Every finding on record at Fairfield Post Acute Rehabilitation

Based on interview, and record review the facility failed to ensure one of three sampled residents, Resident 1 received care in accordance with professional standards of practice when facility staff did not follow physician orders and inaccurately documented medical notes during an emergent change of condition.These failures decreased the facility's potential to safely and effectively provide care to a resident with worsening health conditions.Findings:1a. Licensed Nurse 1 (LN 1) did not follow a physician's order to regulate Resident 1's oxygen flow rate to 3 LPM (LPM, liters per minute, it's a measurement of how much oxygen Resident 1 received) via nasal cannula (NC-nasal cannula, oxygen tubing).A review of Resident 1's Clinical Record indicated Resident 1 was admitted to the facility in May 2026 with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease- a progressive, long-term lung disease that blocks airflow and makes it difficult to breathe), and Acute Respiratory Failure with Hypoxia (a condition where the body's tissues do not receive enough oxygen and considered a medical emergency).During a review of Resident 1's Minimum Data Set (MDS; an assessment tool used to guide care), dated 5/14/26, Cognitive Patterns Section C, indicated a score of 13 out of 15 which indicated the resident was cognitively intact.A review of Resident 1's Order Summary Report (OSR) dated 5/11/26, indicated, Oxygen via NC at 3 LPM continuously every shift.A review of Resident 1's Care Plan dated 5/14/26, indicated, Give oxygen therapy as ordered by the physician.A review of Resident 1's Progress Notes, (PN), as documented by LN 1, dated 5/19/26, at 11:30 a.m., indicated, .O2 2 liters via nasal cannula Saturations [O2 sat, amount of oxygen in the blood] 70-80% .A review of Resident 1's eINTERACT Change in Condition Evaluation (a communication tool used by healthcare workers when there is a change of condition among the residents) dated 5/19/26, at 3:58 p.m., as documented by LN 1, (no time documented as to when event occurred), indicated, .4. Summarize your observations, evaluation and recommendations: Resident having low saturation on 2-liters oxygen via NC. Resident now having SOB [shortness of breath] and chest pain. Resident now getting worse, became nonresponsive with agonal [gasping respiration] breathing.During an interview with LN 1 on 6/23/26 at 12:29 p.m., LN 1 stated Resident 1 was sitting on her bed, at 11:30 a.m., oxygen via NC at 2 LPM, and had O2 sats of 70-80%. LN 1 agreed that an O2 sat of 70-80% was a critical level, (95-100%- normal; 92-94%- mildly low; below 90%- dangerous; 88% or lower- emergency) and typically required immediate 911 activation. LN 1 acknowledged, it was not activated until approximately 1:30 p.m. LN 1 stated she increased Resident 1's O2 level to 4 LMP with no improvement. LN 1 further stated Resident 1 was transported to the acute care hospital and passed away.1b. LN 1 did not follow a physician's order for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (a prescription quick-relief rescue medication used to prevent and treat breathing difficulties) ordered as needed, was not given when SOB was first identified.A review of Resident 1's OSR, dated 5/8/26, indicated, Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for COUGH / SOB /WHEEZING.A review of Resident 1's Medication Administration Record, (MAR) on 5/19/26, Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for COUGH / SOB/WHEEZING. indicated there was no documentation that this had been administered to Resident 1 from May 1, 2026 through May 19, 2026.1c. LN 1 did not follow a physician's order for Torsemide Oral Tablet 20 MG (Torsemide-used to relieve dyspnea by reducing excess fluid buildup in the lungs which makes it significantly easier to breathe) Give 1 tablet by mouth every 12 hours as needed for SHORTNESS OF BREATH. was not administered to Resident 1 when Resident 1 had documented SOB.A review of Resident 1's MAR on 5/19/26, indicated, Torsemide Oral Tablet 20 MG (Torsemide) Give 1 tablet by mouth every 12 hours as needed for SHORTNESS OF BREATH. was also not administered to Resident 1.2. Documentation regarding Resident 1's change of condition was contradictory and inaccurate.A review of Resident 1's eMAR-Medication Administration Note, as documented by LN 1, dated 5/19/26, at 11:30 a.m., indicated .Resident saturation 70's SOB on exertion.A review of Nursing Progress Notes dated 5/19/26 at 11:30 a.m., LN 1 documented O2 2 liters via nasal cannula Saturations 70-80% Resident breathing even and unlabored. Which is contradictory to the Medication Administration Note written by LN 1 at the same time.A review of Resident 1's PN, as documented by LN 1, dated 5/19/26, at 12:57 p.m., indicated .Respiratory: No signs of difficulty breathing. Shortness of breath noted. Resident reported Shortness of breath (while sitting) Nurse observed Shortness of breath (while sitting) . This PN contains contradictory statements from LN 1.During an interview with LN 1 on 6/23/26 at 12:29 p.m., LN 1 acknowledged her documentation was not chronologically documented and inaccurate, yes, I should improve how I write my documentation.During an interview with the Director of Nursing, (DON) on 7/1/26 at 9:13 a.m., the DON agreed that LN 1 should have followed the physician's order to regulate Resident 1's oxygen at 3 LPM and further stated that an O2 sat of 70-80% is critically low. The DON acknowledged that there was a physician's standing order (pre-authorized) for Albuterol inhalation and Torsemide tablet to be given to Resident 1 as needed for SOB, and LN 1 should have administered the medications to Resident 1 at the first sign of respiratory distress or SOB. The DON further stated LN 1's documentation should be chronologically documented and accurate. The DON stated her expectations from the nursing staff were to promote quality of care and patient safety.A review of the facility's policy and procedures, titled Physician Orders, revised 2/26, indicated, It is the policy of this facility that drugs or biological shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs.1. No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses.A review of the facility's policy and procedures, titled Oxygen Therapy, revised 2/26, indicated, It is the policy of this facility to administer oxygen in a safe manner. The rate of flow, route, and rationale.A review of the facility's policy and procedures, titled Change of Condition Reporting, revised 2/26, indicated, .Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician's order(s), physician's visit promptly and/or acute care evaluation.A review of the facility's policy and procedures, titled Documentation and Charting, revised 2/26, indicated, .1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care in an accurate and chronological manner.

Based on interview and record review, the facility failed to ensure medication was accurately reconciled before discharge when Resident 1 was sent home with the wrong insulin (a hormone produced by the body or given artificially to removes excess sugar from the blood) medication.This failure had the potential to cause sudden, severe hypoglycemia (low blood sugar) leading to confusion, seizures, or sudden death.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), indicated he was admitted to the facility on [DATE] for diagnosis including Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 1 was discharged home on 4/11/26.A review of Resident 1's Order summary report for 4/26, indicated he was prescribed NovoLIN R (brand name for man-made human insulin used to treat diabetes) using a FlexPen/Pen-injector (a pre-filled, disposable device used to inject medication-most commonly insulin-into the body) for DM.During an interview on 5/20/26 at 10:50 a.m., with Resident 1's family member (FM), the FM stated the insulin sent home with Resident 1 when he was discharged on 4/11/26 was not the correct insulin he was prescribed. The FM stated instead of the Novolin R (short acting insulin that starts working between 30 to 60 minutes) pen-injector, the facility sent a Novolog (rapid acting insulin that starts working in 10-20 minutes) pen-injector. The FM stated Resident 1 had been using the Novolog for 13 days at home until it was discovered.During a concurrent interview and review of the photo of the insulin pen-injector obtained from the FM on 5/20/26 at 4:09 p.m. with the DON, the photo indicated:The pen-injector blue cap had a sticker of Resident 1's Novolin R prescription.The orange pen-injector containing Novolog had a sticker of the prescription of another facility resident. The DON stated the insulin sent home with Resident 1 was the wrong insulin and can compromise the resident's health condition. During a concurrent interview and record review on 5/20/26 at 4:53 p.m. with the DON, the policy titled, Discharge or transfer revised 2/26 was reviewed. The policy indicated, Nursing to do final medication record review and instructions. The DON stated it was not followed during discharge.

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly, when an unlabeled loose pill and three labeled blister packs (a type of unit-dose packaging with clear plastic bubbles (blisters) holding individual pills) were found on the bottom of a drawer and in the back of the drawers for one out of five sampled medication carts. These failures had the potential for medication error, misuse, or drug diversion.Findings: During an inspection of Medication Cart 5 on 1/6/26 at 12:20 p.m., one unlabeled loose pill and three labeled blister packs were found on the bottom of the drawer and behind the drawers in the back of medication cart 5.During an interview on 1/6/26 at 9:48 a.m. with Nursing Supervisor (NS), NS removed the pill found on the bottom of the drawer and confirmed there was 1 loose pill. NS also confirmed there were three labeled blister packs found behind the drawer at the back of cart 5. The NS stated the carts were cleaned regularly but admitted she did not think of looking behind the drawers. The NS confirmed the loose pill or the misplaced medications in the back of the cart could have led to a mediation error. During an interview on 1/6/26 at 1:29 p.m. with the Director of Nursing (DON), the DON confirmed medications should not be loose in the drawers and medications should not be at the back of the cart behind the drawers. The DON stated, the medication carts should be checked thoroughly, and kept clean. The DON stated the loose pill and medications in the back of the cart could lead to a medication error.During a review of the facility Policy and Procedure (P&P), titled, Storage of Medications, dated May 2022, the P&P indicated, Medications and biologicals are stored safely, securely, and properly .All medications. are stored in the container with the pharmacy label.

Based on observation, interview, and facility document review, the facility failed to store cookware pans and utensils in accordance with professional standards for food service safety when: Frying pans were stacked wet while stored away; and, Ladles and cake slicer were found wet while stored in the drawer.These failures had potential to cause food-borne illnesses in a highly susceptible population of 97 residents who received food from the kitchen.Findings:During a concurrent initial tour observation and interview on 1/6/26 at 8:45 a.m. at the kitchen with the Certified Dietary Manager (CDM), several wet pans and ladles were stacked and stored at the clean and ready-to-use storage areas as indicated below:6 frying pans- different sizes6 ladles - various sizes1 cake slicerThe CDM confirmed that the 6 frying pans, 6 ladles, and 1 cake slicer were wet. CDM stated, the frying pans, ladles, and a cake slicer should have been completely air dried before being stored away.During an interview on 1/8/26 at 10 a.m. with Registered Dietician (RD), the RD stated, the expectation was: the frying pans and ladles including the cake slicer will be cleaned and air dried before it is stored away.During a review of an undated facility's policy and procedure titled, Dishwashing, indicated, .dishes are to be air dried in racks before stacking and storing.

