Every finding on record at Fidelity Health Care

Based on interview and record review, the facility failed to ensure that Resident 1 received treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 1) by:Failure to follow the physician's order regarding medication parameters for an antiarrhythmic (used to prevent, treat, or stop abnormal and irregular heart rhythms), alpha-beta blocker (used for combined effect on vessels and heart rate), and loop diuretic (increase urine output) when Resident 1's blood pressure reading was too low.Failure to follow the facility's policies and procedures (P&P) for change of condition and care plan revision to timely monitor and document assessments and interventions for Resident 1.These deficient practices had the potential to negatively affect the delivery of care and services for Resident 1.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), essential (primary) hypertension (abnormally high blood pressure), and unspecified atrial flutter (a heart rhythm problem where the upper chambers of the heartbeat too fast).During a review of Resident 1's History and Physical (H&P) dated 6/26/26, the H&P indicated Resident 1 has the capacity to understand and make decisions.During a review of Resident's 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 7/2/26, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 required supervisions with eating, and substantial/maximal assistance with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 1's Weights and Vitals Summary for 6/1/26 - 7/31/26, the summary indicated the blood pressure readings were as follows:6/26/26 at 9:21 a.m., 108/86 mmHg (Sitting, right arm)6/27/26 at 9:58 a.m., 106/60 mmHg (Sitting, right arm)6/29/26 at 10:28 a.m., 108/64 mmHg (Sitting, right arm)7/6/26 at 9:18 a.m., 98/70 mmHg (Sitting, right arm)7/11/26 at 10:38 a.m., 108/60 mmHg (Sitting, right arm)7/14/26 at 10:27 a.m., 104/70 mmHg (Sitting, right arm)7/15/26 at 9:55 a.m., 102/60 mmHg (Sitting, right arm)During a review of Resident 1's Medication Administration (MAR) for the month of June 2026, the MAR indicated Resident 1 was prescribed Amiodarone (antiarrhythmic), Carvedilol (alpha-beta blocker), and Furosemide (loop diuretic); medications to treat irregular heart rhythms and hypertension, and for staff to monitor side effects related to hypotension (low blood pressure). The MAR indicated Amiodarone was not given within parameters/MD orders on 6/29/26. The MAR indicated Carvedilol was not given within parameters/MD orders on 6/26/26, 6/27/26 & 6/29/26. The MAR also indicated Furosemide was not given within parameters/MD orders on 6/26/26, 6/27/26 & 6/29/26.During a review of Resident 1's Medication Review Report for active physician orders for the month of June 2026, the report indicated the following:Amiodarone HCI Tablet 200 mg, give 1 tablet by mouth one time a day for A-FIB, hold if SBP <110 or AP <60, Start date 6/26/26.Carvedilol Tablet 6.25 mg, give 1 tablet by mouth two times a day for CHF, hold if SBP <110 or PR <60, take with food, Start date 6/26/26.Furosemide Tablet 40 mg, give 1 tablet by mouth one time a day for HTN, hold if SBP <110 or PR <60, Start date 6/26/26.During a review of Resident 1's Medication Administration (MAR) for the month of July 2026, the MAR indicated Amiodarone was not given within parameters/MD orders on 7/6/26, 7/11/26, 7/14/26 & 7/15/26. The MAR also indicated Furosemide was not given within parameters/MD orders on 7/6/26, 7/11/26, 7/14/26 & 7/15/26.During an interview with the Director of Nursing (DON) on 7/21/26 at 3:30 p.m., the DON stated for Amiodarone and Carvedilol, if parameters are not followed then the risk to Resident 1 was bradycardia or hypotension (which could result in a fall). The DON also stated that if parameters are not followed for Furosemide then the risk to Resident 1 is low blood pressure (which could result in a fall) or dehydration.During a review of the facility's Policy and Procedure (P&P) titled, Specific Medication Administration Procedures, updated, the P&P indicated, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personal authorized to administer medications do so only after they have familiarized themselves with the medication.Obtain and record any vital signs as necessary, prior to medication administration.

