related to Ancillary Services will be documented in residents ' clinical records. 8. Ancillary Service Tracking Log will continue to be maintained by Social Services and will be reviewed regularly to ensure consults remain current. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a condition in which the body fails to process glucose (sugar) correctly ) with proliferative diabetic retinopathy (complications of diabetes that affects patient ' s eye that can lead to blindness), blindness on left eye, normal vision right eye, primary open-angle glaucoma (a chronic and irreversible eye condition that causes gradual vision loss) and depression. During a review of Resident 1 ' s Admission Summary dated 10/26/2023, the Admission Summary indicated Resident 1 was admitted to the facility for osteomyelitis (bone infection) and for continued wound care and treatment with antibiotics (medication for infection) due to right trans metatarsal amputation (a surgical procedure that removes part of the foot) The Admission Summary indicated Resident 1 informed the IP that his vision was impaired, and requested an optometrist ' s consult. The Admission Summary indicated Resident 1 was able to transfer with minimal assistance/supervision from staff. During a review of Resident 1 ' s Physician ' s Order Summary dated 10/26/2023 the Physician ' s Order Summary indicated an order for eye health, vision consult, and follow up with treatment as indicated. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/2/2023, the MDS indicated Resident 1 had moderate impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 1 had moderately impaired vision (limited vision; not able to see newspaper headlines but can identify objects). The MDS indicated it was very important for Resident 1 to choose what clothes to wear and to take care of his personal belongings. The MDS indicated Resident 1 needed set-up or clean-up assistance (staff sets up or cleans up; resident completes activity) for eating, dressing upper body, toileting, and showering. During a review of Resident 1 ' s care plan, titled The resident has impaired visual function related to cataracts (a cloudy area that develops in the lens of the eye, causing vision loss), diabetes, disease process, at risk for complications developed on 3/20/2024 (5 months after admission on 10/26/2023) the goals for Resident 1 included not to have any acute eye problems, not to have a decline in right visual function, and to maintain optimal quality of life within limitation imposed by right visual function. The Care Plan indicated the interventions included to arrange consultations with eye care practitioner (physician) as required, and monitoring/ documenting/ reporting any signs or symptoms of acute right eye problems (sudden visual loss, double vision, tunnel vision [medical condition that makes someone see only things that are directly in front of them], blurred or hazy vision). During a review of Resident 1 ' s Visit Summary Note from OPT 1 dated 3/22/2024, the Visit Summary Note indicated OPT 1 prescribed new eye medications as follows: 1. Rocklatan eye drops (medication used to treat high intraocular pressure [IOP] the pressure or force of fluid inside the eye) at bedtime instill (put) into bilateral (both) eyes. 2. Combigan eye drops (medication used treats high IOP) twice daily instill into bilateral eyes. 3. Acetazolamide oral ([given by mouth] medication used to treat high IOP) one tablet twice a day. The Visit Summary Note indicated Resident 1 reported to OPT 1 he used to take eye drops medication but had not been using them (unknown reason why). The Visit Summary Note indicated OPT 1 stressed tight compliance with medications to preserve his (Resident 1 ' s) current vision and that the resident needed a referral to a glaucoma specialist. The Visit Summary Note indicated at the time of evaluation on 3/22/2024, Resident 1 had 20/40 (sees things at 20 feet that most people who do not need vision correction can see at 40 feet) vision in the right eye enabling the resident to see and move around on his own. The OPT 1 recommended a follow up with retina specialist on next available appointment. During a review of Resident 1 ' s Social Services Note dated 4/1/2024, written by SSD 1, the Social Services Note indicated Resident 1 stated he gave the social services assistant (SSA) phone number to schedule an appointment with his eye doctor (as was recommended by OPT 1). During a review of Resident 1 ' s Social Services Note dated 4/3/2024, the Social Services Note indicated SSA called Resident 1 ' s eye doctor to inquire about the code (not documented what code) that Resident 1 misplaced. The Social Services Notes indicated no documentation of appointment arrangement or future contacts with the eye doctor regarding Resident 1 ' s follow up appointment with the eye doctor after SSA ' s documented entry on 4/3/2024. During a review of Resident 1 ' s in-house (in the facility) Ophthalmology (eye doctors who perform medical and surgical treatments for eye conditions) Exam/Consult and Report Note dated 4/16/2024, the Ophthalmology Exam/ Consult and Report Note indicated the goal for Resident 1 ' s was to maintain quality of life and vision preservation. The Ophthalmology Exam/ Consult and Report Note indicated Resident 1 was being followed by OPT 1 for eye drops and management of both eyes pressure control (Resident 1 was not seen again by OPT 1 after the appointment on 3/22/2024). During a review of Resident 1 ' s change of condition ([COC] a sudden or gradual change in a resident ' s physical, cognitive, behavioral, and functional status) note dated 6/30/2024, the COC note indicated Resident 1 complained of blurry vision in both eyes and was seeing lights and shapes. The COC note indicated MD 1 ordered a STAT (as soon as possible) Comprehensive Metabolic Panel ([CMP] laboratory test). During a review of Resident 1 ' s Nurses Progress Notes dated 6/30/2024, the Nurses Progress Notes indicated Resident 1 called 911 (emergency medical services) on 6/30/2024 and complained of blurry vision. Resident 1 was taken to a general acute care hospital (GACH). Resident 1 was sent back from the GACH with a diagnosis of eye irritation the same day (6/30/2024). During a review of Resident 1 ' s Transfer to Hospital Summary dated 6/30/2024, the Transfer to Hospital Summary indicated Resident 1 called 911 himself due to blurry vision and feeling blind and was transferred to the GACH. During a review of Resident 1 ' s GACH ' s Emergency Department (ED) Documentation dated 6/30/2024, the GACH ' s ED Documentation indicated Resident 1 was seen in the ED with the chief complaint of right eye vision changes since 6/28/2024. The GACH ' s ED Documentation indicated Resident 1 felt as though something was stuck in his right eye but was uncertain. The GACH ' s ED Documentation indicated Resident 1 ' s eyes were irrigated (flush), and he was diagnosed in the ED with eye irritation. The ED physician (MD 5) wrote in the ED Documentation that he called the facility multiple times with no answer to request more information about Resident 1 ' s medication prior to discharge from the GACH. The GACH ' s ED Documentation Discharge Instructions for Resident 1 indicated for Resident 1 to follow up with MD 1, ophthalmologist, and return to the ED for any worsening vision symptoms. The GACH ED Documentation indicated a diagnosis of eye irritation. During a review of Resident 1 ' s Nurses Progress Notes dated 7/1/2024, the Nurses Progress Notes indicated Resident 1 needed insurance authorization (process that health insurance companies use to determine if a medical treatment or service is medically necessary before it can be provided) to see an ophthalmologist (MD 4). The Nurse ' s Progress Notes indicated CM 1 was notified and would follow up on insurance authorization. During a review of Resident 1 ' s Nurses Progress Notes dated 7/2/2024, the Nurses Progress Notes indicated MD 4 ' s office informed the facility staff that MD 4 did not accept Resident 1 ' s medical insurance. The Nurses Progress Notes indicated CM 1 and SSD 1 were notified. During a review of COC note dated 7/5/2024, the COC note indicated Resident 1 was going to the restroom and tripped over something on the floor without injuries noted. During a review of Resident 1 ' s Physician Order Summary, dated 7/8/2024 the Physician Order Summary indicated an order for ophthalmology consult due to Resident 1 ' s witnessed fall on 7/5/2024 related to glaucoma. During a review of Resident 1 ' s Nurses Progress Notes dated 7/9/2024, the Nurses Progress Notes indicated the insurance authorization was received for Resident 1 to see MD 4 and it was faxed to MD 4 ' s office. The Nurses Progress Note indicated staff was to follow up on MD 4 ' s office on the next business day (7/10/2024) to schedule an appointment. The Nurses Progress Notes indicated there was no documented information regarding a follow-up with MD 4 ' s office to schedule Resident 1 ' s appointment, not until 7/15/2024. During a review of Resident 1 ' s COC note dated 7/15/2024, the COC note indicated Resident 1 was complaining of increased blurry vision (COC note did not specify which eye) and Resident 1 verbalized his eyesight was getting worse. The COC note indicated LVN 4 called MD 4 ' s office and faxed over the insurance authorization. During a review of Resident 1 ' s Physician ' s Order Summary, dated 7/16/2024 the Physician ' s Order Summary indicated an order for an appointment with retina specialist (MD 2) on 8/1/2024 at 2 p.m. During a review of Resident 1 ' s Psychiatric Evaluation Note dated 7/18/2024, indicated Resident 1 expressed he was stressed because I am going blind. The Psychiatric Evaluation Note indicated Resident 1 ' s Zoloft (antidepressant medication) was increased from 50 milligram ([mg] a unit of measurement) ordered on 4/28/2024 to 100 mg by mouth daily ordered on 7/18/2024. During a review of Resident 1 ' s MDS dated [DATE], the MDS indicated Resident 1 had intact cognition and had moderate impaired vision. The MDS indicated Resident 1 needed set-up or clean-up assistance for eating, dressing upper body, and toileting. The MDS indicated Resident 1 required supervision or touching assistance for showering. During a review of Resident 1 ' s Visit Summary from the retina specialist (MD 2) on 8/1/2024, the MD 2 ' s Visit Summary indicated Resident 1 ' s IOP in the right eye was 29 millimeters of mercury ([mmHg] a unit of measurement; normal IOP between 10 and 21 mmHg). The MD 2 ' s Visit Summary indicated Resident 1 received two urgent intravitreal injection ([[NAME]] injections that are used to treat a variety of retinal conditions) in the right eye during the appointment on 8/1/2024. The MD 2 ' s Visit Summary indicated MD 2 recommended a follow up appointment in three weeks for pan-retinal photocoagulation ([PRP] a laser treatment that is the standard intervention for patients with proliferative diabetic neuropathy). The MD 2 ' s Visit Summary indicated Resident 1 received two injections in his right eye (Bevacizumab [medication for specific eye disease] 10 mg and Intravitreal injection for diabetic retinopathy with macular (part of the retina at the back of the eye) edema [happens when blood vessels leak into part of the retina, causing swelling]) during the visit. The MD 2 ' s Visit Summary indicated that on 8/1/2024 Resident 1 was newly diagnosed with neovascular glaucoma ([NVG] a serious type of glaucoma that can lead to blindness or vision loss) of the right eye. During a review of Resident 1 ' s Psychiatric Evaluation dated 8/16/2024, indicated Resident 1 expressed concern about his eyes and vision. The Psychiatric Evaluation indicated on 8/16/2024, Resident 1 ' s Zoloft was increased to 150 mg daily for depression as manifested by increasing feelings of hopelessness and helplessness. During a review of Resident 1 ' s MD 2 ' s Visit Summary dated 8/26/2024, the MD 2 ' s Visit Summary indicated MD 2 requested a glaucoma evaluation as soon as possible and recommended retina specialist follow up, and plan for tube surgery (small flexible tube placed in eye to relieve pressure and drain fluid) versus cyclophotocoagulation ([CPC] a laser that reduces eye pressure and treats glaucoma) for the right eye. The MD 2 ' s Visit Summary indicated Resident 1 ' s right eye IOP on 8/26/2024 was 46 mmHg (normal IOP between 10 and 21 mmHg). During a review of glaucoma specialist (MD 3) Visit Summary dated 8/27/2024, the MD 3 ' s Visit Summary indicated Resident 1 was complaining of flashing lights (signs that can indicate a serious medical condition that may result in permanent vision loss), watery eyes, and the right eye pain. MD 3 ' s Visit Summary indicated Resident 1 had an increased IOP in both eyes, and the treatment goal was to bring the right eye IOP down below 21 mmHg and comfort care (a type of medical care that focuses on relieving pain and other symptoms to improve the quality of life for patients) for the left eye. MD 3 ' s Visit Summary indicated Resident 1 had developed new vitreous hemorrhage ([VH] blood in the center of the eye) and NVG in the right eye since he was last seen by specialist (MD 2) on 7/2023. MD 3 ' s Visit Summary indicated Resident 1 developed new blurred vision a few weeks ago (unspecified date). The Visit Summary indicated MD 3 recommended to schedule tube shunt surgery (a type of glaucoma drainage implant that's used in a surgical procedure to reduce pressure on the optic nerve [responsible for transmitting visual information] and prevent vision loss) with corneal patch (a surgical procedure that can be used in conjunction with tube shunt surgery to treat glaucoma) of the right eye as soon as possible. During a review of Resident 1 ' s Physician ' s Order dated 8/27/2024, the Physician ' s Order indicated recommend right eye urgent glaucoma tube shunt surgery. During a review of Resident 1 ' s Physician ' s Order, the Physician ' s Order dated 9/5/2024 indicated Resident 1 was scheduled for emergency right eye tube shunt surgery with corneal patch on 9/10/2024. During an interview on 9/3/2024 at 2:01 p.m., Resident 1 stated he had been asking multiple facility ' s staff including the IP, SSD 1, and charge nurse (not specified) to send him out to his eye specialist (MD 2) since the day he got to the facility on [DATE]. Resident 1 stated he came to the facility with a left eye cataract and blindness, but his right eye vision was intact. Resident 1 stated he had been seeing an outside retinal specialist (MD 2) prior to coming to the facility and he needed to have a follow up appointment. Resident 1 expressed his concerns to IP, SSD 1, and charge nurse (not specified). Resident 1 stated he was not seen by an outside optometrist (OPT 1) until 3/22/2024 and OPT 1 recommended to see a retina specialist and glaucoma specialist. Resident 1 stated the facility never made the appointment. Resident 1 stated, in June 2024, his right eye vision worsened and now he is blind on both eyes. Resident 1 stated he felt very sad that he cannot see his grandkids football games and does not visit his grandkids anymore because he does not want his family to see him blind. Resident 1 stated he would no longer be able to see the joy on his grandkids faces so he would rather not go to visit them. Resident 1 expressed feeling depressed due to being blind. Resident 1 stated the psychiatrist increased his antidepressant medication Zoloft and he was able to pull himself out of that dark place but still felt depressed. Resident 1 stated he was able to finally see MD 2 and MD 3 in August (8/1/2024 and 8/26/2024 with MD 2, and 8/27/2024 with MD 3) and had a scheduled surgery to place a shunt in his right eye to relieve pressure. Resident 1 stated MD 3 informed him that the surgery may or may not improve his eyesight but felt it was worth to try. Resident 1 stated he was so upset with the facility because he informed multiple facility staff members including the IP, SSD 1, and unspecified charge nurses and no one took him seriously until he got Licensed Vocational Nurse (LVN 4) involved. Resident 1 stated LVN 4 got him an appointment quickly to see MD 2. Resident 1 stated the facility just does not understand that they caused his blindness. During a concurrent observation and interview on 9/4/2024 at 9:15 a.m., Resident 1 was sitting in his wheelchair at his bedside trying to open his bedside drawer. Resident 1 was fumbling around trying to find the drawer knob and knocked his hair gel on the floor and yelled. Resident 1 was unable to see the hair gel on the floor and required assistance to pick it up. Resident 1 had an electric razor in his hand and stated he was going to shave himself off memory and then he would have certified nursing assistant (CNA 1) come in and fix any spots he missed and to help him pick out clothes. During an interview on 9/4/2024 at 11:42 a.m., LVN 4 stated Resident 1 used to be able to see with right eye but now he cannot see on both eyes. LVN 4 stated Resident 1 now required more help with ADLs and needed assistance to open his meal tray when he was able to do that by himself when he was first admitted to the facility on [DATE]. LVN 4 stated Resident 1 was a younger guy and tried his best to be independent even with the worsening eyesight, but now Resident 1 required more help. LVN 4 stated Resident 1 verbalized being upset and depressed due to his worsening eyesight. LVN 4 stated she called Resident 1 ' s health insurance and obtained a list of physicians that they covered since they did not cover MD 4. LVN 4 stated she put herself in the resident ' s shoes and pictured how she would feel if she was losing her eyesight and made it her goal to get Resident 1 an appointment as soon as possible (started working on appointment since 7/2024). LVN 4 stated she was not sure if the appointment would have been scheduled if she was not the one calling the health insurance and getting insurance authorization. LVN 4 stated maintaining vision was very important for physical well-being and decreased vision could exacerbate Resident 1 ' s depression. During an interview on 9/4/2024 at 12:34 p.m., SSD 1 stated her role with scheduling appointments was to ensure the resident had transportation to the appointment and the nursing staff was responsible for scheduling appointments. SSD 1 stated, SSA no longer worked at the facility. SSD 1 stated on 4/2024, Resident 1 gave a phone number for his eye specialist to SSA to help him schedule the appointment and it was not done. SSD 1 stated she talked to SSA about that situation because the nurses were supposed to make the appointments not the SSA or SSD 1. SSD 1 stated when a doctor recommended a specialist, a physician ' s order should have been entered in Resident 1 ' s medical record right away, but it was not done by the nursing staff. During an interview on 9/4/2024 at 12:57 p.m., CM 1 stated nursing staff must get the recommendations from the physician, then nursing staff must enter in Resident 1 ' s medical record the physician ' s orders and communicate with CM 1 that an appointment was needed, and insurance authorization was required. CM 1 stated if licensed nurses do not communicate a physician ' s order for scheduling an appointment was placed, CM 1 would not know insurance authorization was required. CM 1 stated the meaning of next available appointment meant right away. During concurrent interview and record review on 9/5/2024 at 3 p.m., the DON reviewed the Visit Summary from OPT 1 dated 3/22/2024 and confirmed there was a recommendation for Resident 1 to see a retina and glaucoma specialist as soon as possible. The DON stated there were no orders placed after Resident 1 ' s visit with OPT 1 on 3/22/2024 for either a retina specialist or glaucoma specialist and there was no documentation in Resident 1 ' s medical records informing MD 1 for retina and glaucoma specialist evaluation as requested by OPT 1. The DON stated the licensed nurse receiving the After Visit Summaries when resident (in general) returned from an appointment should review the document in its entirety to ensure no recommendations were missed. The DON stated this was not done by the licensed nurse after Resident 1 ' s visit with OPT 1 on 3/22/2024. During an interview on 9/5/2024 at 8:43 a.m., MD 2 stated he began seeing Resident 1 in April of 2023 for diabetic retinopathy and Resident 1 was receiving injections and laser treatment (medical procedure to treat some types of glaucoma) to stop bleeding in the eyes. MD 2 stated he last saw Resident 1 in July of 2023 and Resident 1 was blind on the left eye, but he had 20/15 (can see things at 20 feet that people with normal 20/20 vision can see at 15 feet) vision in the right eye. MD 2 stated there was a large gap in seeing Resident 1 and when Resident 1 was seen on 8/1/2024, here was bleeding in the right eye and Resident 1 had lost his right eye vision. MD 2 stated Resident 1 does have glaucoma and advanced diabetic retinopathy but there were treatments such as medications, injections in the eye, and laser treatments that can stop the bleeding in the eye. MD 2 stated, theoretically, if Resident 1 was seen sooner, his right eyesight could have been preserved and the progression of his eye disease slowed down. During an interview on 9/5/2024 at 9:36 a.m., Resident 1 stated he was angry and felt like no one was doing anything to address his concerns of his worsening eyesight. Resident 1 stated when OPT 1 saw him in March 2024, OPT 1 wanted Resident 1 to see the retina specialist. Resident 1 stated the SSD 1 was supposed to set him up with the retina specialist but acted like she could not find the phone number of the retina specialist. Resident 1 stated he was getting so mad at the facility staff because he did not want his vision to get worse so he would yell at staff sometimes. Resident 1 stated that on 6/30/2024, he still had not seen any specialist for his eyes and he started getting extreme eye pain and his vision was increasingly blurred. He felt as though the facility was not taking him seriously, so he called 911 on 6/30/2024 and was taken to the GACH. Resident 1 stated GACH only washed his eyes with water and told him he needed to see an ophthalmologist and sent him back to the facility because they (GACH) did not know his eye medical history. Resident 1 stated, a few days went by (unknown date in July 2024) and his eyes started watering bad and got even more blurry, so he got upset with the facility staff. Resident 1 stated the DON met with him and SSD 1 and he voiced that his vision was getting worse, and he was upset because he had been telling staff that he needed to see the specialist, and no one was taking him seriously and now he was going blind. Resident 1 stated he still was not getting anywhere with the appointments until LVN 4 got involved in mid-July, when LVN 4 obtained an appointment for him with MD 2. Resident 1 stated that he can no longer see his clothes to pick them out, and usually asks CNA 1 to help him pick clothing from his closet. Resident 1 stated his appearance was very important to him and he always took pride in what he was wearing. Resident 1 stated he felt embarrassed, and he cannot even see what he looked like. Resident 1 stated he would rather not see his family until his eyesight issues were sorted out. Resident 1 stated the facility was not taking him seriously when he informed them about his worsening eyesight and the need to see retina specialist. During an interview on 9/5/2024 at 12:02 p.m., the Minimum Data Set Nurse (MDSN) stated Resident 1 should have a care plan regarding impaired vision when he was first admitted or the potential for decreased eyesight due to his diagnoses of diabetes and diabetic retinopathy. The MDSN stated a vision care plan was important to ensure the resident was going to all needed appointments for the eyes and to ensure all the resident ' s needs were met. The MDSN stated she was unable to locate a vision care plan for Resident 1 upon admission and there was no vision care plan initiated until 3/20/2024. The MDSN stated Resident 1 ' s MDS dated [DATE] was coded as the resident had a moderately impaired vision because he could see but it was not clear. The MDSN stated Resident 1 complained about complete vision loss in August 2024, so

Based on interview and record review, the facility failed to ensure the physician was informed of a resident's change in condition (COC) for one of six sampled residents (Resident 1). The facility failed to: 1. Notify Resident 1's physician of Resident 1's continuously high blood sugar (b/s) level for four consecutive days. 2. Notify Resident 1's physician of Resident 1's COC on [DATE], including confusion, lethargy (a state of being drowsy and dull, listless, and unenergetic, indifferent, and lazy, sluggish, and inactive), inability to speak with an oxygen saturation rate of 70% ([O2 Sat] the oxygen concentration level in blood. The reference range is ,d+[DATE]%) on room air. 3. Ensure Licensed Vocational Nurse (LVN 1) notify Resident 1's physician when received a report of Resident 1's change in condition on [DATE] to not delay resident's evaluation and treatment leading to complications of hyperglycemia. This deficient practice resulted in Resident 1 having uncontrolled hyperglycemia (higher than normal amount of glucose (a type of sugar) in the blood) from [DATE] through [DATE]. On [DATE] Resident 1 was noted with confusion, and agitation with deep rapid breathing, an O2 Sat of 70 % on room air, a change in mental status, he was lethargic and became non-responsive. Resident 1 expired at the facility on [DATE] at 2:10 p.m. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including diabetes mellitus ([DM] a disease associated with abnormally high levels of sugar in the blood). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 1, was able to make independent decisions that were reasonable and consistent. During a review of Resident 1's Physician's Order Summary Report dated ,d+[DATE], the Physician's Order Summary indicated the following orders: 1. An order dated [DATE] for Insulin Glargine (a long-acting insulin used to treat DM by lowering the amount of sugar in the blood) solution 100 units per milliliter ([ml] a unit of liquid measurement), to inject 15 units subcutaneously ([SQ] under the skin) at bedtime (9 p.m.) for DM. 2. An order dated [DATE] for Insulin Lispro (a rapid acting form of insulin used to treat DM by lowering the amount of sugar in the blood) injection solution, 100 units per ml, to inject per the Sliding Scale (the progressive increase in the pre-meal or night time insulin dose based on pre-defined blood glucose ranges) subcutaneously before meals and at bedtime for DM. The sliding scale directions indicated the following: 1. For a b/s level range from 70 milligrams/deciliter ([mg/dl] unit of blood sugar measurement) to 150 mg/dl do not give insulin. 2. For a b/s level range from 151 to 200 administer two units of insulin SQ. 3. For a b/s level range from 201 to 250 administer four units of insulin SQ. 4. For a b/s level range from 251 to 300 administer six units of insulin SQ. 5. For a b/s level range from 300 to 350 administer eight units of insulin SQ. 6. For a b/s level range from 351 to 400 administer 10 units of insulin SQ. 7. For a b/s level range from 401 to 450 administer 12 units of insulin SQ. 8. For a b/s level greater than 450 call the primary doctor. During a review of Resident 1's Medication Administration Record (MAR) dated ,d+[DATE], the MAR indicated Resident 1's b/s level and administration of Insulin Lispro per Sliding Scale was as follows: 1. On [DATE] at 6:30 a.m., b/s level was 320 mg/dl, and 8 units of insulin were administered. 2. On [DATE] at 4:30 p.m., b/s was 428 mg/dl, and 12 units of insulin were administered. 3. On [DATE] at 6:30 a.m., b/s level was 396 mg/dl, and 10 units of insulin were administered. 4. On [DATE] at 11:30 a.m., b/s level was 322 mg/dl, and 8 units of insulin were administered. 5. On [DATE] at 4:30 p.m., b/s level was 378 mg/dl, and 10 units of insulin were administered. 6. On [DATE] at 9:00 p.m., b/s level was 386 mg/dl, and 10 units of insulin were administered. 7. On [DATE] at 6:30 a.m., b/s level was 447 mg/dl, and 12 units of insulin were administered. 8. On [DATE] at 11:30 a.m., b/s level was 431 mg/dl, and 12 units of insulin were administered. 9. On [DATE] at 4:30 p.m., b/s level was 446 mg/dl, and 12 units of insulin were administered. 10. On [DATE] at 9:00 p.m., b/s level was 450 mg/dl, and 12 units of insulin were administered. 11. On [DATE] at 6:40 a.m., b/s level was 435 mg/dl, and 12 units of insulin were administered. 12. On [DATE] at 11:30 a.m., b/s was 445 mg/dl, and 12 units of insulin were administered. During a review of Resident 1's Progress Note dated [DATE] at 2:30 p.m., the Progress Note indicated at 2:10 p.m., Resident 1 was not responsive to stimuli (anything that can trigger a physical or behavioral change), was pale and not breathing, his pupils were dilated (pupils that do not respond to light, they widen, often a sign of clinical death or brain death) and staff were unable to obtain any of his vital signs ([v/s] clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). During a review of Resident 1's Progress Note dated [DATE] at 10:05 p.m., the Progress Note indicated Resident 1 expired at the facility on [DATE] at 2 p.m. During a review of Resident 1's medical record, the medical record indicated there was no documented evidence that a Progress Note or COC was created to indicate Resident 1's physician was notified of Resident 1's continuously high b/s levels for four consecutive days from [DATE] to [DATE] or his COC on [DATE]. According to Nationally Recognized Cleveland Clinic blood sugar level above 125 mg/dl indicative of diabetes and blood sugar level greater 180 mg/dl is hyperglycemia and requires a prompt attention. https://my.clevelandclinic.org During a telephone interview on [DATE] at 4:03 p.m., Certified Nursing Assistant (CNA 6) stated on [DATE], earlier that morning, Resident 1 was asleep and snoring with his mouth wide open. CNA 6 stated at breakfast time (,d+[DATE]:30 a.m.) Resident 1 did not have an appetite and only sipped on water and a diabetic shake (a shake given to diabetics that help improve b/s control). CNA 6 stated she reported that to LVN 1, who was the charge nurse. CNA 6 stated she checked on Resident 1 every hour and he seemed a bit agitated and kept taking off his gown saying he was hot, hot, hot, she had to pull his gown and sheet down to his waist. CNA 6 stated Resident 1 was restless, moving around in bed and looked pale. CNA 6 stated by lunch time (12 p.m.) she noticed Resident 1 was more confused and agitated. She tried to reposition him, but he kept trying to take his gown off, and said he felt very hot and was thirsty and asking for a lot of water. CNA 6 stated at 1:15 p.m., on the same day ([DATE]), Resident 1 appeared weak, but he was still trying to move around in bed, and whispered something to her, but she could not understand what he was trying to say. CNA 6 stated she reported Resident 1's COC to LVN 1. During a telephone interview on [DATE] at 4:26 p.m., CNA 3 stated on [DATE] at 1:45 p.m., CNA 3 went to Resident 1's room to wait for the Treatment Nurse (TN 1) so she could assist her (TN 1) with collecting a urine sample from Resident 1. CNA 3 stated she touched Resident 1's skin and it was warm and when she tried to talk to him, Resident 1 opened his jaw wide and stopped breathing. CNA 3 stated she rushed out of Resident 1's room to report Resident 1's status to TN 1 as she (TN 1) was coming into Resident 1's room. During a telephone interview on [DATE] at 4:47 p.m., TN 1 stated on [DATE] at 1:45 p.m., she observed Resident 1 sleeping in his bed, she then left his room to get supplies to collect a urine sample from Resident 1. TN 1 stated, CNA 3 rushed out of Resident 1's room and reported to her that Resident 1 was gone. TN 1 stated she tried to palpate (examine a part of the body by touch) Resident 1's carotid pulse (the pulse by the angle of the jaw on either side of the neck) but was not sure if she felt any pulse. During a telephone interview on [DATE] at 10:21 a.m., Resident 1's Responsible Party (RP 2) stated Resident 1's family member (FM) called her on [DATE] at lunch time (12 pm) and informed her that he (the FM) tried to call Resident 1 around 11 a.m., on [DATE] but Resident 1 did not answer his phone. RP 2 stated Resident 1's FM told her Resident 1's phone was finally answered by a therapist (Certified Occupational Therapist Assistant 1 [COTA 1]) and he (the FM) heard Resident 1 in the background sounding confused and slurring his words. RP 2 stated Resident 1's FM was told by the COTA that Resident 1 was very sleepy, and he was unable to stay awake. During an interview on [DATE] at 11:13 a.m., the Physical Therapy Assistant (PTA 1) stated on [DATE] at 11:45 a.m., he observed that Resident 1 was very sleepy, his breathing was labored, and he was trying to speak in a low muffled voice but was not understandable. PTA 1 stated he and COTA 1 checked Resident 1's O2 Sat and it was 70%. PTA 1 stated he informed LVN 1 about Resident 1's condition. PTA 1 stated LVN 1 reassessed Resident 1's v/s, saw that his O2 Sat was at 70% and placed Resident 1 on 3 liters (l) of oxygen (O2). PTA 1 stated after O2 was administered to Resident 1 his O2 Sat was in the 80s and his breathing was better. During an interview on [DATE] at 11:39 a.m., COTA 1 stated on [DATE] at 11:45 a.m., Resident 1 was not responding to questions, his breathing was slow and labored, he was lethargic and mumbling words that he and PTA 1 could not understand. COTA 1 stated they checked Resident 1's O2 Sat and it was 72%, he and PTA 1 reported Resident 1's COC to LVN 1. The COTA stated LVN 1 rechecked Resident 1's v/s, confirmed his O2 Sat was at 70% and started Resident 1 on 3 liters (l) of oxygen (O2). The COTA stated he and PTA 1 remained in the room with Resident 1 until his v/s were better and his O2 Sat was 87%. LVN 1 instructed us not to continue with therapy for that day and we left Resident 1 in LVN 1's care During an interview on [DATE] at 11:57 a.m., after reviewing Resident 1's MAR, LVN 1 stated Resident 1's b/s level had been abnormally high for four days. LVN 1 stated she did not call Resident 1's physician to notify him of Resident 1's high b/s level because the sliding scale directions were to call the doctor if Resident 1's b/s was over 450 mg/dl and Resident 1's b/s levels were never that high. LVN 1 stated on [DATE], Resident 1 was alert earlier during the day but refused to eat. LVN 1 stated she called Resident 1's physician to notify him of Resident 1's poor intake and he ordered a urine analysis ([UA] a test of the urine used to check for infection, kidney problems or DM) with a culture and sensitivity ([C&S] a test of the urine to check for bacteria or other germs). LVN 1 stated she was never informed about Resident 1's condition by the PTA 1 and COTA 1 at 11:45 a.m., or by CNA 6 at 1:15 p.m. LVN 1 stated at 1:45 p.m., ([DATE]) when she was informed by TN 1 that Resident 1 was not breathing, she tried to take Resident 1's v/s, but they were not registering. LVN 1 stated she and the other licensed nurses should have notified Resident 1's physician that Resident 1's b/s level was consistently high to prevent Resident 1 from having serious complications. During a telephone interview on [DATE] at 6:08 p.m., LVN 2 stated she did not call Resident 1's physician despite Resident 1's high b/s levels because his b/s levels fell below the parameters to call. LVN 2 stated she had access to Resident 1's b/s history via the MAR but she did not recognize Resident 1's continued elevated b/s levels and Resident 1's physician should have been notified of Resident 1's consistently high b/s levels. During an interview on [DATE] at 12:24 p.m., after reviewing Resident 1's MAR, Registered Nurse Supervisor (RNS 1) stated Resident 1's b/s level had been elevated for four days in a row and Resident 1's prolonged elevated b/s levels placed him at risk of developing complications due to hyperglycemia. During an interview on [DATE] at 1:34 p.m., after reviewing Resident 1's MAR, the Director of Nursing (DON) confirmed, Resident 1's b/s levels were elevated during the past four days. The DON stated Resident 1's b/s levels could have been controlled if Resident 1's physician had been notified of Resident 1's continued elevated b/s levels to prevent complications related to hyperglycemia. The DON stated if LVN 1 was informed of Resident 1's COC, she should have assessed Resident 1 and notified Resident 1's physician of her findings. According to Nationally Recognized Cleveland Clinic not receiving enough insulin or other medication to lower blood sugar can lead to hyperglycemia. It is important to treat hyperglycemia. If it is not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma and death. Hyperglycemia usually does not cause symptoms until blood sugar levels are high above 180 mg/dl. If blood sugar rises very high or if high blood sugar levels are not treated, it can lead to two serious conditions: Diabetic ketoacidosis (a serious complication of diabetes that can be life-threatening). If it is not treated, diabetic ketoacidosis can lead to a diabetic coma that can be life-threatening. Hyperosmolar hyperglycemic state (is a life-threatening emergency). If it is not treated, a diabetic hyperosmolar hyperglycemic state can lead to life-threatening dehydration, coma, and death. https://my.clevelandclinic.org During a telephone interview on [DATE] at 2:04 p.m., Resident 1's Physician stated he was not notified of Resident 1's uncontrolled b/s levels nor was he notified of Resident 1's COC on [DATE] at 11:45 a.m., (almost three hours before Resident 1's death at 2:10 p.m., on [DATE]). Resident 1's physician stated if he had been notified of Resident 1 continuously high b/s levels, he could have adjusted Resident 1's medication, and the Insulin sliding scale, ordered labs, and transferred Resident 1 to a General Acute Care Hospital (GACH) as needed. Resident 1's physician stated Resident 1 was in a prolonged state of hyperglycemia that could have contributed to a cardiac event costing him his life. During a review of the facility's Policy and Procedure (P/P), titled, Diabetic Care, revised [DATE], the P/P indicated the facility will ensure residents with diabetes will achieve optimal well-being and must be provided necessary care and services to permit each resident, while monitoring their care for signs and symptoms of hyperglycemia and/or hypoglycemia, initiate interventions as necessary and notify the Attending Physician and responsible party if signs and symptoms are present. During a review of the facility's P/P titled, Change of Condition Notification, revised [DATE], the P/P indicated the facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representatives or an interested family member, when the resident endures a significant change of condition caused by, but not limited to a significant change in resident's physical, mental and/or psychosocial status. The licensed nurses' responsibility to assess the resident during a change in condition and determine the appropriate interventions and to report any emergency resident situation to the physician immediately; especially if the resident is rapidly deteriorating and the symptoms are serious.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to prevent adverse events for three of six sampled residents (Residents 1, 2, and 3) and failed to accurately document medication administration for six of six sampled residents (Residents 1, 2, 3, 4, 5, 6) out of 48 residents receiving narcotic medications. The facility failed to: 1. Ensure Resident 1, who was prescribed Hydrocodone-Acetaminophen ([Norco] an opioid [medication used to treat moderate to severe pain]) did not receive excessive doses of the medication. 2. Ensure Resident 2, who had a history of hypotension (abnormally low blood pressure [B/P] the force of blood pushing against the walls of the blood vessels which is usually less than 120/80 millimeters of mercury (mmHg) unit of measurement) was not administered Norco without taking the resident's blood pressure. 3. Ensure Licensed Vocational Nurse 4 (LVN 4) administered medications that she prepared for Resident 3 and did not give prepared medications to LVN 5 and LVN 6 to administer to Resident 3. 4. Ensure LVN 5 and LVN 6 did not administer medications to Resident 3 that they did not prepare themselves and did not validate the accuracy of the medications against the physician's order and/or the Medication Administration Record (MAR) prior to administration of the medication to the resident. 5. Ensure LVN 2, 4, 5, 6 and 7 accurately documented medications that were administered to Residents 1, 2, 3, 4, 5, and 6 on the MAR and/or the Controlled Drug Receipt/and Disposition ([CDRD] a form used to document and track the administration of controlled substances [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction and may cause significant risk to patient safety]). 6. Ensure the licensed nurses followed the facility's P&P titled Medication-Administration, to prepare medications within one hour of administration and administer medications one hour before or one hour after the scheduled medication administration time. 7. Ensure LVN 4 and LVN 5 and LVN 6 followed the facility's P&P titled Medication-Administration, to administer medications to Resident 3 by the licensed nurse preparing the medication. 8. Ensure the licensed nurses followed the facility's P/P titled, Preparation and General Guidelines for Controlled Medications, to immediately enter the date and time of control medication administration, the signature of the nurse administering the dose, completed after the medication was administered on the accountability record and the MAR. 9. Ensure the licensed nurses followed the facility's P/P titled Pain Management, revised 11/2016, to assess and monitor a resident's level of consciousness and vital signs prior to administration of each dose of opioid to Resident 2 and other 47 residents in the facility receiving opioid medication. These deficient practices resulted in Resident 1 and Resident 2 being transferred to a General Acute Care Hospital (GACH) for evaluation and treatment related to a possible opioid overdose (an excessive and dangerous dose of a drug). Resident 1 was monitored in the emergency room for altered mental status, with an admitting diagnosis of medication overdose and was discharged back to the facility with a diagnosis of confusion. On 6/23/2023 Resident 2's B/P was assessed as 87/49 mmHg, his heart rate ([HR] the number of times each minute that the heart beats, which is normally between 60 and 100 times per minute for adults) was 118 beats per minute (bpm) and his oxygen saturation ([O2 Sat] the amount of oxygen in the blood which normally ranges between 95% - 100%) was 79%-89% on room air (when a person is not receiving any additional oxygen). Resident 2 was transferred to a GACH for evaluation on 6/23/2023 and as of 6/26/2023, Resident 2 had not returned to the facility. These deficient practices placed Residents 3, 4, 5, and 6 at risk for mismanagement of their medication regimen, medication adverse effects, including drowsiness (excess sleepiness), stupor (state of near unconsciousness) and/or insensibility (lack of physical sensibility) related to inaccurate documentation and/or non-reconciliation (the process of identifying the most accurate list of all medications that the patient is taking by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider) of their prescribed medications and/or controlled substances. These deficient practices had the potential for increase in pain and/or uncontrolled pain, for Residents 1, 2, 3, 4, 5, 6 and 42 other residents residing in the facility who received opioids, medication errors and diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of narcotics (a medication used to relieve moderate to severe pain). On 6/27/2023 at 12:06 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM), the Corporate Clinical Consultant 1 (CCC 1) and CCC 2. On 6/28/2023 at 5:25 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP] an intervention to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 6/29/2023 at 9:45 a.m., in the presence of the ADM, the CCC 3, and the Medical Records Consultant (MRC). The IJRP included the following: 1. On 6/19/2023, Resident 1 returned from the GACH to the facility and was reassessed by the licensed nurse. The primary care physician was notified of Resident 1's return to the facility and all of Resident 1's medication orders were verified and carried out. 2. On 6/21/2023, the DON/licensed nurse designee assessed all forty-eight residents for signs and symptoms of possible opiate overdose. No other residents were found to be affected. 3. On 6/21/2023 the DON/Designee and the Resource Nurse initiated in-service education to licensed nurses to review the following: pain management policy and procedures, opioid medication management and use of naloxone ([Narcan] medication used to reverse or reduce the effects of opioids) as warranted and medication administration with emphasis on pour, pass and documentation by the nurse who administers the medications. 4. On 6/23/2023, the ADM/Designees conducted interviews of interview able residents regarding any potential concerns related to medications, which included but was not limited to other licensed nurses administering medications that they did not prepare. No other residents were found to be affected. 5. As of 6/26/2023, Resident 2 had not returned to the facility. 6. On 6/22/2023, Resident 3's primary care physician was notified regarding medication administration prepared by another licensed nurse. A urine drug toxicology (various tests which determine the type and approximate amount of legal and illegal drugs a person has taken) was completed on 6/23/2023 with no other medications flagged. 7. As of 6/27/2023, LVNs 4, 5, and 6's employment was concluded. LVN 4 resigned on 6/20/2023, LVN 5 resigned on 6/26/2023, and LVN 6 was suspended on 6/23/2023 and was subsequently terminated on 6/28/2023. 