Based on interview and record review, the facility failed to ensure 4 of 24 sampled residents (Resident 7, Resident 32, Resident 53, Resident 90) were offered an advance directive (a legal document where a competent adult specifies their future medical care wishes in the event they cannot communicate them themselves, often due to illness or injury). This failure had the potential to result in the residents' medical wishes not being honored.Findings:During a review of Resident 7's admission record (AR), the AR indicated Resident 7 was admitted in November 2025 with several diagnosis including aftercare following surgical amputation (surgical removal of part or all of a body part).During a review of Resident 32's AR, the AR indicated Resident 32 was admitted in November 2025 with several diagnosis including encephalopathy (a condition where brain dysfunction occurs due to a chemical imbalance in the body, often triggered by systemic illnesses or organ dysfunction). During a review of Resident 53's AR, the AR indicated Resident 53 was admitted in December 2025 with several diagnosis including severe protein calorie malnutrition.During a review of Resident 90's AR, the AR indicated Resident 90 was admitted in December 2025 with several diagnosis including acute respiratory failure with hypoxia (low levels of oxygen in tissues and organs). During a review of Resident 7, Resident 32, Resident 53, and Resident 90 's clinical records, the clinical records did not have an advance directive or documentation that indicated an advance directive was offered. During a concurrent interview and record review on 1/8/26 at 2:06 p.m. with Social Services Director (SSD), SSD confirmed Resident 7, Resident 32, Resident 53, and Resident 90 did not have an advance directive or documentation that indicated an advance directive was offered. SSD stated the expectation was for advance directives to be offered at admission. SSD further stated there should have been documentation that indicated an advance directive was offered if residents did not have an advance directive. SSD further stated there was a risk for residents' medical wishes to be unclear when an advance directive was not available. During a review of the facility's policy and procedure (P&P) titled, Advance Directives revised 2/25, the P&P indicated, .it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive Prior to, upon, or immediately after admission, the facility staff will ask residents, and/or their family members, about the existence of any advance directives.Should the resident indicate that he or she has issued advance directives about his/her care and treatment, the facility will require that a copy of such directives be included in the medical record.

Based on observation, interview and record review, the facility failed to store resident food in a safe and sanitary manner in the refrigerators for residents for a census of 97 when:One opened bottle of soda stored past their use by date,Two bottles of opened salad dressings, and one fruit spread found unlabeled,One bag of loaf of bread was unlabeled, undated, and expired; and,Opened container of clam chowder with expired use by date.These failures had the potential to cause foodborne illnesses in a vulnerable resident population. Findings:During a concurrent observation and interview on 1/8/26 at 10:30 a.m. with Certified Dietary Manager (CDM), several resident food items were found in the refrigerators for residents at Nursing Station 1 and Nursing Station 2. The food items found were as follows:Nursing Station 1 refrigerator for residents:One opened bottle of soda stored past their use by date 12/27/25.Two opened salad dressings, and one fruit spread found unlabeled, undatedOpened Clam Chowder with use by date 1/7/26 and unlabeled.Nursing Station 2 refrigerator for residents:One bag of loaf of bread was unlabeled, undated, and expired.CDM confirmed the findings and stated her expectations were to have all residents' food be labelled. CDM further stated, . staff must check the resident refrigerators every night and discard anything that has expired or does not have any labels.During an interview on 1/8/26 at 11 a.m. with the Registered Dietician (RD), RD stated, her expectations were for the staff to label the food received from home, the date, and the location of the resident. RD further stated perishable food that has been opened must be discarded after 3 days.During a review of the facility's policy and procedure titled, Foods Brought by Family or Visitor, revised 2/2025, indicated, .all foods shall be labeled with the resident name, location, and date.perishable prepared foods will be checked by nurse, dietary staff daily and discarded after 3 days of storage.

Based on observation, interview, and record review, the facility failed to ensure proper infection prevention measures were implemented for a census of 97 when:One facility staff did not sanitize the blood pressure (BP-measures the force of blood against artery walls) cuff in between two residents (Resident 2 and Resident 61).These failures had the potential to spread germs.Findings:A review of Resident 2's clinical record indicated Resident 2 was admitted [DATE] with diagnosis that included Chronic Viral Hepatitis C (a long term viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), Immunodeficiency (the immune system can't effectively fight infections and diseases, leading to frequent, severe infections and potentially cancer), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing).A review of Resident 61's clinical record indicated Resident 61 was admitted [DATE] with diagnosis that included Immunodeficiency, and Pneumonia (an infection/inflammation in the lungs).During a concurrent observation and interview on 1/6/26 at 8:47 a.m., 9:01 a.m., and 9:14 a.m., respectively with Licensed Nurse (LN)1, LN 1 did not sanitize the BP cuff before, after or in between taking the BP of Resident 2 and Resident 61. LN 1 stated, .we are supposed to sanitize the blood pressure cuff after each use, but I forgot. LN 1 stated not sanitizing the BP cuff could spread germs.During an interview on 1/6/26 at 12 p.m. with the Nursing Supervisor (NS), the NS stated, the BP cuff and machine needed to be wiped down in between each resident use. The NS stated that not sanitizing can lead to spreading germs.During an interview on 1/6/26 at 1:29 p.m., with the Director of Nursing (DON), the DON stated the expectation was for the BP cuff to be sanitized in between each resident use to prevent the spread of germs.During a concurrent interview on 1/7/26 at 9:56 a.m. with the Infection Preventionist (IP) and Director of Staff Development IP Consultant (DSD IP), the IP and DSD IP stated the expectation for sanitizing the BP cuff was to sanitize the cuff in between each resident use.A review of the facility's policies and procedures (P&P) titled, Infection Control Program, revised 2/2025, indicated, .Patient-care equipment (e.g., blood pressure cuffs).clean and disinfect such equipment before use on another patient.

Based on interview and record review, the facility failed to ensure one of 24 sampled residents (Resident 9) was free of unnecessary psychotropic medications (any drug that affects behavior, mood, thoughts or perception) when Resident 9 did not receive a psychiatric evaluation to determine if their psychotropic medication should be continued.This failure had the potential to result in the use of an unnecessary psychotropic medication that could cause adverse consequences.During a review of Resident 9's admission record (AR), the AR indicated Resident 9 was admitted to the facility in November 2025 with multiple diagnosis including dementia (a progressive state of decline in mental abilities). Resident 9's AR did not indicate a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 9's physician's orders dated 11/7/25, the physician's orders indicated Resident 9 was prescribed quetiapine (a psychotropic medication that treats schizophrenia and bipolar disorder).During a review of Resident 9's Initial Psychology Evaluation dated 11/26/25, the Initial Psychology Evaluation did not include a review of quetiapine or address the reason for starting and continuing quetiapine.During an interview with Neuropsychologist (NPSY) on 1/8/26 at 11:32 a.m., the NPSY confirmed she was the clinician that evaluated Resident 9 on 11/26/25. The NPSY stated quetiapine was not reviewed during the Initial Psychology Evaluation. The NPSY further stated I missed it (quetiapine) on the med (medication) list. The NPSY confirmed Resident 9 did not have a diagnosis of schizophrenia or bipolar disorder.During an interview on 1/9/25 at 10:20 a.m., with the Director of Nursing (DON), DON stated the expectation was for NPSY to review the quetiapine during the Initial Psychology Evaluation on 11/26/25. DON acknowledged the risk for mortality when Resident 9's quetiapine was not reviewed.During a review of the U.S. Food, Drug and Administration (FDA) medication guide for quetiapine, revised 8/19, the FDA medication guide indicated quetiapine increased the risk of death in elderly people with dementia.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Drug Use, revised 2/2025, the P&P indicated, .It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Upon initial comprehensive assessment, SSD and/or nursing designee shall review new admissions for.physician's orders for psychotropic medications. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist.

Based on observation, interview and record review, the facility failed to ensure 28 multiple-resident rooms (rooms 1-9, 11-13, 15-21, 28-35, 37) met the required 80 square feet (sq. ft.) per resident when the following rooms were measured as:room [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personThese failures had the potential to negatively affect the residents' quality of life and result in inadequate space for the provision of care.During observations made throughout the survey in the rooms with three resident occupancies, the space was adequate to store assistive devices in the rooms (such as wheelchairs and/or walkers) and to facilitate provision of care and needs.During an interview on 1/7/26 at 8:22 a.m., a resident in room [ROOM NUMBER] stated he could get around his room without issues when wheelchair and trashcans were not blocking pathways to bathroom.During an interview on 1/7/26 at 8:29 a.m., a resident in room [ROOM NUMBER] stated she had no concerns or issues with the size of the room.During an interview on 1/8/26 at 12:59 p.m. with Licensed Nurse 2 (LN 2), LN 2 stated there were no issues with room sizes. LN 2 further stated there was enough room to do her job. LN 2 further stated wheelchairs and trash cans must be moved to accommodate a Hoyer lift while transferring residents.During an interview on 1/8/26 at 1:05 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated if there was no clutter and resident items were organized, there was enough space in the rooms for her to do her job.During an interview on 1/8/26 at 1:25 p.m., a resident in room [ROOM NUMBER] stated she had no issues moving around in her room.The Department recommends continuation of the waiver for the above-mentioned rooms.