Based on interview and record review, the facility failed to provide a consistent and accurate account for Ozempic (medication to improve type 2 diabetes glycemic [blood sugar] control and reduce cardiovascular events such as heart attack or stroke) through staff documentation for one of two residents (Resident 1).This deficient practice resulted in the facility not providing Resident 1's scheduled dose on 7/4/26 and placed Resident 1 at risk for blood sugar fluctuations and less control over food cravings.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), essential (primary) hypertension (abnormally high blood pressure), and unspecified atrial flutter (a heart rhythm problem where the upper chambers of the heartbeat too fast).During a review of Resident 1's History and Physical (H&P) dated 6/26/26, the H&P indicated Resident 1 has the capacity to understand and make decisions.During a review of Resident's 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 7/2/26, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 required supervisions with eating, and substantial/maximal assistance with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear and personal hygiene.During a review of Resident 1's Medication Review Report for active physician orders for the month of June 2026, the report indicated the following:Ozempic (0.25 or 0.5 milligram (mg)/dose), subcutaneous solution pen-injector 2mg/1.5ml (Semaglutide), inject 2 mg subcutaneously one time a day every Saturday for cardiovascular event reduction, diabetes mellitus type 2, and morbid obesity.During a review of Resident 1's Medication Administration (MAR) for the month of July 2026, the MAR indicated Resident 1's Ozempic dose for 7/4/26 was coded 9 (Other/See Progress Notes).During a review of Resident 1's handwritten Nursing Progress Notes, dated 7/4/26 at 9:00 a.m., the note indicated Ozempic is not administered because it was not available. No harm to the resident. Resident 1's Physician was aware and the re-ordered was sent to the pharmacy.During a review of Resident 1's Change of Conditions for the month of July 2026, there was no documentation in Resident 1's medical record indicating Resident 1's Ozempic medication was missing, and Resident 1 did not receive the scheduled dose on 7/4/26.During an interview with Registered Nurse 1 (RN 1) on 7/21/26 at 11:40 a.m., RN 1 stated the facility received Resident 1's Ozempic medication on 6/30/26.During an interview with RN 1 on 7/21/26 at 12:15 p.m., RN 1 stated she had to re-order Resident 1's Ozempic medication because it was missing on 7/4/26.During an interview with RN 1 on 7/21/26 at 2:50 p.m., RN 1 confirmed there was no change of condition for Resident 1 indicating the Ozempic medication dose was not given on 7/4/26. RN 1 stated, The nurse has 72 hours to indicate a change of condition or update the plan of care. RN 1 stated she did not know why there was no updated care plan or change of condition documentation.During an interview with the DON on 7/21/26 at 3:30 p.m., the DON stated there was no change of condition completed for Resident 1 because the change of condition for Resident 1 on 7/4/26 did not fall under the facility's policy items listed on page 1 of the Change of Condition policy. The DON further stated she updated Resident 1's care plan on 7/21/26 with the following: Ozempic medication was missed on 7/4/26. No harm on the part of the resident.During an interview with the Pharmacy Technician 1 (Pharm 1), on 7/21/2026, at 4:45 pm, Pharm 1 stated Resident 1's Ozempic medication was sent on 6/26/26 to the facility. On 6/30/26, the facility contacted the pharmacy and informed the pharmacy the facility could not find the medication. Pharm 1 stated the pharmacy re-ordered the Ozempic medication (after receiving approval from the facility) and the medication was sent to the facility on 7/7/26.During a review of the facility's Policy and Procedure (P&P) titled, Medication Count Policy, revised October 2017, the P&P indicated, Purpose: To ensure the accurate accountability, security, and documentation of medications, particularly controlled substances, and to promote resident safety and regulatory compliance. The P&P further indicated, Any discrepancy in the medication count must be reported immediately to the charge nurse or supervisor. Medications will be stored in locked medication carts or cabinets with access limited to authorized personnel. Count records must be maintained accurately, legibly and completely.During a review of the facility's Policy and Procedure (P&P) titled, Change of Condition, effective August 2005, the P&P indicated, Objective: To ensure proper assessment and follow through for any resident with a condition change. The P&P further indicated, Procedure: When a resident's condition change for any reason, this facility will insure proper care and follow-up by using a monitoring system using a Nursing 24 Hour Report Form. Each report will have space specifically for condition changes. This will be monitored by the DON.All condition changes will be handled promptly.During a review of the facility's Policy and Procedure (P&P) titled, Care Plan Revision, effective August 2005, the P&P indicated, Policy: Develop and revised by the IDT, with the participation of the resident and/or resident's representative and includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psycho-social needs that are identified in the comprehensive assessment. Procedure: Care Plan is updated as the resident conditions change and as revision(s) is needed.