8. On 6/27/2023, the facility's Licensed Pharmacist (LP) provided an in-service education to ten licensed nurses who were on duty which included medication administration, with emphasis on signs and symptoms of opioid overuse. 9. On 6/27/2023, the Resource Nurse conducted medication administration competency assessments for the licensed nurses. 10. On 6/27/2023, the Director of Nursing/Designees initiated an audit of current residents with opioids to ensure the residents did not receive excessive doses of opioids within the last seven days. There were forty-eight residents with opioid orders and no other residents were affected with excessive doses. 11. On 6/27/2023, the DON/Designees initiated an audit of current residents with opioid orders to ensure the licensed nurses accurately documented in the Medication Administration Record (MAR) and on the Controlled Drug Receipt/and Disposition ([CDRD] a document used to document and track the administration of controlled substances [medications having a high potential for abuse and dependence, with significant risk to patient safety). There were forty-eight residents with opioid orders and seventeen were affected. Corrective actions including assessment of residents and physician notification will be completed by 6/28/2023. 12. On 6/27/2023, the DON/Designees initiated an audit of current residents with opioid orders to ensure vital signs (measurements of the body's most basic functions) were taken prior to the administration of each dose of opioid. There are forty-eight residents with orders for opioid(s) and all were identified to have been affected. The licensed nurses notified the attending physicians for the affected residents and obtained orders to monitor vital signs prior to administration of opioids. Audit and corrections will be completed by 6/28/2023. Findings: a. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including polyneuropathy (when multiple peripheral nerves [the nerves which branch out from the brain or spinal cord] become damaged affecting the nerves of the skin, muscles, and organs), and chronic pain (pain which lasts for more than three months, or in many cases, beyond normal healing time). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/31/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 1 required extensive one-person physical assistance to eat, for toilet use, personal hygiene, bathing, and bed mobility. The MDS indicated Resident 1 received opioids, antipsychotic (a class of medicines used to treat psychosis [abnormal condition of the mind]) medication, and antidepressant medication (a class of medications used to treatment of depression [illness characterized by persistent sadness and a loss of interest in activities one would normally enjoy). A review of Resident 1's History and Physical (H&P), dated 3/15/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Care Plan (CP) dated 11/3/2021, indicated Resident 1 was on pain medication therapy related to neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), chronic pain syndrome, and osteoarthritis (degenerative disease which worsens over time, often resulting in chronic pain). The CP's goal indicated Resident 1 would be free of any discomfort or adverse side effects from pain medication through the review date of 6/13/2023. The CP's interventions included to administer Resident 1's analgesic (medications used to relieve pain) medications as ordered by the physician, monitor the respiratory rate, depth (the amount of air which is inhaled or exhaled in a single breath), and effort (the act or process of breathing) after administration of pain medications, and to monitor/document/report adverse reactions to analgesic therapy including altered mental status (abnormal state of alertness or awareness), dizziness, respiratory distress (a life threatening condition where the lungs cannot provide the body's vital organs with enough oxygen) and sedation (a state of calmness, relaxation, or sleepiness caused by certain drugs). A review of Resident 1's Order Summary Report ([OSR] physician's orders), indicated Resident 1 was to receive the following medications: 1. Lyrica (Pregabalin) 75 milligrams ([mg] a unit of measurement) once a day for nerve pain ordered on 7/29/2023. 2. Norco 5-325 mg every six hours for pain management ordered on 6/15/2023. A review of Resident 1's MAR dated 6/2023, indicated Resident 1 received Lyrica on 6/18/2023 at 9 a.m. A review of Resident 1's the CDRD form dated 6/2023, indicated there was no documentation to indicate Lyrica 75 mg was administered to Resident 1 on 6/18/2023 at 9 a.m. A review of Resident 1's MAR, dated 6/2023, indicated Resident 1's doses of Norco were scheduled at 12 a.m., 6 a.m., 12 p.m., and 6 p.m. A review of Resident 1's Medication Admin Audit Report ([MAAR] a document indicating the exact time medications were documented as administered) dated 6/21/2023, indicated Norco was administered to Resident 1 as follows: 1. On 6/17/2023 - Norco was scheduled to be administered at 6 p.m., however, according to the MAAR Norco was administered to Resident 1 at 10:22 p.m. (over four hours after the scheduled dose). 2. On 6/18/2023 - Norco was scheduled to be administered at 12 a.m., however, according to the MAAR, Norco was administered to Resident 1 at 7:44 a.m. (over seven hours after the scheduled dose). 3. On 6/18/2023 - Norco was scheduled to be administered at 6 a.m., however, according to the MAAR, Norco was administered to Resident 1 at 7:44 a.m. (two doses of Norco was administered at 7:44 a.m. according to documentation). 4. On 6/18/2023 - Norco was scheduled to be administered at 12 p.m., however, according to the MAAR, Norco was administered to Resident 1 at 11:22 a.m. (less than the six hours between doses that the physician prescribed). 5. On 6/18/2023 - Norco was scheduled to be administered at 6 p.m., however, according to the MAAR, Norco was administered to Resident 1 at 10:35 p.m. (over four after Resident 1's scheduled dose at 6 p.m.). A review of Resident 1's CDRD for Norco 5-325 mg dated 6/2023, indicated on 6/18/2023, Resident 1 was administered Norco 5-325 mg at 1 p.m., and at 6 p.m., indicating Resident 1 received a total of seven doses of Norco 5-325 mg within 24 hours (6/18/2023), which was not in accordance with the physician's order of four doses in 24 hours. A review of Resident 1's Transfer to Hospital Summary (THS), dated 6/19/2023 and timed at 4 a.m., indicated at 3:15 a.m., Resident 1 was unresponsive to stimuli (an individual whose level of consciousness is such that they are not responsive to irritants, sights, smells, sounds, or temperature changes). The THS indicated Resident O2 Sat was 87% on room air. A review of Resident 1's Incident Report ([IR] used by emergency medical responders ([EMRs] provide immediate lifesaving care to critical patients who are not in not in the hospital) dated 6/19/2023, indicated Emergency Medical Response ([EMS] a system which provides emergency medical care) were called to the skilled nursing facility (SNF). The IR indicated Resident 1's level of consciousness was six based on the Glasgow Coma Scale ([GCS] a clinical scale used to measure a person's level of consciousness, scored between three and 15 with three being the worst and 15 being the best). The IR indicated Resident 1 was unresponsive with pinpoint pupils (black part of the eye which remains very small even in bright light) and an O2 Sat of 88%. The IR indicated the EMS administered Narcan 4 mg intranasally ([IN] in the nose) and Resident 1 was subsequently transferred to a GACH due to altered level of consciousness ([ALOC] the patient is not as awake, alert, or able to understand or react to the surrounding environment) and overdose. A review of Resident 1's GACH Discharge Instructions (DI), dated 6/19/2023, indicated Resident 1 was evaluated for medication overdose and discharged the same day (6/19/203) with a diagnosis of confusion. The DI indicated confusion may be caused by using too much medicine. During an interview on 6/23/2023 at 9:36 a.m., LVN 2 stated on 6/18/2023 for the 6 p.m., Norco dose, he documented on the MAR that Norco was given at 9:22 p.m. LVN 2 stated there were so many interruptions during his shift that he could not remember what time he actually gave Resident 1 Norco. LVN 2 stated he did not document the 12 a.m., and 6 a.m., doses of Norco on the CDRD on 6/18/2023 and stated he could not remember if he had already administered the medications to Resident 1. LVN 2 stated on 6/18/2023 at 7:44 a.m., he documented the 12 a.m., and 6 a.m., doses of Norco on the MAR but stated he could not remember what time he actually gave Resident 1 her Norco, or if both doses were given at 7:44 a.m. During an interview on 7/1/2023 at 8:37 a.m., Paramedic 1 (PM 1) stated when he arrived at the facility on 6/19/2023 at 3:21 a.m., LVN 8 (who refused to give PM 1 her name) told him (PM 1) that Resident 1's last dose of Norco was on 6/18/2023 at 6 p.m., but when LVN 8 showed him the CDRD sheet, he (PM 1) observed LVN 8 cross out the doses of Norco that were documented at 12 a.m., and 6 a.m., on 6/19/2023. PM 1 stated he assessed Resident 1 at 3:26 a.m., with pinpoint pupils, a GCS of six, and a low O2 Sat of 88% which was indicative of a narcotic overdose. PM 1 stated he administered Narcan 4 mg IN to Resident 1 at 3:35 a.m., and Resident 1's O2 Sat increased to 96% without administering oxygen. PM 1 stated usually if Narcan is given and it is not related to opioid overdose, there would not be an improvement in the resident's status. PM 1 stated when he tried to interview LVN 8 to clarify why she crossed out the 12 a.m., and 6 a.m., doses of Norco on the CDRD, she refused to speak to him. PM 1 stated he was concerned that LVN 8 was documenting medications as given on the CDRD for 6 a.m., when it wasn't 6 a.m., yet and he was also concerned why she would cross out the 12 a.m., dose of Norco and that Resident 1 may have received a double dose of Norco. b. A review of Resident 2's Face Sheet, indicated Resident 2 was admitted to the facility on [DATE]. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had the ability to understand and be understood by others. The MDS indicated Resident 2 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 2 was totally dependent on staff for activities of daily living [ADL] essential, everyday tasks necessary for self-sufficiency and independent living) and required an extensive two plus persons physical assist for transfers and a one-person physical assist for bed mobility, dressing, eating, toilet use and personal hygiene. The MDS indicated, Resident 2 received opioids and antidepressant medication. A review of Resident 2's H&P, dated 6/1/2023, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's OSR dated 6/2023, indicated Resident 2 was to receive the following medications: 1. Midodrine Hydrochloride 5 mg three times a day for hypotension ordered on 5/31/2023. 2. Norco 5-325 mg, 1 tablet every six hours as needed for moderate pain, ordered on 5/31/2023 and discontinued on 6/21/2023. 3. 6/21/2023 - Norco 5-325 mg, 1 tablet every six hours as needed for moderate pain. 4. Norco 5-325 mg 2 tablets every six hours as needed for severe pain ordered on 6/21/2023 A review of Resident 2's CP dated 8/18/2022, indicated Resident 2 had acute/chronic pain related to his disease process, trauma (injury) to his cervical spine (the neck region of your spinal column or back bone), status post (condition after any types of surgery or procedure) multilevel cervical spine laminectomy (surgical procedure to relive pressure or compression on the nerve structures), muscle spasms and neuropathic (a nerve problem which causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) pain. The CP indicated Resident 2 was at risk for opioid overdose and would display a decrease in behaviors of inadequate pain control including, irritability, agitation, restlessness, grimacing (facial expression usually of disgust, disapproval, or pain), perspiring, hyperventilation (rapid or deep breathing), groaning, and crying though the review date of 6/21/2023. The CP interventions indicated to monitor side effects of the pain medication and document. A review of Resident 2's CDRD for Norco 5-325 dated 6/2023, indicated Resident 2 received Norco on 6/9/2023 at 12:30 p.m. A review of Resident 2's MAR for 6/2023 indicated there was documentation indicating that Norco was administered to Resident 2 on 6/9/2023. During an observation, concurrent interview, and record review with LVN 2 on 6/23/2023 at 6:36 a.m., and 6:39 a.m., LVN 2 was observed administering Norco to Resident 2 without assessing Resident 2's vital signs ([v/s] measurements of the body's most basic functions), or pain level prior to administering Norco. LVN 2 stated Norco was given to Resident 2 because of Resident 2's complaint of a pain level of eight out of 10 on a pain scale from zero to 10 (a scale that measures a resident's pain intensity, where zero equals no pain, one to three equals mild pain, four to seven is considered moderate pain and eight and above is severe pain). A record review with LVN 2 of Resident 2's MAR and CDRD for Norco 5-325 mg indicated Resident 2 received Norco 5-325 mg, two tablets on 6/23/2023 at 5:14 a.m. Resident 2's respiratory rate ([RR] the number of breaths a person takes per minute, which can range between 12 to 20 breaths per minute) was 18 breaths per minute (bpm) and his pain level was an eight out of ten. LVN 2 stated he did not have a reason why he documented Resident 2's Norco administration at 5:14 a.m., when he actually administered the Norco to Resident 2 at 6:38 a.m. LVN 2 stated he did not check Resident 2's B/P or respiratory rate and he did not access Resident 2's pain level prior to administering Norco. LVN 2 stated there was no need to check Resident 2's B/P because it was not time for Resident 2 to receive his B/P medication. LVN 2 stated there was a risk of over medicating Resident 2 because of his (LVN 2's) inaccurate documentation of the time Norco was administered to Resident 2, not assessing Resident 2's v/s prior to administering Norco and not assessing Resident 2's pain to determine if Norco was indicated. LVN 2 stated overmedicating a resident could result in overdose which is indicated by low blood pressure, decreased respirations, low O2 Sat, hospitalization , and possible death. LVN 2 stated, this was not the first time he documented a medication was administered prior to administering the medications. During an interview on 6/23/2023 at 8:05 a.m., LVN 3 stated she received a report that Resident 2 was not feeling well. LVN 3 stated she assessed Resident 2 and found his BP was 87/49 mmHg, his heart rate was 118 bpm, and his O2 Sat was 79%-88% on room air. A review of Resident 2's Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form (TF), dated 6/23/2023 and timed at 8:18 a.m., indicated Resident 2 was transferred to a GACH. c. A review of Resident 3's Face Sheet, indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including streptococcal arthritis (bacteria or other tiny disease-causing organisms spread though the blood to a joint) of the left knee, type 2 diabetes mellitus ([DM] a chronic condition which affects the way the body processes blood sugar), congestive heart failure ([CHF] a chronic condition in which the hard doesn't pump blood as well as it should), and essential hypertension (abnormally high blood pressure which is not a result of a medical condition). A review of Resident 3's MDS dated [DATE], indicated Resident 3 had the ability to understand and be understood by others. The MDS indicated Resident 3 made independent decisions that were reasonable and consistent. The MDS indicated Resident 3 received opioids, antidepressant medication, and insulin (a hormone which lowers the level of glucose [a type of sugar] in the blood). A review of Resident 3's H&P dated 8/20/2022, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's OSR dated 6/23/2023, indicated Resident 3 was to receive the following medications: 1. Allopurinol tablet 100 mg once a day for gout (type of inflammatory arthritis which causes pain and swelling in the joints), scheduled at 9 a.m., ordered on 8/20/2022. 2. Aspirin Chewable tablet 81 mg in the morning for Cerebrovascular Accident ([CVA] a stroke) prophylaxis (action taken to prevent disease), scheduled at 9 a.m., ordered on 8/20/2022. 3. Carvedilol tablet 3.125 mg two times a day for hypertension ([HTN] when the pressure in the blood vessels is too high, usually reading 140/90 or higher), scheduled at 8 a.m., and 5 p.m., ordered on 8/20/2022. 4. Dorzolamide Hydrochloride Timolol Mal Solution 22.3-6.8 mg/mL 1 drop in left eye two times a day for glaucoma (a group of eye diseases which cause vision loss and blindness), scheduled at 9 a.m. and 5 p.m., ordered on 8/20/2022. 5. Multivitamin-Minerals tablet once a day as a supplement, scheduled at 9 a.m., ordered on 8/23/2022. 6. Docusate Sodium Capsule (a stool softener) 250 mg in the morning for bowel management, scheduled at 9 a.m., ordered on 9/2/2022. 7. Calcium tablet 500 mg once a day as a supplement, scheduled at 9 a.m., ordered on 10/3/2022. 8. Lantus Solution 100 units/milliliters ([mL] a unit of fluid measurement) subcutaneously (under the skin) one time a day for diabetes ([DM] a disease which occurs when the blood sugar is too high), scheduled at 9 a.m., ordered on11/22/2022. 9. Vitamin D capsule 125 micrograms ([mcg] a unit of measurement) one time a day as a supplement, scheduled at 9 a.m., ordered on 11/22/2022. 10. Ascorbic Acid tablet 500 mg once a day as a supplement, scheduled at 9 a.m., ordered on 1/31/2023. 11. Norco 10-325 mg two times a day for pain management, scheduled at 9 a.m. and 9 p.m., ordered on 2/28/2023. 12. Farxiga Oral tablet 5 mg once a day for DM, scheduled at 9 a.m., ordered on 3/23/2023. 13. Amlodipine Besylate Tablet 10 mg once a day for hypertension, scheduled at 9 a.m., ordered on 5/8/2023. During an interview on 6/21/2023 at 11:34 a.m., Resident 3 stated on 6/11/2023 and on 6/18/2023, LVN 4 prepared his medications but handed them to LVN 5 to administer to him. Resident 3 stated on 6/19/2023 he received medications prepared by LVN 4 but were administered to him by LVN 6. Resident 3 stated both LVN 5 and LVN 6 admitted to him that LVN 4 prepared his medications. Resident 3 stated he knew the medications were prepared by a medication nurse that was not familiar with him because one of his medications was usually cut in half and he noticed those days the medication was not cut in half. Resident 3 stated both LVN 5 and LVN 6 were not his assigned nurses the days he received the medications prepared by LVN 4 and not only did he receive medications prepared by another LVN, but they were given to him late. Resident 3 stated he did not get along with LVN 4 and she was not supposed to be assigned as his medication nurse. Resident 3 stated he was fearful his medications were tampered with because LVN 5 and LVN 6 indicated LVN 4 did not validate that the medication prepared by LVN 4 were correct prior to administering them to him. Resident 3 stated he was told by LVN 5 and LVN 6 that LVN 4 handed them Resident 3's medications to give to him without telling them what medications he was receiving. A review of the facility's Nurse Staffing Assignment and Sign-In Sheet (NSIS) dated 6/11/2023 during the 7 a.m., to 3 p.m., shift, indicated LVN 4 was assigned to Resident 3 as the charge nurse (a nurse who typically administers medication) on Station 2 , where Resident 3 resided. The NSIS indicated LVN 5 was assigned as the Treatment Nurse ([TN] a nurse who treats patient's skin wounds). A review of the facility's NSIS dated 6/18/2023 during the 7 a.m., to 3 p.m., shift LVN 4 was assigned to Resident 3 as the charge nurse on station 2, where Resident 3 resided. The NSIS indicted LVN 6 was assigned as the TN. A review of the facility's NSIS dated 6/19/2023 during the 7 a.m., to 3 p.m., shift indicated LVN 4 was assigned to Resident 3 as the charge nurse on station 2, where Resident 3 resided. The NSIS indicated LVN 5 was assigned as the charge nurse to station 3. A review of Resident 3's MAAR dated 6/2023 indicated LVN 4 documented she administered the following medications to Resident 3: 1. On 6/11/2023 at 10:08 a.m. - Carvedilol, Multivitamin-Minerals Tablet, Docusate Sodium Capsule, Calcium Tablet, Vitamin D, Ascorbic Acid, Allopurinol, Dorzolamide, Aspirin, Amlodipine, Farxiga, and Norco. The MAAR indicated Resident 3 received Carvedilol (two hours and eight minutes after the scheduled administration time of 8 a.m.) 2. On 6/11/2023 at 10:11 a.m. - Lantus. 3. On 6/18/2023 at 10:24 a.m. - Carvedilol, Multivitamin-Minerals Tablet, Docusate Sodium Capsule, Calcium Tablet, Vitamin D, Ascorbic Acid, Allopurinol, Dorzolamide, Aspirin, Amlodipine, Farxiga, and Norco 4. On 6/18/2023 at 10:25 a.m. - Lantus. 5. On 6/19/2023 at 11:18 a.m. - Multivitamin-Minerals, Docusate Sodium, Calcium, Vitamin D, Ascorbic Acid, Allopurinol, Dorzolamide, Aspirin, Amlodipine, Farxiga, and Norco. The MAAR indicated Resident 3 received Multivitamin-Mineral, Docusate Sodium, Calcium, Vitamin D, Ascorbic Acid, Allopurinol, Dorzolamide, Aspirin, Amlodipine, Farxiga, and Norco two hours and eighteen minutes past the scheduled administration time of 9 a.m. 6. On 6/19/2023 at 11:19 a.m. - Carvedilol. The MAAR indicated Resident 3 received Carvedilol three hours and nineteen minutes after the scheduled administration time of 8 a.m. A review of Resident 3's CDRD for Norco 10-325 mg dated 6/2023, indicated Resident 3 received Norco 10-325 on 6/11/2023 at 9 a.m. (the MAAR indicated Norco was administered at 10:08 a.m.) and on 6/19/2023 at 9 a.m. (the MAAR indicated Norco was administered at 11:18 a.m.). The CDRD indicated no documented evidence that Norco was administered on 6/18/2023. During an interview on 6/22/2023 at 10:15 a.m., LVN 5 stated she gave Resident 3 medications prepared by LVN 4 on 6/11/2023 and 6/19/2023. LVN 5 stated she did not validate the medications against the physician's orders and did not see LVN 4 remove the medications from the medication cart. LVN 5 stated licensed nurses should never give medications to residents on behalf of another nurse. During a telephone interview on 6/22/2023 at 1:47 p.m., LVN 4 stated Resident 3 refused to allow her to administer medications to him and she was not supposed to be assigned to him. LVN 4 stated on the days she was assigned to administer medications to Resident 3, she thought she could ask another licensed nurse to give Resident 3 his medications on her behalf. LVN 4 stated on 6/11/2023 and 6/18/2023, Resident 3 received his medications late because she had to wait for LVN 5 and LVN 6 to help her administer Resident 3's medications. LVN 4 stated on 6/19/2023 she was not scheduled to work that day but when a nurse called off sick, she was asked to work and she agreed but did not arrive to the facility until approximately 10:30 a.m., so she was late passing medications. LVN 4 stated she should not have had another LVN administer medication to Resident 3 that she had prepared because there was a risk of the medications being given to the wrong resident. During a phone interview on 6/26/2023 at 7:22 a.m., LVN 6 stated he did not verify Resident 3's medications against the MAR or the physician's orders and he did not see the container where the medications came from prior to administering medication to Resident 3. LVN 6 Resident 3 was at risk of adverse reactions, a change in condition (COC) or harm if he (Resident 3) received the wrong medication. d. A review of Resident 4's Face Sheet, indicated Resident 4 was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), type 2 DM, and aphasia (los [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to maintain, increase, or to prevent further decrease in range of motion [(ROM) a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints, that over time becomes irreversible] for five of six sampled residents (Residents 1, 7, 15, 26, and 32). The facility failed to: 1. Ensure a Restorative Nursing Aide [(RNA) nursing aide program that helps residents maintain their function and joint mobility) services were provided by a certified restorative nursing aides to all eligible residents in the facility from 3/11/2022 to 3/31/2023. 2. Ensure there was an effective system to monitor the residents' joint mobility to identify possible declines in ROM. 3. Ensure an uncertified rehabilitation aide (RA) provided RNA services to residents under the supervision of a licensed therapist. 4. Ensure Resident 1 was provided with ambulation (walking) exercises in accordance with Physical Therapy [(PT) a profession specializing in the restoration, maintenance, and promotion of optimal physical function] recommendations dated 3/11/2022. 5. Ensure Resident 1 was provided with active range of motion [(AROM) movement at a given joint when the person moves voluntarily) exercises to both arms in accordance with Occupational Therapist [(OT) profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities] recommendations dated 6/20/2022. 6. Ensure Resident 1 was provide with AROM exercises to both arms and both legs per physician order dated 2/16/2023. 7. Ensure Resident 26 was provided with RNA program services to maintain or improve mobility after the resident's discharge from PT services. 8. Ensure an uncertified RA provided RNA services to Residents 7, 15, and 32 from 2/21/2023 through 3/29/2023 under the supervision of a licensed therapist. As a result of these deficient practices Resident 1 did not receive AROM exercises to both arms from 6/20/2022 to 3/31/2023 (approximately nine months) and ambulation exercises from 3/11/2022 to 3/31/2023 (approximately 12 months) and experienced a decline in mobility of both shoulders and a significant decline in mobility, Resident 26 experienced a continuous decline in mobility and Residents 7, 15, 32, and all other residents in the facility receiving RA services instead of RNA were placed at risk for injuries. These deficient practices placed the residents at risk for a decline in mobility, decline in activities of daily living [(ADL), everyday tasks such as eating, dressing, and toileting], decline in ROM leading to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints, that over time becomes irreversible) and a decreased quality of life. On 3/31/2023 at 4:51 PM, the California Department of Public Health (CDPH) called an Immediate Jeopardy [(IJ) situation (a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident] in the presence of the [NAME] President of Operations (VPO), Assistant Chief Clinical Officer (ACCO), Minimum Data Set [(MDS) a standardized assessment and care screening] nurse, [NAME] President of Clinical Operations (VPCO), Director of Staff Development (DSD), and Quality Assurance (QA) nurse. On 4/2/2023 at 2:47 PM, the facility provided the Department with an acceptable Immediate Jeopardy Removal Plan (IJRP). The IJRP consisted of the following actions: 1. On 3/29/2023, three dedicated RNAs were assigned to provide restorative nursing services Monday to Friday to residents as ordered by the physician beginning 4/3/2023. 2. On 3/30/2023, an Interdisciplinary Team Meeting (IDT-each residents' health care team from various specialties) met to discuss Resident 1's risk for decline with mobility and ROM. IDT recommended to have PT and OT evaluate Resident 1 and encourage Resident 1 to get out of bed daily as tolerated. 3. On 3/30/2023, Resident 1 was evaluated by PT and was placed on a therapy program four times a week for four weeks. On 3/31/3023, Resident 1 was evaluated by OT and was placed on a therapy program three times a week for 27 days. 4. On 3/30/2023, the Director of Nursing (DON)/Designee obtained physician's orders for PT and OT evaluations for all current residents in the facility. 5. On 3/31/2023, the facility conducted an audit of current residents to identify residents who would benefit from an RNA program or therapy services. 6. On 3/30/2023 and 3/31/2023, the Resource Nurse, Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) initiated an in-service (staff education including knowledge check) to nursing staff regarding the facility's policy and procedures for the RNA program. 7. he DSD and/or the DON will provide skills competency training for all current and new RNAs prior to initiating RNA services to residents by 4/3/2023. 8. On 4/1/2023, the VPR provided education to the rehabilitation staff on the policy and procedures for Rehab Rounding and Screening to identify residents with functional changes to determine if therapy services are indicated. 9. All residents will receive PT and OT evaluations which will include joint mobility assessments containing measurable data of all extremities upon admission (to obtain baseline measurements), quarterly, and upon every change of condition. 10. The Director of Rehabilitation (DOR) or designees will attend the weekly RNA meetings to provide consultation to the nursing team. 11. A licensed nurse must supervise the activities of the RNA program. Licensed rehabilitation professionals may perform repetitive exercises and other maintenance treatments or supervise aides performing these activities. Although Licensed Rehabilitation Professionals may participate in the RNA program, members of the nursing staff are responsible for the overall coordination and supervision of the RNA program. 12. The DON or licensed nurse designees will manage and direct the RNA program. Licensed Rehabilitation Professionals will provide ongoing consultation and education of the RNA program. 13. The Restorative Nursing Program Coordinator (DON or licensed nurse designee) will conduct weekly meetings with the 14. RNA and therapist to discuss the resident's response to the program, including any decline in function, pain management for effectiveness, determination if the resident will be discharged to an RNA program for maintenance, and identification if therapy services are indicated. 15. In the event a rehabilitation aide provides restorative nursing services to residents due to staffing needs, the DON/licensed nurse and DOR/Physical or Occupational Therapist will supervise the care provided by the Rehabilitation aide. On 4/2/2023 at 2:47 PM, while onsite and after confirming the facility's implementation of IJRP actions, the Department accepted the removal plan and removed the IJ, in the presence of the ACCO. Findings: 1.A review of Resident 1's Admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including epilepsy (disorder that causes episodes of seizures or altered consciousness), muscle wasting and atrophy (decrease in muscle mass), and gait (walking pattern) and mobility abnormalities. A review of Resident 1's Census List (record of hospitalization s, room changes, and payer source changes) indicated Resident 1 remained at the facility since re-admission on 2/6/2020. A review of Resident 1's MDS dated [DATE], indicated Resident 1 had impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 required limited assistance for bed mobility, transfers, and toilet use and supervision with walking and locomotion (the ability to move from one place to another) on and off the unit using a walker and wheelchair. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs. A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment (PT Evaluation), dated 1/18/2022, indicated Resident 1's prior level of function was independent with bed mobility, independent with transfers, independent with gait (walking) indoors and short distances to the restroom using a front wheeled walker [(FWW) a mobility device with two wheels in the front used for support when standing or walking], and supervised/touch assistance with gait for 150 feet using a FWW. The PT Evaluation indicated Resident 1 required, at the time of the evaluation on 1/18/2022, supervision/touching assistance with rolling to the left and to the right (bed mobility), partial/moderate assistance (resident requires about 50% physical assistance to perform the task) for transferring from a lying down position to a seated position, partial/moderate assistance for chair and toilet transfers, and was unable to walk. The PT Evaluation indicated the ROM in both of Resident 1's legs were within functional limits [(WFL) sufficient joint movement to functionally complete daily routines]. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 required limited assistance for bed mobility, transfers, and toilet use and supervision with walking and locomotion on and off the unit using a walker and wheelchair. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs. A review of Resident 1's PT Discharge Summary, dated 3/11/2022, indicated Resident 1 required supervision/touching assistance for bed mobility, sit to stand transfers, and bed to chair transfers and was able to walk 50 feet with supervision/touching assistance using a two-wheeled walker. The PT discharge recommendations for Resident 1 indicated Restorative Nursing Program in order to maintain current level of functional mobility and gait ability. A review of Resident 1's medical record revealed there were no physician's orders for Resident 1 to receive RNA program for ambulation exercises per PT recommendations on 3/11/2022. A review of Resident 1's Occupational Therapy Evaluation and Plan of Treatment (OT Evaluation), dated 5/10/2022, indicated the ROM in both of Resident 1's arms were WFL. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 required supervision with walking and locomotion on and off the unit using a walker and wheelchair and limited assistance with bed mobility and transfers. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs. A review of Resident 1's OT Discharge Summary, dated 6/20/2022, indicated Resident 1's reason for discharge was due to Resident 1 achieving her highest practical level in therapy. The OT discharge recommendations for Resident 1 indicated Resident 1 would benefit from an RNA program for AROM exercises to both arms however there is no RNA program in the facility at this time. The OT Discharge Summary indicated OT will re-evaluate resident when there is RNA personnel available. A review of Resident 1's medical record, revealed there were no physician's orders for Resident 1 to receive RNA program for AROM to both arms per OT recommendations until 2/15/2023. A review of Resident 1's medical record, indicated a physician's order dated 2/15/2023 with start date of 2/16/2023, for the RNA to perform AROM to both of Resident 1's arms and legs, at least 15 minutes per day, every day, four times a week. There were no physician's orders for Resident 1 to receive ambulation exercises A review of Resident 1's MDS, dated [DATE], indicated Resident 1 required limited assistance for bed mobility, transfers, and locomotion on and off the unit. Resident 1 did not walk during the assessment period. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs. A review of Resident 1's MDS, dated [DATE] (approximately 14 months from the first MDS), indicated Resident 1 required limited assistance with bed mobility, transfers, and locomotion on and off the unit using a wheelchair and required extensive assistance for toilet use. Resident 1 did not walk during the assessment period. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs. A review of Resident 1's monthly RNA documentation, from 2/2023 to 3/2023, indicated there was no documentation indicating RNA provided AROM exercises to both Resident 1's arms and legs. A review of Resident 1's PT Evaluation, dated 3/31/2023, indicated Resident 1 was referred (a request to another medical specialist for opinion, treatment and/or management of a resident's condition or problem) for a PT evaluation due to a decline in mobility and ambulation. The PT Evaluation indicated Resident 1 required maximum assistance (required 51-75% assistance to complete the task) for rolling and for transferring from a lying down position to a seated position. The PT Evaluation indicated Resident 1 was dependent in sit to stand and bed to chair transfers. During an observation and interview on 3/29/2023 at 2:18 PM, while in the resident's room, Resident 1 was sitting in a wheelchair in a slouched (drooping) posture. Resident 1 was able to raise both arms halfway to shoulder level, bend and straighten both elbows, bend and straighten both wrists, and open and close both hands but could not straighten the middle joint of both small fingers. Resident 1 stated no one comes to do exercises with her but wished someone would. Resident 1 stated she used to be able to walk but cannot walk anymore. Resident 1 stated the nurses get her out of bed to the wheelchair using a mechanical lift (a device that allows a person to be transferred from one surface to another). During an interview on 3/29/2023 at 12:32 PM, the DOR, who was an Occupational Therapist, stated the facility did not have an RNA program. The DOR stated an RNA program was important because it ensured residents maintained the level of function they achieved once discharged from therapy services. The DOR stated if resident required RNA services after discharge from therapy, the therapists wrote the recommendation for a restorative nursing program, but the resident did not receive RNA services since there was no RNA program in the facility. The DOR stated the Rehabilitation Department (RD) did not perform joint mobility assessments on the residents to monitor for declines in ROM. The DOR stated the RD performed Rehab Screens which he defined as a general hands-off assessment of a resident's functional status. The DOR stated Rehab Screens were conducted only upon notification to the Rehab Department that a resident experienced a change of condition, or if nursing notes in the electronic system indicated there was a decline in function and ADL's or during direct observation by the DOR, or by referral from another department. The DOR stated the Rehab Screens did not provide objective, measurable data of a resident's ROM to indicate if the resident was declining in joint mobility. The DOR stated, there was no way to obtain information about the residents ROM baseline unless the resident received an OT and/or PT evaluation upon admission to the facility. During an observation of Resident 1 and concurrent interview with DOR, and record review of the OT evaluation and Discharge Summary on 3/29/2023 at 2:28 PM, the DOR stated Resident 1 had not been seen by OT since the resident was discharged from therapy on 6/20/2022 and did not receive RNA services because there was no RNA program. The DOR re-assessed Resident 1's ROM to both arms on 3/29/2023. The re-assessment revealed the following: 1. Right (R) shoulder flexion (movement at the shoulder with the arm moving upward toward the head): 0-49 degrees (49 degrees of motion, [normal is 0-180 degrees]). 2. R shoulder abduction (movement at the shoulder with the arm moving away from the middle of the body): 0-58 degrees (58 degrees of motion, [normal is 0-180 degrees]). 3. Left (L) shoulder flexion: 0-55 degrees (55 degrees of motion) -L shoulder abduction: 0-73 degrees (73 degrees of motion). The DOR confirmed Resident 1 had a decline in ROM of both shoulders since last being seen by therapy services in 6/2022. The DOR confirmed Resident 1's shoulder ROM was WFL at the time of the OT Evaluation in 5/2022. The DOR defined WFL as adequate movement to use both arms to perform ADLs such as dressing, feeding, grooming, et cetera. The DOR stated Resident 1's shoulder ROM in both arms were not WFL because Resident 1 required assistance with ADLs. The DOR confirmed Resident 1 should have been referred to an RNA program for maintenance of ROM of both arms as recommended by the OT on 6/20/2022 but was never ordered by the therapist because there was no RNA program at the facility. The DOR confirmed RNA was ordered on 2/15/2023 for RNA to perform AROM to both Resident 1's arms and legs but stated Resident 1 was not seen for exercises since there was no RNA program. The DOR confirmed Resident 1 did not receive RNA services from 6/20/2022 to present. The DOR stated there was potential for residents to have a decline in function including physical, cognitive, and emotional if RNA services were not provided to maintain mobility and ROM. During an interview on 3/29/2023 at 4:28 PM, the DON stated the facility agreed to use a rehabilitation aide to perform RNA duties under DOR supervision beginning [DATE] to present after a MOCK (an assessment of the facilities systems conducted by the facility staff) survey was conducted identifying a lack of RNA services. The DON stated the residents could potentially have a decline in function if RNA services were not provided by the facility. The DON stated the facility did not perform joint mobility assessments and used the MDS to monitor joint ROM. During an interview on 3/30/2023 at 12:16 PM, the Rehabilitation Aide (RA) stated she never provided AROM exercises to both Resident 1's arms and legs. The RA stated Resident 1 was never placed on her list by the DON to be seen for RNA services. During an interview on 3/30/2023 at 2:13 PM, Physical Therapist 1 (PT 1) stated there was no RNA program in the facility. PT 1 stated the rehabilitation department has tried to discuss issues related to the lack of RNA services with the DON since May or June of 2022, but nothing was done. PT 1 stated there were many certified RNAs in the facility, but none of them provided restorative nursing services because they were only being used as Certified Nursing Assistants (CNAs). PT 1 stated he eventually stopped inputting RNA orders and writing recommendations for an RNA program for residents he thought would benefit from a maintenance program after discharge from PT therapy because there was no RNA program to discharge a resident to. PT 1 stated the purpose of an RNA program was to ensure residents did not decline functionally by maintaining their function, ROM, and gains achieved during therapy. PT 1 stated there was potential for residents to have a functional decline if RNA services were not provided in the facility. During a phone interview on 3/30/2023 at 3:10 PM, the Medical Director (MD) of the facility, stated she was aware of the lack of RNA program in the facility. The MD stated she had the impression RNA services such as exercises were still being provided to the residents despite the staffing shortage and was not aware of any residents experiencing a decline due to the lack of an RNA program. The MD stated the purpose of an RNA program was to ensure residents maintain their mobility, prevent contractures, and prevent functional declines. The MD stated there was the potential for residents to develop contractures if RNA services were not being provided. During a phone interview on 3/30/2023 at 3:21 PM, Physical Therapist 2 (PT 2) stated she still wrote recommendations for an RNA program if a resident would benefit from maintenance services after discharge from therapy but was frustrated because there was no RNA program in the facility. PT 2 stated she emailed the administrator and the corporate office informing them residents were declining due to lack of RNA services in the facility and did not receive a response back. PT 2 stated the residents in the facility were functionally declining because there were no RNA services to maintain their function after discharge from therapy. PT 2 stated residents continuously had functional declines, were referred to therapy, achieved goals in a therapy program, and declined functionally again after discharge from therapy due to lack of maintenance services. PT 2 stated there were many certified RNAs in the facility, but none of them were being used to perform RNA services because they were all being used as CNAs despite there being an obvious need for RNA services. PT 2 stated the irreversible functional declines the residents were experiencing could have been prevented if there was an RNA program in the facility. PT 2 stated the Rehab department did not perform joint mobility assessments to monitor joint ROM. During an observation of Resident 1 and concurrent interview, and record review of Resident 1's PT Discharge Summary on 3/31/2023 at 2:12 PM, Resident 1 was sitting in the hallway in a wheelchair. At the same time, PT 2 performed the resident's functional evaluation while in the hallway. PT 2 re-assessed Resident 1's ROM of both legs. Resident 1 was unable to move both hips, both knees, and both ankles through full ROM. PT 2 stated she remembered Resident 1 was able to walk from her room to the dining room and to and from the bathroom in the past. PT 2 asked the restorative aid (RA) to assist with Resident 1's sit to stand transfer and pull the wheelchair behind Resident 1 for safety when walking. Resident 1 was able to stand with PT and RA assistance and took about 6 steps with both legs shaking before sitting down. PT 2 stated Resident 1 required a total assistance for transfers, maximal assistance of two persons to stand, and maximal assistance of one person to walk two feet. PT 2 confirmed Resident 1 was previously able to walk 75 feet with touching assistance using a FWW and required supervision/touching assistance with transfers and bed mobility at the time of discharge from PT therapy on 3/11/2022. PT 2 confirmed an RNA program was recommended for ambulation at the time of PT discharge on 3/11/2022 but was not ordered because there was no RNA program in the facility. PT 2 stated Resident 1 experienced a significant preventable decline in mobility due to lack of RNA services in the facility. During an interview on 3/31/2023 at 2:27 PM, CNA 5 stated Resident 1 used to stand, walk to the bathroom without a walker, and performed ADLs by herself about six months ago. CNA 5 stated Resident 1 currently required total care assistance, except for eating her meals. CNA 5 stated Resident 1 used adult briefs because she could no longer walk to the bathroom. CNA 5 stated she had observed the residents in the facility were declining functionally because RNA services were not being