Based on interview and record review, the facility failed to perform the weekly weights for one of the four sampled residents (Resident 1) per order and care plan. This failure exacerbated Resident 1's weight loss significantly.Findings:During a review of Resident 1's admission Record (AR), AR indicated, Resident 1 was admitted on [DATE] with diagnoses which included Metabolic encephalopathy (when the brain does not work because of chemical imbalance or problem in the body's metabolism), Burn of Second Degree of Left Thigh due to heatstroke (heatstroke- when the body overheats dangerously from too much sun, leading to symptoms like confusion, dizziness, high fever, requiring immediate medical help.)During a review of Nutritional Risk Assessment (NRA), dated and signed by Registered Dietician (RD) on 7/8/25, the NRA indicated, .Goals: Maintain weight within +/- 5 pounds of current body weight (CBW). Resident 1's admission weight was 198 lbs. (pounds- a unit of weight measurement).During a review of order summary report (OSR) dated 7/2/25 indicated, Weekly Weights x 4 Weeks every dayshift every 7 day(s) for 4 Weeks.During a review of Resident 1's Care Plan (CP) initiated on 7/4/25, the CP indicated, .potential nutritional problem related to Metabolic Encephalopathy, Burn of Second degree, Heat Stroke with interventions which indicated, .weekly weights x 4 weeks and then monthly if stableDuring a review of Resident 1's average meal intake for the month of 7/25 indicated, the amount eaten for breakfast was 26-50%, Lunch 26-50%, Dinner 51-75%. No evidence in the progress notes that the licensed nurses were notified when his meal intakes were 26-50%. No evidence in the progress notes that licensed nurses were notified when he refused his meals.A review of Resident 1's weight logs indicated, 7/2/25 198 lbs. (admission weight) 7/7/25 190.5 lbs. 7/14/25 No documented weight 7/25/25 173.5 lbs. (18 days since his last weight recorded) 8/2/25 170 lbs.(8 days since last weight was recorded) 8/11/25 165.5 lbs. (9 days since last weight was recorded)An interview with Licensed Nurse (LN)1 on 12/24/25 at 10:10 a.m., stated, newly admitted residents will be weighed within twenty-four hours. LN 1 further stated weekly weights for four weeks and then monthly. During an interview on 12/24/25 at 12:23 p.m. with Registered Dietician (RD), RD stated, resident was weighed upon admission, then weekly for four weeks, then monthly.During an interview on 12/24/25 at 1 p.m. with the Director of Nursing (DON), the DON stated, her expectations were for the staff to follow doctor's orders, follow the care plan, and to notify the licensed nurse when there were changes with their resident's condition or if the meal intake was poor. DON further stated, the certified nurse assistant (CNA) uses the Tasks tab in the electronic medical record (EMR) to document and report the amount eaten for breakfast, lunch, and dinner. DON further stated, if there were any concerns or changes in condition, the CNAs must flag (to mark for attention) and report those concerns through the tasks tab related to the resident through the EMR, or they can verbally addressed the concerns to the licensed nurses. DON further stated, they do not have any policy related to the communication process of CNAs to their LNs related to change of condition or concerns.During a telephone interview on 12/26/25 at 3:27 p.m. with Director of Nursing (DON), DON stated, there was no documentation of weight on 7/14/24. No follow-up documentation was provided related to the missed weight on 7/14/25. During a review of facility's policy and procedure titled, Clinical Practice Guidelines, revised, 2/25, indicated, .each resident is to be weighed within 24 hours of admission, weighed weekly for four weeks upon admission.

Based on interview and record review, the facility failed to provide respiratory care services according to professional standards of quality for one resident (Resident 1), when Resident 1 arrived to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center with an empty oxygen tank. This failure decreased the facility's potential to safely provide Resident 1's oxygen therapy. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in May 2024 with diagnoses including respiratory failure (a condition where there's not enough oxygen in the body) and pneumonitis (inflammation of the lung tissue). A review of Resident 1's Care plan report, dated 5/22/24, indicated Resident 1 required continuous oxygen every shift. A review of Resident 1's physician orders, dated 5/21/24, indicated Resident 1 was scheduled for dialysis on Monday, Wednesday, and Friday with pick up time from facility at 12:45 p.m. and chair time for dialysis at 1:15 p.m. The order further indicated Resident 1 should receive oxygen via nasal cannula two liters per minute continuously every shift. A review of Resident 1's Dialysis Form, dated 5/31/24, indicated Resident 1's pick up time for dialysis was 12:45 p.m. During an interview on 3/3/25 at 2 p.m. with the transport driver, the driver stated the trip from the facility to the dialysis center took about five to 10 minutes and Resident 1 fainted in the van upon arrival to dialysis center. The driver further stated he quickly got Resident 1 inside the dialysis center, staff gave her oxygen and told him the oxygen tank was empty. During an interview on 3/3/25 at 11:36 a.m. with the Dialysis Center Administrative Assistant (DAA), DAA stated Resident 1 passed out upon arrival to the center and needed oxygen. During a concurrent interview and record review on 3/3/25 at 4:30 p.m. with the Administrator (ADM), Resident 1's Late Entry Note, dated 6/8/24, and Dialysis Form, dated 5/31/24, were reviewed. The note indicated Resident 1 arrived at the dialysis center on 5/31/24 and needed oxygen right away. The nursing home oxygen tank was checked and was found to be empty. ADM stated there was no documentation about the status of the oxygen tank prior to leaving the facility and her expectations were that oxygen tanks should be checked before use. A review of the facility's policy and procedure titled, Oxygen Therapy, revised 2/23, indicated, It's the policy of this facility to administer oxygen in a safe manner under physician's orders .

Based on observation, interview, and record review, the facility failed to store and prepare food in a sanitary environment when: 1. Ice packs for resident pain relief were stored in a refrigerator for food, 2. A dietary aide did not correctly test the sanitizer bucket, and 3. A cook did not correctly describe the cool down process. This failure could potentially lead to food-borne illness in vulnerable residents. Findings: 1. During an observation and concurrent interview on 9/12/24 at 2:33 p.m. with Dietary Manager, the Station 1 refrigerator for residents' food had a sign taped to the front that indicated For Resident Food Only. The refrigerator contained a six-pack of Ensure labeled with a resident's name and a bottle of Snapple with a resident name on it. The freezer compartment contained multiple white ice packs with the words Cold Pack in blue print on them. When queried, Dietary Manager stated the ice packs were for if a resident had a headache or something. When asked if ice packs should be in the refrigerator for resident food, Dietary Manager stated her department was just responsible for keeping it clean and recommended speaking to nursing about where the ice packs should be stored. During an observation and concurrent interview on 9/12/24 at 3:42 p.m., when queried, Licensed Nurse D looked at one of the ice packs from the Station 1 refrigerator and stated the ice packs in the Station 1 refrigerator were for when residents asked for an ice pack, and gave the example of a resident who had had a knee replacement surgery and needed the ice pack for pain relief. During an interview on 9/12/24 at 3:46 p.m., when asked if ice packs for pain relief should be in the refrigerator for resident food, Registered Dietitian stated, No there should not be ice packs in the refrigerator for food. 2. During an observation and concurrent interview on 9/12/24 at 2:33 p.m., when queried, Dietary Aide E stated the sanitizer buckets used for cleaning the food preparation surfaces in the kitchen were changed every two hours. Dietary Aide E demonstrated the process for testing the sanitizer in the buckets for the proper concentration. Dietary Aide E got a test strip, dipped it in a sanitizer bucket for one second, and held the strip up to the test strip bottle. When asked what the strip should read, Dietary Aide E stated she needed to ask, and went to Dietary Manager to ask her. When queried, Dietary Aide E verified it was part of her duties to test the sanitizer buckets. Review of facility policy and procedure Quaternary Ammonium Log Policy, dated 2023, indicated, Policy: The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. Procedure: . The solution will be replaced when the reading is below 200 ppm (parts per million). The replacement solution will be tested prior to usage. Read instructions on . the test strips for proper concentration . 3. During an observation and concurrent interview on 9/12/24 at 2:41 p.m., when queried, [NAME] F opened the binder that contained the cool-down log and described the process for cooling down food to a safe temperature for storage. [NAME] F stated that at the end of the process, the food temperature should be 41 degrees. When asked what she would do if the food was 45 degrees at the end of the process, [NAME] F stated, I'm not sure, let me ask, and asked Dietary Manager who stated the food would be discarded. During an interview at 9/12/24 at 3:46 p.m., when queried, Registered Dietitian stated it was best practice for staff to know the answers to questions regarding testing sanitizer buckets and the cool-down process. Review of facility policy and procedure Cooling and Reheating of Potentially Hazardous (PHF) or Time/Temperature Control For Safety (TCS) Food, dated 2023, indicated, When cooked PHF or TCS food will not be served right away it must be cooled as quickly as possible. Discard cooked, hot food immediately when the food is . Above 41 [degrees Fahrenheit] and more than 6 hours into the cooling process.

Based on observation, interview, and record review, the facility failed to keep the trash area clean. This failure could potentially result in an infestation of rodents or other vermin. Finding: During an observation and concurrent interview on 9/12/24 at 2:30 p.m., when asked where the kitchen trash was disposed, Dietary Manager went out to the trash area outside the kitchen back door. The trash area had two dumpsters. Dietary Manager stated one dumpster was for garbage and one for recycling. Behind the dumpster for garbage was a large [NAME] that was full of many pieces of garbage such as drink cups, napkins, and plastic bags. When asked about the [NAME] full of garbage, Dietary Manager stated the garbage was coming from the building next door. The dumpster for garbage was low to the ground with approximately two inches of clearance under it. Shoved underneath the dumpster were plastic bags with napkins, straw wrappers, and plastic utensils in them, such as would be used to eat take-out food. When asked about the trash shoved under the dumpster, Dietary Manager stated it looked like plastic bags and stated she would ask the waste company to clean them when they come back. When queried, Dietary Manager stated the waste company came at 4 a.m. During an interview at 9/12/24 at 3:46 p.m., when queried, Registered Dietitian stated it could be beneficial to keep vigilant with sanitation around the trash area. Review of facility policy and procedure, Trash Collection area, last revised 2/2023, indicated, It is the policy of this facility to keep trash collection area clean as it is a potential feeding ground for vermin and rodents. Procedures: 1. The area must be swept and kept clean on a regular basis.