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary resident room and bathroom for three of four sampled residents (Resident 2, Resident 3, and Resident 4) who shared a room and a bathroom.This deficient practice had the potential for Resident 2, Resident 3 and Resident 4 to be exposed to dirt, mold, and drywall dust, which can cause health and breathing problems.a. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included chronic pulmonary embolism (occurs when blood clots in the lungs do not dissolve, turn into scar tissue, and restrict blood flow to the lungs), and dementia (a progressive state of decline in mental abilities).During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 11/24/2025, the H&P indicated Resident 2 did not have the capacity to understand and make medical decisions.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/25/2026, the MDS indicated Resident 2 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort to complete the activity) with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).b. During a review of Resident 3's (AR), the AR indicated Resident 3 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included gastro-esophageal reflux disease without esophagitis (a chronic digestive condition where stomach acid repeatedly flows back into the esophagus) and dementia. During a review of Resident 3's H&P, dated 1/31/2026, the H&P indicated Resident 3 was able to make needs known, but could not make medical decisions.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severely impaired cognition for daily decision making. The MDS indicated Resident 3 required substantial/maximal assistance with most ADLs.c. During a review of Resident 4's (AR), the AR indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both hips and the right knee, type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), weakness, and other lack of coordination (balance or motor control issues).During a review of Resident 4's H&P, dated 7/18/2025, the H&P indicated Resident 4 was self-responsible and had the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 5/18/2026, the MDS indicated Resident 4 had intact cognition (mental process of thinking and understanding which affects the ability to make daily decisions). The MDS indicated Resident 4 required partial/moderate assistance (helper lifts, holds, supports trunk or limbs, but provides less than half the effort to complete the activity) with oral hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene, and transfers. The MDS indicated Resident 4 required substantial/maximal assistance (helper provides more than half the effort to complete the activity) with showering/bathing self.During an observation on 6/29/26 at 3:12 pm inside the residents' room and bathroom, the following were observed:1. There were dark colored splattered marks on the ceiling at the head of Resident 3's bed;2. There were 2 large, circular, unpainted drywall spots on the adjacent (next to or adjoining) wall to Resident 3's bed;3. Behind the headboard of Resident 3's bed was a wood board with scraped, dented and unpainted areas;4. In the corner of the room, before the bathroom door, on the ceiling were multiple dark splattered marks covering a span of 2 feet by 3 feet and the adjacent wall near the ceiling also had the same dark color splattered markings.5. Bathroom: Unplastered wall areas, unknown dark substance splattered on inside bathroom door, 1-inch by 4-inch rectangular hole on bathroom door, and door frame were chipped, dented, and dirty.6. Bathroom: On the floor at the bottom of the toilet, the caulking had scattered areas of dark black substance that looked like mold.During a concurrent observation and interview with Housekeeper 1 (HK 1) on 6/29/2026 at 3:20 p.m. inside Resident 2's, Resident 3's, and Resident 4's bathroom, HK 1 stated the bathroom needed repairs and did not have a good appearance for the residents that used the bathroom.During a concurrent observation and interview with Certified Nursing Assistant 4 (CNA 4) on 6/29/26 at 3:30 p.m. inside Resident 2's, Resident 3's, and Resident 4's bathroom, CNA 4 stated the bathroom was dirty, and housekeeping and maintenance were responsible for maintaining the bathroom in good condition. CNA 4 stated housekeeping or maintenance were notified for cleaning or repairs. CNA 4 stated there is no maintenance logbook; CNA 4 informed CNA 4's supervisor about the condition of the bathroom as needed. CNA 4 stated CNA 4 had not reported anything about the bathroom.During a concurrent observation and interview with Registered Nurse Supervisor 2 (RN 2) on 6/29/26 at 3:50 p.m. inside Resident 2's, Resident 3's, and Resident 4's bathroom, RN 2 stated the bathroom was not clean and posed a health risk to the residents who used it.During a concurrent observation and interview with Resident 4 on 6/29/26 at 4:30 p.m., Resident 4 stated, I've been at the facility for seven years, the room has always been the same, never painted. The facility started painting in the front of the building and painted the hallways near my room, but they have not painted in my room at all. They make everything look nice outside except the residents' rooms. The bathroom is disgusting and I don't like to use it if I don't have to. Resident 4 stated, The spots on the ceiling in the corner of the (my) room were from when a resident threw coffee from a cup onto the ceiling some time ago, but it hasn't been cleaned.During a review of the facility's current Policy & Procedure (P&P) titled, Maintenance Policy, reviewed April 2016, the P&P indicated, Purpose: To ensure the nursing home environment is safe, clean, functional, and well-maintained in accordance with health, safety, and regulatory standards. This policy outlines procedures for preventative, routine, and emergency maintenance. Scope: This policy applies to all physical structures, systems, equipment, and grounds of the facility, and it is relevant to all staff, contractors, and maintenance personnel. The P&P further indicated, Objectives: Maintain a safe and comfortable environment for residents, staff, and visitors. Prevent breakdowns and hazardous conditions through regular inspections and preventative maintenance. Ensure timely response to repair and maintenance requests. Comply with local, state, and federal building codes and healthcare regulations.