provided. CNA 5 stated the facility did not have RNA services and needed RNAs to help maintain the mobility and function of all the residents in the facility. During an interview and record review of Resident 1's RNA documentation record with the Quality Assurance supervisor (QAS), on 3/31/2023 at 3:00 PM, the QAS stated an empty box on the record indicated RNA services were not provided. QAS confirmed a physician's order for RNA for AROM exercises for both Resident 1's arms and legs was ordered on 2/15/2023 with a start date of 2/16/2023 but was not carried as evidenced by the boxes on the documentation record for February 2023 and March 2023 that were empty. During an interview on 3/31/2023 at 4:30 PM, the DOR confirmed Resident 1 experienced a significant decline in function since discharge from PT on 3/11/2022. The DOR confirmed he never received notice that Resident 1 experienced a change in condition while in the facility. The DOR stated he never performed any Rehab Screens and/or joint mobility assessments on Resident 1 to identify any decline. The DOR stated Resident 1's decline could have been caught and prevented if there was a monitoring system in place to identify measurable degrees of functional decline. The DOR stated Resident 1's functional decline could have been prevented had Resident 1 received RNA services to maintain the level of function she achieved after she was discharged from therapy. During an interview on 4/1/2023 at 11:06 AM, the VPR, who was a Physical Therapist stated the facility used the MDS and Rehab Screens to assess joint mobility and did not perform routine joint mobility assessments for residents in the facility. The VPR acknowledged the Resident Assessment Instrument [(RAI), comprehensive and care planning tool], MDS, and Rehab Screens did not capture changes in joint ROM and did not contain measurable, objective data to detect declines in joint mobility. The VPR stated the only way the facility was able to obtain a baseline measurement of a resident's joint ROM was if the resident received a formal OT and/or PT evaluation during his/her stay in the facility. During an interview on 4/2/2023 at 1:46 PM, the MDS nurse stated the facility monitored joint mobility by the RAI. The MDS nurse stated the RAI tool did not provide data regarding location and degree of ROM impairment of the joints. MDS nurse stated there was no objective, measurable data in the RAI tool to determine subtle changes in ROM and if a resident was having a decline until it significantly impacted ADL performance. During an observation and interview on 4/2/2023 at 2:00 PM, in Resident 1's room, the MDS nurse assessed Resident 1's ROM in both arms and both legs. Resident 1 could not raise both arms to shoulder level. Resident 1 was able to touch behind her head with both hands. Resident 1 was unable to point toes upwards, minimally moved both ankles up and down, and was unable to straighten both knees. Resident 1 was able to shuffle both legs minimally on the ground to move her wheelchair forward. The MDS nurse stated Resident 1 had obvious ROM limitations in both shoulders, both ankles, and both knees but would still code Section G0400 in the RAI as no impairment because she was able to use both arms and both legs functionally based on the RAI coding instructions. The MDS nurse stated the system of using the RAI as the only tool to monitor joint mobility was ineffective in capturing changes or declines in joint mobility. During an interview on 4/3/2023 at 3:15 PM, the ADM stated it was important to have RNA services because it was a maintenance program for residents transitioning from skilled services to custodial services (non-medical care). The ADM stated an RNA program was an important service to ensure residents did not decline functionally. B. A review of Resident 26's AR indicated Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle wasting, atrophy (decrease in size and wasting of muscle tissue), gait and mobility abnormalities. A review of Resident 26's MDS, dated [DATE], indicated Resident 26 had moderately impaired cognitive skills for daily decision making and required extensive assistance for bed mobility, transfers, and toilet use. Resident 26 did not ambulate during the assessment period. A review of Resident 26's PT Evaluation, dated 6/30/2022, indicated Resident 26 was referred to PT services due to a decline in mobility. The PT Evaluation indicated Resident 26 required supervision/touching assistance for rolling, maximal assistance for transfers, and maximal assistance for walking 10 feet with a two wheeled walker. A review of Resident 26's PT Discharge Summary, dated 7/27/2022, indicated Resident 26's reason for discharge was due to Resident 26 achieving his highest practical level in therapy. The PT discharge recommendations for Resident 26 indicated RNA is recommended. However, there is currently no RNA program in this facility. Administration is aware. A review of Resident 26's all physician's orders, revealed there were no physician's orders for Resident 26 to receive RNA program for ambulation and/or mobility exercises on 7/27/2022. A review of Resident 26's PT Evaluation, dated 8/24/2022, indicated Resident 26 was referred for PT services per Resident 26's request for therapy due to a decline in ambulation. The PT Evaluation indicated Resident 26 required maximal assistance for rolling to the left and right (bed mobility, maximal assistance for transfers, and moderate assistance for walking 10 feet with an FWW. The PT Evaluation indicated Resident 26's decline is attributed to lack of RNA services in the building (Administration already notified at previous discharge. Resident would benefit from skilled PT to regain gait, however, with no program in place for maintenance, gains will be short term. A review of Resident 26's PT Discharge Summary, dated 10/19/2022, indicated Resident 26's reason for discharge was due to Resident 26 achieving his maximal potential with skilled therapy services. The PT Discharge Summary did not indicate discharge recommendations. During a phone interview on 3/30/2023 at 3:21 PM, Physical PT 2 stated Resident 26 was constantly being evaluated and re-evaluated by PT due to continuous declines in mobility after discharge from skilled PT services due to a lack of an RNA program for maintenance. PT 2 stated she eventually refused to perform evaluations and discharges on long term residents such as Resident 26 because there was no RNA program to maintain the gains residents made during therapy. PT 2 stated the functional declines the residents were experiencing could have been prevented if there was an RNA program in the facility During an observation and interview on 4/3/2023 at 11:41 AM, in the resident's room, Resident 26 was lying on his back. Resident 26 stated staff come in every now and then to walk with him. Resident 26 had difficulty bending the left knee because it was his bad knee from the war and stated both knees felt stiff often. During an interview and record review of Resident 26's PT notes on 4/3/2023 at 3:15 PM, the ADM confirmed Resident 26 experienced continuous decline in mobility due to lack of RNA services in the facility. The ADM stated that right away the facility should have escalated the issue of lack of RNA services to the facility consultants, initiated a Quality Assurance and Performance Improvement [(QAPI) a committee consisting of key facility staff that meets regularly to address systemic facility failures] as soon as possible to ensure an RNA program would be initiated for all residents after they discharged from therapy and other residents needed an RNA program. The ADM stated she knew QAPI was conducted in February 2023 to address the lack of RNA services but was unsure if a QAPI was done prior since it was such a long-standing issue. The ADM stated the facility should have come up with a solution to address the lack of RNA services. The ADM stated it was important to have RNA services because it was a maintenance program for residents transitioning from skilled services to custodial services (non-medical care). The ADM stated an RNA program was an important service to ensure residents did not decline functionally. During a phone interview on 3/30/2023 at 3:21 PM, Physical PT 2 stated Resident 26 was constantly being evaluated and re-evaluated by PT due to continuous declines in mobility after discharge from skilled PT services due to a lack of an RNA program for maintenance. PT 2 stated she eventually refused to perform evaluations and discharges on long term residents such as Resident 26 because there was no RNA program to maintain [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide the resident, who attempted to get out of bed unsupervised and was at risk for falls, with supervision and interventions to prevent from falls and injury for one of two sampled residents (Resident 1). The facility failed to ensure: 1. Resident 1's care plan (CP) titled, 'The resident is high risk for falls' was reviewed after Resident 1's first fall, on 11/24/2021 to evaluate the effectiveness of care plan intervention and implement different intervention to safeguard the resident from future falls. 2. The staff conducted frequent periodic visual monitoring of Resident 1 to ensure the resident was safe as documented on Bed Rail Assessment and to specify the frequency of visual monitoring for staff to follow and as indicated in the resident's short-term care plan titled, Status Post ([S/P] condition after a treatment and/or procedure) unwitnessed fall. 3. Resident 1 had upper side rails up and padded to prevent the resident from injury due to diagnosis of [CONDITION(S)] as indicated in the facility's policy and procedure titled Bed Rails. 4. An Interdisciplinary Team ([IDT] a meeting with professionals to create a plan of care for residents) conducted Resident 1's assessment after the resident's first fall on 11/24/2021 as outline in the facility's policy and procedure titled 'Fall Prevention and Management Program.' Resident 1 had severely impaired cognitive skills (thought process) for daily decision-making, had diagnosis of [CONDITION(S)] (paralysis of all four limbs) with ventriculostomy (a surgical opening with a catheter placed to drain excess fluid from the brain) in place was receiving blood thinning medications (medications used to thin the blood and treat/prevent blood clots). These conditions placed Resident 1 at risk for falls, injuries, and bleeding. Resident 1 had two falls within four days and sustained a head injury. This deficient practice resulted in Resident 1 falling twice from the bed onto the floor and sustain a 6.0 centimeter ([cm] unit of measurement) right parietal (the area at the posterior end of the skull near the midline) subdural hematoma (a collection of blood on the brain due to injury or trauma). On 11/28/2021, Resident 1 was transferred to a general acute care hospital (GACH) where the resident was diagnosed with [MEDICATION(S)] head trauma ([BHT] head injury) and was admitted to the intensive care unit ([ICU] higher level of care) for five days. Findings: During a review of Resident 1's history and physical (H/P) from the GACH dated 9/17/2021, prior to admission to the facility, the H/P indicated Resident 1 had a traumatic (stressful, frightening or distressing events) brain injury requiring a ventriculostomy placement. The H/P indicated Resident 1 became a quadriplegic (permanent immobility of both arms and both legs) after a traumatic motor vehicle accident. The H/P indicated Resident 1 underwent multiple major surgeries and procedures and remained hospitalized for two months. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] (condition in which the blood does not have enough oxygen or has too much carbon [MEDICATION(S)] [resulting in difficult breathing]) with a [CONDITION(S)] ([[CONDITION(S)]] an opening in the windpipe), muscle weakness, dysphagia (difficulty swallowing), cognitive (thought process) communication deficit, traumatic subdural hemorrhage (blood collects between the brain surface and the skull), functional quadriplegic and [CONDITION(S)] (abnormal brain activity that causes episodes of uncontrolled body jerking and loss of mental awareness). Resident 1 was receiving medical grade oxygen supplement via a T-collar (placed over the [CONDITION(S)] with humidified oxygen). During a review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 11/17/2021, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making and required a total assistance with one-person physical assistance for bed mobility, transfers, toilet use and personal hygiene. The MDS indicated Resident 1 had impairment to both upper and lower extremities and did not utilize any mobility devices. During a review of Resident 1's Clinical Admission Evaluation (CAE), dated 11/10/2021 and timed at 4:50 p.m., the CAE indicated Resident 1 was disoriented (confused and unable to think clearly) with severely impaired cognition, paralysis, weakness and impairment to upper and lower extremities (arms/legs). During a review of Resident 1's Fall Risk Assessment (FRA), dated 11/10/2021 and timed at 4:50 p.m., the FRA indicated Resident 1 had a fall score of 12. According to the FRA, a total score of 10 or more indicated a high risk for falls. During a review of Resident 1's CP, dated 11/11/2021 and titled, The resident is high risk for falls related to deconditioning (process of body change with periods of inactivity, bedrest that results in loss of mental status, continence (ability to control bowel and bladder) and everyday activities) gait/balance problems, incontinence (inability to control bowel and bladder), poor communication/comprehension, unaware of safety needs, the care plan indicated the following staff's interventions: 1. Follow the facility's policy and procedure titled 'Fall Prevention and Management Program.' 2. Place the resident on a low bed. 3. Place a call light within the resident's reach. 4. Place bilateral (both) floor mats on the floor. During a review of Resident 1's Bed Rail Assessment (BRA), dated 11/10/2021 the BRA indicated the following: 1. Resident 1 was non-ambulatory. 2. Resident 1 had fluctuating consciousness. 3. Resident 1 had alteration in safety awareness due to cognitive decline. 4. Resident 1 displayed poor bed mobility/difficulty moving in bed. 5. Resident 1 ad difficulty with balance and poor trunk control. The interventions included: 1. Lower bed to the floor. 2. Provided frequent staff monitoring at night. Side Rail Placement: None recommended and side rail assist bar not indicated at this time. During a review of an article last updated on 9/2/2021 and titled, [CONDITION(S)] Precautions, the article indicated under Ensuring Safety Precautions, to make sure the resident is in a bed with padded side rails for safety https://www.ncbi.[NAME].nih.gov/books/NBK 8/ During a review of Resident 1's CP, dated 11/11/2021 and titled, the resident is on anticoagulant (medication used to thin blood) therapy related to disease process and post-surgery, the care plan indicated the following staff's interventions: Resident/family/caregiver teaching to include take/give medication at the same time each day, use soft toothbrush use electric razor, avoid activities that could result in injury, take precautions to avoid falls, signs/symptoms of bleeding, avoid foods high in Vitamin K. A review of Resident 1 recapitulated physician's orders ([recap] order summary) for the month of 11/2021, the orders indicated Resident 1 was receiving the following medications: 1. [MEDICATION(S)] (a medication used to treat and prevent blood clots) 5,000 units ([U] a unit of measurement) subcutaneous injection (injection of medication into the fatty tissue under the skin), every eight hours for [CONDITION(S)] ([DVT] blood clot that forms in a deep vein). 2. [MEDICATION(S)] (medication to prevent and control seizures) 1,500 milligrams ([mg] unit of measurement), through the gastrostomy ([G-tube] a tube surgically placed into the stomach for feeding, medication, and hydration), twice daily for seizures. 3. [MEDICATION(S)] (medication used to treat seizures) 10 mg, through the G-tube, twice daily for [CONDITION(S)]. 4. [MEDICATION(S)] (medication used to prevent serious blood clots) 5 mg, through the G-tube, twice daily for DVT. During a telephone interview on 3/24/2022 at 5:13 p.m., the Director of Nursing (DON) stated residents taking blood thinners and/or anticoagulants are prone to bleeding and any impact from injury, such as from fall, would cause them to bleed. The DON stated a fall could cause the resident to bleed. During a review of Resident 1's Skilled Evaluation Note (SEN), dated 11/23/2021 and timed at 10:48 a.m., the SEN indicated Resident 1 had mild cognitive impairment, was inattentive and required cues (signals, reminders). According to the SEN, Resident 1 was bedfast with an unsteady gait (to walk) and had poor balance (functional quadriplegic). During a review of Resident 1's Change of Condition (COC) note, dated 11/24/2021 and timed at 4:45 a.m., the COC note indicated at 4:30 a.m., on 11/24/2021, Resident 1 had an unwitnessed fall, and was found on the floor lying on his right side next to his bed with his legs still on the bed. The COC indicated Resident 1 was assisted back to bed, was assessed by a licensed nurse. Resident 1 did not sustain any physical injuries and the physician was notified. During a review of Resident 1's Post Fall Evaluation (PFE), dated 11/24/2021 and timed at 12:31 p.m., the PFE indicated Resident 1 had an unwitnessed fall from his bed on 11/24/2021 at 12 a.m. [sic]. The PFE indicated Resident 1 fell from his bed due to repositioning himself. The PFE indicated Resident 1 was found on the floor next to his bed with both legs still on the bed. During an interview on 3/3/2022 at 12:06 p.m., the DON stated on 11/24/2021, Resident 1 rolled out of his bed and fell on to the floor but was able to stand. The DON stated when Resident 1 fell on [DATE], there were no floor mats at the resident's bedside prior to 11/24/2021. The DON stated Resident 1 did not have any bed rails because the facility did not use bed rails. During a review of Resident 1's physician's order dated 11/24/2021 and timed at 6:45 a.m., the order indicated for Resident 1 to have a STAT (immediate) x-ray (a test that produces images of the structures inside of the body) of the skull, bilateral (both) shoulder, and a bilateral hip due to a fall. During a review of Resident 1's physician's order dated 11/24/2021 and timed at 7 a.m., the order indicated for Resident 1 to have bilateral landing pads (floor mats) on the floor for protection from injury. During a review of Resident 1's short-term CP, dated 11/24/2021 and titled, Status Post (S/P) unwitnessed fall, the care plan indicated the staff's interventions included to obtain orders for diagnostics x-ray to rule out (r/o) any fractures (broken bones) secondary to the fall, frequent visual check (the CP did not indicate a frequency for visual checks), floor mats as ordered, low bed at all times, and to access the need for a bed alarm. This care plan had no new interventions to prevent Resident 1 from falling. During a review of the facility's Incident Report (IR), dated 11/24/2021, the IR indicated when Resident 1 was asked what happened after he fell at 4:30 a.m., Resident 1 mouthed he wanted to go to the bathroom. During a review of the facility's Investigative Interview Report (IIR), dated 11/24/2021 and timed at 5:30 a.m., the IIR indicated the Respiratory Therapist 1 ([RT 1] a healthcare practitioner trained to provide respiratory care and treatment to individuals with lung conditions and diseases) while conducting routine morning treatments on 11/24/2021, found Resident 1 lying on the floor on his right side with his legs still on the bed. According to the IIR, RT 1 immediately reported Resident 1's fall to the Registered Nurse Supervisor 1 (RNS 1). During a review of Resident 1's SEN, dated 11/25/2021 and timed at 9:47 a.m., the SEN indicated Resident 1 made three attempts to get out of bed on 11/25/2021. The SEN indicated frequent visual checks was conducted. During a review of Resident 1's SENs there was no documented evidence of frequent visual checks/monitoring of Resident 1 conducted by the staff. During a telephone interview on 3/24/2022 at 5:20 p.m., the DON was asked about Resident 1's SEN dated on 11/25/2021 and timed at 9:47 a.m. and was asked how the staff conducted frequent visual checks/monitoring. The DON the facility did not have a protocol regarding the frequency of monitoring residents. The DON stated staff used their own perceptions of timeframe/frequency for visually monitoring residents. The DON stated the only visual monitoring document was when the CNAs documented ADL care. The DON was asked how often the staff monitored Resident 1 on 11/25/2021, the DON then stated every 15 minutes, but the staff did not document. During a review of Resident 1's SEN, dated 11/27/2021 and timed at 11:25 a.m., the SEN indicated the resident was confused and did not follow simple commands. The SEN indicated Resident 1 tried to get out of bed. During a review of Resident 1's COC note, dated 11/28/2021 and timed at 9:34 a.m., the COC note indicated Resident 1 had a second unwitnessed fall and was observed lying on a padded mattress, on the floor, on the left side of the bed. The COC note indicated Resident 1 was nonverbal and unable to explain what happened. The COC indicated Resident 1 did not sustain any physical injuries. During a review of Resident 1's PFE, dated 11/28/2021 and timed at 12:17 p.m., the PFE indicated Resident 1 had an unwitnessed fall from the bed on 11/28/2021 at 8:15 a.m. The PFE indicated Resident 1 fell from his bed due to repositioning himself. The PFE indicated Resident 1 was found on the floor next to his bed with both legs still on the bed. A review of Resident 1's physician's order, dated 11/28/2021 and timed at 9 a.m., the order indicated for the nursing staff to transfer Resident 1 to the GACH for further evaluation due to a fall. During a review of Resident 1's Nurse's Progress Note (NPN), dated 11/28/2021 and timed at 12:24 p.m., the NPN indicated because of Resident 1's fall, the resident was transferred to another room closer to the nurses' station after the second fall, for frequent visual monitoring. The NPN indicated at 8:40 a.m., a physician's order was obtained to transfer Resident 1 to the hospital for further evaluation. The NPN indicated a private ambulance company was called and the estimated time of arrival to pick up Resident 1 was one to two hours. The NPN indicated at 11:15 a.m., Resident 1 was transported to the GACH by a private ambulance company. During a review of Resident 1's GACH Emergency Department (ED) H/P, dated 11/28/2021 and timed at 12:08 p.m., the H/P indicated Resident 1 was transported to the ED after being found on the floor by the facility's nursing staff. According to the H/P, the facility's nursing staff indicated Resident 1 was non-verbal and could not follow verbal commands. According to the H/P, Resident 1 had a computerized tomography ([CT scan] detailed pictures of parts of the body and the structures inside the body) of the brain due to trauma which resulted in a 6.0 cm right parietal subdural hematoma. The H/P indicated Resident 1 was admitted into the ICU unit for close monitoring for a total of five days and required treatment by a neurosurgeon (a physician that specializes in surgically treat disorders of the nervous system [brain and spinal cord] including trauma, tumors). During a review of Resident 1's Clinical Admission Evaluation (CAE), dated 12/2/2021 and timed at 6:30 p.m., the CAE indicated Resident 1 was readmitted to the facility, was assessed as being confused, disoriented, required cues, due to severe impaired cognition with incoherent (unclear) speech and weakness and impairment to upper and lower extremities. During an interview on 12/15/2021 at 6:17 p.m., DON stated she did not investigate Resident 1's fall occurred on 11/28/2021 but did document a post-fall note for Resident 1. During an observation on 12/15/2021 at 6:30 p.m., Resident 1 was sitting in bed watching television with [CONDITION(S)] in place and with intact bandage to forehead. During an interview on 3/3/2022 at 12:06 p.m., DON stated after Resident 1's second fall on 11/28/2021, Resident 1 was transferred to the hospital because he was receiving blood thinners (medications), sustained a hematoma, and was hospitalized . The DON stated Resident 1 was assessed upon the initial admission to the facility as being at risk for falls. The DON was asked how the facility's staff would prevent Resident 1 from recurrent falls. The DON stated after the second fall on 11/28/21 Resident 1 was moved to a room closer to the nursing station so the nurses could visually monitor Resident 1. During a concurrent interview and review of Residents 1's SEN with the DON on 3/3/2022 at 1:29 p.m., the DON was asked about Resident 1's SEN, dated 11/25/2021 and timed at 9:47 a.m., indicating Resident 1 made three attempts to get out of bed and received frequent visual checks. The DON was asked did the staff prevent Resident 1 from attempting to get out of bed and falling. The DON stated Resident 1 was moved to a room closer to the nursing station on 11/28/2021 and after Resident 1's second fall. The DON stated the nurses were not always sitting at the station. The DON was asked how often the staff performed frequent visual checks and did the staff document the visual checks, the DON stated the staff checked Resident 1 as often as they could. During a telephone interview on 3/4/2022 at 4:35 p.m., Registered Nurse 2 (RN 2) stated that on 11/28/2021, Resident 1 had an unwitnessed fall and was found on the floor and sent to the hospital. RN 2 stated when Resident 1 was initially admitted to the facility he was weak and was diagnosed as a quadriplegic but could move and dangle his legs. RN 2 stated he was unsure if Resident 1 had floor mats, because floor mats were considered a restraint. RN 2 stated Resident 1 was moved to a room closer to the nursing station when he returned from the hospital due to the second fall. During a telephone interview on 3/9/2022 at 4:02 p.m., Certified Nursing Assistant 1 (CNA 1), stated she was assigned to Resident 1 on 11/28/2021. CNA 1 stated Resident 1 tried to get out of bed and sat on the side of the bed on several occasions. CNA 1 stated Resident 1 was weak and a fall risk. CNA 1 stated Resident 1 did not have a sitter and she was instructed to check on Resident 1 but with no specific timeframe. CNA 1 stated she would check on Resident 1 whenever she passed by Resident 1's room and was unsure how often she conducted visual checks. During a telephone interview on 3/24/2022 at 4:48 p.m., the DON was asked about Resident 1's bed rail assessment dated on 11/10/2021 and timed at 4:50 p.m. The DON stated Resident 1 did not require bed rails on because bed rails caused entrapment. The DON stated if Resident 1 had a [CONDITION(S)] his legs and/or hands could get caught in the side rail. The DON stated there were no [CONDITION(S)] precautions in place for Resident 1, but the goal was to prevent Resident 1 from injury. The DON stated [CONDITION(S)] precautions included a low bed, floor mats and pillows on the side of the bed. According to the DON, the licensed nurse who conducted Resident 1's bed rail assessment indicated Resident 1 did not require bed rails because the resident had a [CONDITION(S)] and a G-tube. The DON stated Resident 1 was re-assessed for utilizing bed rails on 12/2/2021 and on 12/2/2021, side-rails were not indicated for Resident 1. The DON asked which [CONDITION(S)] precautions were utilized for Resident 1, the DON stated a low bed and floor mats. The DON stated she has cared of a [CONDITION(S)] resident in over [AGE] years and there were no in-services provided to the staff regarding residents with [CONDITION(S)] disorders. The DON stated Resident 1 was not on [CONDITION(S)] precautions because the resident did not have any [CONDITION(S)] activity, his seizures were not real, and the resident was on [CONDITION(S)] medication. During a telephone interview on 3/28/2022 at 2:17 p.m., the DON stated the facility had not used bed alarms for over a year. The DON stated the bed alarms had the same alarm sound as the ventilator (a machine that helps you breathe or breathes for you) alarms and the sound was misleading and would confuse the staff. The DON asked about the risk for fall prevention for the residents who moved around in bed and attempted to get out of bed, the DON stated the staff would attend to those residents as quickly as possible by conducting visual checks for at least every 15 to 30 minutes. During a review of the facility's revised policy and procedure (P/P), dated 8/1/2014 and titled, Fall Prevention and Management Program the P/P indicated for the facility to provide a safe environment that minimizes complications associated with falls. The P/P indicated the IDT would initiate, review, and update fall risks and plan of care at the following intervals: admission, quarterly, annually, upon significant change of condition identification and post fall. The P/P indicated the Licensed Nurses would evaluate the resident's response to the plan of care during weekly summary evaluation and update the resident's care plan as necessary. During a telephone interview on 3/28/2022 at 2:25 p.m., DON stated there was no IDT conducted on Resident 1 after the resident's fall on 11/24/2021 and 11/28/2021. During a review of the facility's revised P/P, dated 12/4/2021 and titled, Bed Rails the P/P indicated the facility will adequately evaluate the use of bed rails and prevent potential entrapment or other safety hazards. The P/P indicated a bed rail is an assistive device and must be used in only to treat a resident's medical symptoms. The P/P indicated a padded bed rails will be used to prevent injury to the resident in case of uncontrolled (unable to control and/or stop) movement. During a review of the facility's revised P/P, dated 1/1/2012 and titled, [CONDITION(S)] Precautions the P/P indicated during admission, residents will be evaluated for potential for [CONDITION(S)] activity and findings will be documented in the resident's care plan. The P/P indicated if the resident has potential for [CONDITION(S)] activity, the resident's room will be prepared accordingly.

Based on observation, interview and record review, the facility failed to ensure the call light system was operable with visual and audible in all of the residents' rooms, bathrooms, and at the nursing stations, to alert and relay the residents' needs to the staff for 19 of 19 residents (Residents 5, 10, 11, 14, 21, 23, 26, 43, 47, 52, 53, 63, 77, 80, 81, 83, 88, 89, and 98) with a universe of 94, and had the potential to affect all the residents who resided in the facility. During a review of the facility's Resident Census and Conditions of Residents (CMS 672 form) completed by the facility, the CMS 672 indicated the facility had 60 residents occasionally or frequently were incontinent (inability to control) of bladder; 68 residents occasionally or frequently were incontinent of bowel; 68 residents with contractures (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints); 62 residents receiving preventative skin care; 28 resident who require suctioning; and 19 residents on a pain management program. This deficient practice of the facility's inoperable call light system had the potential to result in adverse consequences to the residents (Residents 5, 10, 11, 14, 21, 23, 26, 43, 47, 52, 53, 63, 77, 80, 81, 83, 88, 89, and 98) due to not having the ability to communicate their needs and needs met timely. During an annual recertification survey on 7/7/2021 at 3 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was identified and declared and the facility's administrator (ADM) and Director of Nursing (DON) were informed of the facility's non-compliance to ensure the call light system was operable to meet the residents' needs. During an interview on 7/9/2021 at 2:11 p.m., the ADM and the DON were informed the IJ was lifted after implementation of the acceptable plan of action ([POA], interventions to correct the deficient practice) was verified and confirmed while on onsite via observation, interview and record review. The acceptable POA included the following actions: 1. On 7/6/2021, the Assistant DON (ADON) conducted room rounds to the affected residents' rooms to ensure residents' needs were attended and to ensure safety of residents. 2. On 7/6/2021, the Licensed Nurses provided call bells to the affected residents with call lights malfunction, who can utilize them. 3. On 7/6/2021, the maintenance supervisor immediately repaired the call lights malfunction and was resolved within 5 minutes. 4. On 7/6/21 and 7/7 /21, a total of 29 residents located from rooms 31 through 42, were identified to be affected by the call light malfunction. 5. On 7/7/2021: a. Maintenance Supervisor immediately repaired the call lights malfunction and was resolved within 2 hours. b. The ADM called an outside company to come into the facility to check the call light systems and ensure the affected call lights were fixed c. The DON/Designee, informed the affected residents with call light malfunction and provided education to the residents on how to use the call bell for those residents who were able to utilize the call bells and provided 1:1 monitoring for those residents who refused to utilize the manual call bell and are unable to utilize the manual call bell. d. The DON together with the Licensed Nurses, immediately assessed the residents with call lights malfunction to ensure resident's safety and immediate needs were attended. e. The DON/Designees conducted hourly monitoring of the affected residents with malfunction call lights to ensure residents' safety and needs are being attended such a toileting, turning and repositioning, activities of daily living (ADL) care, nutrition, and hydration needs. The Minimum hourly rounds is based on the residents' conditions and individual needs and if there is a change of condition, the monitoring could be much more frequent such as for those residents who are total dependent residents, residents who are risk for falls, have behaviors, the Licensed Nurse can increase the monitoring frequency. f.Licensed Nurses and Certified Nursing Assistants (CNAs) provided call bells to the affected residents with call light malfunction, who can utilize them. g. The Facility Staff were assigned in each room of the affected hallway and were readily available to respond and ensure resident's safety and needs are attended. h. The Vice President of Operations submitted a request for quotes to replace the entire call light system of the facility. i. The DSD initiated an in - service education to the facility staff - licensed nurses, CNAs, Restorative Nursing Assistants (RNAs), Rehab Department, Respiratory Therapist, Housekeeping, Laundry, Maintenance, Kitchen, Social Services, Activities, Business Office and Receptionist, regarding the policy and procedures for Communication - Call System and discussed the facility's performance improvement an j. The maintenance supervisor and will document hourly rounds {See enclosed) daily during the day between 9am and 5 pm (Monday to Friday) to ensure call lights are functioning until the call lights system is replaced, installed, and functioning. Any identified concerns will be addressed and reported to the Administrator and DON. k. The RN Supervisors/Designee will document hourly rounds daily from 5 pm to 9 am and on the weekends 24 hours/day to ensure call lights are functioning until the call lights system is installed and replaced. Any identified concerns will be addressed and reported to the Administrator and DON. 6. Once the new call light system is installed, the maintenance supervisor and/ or designee will continue to monitor daily x2/ per day for 2 weeks. 7. The Department Managers will be assigned to designated rooms for daily rounds and will interview residents and/or family members daily (Monday-Friday) and RN Supervisors during the weekends to ensure that residents' needs are attended. Any concerns identified will be addressed and reported to the Administrator for further resolution as warranted. 8. The maintenance supervisor will conduct hourly rounds daily during the day between 9 am and 5 pm (Monday to Friday) to ensure call lights are functioning until the entire call lights system is replaced, installed, & functioning. Any identified concerns will be addressed and reported to the Administrator and DON. 9. The Administrator will present the results of the call light audits to the Quality Assurance and Performance Improvement Committee monthly for the next 3 months, then quarterly thereafter until substantial compliance is sustained. 10. The Administrator and the Director of Nursing are responsible to ensure sustained compliance. Findings: During observations of the initial tour of the facility on 7/6/2021 at 10:50 a.m., in rooms 36-42, the call lights had no audible sound heard and light not flashing inside or outside residents' room after activating the system. During a review of Resident 14's Admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE]. Resident 14's diagnoses included dementia (disorder of the mental processes caused by brain disease or injury and marked by memory disorders , personality changes, and impaired reasoning), paranoid [CONDITION(S)] (mental disorder involving breakdown in relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions or feelings, and withdrawal from reality), and muscle weakness. During a review of Resident 14's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 5/28/2021, the MDS indicated Resident 14 was moderately impaired cognitively (thought). The MDS indicated Resident 14 required extensive assistance of one person-physical assist to provide weight bearing support to move to from the bed to wheelchair or standing position, use the toilet, to get dressed, and to maintain personal hygiene. During a review of Resident 14's care plan titled, At risk for falls, the care plan indicated Resident 14 had limited mobility, poor balance, lack of awareness, was incontinent, and had cognitive deficits. The care plan also indicated Resident 14's call light to be kept within reach and remind resident to use the call light. During a review of Resident 14's care plan titled, Activities of daily living, updated 4/17/2021. The care plan indicated Resident 14 required assistance with walking, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. During an interview on 7/6/2021 at 10:37 a.m., Resident 14 was nodding her head for a yes or no as an answer to questions during the interview to answer questions. Resident 14 nodded her head indicating the staff do not come right away when she presses the call light to ask for assistance. During a review of Resident 52's Face Sheet, the face sheet indicated Resident 52 was admitted to the facility on [DATE]. Resident 52's diagnoses included respiratory failure (condition in which blood does not have enough oxygen or has too much carbon dioxide), cognitive communication deficit, difficulty walking, need for assistance with personal care, and seizures (burst of uncontrolled electrical activity between brain cells that causes stiffness, twitching or limpness) disorder. During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52 had severely impaired cognitive skills. The MDS also indicated Resident 52 was totally dependent on staff seven days a week for assistance with moving in bed, getting dressed, eating, personal hygiene, bathing, and toilet use. During a review of Resident 52's care plan titled, At risk for falls the care plan indicated Resident 52 had limited mobility, poor balance, lack of awareness, was incontinent, had a history of falls, and had communication deficits. The care plan also indicated Resident 52's call light to be kept in reach and to remind her to use the call light. During a review of Resident 88's Face Sheet, the face sheet indicated Resident 88 was admitted to the facility on [DATE]. Resident 88's diagnoses included respiratory failure (a condition that causes difficulty breathing), muscle weakness, and hypertension (high blood pressure). During a review of Resident 88's MDS, dated [DATE], the MDS indicated Resident 88 had severe cognitive impairment and was rarely/never understood. During an observation on 7/6/2021 at 10:41 a.m., Resident 14's call light was tested unsuccessfully, and indicator light appeared outside of the door, there was no audible sound heard and the call light cancel light did not flash inside Resident 14's room. During an interview on 7/6/2021 at 10:44 a.m., Certified Nursing Assistant 1 (CNA 1) stated and confirmed Resident 14's call light was not working. During an interview on 7/6/2021 at 11:24 a.m., Housekeeper (HS 2) stated the facility's electrical breaker had a malfunction earlier, which cause the call lights to malfunction. During an observation on 7/7/2021 at 9:54 a.m., the Director of Staff Development (DSD) tested the call lights in rooms 31-42 and confirmed Residents' 63, 47, 88, 10, 14, 89, 5, 21, 98, 43, 83, 81, and 53 call lights were not functioning. During an interview on 7/7/2021 at 10:47 a.m., CNA 6 stated and acknowledged he was unable to hear the call lights at the nurses' station panel during checks. CNA 6 stated the residents were given bells to use until the call light were fixed and if the residents were unable to move, rounds were made often to check on residents. CNA 6stated having inoperable call lights places the residents at risk for falls. During an interview on 7/7/2021 at 11:10 a.m., CNA 7 stated call lights were checked at the start of each and if a call light was found to be malfunctioning, the maintenance supervisor was made aware. CNA 7 stated he tells the residents to yell out if their call lights are not working, and if they cannot talk, he checks often on the residents. During a concurrent observation and interview on 7/7/2021 at 11:35 a.m. CNA 8 tested the call light located in room 39. CNA 8 acknowledged the Nurse's station was not visible from room 39 and she could not see if the call light was buzzing at the nurse's station. CNA 8 stated she was unaware the call lights were not working. CNA 8 stated, We cannot always hear the resident calling but there are other staff in the hallway and the hallway is never empty. Residents can fall if not attended to right away. The call lights are important. During an interview on 7/7/2021 at 12:02 p.m., the DSD stated all staff were responsible for answering the call lights and the call lights should be answered immediately and not ring for more than 2-3 minutes. The DSD stated if the CNA could not provide service at the time the call light was pressed by the resident, then the CNA has to get another staff to address the concern and inform the residents someone would be returning to address their concerns. The DSD stated CNA's conduct rounds and call light check at the start of their shift and ensure call lights are within reach and functional. The DSD stated it was the job of the CNAs to notify maintenance right away of the call lights malfunction and conduct hourly rounds. During an interview on 7/7/2021 at 12:13 p.m., the Director of Maintenance (DOM) stated, We test the call lights once a day. We test the lights outside of each door, inside each room and at nurse's station. This issue of the call lights being broken, started yesterday (7/6). We believe the capacitor (a device that stores electrical energy) overheated so today and the technician is coming to fix the problem. I don't think we have a backup system. I'm new here. We have parts for cords; however, we communicate work orders by group text and department heads. During an interview on 7/7/2021 at 1:30 p.m., the ADON stated rooms 31 to 41 call lights were not functioning. The ADON stated the MS was informed of the call lights malfunctioning and handed out tabletop bells to the residents who had broken call lights. The ADON stated the facility had the same call lights from rooms 31 to 42 malfunctioning. The ADON stated the purpose of the call light was for nurses to be available when residents have needs. Residents can't call for help or get the care they need if the calls were not working. During an interview on 7/8/2021 at 10:39 a.m., the Medical Director (MD) stated call light malfunctioning has been brought up before in Quality Assurance and Performance Improvement ([plan discussed to improve health care delivery and resident quality of life] QUAPI) meetings. The MD also stated the facility informed her today the call light system was going to be replaced. During review of undated facility's record under section, List of Residents requires adaptive equipment/call light alternative indicated seven (7) residents required a call light alternative. During a review of the facility's Direct Supply Tels: Logbook Documentation indicated the call lights were last tested on [DATE]. During a review of the facility's policy and procedures (P/P), titled, Communication - Call System, dated 1/1/2012, the P/P indicated the purpose of the P/P was to provide a mechanism for residents to promptly communicate with Nursing Staff. The P/P indicated the facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. Nursing Staff will answer call bells promptly, in a courteous manner. In answering to request, Nursing Staff will return to the resident with the item or reply promptly. Assistance will be offered before leaving. The P/P also indicated if call bell is defective, it will be reported immediately to maintenance and replaced immediately. The P/P indicated call bells located within the resident bathrooms are considered emergency calls due to the potential for falls and injury. These lights have more frequent audio sound and the call light above the room door may be red or will flash on and off. Emergency calls must be answered promptly. The P/P further indicated adaptive call bells will be provided to resident per resident's needs.