Based on observation, interview, and record review, the facility failed to maintain safe water temperatures at resident sinks when 6 of 22 resident bathroom sinks had water that was too hot to touch. This failure caused two residents to feel afraid of getting burns and one resident to yell out in pain when a hot wash cloth touched her hands. Findings: During an observation on 9/9/24 at 10:49 a.m., the hot water from the sink in the room [ROOM NUMBER] bathroom felt very hot to the touch. The water was too hot for this surveyor to keep a finger under the stream of water for more than one second. The temperature of the hot water using the surveyor's thermometer was 118 degrees Fahrenheit (F) after 20 to 30 seconds. During an observation on 9/9/24 at 12:29 p.m., a staff brought a lunch tray to Resident 6, who was in her bed, and set it on the overbed table. The staff got a washcloth and turned on the faucet in the bathroom, then brought the washcloth to Resident 6 and began to wash her hands. Resident 6 yelled, It's too hot! when the washcloth touched her hands. During an observation on 9/10/24 at 11:30 a.m., additional water temperatures for sinks in resident rooms were tested with the surveyor's thermometer. The hot water in the shared bathroom for rooms [ROOM NUMBERS] tested at 121.1 F, the shared bathroom for rooms [ROOM NUMBERS] tested at 120.6 F, shared bathroom for rooms [ROOM NUMBERS] tested at 120.6 F. During an interview on 9/10/24 at 11:50 a.m., Environmental Services Supervisor and Maintenance Assistant stated Maintenance Supervisor was on vacation this week. Maintenance Assistant stated Maintenance Supervisor checked the water temperatures and filled out a log. Maintenance Assistant stated he did not know how often Maintenance Supervisor checked the water temperatures. Both Environmental Services Supervisor and Maintenance Assistant stated no one had asked them to check the water temperatures while Maintenance Supervisor was on vacation. During an interview on 9/10/24 at 12 p.m., CNA J stated that she has had experiences with showers and sinks having water too hot intermittently. CNA J stated that at times, the water had been too hot and it took a while to get comfortable. CNA J stated that she told the janitor but could not remember when. During an interview on 9/10/24 at 12:03 p.m., CNA K stated that sometimes the water was too hot, but it took a short time to adjust it comfortably. During an observation and concurrent interview on 9/10/24 at 12:06 p.m., Maintenance Assistant tested the hot water temperature in the sink of the shared bathroom for rooms [ROOM NUMBERS] with the facility thermometer. The temperature of the hot water reached and stayed at 118.9 degrees F after approximately 30 seconds. Maintenance Assistant verified the thermometer read 118.9 degrees F. Maintenance Assistant tested the hot water temperature in the sink of the shared bathroom for rooms [ROOM NUMBERS] with the facility thermometer. The temperature of the hot water reached and stayed at 121.8 degrees F after approximately 30 seconds. Maintenance Assistant verified the thermometer read 121.8 degrees F. During a record review and concurrent interview on 9/10/24 at 1:54 p.m., Administrator stated the facility did not have a policy on water temperatures for residents' bathroom sinks. Administrator stated the facility followed the guidance provided in the user manual for the electronic log platform used for tracking water temperatures. Administrator stated Maintenance Director checked the water temperatures weekly. Administrator provided a copy of this guidance and a print-out of the water temperature log for 9/8/24. Review of the water temperature log for 9/8/24 revealed the temperatures were entered by Maintenance Director and the water temperature for the shared bathroom for rooms [ROOM NUMBERS] was 111.9 degrees. The water temperature log also indicated the water temperature for the shared bathroom for rooms [ROOM NUMBERS] was 111.7 degrees. When asked about the discrepancy between the temperatures obtained by Maintenance Assistant (at 12:06 p.m.) and the temperatures documented by Maintenance Director (a difference of seven and ten degrees respectively), Administrator stated she expected water temperatures to fluctuate. Review of the provided electronic water temperature log platform guidance, not dated, indicated, F-689 Accidents - Water Temperatures . Purpose - The purpose of recording your water temperatures is to assure the Surveyor that your facility is remaining as free from accidental burns and scalds as possible and that any issues are addressed in a prompt and consistent manner. Common Causes - A common cause of tap water burns to the elderly include . Residents may . not check the water before touching it. Task Instructions . As the temperature of the water is taken, hold your hand under the running water at about the same time to assess how the water feels on your skin. 39792 46132 During a concurrent observation and interview on 9/10/24 at 10:01 a.m.,when tested , the water temperature on room [ROOM NUMBER]'s sink was 120.2 degrees Fahrenheit (F, scale of temperature). Resident 45 stated it was too hot for her when she uses it and was scared it would burn her. During a concurrent observation and interview on 9/10/24 at 10:24 a.m., when tested , the water temperature on room [ROOM NUMBER]'s sink (shared with room [ROOM NUMBER]) was 118.9 degrees F. Resident 46 stated the water was too hot and very uncomfortable. Resident 46 stated she wished it was not too hot as she was scared to get burned. Resident 46 stated staff were aware and had the same observation. When asked what she meant by that, Resident 46 stated staff told her the water was too hot for them as well. During an interview on 9/10/24 at 11:58 a.m., LN D stated some rooms water temperature from the faucet comes out pretty hot when she uses it. LN D tated it was important to ensure temperature was not too hot because residents' skin were sensitive and thinner and they could burn easily. During a concurrent observation and ierview on 9/10/24 at 12:05 p.m., LN N placed her hand under the running water from room [ROOM NUMBER]s faucet and stated it would be too hot for the resident. LN N stated the temperature could result to injury because resident skin was fragile. During a concurrent observation and interview on 9/10/24 atb 12:09 p.m., LN L placed her hand under the running water from room [ROOM NUMBER]s faucet and stated it was hot to her touch and might even be hotter for Resident 45 because of her fragile skin. LN L stated it was important to ensure water temp from the faucet was comfortable for the residents to decrease risk for injuries and burn.

Based on interviews and record reviews, the facility failed to ensure they were adequately staff when: 1.five out of five residents (Residents 64, 47, 295, 10 and Anonymous 1) complained of short staffing and were left sitting on their urine or feces for over an hour, 2. staff complaints of short staffing and difficulty completing their task timely. These failures resulted in residents feeling sorry for themselves, feeling frustrated, humiliated, embarrassed and worried about their safety and Resident 295 fearful she might get a wound infection. Findings: During an interview on 9/9/24 at 10:40 a.m., Resident 64 stated the facility was short staffed, and it did not matter what shift, weekdays or weekends, the facility was still short staffed. Resident 64 stated he had talked to the Director of Staff Development (DSD) about the short staffing, but the DSD had no answer. Resident 64 stated due to lack of staff, Certified Nursing assistant (CNA) left him sitting on his feces for over an hour. Resident 64 stated he felt frustrated, humiliated, and embarrassed. A review of Resident 64 Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score, dated 7/21/24, was 15 out of 15 indicating intact cognition. Resident 64 needed assistance with toileting and personal hygiene and was incontinent of bowel and bladder per his MDS (MDS, federal mandated assessment tool). [NAME] an interview on 9/9/24 at 11:07 a.m., Resident 47 stated the facility was short staffed. Resident 47 stated staff had up to 13 residents to care for per shift. Resident 47 stated that was too much for staff to handle especially if the residents they were caring for were dependent like her. Resident 47 stated due to short staffing, staff were always in a rush to help her. Resident 47 stated she could not see and when staff serve her meal and they were short staffed, staff would be in a rush they would not even tell her were her food was located so she would use her hand to locate her food. Resident 47 stated she was also left sitting on her urine for long period of time which was embarrassing. Resident 47 stated short staffing also left her worried about heart attack, falls and worried about what could happen to her. Per her MDS, Resident 47's vision was highly impaired, she had a moderately impaired cognition, she required substantial assistance of staff during toileting hygiene, and was always incontinent of bladder and bowel. During an interview on 9/9/24 at 12:18 p.m., Anonymous 1 stated the facility was short staff. Anonymous 1 stated staff would take a long time to answer call light, about an hour. Anonymous 1 stated had experienced sitting in feces and urine for long period of time on afternoon and night shift. Anonymous 1 stated this was very humiliating and felt sorry for herself. During an interview on 9/9/24 at 1:30 p.m., a responsible party (RP, decision maker) for Resident 5 stated the facility was short staffed. The RP stated she comes to the facility to take care of her mom. The RP stated she would press the call button for her mom's roommate and CNA would not come until an hour later. RP stated it was heart breaking. RP stated CNAs were always in a rush and had too many residents to care for because they were mostly short staffed. During an interview on 9/9/24 at 3:50 p.m., Resident 295 stated staffing could be improved. Resident 295 stated there were not enough staff to care for the residents at the facility and staff does not answer call light promptly. Resident 295 stated sometimes she had to wait for up to an hour before her call light was answered. Resident 295 stated this was very frustrating and she felt helpless. Resident 295 stated she was left lying in her urine for a long time and she could feel her urine seeping through the wound on her back. Resident 295 stated she was fearful she might get a wound infection. A review of Resident 295's BIMS score dated 9/12/24 was 15 out of 15 indicating intact cognition. Resident 295's MDS dated [DATE] indicated she was dependent on staff during toileting hygiene and was frequently incontinent of bowel and bladder. Resident 295 had a surgical incision from her mid to lower back. During an interview on 9/9/24 at 5:01 p.m., Resident 10 stated the facility was short staffed. Resident 10 stated staff was always rushing and would come after an hour when you press the call light due to short staffing. Resident 10 stated he had experienced sitting on his feces and urine for a long time. A review of Resident 10's BIMS score dated 8/13/24 was 15 out of 15 indicating intact cognition. Resident 10 MDS dated [DATE] indicated he was dependent on staff during toileting hygiene and was frequently incontinent of bowel and bladder. During an interview on 9/11/24 at 9:19 a.m., LN B stated there were times the facility was short staffed. LN B stated he had come in and found residents soaked in feces or urine and that was not okay. LN B stated short staffing could lead to late response to call light, increased incidence of falls, accidents and skin impairments. LN B stated short staffing could also lead to delayed incontinence care provided to the residents which could result in wound infections especially if the wound was on the back area or the buttocks. LN B stated it was not acceptable to answer call light after 10 minutes because by then resident might have an accident already. During an interview on 9/11/24 at 10:10 a.m., the Staffing Coordinator (SC) stated she also works as a CNA and was in fact working on the floor as a CNA today. The SC stated she mostly worked on the floor as a CNA when needed or when the facility was short staffed. The SC stated the facility does get short staffed because of call offs. SC stated depending on how many CNAS called off, the residents assigned to them would be divided among the CNAs left on the floor. When asked what the risks for the residents could be then if the facility was short staffed, she stated, it becomes a safety issue. SC stated short staffing could lead to decreased quality of care. SC stated it could also affect how fast staff answered the call lights. During an interview on 9/11/24 at 12:20 p.m., the Director of Staff Development (DSD) stated call lights should be answered immediately. When asked what a reasonable time frame for staff was to answer a residents call light, the DSD stated it depends on whether the CNA was busy helping another resident. When asked if it was reasonable to answer call lights between 20 minutes up to an hour later, the DSD stated no. The DSD stated not answering the call light promptly could lead to accidents and falls. the DSD stated it was important to ensure facility was adequately staffed to ensure safe and quality care were provided for the residents. During an interview on 9/12/24 at 5:28 p.m., the Infection Preventionist (IP) stated it was important to have adequate staffing to provide good care for the resident and to provide resident needs safely. IP stated short staffing could result in late provision of care, late response to call light and sometimes could lead to falls and accidents . When asked what the facility's policy on call light was, the IP stated call light should be answered as soon as possible. When asked if it was reasonable for staff to answer a call light between 20 minutes up to an hour later, the IP stated no. During an interview on 9/13/24 at 11:08 a.m., Restorative Nursing Aide G (RNA G) stated she had been pulled to work on the floor as a CNA especially if the facility was really short staffed. RNA G stated she gets pulled to work on the floor at least once a week. RNA G stated short staffing could lead to negligence, staff could not provide quality care to the residents, staff could not provide care to the residents safely and staff might not answer call light promptly. RNA G stated call light should be answered as soon as possible. When asked if it was acceptable and reasonable to answer call light after 20 minutes or 1 hour later, RNA G stated no. During an interview on 9/13/24 at 1:34 p.m., the Director of Nursing (DON) stated staffing was based on census, facility assessment, admissions, acuity and depending on resident's needs. The DON stated short staffing put the residents at risk for not meeting their needs, risk for falls and not providing care for the residents. The DON stated short staffing could possibly affect response time to call light resulting in late provision of care. The DON stated the facility did not have a Staffing policy and procedure but uses the Facility Assessment as the policy when staffing the facility. The facility did not have a policy and procedure specific for staffing. A review of the facility's policy and procedure (P&P) titled Call Light/Bell, revised 2/2023, the P&P indicated calls for assistance should be answered within a reasonable time frame and as soon as possible .urgent requests for assistance should be addressed immediately. 48660