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 4's) environment was safe, clean, comfortable and homelike when there was clutter around Resident 4's bed which blocked the way to the resident's bed.This deficient practice placed Resident 4 at risk for falls and injuries from excessive clutter surrounding Resident 4's bed and had the potential for Resident 4 receiving delayed emergency care while in bed.During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both hips and the right knee, type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), weakness, and other lack of coordination (balance or motor control issues).During a review of Resident 4's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 7/18/2025, the H&P indicated, Resident 4 was self-responsible and had the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 5/18/2026, the MDS indicated Resident 4 had intact cognition (mental process of thinking and understanding which affects the ability to make daily decisions). The MDS indicated Resident 4 required partial/moderate assistance (helper lifts, holds, supports trunk or limbs, but provides less than half the effort to complete the activity) with oral hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene, and transfers. The MDS indicated Resident 4 required substantial/maximal assistance (helper provides more than half the effort to complete the activity) with showering/bathing self.During a review of Resident 4's Care Plan (CP) titled, Non-compliance, dated 7/18/2025, the CP indicated Resident 4 was non-complaint with safety measures as evidenced by Resident 4 having many personal items around Resident 4's bed. The CP interventions included involving the resident and significant others in care to gain resident's cooperation, discussing with resident and significant others the risk and consequences of non-compliance, and offering any alternative of care and or treatment that is not in conflict with the resident's plan of care.During a review of Resident 4's Interdisciplinary Team Conference Record (ITCR), dated 5/8/2026, the ITCR indicated the meeting was conducted due to Resident 4's refusal for staff (in general) to touch and clean up Resident 4's belongings. The ITCR indicated, Social Services Director (SSD) and the housekeeping supervisor went to Resident 4's room and asked Resident 4 if housekeeping could clean Resident 4's room and also remove items that the resident no longer needed but Resident 4 said, No, don't touch my belongings even after the SSD explained the risks and benefits of cleaning Resident 4's room. The SSD explained to Resident 4 in case of an emergency paramedics would not be able to move freely in Resident 4's room due to the clutter around Resident 4's bed but Resident 4 continued to refuse staff (in general) to clean up items around the bed. Resident 4's Family Member (FM) 1 was aware that Resident 4 kept a lot of personal items around the bed.During an observation on 6/29/2026 at 3:12 p.m. in Resident 4's room, there was clutter surrounding Resident 4's bed. The multiple items around the bed and adjacent to the bed included:1. On the right side of the bed on the floor was a tissue box, broken light lamp, small, beige waste can, paper/mail under the bed;2. Against the right side of the wall, pathway to bed partially blocked;3. [NAME] 4-plug extension cord underneath right side of bed with multiple cords plugged into it and papers/mail nearby;4. On the left side of the bed: bedside table with multiple food items stacked on top of the table; perishable items: milk, food sauces, Miracle Whip plastic jar. sliced lemon in small plastic container.During a concurrent observation and interview with Certified Nursing Assistant 4 (CNA 4) on 6/29/26 at 3:30 p.m. inside Resident 4's room, CNA 4 stated Resident 4's side of the room has always been cluttered because Resident 4 did not want anyone to touch Resident 4's personal items. CNA 4 stated it was very difficult to get past all the stuff on the floor to get to the right side of Resident 4's bed. CNA 4 stated all the items on the floor were a tripping hazard and unsafe for staff (in general) and Resident 4. CNA 4 stated if there were an emergency and staff and or paramedics had to come to provide help to Resident 4, then there would be a delay in giving care because all the stuff around Resident 4's bed would have to be moved out of the way first.During a concurrent observation and interview with Resident 4 on 6/29/26 at 4:30 p.m., Resident 4 stated Resident 4 asked the facility staff to help Resident 4 clean up Resident 4's room because Resident 4 had trouble standing up for long periods of time. Resident 4 stated, Staff said they would (help), but they never came to help me.During a review of the facility's current Policy & Procedure (P&P) titled, Homelike Environment Policy, revised April 2018, the P&P indicated, Policy: The purpose of this policy is to establish guidelines for maintaining a homelike environment within the nursing home to promote residents' comfort, dignity, and overall well-being. The P&P further indicated, Policy Statement: The nursing home is committed to fostering a homelike atmosphere by ensuring: A welcoming, clean, and aesthetically pleasing environment. Physical Environment Enhancements: The facility will maintain clean, well-lit, and temperature-controlled common areas.During a review of the facility's current Policy & Procedure (P&P) titled, Maintenance Policy, reviewed April 2016, the P&P indicated, Purpose: To ensure the nursing home environment is safe, clean, functional, and well-maintained in accordance with health, safety, and regulatory standards. This policy outlines procedures for preventative, routine, and emergency maintenance. Scope: This policy applies to all physical structures, systems, equipment, and grounds of the facility, and it is relevant to all staff, contractors, and maintenance personnel. The P&P further indicated, Objectives: Maintain a safe and comfortable environment for residents, staff, and visitors. Prevent breakdowns and hazardous conditions through regular inspections and preventative maintenance. Ensure timely response to repair and maintenance requests. Comply with local, state, and federal building codes and healthcare regulations.