Based on observation, interview, and record review, the facility failed to implement infection control interventions in the yellow zone (unit for residents suspected Corona Virus [COVID-19] a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) to prevent and control the spread of COVID-19 for six (6) of thirteen (13) residents (Residents 1, 2, 3, 4, 5, and 6) and three (3) out of four (4) staff in the facility in accordance with the facility's infection control policies and procedures (P/P) and mitigation plan ([MP] a plan to reduce the spread of the COVID-19 virus) by failing to: 1. Provide and ensure that four of four visitors (Visitor 1, 2, 3 and 4) in the yellow zone are wearing required Personal Protective Equipment (PPE, gowns, gloves, N95 -facemask that filters out a minimum of 95 percent of airborne particles and gloves). 2. Provide education to four of four visitors (Visitor 1, 2, 3 and 4) regarding Covid-19 protocols and PPE requirements in the yellow zone. 3. Ensure two of three staff (CK1 and KA1) were wearing a face mask while preparing food. 4. Ensure one of two unvaccinated staff (KA1) and two of two vaccinated staff (CK1 and SCR1) in the facility were fit tested for N95 respirator. 5. Ensure Certified Nurse Assistant (CNA1) put on face shield and gown prior to entering the residents' room in the yellow zone and providing care to the resident. These deficient practices had the potential to result in the spread of COVID-19 infection to Residents 2 and 4, who were not vaccinated (not inoculated with a vaccine to provide immunity against a disease), vaccinated Residents 1, 3, 5, and 6, staff members, and visitors which can potentially lead to serious respiratory illness, hospitalization , and death to others. On 8/19/2021, at 6:55 p.m., the newly hired Administrator (ADM1), current Administrator (ADM2), Assistant Director of Nursing (ADON), Infection Preventionist (IP) and Registered Nurse Consultant (RNC1), were notified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident), was called for the facility's staff inability to follow and implement infection protocols to prevent the spread of COVID-19 in the facility. The facility's ADM1, ADM2, ADON, IP and RNC1 were notified of the immediacy and seriousness of other residents' and staff members health and safety being threatened for not adhering to infection control protocols. On 8/21/2021 at 5:32 p.m., the facility submitted an acceptable Plan of Action (POA) and indicated the following actions for the IJ removal: 1. On 8/19/21, Infection Preventionist and Regional Quality Management Consultant (RQMC) made rounds to see if there were any visitors in the yellow zone without proper PPE. None were observed. 2. On 8/20/21, the facility receptionist was provided 1:1 education by the RQMC regarding visitation guidance specifically the requirement for facility staff to provide education and supervise the visitor's donning and doffing PPE. PPE is required regardless of vaccination status per the COVID-19 mitigation plan. 3. On 8/19/21, unvaccinated dietary staff were immediately provided N95 mask by the Infection Preventionist to be worn at all times while within the facility. 4. On 8/19/21, all dietary staff were immediately in serviced by Infection Preventionist about wearing appropriate masks at all times while within the facility. 5. On 8/19/21, the staff member in the yellow zone was provided 1:1 education by the Infection Preventionist regarding proper infection control practices and usage of appropriate PPE per the COVID-19 mitigation plan. 6. On 8/19/21, staff present in the facility were in serviced by Infection Preventionist nurse regarding proper infection control practices and usage of appropriate PPE per the COVID-19 mitigation plan while providing care in the yellow zone. 7. On 8/19/21, Infection Preventionist completed rounds to identify other visitors or staff within the facility without proper PPE, there were no other visitors or staff were identified to be in the facility without proper PPE. 8. On 8/19/21 and 8/20/21, the licensed nurses conducted an assessment of 98 residents who were assessed to identify residents who were affected by the deficient practice. No residents were identified to be affected. 9. On 8/20/21, the Infection Preventionist administered a Covid-19 [MEDICATION(S)] test for the 13 residents in the yellow zone to identify residents who were affected by the deficient practice. No residents were identified to be affected. 10. On 8/19/21, the Regional Quality Management Consultant, Director of Staff Development, and/or the Infection Preventionist provided education to the staff on COVID-19 mitigation plan with emphasis on visitation guidance and proper usage of PPE. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work prior to start of shift. As of 8/21/21, 109 of 139 staff members have been educated. 11. The PM Shift RN Supervisor/Designee will make facility infection control rounds twice a shift to assure the proper use of PPE in the yellow zone. 12. The Night Shift Supervisor/Designee will make facility infection control rounds twice a shift to assure the proper use of PPE in the yellow zone. 13. The Receptionist will screen all visitors upon arrival to the facility and notify the licensed nurse of the visitors' arrival. The licensed nurse will provide the visitors with the appropriate PPE such as N95 mask, provide the visitors education on the proper usage of PPE, and escort the visitors to the unit and provide visitors with the remainder of the required PPE. 14. On 8/19/21, all unvaccinated staff present in the facility were provided education by the Infection Preventionist nurse about wearing N95 masks when in indoor settings where 1) care is provided to residents, 2) residents have access for any purpose. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work prior to start of shift. As of 8/21/21, 12 out of 14 unvaccinated staff members were provided education. 15. On 8/19/21, all dietary staff present in the facility were provided education by the Infection Preventionist nurse about wearing appropriate masks at all times while within the facility. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work, prior to start of shift. 16. On 8/19/21, staff were provided education by the Infection Preventionist on wearing needed PPE (N95 masks, gowns, face shields and gloves) when entering residents' rooms in the yellow zone. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work, prior to start of shift. 17. On 8/20/21, the receptionist was provided education by the Infection Preventionist and RQMC regarding visitation guidance specifically the requirement for facility staff to provide education and supervise the visitors' donning and doffing of PPE. PPE is required regardless of vaccination status per the COVID-19 mitigation plan. 18. All the visitors will be screened at front entrance door and informed/educated regarding proper PPE use in the yellow zone during visitation. This shall be initiated by the receptionist or designee and documented on Visitation Log for Yellow Zone. 19. The RN supervisor or designee shall monitor visitors' compliance of keeping PPE on during visitation in the yellow zone. If a visitor is found to be non-compliant, they will be encouraged to comply or will be asked to leave the facility. 20. A sign was placed on each room's door in the yellow zone to alert visitor to wear proper PPE prior to entering the patient room. 21. The dietary staff shall be monitored by the Dietary Supervisor or designee twice a shift for use of proper PPE/masks using an Employee PPE log. 22. All staff providing care in the yellow zone shall use proper PPE as per mitigation plan. Infection Preventionist nurse/designee shall conduct infection control compliance rounds to assure proper use of PPE in the yellow zone two times a shift. 23. The Administrator and Director of Nursing will review the monitoring rounds and employee PPE log on a daily basis and present the non-compliance issues to the Quality Assurance and Performance Improvement Committee monthly for further review and interventions for the next 3 months, then quarterly thereafter until substantial compliance is sustained. 24. The Administrator and the Director of Nursing are responsible to ensure sustained compliance. Findings: 1. During a concurrent observation and interview with visitor 1 (V1) in the yellow zone on 8/19/2021 at 12:48 p.m., V 1 was observed in the residents' room, cleaning Resident 1's hands. V 1 was not wearing an N95 mask. V 1 stated she was not offered one by the facility and was not made aware that she needed a N95 mask. During a review of Resident 1's Admission Record (Face Sheet), face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/5/2021, the MDS did not indicated Resident 1's cognition (thought process), but indicated needed total physical assistance with activities of daily living (ADL) such as personal hygiene, toilet use, transferring and getting dressed. During a review of Resident 1's Health and Social History, the record indicated Resident1 received his first dose of COVID-19 vaccine on 2/1/21 and second dose on 3/4/21. 2. During an observation in the yellow zone on 8/19/2021 at 12:57 p.m., Visitor 2 (V2) was observed not wearing an N95 or any kind of facial covering, face shield, gown and gloves while standing in the yellow zone hallway in front of room [ROOM NUMBER]. Certified Nurse Assistant (CNA1) was observed passing V 2 as he was walking out of room [ROOM NUMBER], V 2 proceeded to enter room [ROOM NUMBER] and taking a seat on Resident 2's bed. CNA1 did was not observed to address and/or educate V 2's lack of PPE. There were three residents (Resident 2, 4, and 5) observed residing in room [ROOM NUMBER]. During a review of Resident 2's Admission Record (Face Sheet), face sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/20/2021, the MDS indicated Resident 2 has no cognition (thought process) impairment and required physical assistance with activities of daily living (ADL) such as transferring, personal hygiene, toilet use, eating and getting dressed. During a review of Resident 4's Admission Record (Face Sheet), face sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/18/2021, the MDS indicated Resident 4's has no cognition (thought process) impairment and required physical assistance with activities of daily living (ADL) such as personal hygiene, toilet use and getting dressed. During a review of Resident 5's Admission Record (Face Sheet), face sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 5's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/18/2021, the MDS indicated Resident 5's has no cognition (thought process) impairment and required physical assistance with activities of daily living (ADL) such as personal hygiene, toilet use and getting dressed. During a review of Resident 5's Immunization History Report, the record indicated Resident 5 received one of one dose of COVID-19 vaccine on 4/8/2021. During an interview on 8/19/2021 at 1:12 p.m. with V 2, V 2 stated, he was not informed that he had to wear a mask or any of the other PPE. V 2 stated, he walked in through facility's front entrance, his temperature was taken, and he walked to room [ROOM NUMBER]. V 2 stated he was not offered any kind of PPE and was not given any education or instructions about what was expected of him, like informing the facility if he had signs and symptoms of COVID-19. During an interview on 8/19/2021 at 1:08 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated anyone in the yellow zone, including visitors, need to comply with PPE requirements such as N95 mask, face shield, gown, and gloves. LVN 3 stated it is the staff's responsibility to educate and provide PPE to visitors when visitation is in the yellow zone. LVN 3 expressed that upon entrance to the residents' rooms, all PPE should be on to prevent the spread of COVID-19 infection. LVN 3 stated that aside for Resident 2 there are two other residents in room [ROOM NUMBER] (Resident 4 and 5) who are put at risk for infection due to Visitor 2's lack of PPE. LVN 3 educated and instructed Visitor 2 to hand sanitize, put on N95, face shield, gowns, and gloves on. During an interview on 8/19/2021 at 2:51 p.m. with the Receptionist (RCP), RCP stated she was responsible for educating visitors on what type of PPE to wear, but she failed to educate V 2. She stated she did not provide V 2 with PPE as well, because she was not aware that the resident Visitor 2 was visiting, was moved to the yellow zone and didn't realize V 2 was heading to the yellow zone. During an interview on 8/19/2021 at 2:16 p.m. with the Infection Preventionist (IP), IP stated the visitors are screened by the receptionist for covid-19 symptoms, temperature checked, rapid tested if not fully vaccinated, educated about reporting to facility if the visitors start to develop symptoms, hand sanitizing, PPE needed during the visitation and what was expected of them during the visit. The IP stated those visiting the yellow zone check in and proceed to meet with yellow zone staff who will provide them with PPE, which includes N95, face shield, gowns, gloves. IP stated she does not know what happened with the observed visitors not wearing PPE's, because the charge nurse was supposed to give them PPE's, monitor donning and doffing and provide more education. The IP emphasized that N95 and PPE are important to be in place to protect residents, staff and visitors from Covid-19. 3. During a concurrent observation and interview on 8/19/2021 at 1:20 p.m. with two visitors (V 3 and V 4) V 3 and V 4 were observed in the Resident 3's room (room [ROOM NUMBER]) at bedside wearing only a face mask with no face shield, gown or gloves. V 3 stated temperature and sign and symptoms questionnaire were asked upon entrance, but were not offered N95 masks or any other PPE after signing in. V 4 stated, no instructions were provided regarding what was required for the visit in the yellow zone. License Vocational Nurse 2 (LVN 2) was observed to approach V 3 and V 4 to offer the visitors a N95 mask, face shield, gown, and gloves. V 3 and V 4 stated there was no need for the PPE because they are finished with the visit. There were two residents (Resident 3 and 6) observed residing in room [ROOM NUMBER]. During a review of Resident 3's Admission Record (Face Sheet), face sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/18/2021, the MDS indicated Resident 3 had no cognition (thought process) impairment and required supervised one person assistance with activities of daily living (ADL) such as personal hygiene, transferring, toilet use, eating and getting dressed. During a review of Resident 3's Vaccination Record Card, the record indicated Resident 3 received his first dose of COVID-19 vaccine on 3/26/2021 and second dose on 4/6/2021. During a review of Resident 6's Admission Record (Face Sheet), face sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 6's History and Physical (H&P), dated 8/23/2021 indicated the Resident 6 has the capacity to understand and make decisions. During a review of Resident 6's Immunization History Report, the record indicated Resident 6 received his first dose of COVID-19 vaccine on 3/30/2021 and second dose on 4/27/2021. During an interview on 8/19/2021 at 1:04 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated V 3 was not wearing an N95, and V 4 was not wearing any type of facial covering, face shield, gown, or gloves. LVN 2 stated she was not sure what PPE yellow zone visitors needed. LVN 2 stated staff should be wearing an N95, face shield, gown, and gloves, so maybe visitors should be wearing the same to prevent the spread of COVID-19. 4. During an observation on 8/19/2021 at 3:06 p.m., Kitchen Aide (KA1) was observed with his N95 mask resting on his chin while inside the kitchen. KA1 pulled N95 up when surveyor entered but continued to pull mask down during interview while speaking. During an interview on 8/19/2021 at 3:06 p.m. with KA1, KA1 stated he was taking his mask on and off because it is difficult to speak with the mask on. KA1 stated that he was not fit tested for an N95 mask yet, but he was aware that he should be wearing an N95 mask at all times due to his incomplete Covid-19 vaccine dose. KA1 stated, it's important for him to wear the N95 mask in order to prevent the spread of the virus to protect himself and others. During a concurrent interview and record review on 8/19/2021 on 3:30 p.m. with the IP, IP stated that KA1 is not fully vaccinated, but also does not have fit testing record. She stated he should be wearing and N95 mask at all times, because he is not fully vaccinated. IP stated she will do an N95 fit test for him today. 5. During a concurrent observation and interview on 8/19/2021 at 3:10 p.m. with Cook (CK1), CK1 was observed not wearing a mask while chopping cucumbers. CK1 stated he should be wearing a mask at all times inside the facility and while preparing food to prevent the spread of the COVID 19 virus. CK1 stated he was not wearing a mask because it was hot in the kitchen and was aware that the mask is to protect residents, staff and himself from the Covid-19 virus. CK1 stated he is fully Covid-19 vaccinated but was not N95 fit tested . During a concurrent interview and record review on 8/19/2021 on 3:30 p.m. with the IP, IP stated CK1 should be wearing a face mask at all times, especially when preparing food to prevent the spread of the virus. The IP stated that CK1 is fully vaccinated but does not have a fit testing record. 6. During an interview on 8/19/2021 at 2:51 p.m. with Receptionist (RCP), RCP stated she was responsible for screening/educating staff and visitors coming into the facility regarding Covid-19. She stated that she was not N95 fit tested because she does not use the mask even when screening the staff and visitors. During a concurrent interview and record review on 8/19/2021 on 3:30 p.m., IP stated RCP does not have an N95 test in her record. IP stated she should be wearing an N95 because she is the front-line staff that screens staff and everyone else who walks in the facility. 7. During an observation on 8/19/2021 on 3:54 p.m., Certified Nurse Assistant 1 (CNA1) was observed entering the yellow zone room without a face shield and a gown. CNA1 was also observed wearing his mask over the bottom of his eyeglasses. Licensed Vocational Nurse 4 (LVN 4) was observed telling CNA1 to wear the mask under his eyeglasses. During an interview on 8/19/2021 on 4:01 p.m. with CNA1, CNA 1 stated that he only wears a face shield and gown when performing direct resident care or if he needed to touch resident. CAN 1 stated if he is not touching a resident, he does not need to wear the gown or face shield. CNA1 stated he received PPE in-service and the PPE is to protect the residents from infection. During an interview on 8/19/2021 on 4:10 p.m. with LVN 4, LVN 4 stated staff in the yellow zone are to wear an N95 and face shield for the duration of the shift. LVN 4 stated when entering a yellow zone room, staff is to wear full PPE which includes N95, face shield, gown, and gloves to protect the resident and staff from infection. A review of the facility's COVID-19 Mitigation Plan (MP) revised on 8/6/2021, the MP indicated visitors will be informed they must notify the facility if they develop respiratory symptoms or test positive for COVID-19 during the period of 14 days following their visit to the facility, the date of their visit, who they were in contact with and locations of the facility they visited. MP further indicated for visits requiring visitors to wear PPE due to the resident being in quarantine or isolation, facility staff will provide education and supervise the visitor's donning and doffing of PPE. PPE is required regardless of vaccination status. MP continues to indicate, Full PPE (gloves, gown, eye protection and N95 respirator) must be worn during visitation in the yellow zone (observation or exposed status). Visitors must be instructed in performing a seal check for N95 respirator. MP also addressed that in yellow area N95 respirator should be worn for duration of the shift and doffed when contaminated, goggles or face shield should be worn when providing care within six feet of a resident. Gowns should be worn and changed between resident encounters. MP further indicated that staff should always wear a surgical/procedure mask (unless N95 respirator is required) for universal source control while they are in the facility. It also indicated that that the unvaccinated worker must wear a surgical mask or higher level of respirator approved by NIOSH at all times while in the facility. During a review of the California Department of Public Health All Facilities Letter (AFL) 20-22.9 (AFL 20-22.9), dated 8/12/2021, indicated visits for residents who share a room should be conducted in a separate indoor space or with the roommate not present in the room (if possible), regardless of roommate's vaccination status. Visitors should be provided personal protective equipment (gloves, gown, eye protection and N95 respirator) and instructed in a N95 respirator seal check for visitation of residents in yellow (exposed or observation status) areas. During a review of the California Department of Public Health All Facilities Letter (AFL) 21-28 (AFL 21-28), dated 8/3/2021, under section 'Additional Personal Protective Equipment and Masking for Unvaccinated HCP' indicated The Aerosol Transmissible Disease (ATD) Standard (Title 8 of the California Code of Regulations section 5199) requires all employees in an area or residence where a suspected or confirmed COVID-19 case is present to use National Institute for Occupational Safety and Health (NIOSH) approved respirators. An N95 is the minimum protection permitted for these employees. AFL21-28 further indicates that facilities must provide respirators to all unvaccinated or workers who work in indoor work settings where (1) care is provided to patients or residents, or (2) to which patients or residents have access for any purpose. During a review of the California Occupational Safety and Health ([Cal/OSHA], a program responsible for enforcing California laws and regulations pertaining to workplace safety and health) guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages dated 8/2020 indicated employers must implement work practices to minimize the number of employees exposed to suspected and confirmed COVID-19 residents. The guidelines also indicated initial respirator fit testing was required before an employee used a respirator, or when an employee changed to a different model, make, or size of respirator. According to the guidelines, annual respirator fit testing was required by all facilities.

Based on observation, interview, and record review, the facility failed to implement infection control interventions in the yellow zone (unit for residents suspected Corona Virus [COVID-19] a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) to prevent and control the spread of COVID-19 for six (6) of thirteen (13) residents (Residents 1, 2, 3, 4, 5, and 6) and three (3) out of four (4) staff in the facility in accordance with the facility's infection control policies and procedures (P/P) and mitigation plan ([MP] a plan to reduce the spread of the COVID-19 virus) by failing to: 1. Provide and ensure that four of four visitors (Visitor 1, 2, 3 and 4) in the yellow zone are wearing required Personal Protective Equipment (PPE, gowns, gloves, N95 -facemask that filters out a minimum of 95 percent of airborne particles and gloves). 2. Provide education to four of four visitors (Visitor 1, 2, 3 and 4) regarding Covid-19 protocols and PPE requirements in the yellow zone. 3. Ensure two of three staff (CK1 and KA1) were wearing a face mask while preparing food. 4. Ensure one of two unvaccinated staff (KA1) and two of two vaccinated staff (CK1 and SCR1) in the facility were fit tested for N95 respirator. 5. Ensure Certified Nurse Assistant (CNA1) put on face shield and gown prior to entering the residents' room in the yellow zone and providing care to the resident. These deficient practices had the potential to result in the spread of COVID-19 infection to Residents 2 and 4, who were not vaccinated (not inoculated with a vaccine to provide immunity against a disease), vaccinated Residents 1, 3, 5, and 6, staff members, and visitors which can potentially lead to serious respiratory illness, hospitalization, and death to others. On 8/19/2021, at 6:55 p.m., the newly hired Administrator (ADM1), current Administrator (ADM2), Assistant Director of Nursing (ADON), Infection Preventionist (IP) and Registered Nurse Consultant (RNC1), were notified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident), was called for the facility's staff inability to follow and implement infection protocols to prevent the spread of COVID-19 in the facility. The facility's ADM1, ADM2, ADON, IP and RNC1 were notified of the immediacy and seriousness of other residents' and staff members health and safety being threatened for not adhering to infection control protocols. On 8/21/2021 at 5:32 p.m., the facility submitted an acceptable Plan of Action (POA) and indicated the following actions for the IJ removal: 1. On 8/19/21, Infection Preventionist and Regional Quality Management Consultant (RQMC) made rounds to see if there were any visitors in the yellow zone without proper PPE. None were observed. 2. On 8/20/21, the facility receptionist was provided 1:1 education by the RQMC regarding visitation guidance specifically the requirement for facility staff to provide education and supervise the visitor's donning and doffing PPE. PPE is required regardless of vaccination status per the COVID-19 mitigation plan. 3. On 8/19/21, unvaccinated dietary staff were immediately provided N95 mask by the Infection Preventionist to be worn at all times while within the facility. 4. On 8/19/21, all dietary staff were immediately in serviced by Infection Preventionist about wearing appropriate masks at all times while within the facility. 5. On 8/19/21, the staff member in the yellow zone was provided 1:1 education by the Infection Preventionist regarding proper infection control practices and usage of appropriate PPE per the COVID-19 mitigation plan. 6. On 8/19/21, staff present in the facility were in serviced by Infection Preventionist nurse regarding proper infection control practices and usage of appropriate PPE per the COVID-19 mitigation plan while providing care in the yellow zone. 7. On 8/19/21, Infection Preventionist completed rounds to identify other visitors or staff within the facility without proper PPE, there were no other visitors or staff were identified to be in the facility without proper PPE. 8. On 8/19/21 and 8/20/21, the licensed nurses conducted an assessment of 98 residents who were assessed to identify residents who were affected by the deficient practice. No residents were identified to be affected. 9. On 8/20/21, the Infection Preventionist administered a Covid-19 antigen test for the 13 residents in the yellow zone to identify residents who were affected by the deficient practice. No residents were identified to be affected. 10. On 8/19/21, the Regional Quality Management Consultant, Director of Staff Development, and/or the Infection Preventionist provided education to the staff on COVID-19 mitigation plan with emphasis on visitation guidance and proper usage of PPE. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work prior to start of shift. As of 8/21/21, 109 of 139 staff members have been educated. 11. The PM Shift RN Supervisor/Designee will make facility infection control rounds twice a shift to assure the proper use of PPE in the yellow zone. 12. The Night Shift Supervisor/Designee will make facility infection control rounds twice a shift to assure the proper use of PPE in the yellow zone. 13. The Receptionist will screen all visitors upon arrival to the facility and notify the licensed nurse of the visitors' arrival. The licensed nurse will provide the visitors with the appropriate PPE such as N95 mask, provide the visitors education on the proper usage of PPE, and escort the visitors to the unit and provide visitors with the remainder of the required PPE. 14. On 8/19/21, all unvaccinated staff present in the facility were provided education by the Infection Preventionist nurse about wearing N95 masks when in indoor settings where 1) care is provided to residents, 2) residents have access for any purpose. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work prior to start of shift. As of 8/21/21, 12 out of 14 unvaccinated staff members were provided education. 15. On 8/19/21, all dietary staff present in the facility were provided education by the Infection Preventionist nurse about wearing appropriate masks at all times while within the facility. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work, prior to start of shift. 16. On 8/19/21, staff were provided education by the Infection Preventionist on wearing needed PPE (N95 masks, gowns, face shields and gloves) when entering residents' rooms in the yellow zone. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work, prior to start of shift. 17. On 8/20/21, the receptionist was provided education by the Infection Preventionist and RQMC regarding visitation guidance specifically the requirement for facility staff to provide education and supervise the visitors' donning and doffing of PPE. PPE is required regardless of vaccination status per the COVID-19 mitigation plan. 18. All the visitors will be screened at front entrance door and informed/educated regarding proper PPE use in the yellow zone during visitation. This shall be initiated by the receptionist or designee and documented on Visitation Log for Yellow Zone. 19. The RN supervisor or designee shall monitor visitors' compliance of keeping PPE on during visitation in the yellow zone. If a visitor is found to be non-compliant, they will be encouraged to comply or will be asked to leave the facility. 20. A sign was placed on each room's door in the yellow zone to alert visitor to wear proper PPE prior to entering the patient room. 21. The dietary staff shall be monitored by the Dietary Supervisor or designee twice a shift for use of proper PPE/masks using an Employee PPE log. 22. All staff providing care in the yellow zone shall use proper PPE as per mitigation plan. Infection Preventionist nurse/designee shall conduct infection control compliance rounds to assure proper use of PPE in the yellow zone two times a shift. 23. The Administrator and Director of Nursing will review the monitoring rounds and employee PPE log on a daily basis and present the non-compliance issues to the Quality Assurance and Performance Improvement Committee monthly for further review and interventions for the next 3 months, then quarterly thereafter until substantial compliance is sustained. 24. The Administrator and the Director of Nursing are responsible to ensure sustained compliance. Findings: 1. During a concurrent observation and interview with visitor 1 (V1) in the yellow zone on 8/19/2021 at 12:48 p.m., V 1 was observed in the residents' room, cleaning Resident 1's hands. V 1 was not wearing an N95 mask. V 1 stated she was not offered one by the facility and was not made aware that she needed a N95 mask. During a review of Resident 1's admission Record (Face Sheet), face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses include chronic respiratory failure (condition where lungs have a hard time loading your blood with oxygen or removing carbon dioxide), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis of one side of the body), heart failure (condition where the heart doesn't pump blood as well as it should), diabetes (condition in which body ineffective uses blood sugar) and hypertension (force of blood against artery walls is too high). During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/5/2021, the MDS did not indicated Resident 1's cognition (thought process), but indicated needed total physical assistance with activities of daily living (ADL) such as personal hygiene, toilet use, transferring and getting dressed. During a review of Resident 1's Health and Social History, the record indicated Resident1 received his first dose of COVID-19 vaccine on 2/1/21 and second dose on 3/4/21. 2. During an observation in the yellow zone on 8/19/2021 at 12:57 p.m., Visitor 2 (V2) was observed not wearing an N95 or any kind of facial covering, face shield, gown and gloves while standing in the yellow zone hallway in front of room [ROOM NUMBER]. Certified Nurse Assistant (CNA1) was observed passing V 2 as he was walking out of room [ROOM NUMBER], V 2 proceeded to enter room [ROOM NUMBER] and taking a seat on Resident 2's bed. CNA1 did was not observed to address and/or educate V 2's lack of PPE. There were three residents (Resident 2, 4, and 5) observed residing in room [ROOM NUMBER]. During a review of Resident 2's admission Record (Face Sheet), face sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses include hypertension (force of blood against artery walls is too high), cerebral ischemia (lack of blood flow to the brain) and encephalopathy (disease that alters brain function or structure). During a review of Resident 2's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/20/2021, the MDS indicated Resident 2 has no cognition (thought process) impairment and required physical assistance with activities of daily living (ADL) such as transferring, personal hygiene, toilet use, eating and getting dressed. During a review of Resident 4's admission Record (Face Sheet), face sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses include hypertension (force of blood against artery walls is too high), anemia (lack healthy red blood cell to carry adequate oxygen to body tissue), obesity (excessive body fat), and atherosclerosis (buildup of fats, cholesterol, and other substances in and on the artery walls). During a review of Resident 4's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/18/2021, the MDS indicated Resident 4's has no cognition (thought process) impairment and required physical assistance with activities of daily living (ADL) such as personal hygiene, toilet use and getting dressed. During a review of Resident 5's admission Record (Face Sheet), face sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses include hypertension (force of blood against artery walls is too high), breast cancer (malignant tumor that forms from the uncontrolled growth of abnormal breast cells), atherosclerosis (buildup of fats, cholesterol, and other substances in and on the artery walls) and diabetes (condition in which body ineffective uses blood sugar). During a review of Resident 5's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/18/2021, the MDS indicated Resident 5's has no cognition (thought process) impairment and required physical assistance with activities of daily living (ADL) such as personal hygiene, toilet use and getting dressed. During a review of Resident 5's Immunization History Report, the record indicated Resident 5 received one of one dose of COVID-19 vaccine on 4/8/2021. During an interview on 8/19/2021 at 1:12 p.m. with V 2, V 2 stated, he was not informed that he had to wear a mask or any of the other PPE. V 2 stated, he walked in through facility's front entrance, his temperature was taken, and he walked to room [ROOM NUMBER]. V 2 stated he was not offered any kind of PPE and was not given any education or instructions about what was expected of him, like informing the facility if he had signs and symptoms of COVID-19. During an interview on 8/19/2021 at 1:08 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated anyone in the yellow zone, including visitors, need to comply with PPE requirements such as N95 mask, face shield, gown, and gloves. LVN 3 stated it is the staff's responsibility to educate and provide PPE to visitors when visitation is in the yellow zone. LVN 3 expressed that upon entrance to the residents' rooms, all PPE should be on to prevent the spread of COVID-19 infection. LVN 3 stated that aside for Resident 2 there are two other residents in room [ROOM NUMBER] (Resident 4 and 5) who are put at risk for infection due to Visitor 2's lack of PPE. LVN 3 educated and instructed Visitor 2 to hand sanitize, put on N95, face shield, gowns, and gloves on. During an interview on 8/19/2021 at 2:51 p.m. with the Receptionist (RCP), RCP stated she was responsible for educating visitors on what type of PPE to wear, but she failed to educate V 2. She stated she did not provide V 2 with PPE as well, because she was not aware that the resident Visitor 2 was visiting, was moved to the yellow zone and didn't realize V 2 was heading to the yellow zone. During an interview on 8/19/2021 at 2:16 p.m. with the Infection Preventionist (IP), IP stated the visitors are screened by the receptionist for covid-19 symptoms, temperature checked, rapid tested if not fully vaccinated, educated about reporting to facility if the visitors start to develop symptoms, hand sanitizing, PPE needed during the visitation and what was expected of them during the visit. The IP stated those visiting the yellow zone check in and proceed to meet with yellow zone staff who will provide them with PPE, which includes N95, face shield, gowns, gloves. IP stated she does not know what happened with the observed visitors not wearing PPE's, because the charge nurse was supposed to give them PPE's, monitor donning and doffing and provide more education. The IP emphasized that N95 and PPE are important to be in place to protect residents, staff and visitors from Covid-19. 3. During a concurrent observation and interview on 8/19/2021 at 1:20 p.m. with two visitors (V 3 and V 4) V 3 and V 4 were observed in the Resident 3's room (room [ROOM NUMBER]) at bedside wearing only a face mask with no face shield, gown or gloves. V 3 stated temperature and sign and symptoms questionnaire were asked upon entrance, but were not offered N95 masks or any other PPE after signing in. V 4 stated, no instructions were provided regarding what was required for the visit in the yellow zone. License Vocational Nurse 2 (LVN 2) was observed to approach V 3 and V 4 to offer the visitors a N95 mask, face shield, gown, and gloves. V 3 and V 4 stated there was no need for the PPE because they are finished with the visit. There were two residents (Resident 3 and 6) observed residing in room [ROOM NUMBER]. During a review of Resident 3's admission Record (Face Sheet), face sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses include diabetes (condition in which body ineffective uses blood sugar), cellulitis of right upper limb (bacterial infection involving inner layers of the skin) and generalized muscle weakness (reduced muscle strength). During a review of Resident 3's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/18/2021, the MDS indicated Resident 3 had no cognition (thought process) impairment and required supervised one person assistance with activities of daily living (ADL) such as personal hygiene, transferring, toilet use, eating and getting dressed. During a review of Resident 3's Vaccination Record Card, the record indicated Resident 3 received his first dose of COVID-19 vaccine on 3/26/2021 and second dose on 4/6/2021. During a review of Resident 6's admission Record (Face Sheet), face sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses include hypertension (force of blood against artery walls is too high), human immunodeficiency virus ([HIV] - virus that attacks the body's immune system), colon cancer (tumorous growth develop in the large intestine) and liver cancer (growth and spread of unhealthy cells in the liver). During a review of Resident 6's History and Physical (H&P), dated 8/23/2021 indicated the Resident 6 has the capacity to understand and make decisions. During a review of Resident 6's Immunization History Report, the record indicated Resident 6 received his first dose of COVID-19 vaccine on 3/30/2021 and second dose on 4/27/2021. During an interview on 8/19/2021 at 1:04 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated V 3 was not wearing an N95, and V 4 was not wearing any type of facial covering, face shield, gown, or gloves. LVN 2 stated she was not sure what PPE yellow zone visitors needed. LVN 2 stated staff should be wearing an N95, face shield, gown, and gloves, so maybe visitors should be wearing the same to prevent the spread of COVID-19. 4. During an observation on 8/19/2021 at 3:06 p.m., Kitchen Aide (KA1) was observed with his N95 mask resting on his chin while inside the kitchen. KA1 pulled N95 up when surveyor entered but continued to pull mask down during interview while speaking. During an interview on 8/19/2021 at 3:06 p.m. with KA1, KA1 stated he was taking his mask on and off because it is difficult to speak with the mask on. KA1 stated that he was not fit tested for an N95 mask yet, but he was aware that he should be wearing an N95 mask at all times due to his incomplete Covid-19 vaccine dose. KA1 stated, it's important for him to wear the N95 mask in order to prevent the spread of the virus to protect himself and others. During a concurrent interview and record review on 8/19/2021 on 3:30 p.m. with the IP, IP stated that KA1 is not fully vaccinated, but also does not have fit testing record. She stated he should be wearing and N95 mask at all times, because he is not fully vaccinated. IP stated she will do an N95 fit test for him today. 5. During a concurrent observation and interview on 8/19/2021 at 3:10 p.m. with [NAME] (CK1), CK1 was observed not wearing a mask while chopping cucumbers. CK1 stated he should be wearing a mask at all times inside the facility and while preparing food to prevent the spread of the COVID 19 virus. CK1 stated he was not wearing a mask because it was hot in the kitchen and was aware that the mask is to protect residents, staff and himself from the Covid-19 virus. CK1 stated he is fully Covid-19 vaccinated but was not N95 fit tested. During a concurrent interview and record review on 8/19/2021 on 3:30 p.m. with the IP, IP stated CK1 should be wearing a face mask at all times, especially when preparing food to prevent the spread of the virus. The IP stated that CK1 is fully vaccinated but does not have a fit testing record. 6. During an interview on 8/19/2021 at 2:51 p.m. with Receptionist (RCP), RCP stated she was responsible for screening/educating staff and visitors coming into the facility regarding Covid-19. She stated that she was not N95 fit tested because she does not use the mask even when screening the staff and visitors. During a concurrent interview and record review on 8/19/2021 on 3:30 p.m., IP stated RCP does not have an N95 test in her record. IP stated she should be wearing an N95 because she is the front-line staff that screens staff and everyone else who walks in the facility. 7. During an observation on 8/19/2021 on 3:54 p.m., Certified Nurse Assistant 1 (CNA1) was observed entering the yellow zone room without a face shield and a gown. CNA1 was also observed wearing his mask over the bottom of his eyeglasses. Licensed Vocational Nurse 4 (LVN 4) was observed telling CNA1 to wear the mask under his eyeglasses. During an interview on 8/19/2021 on 4:01 p.m. with CNA1, CNA 1 stated that he only wears a face shield and gown when performing direct resident care or if he needed to touch resident. CAN 1 stated if he is not touching a resident, he does not need to wear the gown or face shield. CNA1 stated he received PPE in-service and the PPE is to protect the residents from infection. During an interview on 8/19/2021 on 4:10 p.m. with LVN 4, LVN 4 stated staff in the yellow zone are to wear an N95 and face shield for the duration of the shift. LVN 4 stated when entering a yellow zone room, staff is to wear full PPE which includes N95, face shield, gown, and gloves to protect the resident and staff from infection. A review of the facility's COVID-19 Mitigation Plan (MP) revised on 8/6/2021, the MP indicated visitors will be informed they must notify the facility if they develop respiratory symptoms or test positive for COVID-19 during the period of 14 days following their visit to the facility, the date of their visit, who they were in contact with and locations of the facility they visited. MP further indicated for visits requiring visitors to wear PPE due to the resident being in quarantine or isolation, facility staff will provide education and supervise the visitor's donning and doffing of PPE. PPE is required regardless of vaccination status. MP continues to indicate, Full PPE (gloves, gown, eye protection and N95 respirator) must be worn during visitation in the yellow zone (observation or exposed status). Visitors must be instructed in performing a seal check for N95 respirator. MP also addressed that in yellow area N95 respirator should be worn for duration of the shift and doffed when contaminated, goggles or face shield should be worn when providing care within six feet of a resident. Gowns should be worn and changed between resident encounters. MP further indicated that staff should always wear a surgical/procedure mask (unless N95 respirator is required) for universal source control while they are in the facility. It also indicated that that the unvaccinated worker must wear a surgical mask or higher level of respirator approved by NIOSH at all times while in the facility. During a review of the California Department of Public Health All Facilities Letter (AFL) 20-22.9 (AFL 20-22.9), dated 8/12/2021, indicated visits for residents who share a room should be conducted in a separate indoor space or with the roommate not present in the room (if possible), regardless of roommate's vaccination status. Visitors should be provided personal protective equipment (gloves, gown, eye protection and N95 respirator) and instructed in a N95 respirator seal check for visitation of residents in yellow (exposed or observation status) areas. During a review of the California Department of Public Health All Facilities Letter (AFL) 21-28 (AFL 21-28), dated 8/3/2021, under section 'Additional Personal Protective Equipment and Masking for Unvaccinated HCP' indicated The Aerosol Transmissible Disease (ATD) Standard (Title 8 of the California Code of Regulations section 5199) requires all employees in an area or residence where a suspected or confirmed COVID-19 case is present to use National Institute for Occupational Safety and Health (NIOSH) approved respirators. An N95 is the minimum protection permitted for these employees. AFL21-28 further indicates that facilities must provide respirators to all unvaccinated or workers who work in indoor work settings where (1) care is provided to patients or residents, or (2) to which patients or residents have access for any purpose. During a review of the California Occupational Safety and Health ([Cal/OSHA], a program responsible for enforcing California laws and regulations pertaining to workplace safety and health) guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages dated 8/2020 indicated employers must implement work practices to minimize the number of employees exposed to suspected and confirmed COVID-19 residents. The guidelines also indicated initial respirator fit testing was required before an employee used a respirator, or when an employee changed to a different model, make, or size of respirator. According to the guidelines, annual respirator fit testing was required by all facilities.