Based on observation, interview, and record review, the facility failed to initiate a care plan for falls when one of two residents sampled (Resident 48) fell which resulted in a hematoma (collection of blood beneath the skin) on her forehead and a laceration on her right foot. This failure had the potential to place Resident 48 at risk for insufficient provision of care and services when her care givers may be unaware of the plan of care for her wounds. Finding: Review of Resident 48's face sheet revealed an admitted [DATE]. Review of Resident 48's Interdisciplinary Team note dated 9/3/24 revealed Resident 48 had fallen on 9/2/24 trying to get out of bed which resulted in a hematoma on the side of her face and a laceration on her right foot. Review of Resident 48's care plan revealed no focus area regarding the injuries that resulted from the fall. Review of Resident 48's physician orders revealed orders dated 9/2/24 to monitor the forehead hematoma and right foot laceration daily for signs of infection, but no orders for treatment for the head and foot injuries. Review of Resident 48's MDS (minimum data set, an assessment tool) dated 6/14/24 indicated Resident 48 was on hospice care. During an observation on 9/12/24 at 8:46 a.m., Resident 48 was sitting in her wheelchair in her room. Resident 48 had bruising on the right side of her face, and her feet were noted to be in socks and were moderately swollen. During a record review and concurrent interview on 9/13/24 at 9:59 a.m., MDS Assistant reviewed Resident 48's chart and stated she could not find a care plan for the foot or head wound that resulted from the 9/2/24 fall. MDS Assistant verified there should be a care plan for the wounds. When queried, MDS Assistant stated it was the responsibility of the nurse who was assigned to Resident 48 at the time of the fall to initiate the care plan. When asked the rationale for initiating the care plan, MDS Assistant stated it was important to initiate the interventions we need to do for the wounds, to set goals for the wounds, and so the care team knows the plan for the resident's wounds. During a record review and concurrent interview on 9/13/24 at 12:08 p.m., Director of Nursing (DON) stated Resident 48 was on hospice care and described the interventions the staff were using to keep her safe from falling again. DON reviewed Resident 48's care plan and verified the care plan did not include Resident 48's injuries to her head and right foot. When queried, DON stated any change of condition required a care plan, and stated whoever initiated the change of condition documentation was responsible for initiating the care plan. Review of facility policy and procedure, Care Planning, last revised 11/2023, indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable physical, mental and psychosocial well-being.

48660 Based on interview and record review, the facility failed to implement all care measures specified in one resident's (Resident 345) Comprehensive Care Plan, when there was no documented evidence Resident 345 was turned and repositioned every two hours. This failure had the potential to delay wound healing. Findings: Record review of a document titled, Admission Record indicated Resident 345 was admitted to the facility on [DATE] with diagnoses of Aftercare Following Joint Replacement Surgery, Presence of Left Artificial Knee Joint, Iron deficiency Anemia (a condition in which blood lacks adequate healthy red blood cells, which are necessary to carry oxygen to the body's tissues), and Down Syndrome (a genetic disorder causing developmental and intellectual delays). Record review of Resident 345's care plan, initiated on 11/29/23, which focused on Resident 345's potential for pressure ulcer development indicated the following nursing intervention, Needs monitoring/reminding/assistance to turn/reposition. Record review of Resident 345's care plan, initiated on 11/29/23, which focused on Resident 345's Activities of Daily Living (ADL) self-care performance deficit indicated the following nursing intervention, Is totally dependent on staff for repositioning and turning in bed. A review of a facility document titled Document Survey Report dated May 2024, indicated there was no documented evidence staff repositioned Resident 345 on the following dates and times: 5/6/24: 2 p.m., 4 p.m., 6 p.m., 8 p.m. 5/7/24: 10 p.m. 5/8/24: 12 a.m., 2 a.m., 4 a.m. 5/9/24: 2 p.m., 4 p.m., 6 p.m., 8 p.m. 5/14/24: 2 p.m., 4 p.m., 6 p.m., 8 p.m. 5/20/24: 2 p.m., 4 p.m., 6 p.m., 8 p.m. 5/22/24: 6 a.m., 8 a.m., 10 a.m., 12 p.m. 5/24/24: 6 a.m., 8 a.m., 10 a.m., 12 p.m., 2 p.m., 4 p.m., 6 p.m., 8 p.m. 5/25/24: 6 a.m., 8 a.m., 10 a.m., 12 p.m. 5/26/24: 6 a.m., 8 a.m., 10 a.m., 12 p.m., 4 p.m., 6 p.m., 8 p.m. 5/27/24: 10 p.m. 5/28/24: 12 a.m., 2 a.m., 4 a.m., 6 a.m., 8 a.m., 10 a.m., 12 p.m. 5/29/24: 6 a.m., 8 a.m., 10 a.m., 12 p.m., 4 p.m., 6 p.m., 8 p.m. 5/30/24: 6 a.m., 8 a.m., 10 a.m., 12 p.m. During an interview and record review on 9/13/24 at 9:44 a.m., the Director of Nursing (DON) stated nursing staff were trained to turn and reposition residents every two hours. The DON further stated, The golden rule is if it's not documented it's not done. After reviewing the Documentation Survey Reports for Resident 345, the DON stated there had been a gap in the required care. During an interview and record review on 9/13/24 at 12:37 p.m., the Director of Staff Development (DSD), stated nursing staff were trained on pressure ulcer care and prevention. The DSD stated the standard intervention for a resident with, or at risk for pressure ulcer development, was to turn and reposition every two hours. The DSD stated, If you did not document it didn't happen. During an interview on 9/13/24 at 2:08 p.m., Licensed Nurse L (LN L) stated we turned and repositioned every two hours to prevent pressure ulcer. If the resident was not turned and repositioned every two hours, they could have developed a pressure injury and an infection because of open skin. During an interview on 9/13/24 at 2:15 p.m., Licensed Nurse D (LN D) stated Certified Nursing Assistants (CNAs) and Licensed Nurses were responsible for turning and repositioning the residents. LN D stated CNAs documented turning and repositioning in the electronic medical record system. LN D stated, If not documented technically it did not happen. LN D further stated, Skin breakdown could occur if not turned and repositioned every two hours. Record review of a document titled, Certified Nursing Assistant Job Description, dated 12/17/21 included as an Essential Duty and Responsibility, Turn bedfast residents at least every two hours. Record review of a document titled, Policy and Procedure for Documentation and Charting, dated February 2023, indicated, It is the policy of this facility to provide a complete account of the resident's care .in an accurate and chronological manner.