Based on interview and record review, the facility failed to ensure residents' weights were documented accurately on the residents' medical record (chart) and electronic medical record (EMR) for two of two sampled residents (Residents 2 and 4). These failures resulted in inaccurate information for Residents 2 and 4 and had the potential to negatively affect Residents 2 and 4's care and treatment received from the facility. Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 9/26/2023 and readmitted on [DATE] with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), gastroesophageal reflux disease (GERD, a chronic digestive disorder occurring when stomach acid repeatedly flows back into the esophagus), and diverticulosis (presence of small, bulging pouches in the lining of the large intestine). During a review of Resident 4's untitled Care Plan (CP) dated 12/26/2025, the CP indicated Resident 4 was on pureed (foods blended to a smooth, pudding-like texture that requires no chewing) and therapeutic diet (specialized meal plan to manage, treat, or prevent a specific medical condition). The CP interventions included monitoring weight and reporting weight loss or gain and significant weight changes to the medical doctor (MD). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 4/1/2026, the MDS indicated Resident 4 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 4 was independent with eating and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with oral hygiene and upper body dressing. The MDS indicated Resident 4 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting and lower body dressing. The MDS indicated Resident 4 required partial/moderate assistance (helper did less than half the effort) with shower and personal hygiene. During a review of Resident 4's Order Summary Report (OSR) dated 5/7/2026, the OSR indicated Resident 4 had an order for staff to monitor the resident's weight weekly for four weeks. During a review of Resident 4's Weekly Weights Monitoring (WWM) in Resident 4's chart, the WWM indicated Resident 4 weighed 99 pounds (lbs.) on 5/8/2026, 97 lbs. on 5/15/2026, 97 lbs. on 5/23/2026 and 97 lbs. on 5/29/2026. During a review of Resident 4's Weights and Vital Summary (WVS) in Resident 4's EMR from 2/19/2026 to 5/14/2026, the WVS indicated Resident 4 weighed 113 lbs. during each measurement. During a concurrent interview and record review on 6/3/2026 at 9:13 am with Licensed Vocational Nurse 3 (LVN 3), Resident 4's WWM in the chart dated 12/26/2025, 1/2/2026, 1/9/2026, 1/16/2026, 5/8/2026, 5/15/2026, 5/23/2026, 5/29/2026 and Resident 4's WVS in the EMR from 2/19/2026 to 5/14/2026 were reviewed and compared. LVN 3 stated the correct weights of Resident 4 were the weights documented in the WWM in the chart. LVN 3 stated the weights were incorrectly documented in the EMR. LVN 3 stated Resident 4's weights should have been documented accurately to properly care for and manage Resident 4's changes in weights. During an interview on 6/5/2026 at 9:15 am with the Director of Nursing (DON), the DON stated nursing staff were incorrectly copying and entering historical weight into the residents' EMR. The DON stated documenting incorrect weights could cause confusion and problems in managing the residents' weights. During a review of the facility's undated Policy and Procedure (P&P) titled, Documentation, the P&P indicated, It is the policy of the facility to document in the medical record any changes in the resident's medical or mental condition and all services provided. All observations, medications administered services performed, etc. must be documented in the resident's clinical record. b. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle wasting and atrophy (shrinkage) and dementia (a progressive state of decline in mental abilities) with mood disturbance. During a review of 2's OSR dated 4/8/2026, the OSR indicated an active order for Resident 2 to have weekly weights taken for four weeks and then monthly. During a review of Resident 2's History and Physical (H&P), dated 4/9/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions and was at risk for malnutrition, weight variance, and dehydration. During a review of Resident 2's untitled CP dated 4/9/2026, the CP indicated Resident 2 had potential for excessive weight loss with a plan to continue to monitor weight weekly for four weeks, then monthly and report continued weight loss to the physician and dietitian promptly. During a review of Resident 2's Dietary Profile (DP) dated 4/13/2026, the DP indicated Resident 2 was readmitted with a weight of 136 pounds (lbs.), below the ideal body weight (IBW - optimal or healthy weight for a person based primarily on their height and gender) range of 139 lbs. to 169 lbs. and to continue with the plan of care. During a review of Resident 2's Weekly Weights Monitoring (WWM) in the paper medical record, the WWM indicated Resident 2 weighed: 135 lbs. on 4/17/2026, 136 lbs. on 4/24/2026, 136 lbs. on 5/1/2026, and 136 lbs. on 5/8/2026. During a review of Resident 2's Weights and Vitals Summary from 1/8/2026 to 5/25/2026 in the electronic medical record, Resident 2 weighed 