Based on observation, interview, and record review, the facility failed to: 1. Monitor all exit doors and ensure the wander guard system ([Resident Monitoring System] a device that alarms when residents attempt to elope [leaving the facility without permission] or wander [to move aimlessly from place to place] from a safe environment) was working properly on all exit doors for five of eight sampled residents (Resident 14, Resident 15, Resident 16, Resident 17, and Resident 18) with elopement and wandering risk. 2. Ensure one of eight sampled residents (Resident 14) at risk for elopement received supervision. Resident 14 with moderately impaired cognition (mental action or process of acquiring knowledge and understanding), who was identified as a high risk for elopement due to previous history of trying to elope and verbalizing he wanted to leave facility, exited the building unsupervised on 3/13/2021 and 3/19/2021. These deficient practices resulted in Resident 14, who required close supervision, to be missing and the facility was unable to locate Resident 14 as of 4/1/2021 from 3/19/2021 (13 days). These deficient practices had the potential to result in harm, injury, or death of the five residents (Resident 14, Resident 15, Resident 16, Resident 17, and Resident 18). 3. Provide supervision to one of eight sampled residents (Resident 15) with wandering behavior to other residents' rooms. Resident 15, who had episodes of wandering to other residents' room, history of striking out staff, required close supervision but was not being closely monitored by the facility's staff resulting in unsafe environment for three of eight sampled residents (Resident 1, Resident 2, and Resident 3). Resident 1 was upset when Resident 15 grabbed his blanket that provoked Resident 1 to slap Resident 15's hand to stop Resident 15 from grabbing his blanket. Resident 2 was upset because Resident 15 went to his room and Resident 2 thought Resident 15 was stealing his belongings. Resident 3 was upset because Resident 15 was touching his belongings, tried to pee on him. This deficient practice resulted in a physical altercation (aggression) between Resident 1 and Resident 15, Resident 2 feeling upset, and Resident 3 feeling fearful and experiencing anxiety and interrupted sleep. A pattern of the facility's system failure to implement its policy and procedure to ensure residents, who were at risk for elopement and required supervision and/or monitoring, was being supervised. On 3/24/2021 at 4:25 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the seriousness of the residents' health and safety being threatened by not being supervised for aggressive behavior and elopement. On 3/26/2021 at 3:46 p.m., the facility submitted an acceptable Plan of Action (POA) and the IJ was lifted on 3/26/2021 at 4:14 p.m., after the team verified and confirmed the POA was implemented through observation, interview and record review as follows: 1. On 3/24/21, Sensor Alarms were installed in all three exit doors, the front entry door by the receptionist, Sub-Acute exit door, and by the kitchen. 2. On 3/25/21, Sounding Alarms were installed on all four exit doors, the front entry door by the receptionist, Sub-Acute Station 3, by the kitchen, and by the dining room. 3. On 3/25/21, the attending physicians were notified of the two residents (Resident 15 and Resident 16) who were identified to be at risk for elopement and orders were obtained for wander guards (bracelets). 4. On 3/22/21, the Maintenance Supervisor ordered parts for the wander guard system for the front door and device tester. The exit doors wander guard system by the kitchen and Sub- Acute area are functional. 5. On 3/25/21, an electrical contractor was contacted to assess and repair the wander guard system in the front entry door. 6. On 3/25/21 at 2:15 p.m. the wander guard system was repaired and in operational condition. 7. On 3/24/21, the DON, RN2, RN3, LVN5 and LVN 10 conducted an audit of 84 residents to identify residents who are high risk for elopement. Three (3) residents (Resident 15, Resident 16, and Resident 17) were identified to be at high risk for elopement and the residents are on hourly monitoring to ensure safety of the residents. 8. On 3/24/2021, the Regional Quality Management Consultant and/or Director of Staff Development provided education to the staff on Elopement Policy and Procedures. This education will be completed by 3/28/2021. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON or Director of Staff Development (DSD) upon return to work prior to start of shift. 9. The DON and DSD will provide monthly education to staff on Elopement Policy and Procedure for the next 6 Months. 10. Nursing staff (licensed and certified) will conduct shift huddles to review the status of residents who are at risk for elopement and to conduct frequent visual check of residents in the facility to ensure that the residents' needs are met and to minimize or prevent any falls. 11. The Maintenance Supervisor shall conduct weekly door alarm checks and document the results in a log and issues identified will be immediately addressed and reported to the administrator for further resolution as warranted. 12. The Licensed Nurses will conduct every (q) shift monitoring of placement of the wander guards and document on the Medication Administration Record (MAR). 13.The Department heads shall conduct Ambassador Rounds (a system of visiting the residents or inspecting the resident's environment) with their assigned rooms to ensure residents are safe. Findings of the rounds will be discussed with the Administrator during Morning Stand-Up Meetings and issues or concerns will be addressed immediately. 14.During Stand up Meetings M-F (Monday to Friday) with the Interdisciplinary Team ([IDT], a group of professionals from different disciplines discussing and communicating the resident's plan of care), all new changes of condition and incidents or elopements and new high risk residents will be discussed to ensure that required assessments and monitoring have been completed by the licensed nurses according to policy. Issues identified during the review will be addressed immediately. 15. The Administrator together with the Department Heads will conduct weekly compliance status review and will present the results of the weekly compliance review and Ambassador Rounds to the Quality Assurance and Performance Improvement Committee for review and recommendations monthly for 3 months then quarterly thereafter until substantial compliance achieved. The facility check of resident monitoring system documentation shall be reviewed in monthly Quality Assurance and Assessment (QAA) committee for further review and interventions for continued compliance. Findings: a. A review of Resident 16's Admission Record indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's diagnoses included dementia (loss of cognitive functioning, thinking, remembering, and reasoning), cognitive communication deficit (inability to initiate and sustain appropriate conversation), and abnormality of gait (manner of walking). A review of Resident 16's Minimum Data Set (MDS), an assessment and care-planning tool, dated 01/29/2021, indicated Resident 16 was severely impaired with cognitive skills for daily decision-making, required total dependence with 1 person assist with locomotion (ability to move from one place to another) on and off the unit and has impairment on both sides of lower extremity. On 3/23/2021 at 2:30 p.m., upon entrance to the facility, there was no information posted at the entrance door or anywhere in the facility to notify staff, visitors, and residents of ongoing repairs to the facility's Resident Monitoring System. During an observation on 3/23/2021 at 2:39 p.m., Resident 16 was wearing a wander guard bracelet (a monitoring device) on his right wrist and the resident was sitting on a wheelchair outside his room. Resident 16 wheeled himself to the hallway towards the dining room. During a concurrent interview with Resident 16, he stated he was looking for food. During a concurrent observation and interview with the Maintenance Director (MD) on 3/23/2021 at 3:16 p.m., the MD stated there were no security alarm on the three exit doors, on the front entry door by the receptionist, Sub-Acute unit exit door, and by the kitchen, but the three exit doors have a wander guard system that was used for monitoring residents who were high risk for elopement. The MD stated the wander guard system on the three exit doors will alarm once the resident (with a wander guard bracelet) was near the door's monitoring device. The MD tested the monitoring device at the front entry door near the receptionist by placing the wander guard bracelet about 2 inches near the monitoring device, but there was no alarm that sounded. The MD stated the test for the front entry door monitoring device failed and was not working since 3/1/2021 because the mother board was fried (the main circuit board was not working). The wander guard system by the Sub-Acute exit door and by the kitchen created an audible alarm during testing and the MD stated it passed the test and were functional. During a concurrent interview and record review of list of residents who were wearing wander guard with the DON, on 3/23/2021 at 3:20 p.m., the DON stated as of 3/23/2021, there were 2 residents (Resident 16 and Resident 17) who were currently being monitored for wandering and both residents were wearing wander guard bracelets. The DON stated there were no other residents who had wandering behavior. A review of list of residents wearing a wander guard bracelet indicated there were two residents (Resident 16 and Resident 18) who were wearing wander guard bracelet for the month of February 2021 and 3 Residents (Resident 16, Resident 17 and Resident 18) for the month of March 2021. During an interview with the Maintenance Director (MD), on 3/24/2021 at 2:40 p.m., he stated he was the person responsible to check the wander guard bracelets, but the device tester used to check for residents' wander guard bracelets was missing. The MD stated there were 2 residents who were wearing wander guard bracelets and he would bring the residents to the wander guard system by the door to check if the wander guard bracelet was working properly. The MD stated there was no documentation that he was testing the wander guard bracelets and he was unaware of the residents who were wearing the bracelets, when he conducted the testing for the bracelets, and what were the result of the test. During an interview with Medical Record (MR) staff on 3/24/2021 at 2:50 p.m., she stated there were no documentations that indicated Resident 16 and Resident 17 were being closely monitored for wandering. The MR stated she was unable to find documentation indicating the facility were checking the wander guard bracelets for Resident 16 and Resident 17. During an interview with Registered Nurse Consultant 2 (RNC 2) on 3/24/2021 3:18 p.m., she stated that the facility currently does not have a policy regarding checking the wander guard system. The RNC stated the facility was following the manufacturer's recommendation that the wander guard system should be checked daily, and the daily checks should be documented. A record review of logbook documentation, Resident Monitoring System: Check operations of door monitors and patient wandering system, dated 2/26/2021, indicated the test for the resident monitoring system at the back door by the kitchen failed on 2/22/2021 and 2/24/2021 and the system is in need of repair and waiting for parts. A record review of logbook documentation, Resident Monitoring System: Check operations of door monitors and patient wandering system, dated 3/5/2021, indicated the test for the resident monitoring system at the front door entry failed on 3/1/2021, 3/3/2021, 3/5/2021, 3/15/2021, 3/17/2021 and 3/19/2021 and was not working. During an interview with the DON and the ADM, on 3/24/2021 at 4:15 p.m., the ADM and DON both stated they were not aware the front door Resident Alarm System was not working, and they were not able to have an alternative plan to closely monitor the resident. The ADM stated that if the wander guard system was not working, they (the facility staff) should closely monitor the residents. The ADM stated that if he was informed, the facility would have put in place a 24-hour receptionist and increase the frequency of rounding (visiting or monitoring the residents). The DON stated the facility currently has a receptionist only until 8 p.m. and the staff (certified and licensed nurses) were only charting rounding and resident monitoring every shift. During an interview with the ADM, on 4/2/2021 at 2:30 p.m., the ADM stated that he was aware that the kitchen's back door's wander guard system was not working on 2/22/2021 and 2/24/2021. The ADM stated the facility ordered parts of the mother board on 3/2/2021 but he was not aware that they have not received the part of mother board that was ordered and that wander guard system was not yet fixed. A review of the wander guard system manufacturer user instruction, undated, indicated to test each signaling device before using. Thereafter, test the device daily and record the results in the resident's record. b. A review of Resident 14's Admission Record indicated Resident 14 was admitted to the facility on [DATE]. Resident 14's diagnoses included traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow in the head) and [CONDITION(S)] (burst of uncontrolled electrical activity between brain cells that causes abnormal movements). A review of Resident 14's Minimum Data Set (MDS), an assessment and care-planning tool, dated 12/23/2020, indicated Resident 14 was moderately impaired with cognitive skills for daily decision-making, required supervision for locomotion ((ability to move from one place to another) on and off the unit and for activities of daily living (ADL, such as eating toileting and grooming). The MDS indicated Resident 14 was on antipsychotic medications (used to treat mental health illness) on a routine basis and had diagnoses that included anxiety disorder (feeling of worry, anxiety, or fear that are strong enough to interfere with daily activities) and [CONDITION(S)] (mental disorder which people interpret reality abnormally). A review of Resident 14's care plan, initiated on 3/3/2020, indicated the resident had a history of attempting to leave facility. A review of Resident 14's care plan, initiated on 3/3/2020, indicated the resident has [CONDITION(S)] and behavioral symptoms manifested by paranoia (an unrealistic distrust of others) and stating the facility was holding him against his will. A review of Resident 14's psychological consultation, dated 3/17/2020, indicated the resident had reported he wanted to get out of the facility and live on his own. A review of Resident 14's Elopement Risk Tool, dated 9/26/2020 at 12:08 p.m., indicated Resident 14 had not shared concerns that the resident may have wandering/elopement tendencies and Resident 14 has not been found to be at risk for elopement at this time despite Resident14's history of attempting to leave facility on 3/3/2020 and the resident verbalizing he wanted to get out of the facility. A review of Resident 14's care plan, initiated on 12/2/2020, indicated to monitor the resident for episodes of paranoia as evidenced by stating facility was holding him against his will and monitor the resident for cognitive changes such as hallucinations (sensing things such as visions, sounds or smells that seem real but are not), delusions (believing things that are not true) or disorganized thinking. A review of Resident 14's Psychiatric Note, dated 1/13/2021, indicated Resident 14 was labile (change easily), grandiose (state of being grand or magnificent), poor insight into mental illness, refuse care because grandiose and threatening, and had a diagnosis [CONDITION(S)]. The psychiatric note indicated Resident 14 was refusing medication and may require higher level of care. A review of Resident 14's Physician's Order, dated 3/5/2021, indicated an order of [MEDICATION(S)] (medication that can help prevent severe mood swing) 100 mg (milligrams) twice a day for [CONDITION(S)] manifested by paranoia stating the facility was holding him against his will. A review of Resident 14's MAR for March 2021 indicated the resident was on [MEDICATION(S)] for [CONDITION(S)] manifested by stating the facility was holding him against his will. The MAR indicated Resident 14 had manifested the behavior of stating the facility was holding him against his will 17 times from 3/1/2021 to 3/8/2021. A review of Resident 14's Nursing Notes, dated 3/13/2021 at 3:53 p.m., indicated the resident walked out the building using the side door by Room 21 and Station 3. Resident 14 slammed the door open and said, Bye bye, and then ran off. Registered Nurse 1 (RN 1) paged the staff to notify the episode of elopement and tried to catch up with Resident 14. Three charge nurses (not identified) went out the main door of the facility and saw the resident enter the facility the same day by walking towards the front door. A review of Resident 14's Elopement Risk Tool, dated 3/13/2021 at 3:48 p.m., indicated Resident 14 had left the facility without informing staff and had been found to be at risk for elopement. A review of Resident 14's Nursing Notes, dated 3/13/2021 4:14 p.m., indicated Resident 14 got out of the facility and the RN supervisor (RN 1) tried to stop him. Resident 14 stated Bye bye, and got out the facility's side door. RN 1 saw Resident 14 walking towards the front door. A review of Resident 14's Care Plan, initiated 3/13/2021, indicated the resident was a risk for wandering or elopement but the care plan did not indicate Resident 14 would need close monitoring. A review of Resident 14's IDT meeting record, dated 3/15/2021, indicated the IDT team recommended for Resident 14 to have a wander guard (bracelet) but the resident, who was alert and oriented, refused. The record indicated Resident 14 expressed his desire to leave the facility during the IDT meeting and he stated he could leave the facility anytime. A review of Resident 14's Physician's Progress Note, dated 3/16 with the year not written, indicated a family member was concerned that Resident 14 will leave AMA (against medical advice). The physician's progress note indicated Resident 14 was homeless and [CONDITION(S)]. A review of Resident 14's Social Service Director (SSD) notes, dated 3/16/2021 at 2:44 p.m. indicated the SSD spoke with the resident on 3/16/2021 morning regarding Resident 14 wanting to leave AMA. Resident 14 stated he will live in a homeless shelter and he had verified there was an available bed for him. The SSD contacted the homeless shelter and it was closed for 14 days. The SSD encouraged Resident 14 to contact his family (RF) to arrange pick up at the facility as soon as he agreed to move to a homeless shelter in another location with an available bed. The SSD called RF and she stated she can pick him up on 3/22/2021 but SSD would need to verify with the homeless shelter if a bed was available for the resident. A review of Resident 14's nurses notes, dated 3/19/2021 from 11 p.m. to 7 a.m. (night shift), indicated that at 6:50 a.m., while Licensed Vocational Nurse 8 (LVN 8) was passing medications, the resident was not in his room. LVN 8 then received a phone call that the resident was witnessed two blocks away from the facility. LVN 8 went with another staff (not identified) to find the resident but they could not find the resident. LVN 8 called the local law enforcement and filed for a missing person report. LVN 8 notified Resident 14's physician and left a message to the resident's family. A review of Resident 14's Situation, Background, Assessment, Recommendation (SBAR, a communication tool) form indicated Resident 14 had an episode of elopement on 3/19/2021. During an interview with RF, on 3/23/2021 at 2:40 p.m., RF stated the elopement (on 3/19/2021) was a little unexpected because Resident 14 knew RF was coming on 3/22/2021 to pick him up. RF stated Resident 14 had been saying he did not want to be at the facility. RF stated Resident 14 had a previous episode of trying to leave the facility on 3/13/2021 but he returned to the facility. RF stated she tried to look for Resident 14 at the places she thought he might go, and she tried to call him, but he was not answering his phone. RF stated that as of 3/23/2021, Resident 14 was still not found and she was afraid the resident will be found severely beaten again like how he was found before that caused him to be comatose (in a state of deep unconsciousness) for over a month. During an interview with the DON, on 3/23/2021 at 6:10 p.m., the DON stated LVN 3 should have revised the care plan (dated 3/13/2021) if the previous plan of care did not prevent Resident 14 from eloping on 3/13/2021. The DON stated LVN 3 should have increased the frequency of monitoring Resident 14 to at least every 2 (q2) hours and created a log to document the monitoring conducted. During a concurrent interview and review of Resident 14's clinical record with MR, on 3/24/2021 at 2:50 p.m. she stated there were no wandering, elopement log or documentation that indicated Resident 14 was being closely monitored. During an interview and concurrent review of Resident 14's clinical record with LVN 3 on 3/24/2021 at 3:46 p.m., LVN 3 stated they (the licensed nurses) were only charting monitoring for behavior of wandering or elopement every shift and there was no log to document frequent monitoring. LVN 3 stated he created the care plan (dated 3/13/2021) but he did not revise the care plan to increase the frequency of monitoring despite Resident 14 able to leave facility on 3/13/2021 unsupervised. During an interview with Certified Nurse Assistant 4 (CNA 4), on 3/24/2021 at 4:37 p.m., she stated on 3/19/2021 at 7:10 a.m. she saw Resident 14 standing at a corner 0.3 miles away from the facility while she was driving home. CNA 4 stated she recognized Resident 14 because Resident 14 looked at her and Resident 14 was wearing clothes he regularly wore, gray shirt and exercise pants, and beanie. CNA 4 stated she called CNA 5 and CNA 5 stated the resident was not at the facility. CNA 4 stated she was unable to follow Resident 14 because there were a lot of cars behind her. c (1). A review of Resident 15's Admission Record, the record indicated Resident 15 was admitted to the facility on [DATE]. Resident 15's diagnoses including dementia (loss of cognitive functioning, thinking, remembering, and reasoning), cognitive communication deficit (inability to initiate and sustain appropriate conversation), impulse disorder (failure to resist a temptation, an urge, or an impulse), and altered mental status. A review of Resident 15's Care Plan, initiated on 2/16/2021, indicated he had history of striking out staff during care. A review of Resident 15's MDS, dated [DATE], indicated Resident 15 was severely impaired with cognitive skills for daily decision-making and was totally dependent on staff for activities of daily living, had not exhibited wandering behavior, and was not using wheelchair for mobility device. During an observation on initial tour of the facility and concurrent interview with Resident 15 on 3/22/2021 at 2:15 p.m., Resident 15 was sitting on his wheelchair, inside his room by the door. Resident 15 stated Resident 1 tried to hurt him, grabbed his finger and his hands. Resident 15's voice was observed increasing in tone and he had an angry facial expression. Resident 15 appeared agitated and the interview stopped to let resident calm down. During an interview with the Director of Rehabilitation (DR), on 3/22/2021 at 2:30 p.m., the DR stated Resident 15 could get loud, was observed with increased tone of voice, but he was not physically aggressive to others and he never said bad words. The DR stated Resident 15 would move his hands but would not physically hit anyone nor was he intentionally aggressive to others. The DR stated Resident 15 could easily get upset but he was easy to redirect. Resident 15 had dementia, would stroll outside the room and would ask on the middle of the day to take him home. The DR stated she had observed Resident 15 wandering the hallway using his wheelchair and that the resident needed to be redirected back to his bed. A record review of Resident 15's Care Plan, initiated on 2/16/2021, indicated he had history of striking out staff during care. During a telephone interview and concurrent review of Resident 15's clinical record with LVN 4, on 4/1/2021 at 12:30 p.m., LVN 4 stated he was not able to find documentation that indicated the resident was being closely monitored for wandering or aggressive behavior. LVN 4 was not aware Resident 15 required closed supervision. During a telephone interview and concurrent review Resident 15's clinical record with the DON on 4/2/2020 at 3 p.m., the DON stated that wandering, touching other resident's belongings, and striking out staff were behaviors which could lead to conflict, neglect and abuse, so it was important that Resident 15's behaviors were care planned for appropriate interventions and monitoring. c (2). A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. The resident's diagnoses included [CONDITION(S)] (a condition that causes seizures: temporary glitches in the brain's electrical activity), [CONDITION(S)] (a progressive nervous system disorder that affects movement), malignant neoplasm of the brain (tumor in the brain due to an abnormal growth or division of cells), and generalized muscle weakness (muscle weakness throughout the body). A review of Resident 1's History and Physical (H/P), dated 2/25/2021, indicated that the resident had the capacity to understand and make decisions. A review of Resident 1's MDS, dated [DATE], indicated Resident 1's cognitive skills for daily decisions were moderately impaired with no indication of [CONDITION(S)] (mental disorder characterized by a disconnection from reality). The MDS indicated Resident 1 was totally dependent with one-person physical assist for locomotion in room and extensive assistance with one person assist for toilet use. Resident 1 had range of motion (ROM, the full movement potential of a joint) limitation to bilateral (both) lower extremities. Resident 1 had the ability to move from seat to standing position, on and off the toilet, his surface to surface transfer was not steady, and he could only able to stabilize himself with staff assistance. Resident 1 utilized a wheelchair for mobility. A review of Resident 15's Nurses Notes on 3/18/2021 12:42 p.m. indicated LVN 3 interviewed Resident 15 and the resident stated that he was just trying to get his blanket back but Resident 1 refused to give it back. The nurses notes indicated that when Resident 15 was pulling the blanket, Resident 1 smacked his wrist. A review of Resident 15's care plan, initiated on 3/18/2021, indicated resident has physical and verbal aggression received from another resident (Resident 1). During an interview with Resident 1, on 3/22/2021 at 3 p.m., he stated that while he was lying in bed in his room, Resident 15 was grabbing his blanket on 3/18/2021. Resident 1 stated he told Resident 15 to stop but Resident 15 continued to grab his blanket. Resident 1 stated he got upset and he slapped Resident 15's hand to stop him from grabbing his blanket. Resident 1 stated he did not intend to hurt Resident 15 and he was just trying to stop him. Resident 1 stated that the staff (not identified) separated him and Resident 15 to stop another confrontation. c (3). A review of Resident 2's Admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. The resident's diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), [CONDITION(S)], generalized muscle weakness (muscle weakness throughout the body), and dependence on supplemental oxygen (oxygen therapy which help get oxygen to lungs, heart and other parts of the body). A review of Resident 2's MDS, dated [DATE], indicated the resident's cognitive skills for daily decision making was cognitively intact. The MDS indicated Resident 2 required extensive assistance with one-person physical assist for locomotion in room and toilet use. Resident 2 was able to move from seat to standing position, on and off toilet, his surface to surface transfer was not steady, and he could only able to stabilize himself with staff assistance. Resident 2 utilized a walker and a wheelchair for mobility. During a walk through at the facility, on 3/22/2021 at 3:15 p.m., Resident 15 was observed wheeling himself and entering Resident 2's room. During an interview with Resident 2, on 3/25/2021 at 11:19 p.m., Resident 2 stated that Resident 15 goes to his room and touches his belongings, causing him to be upset because Resident 15 was trying to steal his belonging. c (4). A review of Resident 3's Admission Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. The resident's diagnoses included cerebral infraction (damage to tissues in the brain due to loss of oxygen to the area), left side [CONDITION(S)] (paralysis on one side of the body), generalized muscle weakness (muscle weakness throughout the body), and anxiety disorder (psychiatric disorders that involve extreme fear or worry). A review of Resident 3's MDS, dated [DATE], indicated the resident's cognitive skills for daily decision making was cognitively intact, and he was totally dependent on staff with one person physical assist for transfer, locomotion on/off unit, eating, toilet use and personal hygiene. Resident 3 also required extensive assistance with one-person physical assist for bed mobility and dressing. Resident 3 had ROM impairment on one side of both upper and lower extremities. During an interview with Resident 3 on 3/26/2021 at 2:25 p.m., Resident 3 stated he was upset because Resident 15 would touch his belongings. Resident 3 stated that he woke up on 3/22/2021 at 2 a.m. and Resident 15 was standing at the side of his bed staring at him and wanted to pee on him. Resident 3 stated he was startled and could not go back to sleep because the incident gave him fear and anxiety. A review of Resident 15's SSD note dated 3/23/2021 at 8:15 a.m., indicated the SSD asked Resident 15 to move to another room due to Resident 3 complained regarding Resident 15 touching his belongings. During an interview and concurrent review of list of residents being monitored for wandering dated 3/23/2021, on 3/23/2021 at 3 p.m., the DON identified only Resident 16 and Resident 17 as the only 2 residents being monitored for wandering. The DON was not aware Resident 15 who required closed supervision was not being monitored for wandering because Resident 15 had no history of trying to elope. A review of Resident 15's Risk for Elopement, dated 3/24/2021 at 5:36 p.m., indicated Resident 15 has not been found to be at risk for elopement at this time despite resident having pattern of wandering through out the facility including wandering into other resident's rooms. During an interview with LVN 5 on 3/26/2021 at 2:45 p.m., LVN 5 stated that Resident 15 was a high risk for elopement

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent and eradicate (destroy) gnats (small long legged flying insects) infestation (presence of an unusually large number) throughout the facility for 84 of 84 residents who were eating food and drinking in their room. This deficient practice resulted in the presence multiple gnats observed in the residents' rooms, food items, curtains, bed, blankets, bathrooms, shower rooms, hallway walls, food trays left in the hallways, and kitchen. The gnats' infestation placed all 84 residents, including 20 residents in the sub-acute unit (a unit for residents requiring a higher level of care) than those in a skilled nursing facility) at risk of parasite (organism that lives on a host organism and gets its food from it) diseases (illnesses that results from infections transmitted to humans by insects, such as gnats) and bites. During the investigation on 3/23/2021 at 5:30 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was identified and declared and the facility's administrator (ADM) and Registered Nurse Consultant (RNC) were notified of the gnats found throughout the facility. During an interview on 3/29/2021 at 5:06 p.m., the ADM and the RNC were informed the IJ was lifted after implementation of the acceptable plan of action ([POA], interventions to correct the deficient practice) was verified and confirmed while on onsite via observation, interview and record review. The acceptable POA included the following actions: 1. On 3/23/2021, upon identification of the gnats throughout the facility and within resident's rooms, maintenance director (MD) contacted an outside exterminator (a person whose job is to kill a particular type of animal that is not wanted in a place). 2. On 3/23/2021, the exterminator was able to apply germicide (a substance that kills germs) without affecting the residents and without having to move the residents. Rooms 36, 37, 38 and 39, in addition to the kitchen, were areas identified as concerns. The gnats where noted in other areas of the facility but the extent was minimal and not an immediate concern. 3. On 3/21/2021, the MD and the exterminator conducted a walkthrough of the entire facility and applied the germicide. 4. On 3/23/2021, the ADM developed a tracking tool for MD as to monitor the entire facility on a weekly basis for the presence of pests or rodents (a small mammal that has a pair of incisor teeth). Subsequently, the MD began the use of tracking tool for weekly monitoring. 5. On 3/24/2021, the MD and consultants determined all drains be disinfected for two (2) weeks with diluted bleach to kill any potential gnats' larvae (the active immature form of an insect). 6. On 3/24/2021, a second treatment of a germicide was done by the exterminator for the gnats. 7. On 3/25/2021, from 7 p.m. until midnight, the facility's team lead by the ADM, Registered Dietitian (RD), and the maintenance supervisor (MS), cleaned up the kitchen and the dry storage area (where dried foods are kept). Cleaning the kitchen included: all preparation areas, walls, racks, under sink, hoods, vents, oven, equipment, refrigerator, and the office area. 8. On 3/24/2021, the director of staff development (DSD) provided education to the staff on the importance of an effective pest control program. The staff members were instructed by the DSD to immediately notify the MD of any issues, so the facility remained free of pest and rodents. 9. On 3/25/2021, due to less satisfactory conditions and notation of pest in the kitchen, the dietary manager (DM) created a daily cleaning schedule log to ensure there would be a clean and sanitary kitchen in the areas, such as the floors, sinks, preparation areas, machines, kitchen equipment, trash cans, drains, walls, dry storage area, oven, burners, shelves, tables, hood, carts, dish room, chemical room, freezer, refrigerator and juice machine. 10. The DM will ensure completion of each duty by initialing completion on both daily and weekly logs and report any concerns to ADM during morning Department stand-up meetings. 11. The pest control company will continue to inspect and treat the facility monthly, and as needed after the resolution of the current gnats/pest issue. 12. The MD and administrator will provide monthly education to staff for the next 3 months on: a. Timely notification to the maintenance department of pest. b. Findings of weekly tracking tool with staff. c. Submission of any found issues as it relates to a pest and/or rodent problem areas including but not limited to wet areas, problem drains, excessively dirty areas, or resident's rooms. d. Notification of resident's rooms in which food was kept in an unsanitary manner as to attract pest. Findings: During a review of the facility's census report, dated 3/24/2021, the census report indicated there were 84 residents residing in the facility (20 of the residents were in the subacute unit on ventilators [breathing machines]). During a review of the Pest Management Sanitation Report (PMSR), dated 3/18/2021, the report indicated pest (gnats) activity was found in a restroom located in Room 37. The PMSR indicated spot treatment was done while onsite. During a review of the PMSR, dated 3/24/2021, the PMSR indicated pest (gnats) activity was found, and control measures were initiated. The PMSR indicated the hallways, shower rooms, Nurse Station 1, Rooms 36 through 42, five (5), employee bathrooms, residents' bathrooms connected from Rooms 38 thru 40 had the most pest activity, the bathroom in Room 39 had moisture around the commode (portable toilet) and bed pans on the floor were treated for gnats. The report indicated gnats were located on Room 39's ceiling, windows, and walls and were difficult to rid. During a Concurrent observation and interview, on 3/23/2021 at 1:55 p.m., with Resident 6, in Room 39, Resident 6's room was observed with multiple gnats flying over Resident 6, the resident's covered food tray, personal items, and privacy curtain. Resident 6 was observed unable to lift his arms to swat the gnats away. Resident 6 stated the gnat problem had been ongoing for over a month and the staff knew about it but did not care for it. Resident 6 stated, I do not want to eat this F****** (expletive) food, it is nasty (referring to the gnats). I have F****** (expletive) told them multiple times and they don't care, I told them I could move rooms, this is disgusting. During a concurrent observation and interview on 3/23/2021 at 2:10 p.m., with MD, in room 39, Resident 6's room was observed to have gnats on the resident's personal belongings and the privacy curtain. MD stated the facility was aware of the ongoing problem of gnats for more than four (4) days. MD stated the pest control company came to the facility a few weeks prior ago but he did not have any of service documentations available that indicated the date and the treatment provided to the facility. During a concurrent observation and interview on 3/23/2021 at 3:30 p.m., with Resident 7, in Room 38, two (2) gnats were observed flying over Resident 7's packaged food and privacy curtain. Resident 7 stated her has been bothered with gnats flying over her food while eating for over three (3) weeks and the facility's staff not doing anything about it. Resident 7 stated, It's nasty to be having them (gnats) all over my food and the curtains. I feel disgusted and bothered by them. During a concurrent observation and interview on 3/23/2021 at 4:08 p.m., with Dietary Aide 1 (DA 1) and DA 2, in the kitchen, gnats were observed flying. The kitchen doors have gaps and did not close properly. There were old food particles on the floor corners, under the sinks, and drainage for ice machine and sinks. DA 1 stated moths (flies) were noted on the uncollected food trays and she observed gnats on the kitchen wall by the exit door. During a concurrent observation and interview on 3/25/2021 at 2:10 p.m., with Housekeeper 1 (HK 1), in a shared restroom (Rooms 37 and 38), the restroom was observed to have gnats. HK 1 stated gnats were observed for 10 days in the shared bathroom because of the pee and poop of a resident. During a concurrent observation and interview on 3/25/2021 at 2:20 p.m., with Maintenance Assistant Director (MAD), in shared restroom between rooms 37 and 38, the pipes were observed to have mold and moisture. MAD stated the mold and moisture from the pipes caused the gnats to accumulate and infest the entire facility within a month. During an interview on 3/26/2021 at 2:06 p.m., the Dietary Supervisor (DS) stated he has seen gnats in the facility for a few weeks. The DS stated the kitchen was not being cleaned properly as observed during a tour of the kitchen. The DS stated there was not a log to indicate the days the kitchen was sanitized (made clean and hygienic; disinfected) and water drainage cleaned. During a review of an article titled, How Serious are Gnats, the article indicated gnats are a nuisance since they do not cause major damage to homes. However, gnats may threaten human health should they transport pathogens from their unsanitary development sites. The article further indicates the female of some species, such as the black gnat or black fly, feed on blood. These gnats have been known to carry parasites and spread diseases to humans. https://www.orkin.com/flies/gnats During a review of the Center for Disease Control and Prevention ([CDC] a division for Vector-Borne (a live carrier that transfers infectious pathogens from one living organism to other living organisms) disease, updated on 8/24/2020, the report indicated flies bred in, and fed on, moist decaying organic matter, and frequented unsanitary areas and potentially spread disease-causing bacteria onto exposed food products or food preparation surfaces when found in facilities. The report indicated flies could be found breeding wherever moisture existed around plumbing and drains in bathroom, kitchen areas, garbage containers, garbage disposals, wall, and basements where plumbing leaks. These breeding areas were occasionally very difficult to locate. Other areas to check where any fruits or vegetables that are stored outside of refrigerators or coolers, also inspect recycling bins, garbage cans, damp mop closets and used rag storage bins, and beneath refrigerators where dust and other organic deposits can be found in damp evaporation pans. The report indicated when, searching for breeding sources, remember that the larva can only survive in decaying organic matter that remains moist. http://www.publichealth.lacounty.gov/eh/docs/Specialized/Vector_Management/phoridFlies.pdf During a review of the facility's P/P titled, Housekeeping-Pest Control, dated 1/1/2012, the P/P indicated the purpose of the P/P was to ensure the facility was free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff and visitor. The P/P indicated the facility would maintain an ongoing pest control program to ensure the building and grounds were kept free of insects, rodents, and other pests. The P/P indicated the Administrator (ADM) arranged for a pest control company to visit and inspect the facility at least once a year for insects, termites, rodents, and any other pest that may cause damage to the facility. The P/P indicated the staffs' role consisted on notifying the Housekeeping Supervisor (HS) of any signs of rodents or insects, including ants in the facility; HS would take immediate action to remove the pest and will notify the ADM and call exterminator company for assistance.