Based on observation, interview and record review, the facility failed to ensure resident bedrooms provided at least 80 square feet of living space per resident in 29 multiple resident bedrooms. This failure had the potential for residents not to have enough personal space to live comfortably. Findings: During an observation on 6/27/24, at 2:50 p.m., the facility's Administrative Staff A measured resident bedrooms [ROOM NUMBER]. Each bedroom had three beds and were occupied by three residents. Administrative Staff A's measurements indicated resident bedrooms 6, 7 and 8 measured 12 feet and 5 inches by 18 feet and 3 inches each excluding the space occupied by the movable warbrobe. This resulted in a total living space area of 226.6 square feet or 75.5 square feet per resident. During a concurrent interview, Administrative Staff A stated all facility multiple resident bedrooms with three beds had the same measurements. A review of the facility census for 6/27/24 indicated 29 multiple resident bedrooms with three beds. During an interview on 6/27/24, at 3:05 p.m., the confidential family member of a resident in a room with three bedrooms stated the resident's space was tight and wished they had more personal space. During an interview on 6/27/24, at 3:25 p.m., the confidential family member of a resident in a room with three bedrooms stated the resident needed additional personal space.

Based on interview and record review, the facility failed to ensure residents were provided the needed services that was ordered by the doctor and in accordance with the resident's preferences and goals for care for 1 out of 2 sampled residents (Resident 1) when she missed two sessions of Restorative Nurse Assistant program (RNA, requires using special knowledge and skills to perform rehabilitative and therapeutic techniques ordered and supervised by licensed medical staff). This failure could lead to further weakness and decline. Findings: During a review of Resident 1's face sheet (demographic), it indicated she was admitted to the facility on [DATE]. Her diagnoses included Hemiparesis (a mild or partial weakness or loss of strength on one side of the body) and Hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) following Cerebral Infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side. Her Minimum Data Set assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 12/23/22, Brief Interview for Mental Status (BIMS, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) score was 3 indicating severe cognitive impairment. During an interview on 1/6/23 at 4:00 p.m., the Director of Staff Development (DSD) stated RNA treatments was physician ordered and as such, it needed to be followed. The DSD stated, the RNA treatment sessions were important for strengthening and to prevent further decline. The DSD stated, if a resident was to miss an RNA treatment session, resident could be at risk for weakness and decline During an interview on 1/6/23 at 4:30 p.m., the DON verified Resident 1 had a physician's order for an RNA program on [DATE]. The DON verified Resident 1 was assessed by the rehabilitation therapist on 12/23/22. The DON verified Resident 1 was scheduled to work with the RNA for strengthening twice a week. The DON verified there was an RNA staff scheduled for Tuesdays through Saturdays, but she was not sure as to why Resident 1 missed two of her RNA treatment session last 12/2022. The DON was also unable to provide documentation on why Resident 1 missed two of her RNA treatment session last 12/2022. The DON stated Resident 1 missing on RNA treatment session could result to further decline. During a review of the facility's policy and procedure (P&P) titled Restorative Nursing, Documentation, revised 2/2022, the P&P indicated the physician's order were to be obtained when a resident is to participate in the facility's restorative nursing program .when a treatment is refused or withheld, the reason shall be documented, and the charge nurse notified.

Based on observation, interviews and record reviews, the facility failed to ensure residents environment remains as free of accident hazards as is possible when an exit door leading to and away from the COVID unit was propped or left open. This failure had the risk for uncontained infection, unauthorized person going in and out of the COVID unit and residents leaving the COVID unit unsupervised. Findings: During an interview on 1/5/23 at 3:10 p.m., the Infection Preventionist (IP) stated, the facility policy was to ensure the exit door leading to and away from the COVID unit (red zone) was always closed. The IP stated that if there was an incident where this door was left opened, the facility policy was not followed. She stated leaving the door opened or propped open was a safety risk. The IP stated people could get in the red zone and get sick, or residents from red zone could leave via the open door and could get hurt. She stated, the exit door leading to and away from the COVID unit (red zone) should be always closed to contain infection and to ensure residents safety. During an interview on 1/5/23 at 3:10 p.m., Unlicensed Staff A stated residents ' rooms and the exit door leading to and away from the red zone should remain closed at all times for safety reasons. Unlicensed Staff A stated there was a resident in the red zone currently who had dementia and was capable of leaving the building without assistance. Unlicensed Staff A stated this was also a reason why the exit door leading to and away from the COVID unit (red zone) should remain closed at all times. During an interview on 1/5/23 3:20 p.m., Licensed Staff B stated the exit door leading to and away from the red zone should remain closed at all times for resident safety. She stated it was important to ensure unauthorized personnel does not get into the red zone unit easily and to ensure residents in the red zone unit does not leave the red zone unit while they had an active infection. During an interview on 1/5/23 at 3:28 p.m., Licensed Staff C stated the exit door leading to and away from the red zone must remain closed at all times for residents safety. Licensed Staff C stated there was no reason why it should be left propped or left open in the first place. Licensed Staff C stated leaving the exit door open could result to infection not being contained. Licensed Staff C stated it was also a safety issue since unauthorized person can get into the red zone. Licensed Staff C stated residents in red zone could also leave the unit. She stated this could result to resident ' s accidents or falls. During an interview on 1/5/23 at 3:35 p.m., the DON verified the exit door leading to and away from the red zone should remain closed at all times. The DON stated it was to ensure residents safety. During an interview on 1/5/23 at 3:45 p.m., Licensed Staff D stated the door leading to and away from the red zone unit should always remain closed to contain the infection and for resident safety. During an interview on 1/5/23 at 4:00 p.m., the Director of Staff Development (DSD stated the exit door leading to and away from the red zone unit should remain closed at all times for residents safety and to contain the infection. During an interview on 1/30/23 at 3:05 p.m., Resident 1 was in bed, awake. When asked if she recalled incidents on where the door in the COVID area was left open and how she felt about it, Resident 1 responded, the door was being left open at times and she felt scared because anyone can come in. Based on federal regulation, example of hazards included exit/fire doors that were propped open.

The facility failed to ensure the environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for Resident 15 who was identified by the facility to be at high risk for falls, was known to remove her alarm, required staff assistance and a walker when getting out of bed. Resident 15 had entered the unlocked kitchen area, experienced a fall, sustained a fracture of her spine, a deep cut to the head, abrasions and bruising to both lower legs and experienced severe pain. Resident 15 was found alone in the kitchen area and had sustained injuries that required transfer to an acute hospital for medical evaluation and treatment including stitches to her head. This practice had the potential for entrapment, other serious injuries, and death to Resident 15 and other residents who had access to the unlocked kitchen area that was unsupervised and where dangerous equipment and appliances were readily accessible. Review of Resident 15's clinical record revealed that she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During review of resident's "Fall risk evaluation" dated 2/9/13, 4/13/13 and 10/9/13, resident had a score of higher than 10 which per facility document a total score of 10 or above represents high risk. Review of resident care plan dated 2/10/13& 10/12/13, indicated "At risk for fall- Frequent falls, altered gait/unsteady" intervention/plans indicated "Provide bathroom time." Resident 15's clinical record did not indicate a bathroom schedule for her. During observation and concurrent interview on 1/7/14, at 8 a.m., Resident 15 was observed sitting up in bed, awake with a nasal cannula applied (a nasal cannula is a device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help). Resident stated, through the translator ADON (Assistant Director of Nursing), that she was walking in the hallway with her walker, she felt dizzy and fell on the day when she was injured. She stated that she experienced "a lot of pain" in her back and was sent to the hospital. She stated that she now did not get out of bed or go to activities because it was too painful to do so. Staff would get her up to shower, which was "very painful" when staff would have to move her to get her out of bed. During an interview on 1/7/14, at 9:05 a.m., MDS (an assessment tool) coordinator stated that Resident 15's last MDS (a discharge MDS) was completed on 12/27/13 when she was transferred to the acute care hospital for evaluation and treatment related to a fall during which she experienced a fracture of her spine and a laceration (a deep cut or tear in skin) to the right side of her head requiring stitches. Resident 15 was re-admitted to the facility on [DATE]. During an interview on 1/7/14, at 10:15 a.m., Administrative Staff A stated that, per staff report, Resident 15 was looking for the bathroom and instead went to the kitchen, a few doors down from her room, which was where she fell and sustained a head laceration and a fracture. A CNA who went to the kitchen to get ice found Resident 15 on the floor by herself near the steps leading to the dietary office. Observation of the kitchen area, on 1/7/14 at 10:40 a.m., where Resident 15 had fallen on 12/27/13 revealed there was a step that was approximately four inches high, leading to the dietary office where Resident 15 was found on the floor the night of the incident. Equipment and appliances in the kitchen area where confused and wandering residents could injure themselves or get entrapped included: Gas stove burners, sharp knifes, and other sharp utensils. During an interview, on 1/7/14 at 10:20 a.m., Dietary Staff I stated she had been employed at the facility since August 2013 and usually worked the evening shift from 1 p.m. to 9:30 p.m. She stated she had not been told to keep the door to the kitchen locked until recently after a resident wandered into the kitchen during the night and fell . During a subsequent interview, on 1/7/14 at 10:35 a.m., Registered Dietician E stated she was not aware of the facility policy in regards to keeping the door to the kitchen locked at night. During a telephone interview on 1/10/14 at 10:10 a.m., Unlicensed Staff Y stated that the night of the incident (12/27/13), Unlicensed Staff X had called her to let her know that Resident 15 had fallen in the kitchen. Unlicensed Staff Y stated she knew that Resident 15 was not steady on her feet without her walker, had a tab alarm (a tab alarm features a pull-string that attaches magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair or bed the pull-string magnet is pulled away from the alarm which causes the alarm to sound, alerting the caregiver). Unlicensed Staff Y stated that Resident 15 would frequently disconnect the alarm and get out of bed without assistance when she could not wait for her call light to be answered. Unlicensed Staff Y said that Licensed Staff P met her and Unlicensed Staff X as they we were leaving the kitchen and walking Resident 15 back to her room. The facility then called 911 and Resident 15 was sent to the hospital around 4:30 a.m. During a telephone interview on 1/10/14 at 1:05 p.m., Licensed Staff P caring for the resident the night of the incident, stated one of the CNAs called her to the kitchen and she saw that two CNAs were walking Resident 15 back to her room. Resident 15 told her she wanted to use the toilet, became dizzy and fell . Licensed Staff P stated she offered Resident 15 a bed pan, applied oxygen, and called 911. Licensed Staff P also stated Resident 15 had disconnected her tab alarm before getting out of bed by herself "which she has done many times in the past." She said that to be safe, Resident 15 required a walker with one person assisting her at all times. She stated Resident 15 was not using her walker and was by herself when she fell and injured herself. Licensed Staff P further stated she assessed Resident 15 and determined that she had sustained a laceration to the right side of her head and was unable to explain how she got injured. Review of facility policy titled "Fall Prevention Program" (undated), indicated "Following a resident's fall, the licensed nurse will assess the resident for injuries and necessary treatment. If no apparent injuries assist off floor." Review of the acute care hospital admission records, history and physical dated 12/27/13, indicated the admitting [DIAGNOSES REDACTED]." Hospital records also indicated that surgical intervention for the compression fracture was not an option due to patient requiring medical management due to her overall condition and medical problems including cardiomegaly (enlarged heart) with congestive heart failure (occurs when the heart is unable to provide sufficient pump action to maintain blood flow to meet the needs of the body) and coronary artery disease (when the arteries that supply blood to heart muscle become hardened and narrowed). Resident 15 was discharged back to the facility on [DATE]. These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious pyhsical harm would result and was a direct proximate cause of the death of the resident.