132 lbs. during each measurement. During an interview on 6/4/2026 at 1:47 pm with Licensed Vocations Nurse 2 (LVN 2), LVN 2 stated LVN 2 checked resident weights in both the paper and electronic medical records. During a concurrent interview and record review on 6/5/2026 at 9:15 am with the DON, the WWM dated 4/17/2026 to 5/8/2026, and WVS dated 1/8/2026 to 5/25/2026, the DON stated staff were incorrectly copying and entering a previous weight into the electronic medical record. The DON stated the incorrect weights could cause confusion and problems with monitoring the resident's weights correctly. During a review of the facility's undated P&P titled, Documentation, the P&P indicated it was the policy of the facility to document any changes in the resident's medical or mental condition and all services provided in the medical record. The P&P indicated all observations, medications administered, services performed, etc. must be documented in the resident's medical record. During a review of the facility's P&P titled, Nutrition and Hydration, dated 10/2017, the P&P indicated nursing staff shall monitor residents for weight loss or gain and staff shall document weight monitoring.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach and appropriate to the resident's physical ability for two of two sampled residents (Residents 13 and 56). These failures had the potential for Residents 13 and 56 not to receive necessary care or receive delayed services to meet their needs. Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated the facility initially admitted Resident 13 on 2/7/2023 and readmitted on [DATE] with diagnoses including osteoporosis (weak and brittle bones), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool), dated 3/19/2026, the MDS indicated Resident 13 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 13 required partial/moderate assistance (helper did less than half the effort) with eating and oral hygiene. The MDS indicated Resident 13 required substantial/maximal assistance (helper did more than half the effort) with toileting, shower, upper/lower body dressing and personal hygiene. During a concurrent observation inside Resident 13's room and interview on 6/3/2026 at 10:54 am with Certified Nurse Assistant 2 (CNA 2), Resident 13 was lying in bed with push button call light at the back of Resident 13's headboard. CNA 2 stated Resident 13 was confused. CNA 2 stated Resident 13 could not reach the push button call light and did not know and understand how to use the push button call light. CNA 2 stated call lights should be placed next to the resident to call staff for assistance. During an interview on 6/4/2026 at 11:47 am with the Director of Nursing (DON), the DON stated Resident 13 was confused and could not follow and understand simple commands like pressing the call light. The DON stated a sensor pad call light (flat call light activated by gross movement) was more appropriate for Resident 13's physical and functional ability to call and alert the staff when the resident needed help. During a review of the facility's Policy and Procedure (P&P) titled, Call Lights and Use of the Call Cord System, dated 8/2005, the P&P indicated, the purpose of the P&P was to assure that residents receive assistance promptly and to assure that the staff know how to place and use the call cord system. The P&P indicated assure that the call light is within the resident's reach when in their room or on the toilet. During a review of the facility's P&P titled, Meeting Residents Need According to Functional Ability and Capability, dated 7/2018, the P&P indicated, Adaptive equipment and assistive devices shall be utilized when appropriate to maximize independence. b. During a review of Resident 56's AR, the AR indicated the facility admitted Resident 56 on 12/13/2021 and readmitted on [DATE] with diagnoses including weakness, overactive bladder (the bladder muscles contracted involuntarily and caused a sudden, uncontrollable urge to urinate), and psychosis (a severe mental condition in which thought, and emotions were affected that contact was lost with reality). During a review of Resident 56's History and Physical (H&P) dated 12/6/2025, the H&P indicated Resident 56 did not have the capacity to understand and make decisions due to psychosis. During a review of Resident 56's ADL (Activities of Daily Living) Maintenance/ Pattern Care Plan (CP) dated 12/8/2025, the CP indicated Resident 56 required assistance with ADL due to muscular weakness. The CP indicated a goal to meet all of Resident 56's needs daily. The CP intervention indicated for nursing staff keep the call light within Resident 56's reach. During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had severely impaired cognition. The MDS indicated Resident 56 required setup assistance from staff with eating. The MDS indicated Resident 56 required supervision from staff with bed-to-chair transferring. The MDS indicated Resident 56 required moderate assistance (helper did less than half the effort) from staff with oral hygiene, toileting hygiene, personal hygiene, and toilet transferring. The MDS indicated Resident 56 needed