Based on observation, interview and record review, the facility failed to ensure the call light system was operable in all of the residents' rooms and bathrooms with visual and audible signals and at the nursing stations to alert and relay the residents' needs to the staff and prevent possible falls with injuries for 9 of 84 residents (1, 2, 3, 6, 8, 9, 10, 11, and 12) and had the potential to affect all the residents who resided in the facility (Crossed reference to F 558). A review of the facility's Resident Census and Conditions of Residents (CMS 672 form) completed by the facility, the CMS 672 indicated the facility had 58 residents occasionally or frequently were incontinent (inability to control) of bladder; 68 residents occasionally or frequently were incontinent of bowel; 62 residents with contractures (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints); 56 residents receiving preventative skin care; 26 resident who require suctioning; and 36 residents on a pain management program. This deficient practice resulted in the following: 1. Residents 1, 2, 3, and 6, who had high risk for falls, needs were not being met timely. 2. Resident 1, who requires an extensive assist with a one-person physical assist with toileting and mobility, was calling out for staff assistance, as the call light was not working, with no response and had a fall in the bathroom and sustained back pain after waiting for an hour and 45 minutes for the staff to come. 3. Residents 6, 8, 9, 10, 11, and 12 were not assessed on their needs for an adaptive call lights, as they could not activate the call light due to the resident's disabilities. This deficient practice of not having functioning call lights resulted in Resident 1, who required assistance with toileting and mobility and had a high risk for falls, fell and was left unattended for over an hour. The facility's inoperable call light system had the potential to result in adverse consequences to the due to the residents (Residents 2, 3,6, 8, 9, 10, 11 and 12) not having the ability to communicate their needs and needs met timely. During an interview on 3/22/2021 at 7:49 p.m., the facility's Administrator (ADM), Director of Nursing (DON), Director of Medical Records (DMR) and the facility's Registered Nurse Consultant (RNC 1) were informed that an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident), was identified and declared for the facility's non-compliance to ensure the call light system was operable to meet the residents' needs under F919. The ADM, DON, DMR and RNC 1 were notified of the serious noncompliance that threatened the residents' health and safety and the need for the immediate corrective plan of action ([POA] interventions to correct the deficient practice). The facility provided an acceptable POA on 3/25/2021 at 12:50 p.m. The acceptable POA included the following: 1. On 3/21/2021, upon the facility's identification of the Call Light System Malfunction in Rooms 26-42, the ADM and Maintenance Supervisor (MS) were immediately made aware on 3/21/2021 at 10:36 a.m. 2. On 3/21/2021, the RN Supervisor immediately notified the certified nurse assistants (CNAs) and Licensed Nurses Vocational Nurses (LVNs) of the call light system malfunction for a total of 37 residents and were instructed to immediately conduct an every 15-minute room check rounds to ensure the residents needs were met and addressed. 3. On 3/21/2021, the MS contacted a call light repair vendor at 10:51 a.m. to schedule an appointment for repair the next day. The company provided call light repair service on 3/22/2021 at 3 p.m. 4. On 3/22/2021 at 5:30 p.m., the call light repair company was able to fix the call lights for all the rooms except for Room 32. The resident in Room 32 was transferred to another room. 5. On 3/22/2021, the Regional Quality Management Consultant (RQMC) and the ADM in-serviced all the staff on the evening and night shift regarding management and response to call light malfunction. 6. On 3/22/2021 and 3/23/2021, the Department heads conducted Ambassador Rounds to identify issues related to care including call lights and toileting needs. Concerns that were identified were placed in Grievance forms for investigation and resolution. 7. On 3/22/2021, the DON and designee conducted an audit of residents to identify residents who may benefit with another form of call light to use. There were total of seven (7) residents, who were identified and could benefit with an alternative call light device. 8. On 3/22/2021, the RQMC and the Administrator provided education to the staff on the Management and Response to Call Light System Malfunction including Unusual Occurrence Reporting, Timely response to call light system, Fall Management including Reporting of falls and assessment post reporting of Fall including documentation requirements, Pain Assessment, Notification of MD on Changes of Condition. This education will be completed by 3/28/2021. The staff who were not scheduled to work or on leave of absence will be provided with education by the DON or Director of Staff Development (DSD) upon return to work prior to start of shift. 9. The DON and DSD will provide Monthly Education to Staff for the next six (6) months on call lights and fall management. 10. The MS will conduct daily checks on the facility's call light system for 7 days and weekly thereafter and document the checks in the TELS (the equipment lifecycle system [a system for maintenance/repair services management]). 11. The Administrator together with the Department Heads will conduct weekly compliance status review and will present the results of the Call Light Rounds and Ambassador Rounds to the Quality Assurance and Performance Improvement Committee for review and recommendations monthly for three (3) months then quarterly thereafter until substantial compliance achieved the facility check of call light system documentation. 12. On 3/23/2021 (two days after the call lights malfunction), the facility purchased an additional 39 call bells. 13. On 3/24/2021, licensed nurses obtained orders for 6 residents for Occupational Therapy (OT) Evaluation for adaptive equipment/call light alternative and orders were communicated to the Director of Rehabilitation. Five (5) residents were provided with an alternative call light pad and one resident was provided with based on the assessment and recommendation of the OT. On 3/25/2021 at 3:32 p.m., the IJ was lifted in the presence of the ADM and RNC after implementation of the acceptable POA was verified and confirmed while the team was onsite per observation, interview, and record review. Findings: a. During the tour of the facility on 3/22/2021 at 3 p.m., there were 37 residents identified with inoperable call lights in Rooms 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42. During an observation on 3/22/2021 at 3:05 p.m., the call lights was tested in Room 30 bed C. There was no audible sound heard and light not flashing outside the residents' room. During an observation on 3/22/2021 at 3:35 p.m., in Room 34 bed A, B, and C and the bathroom the call lights were tested with no sound heard or flashing light inside or outside residents' room after activating the system. During an observation on 3/22/2021 at 3:45 p.m., the call light in Room 33 bed A, B, and C were observed with no sound heard or flashing light inside or outside residents' room after activating the call light system. During an interview on 3/22/2021 at 3:54 p.m., the MS stated call lights stopped working on 3/21/2021 at approximately 7 a.m. after a two (2) seconds power surge (a form of electrical power disturbance). The MS stated call bells were distributed to the residents between the hours of 8 a.m. to 9 a.m. on 3/21/2021, but the MS stated he was not sure how many. The MS stated the call light service vendor informed him they would send a service technician (Tech 1) today (3/22/2021) at 7 a.m., but the vendor did not come until 3 p.m. and Tech 1 was still working on the call lights at that time. During an interview on 3/22/2021 at 4:15 p.m., Tech 1 stated he arrived at the facility on 3/22/2021 at 3 p.m. Tech 1 stated he was able to fix the call lights but does not know for how long they will remain working. Tech 1 stated the call light system was old and anything, such as a power surge, can trigger it inoperable. During a concurrent observation and interview on 3/22/2021 at 4:27 p.m. with CNA 2, the call lights for Rooms 32, 33, 34, 35, and 36 and their respective bathroom call lights had no audible sound and/or flashing lights. CNA 2 stated the calls were just serviced, but they are not working again. When asked, CNA 2 stated she was not aware of rounding logs to be utilized to monitor the residents while the call lights were not working. CNA 2 stated they checked on the residents about every hour or so but do not document it. During interview on 3/22/2021 at 4:58 p.m., the ADM stated he was aware the facility's call lights were not working again. The ADM stated a technician have been called to come back to the facility. During an observation on 3/22/2021 at 5:40 p.m., the call light service company was back in the facility attempting to repair the call light system again. During a concurrent observation and interview on 3/22/2021 at 6:16 p.m., a tour was conducted with the administrator to inspect/check if the call lights were operational. The ADM stated the call lights were back working again, except for Room 32. Room 32's call lights remain under repair and required parts for repair. The resident in Room 32 will be relocated to Room 35 C. During an interview on 3/23/2021 at 2:45 p.m., the ADM stated he received a report from RN 1 on 3/21/2021 at 10:40 a.m. that Rooms 32-30 call lights were not working. The ADM stated he instructed RN 1 to do rounds every 15 minutes to monitor residents. The facility was unable to provide the documentation of the staff making rounds every 15 minutes to check the residents. During an interview on 3/23/2021 at 2:50 p.m., the Social Service Director (SSD) stated they did not have a log to document staff rounding, but she made rounds in the facility and told the charge nurses to make frequent rounds. The facility was not able to provide any documentation the residents were being monitored when the call lights were inoperable. During an interview on 3/23/2021 at 5:40 p.m., Registered Nurse Consultant 2 (RNC 2) stated six (6) of the seven (7) residents (Residents 6, 8, 9, 10, 11, and 12), who required a call light alternative because of the inability to activate the call light due to the residents' physical impairment were not provided with an alternative call light. During an interview on 3/26/2021 at 2:26 p.m., the MS stated he did not have any documentation of the staff checking the residents' call light system when it failed on 3/21/2021. The MS stated the last time he conducted a test of the residents' call light system was on 2/26/2021. b. During an interview on 3/22/2021 at 3:05 p.m., Resident 1 stated he fell in the bathroom the night prior (3/21/2021) and yelled for help in the bathroom, but no one came to assist him. Resident 1 stated he crawled back to bed, pressed the call light, and waited for an hour and 45 minutes after the fall before any staff came. During a concurrent observation on 3/22/2021 at 3:05 p.m., the call light string was pulled in Resident 1's bathroom to test if the emergency call system was working. There was no sound heard and no light flashing once the call light string was pulled. There was no bell found inside the Resident 1's bathroom or any means for Resident 1 to communicate if he needed help while in the bathroom. During an interview on 3/22/2021 at 4 p.m., CNA 1 stated the call lights were not working since 3/21/2021. CNA 1 stated they had no documentation to show resident were being monitored every 15 minutes. CNA 1 stated Resident 1 stated he had an unwitnessed fall in the bathroom on 3/21/2021 and she reported the fall to Licensed Vocational Nurse 1 (LVN 1). During a concurrent interview and record review on 3/22/2021 at 5:10 p.m., LVN 1 stated Resident 1 reported he had a fall on 3/21/2021. A review of Resident 1's record indicated there was no documentation of a fall assessment, change of condition, or that the physician was notified of Resident 1's fall. LVN 1 stated she did not document her assessments because she thought Resident 1 was delusional (a belief that is clearly false and that indicates an abnormality in the affected person's content of thought). LVN 1 stated the process after a fall was to do an assessment, change of condition, neurological check (define), and notify physician and family. During a review of Resident 1's Admission Face Sheet, the Face Sheet indicated Resident 1 was recently admitted to the facility on [DATE]. Resident 1's diagnoses included [CONDITION(S)] (a condition that causes seizures: temporary glitches in the brain's electrical activity), [CONDITION(S)] (a progressive nervous system disorder that affects movement), malignant neoplasm of the brain (tumor in the brain due to an abnormal growth or division of cells), generalized muscle weakness (muscle weakness throughout the body). During a review of Resident 1's history and physical (H/P), dated 2/25/2021, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated 3/2/2021, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired with no indication of [CONDITION(S)] (mental disorder characterized by a disconnection from reality). The MDS indicated Resident 1 was totally dependent with a one-person physical assist for locomotion in the room and required an extensive assist with a one-person assist for toilet use. Resident 1 had range of motion ([ROM] full movement potential of a joint, usually its range of flexion and extension) limitation to bilateral lower extremities. Resident 1 utilized a wheelchair for mobility. The MDS indicated Resident 1 was incontinent (inability to control) of bladder and bowel. During a review of Resident 1's Morse Fall Risk Assessment (method of assessing a resident's likelihood of falling), dated 3/24/2021, the fall assessment indicated Resident 1 had a high risk for fall. During interview on 3/22/2021 at 3 p.m., Resident 1 stated he fell the night prior (3/21/2021) at approximately 10:30 p.m. to 11:30 p.m. Resident 1 stated he was pressing the call light, but no one came to assist him. Resident 1 stated he had not been changed and the staff did not check on him. Resident 1 stated he went to the bathroom on his own to use the toilet, cleaned up, stood up, held up his pants, and fell hitting his back on the toilet. Resident 1 stated he was screaming for help in the bathroom, but no one came to help him. Resident 1 stated he crawled back to his bed and grabbed the side rail to get back in bed. Resident stated he was screaming for help, but it took staff an hour and 45 minutes to come in to assist him. Resident 1 stated the staff did not specifically tell him the call lights were not working on 3/21/2021, but they did show him how the temporary hand bell worked. Resident 1 stated the staff did not make frequent rounds and the hand bells provided did not seem to work because no one came to help him. Resident 1 stated after the fall he experienced pain level of 7/10 (0 being no pain and 10 being the worse pain) to his back. During an interview on 3/22/2021 at 4 p.m., CNA 1 stated Resident 1 informed her he had an unwitnessed fall in the bathroom, and she reported the unsupervised fall to LVN 1. c. During review of Resident 2's Admission Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included [CONDITION(S)], diabetes, generalized muscle weakness (muscle weakness throughout the body). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision-making was intact. The MDS indicated Resident 2 required an extensive assistance of a one-person physical assist for locomotion in room and toilet use. The MDS indicated Resident 2's ability to move from seat to standing position, on and off toilet and surface to surface transfer was not steady and could only be stabilize with staff assistance. Resident 2 utilizes a walker and a wheelchair for mobility. According to the MDS, Resident 2 was always incontinent of bladder and bowel. During a review of Resident 2's Morse Fall Risk Assessment, dated 3/24/2021, the fall assessment indicated Resident 2 had a high risk for falls. During an interview on 3/22/2021 at 3:35 p.m., Resident 2 stated he does not know exactly when the call lights stopped working because the staff usually takes almost two hours to answer call lights anyway. Resident 2 stated he was given a bell at 5 p.m. on Sunday (3/21/2021) and was told the call lights have been out of service since early that morning. Resident 2 stated he should have been informed about the call lights not working as soon as they stopped working, not at 5 p.m. Resident 2 stated if the call lights were not working, the staff should make an extra effort to check on him in the room. Resident 2 stated there has not been any staff, the day before or today, to come in to check on him every hour or even longer. Resident 2 stated he was given a bell, but stated the staff, were either ignoring the bell or could not hear the bell. Resident 2 stated he was oxygen dependent and needed assistance with some of his daily activities. Resident 2 expressed concern about his and other residents' safety during an emergent situation because the staff were not responding to the temporary bells. d. During review of Resident 3's Admission Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included left side [CONDITION(S)] (paralysis on one side of the body), dysphagia (difficulty swallowing), and generalized muscle weakness (muscle weakness throughout the body). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily-decision making was intact. The MDS indicated Resident 3 was totally dependent on a one-person physical assist for transfer, locomotion on/off unit, eating, toilet use and personal hygiene. Resident 3 also required an extensive assistance with a one-person physical assist for bed mobility and dressing. According to the MDS, Resident 3's range of motion (ROM) was impaired on one side of both upper and lower extremities. The MDS indicated Resident 3 was always incontinent of bladder and bowel. During an interview on 3/22/2021 at 3:45 p.m., Resident 3 stated the call lights have not been working for about three (3) days, since 3/20/2021. Resident 3 stated no one was answering his call light starting on mid-day on Saturday, 3/20/2021. Resident 3 stated he resorted to yelling for the nurse because he needed his diaper changed and it have been over an hour and no one came to answer his call light. Resident 3 stated the staff came to check on his call light and did confirmed it was not lighting up. Resident 3 stated there had been times when his family member (FM 1) would call the facility to let them know he needs assistance. Resident 3 stated, The bell the facility provided does not make a difference because the staff probably can't hear the bell unless they're standing right by the door. Resident 3 stated if the call lights are not working, he expected staff to check on him more, but he did not see any staff coming in to check on him. Resident 3 stated it concerns him the facility is not more active in making sure the residents have a way of reaching the staff, especially if there was an emergency. Resident 3 stated he was frustrated with the call light situation. During a face time interview on 3/22/2021 at 3:45 p.m., Resident 3's family (FM 1) stated the call lights have not been working for a couple of days. FM 1 stated she called the facility on 3/21/2021, during the night shift, to let the facility's staff know Resident 3 was having issues with his call light. FM 1 stated she spoke with LVN 1. FM 1 stated it takes the staff awhile to assist the resident and there have been times when she had to call the facility to let them know Resident 3 was in need of assistance. FM 1 expressed she cannot stand the thought Resident 3 had to sit in his wet diaper for so long because the call lights are not working. e. During review of Resident 5's Admission Face Sheet, the assessment indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included metabolic [CONDITION(S)] (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), neuromuscular dysfunction of bladder (problem in your brain, spinal cord, or central nervous system makes you lose control of bladder function) and generalized muscle weakness (muscle weakness throughout the body). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognition was intact. The MDS indicated Resident 5 was totally dependent on the staff with a one-person physical assist for bed mobility, dressing, toilet use and personal hygiene. According to the MDS, Resident 5 has an indwelling urinary catheter (a tube placed in the bladder to drain urine) in place and was always continent (able to control movement of bowels or bladder) of bowel. During a review of Resident 5's Morse Fall Risk Assessment, dated 3/24/2021, the assessment indicated Resident 5 had high risk for falls. During interview on 3/23/2021 at 4:23 p.m., Resident 5 stated the call lights were not working for a couple of days, but not sure how long. Resident 5 stated if the call lights are down, he expected the staff be more alert and involved and do more checking of the residents. Resident 5 stated, Because residents don't have a way to reach staff without call lights not working. Resident 5 stated he did not see staff rounding or checking on the residents. Resident 5 expressed concerned about potential emergencies in the facility that can occur and not be attended to right away. Resident 5 stated he did not get a call bell, but he can use his voice to call out to staff. Resident 5 stated he does not personally have issues with the call lights, but he gets upset for his roommate, Resident 6, for always having to wait. Resident 5 stated his roommate, Resident 6, needed to be changed last night around 2 a.m. and they did not come for over an hour. Resident 5 stated there has been times he had to call for assistance for his roommate. f. During an interview on 3/23/2021 at 5:40 p.m., RNC 2 stated six (6) out of seven (7) residents (Residents 6, 8, 9, 10, 11, 12), who needed alternative call lights, were not given them. f 1. During a review of Resident 6's Admission Face Sheet, the Face Sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses included spastic quadriplegic [CONDITION(S)] (disorder of movement and muscle tone of the whole body), contracture of right wrist and unspecified joint (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints), and muscle weakness (muscle weakness throughout the body). During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 requires total dependence for bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS indicated Resident 6 had an external urinary catheter and was always continent bowel. During a review of Resident 6's Morse Fall Risk Assessment, dated 3/24/2021, the assessment indicated Resident 6 had a high risk for falls. During an interview on 3/23/2021 at 3:57 p.m., Resident 6 stated and demonstrated how difficult it was for him to use the call light due to his right wrist contraction and left side weakness. Resident 6 stated there has been many times that his roommate, Resident 5, has had to call for assistance for him. Resident 6 stated he called for assistance early this morning on 3/23/2021 at 1:30 a.m. but did not get assistance until 2:30 a.m. Resident 6 stated he was upset and started hollering because he needed to be cleaned. f 2. During a review of Resident 8's Admission Face Sheet, the Face Sheet indicated Resident 8 was admitted to the facility on [DATE]. Resident 8 diagnoses included right side [CONDITION(S)] (paralysis on one side of the body), contracture of joint right knee, right hand, left knee, left hand, left ankle, and muscle weakness (muscle weakness throughout the body). During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8's cognition was severely impaired. Resident 8 was dependent with a one-person physical assist for bed mobility, dressing, eating, toilet use and personal hygiene and required a two-person physical assist for transfer. The MDS indicated Resident 8 was always incontinent of bladder and bowel. During a review of Resident 8's Morse Fall Risk Assessment, dated 3/24/2021, the assessment indicated Resident 8 forget limitations, and had a high risk for falls. f 3. During a review of Resident 9's Admission Face Sheet, the Face sheet indicated Resident 9 was admitted to the facility on [DATE]. Resident 9's diagnoses included right side [CONDITION(S)], [CONDITION(S)] (disease that affects the function or structure of the brain), and generalized muscle weakness (muscle weakness throughout the body). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 cognition was moderately impaired. The MDS indicated Resident 9 was dependent with a one-person physical assist for transfer, locomotion on/off unit, dressing, eating, and toilet use. Resident 9 required extensive assistance with one-person physical assist for bed mobility and personal hygiene. Resident 9's ROM was impaired on one side of both upper and lower extremities. The MDS indicated Resident 9 had an indwelling catheter and was always incontinent of bowel. f 4 During a review of Resident 10's Admission Face Sheet, the face sheet indicated Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses included cerebral infraction (damage to tissues in the brain due to loss of oxygen to the area), [CONDITION(S)] (a condition that causes seizures: temporary glitches in the brain's electrical activity), contracture of joint ankle (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints), and generalized muscle weakness (muscle weakness throughout the body). During a review of Resident 10 MDS, dated [DATE], the MDS indicated Resident 10's cognition was moderately impaired. The MDS indicated Resident 10 was dependent with a one-person physical assist for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Resident 10's ROM was impaired on both side of lower extremities. The MDS indicated Resident 10 had a urinary indwelling catheter and always incontinent of bowel. f 5. During a review of Resident 11's Admission Face Sheet, the face sheet indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included left side [CONDITION(S)] and generalized muscle weakness (muscle weakness throughout the body). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11's cognition was severely impaired. Resident 11's MDS indicated Resident 11 was dependent with a one-person physical assist for bed mobility, transfer, and locomotion on/off unit, dressing, eating, toilet use, and personal hygiene. Resident 11 had ROM impairment on one side of upper extremities and both sides of lower extremities. The MDS indicated Resident 11 had an indwelling urinary catheter and was always incontinent of bowel. f 6. During a review of Resident 12's Admission Face Sheet, the Face sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnoses included functional [CONDITION(S)] (complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to spinal cord), left side [CONDITION(S)] (paralysis on one side of the body), [CONDITION(S)] (condition that causes seizures: temporary glitches in the brain's electrical activity), generalized muscle weakness (muscle weakness throughout the body). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognition was moderately impaired. The MDS indicated Resident 12 was dependent with a one-person physical assist for transfer, dressing and toilet use and an extensive assistance of a one-person physical assist for bed mobility, eating and personal hygiene. Resident 12's ROM was impaired on one side of upper extremities and both sides of lower extremities. The MDS indicated Resident 12 was always incontinent of bladder and bowel. During review of undated facility's record under section, List of Resident requires adaptive equipment/call light alternative indicated seven (7) residents required a call light alternative. During a review of the facility's Direct Supply Tels: Logbook Documentation indicated the call lights were last tested on [DATE]. During a review of the facility's policy and procedures (P/P), titled, Communication - Call System, dated 1/1/2012, the P/P indicated the purpose of the P/P was to provide a mechanism for residents to promptly communicate with Nursing Staff. The P/P indicated the facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. NS will answer call bells promptly, in a courteous manner. In answering to request, NS will return to the resident with the item or reply promptly. Assistance will be offered before leaving. The P/P also indicated if call bell is defective, it will be reported immediately to maintenance and replaced immediately. The P/P indicated call bells located within the resident bathrooms are considered emergency calls due to the potential for falls and injury. These lights have more frequent audio sound and the call light above the room door may be red or will flash on and off. Emergency calls must be answered promptly. The P/P further indicated adaptive call bells will be provided to resident per resident's needs.

Based on observation, interview and record review, the facility failed to ensure psychoactive (chemical substance that changes the nervous system function resulting in alterations in perception, mood, consciousness, cognition, or behavior) medications were used only as necessary to treat symptoms of a diagnosed and documented medical condition and not for staff convenience in one of four sampled residents (Resident 1.) Resident 1 had episodes of removing [MEDICAL CONDITION] (incision in the windpipe (neck) with tube placed to help breathing) and dependence on a mechanical ventilation (machine to assist with breathing), thrashing (moving abruptly) in bed, feeling sad and crying. Resident 1 did not have a [DIAGNOSES REDACTED]. (Crossed referenced to F604 and F758). This deficient practice resulted in Resident 1 having an increase in sedation and inability to perform physical, occupational, speech therapy and potentially lead to failure of Resident 1's progress to his full functional status. On 10/14/2020 at 4:18 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to protect two of four residents from being physically restraint. The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 10/16/2020 at 5:49 p.m., the ADM and DON submitted an acceptable Plan of Action (POA) and IJ was removed after verifying and confirming on-site the implementation of the POA which included: 1) Resident 1 was seen by the psychiatrist (medical practitioner specializing in the [DIAGNOSES REDACTED]. Order to discontinue [MEDICATION NAME] (([MEDICATION NAME] HCL) antidepressant (medications used to treat major [MEDICAL CONDITION], some anxiety disorders, some chronic pain conditions, and to help manage some addictions)), [MEDICATION NAME] ((Quetiapine [MEDICATION NAME]) antipsychotic) and [MEDICATION NAME] (([MEDICATION NAME]) antipsychotic). 2) On 10/14/2020, Resident 1 was assessed by the licensed nurse for possible side effects including over sedation. Resident 1 was alert and responsive and able to follow simple commands. Will continue to monitor for possible side effects and notify physician and psychiatrist. 3) Behavior management committee will meet on 10/15/2020 for reviewing of possible dose reductions or discontinuation of [MEDICATION NAME] (([MEDICATION NAME]) sedative), [MEDICATION NAME] ([MEDICAL CONDITION]), Klonopin (([MEDICATION NAME]) sedative) if a trial of non-pharmacological interventions for 3 days is effective. 4) On 10/5/2020, facility pharmacy consultant reviewed resident 1's multiple medications with the same action. If pharmacy recommendations indicate, the attending physician will be informed to address the recommendations. 5) On 10/14/2020, the licensed nurses notified resident 1's attending physician for obtaining informed consent for the use of psychoactive medications. The physician obtained consent from the responsible party. 6) On 10/15/2020, Behavior Management Committee reviewed 35 residents with psychoactive medications for appropriateness of diagnosis, dosage, manifestation and trial of non-pharmacological interventions prior to use of psychoactive medications and will ensure informed consent by the physician with the 35 resident's responsible party is obtained. 7) In-service was provided to licensed nurses regarding transcribing orders upon receipt, following physician orders, care planning for changes in behavior, knowledge of less restrictive measures prior to the utilization of restraints, knowledge of the policy for physical restraints, obtaining informed consent by the prescribing physician and verification of informed consent by the facility representative. 8) The facility will conduct monthly random licensed nurse competency checks regarding the use of physical restraints, timely transcription of orders and monitoring for effectiveness and safety by the DON or designee. 9) New admitted residents with new orders for physical restraints will be reviewed during daily clinical meetings for assessment of appropriateness, indication, and informed consent. Ensure a care plan is developed and monitoring implemented according to the physician orders. 10) MRD (Medical Records Director) will conduct auditing of the resident's charts with restraints to ensure an order, consent, care plan and IDT in in place. 11) Negative findings will be submitted to the Quality Assurance Committee for review for the next three months. 12) Correction completions by 10/16/2020 Findings: A review of Resident 1 Face sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H/P), dated 9/18/2020, indicated Resident 1 was able to make his needs known but was unable to make medical decisions. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 9/24/2020, indicated Resident 1 rarely or never understood or was understood. The MDS indicated Resident 1 was severely impaired in cognitive skills (thought process) for daily decision-making and was totally dependent on one-staff with physical assist for bed mobility, transfer, eating, and personal hygiene. A review of Resident 1's Care Plans, dated 9/2020 indicated no care plan for the use of psychoactive medications was initiated. A review of Resident 1's, Behavior Management/Psychoactive Committee Review-Initial/Change in Condition (COC), dated 9/21/2020 indicated Resident 1 was recently admitted to the facility on [DATE] with orders of various psychoactive medications. The Behavior Management indicated the staff attempted one-on-one (1:1) visits, pain management, family support, environmental changes (sic) and a sitter every shift. The recommendations from the committee were to have psychologist review medications and for staff to continue monitoring behaviors. No documentation found in Resident 1's clinical chart for pain management visit, care plans for the use of psychoactive medications and environment changes. A review of Resident 1's physician telephone order, dated 9/25/2020, indicated for Resident 1 to have a psychiatric consultation for medication review on 9/28/2020. A review of Resident 1's Physician orders [REDACTED]. 1) [MEDICATION NAME] (([MEDICATION NAME]) narcotic for moderate to severe pain) two (2) milligrams ((mg) units of measurement) tablet via nasogastric tube ((N[DEVICE]) plastic tube through the nose, past the throat, and down into the stomach to assist with feeding) every four (4) hours (hrs.) as needed (PRN) for pain ordered on [DATE]. A review of Resident 1's Narcotic and Hypnotic Record, dated 9/18/2020 through 9/30/2020 indicated Resident 1 received 4 doses of [MEDICATION NAME] for generalized body pain. 2) [MEDICATION NAME] 5 mg tablet give 2 tablets (10 mg) via N[DEVICE] every 12 hours for [MEDICAL CONDITION] (severe mental disorder affecting thought, emotions and loss of reality) manifested by striking out. ordered on [DATE]. A review of Resident 1's Medication Administration Record [REDACTED]. 3) Quetiapine [MEDICATION NAME] 100 mg tablets give 1 tablet via N[DEVICE] every 12 hours at 6 a.m. and 6 p.m. for [MEDICAL CONDITION] manifested by removing medical tubes. ordered on [DATE]. A review of Resident 1's Medication Administration Record [REDACTED]. 4) Quetiapine [MEDICATION NAME] 300 mg tablets give 1 tablet via N[DEVICE] at nighttime for [MEDICAL CONDITION] manifested by climbing out of bed. ordered on [DATE]. A review of Resident 1's Medication Administration Record [REDACTED]. 5) [MEDICATION NAME] (([MEDICATION NAME]) sedative) 2 mg tablet give 1 tablet every 4 hrs. PRN via N[DEVICE] for anxiety (feelings of worry or fear) manifested by agitation. ordered on [DATE]. A review of Resident 1's Behavior Log, dated 9/18/2020 through 9/20/2020 indicated Resident 1 received 4 doses of [MEDICATION NAME] via N[DEVICE] for thrashing in bed in 3 days. 6) [MEDICATION NAME] 1 mg tablet give 1 tablet every 12 hrs. PRN via N[DEVICE] for anxiety (feelings of worry or fear) manifested by thrashing in bed. ordered on [DATE]. Re-evaluate in 14 days. A review of Resident 1's Narcotic and Hypnotic Record, dated 9/22/2020 through 10/1/2020 indicated Resident 1 received 10 tablets via N[DEVICE] in 7 days. A review of Resident 1's Behavior Log, dated 9/22/2020 through 9/30/2020 indicated Resident 1 received 8 doses in 7 days. 7) [MEDICATION NAME] 1 mg tablet give 1 tablet via N[DEVICE] every 8 hours for anxiety manifested by anxiety. ordered on [DATE]. A review of Resident 1's MAR, dated 9/17/2020 through 10/8/2020 (22 days) indicated Resident 1 received 47 tablets. A review of Resident 1's Narcotic and Hypnotic Record, dated 9/29/2020 through 10/8/2020 indicated Resident 1 received 16 tablets of [MEDICATION NAME] 1 mg via N[DEVICE] for 6 days. 8) [MEDICATION NAME] HCL 100 mg tablet give 1 tablet via N[DEVICE] every 12 hours for depression manifested by sad facial expressions. ordered on [DATE]. A review of Resident 1's MAR indicated [REDACTED]. A review of Resident 1's Physician orders [REDACTED]. A review of Psychiatrist progress note dated, 10/5/2020 indicated to discontinue [MEDICATION NAME] and [MEDICATION NAME] all benzos (tranquilizers). The Note indicated for new orders for [MEDICATION NAME] (antipsychotic) 2 mg via N[DEVICE] three times a day (TID), [MEDICATION NAME] (antidepressant) 30 mg via N[DEVICE] daily, Klonopin 1 mg via N[DEVICE] every eight hours and [MEDICATION NAME] 250 mg via N[DEVICE] three times a day. A review of Sitter 2's written declaration, dated 10/7/2020 indicated witnessing Resident 1 tied to the bed side rails with a red rubber band and hand mittens. The declaration stated Resident 1 became restless after receiving his medications. On 10/6/2020 at 5:37 p.m., during a telephone interview, Resident 1's Responsible Party 1 (RP 1) stated Sitters 1, 2 and 3 informed her Resident 1 was being tied to the bed by the staff members. Resident 1's RP 1 was heard crying and stating every time she would face time Resident 1; he would be crying and was afraid pointing with his eyes to the facility staff caring for him. RP 1 stated she was scared for Resident 1 and stated residents deserved to be treated with respect and dignity and not be abused. On 10/7/2020 at 9:51 a.m., during a telephone interview, Resident 1's RP 2 stated every time she would call Resident 1, he was sedated and unable to speak. RP 2 was heard crying and stating the facility did not care for Resident 1 and allowed for staff to hurt and neglect him because he was overweight. RP 2 stated being concerned Resident 1 was always sleepy and requested the list of medications the resident was taking. The RP 2 stated calling the resident's insurance after the facility refused to give her the name of the medications and requested to have a meeting. RP 2 stated on 10/5/2020 she was informed during a meeting with the psychiatrist and the facility staff, Resident 1's medications would be changed due to the unnecessary duplications of medications. On 10/7/2020 at 2:05 p.m., during an interview with Resident 1 and Sitter 2, Resident 1 nodded yes when he was asked if the staff was tying him up to the bed rails more than 3 times. Sitter 2 stated various staff would come to the resident's room once every 12 hours and would tie Resident 1 to the side rails utilizing an elastic orange band and the hand mittens to provide care even if the resident was calm. On 10/7/2020 at 4:35 p.m., during a telephone interview, Sitter 3 stated during her 12 hours shift, she did not see facility staff come into the room to see Resident 1. On 10/8/2020 at 5:35 p.m., during an interview, Registered Nurse 1 (RN 1) stated they give the medications to the residents as indicated by the primary physician. RN 1 stated the facility staff has not assessed Resident 1's sadness or changes in mood. RN 1 stated not being aware why Resident 1 was sad or agitated but appeared his mood had improved since 10/7/2020. RN 1 stated not being able to locate the care plans for the use of psychoactive medications upon admission. On 10/14/2020 at 1:05 p.m., during an interview in the presence of the DON, facility's pharmacist consultant (PC) stated all medications need a medical [DIAGNOSES REDACTED]. On 10/14/2020 at 1:48 p.m., during an interview and record review of Resident 1's MARs, H/P and preadmission general acute care hospital (GACH) record, DON stated no mental illness was identified in Resident 1's chart that warrant the use of the psychoactive medications. The DON stated the policy of the facility was for the resident's physician to obtain a consent from the family for the use of the medications prior to the use of the medications and then verified by the licensed nurse. The DON stated Resident 1's clinical record contained no documentation by the primary physician supporting the use of psychoactive medications On 10/14/2020 at 4:34 p.m., during a telephone interview in the presence of the ADM and DON, the Psychiatrist Nurse Practitioner (PNP) stated not having an opportunity to assess Resident upon his admission but was able to assess him on 10/5/2020 and noticed Resident 1 was taking two strong antipsychotics that cause sedation. The PNP stated conducting an assessment because Resident 1's RPs 1 and 2 were concerned about the medications the resident was receiving. The PNP stated she discontinued three psychoactive medications and prescribed four different medications with less sedative effect to help decrease the effects of the medications without causing an adverse reaction on the resident. The PNP stated Resident 1 had no mental illness to be taking the medications and the anxiety and [MEDICAL CONDITION] can be cause by the life change of being intubated (tube in the throat to help move air in and out the lungs). On 10/15/2020 at 12 p.m., during an interview, the Director of Rehabilitation (DR) stated Resident 1 was unable to perform his occupational, physical and speech therapy from 9/18/2020 through 10/9/2020 because he appeared always tired and sleepy. The DR stated Resident 1 was able to participate in his therapy for the first time on 10/14/2020 and was able to tolerate using the speaking valve during therapy without difficulty. On 10/16/2020 at 4:15 p.m., during the observation conducted in Resident 1's room and concurrent interview, Resident 1 had a speaking valve placed on his [MEDICAL CONDITION] (incision in the windpipe (neck) with tube placed to help breathing) by the Respiratory Therapist ((RT) specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine in order to work therapeutically with people suffering from acute critical conditions, cardiac and [MEDICAL CONDITION] disease) that allowed Resident 1 to communicate. During the interview, Resident 1 was seen crying while stating he remembered being tied to the bed rails and yelled at by the staff but did not know why. Resident 1 stated he felt, sad, humiliated and embarrassed because he did not do anything wrong and stated that he did not want to be at the facility. On 10/16/2020 at 12:16 p.m., during a telephone interview, facility's Medical Director (MD) stated the facility uses standard protocols that are not restraints. The MD stated they use less restrictive measures, assess, care plan, and IDT other measures prior to the use of restrictive measures. The MD stated not being aware no consents or assessments of residents prior to the use of restraints were not being done by the physicians. The MD stated all physician's [MEDICATION NAME] in the facility were aware of the policy for physical and chemical restraints. On 10/21/2020 at 2:28 p.m., during a telephone interview, Resident 1's physician (Physician 1) stated assessing Resident 1 upon his admission to the facility on [DATE]. Physician 1 stated reviewing the psychoactive medications Resident 1 came in from the GACH and considered them to be appropriate during resident's admission, but now after reviewing the medications, he did considered they were use in excess and could potentially be dangerous to the resident and cause respiratory depression. Physician 1 stated he communicated with Resident 1's RP 1 through the window of the resident's room to informed RP 1 the psychoactive medications Resident 1 was continued on. Physician 1 stated he authorized the orders for bilateral hand mittens and the continuation of the psychoactive medications due to the staff having difficulty controlling the resident's behaviors. Physician 1 stated he did not assess Resident 1's mood behaviors to attempt and identify the cause for Resident 1 to crying, sad and thrashing in bed. Physician 1 stated being aware of the facility's policy to attempt less-restrictive measures prior to the utilization of physical and chemical restraints. Physician 1 stated what happened to Resident 1 should have never happened and moving forward he will pay closer attention to his residents. A review of the facility's policy and procedures (P/P) titled, Behavior/Psychoactive Drug Management, dated 11/2018, indicated upon a resident's admission, the facility would collect information about the resident's physical, functional, psychological and environmental condition to better understand how the resident communicates distress, pain, hunger, discomfort, anger and frustration. The P/P indicated the licensed nurse, IDT, and physician would collaborate with the resident and representative to assess the non-drug interventions for further recommendations. The P/P indicated psychoactive drug dosage maintained or improved the resident's functional capacity and it's not used in excess unless specifically documented by the prescribing physician. The P/P indicated when an order for [REDACTED]. A review of the facility's P/P titled, Restraints, dated 1/1/12 indicated before a restrained is used the licensed nurse verifies an informed consent was obtained from the resident's surrogate and had been documented in the resident's medical record. The P/P indicated the facility staff would ensure to assess upon admission, pre-existing medical conditions or any physical disability or limitation that would place the resident at greater risk during the restraints. The P/P indicated prior to the use of chemical restraints, alternative behavior management programs were attempted and documented.