Based on staff and family interviews, and facility record review the facility failed to ensure 1 of 18 sampled residents (Resident 14) that: 1. Licensed Staff recognized, assessed, and monitored Resident 14 for a change of condition when Resident 14 complained of abdominal pain; 2. Staff did not initiate timely Cardio/Pulmonary Resuscitation (a procedure used to restore breathing and heart function) (CPR) consistent with Resident 14's POLST (Physician order [REDACTED]. These failures of not recognizing Resident 14's deteriorating medical condition and delay in initiating CPR resulted in Resident 14 having a Cardio/Pulmonary arrest, unsuccessful resuscitation (restoration of breathing and heart function) and was pronounced dead later that day at an acute care hospital. Findings: Resident 14 was admitted to the facility on [DATE] for short-term rehabilitation following a surgical repair of a left [MEDICAL CONDITION]. Review of Admission Assessment (dated [DATE]) and nurses notes, (dated [DATE]), indicated Resident 14 was "very with it," cooperative, and able to make her needs known. It was also noted her directive (POLST- Physician order [REDACTED]. During an interview on [DATE] at 8:20 a.m., Family Member 1 (family of Resident 24) stated he met Resident 14 on [DATE], when his mother (Resident 24) was admitted to the facility and was placed in the bed next to Resident 14. Family member 1 stated Resident 14 was alert, oriented and very pleasant. Family Member 1 stated he and his wife (Family Member 2) decided to take turns staying with Resident 24 (his mother) due to her confusion and dementia. Family Member 1 stated he decided to stay the night ([DATE]) and Family Member 2 would come in the next morning, [DATE] at 5:30 a.m. Family Member 1 stated around midnight on [DATE], he heard Resident 14 complaining of abdominal pain so he put the call light on for Resident 14. He stated 15 minutes later a CNA (Certified Nursing Assistant) came in and when Resident 14 told the CNA about her abdominal pain the CNA stated she would tell the nurse. Family Member 1 stated later a nurse or a CNA (he didn't remember who) came in as Resident 14 had a bowel movement and needed to be cleaned up. The nurse/CNA told Resident 14 maybe that's why she had a stomach ache. Family Member 1 stated awhile later, between 12 a.m. and 1 a.m., Resident 14 "started vomiting." Resident 14 was given a small basin by a CNA and told Resident 14 she would let the nurse know. Family Member 1 stated Resident 14 kept moaning with abdominal pain, grabbing her stomach all night and he heard her "vomiting" at times. Family Member 1 stated he kept waiting for someone to come to help Resident 14. Family Member 1 stated around 5 a.m., Resident 14 did receive medication for pain. During an interview on [DATE] at 9:10 a.m., (and review of a signed, written declaration by Family Member 2), Family Member 2 (for Resident 24) stated she had met Resident 14 on [DATE], and found Resident 14 to be very "with it," a sweet person, alert and oriented and seemed very intelligent. Family Member 2 stated when she returned to the facility the next morning ([DATE]) at 5:30 a.m., she found Resident 14 to be a "totally different person." Family Member 2 stated when she asked Resident 14 how she was feeling Resident 14 told her she was having a lot of stomach pain and asked Family Member 2 to help her. Family Member 2 stated she went out in the hall and saw a man wearing scrubs so she asked him to help Resident 14 who was in a lot of pain. He stated he would tell the nurse. Family Member 2 stated from 5:30 a.m. until 7:30 a.m., she notified different staff three times that Resident 14 was in a lot of pain, and needed help. She stated "nothing was done, no medication was given, no staff member or nurse came in." Family Member 2 stated she told Resident 14 that she had notified staff and they were coming. Family Member 2 stated she was trying to provide Resident 14 with "a sense of comfort." Family Member 2 stated Resident 14 continued to moan in pain and was trying to get out of bed. Family Member 2 stated she went out in the hall and even asked "the cleaning lady" to come help. The "cleaning lady" came into the room and put on Resident 14's call light then left the room. Family Member 2 stated a CNA (Certified Nurses Assistant) came in (doesn't remember the exact time) and re-positioned Resident 14 and reminded her not to get out of bed, then left the room. Family Member 2 stated Resident 14 was still moaning in pain. Family Member 2 stated around 7:30 a.m., a CNA came in to "clean up" Resident 14 and during the whole time the CNA was "cleaning her" Resident 14 was moaning and crying out saying she was in pain. Another CNA came in and both CNAs transferred Resident 14 to a wheelchair for breakfast. The CNAs left the room. Family Member 2 stated after the CNAs left the room she heard a gurgling sound from Resident 14 and then there was silence. She stated she peeked around the curtain and saw Resident 14 in the wheelchair with her head down. Family Member 2 stated she went down the hall to the public bathroom and upon returning to the room the CNA was right behind her. Family Member 2 stated she told the CNA that Resident 14 was not okay, and the CNA replied she knew that Resident 14 was in pain. Family Member 2 stated she told the CNA she thought that Resident 14 had passed away. The CNA put on the call light and another CNA came into the room, and they transferred Resident 14 onto the bed and "cleaned her." She stated after the CNAs left the room she looked around the curtain and noted Resident 14 was laying in the bed and was covered with a white sheet. Family Member 2 stated two nurses (did not know their names) then came into the room and were talking for about five minutes. Family Member 2 stated around 8 a.m., she heard a woman (who she thought to be the Registered Nurse for Managed Care not employed by the facility)(PCC T) come to the doorway and asked where the resident was (referring to Resident 14) and was told on the bed. She then asked if CPR had been started, and the response was "No." She also asked if the directive (POLST) had been addressed and again the answer was "No." Family Member 2 stated the PCC T said CPR needed to be started immediately since Resident 14's directive indicated full CPR. Family Member 2 stated one of the nurses (Licensed Staff O) asked PCC T "Do we have to start CPR?" and PCC T stated, "Yes. Now." Family Member 2 stated PCC T was directing the nurses how to do chest compressions, and seemed irritated that they were not doing the chest compressions correctly. Family Member 2 stated it had been "20 minutes" after she had seen Resident 14 slumped in the wheelchair before any CPR was started. She stated when the Paramedics arrived they asked the staff how long they had been doing CPR and were told at least for 10 minutes. Family Member 2 stated "That was not true," and stated she shook her head "No" to one of the Paramedics. Review of the Paramedics flow sheet indicated paramedics initiated an assessment of Resident 14 on [DATE] at 8:19 a.m. Review of the emergency room notes indicated Resident 14 expired on [DATE] at 9:01 a.m. During an interview on [DATE] at 3:15 p.m., PCC T stated on [DATE] she went to the facility around 7:30 a.m., and was in her usual work space across from Nurses Station 2. She stated around 8 a.m., Licensed Staff O came to her and stated Resident 14 was gone. PCC T stated when she asked Licensed Staff O to clarify what she meant by "gone," Licensed Staff O told her Resident 14 was found unresponsive and had no pulse. PCC T asked Licensed Staff O if the POLST had been checked for code status and Licensed Staff O stated "No." PCC T stated when she checked Resident 14's chart, she noted that Resident 14's POLST stated full code, ( Cardio/Pulmonary Resuscitation). PCC T told Licensed Staff O to call a code, start CPR (Cardio/Pulmonary Resuscitation), and call 911. PCC T stated when she went into Resident 14's room she noted another nurse (did not know her name but stated she was an RN), was not doing chest compressions but was doing the [MEDICATION NAME] procedure (a technique used for removing a foreign body from the trachea or mouth where it is preventing airflow; on an unconscious patient lying supine on the floor, the rescuer exerts a sudden upward pressure on the abdomen; also is referred to as an abdominal thrust maneuver). PCC T stated she had to show the nurse (an RN) how to do chest compressions. PCC T stated when she asked for the Ambu-bag from the crash cart, (a bag-valve mask unit used to provide artificial breaths for a person who can not breathe on their own) she noted there was no mask attached. PCC T stated when the paramedics arrived (around 8:15 a.m.) she left the room. PCC T stated she did not know why Licensed Staff O came to her initially instead of initiating CPR immediately for Resident 14. PCC T stated after observing the two RNs she realized they were not competent with initiating a code blue or delivering CPR correctly. During an interview on [DATE] at 6:30 a.m., Unlicensed Staff R stated she cared for Resident 14 on the night shift 11 p.m. on [DATE] until 7 a.m., [DATE]. She stated soon after shift report (around midnight), she had answered Resident 14's call light. Unlicensed Staff R stated Resident 14 complained of a stomach ache and thought she needed to have a bowel movement. Unlicensed Staff R stated she informed Licensed Staff P, who came into the room, asked Resident 14 about her abdominal pain and offered to help her to the bathroom. Resident 14 did not want to get up and asked that Attends (adult briefs) be placed on her. Unlicensed Staff R stated Resident 14 did have two bowel movements, and stated she felt better. Unlicensed Staff R stated awhile later Resident 14 complained of nausea, so she gave Resident 14 a small basin and some tissues. Unlicensed Staff R was not aware that Resident 14 had any vomiting and stated when she checked on Resident 14 later (doesn't remember any times) Resident 14 was sleeping. Unlicensed Staff R stated on her last rounds around 5 a.m., Resident 14 did complain of left arm pain. Unlicensed Staff R told Licensed Nurse P and Licensed Staff P did give Resident 14 Tylenol for her arm pain. During an interview on [DATE] at 9:30 a.m., Licensed Staff P stated she was the nurse for Resident 14 on the night shift 11 p.m., [DATE], to 7 a.m., [DATE]. Licensed Staff P stated the CNA, ( Unlicensed Staff R) did tell her Resident 14 was complaining of left arm pain so she gave her Tylenol. She stated that was at 5 a.m., [DATE]. Licensed Staff P stated she did not receive any report from the CNA of Resident 14 having any other pain during the night, only the one time at 5 a.m. Review of the Medication Administration Record [REDACTED]. 2 tabs at 5 a.m., for ,[DATE] left arm pain. Review of Resident 14's chart, nurses notes revealed no documentation of assessments or interventions for Resident 14, from [DATE], 7:30 p.m., until [DATE] at 8 a.m. During an interview on [DATE] at 1:45 p.m., Unlicensed Staff Q stated she was assigned to Resident 14 the day shift on [DATE]. Unlicensed Staff Q stated the only report she received from the night CNA (Unlicensed Staff R) was that Resident 14 was asking for her husband and did try to get out of bed one time. Unlicensed Staff Q stated at 6:15 a.m. on [DATE] she answered Resident 14's call light. Resident 14 was asking to speak with her husband. Unlicensed Staff Q told Resident 14 that her husband would be there later. Unlicensed Staff Q stated she "cleaned up" Resident 14 and then she and another CNA transferred Resident 14 to the wheelchair for breakfast. Unlicensed Staff Q stated she left the room to deliver breakfast trays and upon returning to the room with Resident 14's tray she noted Resident 14 was pale and not responsive. Unlicensed Staff Q stated she went to get the nurse and a code was called. During an interview on [DATE] at 2:30 p.m., Licensed Staff O stated she worked the day shift on [DATE] which began at 7 a.m. She stated when she received shift report from the night nurse there was no mention that Resident 14 had any problems during the night. Licensed Staff O stated at 8 a.m., Unlicensed Staff Q reported to her that Resident 14 was pale and unresponsive. Licensed Staff O stated she went right away to check Resident 14 and found Resident 14 sitting in a wheelchair, pale, without a pulse, and non-responsive. She stated she then called a code blue, started CPR, and called 911. Licensed Staff O stated CPR was initiated ,[DATE] minutes after Unlicensed Staff Q found Resident 14 unresponsive. Licensed Staff O stated the paramedics arrived shortly after and transferred Resident 14 to the hospital. During an interview on [DATE] at 11:30 a.m., Administrative Staff B was asked for the facility's policy and procedure for the resuscitation of an unresponsive resident, including roles and responsibilities of licensed and unlicensed staff. She stated the facility did not have such a policy, but followed the American Heart Association's 2010 Guidelines for CPR, (early recognition of [MEDICAL CONDITION], immediate CPR can double or triple a victim's chance of survival; there are two steps to "Staying Alive", call 911 and push hard and fast with hands on center of chest, i.e.: chest compressions, a critical component, creates blood flow to the heart.) During an interview on [DATE] at 9:10 a.m. Administrative Staff B stated CPR inservices ( training) were conducted on [DATE] for licensed nurses on the day and evening shifts following the death of Resident 14. When asked why the licensed nurses on the night shift were not inserviced, Administrative Staff B stated, "There was no need," since it was the day shift that was involved in the incident on [DATE]. During an interview on [DATE] at 11:32 a.m., the Medical Director stated it was "unacceptable" that facility staff did not know the proper technique or procedure for initiating CPR and that he wanted the staff to follow the American Heart Association's Guidelines for CPR, which was early recognition of a [MEDICAL CONDITION], immediate and proper technique with initiation of chest compressions. When asked if a 10 to 15 minute delay in the initiation of CPR was acceptable, the Medical Director stated it was "not acceptable."