maximum assistance (helper did more than half the effort) from staff with showering/ bathing. During a concurrent observation and interview on 6/2/2026 at 9:23 am with Resident 56 inside Resident 56's room, Resident 56 was awake and lying in bed. The call light was not within Resident 56's reach. Resident 56's call light was on Bed A (empty bed next to Resident 56). Resident 56 stated Resident 56 could not reach the call light. During an observation on 6/2/2026 at 11:25 am inside Resident 56's room, Resident 56 was sitting in the wheelchair at bedside with the call light not within Resident 56's reach. Resident 56's call light was on Bed A. During a concurrent picture review and interview on 6/3/2026 at 11:50 am with Certified Nurse Assistant 1 (CNA 1), the picture dated 6/2/2026 at 9:23 am was reviewed, CNA 1 stated the picture indicated the call light was not within Resident 56's reach. CNA 1 stated the call light should be placed on the bed by Resident 56. During a concurrent picture review and interview on 6/3/2026 at 11:50 am with CNA 1, the picture dated 6/2/2026 at 11:25 am was reviewed, CNA 1 stated the picture indicated the call light was not within Resident 56's reach. CNA 1 stated the call light should be placed with the resident on the wheelchair for safety. CNA 1 stated the CNA should ensure the call light was within reach for residents during rounds (nurses went room to room to check on the residents to ensure the residents were safe and cared for). CNA 1 stated the CNA (in general) should put the call light in the resident's hand or clip the call light on the bed when the resident was in bed. CNA 1 stated residents use the call light to call for help when assistance was needed. CNA 1 stated it was important to keep the call light within resident's reach. CNA 1 stated Resident 56 had behavior of throwing the call light on the floor. CNA 1 stated everyone in the facility should ensure the call light was within Resident 56's reach regardless of behavior. During an interview on 6/4/2026 at 1:23 pm with the Director of Nursing (DON), the DON stated Resident 56 was at risk of falling. The DON stated Resident 56 could not call for help when needed if the call light was not within reach. The DON stated the resident was at risk of injury, harm, and accident. During a review of Resident 56's Fall Risk Evaluation (FRE- method of assessing a patient's likelihood of falling) dated 6/5/2026, the FRE indicated Resident 56 was assessed as high risk for falls because Resident 56 was chairbound, had intermittent confusion and balance problem while standing and walking, and required the use of assistive devices. During a review of the facility's P&P titled, Call Lights and Use Of the Call Cord System, dated 8/2005, the P&P indicated the facility should ensure the call light was within the resident's reach when in their room or on the toilet.

Based on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Resident Assessment Instrument, and Minimum Data Set (MDS- a resident assessment tool) for three of three sampled residents (Residents 6, 56, and 83) by failing to ensure the MDS assessment was coded accurately for: a. Resident 6's fall on 4/10/2026.b. Resident 56's psychotic disorder and behavior.c. Resident 83's discharge home from the facility. These failures resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential for Residents 6, 56, and 83 not to receive interventions to address their specific care concerns. Findings: a. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 1/12/2026 and re-admitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control) without complications, weakness, and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 6's Incident Note (IN) dated 4/10/2026, the IN indicated Resident 6 stumbled backwards and fell while ambulating (walking) in the facility hallway. During a review of Resident 6's Change in Condition Evaluation (CIC), dated 4/10/2026, the CIC indicated Resident 6 had a fall and the physician was notified. During a review of Resident 6's History & Physical (H&P) dated 4/25/2026, the H&P indicated Resident 6 had a recent fall. During a review of Resident 6's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 6 did not have a fall any time in the last month and in the last two to six months prior to admission or reentry. During an observation on 6/4/2026 at 8:37 am, Res 6 was walking inside Resident 6's room. During an interview on 6/4/2026 at 2:06 pm with Registered Nurse 1 (RN 1), RN 1 stated Resident 6 was a fall risk with an unsteady gait and had last fallen in the facility on 4/10/2026. During a concurrent interview and record review on 6/4/2026 at 2:24 pm with Minimum Data Set Director (MDSD), Resident 6's MDS dated [DATE] was reviewed. The MDS indicated Resident 6 did not have a fall any time in the last month or last two to six months prior to admission or reentry to the facility. The MDSD stated the MDS was inaccurate because Resident 6 had a fall on 4/10/2026. The MDSD stated that it was important that the MDS was accurate because it reflected the resident's care and condition. During an interview on 6/5/2026 at 9:22 am with the