Based on observation, interview and record review, the facility failed to ensure that one of four sampled resident (Resident 1) was free from receiving medications with the same drug therapy effects, without adequate monitoring of the effects and potential adverse consequences of the seven psychoactive (chemical substance that changes the nervous system function resulting in alterations in perception, mood, consciousness, cognition, or behavior) medications prescribed, and without a medical [DIAGNOSES REDACTED]. These deficient practices resulted in Resident 1 being overly sedated (state of calm or sleep) and unable to participate in physical, occupational and speech therapy. On 10/14/2020 at 4:18 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to protect one of four residents from being chemically restrained (a form of medical restraint in which a drug is used to restrict freedom of movement of a resident or in some cases to sedate the resident). The facility's ADM and DON were notified of the immediacy and seriousness of Resident 1's health and safety being threatened. On the ADM and DON submitted an acceptable Plan of Action (POA), after verifying and confirming on-site the implementation of the POA the IJ was removed on 10/16/2020 at 5:49 p.m. The POA included: 1) Resident 1 was seen by the psychiatrist ((psych) medical practitioner specializing in the [DIAGNOSES REDACTED]. The psychiatrist ordered to discontinue [MEDICATION NAME] (([MEDICATION NAME] HCL) antidepressant), [MEDICATION NAME] ((Quetiapine [MEDICATION NAME]) antipsychotic) and [MEDICATION NAME] (([MEDICATION NAME]) antipsychotic). 2) On 10/14/2020, Resident 1 was assessed by the licensed nurse for possible side effects including over-sedation. Resident 1 was alert and responsive and able to follow simple commands. The licensed nurse will continue to monitor for possible side effects and notify the physician and psychiatrist. 3) Behavior management committee will meet on 10/15/2020 for reviewing Resident 1 of possible dose reductions or discontinuation of [MEDICATION NAME] (([MEDICATION NAME]) sedative), [MEDICATION NAME] ([MEDICAL CONDITION]), Klonopin (([MEDICATION NAME]) sedative) if a trial of non-pharmacological interventions for three days is effective. 4) On 10/15/2020, facility pharmacy consultant reviewed resident's with multiple medications with the same action. If pharmacy recommendations note a problem (irregularities in the mediation regimen), the attending physician will be informed to address the recommendations. 5) On 10/14/2020, the licensed nurses notified Resident 1's attending physician for obtaining informed consent for the use of psychoactive medications. The physician obtained consent from the responsible party. 6) On 10/15/2020, Behavior Management Committee reviewed 35 residents with psychoactive medications for appropriateness of diagnosis, dosage, manifestation and trial of non-pharmacological interventions prior to use of psychoactive medications and will ensure informed consent by the physician with the 35 resident's responsible party is obtained. 7) In-service was provided to licensed nurses regarding transcribing orders upon receipt, following physician orders, care planning for changes in behavior, knowledge of less restrictive measures prior to the utilization of restraints, knowledge of the policy for physical restraints, obtaining informed consent by the prescribing physician and verification of informed consent by the facility representative. 8) The facility will conduct monthly random licensed nurse competency checks regarding the use of unnecessary medications, timely transcription of orders and monitoring for effectiveness and safety by the DON or designee. 9) New admitted residents with new orders for psychoactive medications will be reviewed during daily clinical meetings for assessment of appropriateness, indication, and informed consent. Ensure a care plan is developed and monitoring implemented according to the physician orders. 10) Medical Records Director (MRD) will conduct auditing of the resident's charts with chemical restraints to ensure an order, consent, care plan and Interdisciplinary ((IDT) group of health care professionals with various areas of expertise working together toward the goals of their residents) is in place. 11) Negative findings will be submitted to the Quality Assurance Committee for review for the next three months. 12) Correction completions by 10/16/2020 Findings: A review of Resident 1 Face sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H/P), dated 9/18/2020, indicated Resident 1 was able to make his needs known but was unable to make medical decisions. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 9/24/2020, indicated Resident 1 rarely or never understood or was understood by others. The MDS indicated Resident 1 was severely impaired in cognitive skills (thought process) for daily decision-making and was totally dependent on one-staff with physical assist for bed mobility, transfer, eating, and personal hygiene. A review of Resident 1's Baseline Care Plan, dated 9/17/2020 indicated Resident 1 was receiving multiple psychoactive medications and was being monitored for behaviors. The care plan indicated for Resident 1 to have a psych consult as needed and sitter assessed every three days. A review of Resident 1's, Behavior Management/Psychoactive Committee Review-Initial/Change in Condition (COC), dated 9/21/2020, indicated Resident 1 was recently admitted to the facility on [DATE] with orders of various psychoactive medications. The Behavior Management indicated the staff attempted one-on-one (1:1, one staff assigned to one resident) visits, pain management, family support, environmental changes (sic) and a sitter every shift. The recommendations from the committee were to have a psychologist review the medications and for staff to continue monitoring behaviors. No documentation found in Resident 1's clinical chart for pain management visit and environment changes. A review of Resident 1's physician telephone order, dated 9/25/2020 indicated for Resident 1 to have a psych consultation for medication review on 9/28/2020. A review of Resident 1's Physician orders [REDACTED]. 1) [MEDICATION NAME] (([MEDICATION NAME]) narcotic for moderate to severe pain) two (2) milligrams ((mg) units of measurement) tablet via nasogastric tube ((N[DEVICE]) plastic tube through the nose, past the throat, and down into the stomach to assist with feeding) every four (4) hours (hrs.) as needed (PRN) for pain ordered on [DATE]. 2) [MEDICATION NAME] 5 mg tablet give 2 tablets (10 mg) via N[DEVICE] every 12 hours for [MEDICAL CONDITION] (severe mental disorder in which thought, and emotions are impaired that contact is lost with external reality) manifested by striking out. ordered on [DATE]. 3) Quetiapine [MEDICATION NAME] 100 mg tablets give 1 tablet via N[DEVICE] every 12 hours at 6 a.m. and 6 p.m. for [MEDICAL CONDITION] manifested by removing medical tubes. ordered on [DATE]. 4) Quetiapine [MEDICATION NAME] 300 mg tablets give 1 tablet via N[DEVICE] at nighttime for [MEDICAL CONDITION] manifested by climbing out of bed. ordered on [DATE]. 5) [MEDICATION NAME] (([MEDICATION NAME]) sedative) 2 mg tablet give 1 tablet every 4 hrs PRN via N[DEVICE] for anxiety (feelings of worry or fear) manifested by agitation. ordered on [DATE]. 6) [MEDICATION NAME] 1 mg tablet give 1 tablet every 12 hrs PRN via N[DEVICE] for anxiety manifested by thrashing (move in violent behavior) in bed. ordered on [DATE]. Re-evaluate in 14 days. 7) [MEDICATION NAME] 1 mg tablet give 1 tablet via N[DEVICE] every 8 hours for anxiety manifested by anxiety. ordered on [DATE]. 8) [MEDICATION NAME] HCL 100 mg tablet give 1 tablet via N[DEVICE] every 12 hours for depression manifested by sad facial expressions. ordered on [DATE]. A review of Resident 1's Physician orders [REDACTED]. A review of Resident 1's Medication Administration Record [REDACTED] [MEDICATION NAME] 5 mg tablet give 2 tablets (10 mg) 26 doses received. Quetiapine [MEDICATION NAME] 100 mg tablets 32 doses received. Quetiapine [MEDICATION NAME] 300 mg tablets 16 doses received. [MEDICATION NAME] (([MEDICATION NAME]) sedative) 2 mg, 4 doses received. [MEDICATION NAME] 1 mg, 10 doses received. [MEDICATION NAME] 1 mg 47 tablets received. [MEDICATION NAME] HCL 100 mg 32 doses received. A review of Resident 1's Narcotic and Hypnotic Record, for the month of 9/18/2020 to 10/5/2020 indicated the resident received the following medications: [REDACTED] [MEDICATION NAME] for generalized body pain, 4 doses received. [MEDICATION NAME] 1 mg 10 doses received. [MEDICATION NAME] 1 mg 16 doses received. A review of Resident 1's Behavior Log, dated 9/18/2020 through 9/20/2020 indicated Resident 1 received 4 doses of [MEDICATION NAME] via N[DEVICE] for thrashing in bed in 3 days. A review of Psychiatrist progress note, dated 10/5/2020, indicated to discontinue [MEDICATION NAME] and [MEDICATION NAME] all benzos. The note indicated for new orders for [MEDICATION NAME] ((antipsychotic) class of medication that can reduce or relieve symptoms of [MEDICAL CONDITION], such as delusions (false beliefs) and hallucinations (seeing or hearing something that is not there) 2 mg via N[DEVICE] three times a day (TID), [MEDICATION NAME] (antidepressant) 30 mg via N[DEVICE] daily, Klonopin 1 mg via N[DEVICE] every eight hours and [MEDICATION NAME] 250 mg via N[DEVICE] three times a day. On 10/7/2020 at 9:51 a.m., during a telephone interview, Resident 1's Responsible Party (RP 2) stated every time she would call Resident 1, he was sedated and unable to speak. RP 2 was heard crying and stating the facility did not care for Resident 1 and allowed for him to be hurt and neglected by the staff due to him being overweight. RP 2 stated being concern that Resident 1 was always sleepy and RP 2 requested from RN 1 the list of medications the resident was taking. The RP 2 stated calling the resident's insurance after the facility refused to give her the name of the psychoactive and requested to have a meeting. RP 2 stated on 10/5/2020, she was informed during a meeting with the psychiatrist and the facility staff, Resident 1's medications would be changed due to the unnecessary duplications of medications. On 10/8/2020 at 5:35 p.m., during an interview, Registered Nurse 1 (RN 1) stated they give the medications to the residents as indicated by the primary physician. RN 1 stated the facility staff has not assessed Resident 1's sadness and changes in mood. RN 1 stated not being aware why Resident 1 was sad or agitated but appeared his mood had improved since 10/7/2020. RN 1 stated not been able to locate the care plans for the use of psychoactive medications upon admission. On 10/14/2020 at 1:05 p.m., during an interview in the presence of the DON, the facility's pharmacist consultant (PC) stated all medications need a medical [DIAGNOSES REDACTED]. On 10/14/2020 at 1:48 p.m., during an interview and record review of Resident 1's MAR's, H/P and preadmission general acute care hospital (GACH) record, the DON stated no mental illness was identified in Resident 1's chart that warranted the use of the psychoactive medications. The DON stated the policy of the facility was for the resident's physician to obtain a consent from the family for the use of the medications prior to the use of the medications and then verified by the licensed nurse. The DON stated physician's informed consent for the use of psychoactive medications was not done for Resident 1. On 10/14/2020 at 4:34 p.m., during a telephone interview in the presence of the ADM and DON, the Psychiatrist Nurse Practitioner (PNP) stated not having an opportunity to assess Resident 1 upon his admission but was able to assess him on 10/5/2020 and noticed Resident 1 was taking two strong antipsychotics, [MEDICATION NAME] and [MEDICATION NAME], that cause sedation. The PNP stated she was conducting an assessment because Resident 1's RP 1 and 2 were concerned about the medications the resident was receiving. The PNP stated she discontinued three psychoactive medications on 10/5/2020 and prescribed four different medications on the same day with less sedative effects to help taper down the effects of the medications without causing an adverse reaction on the resident. The PNP stated Resident 1 had no mental illness to be taking the medications, and the anxiety and [MEDICAL CONDITION] can be caused by the life change of being intubated. On 10/15/2020 at 12 p.m., during an interview, the Director of Rehabilitation (DR) Department stated Resident 1 was unable to perform his occupational, physical and speech therapy from 9/18/2020 through 10/9/2020 because he was always tired and sleepy. The DR stated Resident 1 was able to participate in his therapy for the first time on 10/14/2020 and was able to tolerate using the speaking valve during therapy without difficulty. On 10/16/2020 at 12:16 p.m., during a telephone interview, facility's Medical Director (MD) stated the facility uses standard protocols that are not chemical restraints. The MD stated they use less restrictive measures, assess, care plan, and IDT other measures prior to the use of restrictive measures. The MD stated not being aware no consents or assessments of residents prior to the use of any type of restraints were not being done by the physicians. On 10/16/2020 at 4:15 p.m., during the observation conducted in Resident 1's room and concurrent interview, Resident 1 had a speaking valve placed on his [MEDICAL CONDITION] (incision in the windpipe (neck) with tube placed to help breathing) by the Respiratory Therapist ((RT) specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine in order to work therapeutically with people suffering from acute critical conditions, cardiac and [MEDICAL CONDITION] disease) that allowed Resident 1 to communicate. During the interview, Resident 1 was seen crying while stating he felt, sad, humiliated and embarrassed and did not want to be in the facility. On 10/21/2020 at 2:28 p.m., during a telephone interview, Resident 1's physician (Physician 1) stated he assessed Resident 1 upon his admission to the facility on [DATE]. Physician 1 stated he reviewed the psychoactive medications when Resident 1 came in from the GACH and he considered the psychoactive medications to be appropriate during the resident's admission. Physician 1 stated after reviewing the medications, he considered they were use in excess and could potentially be dangerous to the resident and cause respiratory depression. Physician 1 stated he communicated with Resident 1's RP 1 through the window of the resident's room to inform RP 1 the psychoactive medications Resident 1 was continued on. Physician 1 stated he authorized the orders for the continuation of the psychoactive medications due to the staff having difficulty controlling the resident's behaviors. During the interview, on 10/21/2020 at 2:28 pm., Physician 1 stated he did not assess Resident 1's mood and behaviors to attempt and identify the cause for Resident 1's behaviors of crying, sadness and thrashing in bed. Physician 1 stated being aware of the facility's policy to attempt less-restrictive measures prior to the utilization of chemical restraints. Physician 1 stated what happened to Resident 1 should have never happened and moving forward he will pay closer attention to his residents. A review of the facility's policy and procedures (P/P) titled, Behavior/Psychoactive Drug Management, dated 11/2018 indicated upon a resident's admission, the facility would collect information about the resident's physical, functional, psychological and environmental condition to better understand how the resident communicates distress, pain, hunger, discomfort, anger and frustration. The P/P indicated the licensed nurse, IDT, and physician would collaborate with the resident and representative to assess the non-drug interventions for further recommendations. The P/P indicated psychoactive drug dosage maintained or improved the resident's functional capacity and it's not used in excess unless specifically documented by the prescribing physician. The P/P indicated when an order for [REDACTED].

Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraint for two of four sampled residents (Residents 1 and 2). The facility failed: 1. Ensure Sitter 3 did not tie Resident 1 bilateral (both) hand mitts to the bed siderails causing Resident 1 to sustain wrist soft tissue hematoma (injury to the tissue underneath your skin as a result of blood vessels leakage) and prevent him from moving his hands and arms. 2. Ensure various licensed nurses utilize a less restrictive measure prior to use of restraints as outline in the facility's policy and procedure for Restraints. 3. Ensure various licensed nurses implemented Resident 1's care plan for restraints to release hand mittens every two hours for 15 minutes for circulation and skin integrity. 4. Ensure Resident 1's physician obtained informed consent for hand mitts as stated in the facility's policy and procedures for restraints. 5. Ensure the licensed nurses did not use hand mitts on Resident 2 without physician's orders [REDACTED]. These deficient practices resulted in Resident 1's and Resident 2's rights to be free of restraints violated, subjected to loss of freedom of movement and caused emotional distress, humiliation and embarrassment. Resident 1 sustained a right wrist soft tissue hematoma and feeling sad and scare of being in the facility. On 10/14/2020 at 4:18 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to protect two of four residents from being physically restraint. The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 10/16/2020 at 5:49 p.m., the ADM and DON were notified the IJ was lifted after review and on-site validation of the Plan of Action (POA) via observations, interviews and record review of the following: 1) On 10/14/2020, Resident 1 was observed by the Interdisciplinary Team ((IDT) healthcare professionals from different fields who work together toward the same goal to provide the best care for residents) and DON for trial of non-restrictive measures without use of hand mittens. Resident was observed not trying to remove tubes or any medical devices. DON and IDT completed the physical restraint assessment including the outcome of the trial of non-restrictive measures. The attending physician was informed regarding the observations. The physician gave orders to hold hand mittens for 72 hours for trial reduction. 2) Continuous sitter at bedside if medically necessary. 3) Resident 2 no longer residing at the facility. 4) Medical records Director (MRD) and DON checked 4 residents with physical restraints orders for trial of non-restrictive measures prior to the use of restraints and releasing every 2 hours for 15 minutes and during care. A new form was created for the monitoring of the hand mittens removal for circulation purposes as indicated in the physician orders. 5) In-service was provided to licensed nurses regarding transcribing orders upon receipt, following physician orders, care planning for changes in behavior, knowledge of less restrictive measures prior to the utilization of restraints, knowledge of the policy for physical restraints, obtaining informed consent by the prescribing physician and verification of informed consent by the facility representative. 6) The facility will conduct monthly random licensed nurse competency checks regarding the use of physical restraints, timely transcription of orders and monitoring for effectiveness and safety by the DON or designee. 7) New admitted residents with new orders for physical restraints will be reviewed during daily clinical meetings for assessment of appropriateness, indication, and informed consent. Ensure a care plan is developed and monitoring implemented according to the physician orders. 8) MRD will conduct auditing of the resident's charts with restraints to ensure an order, consent, care plan and IDT is in place. 9) Certified Nurse Assistants (CNA) will be in-serviced regarding the use of physical restraints and observe for skin discoloration while providing care and documentation of removal of restraints. 10) Negative findings will be submitted to the Quality Assurance Committee for review for the next three months. 11) Correction completions by 10/16/2020 Findings: a. A review of Resident 1 Face sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had a [MEDICAL CONDITION] (incision in the windpipe (neck) with tube placed to help breathing) in place due to dependency on a mechanical ventilation (machine to assist with breathing) and asthma (respiratory condition marked by spasms in the lungs that causes difficulty breathing). A review of Resident 1's History and Physical (H/P), dated 9/18/20 indicated Resident 1 was able to make his needs known but was unable to make medical decisions. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/24/20, indicated Resident 1 rarely or never understood or was understood. The MDS indicated Resident 1 was severely impaired in cognitive skills (thought process) for daily decision-making and was totally dependent for activities of daily living with one-person physical assistance for bed mobility, transfer, eating, and personal hygiene. A review of Resident 1's physician telephone order, dated 9/23/20 indicated an order for [REDACTED]. A review of Residents 1's care plan for Physical Restraints, dated 9/23/20 indicated the resident had a right-hand mitt for poor safety awareness and inability to control body positioning. The care plan indicated the hand mitt enabled Resident 1 and limited his freedom of movement. The staffs' interventions included to release restraint during direct supervision by the sitter, during care, and to obtain an informed consent, release every two hours for 15 minutes for skin integrity and circulation and notify physician of any changes in condition (COC). A review of Resident 1's physician telephone order, dated 9/23/20 indicated to provide a one-to-one (1:1) sitter for safety. A review of Resident 1's physician telephone order, dated 9/28/20 indicated, for the left-hand mitten, to prevent resident from pulling out medical tubing and devices, release every two hours for 15 minutes for circulation and skin integrity. A review of Resident 1's physician telephone order, dated 10/1/20 indicated there was an order for [REDACTED]. A review of Resident 1's care plan to use bilateral hand mitts for 9/23/2020, 9/28/2020 and 10/1/2020 were found in the chart. A review of Resident 1's informed consent, dated 9/23/20 indicated the benefits and contraindications for the use of right-hand mittens as restraints were explained to responsible party. The informed consent did not indicate the resident's primary physician talked to the responsible party prior to the use of the restraints as indicated in the facility's policy. A review of Resident 1's informed consent, dated 10/1/20 indicated the benefits and contraindications for the use of bilateral hand mittens as restraints were explained to responsible party. The informed consent did not indicate the resident's primary physician talked to the responsible party prior to the use of the restraints as indicated in the facility's policy. A review of Resident 1's Situation Background Assessment and Response ((SBAR) an internal communication form), dated 10/3/20 and timed at 3:50 p.m., indicated that on 10/2/2020 at 3:10 p.m., during afternoon rounds Registered Nurse 1 (RN 1) informed Sitter 3 to remove Resident 1's bilateral hand mitts every two hours for circulation and skin integrity if resident was not showing signs of agitation or harm to self. The SBAR indicated at 4:50 p.m., RN 1 walked into Resident 1's room when she heard the resident calling for a nurse. Upon entering the room, RN 1 noticed Resident 1 bilateral hands spread out (one on each side of the bed rails) with forearms leaning against the side rails and wearing bilateral hand mittens tied up against the side rails with the garter (band or string). The SBAR indicated RN 1 immediately removed the hand mittens and informed Sitter 3 of the facility's non-restraining policy. A review of Resident 1's COC, dated 10/4/2020 and timed at 10:58 a.m., indicated Resident 1 was noted with right wrist anterior (front) discoloration. The COC indicated Resident 1 was noted with a red/purplish discoloration measuring 0.4 centimeters ((cm) unit of measurement) by (x) 1.0 cm. A review of Resident 1's Restraints and Safety Devices (RSD) sheet, indicated an order dated 9/23/20 for right hand mitten to prevent Resident 1 from pulling out medical tubing and devices, release for 15 minutes every two hours for circulation and skin integrity on every shift at 7 a.m., 3 p.m., and 11 p.m. The RSD sheet indicated the restraints were monitor three (3) times a day from 10/1/2020 through 10/8/2020 and removed 21 times in eight (8) days. A review of Sitter 2's written declaration, dated 10/7/20, indicated witnessing Resident 1 tied to the bed side rails with a red rubber band and hand mittens. The declaration stated Resident 1 became unstable after receiving his medications. On 10/7/20 at 9:51 a.m., during a telephone interview, RP 2 stated, (RN 1) called on 10/3/20 to notify her Sitter 3 tied Resident 1 to the bed. RP 2 stated on 10/4/20, early morning, (RN 1) called to inform her Resident 1 had bruises (discoloration) on his right wrist as a result from Resident 1 being tied to the bed. While on the phone RP 2 was heard crying and stated, the facility did not care for (Resident 1) who they hurt and neglected. On 10/7/20 at 2:05 p.m., during an interview with Resident 1 and Sitter 2, Resident 1 nodded Yes when he was asked if the staff was tying him up to the bed rails. Resident 1 stated he was tied to the side rails more than 3 times. Sitter 2 stated the facility staff would tie Resident 1 to the side rails utilizing an elastic orange band and the hand mittens. Sitter 2 stated he witnessed Resident 1 being tied to the bed rails by various facility's staff members a few times to clean Resident 1 even though the resident was calm. Sitter 2 stated not knowing who the staff members were since the gown covered their name badge and with the mask it was hard to identify them. On 10/7/20 at 3:49 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated she was removing Resident 1's hand mittens at times. CNA 1 stated he did not remember how many times he removed Resident 1's hand mittens or at what times mittens were removed since they do not document. On 10/7/2020 at 4:18 p.m., during an interview, RN 1 stated on 10/3/20 afternoon, Sitter 1 tied Resident 1 to the side rails utilizing the resident's hand mitten bands. RN 1 stated physical restraints were not allowed in the facility and sitters were not allowed to apply restraint. On 10/7/2020 at 4:35 p.m., during a telephone interview, Sitter 3 stated that on multiple occasions she witnessed Resident 1 with both hand mittens tied. Sitter 3 further stated that during her 12 hours shift she did not see facility's staff come into Resident 1's room to release the resident's hand mittens. Sitter 3 stated Resident 1 had bilateral wrist skin discoloration due to the mittens. On 10/8/2020 at 3:37 p.m. during an interview, Sitter 3 stated witnessing staff members strap Resident 1 to the side rails utilizing an orange band attach to the side rails of the bed. Sitter 3 stated on 10/3/2020 approximately at 1:40 p.m., she called nurses to come into room due to Resident 1 being agitated and attempted to get out of bed. However, no one came, and Sitter 3 decided to loosely tie Resident 1 to the bed utilizing the left-hand mitten strap. Sitter 3 stated she thought it was fine since in previous days various staff members would ask to tie Resident 1 to the side rails utilizing the hand mittens. Sitter 3 stated feeling bad and apologized for what she had done after RN 1 told her restraints were not allowed in the facility. A review of Sitter 3's written declaration, dated 10/8/20 and timed at 4:38 p.m., indicated that various CNA's and staff members instructed her to apply mittens to Resident 1's bilateral hands. According to the declaration written statement Sitter 3 thought it was part of her job to place hand mittens on Resident 1. In the declaration written on 10/3/20 at approximately 1:30 p.m., Sitter 3 indicated a staff CNA was taking Resident 1's vital signs and noted Resident 1 had his left-hand mitten strapped to the bed side rail and did not say anything. Twenty minutes later RN 1 came into the room and told Sitter 3 restraints were not allowed. Sitter 3 documented in her declaration that she was sorry for what she had done to Resident 1. On 10/14/2020 at 3:45 p.m., during an interview with Director of Nursing (DON) and concurrent Resident 1's record review, including care plans, IDT notes and RSD sheets, DON confirmed and stated the staff fail to follow the facility's policy and the physician orders [REDACTED]. The DON stated not being aware the staff was asking the sitters to place the hand mittens on Resident 1. The DON stated it was not under the scope of practice the sitter to place or remove the hand mittens on Resident 1 or any other resident. On 10/16/2020 at 4:15 p.m., during the observation conducted in Resident 1's room and concurrent interview, Resident 1 had a speaking valve placed on his [MEDICAL CONDITION] (incision in the windpipe (neck) with tube placed to help breathing) by the Respiratory Therapist ((RT) specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine in order to work therapeutically with people suffering from acute critical conditions, cardiac and [MEDICAL CONDITION] disease) that allowed Resident 1 to communicate. During the interview, Resident 1 was seen crying while stating he remembered being tied to the bed rails and yelled at by the staff but did not know why. Resident 1 stated he felt, sad, humiliated and embarrassed because he did not do anything wrong and stated that he did not want to be at the facility. On 10/16/20 at 5:37 p.m., during a telephone interview, Resident 1's Responsible Party 1 (RP 1) stated Sitter 2 informed her Resident 1 was being tied to the bed by the staff members. While on the phone, RP 1 was heard crying and stated, when she would have live phone video communication with Resident 1, he would cry and was afraid pointing with his eyes to the facility staff caring for him. RP 1 stated being scared for Resident 1 and stated all residents deserved to be treated with respect and dignity, and not be subjected to abuse. b. A review of Resident 2 Face sheet (Admission Record) indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE] indicated Resident 2 rarely or never understood or was understood. The MDS indicated Resident 2 had severely impaired cognitive skills (thought process) for daily decision-making and was totally dependent on staff for activities of daily living with one-person physical assistance for bed mobility, transfer, eating, and personal hygiene. On 10/7/2020 at 3:10 p.m., during a concurrent observation, interview and record review of Resident 2's physician orders, care plans and IDT notes, Resident 2 was observed with bilateral hand mittens, in bed without attempting to remove or touch medical tubing or devices. During the review of Resident 2's physician orders, care plans and monitoring log, the DON confirmed no order for the use of [REDACTED]. On 10/7/20 at 4:18 p.m., during an interview and concurrent review of Resident 2's physician orders, RN 1 stated that on 9/21/20 upon Resident 2's admission she obtained an order from the physician for bilateral hand mittens because the resident had attempted to remove his tubing while in the general acute care hospital (GACH). RN 1 stated she did not witness Resident 2 attempting to remove medical tubing or devices and no other less restrictive measures were attempted prior to obtaining order for restraints. RN 1 stated she called physician 2 upon Resident 2's admission to obtain an order for [REDACTED]. On 10/16/20 at 12:16 p.m., during a telephone interview Medical Director (MD) stated the facility uses standard protocols for no restraints. The MD stated they use less restrictive measures prior to the use of restraints. The MD stated he was not aware there were no consents or residents' assessments done prior to the use of restraints, and that physicians were not discussing consents with a residents or responsible parties as indicated on the facility's policy. the MD stated all physician's [MEDICATION NAME] in the facility were aware of the policy for physical and chemical restraints. A review of the facility's policy and procedure (P/P) titled, Restraints, revised on 1/1/12, indicated the facility used the least restrictive alternatives for the least amount of time, and only under careful monitoring. The P/P indicated the licensed nurse would verify a consent was obtain prior to the use of the restraints. The P/P indicated that staff would assess the resident for techniques, tools, or methods that can help the resident control his/her behavior. The P/P indicated the IDT committee will determined if restraints are necessary and ensure there is a medical condition that requires the use of restraints, type, and time period for use. The P/P indicated the licensed nurse would release the restraints every two hours to promote circulation and document the effectiveness of its use. A review of the facility's P/P titled, Abuse-Prevention, Screening, and Training Program, last revised 7/18 indicated the facility did not condone any type of abuse, neglect including physical and chemical restraints not required to treat medical symptoms. The P/P indicated the use of physical restraints for discipline or convenience was defined as using such restraints when they are not required to treat the resident's medical symptoms. The P/P indicated care planning for appropriate interventions and monitoring of residents with needs and behaviors was conducted prior to its use.