Based on interviews and record review, the facility failed to ensure the environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 18 sampled residents (Resident 15) who was identified by the facility to be at high risk for falls, was known to remove her alarm, required staff assistance and a walker when getting out of bed. Resident 15 had entered the unlocked kitchen area, experienced a fall, sustained a fracture of her spine, a deep cut to the head, abrasions and bruising to both lower legs and experienced severe pain. Resident 15 was found alone in the kitchen area and had sustained injuries that required transfer to an acute hospital for medical evaluation and treatment including stitches to her head. This practice had the potential for entrapment, other serious injuries, and death to Resident 15 and other residents who had access to the unlocked kitchen area that was unsupervised and where dangerous equipment and appliances were readily accessible. Findings: Review of Resident 15's clinical record revealed that she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During review of resident's "Fall risk evaluation" dated 2/9/13, 4/13/13 and 10/9/13, resident had a score of higher than 10 which per facility document a total score of 10 or above represents high risk. Review of resident care plan dated 2/10/13& 10/12/13, indicated "At risk for fall- Frequent falls, altered gait/unsteady" intervention/plans indicated "Provide bathroom time." Resident 15's clinical record did not indicate a bathroom schedule for her. During observation and concurrent interview on 1/7/14, at 8 a.m., Resident 15 was observed sitting up in bed, awake with a nasal cannula applied (a nasal cannula is a device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help). Resident stated, through the translator ADON (Assistant Director of Nursing), that she was walking in the hallway with her walker, she felt dizzy and fell on the day when she was injured. She stated that she experienced "a lot of pain" in her back and was sent to the hospital. She stated that she now did not get out of bed or go to activities because it was too painful to do so. Staff would get her up to shower, which was "very painful" when staff would have to move her to get her out of bed. During an interview on 1/7/14, at 9:05 a.m., MDS (an assessment tool) coordinator stated that Resident 15's last MDS (a discharge MDS) was completed on 12/27/13 when she was transferred to the acute care hospital for evaluation and treatment related to a fall during which she experienced a fracture of her spine and a laceration (a deep cut or tear in skin) to the right side of her head requiring stitches. Resident 15 was re-admitted to the facility on [DATE]. During an interview on 1/7/14, at 10:15 a.m., Administrative Staff A stated that, per staff report, Resident 15 was looking for the bathroom and instead went to the kitchen, a few doors down from her room, which was where she fell and sustained a head laceration and a fracture. A CNA who went to the kitchen to get ice found Resident 15 on the floor by herself near the steps leading to the dietary office. Observation of the kitchen area, on 1/7/14 at 10:40 a.m., where Resident 15 had fallen on 12/27/13 revealed there was a step that was approximately four inches high, leading to the dietary office where Resident 15 was found on the floor the night of the incident. Equipment and appliances in the kitchen area where confused and wandering residents could injure themselves or get entrapped included: Gas stove burners, sharp knifes, and other sharp utensils. During an interview, on 1/7/14 at 10:20 a.m., Dietary Staff I stated she had been employed at the facility since August 2013 and usually worked the evening shift from 1 p.m. to 9:30 p.m. She stated she had not been told to keep the door to the kitchen locked until recently after a resident wandered into the kitchen during the night and fell . During a subsequent interview, on 1/7/14 at 10:35 a.m., Registered Dietician E stated she was not aware of the facility policy in regards to keeping the door to the kitchen locked at night. During a telephone interview on 1/10/14 at 10:10 a.m., Unlicensed Staff Y stated that the night of the incident (12/27/13), Unlicensed Staff X had called her to let her know that Resident 15 had fallen in the kitchen. Unlicensed Staff Y stated she knew that Resident 15 was not steady on her feet without her walker, had a tab alarm (a tab alarm features a pull-string that attaches magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair or bed the pull-string magnet is pulled away from the alarm which causes the alarm to sound, alerting the caregiver). Unlicensed Staff Y stated that Resident 15 would frequently disconnect the alarm and get out of bed without assistance when she could not wait for her call light to be answered. Unlicensed Staff Y said that Licensed Staff P met her and Unlicensed Staff X as they we were leaving the kitchen and walking Resident 15 back to her room. The facility then called 911 and Resident 15 was sent to the hospital around 4:30 a.m. During a telephone interview on 1/10/14 at 1:05 p.m., Licensed Staff P caring for the resident the night of the incident, stated one of the CNAs called her to the kitchen and she saw that two CNAs were walking Resident 15 back to her room. Resident 15 told her she wanted to use the toilet, became dizzy and fell . Licensed Staff P stated she offered Resident 15 a bed pan, applied oxygen, and called 911. Licensed Staff P also stated Resident 15 had disconnected her tab alarm before getting out of bed by herself "which she has done many times in the past." She said that to be safe, Resident 15 required a walker with one person assisting her at all times. She stated Resident 15 was not using her walker and was by herself when she fell and injured herself. Licensed Staff P further stated she assessed Resident 15 and determined that she had sustained a laceration to the right side of her head and was unable to explain how she got injured. Review of facility policy titled "Fall Prevention Program" (undated), indicated "Following a resident's fall, the licensed nurse will assess the resident for injuries and necessary treatment. If no apparent injuries assist off floor." Review of the acute care hospital admission records, history and physical dated 12/27/13, indicated the admitting [DIAGNOSES REDACTED]." Hospital records also indicated that surgical intervention for the compression fracture was not an option due to patient requiring medical management due to her overall condition and medical problems including cardiomegaly (enlarged heart) with congestive heart failure (occurs when the heart is unable to provide sufficient pump action to maintain blood flow to meet the needs of the body) and coronary artery disease (when the arteries that supply blood to heart muscle become hardened and narrowed). Resident 15 was discharged back to the facility on [DATE].