Based on interview and record review, the facility failed to implement its policies and procedures on abuse and resident's plan of care to ensure one of three sampled residents (Resident 1) was free for sexual abuse including but not limited to (cross referenced to F 607 and F 609): 1. Failure to ensure Resident 1 was free from sexual abuse from Certified Nursing Assistant 1 (CNA1). Resident 1, who was quadriplegic (paralysis caused by illness or injury that results in partial or total loss of use of all their limbs and torso), reported sexual abuse of his scrotum being squeezed too hard by CNA 1. 2. Failure to implement its policy on abuse reporting and investigations, which indicated the administrator would immediately remove the suspected employee from the care of the resident and immediately suspend the employee pending the outcome of the abuse investigation. CNA 1 continued to care for Resident 1 after the abuse incident (May 17, 2019). 3. Failure to follow Resident 1's care plan, which stipulated that the staff would provide care to the resident's scrotum area only upon his request and permission. These deficient practices resulted in Resident 1 yelling out in pain after CNA 1 grabbed his scrotum and squeezed them hard. Resident 1 stated he felt sexually assaulted (physically attacked), upset, personally violated, disrespected, and unsafe at the facility after the incident. Findings: A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on (MONTH) 28, 2019. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated (MONTH) 4, 2019, indicated a Brief Interview for Mental Status ((BIMS) mental assessment test) score of 15 (13-15 no cognitive (thought process) impairment), which indicated that Resident 1 did not have problems with memory and/or cognition (thought process). The MDS indicated Resident 1 was totally dependent and required physical assistance with eating, toileting, bed mobility and personal hygiene. According to the MDS, Resident 1 had an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). A review of Resident 1's Bowel and Bladder Care Plan, dated (MONTH) 28, 2019, indicated at Resident 1's request, staff were to gently lift and wipe the resident's scrotum (a sac of skin that holds two testicles and hangs below the penis between the legs) when providing care. A review of Resident 1's Catheter Care Plan, dated (MONTH) 28, 2019, indicated the resident had a suprapubic catheter (a flexible plastic tube inserted, through a small hole in the abdomen, into the bladder to provide continuous urinary drainage) and would be free from pain or discomfort by (MONTH) 20, 2019. The staff's interventions included encouraging the resident to call for assistance with toileting and providing catheter care as ordered. A review of Resident 1's Change in Condition (C[NAME]) record, dated (MONTH) 21, 2019, indicated Resident 1 reported being intentionally sexually attacked, by a staff member. A review of the facility's Corrective Action Memo, dated (MONTH) 21, 2019 indicated CNA 1 was not suspended until four (4) days after the alleged abuse on (MONTH) 21, 2019 and after the Department initiated an investigation that was not reported by the facility. A review of CNA 1's Daily Timesheet indicated the CNA worked on the following days and times: 1. Friday, (MONTH) 17, 2019, CNA 1 worked from 3:10 p.m. to 10:55 p.m. 2. Tuesday, (MONTH) 21, 2019, CNA 1 worked 2:55 p.m. to 6:30 p.m. On (MONTH) 21, 2019 at 3:20 p.m., during an interview, CNA 1 stated the day of the incident (May 17, 2019), he entered Resident 1's room to assist a resident in the bed next to Resident 1. According to CNA 1, Resident 1 was yelling at him and asking for assistance with his catheter. CNA 1 stated he told Resident 1 to stop talking to him like a child. CNA 1 stated he went to look at Resident 1's penis catheter (sic) and proceeded to lift the resident's scrotum sac. CNA 1 stated Resident 1 screamed out Ouch, you squeezed my balls (two testicles inside the scrotum) too hard. CNA 1 stated Resident 1 would normally give approval before the staff would touch his scrotum, but that day the resident did not ask and he (CNA1) did not receive approval before he touched and lifted the resident's scrotum. CNA 1 stated that he should have let Resident 1 know that he would be touching and moving the resident's scrotum. CNA 1 stated that inappropriate touching could be considered sexual abuse, but CNA1 stated since he was not gay, he could not be sexually abusive toward another man. CNA1 stated he reported the abuse allegation to the registered nurse (RN 1) and a licensed vocational nurse (LVN 1) of the incident and continued to provide care to Resident 1 for the rest of the shift. CNA 1 denied being suspended or interviewed by anyone at the facility regarding the incident. At 3:35 p.m., on (MONTH) 21, 2019, during a concurrent interview and record review, LVN 1 stated the day of the incident (May 17, 2019), he was walking in the hall near Resident 1's room and heard Resident 1 yelling at CNA 1 from inside of the room. LVN 1 stated he entered Resident 1's room and Resident 1 reported pain in his stomach coming from his suprapubic catheter. LVN 1 stated he observed CNA 1 lift Resident 1's thigh and lift the resident's scrotum. LVN 1 stated Resident 1 then screamed out and said stop doing that, you are hurting me. LVN 1 stated Resident 1 did not ask to have his scrotum repositioned and CNA 1 did not notify the resident that he was going to lift his scrotum. LVN 1 stated that CNA 1 should have notified the resident that he would be lifting his scrotum prior to performing the task. LVN 1 stated he reported the incident to RN 1 and told the RN that he did not believe that CNA 1 had hurt Resident 1. LVN 1 stated he did not complete any documentation for the incident because he thought RN 1 would do the documentation and reporting. LVN 1 denied knowing if RN 1 had documented the incident or reported the incident to the administrator or director of nurses (DON), as per the facility's policy. While reviewing Resident 1's chart, LVN 1 was unable to locate any documentation of the incident. At 4:45 p.m., on (MONTH) 21, 2019, during an interview, Resident 1 stated on Friday (MONTH) 17, 2019, after his call light had remained unanswered for 45 minutes, he saw CNA 1 in the hallway near his room and yelled out for the CNA's assistance with his suprapubic catheter. Resident 1 stated he had requested for CNA 1 to assist with his suprapubic catheter, because the tubing was pulling. Resident 1 stated CNA 1 entered his room and did not assist him, but his roommate. According to Resident 1, as CNA 1 assisted the roommate he (CNA1) was yelling at him. Resident 1 stated CNA 1, in the presence of LVN 1, walked over to the bed and put his hands between his legs and grabbed his scrotum and squeezed hard. Resident 1 stated he yelled out in pain. Resident 1 stated whenever he needed his scrotum repositioned, he would ask staff to do so and he was confused why CNA 1 touched his scrotum when he had only asked for help with his supra pubic catheter, which was located nowhere near his scrotum. On (MONTH) 21, 2019 at 5:05 p.m., during an interview in the presence of the administrator, the DON stated he was informed by RN 1 on the night of the incident (May 17, (YEAR)) of Resident 1's allegation. The DON stated he spoke to LVN 1 about the incident and was told that Resident 1 only wanted an apology from CNA 1. The DON stated he informed RN 1 to notify the administrator of Resident 1's abuse allegations. The DON stated private parts are sensitive areas and if he was taking care of a resident, he would ask the resident prior to providing any care to the private parts. The DON stated he did not consider Resident 1's allegation of having his scrotum pulled too hard by CNA 1 to be an allegation of abuse. The DON denied speaking to Resident 1 regarding the abuse allegation. On (MONTH) 21, 2019 at 5:14 p.m., during an interview in the presence of the DON, the administrator denied speaking to Resident 1 about the abuse allegation. At 5:20 p.m., on (MONTH) 21, 2019, during an interview in the presence of the DON, Resident 1 stated he felt sexually assaulted, upset, violated and disrespected after the incident. Resident 1 denied feeling safe at the facility. Resident 1 stated after the incident with CNA 1, he notified LVN 1 that he wanted to speak to the administrator but was told the administrator was no longer at the facility. Resident 1 stated he asked LVN 1 and RN 1 if they made a report about the incident and they both denied doing so. Resident 1 stated he notified RN 1 that he felt violated by the incident and wanted the incident documented and the administrator notified. Resident 1 stated no one had followed up with him, checked on him or spoken to him regarding the incident. On (MONTH) 21, 2019 at 5:50 p.m., during an interview in the presence of the director of staff development (DSD), the administrator stated Resident 1 had never used the words sexually assaulted and never stated it was an issue of abuse when he notified the staff that CNA 1 had squeezed his scrotum too hard. The administrator stated the facility was responsible for knowing what constituted abuse and what needed to be reported. On (MONTH) 10, 2019 at 4:18 p.m., during a telephone interview, RN 1 stated LVN 1 notified her that Resident 1 stated CNA 1 had grabbed his scrotum. RN 1 stated she had spoken to Resident 1 about the incident and the resident stated he needed an apology from CNA 1. RN 1 stated when she arrived to work the next day (May 18, 2019), Resident 1 asked to see a report of the incident. RN 1 stated LVN 1 did not do a report because the resident had previously stated he only wanted an apology from CNA 1. RN 1 stated after Resident 1 asked for a report, she decided to notify the DON and administrator of Resident 1's abuse allegations. RN 1 stated all allegations of abuse were to be reported to the DON right away and failure to report allegations of abuse could cause the resident additional harm. RN 1 stated she should have notified the DON and administrator immediately after being notified of Resident 1's allegations. On (MONTH) 11, 2019 at 11:23 a.m., during an interview, the DSD stated regardless of how long staff had been caring for a resident, staff were instructed to always tell the resident what they were going to do prior to providing any care to the resident's genitals. The DSD stated the resident could be harmed if they were not notified by staff prior to providing care. On (MONTH) 11, 2019 at 2:50 p.m., during an interview, LVN 2 stated the only time that she repositioned Resident 1's scrotum was when the resident requested for her to do so, because Resident 1 has spasms in his legs which made it difficult to move his scrotum. LVN 2 stated moving a resident's scrotum without the resident's consent could be considered abuse. LVN 2 stated it should have been reported right away to the administrator as possible abuse. On (MONTH) 11, 2019 at 3:10 p.m., during an interview, CNA 2 stated touching or repositioning a resident's genitals without consent was considered sexual abuse. A review of Resident 1's Interdisciplinary Team (IDT) Conference record, dated (MONTH) 18, 2019, indicated Resident 1 stated he felt CNA 1 was a threat and did not feel comfortable with CNA 1 continuing to work in the same unit of the facility where his room was located. A review of the facility's policy and procedure dated (MONTH) (YEAR) and titled, Abuse - Reporting & Investigations, indicated if the suspected perpetrator of abuse was an employee, the administrator would immediately remove the employee from the care of the resident and immediately suspend the employee pending the outcome of the abuse investigation. According to the policy, a safe environment would be provided for the resident. A review of the facility's policy and procedure, revision date of (MONTH) (YEAR) and titled, Abuse - Prevention, Screening & Training Program, indicated the facility's administrator was the abuse coordinator and was responsible for implementation of the facility's abuse policies. The policy indicated the facility would identify, correct and intervene in situations where abuse was more likely to occur. A review of the facility's policy and procedure, titled Perineal Care, with a revision date of (MONTH) 1, 2012, indicated staff would explain the procedure to the resident and provide privacy prior to performing perineal care on resident.

Based on interview and record review, the facility failed to ensure that two of three sampled residents (Residents 1 and 2) were provided with adequate care and services to prevent the development of a pressure sores (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) as per facility policy and the resident's plan of care. Resident 1's sacro-coccygeal area (pertaining to both the sacrum and coccyx (the tailbone)) wound was not accurately assessed, consistently monitored, and thoroughly documented. The facility's staff including the Interdisciplinary Team ((IDT) a group of healthcare professionals from diverse areas who coordinate toward a common goal for the resident) failed to identify, address, and/or report to the physician the changes in the resident's skin condition. Resident 2 had a Stage IV wound (full thickness skin loss with exposed underlying structures) that was not referred to the wound specialist (WS) for assessment and treatment per the facility's policy and the resident's plan of care was not followed to keep the resident clean and dry. These deficient practices resulted in Resident 1's MASD wound (moisture associated skin damage) worsening within seven (7) days of readmission and became an unstageable wound (tissue loss in which the base of the sore is covered by slough (soft, moist, dead tissue) and/or eschar (a hard crust or scab) and cannot be seen) pressure sore within eight days that worsened and was transferred to the general acute care hospital (GACH) and treated by a wound care specialist. Resident 2 was not being assessed and treated by the WS, which had the potential for the wound to worsen. Findings: a. A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. throat, and into the stomach, to deliver food, fluid, and medicine. A review of Resident 1's GACH Discharge to Post-Acute/SNF (Skilled Nursing Facility) Report, dated [DATE], indicated the resident had MASD to the sacrum (triangular bone situated near the lower end of the spinal column (no pressure ulcers)). A review of Resident 1's History and Physical upon readmission to the facility, dated [DATE], indicated the resident was obtunded (mentally dulled) with eyes open, but was unresponsive. The record indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Care Plan titled, At Risk Further Skin Breakdown, with an initiating date of [DATE] (upon readmission), indicated to clean the resident's skin after each episode of incontinence (inability to voluntarily control retention of urine or feces in the body), and to notify the physician for changes in the wound progress. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's Skin Breakdown Detail-Supplement Assessment, dated [DATE], indicated the resident had MASD to the left and right buttock. A review of Resident 1's Short-Term Care Plan/Weekly Skin Sheets, dated [DATE], indicated the resident had left buttock MASD, described as [DIAGNOSES REDACTED] (redness of the skin), and non-blanchable (a defined area of redness that does not become pale under applied light pressure). The record indicated interventions to monitor skin healing for any changes, notify the physician for any improvements or declines, and to keep the skin clean and dry. A review of Resident 1's Non Pressure Injury Management Record, dated [DATE], indicated there was no documentation of the resident's skin condition and assessment of the MASD after the resident's admission until the resident was transfer to the GACH on [DATE] (one week later). On [DATE], at 1:55 p.m., during an interview and record review, LVN 1 stated Resident 1's MASD assessment could have been more thoroughly described on the Non Pressure Injury Management Record. A review of Resident 1's Daily Body Check Report, dated [DATE], indicated Certified Nursing Assistant 1 (CNA 1) documented ongoing treatment on the report and did not accurately document the skin observation according to the illustrated Code, which identified specific skin problems. A review of Resident 1's Registered Dietician (RD) Note, dated [DATE], indicated the resident had a low [MEDICATION NAME] (a protein in the body that nourishes tissues, transports hormones, vitamins, drugs, and substances throughout the body) level of 2.3 (Normal Range Reference (NRR) is 3.5 to 5.5 grams (g) per deciliter (dL). The record indicated the current tube feeding order was unable to meet the resident's nutritional needs. A review of an online article titled, NPUAP Pressure Injury Stages, by The National Pressure Ulcer Advisory Panel - NPUAP, dated [DATE], indicated the importance of maintaining nutrition, especially protein levels in the prevention of pressure ulcers development. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ A review of Residents 1's Braden Scale score (a tool used to assess the risk of developing pressure sores), dated [DATE], indicated a score of six, which indicated the resident had a severe risk for developing pressure sores. A review of Resident 1's Interdisciplinary Team (IDT) Conference Record, dated [DATE], four days after the resident was readmitted , indicated the resident's care area for skin was not addressed, as per the facility's policy. A review of Resident 1's CNA Bowel and Bladder Charting, from [DATE] to [DATE], indicated the resident was incontinent of loose stool on [DATE] at 12:13 p.m., and [DATE] at 2:18 p.m. and 7:09 p.m. A review of Resident 1's Skilled Nursing Notes, dated [DATE], indicated the resident was unable to understand and verbalize or express needs. The note indicated the resident was incontinent of urine and stool, and was totally dependent with bed mobility, transferring, and toileting. A review of Resident 1's Skin Breakdown Detail-Supplement Assessment, dated [DATE], documented at the time of the resident's transfer to the GACH, indicated the resident had skin problems with no changes since the latest documented assessment. A review of Resident 1's Emergency Transfer Communication Record, dated [DATE], indicated the resident was being transferred due to shortness of breath (SOB), with a low oxygen (O2) saturation of ,[DATE] percent ((%) NRR is 95 to 100%) while receiving 4 liter of O2 via nasal cannula (tubing prongs into nose for delivery of O2). According to record, the body diagram indicated Resident 1 had a gastrostomy tube, [MEDICAL CONDITION] (swelling) to the left and right arm, but did not indicate the resident had MASD to the left or right buttocks. A review of resident's GACH admission Face Sheet indicated Resident 1 was admitted on [DATE] with the [DIAGNOSES REDACTED]. A review the Wound Care Consultation from the GACH, dated [DATE], indicated Resident 1 had a large, opened wound to the sacral (area pertaining to the sacrum) area that looked significantly worse, than when the resident was previously discharged on [DATE]. The record indicated the wound was an unstageable pressure sore, measuring 13.7 centimeters (cm) in length by 12.3 cm in width, and indicated the resident had very loose stool noted while cleaning the resident. According to the Consultation Note, the wound's color was described as being black with eschar with areas of pink, reddened, and maroon discolorations with bleeding. The wound report indicated Resident 1's [MEDICATION NAME] level was low at 2.2 mg/dl. A review of the GACH's Patient Transfer and Referral Record, dated [DATE], indicated Resident 1 was discharged back to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. A review of Resident 1's readmission Skin Breakdown Detail-Supplement Assessment, dated [DATE], indicated the resident had an UTD (unable to determine/unstageable) pressure sore on the sacrococcyx, measuring 9 cm in length by 15 cm in width. The assessment indicated the resident's UTD pressure sore had yellow slough and epithelium tissue (the thin tissue forming the outer layer of the skin), with periwound (the tissue surrounding the wound itself) macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture). On [DATE], at 10:45 a.m., an interview and observation of Resident 1 was attempted, but Resident 1 was no longer in the facility, he had expired on [DATE] after being placed on Do Not Resuscitate (DNR) status. b. A review of Resident 2's Admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 2's history and physical examination [REDACTED]. This record indicated the resident had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (MDS), dated [DATE], indicated the resident had the ability to make himself understood and the ability to understand others, and was able to report the correct year and month. The MDS indicated the resident needed extensive assistance for bed mobility, transferring, toilet use, and personal hygiene. The MDS indicated the resident was incontinent of stool. A review of Resident 2's Provider Pressure Injury Assessment And Orders, dated [DATE], indicated this resident had a Stage IV (full thickness skin loss with exposed underlying structures) pressure sore and macerated periwound (the tissue surrounding a wound). A review of the facility's Policy and Procedure titled Pressure Injury Prevention, revision dated [DATE], indicated to develop a care plan in consultation with the Attending Physician, IDT, and RD. The policy and procedure indicated that Licensed Nurses would document the effectiveness of pressure injury prevention techniques on a weekly basis. A review of an online article titled, NPUAP Pressure Injury Stages, by The National Pressure Ulcer Advisory Panel - NPUAP, dated [DATE], indicated non-blanchable [DIAGNOSES REDACTED] of intact skin was a Stage 1 Pressure Injury. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ On [DATE], at 1:30 p.m. and 1:46 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated a Stage 1 pressure sore is not blanchable and the skin is intact. LVN 1 stated a whole body assessment was completed when a resident was transferred out of the facility or admitted to the facility. On [DATE], at 8:05 a.m., during an interview, LVN 1 stated that MASD was usually treated with Zinc Oxide and an antifungal (a medication that limits or prevents the growth of yeasts and other fungal organisms) medication for 21 days, and that MASD was usually not measured. LVN 1 stated the Wound Specialist (WS) does wound assessments of the residents in the facility every Wednesday, to evaluate and measure skin-related problems of the residents. LVN 1 stated skin assessments are conducted and recorded prior to transferring a resident to another facility or the GACH. On [DATE], at 8:15 a.m., during an interview, Resident 2 stated, They don't always come when I go poop. Resident 2 stated he would wait up to one to one and a half hours to be cleaned. Resident 2 stated, Sometimes, it's almost every day. On [DATE], at 9 a.m., during an interview and record review, LVN 1 stated if a resident was a new admission to the facility, and had a skin impairment (pressure sore or non-pressure sore) the WS would evaluate and validate the resident's skin condition with the treatment nurse for consultation and appropriate treatment. At 12 p.m., on [DATE], during a telephone interview, the WS stated every Wednesday he made rounds at the facility, and evaluated the resident's skin-related issues. The WS stated he would assess residents who were new admissions with skin impairments (pressure and non-pressure sores), and especially those at risk for skin breakdown. The WS stated that the nurses needed to inform him of any specific residents they would like for him to assess and provide consultation. On [DATE], at 12:40 p.m., during an interview and record review, CNA 1 stated she was told by the Charge Nurse to write ongoing treatment, if the resident already had a wound. On [DATE], at 1:40 p.m., during an interview, LVN 1 stated the treatment nurse communicated with the WS about newly admitted residents who needed to be evaluated for skin impairments, or residents who have a change of condition (C(NAME)) with their wounds. LVN 1 stated the WS was not notified to evaluate the resident (Resident 2) because the wound was minor and if it's manageable by us, we just do it ourselves. LVN 1 stated, I would've told the doctor if the wound got worse. On [DATE], at 2:10 p.m., during an interview and record review, the Director of Nursing (DON) stated the Licensed Nurse in charge of the transfer, or the Nursing Supervisor, was responsible for completing all areas of the Emergency Transfer Communication Record, including the skin section. The DON stated the nurses are responsible for performing wound care treatments, monitoring the wounds, and notifying the WS if the wound was worsening or not improving. The DON stated the CNAs should use the code provided on the Daily Body Check Report, when documenting the daily body checks and not document Ongoing Treatment. A review of the facility's Policy and Procedure (P/P) titled, Pressure Injury Prevention, revision dated [DATE], indicated to develop a care plan in consultation with the Attending Physician, IDT, and the RD (registered dietician). The P/P indicated that Licensed Nurses would document the effectiveness of pressure injury prevention techniques on a weekly basis.

Based on observation, interview, and record review, the facility failed to follow its policy to report unwitnessed falls, a resident plan of care addressing assistance with transfers, and to ensure one of five sampled residents (Resident 1) received supervision and assistance with toileting. These deficient practices resulted in Resident 1 being left unsupervised in the bathroom and led to the resident falling, sustaining a right hip fracture (broken bone), undergoing surgical repair and being admitted to the general acute care hospital (GACH) for seven (7) days. Findings: On 9/11/17 at 6:41 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that residents who are at risk for falls should have floor mats, beds in the lowest position, use of a fall arm band, and have their curtains pulled back (open) for visual assessment. At 7:26 p.m. on 9/11/17, during an interview, the facility's Administrator stated floor mats on each side of the bed, bed alarms, and a fall risk picture should be on the resident's foot board, for residents who are at risk for falls. On 9/11/17 at 7:39 p.m. during an observation and interview, Resident 1 was observed in the bed and when asked about her fall, the resident stated a staff member left her in the bathroom alone. Resident 1 stated she felt terrible about the fall because the facility's Restorative Nurse Assistant 1 (RNA 1) stated she had to go to the bathroom as well. According to Resident 1, RNA 1 asked her to call for help when she finished using the toilet. Resident 1 stated that she was screaming for help, but no one responded. The resident further stated that she tried to get up from the toilet seat, felt dizzy, and fell to the floor. According to Resident 1, she continued to scream for another 10 minutes in the bathroom, after the fall, before staff came and helped her up from the bathroom floor. On 9/11/17 at 7:55 p.m., during an interview and concurrent observation of Resident 1's bedside with LVN 3, LVN 3 stated that Resident 1 had a high risk for falls with a history of falls. LVN 3 stated Resident 1 did not have floor mats, but should have had them. LVN 3 also stated Resident 1's bed was elevated, but should have been in the lowest position. On 9/11/17 at 8:04 p.m., during a concurrent observation and interview, Registered Nurse 1 (RN 1) stated Resident 1 did not have a floor mat, a yellow armband, or a fall risk picture on the footboard indicating that the resident was at risk for falls. On 9/11/17 at 9:05 p.m., during an interview, the Director of Nurses (DON) stated on 7/28/17, RNA 1 left Resident 1 in the restroom unattended and the resident fell . On 9/12/17 at 2 p.m., during an interview, Certified Nursing Assistant 4 (CNA 4) stated on 7/28/17 at 1:30 p.m., she was assisting another resident when Resident 1 had called for help. According to CNA 4, RNA 1 stated she would take Resident 1 to the bathroom and told her to assist the resident back to bed. CNA 4 stated that she told RNA 1 she was not able to assist Resident 1 at the time because she had to take care of another resident. CNA 4 stated she thought RNA 1, was going to stay in the bathroom with Resident 1. She found found out later that RNA 1 left the resident in the toilet and Resident 1 had fallen. According to Resident 1's Admission Face sheet Record, the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] post surgery. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 11/11/16, indicated Resident 1 could understand and be understood by others and had a Brief Intervention of Mental Status (BIMS) score of 15 (8-15= interviewable). According to the MDS, Resident 1 was totally dependent on the staff moving from a seat (toilet) to a standing position, moving from one unit to another, using the toilet and dressing. Resident 1 used a wheelchair and walker for mobility. A review of Resident 1's occupational therapy (OT) and physical therapy (PT) care plan, dated 5/16/17, indicated the resident had an extensive deficit with self-care, dressing, bathing, toileting and transferring. The care plan indicated Resident 1 had an impairment of both balance and gait (walking). The staff's intervention included for Resident 1 to be assisted with transfers and to us a front wheel walker ((FWW) a device made of lightweight metal used to provide support during walking). A review of Resident 1's care plan, dated 7/28/17, indicated the resident was at risk for falls. A review of Resident 1's Fall Risk Assessment, dated 8/5/17, indicated the resident had a high risk for falls. According to the assessment, Resident 1 had a history of [REDACTED]. Under transfer score, the assessment indicated Resident 1 required major help in transferring. A review of Resident 1's History and Physical (H/P) indicated the resident had generalized joint pain especially with ambulation, claudication (pain and cramping in the lower leg due to inadequate blood circulation to the muscles) and neuropathy (weakness, numbness and pain in the hands and feet). A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's X-ray and Computerized Tomography ((CT) a series of images of the body) of the right hip and pelvis results, dated 7/28/17, indicated the resident had a right hip (femoral neck) fracture (broken bone) with angulation (twisting). A review of Resident1's physician's orders [REDACTED]. A review of the GACH emergency room (ER) note, dated 7/28/17, indicated Resident 1 was getting up from a sitting position, felt dizzy and fell . According the ER note, Resident 1 complained of pain 8 out of 10 (10 being the worse pain) to the head, right hip, wrist, and shoulder. A review of Resident 1's GACH Operative or Procedure Report, dated 7/29/17, indicated the resident sustained [REDACTED]. Resident 1 underwent a right hip repair with screws (hip pinning). The post-operative plan included weightbearing as tolerated and administration of Lovenox (blood thinner) in two weeks for staple removal. A review of Resident 1's GACH Discharge Summary, dated 8/4/17, indicated the resident had sustained a right hip fracture following a fall. The resident underwent [REDACTED]. A review of the facility's Fall Management Program policy, dated 11/7/16, indicated the Administrator would notify the appropriate local agencies and law enforcement, according to the state and federal regulation when a fall was not witnessed. It also indicated a high fall risk resident would be idenfied by a special logo to alert staff of the resident's risk activity.

Based on observation, interview, and record review, the facility failed to ensure received the necessary care and services for pressure sore (an injury to the skin caused by constant pressure) prevention by not following its policy and the resident's plan of care for two of four sampled residents (Residents 1 and 4). Resident 1 was admitted to the facility without a pressure sore, but was inadequately assessed for pressure sore risk, not turned every two hours, as per the facility's policy and Resident 1's plan of care. Resident 1 developed multiple Stage III-IV pressure sores (Stage III =a deep wound, the loss of skin usually exposes some fat; Stage IV a pressure sore that is very deep, reaching into muscle and bone and causing extensive damage) that became infected. This deficient practice resulted in Resident 1 not being identified as a high risk for pressure sores development; developing many Stage III and IV pressure sores; becoming unresponsive and requiring an emergency transfer (911) to a general acute care hospital (GACH) on 6/29/16. Resident 1 required an intensive care unit admission, fluid intravenously ((IV) into vein), multiple IV antibiotics and aggressive wound care twice a day, and pain medications. Resident 1 required a 21-day hospital stay for care and treatment of [REDACTED]. Resident 4, who was admitted to the facility with a Stage II pressure ulcer (an injury to the skin and underlying tissue) was not turned every two hours per the resident's plan of care and facility's policy and provided with a clean technique during wound care. This deficient practice had the potential to result in Resident 4's pressure ulcer worsening. Findings: a. A review of Resident 1's Admission Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. introduction of food and fluids), end stage [MEDICAL CONDITION] (([MEDICAL CONDITION]) last stage of [MEDICAL CONDITION] (CKD) and [MEDICAL TREATMENT] or transplant is required to stay alive) requiring [MEDICAL TREATMENT] treatments (process of removing waste products and excess fluid from the body) three times a week (Monday, Wednesday, and Fridays (MWF)), [MEDICAL CONDITION] (too much body fat for your height; is when the excess body fat becomes a danger to ones' overall health). A review of Resident 1's skin assessment upon admission, dated 11/10/15, indicated Resident 1 had redness to the perineal area (between the vulva (external genital organs) and anus (rectum)) and surrounding the [DEVICE] area was a hard mass (a lump that can be within the skin, in the tissues, under the skin or attached to the skin and/or underlying tissues) to the lower abdominal fold area with no pain. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/30/15, indicated Resident 1 was alert and oriented to person, place, and time as evidenced by the brief interview of mental status (BIMS) with a score of 15 (score of 8 to 15=inter-viewable). The MDS, under Section G, Functional Status, indicated Resident 1 was totally dependent on staff requiring a two+ physical assist for turning in bed and of any slight position changes, movement on and off the unit, dressing, eating, toilet use, and personal hygiene, with the exception of eating, Resident 1 required a one-person physical assist. According to the MDS, Resident 1 was non-ambulatory and incontinent (unable to control) of bowel and bladder. On 7/15/16 at 1:26 p.m., the treatment nurse (a licensed vocational nurse (LVN 1)) was asked for Resident 1's Braden Scale (an assessment tool for predicting pressure sore risk) from admission. LVN 1 and the facility's staff were unable to provide Resident 1's admission Braden Scale, but presented a Braden Scale, dated 3/2016. LVN 1 stated Resident 1 did not have any pressures sores upon admission to the facility. On 7/15/16 at 2:40 p.m., during an interview, a certified nursing assistant (CNA 1) stated she took care of Resident 1 during the first week of admission and stated Resident 1 had no pressure sores, only redness under Resident 1's breast and stomach folds. CNA 1 stated there was a pubic area mass. CNA 1 was asked how often she turned the residents in the subacute unit. CNA 1 stated the residents were supposed to be turned every two hours, but sometimes the residents were only turned once a shift when she was busy. CNA 1 stated, I would like to turn the residents every two hours, but sometimes it's not possible, because it's only two CNAs in Sub Acute Unit (a higher level of care than a skilled nursing facility (SNF)). We have 10 residents each on an average shift and sometimes up to 12 residents on a shift, with most of the residents being bedbound (spends most of the time in bed) on ventilators. A review of Resident 1's skin assessment, dated 12/23/15, indicated Resident 1's right and left buttock and right groin area were excoriated (damage or remove part of the surface of (the skin) and the abdomen at the GT site was ulcerated. A review of Resident 1's care plan, dated 12/25/15 (a month and half after admission), and titled, High risk for skin breakdown, related to abdominal surgical dehiscence (a surgical complication in which a wound ruptures along a surgical incision) abdominal wound, [DEVICE] ulceration (a sore on the skin or a mucous membrane), and excoriation of the left ischial (lower and back part of the hip bone), bilateral (both) buttocks, left abdominal fold, and the right groin, and diabetes, incontinence of bowel and bladder (B/B), fragile skin, limited mobility, and obesity. The staff's interventions included using pillows, pads, wedges to reduce pressure on heels and pressure points; and to turn and reposition Resident 1 every two hours and PRN (as needed). A review of Resident 1's Braden Scale, initiated on 3/2/16, indicated the facility's staff scored Resident 1 with a score of 16 on 3/2/16 and 4/20/16; a score of 18 on 4/29/16; 17 on 5/9/16 and 5/11/16 and a score of 18 on 5/18/16. According to the Braden scale, a total score of 10-12 represented a high risk and 15-18 was a mild risk for developing pressure sores. A review of Resident 1's laboratory results, dated 4/5/16, indicated a low [MEDICATION NAME] level at 2.8 g/dl (NRR 3.5-5.2) and a low pre-[MEDICATION NAME] level at 9.5 (NRR 18-33.8). An article by NPUAP (National Pressure Ulcer Advisory Panel), dated 2009, indicated nutrition was an important aspect of a comprehensive care plan for prevention and treatment of [REDACTED]. Adequate calories, protein, fluids, vitamins and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown. On 7/15/16 at 3:02 p.m., during a concurrent interview and record review of Resident 1's Braden Scale, the director of nursing (DON) stated, after recalculating Resident 1's score, Resident 1 should have had a score of 12 (high risk) on all the assessments, as opposed to the score of 16-18 (a mild risk). The DON stated Resident 1's pressure sore risk was inaccurately assessed, which resulted in an inaccurate Braden Scale score. The DON stated an inaccurate assessment can result in an inaccurate plan of care for Resident 1. The DON stated the facility's Subacute Unit has 23 beds with only two CNAs to care for the high acuity (the level of severity of an illness) residents. A review of the facility's policy, dated 1/1/12, and titled, Pressure Ulcer Prevention, indicated the Licensed Nurse will develop a care plan that contains interventions for residents who have a Braden Scale score of 12 or less, and therefore considered to be a high risk for developing pressure ulcers. The policy stipulated the nursing staff will develop a care plan specific to the resident's risk factors and implement interventions identified in the care plan, which may include, but are not limited to pressure redistributing devices (per the attending physician's orders [REDACTED]. A review of a wound care assessment of pressure sores for Resident 1, dated 6/9/16, indicated the following: 1. Pubic region necrotic wound measured 10 centimeter (cm) by 15 cm by UTD (unable to determine). 2. Right hip necrotic wound measured 8 cm by 4 cm by UTD. 3. Left lower abdomen necrotic wound measured 11 cm by 7 cm by UTD. 4. Left lateral thigh necrotic wound measured 1.5 cm by 2 cm by UTD. On 7/18/16 at 9:12 a.m., during a telephone interview, Resident 1's family member (FM 1) stated he visited Resident 1 every day in the SNF and sometimes twice a day. FM 1 stated the facility did not provide good care in cleaning Resident 1 and he would have to ask them to turn her and or get her up out of the bed, as was ordered by the physician. FM 1 stated he was first informed in 5/2016 of Resident 1 having a blister (a small pocket of fluid within the upper layers of the skin) on the abdomen, but was told by a licensed nurse there was nothing to be concerned about. FM 1 stated it was not until 6/2016, when a certified nursing assistant (CNA 4) asked him if he had seen Resident 1's wounds. He stated he then spoke to the wound care physician and was told there were several wounds that were large and infected with a foul smell. FM 1 stated the facility did not do any wound cultures of the Resident 1's wounds, although the wounds smelled and had drainage. FM 1 stated when he would ask the staff if they turned Resident 1, they would tell him Resident 1 refused, but Resident 1 would tell him they never asked. FM 1 stated on 6/29/16, at approximately 10 a.m., he called the facility and spoke to the registered nurse supervisor (RN 1) in the sub-acute unit. FM 1 stated RN 1, informed him Resident 1 was doing well without any problems. However, FM 1 stated he arrived at the facility about one hour later to find Resident 1 back on the ventilator with the oxygen saturation decreased to 92 to 93 percent (%), which was normally at 98 %, lying on her back, and unresponsive with eyes rolled back. FM 1 stated he was upset and had to insist that the facility called 911 due to Resident 1's change in mental status. FM 1 stated Resident 1's blood pressure was low upon his arrival at 60/30. FM 1 stated he was told by the GACH's physician Resident 1 was septic secondary to the many infected pressure sores. At 10:07 a.m., during a telephone interview, RN 1 (supervisor of the subacute unit) stated FM1 would visit Resident 1 and called all the time regarding her care and condition. RN 1 stated on the morning of 6/29/16, FM 1 had called and came to the facility. RN 1 stated FM 1 wanted Resident 1 transferred to the hospital, but he thought she was alright and did not need to go. RN 1 stated Resident 1 was lethargic and her heart rate was elevated, but her oxygen saturation was normal, but RN 1 stated they put Resident 1 back on the ventilator (sic). RN 1 stated FM 1 was persistent in getting Resident 1 transferred to the hospital, so he called 911, because the basic ambulance would not have taken her with an elevated heart rate. A review of the SNF's (skilled nursing facility) physician orders, dated 5/8/16, indicated Resident 1 can be up in chair from 8-10 a.m.,12-2 p.m. (on non-[MEDICAL TREATMENT] days), and 4-6 p.m. every day (7 days a week). A review of the Paramedic's Report, dated 6/29/16, and timed at 12:54 p.m., indicated Resident 1's GCS ((Glasgow Coma Scale) a scoring system for assessing the severity of brain impairment with sum of scores given for eye-opening, verbal, and motor responses (maximum of 15)). Resident 1's GCS score was 9 (GCS 9 -12 is Moderate impairment (3 for eye opening, 1 for verbal, and 5 for motor)) prior to being transported to the GACH. At 12:57 p.m., on 6/29/16, Resident 1 had a low systolic blood pressure ((top number of blood pressure) amount of pressure that blood exerts on the vessels while the heart is beating) was under 78 (normal reference range (NRR)=120), the heart rate was 106 (NRR=60-100 BPM (beats per minute)), oxygen saturation was WNL (within normal limits) at 95 percent while Resident 1 receiving Bag-valve-mask (BVM) ventilation (an essential emergency technique used for residents who are not breathing or not breathing adequately). Resident 1's respiratory rate was 16 and the blood sugar was elevated at 240 (NRR is 135 to 140 milligrams per deciliter (dl)). Resident 1's weight was 240 lbs. A review of Resident 1's GACH's emergency department (ED) record, dated 6/29/16, and timed at 1 p.m., indicated Resident 1's mental status was altered upon arrival to the GACH. Resident 1, who typically on a ventilator only at night, was placed on a ventilator continuously (per the SNF's physician's orders [REDACTED]. A review of the GACH's history/physical for Resident 1 indicated Resident 1 was transferred from the SNF to the GACH due to an altered level of consciousness and shortness of breath. The ED's record indicated Resident 1 was lethargic (sluggish slow-moving or inactive) and unable to answer any questions. Resident 1's vital sign at 1:45 p.m. on 6/29/16 were as follows: Temp: 99.8 F (rectally (NRR= 99.6°F)), pulse at 100 BPM, Blood Pressure 111/33, respiratory rate at 16, and a pulse oximetry (saturation of oxygen in the blood) was 99 percent (%) on 100% FIO2 (fractional inspired oxygen). A review of Resident 1's GACH laboratory report, dated 6/29/16, indicated Resident 1 had a low [MEDICATION NAME] level ([MEDICATION NAME] is a serum protein produced in the liver that is essential for proper blood circulation, metabolism, and wound healing) of 2.4 grams per deciliter (g/dl), with a NRR listed as 3.2 - 4.8 g/dl, elevated white blood cell ((WBC) indicative of an infection) of 20.1 (NRR 4.3-10.0). The ED physician documented on the ED Encounter Form that Resident 1 was in moderate severe distress with a change in mental status that worsened due to underlying pneumonia [MEDICAL CONDITION] with [MEDICAL CONDITION]. The ED note indicated Resident 1 had multiple Stage IV decubitus ulcers with a foul odor. The ED physician [MEDICAL CONDITION] secondary to pneumonia and decubitus ulcers. The GACH's infectious disease (ID) consultation, dated 6/30/16, indicated Resident 1 was awake, but did not readily respond and had multiple decubitus ulcers. The ID physician (are trained in internal medicine and specialize in diagnosing, treating, and managing infectious diseases) documented Resident 1 had multiple Stage III-IV decubitus ulcers with some exposing bone and having necrotic tissue and having a foul smell. The ID physician indicated there was a large necrotic wound over Resident 1's inferior pannus (an abnormal layer of tissue) on the suprapubic (of the abdomen located below the umbilical (naval)) region. A review of pictures of Resident 1's various stages of Stage III-IV pressure sores from the GACH, dated 6/30/16 and 7/6/16, taken by a registered nurse treatment nurse, indicated Resident 1 had foul smelling pressure sores on the following sites upon admission: · Left upper posterior thigh · Left lower abdomen · Right hip with 50 % necrotic tissue; exposed bone measuring 10 cm by 4.5 cm by 2 cm in depth. · Left thigh · Right lower abdomen · Lower abdomen (black in color unstageable; documented as larger wound with black eschar and foul smelling drainage) · Coccyx (unable to determine stage by looking at the picture) · Abdominal wound A review of Resident 1's GACH discharge summary, dated 7/19/16 indicated all of Resident 1's wounds had improved with less necrotic tissue with an improved clean base. The discharge summary indicated Resident 1's wounds no longer required a [DEVICE] (a device which conducts negative pressure wound therapy (NPWT); device consists of a dressing which is fitted with a tube and attached to the wound). According to the discharge summary, Resident 1 was treated for [REDACTED]. Resident 1 was weaned off ventilator support and was placed on 40% [MEDICAL CONDITION] (one-piece collar that secures [MEDICAL CONDITION]). Resident 1 transferred to another subacute facility on 7/19/16. b. A review of Resident 4's Admission Face sheet indicated Resident 4 was admitted to the facility on [DATE] at 7:20 p.m. Resident 4's [DIAGNOSES REDACTED]., wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister or a shallow crater in the skin) to right and left buttock. On 7/8/16 at 10:30 a.m., during a wound care observation of Resident 4's pressure sore (a sore caused by pressure from the body itself when remained immobiled in bed for an extended period of time) to left and right buttock. A licensed vocational nurse (LVN 1/treatment nurse) was observed providing wound care to Resident 4. Resident 4's area around the Stage II pressure sore was dark. LVN 1 began to clean the wound with normal saline by wiping from the anus (the outlet of the rectum lying in the fold between the buttocks) to the outer area of the buttocks. During wound the wound care, Resident 4 was lying on top of a bed pad that was visibly soiled with brownish -red substances. Post wound care, LVN 1 placed Resident 4 back on the soiled bed pad, exposing the Resident 4's right and left buttock wounds (that were left open to air) to the soiled bed pad, thus increasing the risk of cross contamination and possible infection. On 7/8/16 at 2 p.m., during an Interview, LVN 1 was asked to explain techniques to provide wound care. LVN 1 stated, I'm supposed to wash my hands before the treatment and after and place all clean dressing and equipment on a clean surface and all the soiled dressing at the foot of the bed in a bag. Then I would clean the wound from the inner area to the outer area, clean to dirty. When questioned concerning what was the facility ' s policy regarding positioning related pressure sore prevention. The treatment nurse indicated, We turn patients every two hours. On 7/8/16 at 10:21 a.m., during an interview, Resident 4, who was alert and oriented times four (person, place, time and situation) was asked if the facility's staff was turning him every two hours. Resident 4 stated, They only turn me if I ask them to turn me.