Director of Nursing (DON), the DON stated Resident 6 had a recent fall. The DON stated the MDS needed to be accurately documented because it was the resident's data set that allowed the facility to determine that appropriate care was provided to the resident. During a review of the facility's P&P titled, Resident Assessment Instrument, dated 5/2017, the P&P indicated, the MDS Coordinator shall oversee the completion of all required assessments. The MDS assessments shall be accurate. During a review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1, dated 10/2025, the manual indicated the RAI process had multiple regulatory requirements. The manual indicated, federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) required that the assessment accurately reflected the resident's status. b. During a review of Resident 56's AR, the AR indicated the facility admitted Resident 56 on 12/13/2021 and readmitted on [DATE] with diagnoses including overactive bladder (the bladder muscles contract involuntarily and cause a sudden, uncontrollable urge to urinate) and psychosis (mental condition in which thought and emotions were affected that contact with reality is lost). During a review of Resident 56's H&P dated 12/6/2025, the H&P indicated Resident 56 did not have the capacity to understand and make decisions due to psychosis. During a review of Resident 56's Psychiatric Progress Note (PPN) dated 2/28/2026, the PPN indicated Resident 56 had a psychotic disorder (a condition where a person lost touch with reality). During a review of Resident 56's Social Service Quarterly Note (SSQN) dated 3/9/2026, the SSQN indicated Resident 56 had a period of screaming without reason, striking out, and hitting staff. During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 56 required setup assistance from staff with eating. The MDS indicated Resident 56 required supervision from staff with bed-to-chair transferring. The MDS indicated Resident 56 required moderate assistance (helper did less than half the effort) from staff with oral hygiene, toileting hygiene, personal hygiene, and toilet transferring. The MDS indicated Resident 56 needed maximum assistance (helper did more than half the effort) from staff with showering/ bathing. During a concurrent record review and interview on 6/3/2026 at 2:23 pm, with the MDS Coordinator (MDSC), Resident 56's MDS dated [DATE] was reviewed. The MDSC stated the MDS dated [DATE] did not indicate Resident 56 had a diagnosis of psychotic disorder and should have been documented. The MDSC stated the MDSC should review the resident's whole medical records including MAR, physician orders, physician progress notes, resident's diagnosis list, and resident's medication list when completing the MDS. During a concurrent record review and interview on 6/3/2026 at 2:23 pm, with the MDSC, Resident 56's Medication Administration Record (MAR) for 3/2026 was reviewed. The MAR indicated Resident 56 had behavior of striking out on 3/12/2026, 3/14/2026, and 3/15/2026. The MAR indicated Resident 56 had daily behavior yelling. The MAR indicated Resident 56 had behavior of hitting staff on 3/12/2026 and 3/14/2026. The MDSC stated Resident 56's MAR indicated Resident 56 had behaviors of striking out, yelling, and hitting staff before 3/17/2026. During a concurrent record review and interview on 6/3/2026 at 2:23 pm, with the MDSC, Resident 56's MDS dated [DATE] was reviewed. The MDSC stated the MDS indicated Resident 56 did not have physical behavior symptoms directed toward others or other behavior symptoms not directed toward others. The MDSC stated the MDSC should review Resident 56's medical record before 3/17/2026 because the MDS assessment's completion date was 3/17/2026. The MDSC stated the MDS assessment was not an accurate assessment. The MDSC stated the MDS should have coded physical behavior symptoms directed toward others occurred one to three days. The MDSC stated the MDS should have coded other behavior symptoms not directed toward others occurred daily. The MDSC stated the MDS assessment should reflect the resident's condition. The MDSC stated the facility interdisciplinary team (IDT, a team that worked together to plan a resident's care) members completed the MDS assessment. The MDSC stated the social service department was responsible for completing the behavior section in the MDS assessment. The MDSC stated the designated staff should review the resident's entire medical record to obtain necessary information to complete the MDS assessment. The MDSC stated it was important to submit an accurate MDS assessment to CMS so that CMS would have the correct resident assessment. The MDSC stated CMS did not receive the correct resident information and affected the residents' care. The MDSC stated that the MDSC's signature verified the MDS assessment's accuracy and completion. During an interview on 6/4/2026 at 1:23 pm with the Director of Nursing (DON), the DON stated the MDS assessment was a snapshot of the resident's overall condition, change of condition, and how to manage the resident's needs including mental, physical, and activities of daily living. The DON stated the DON signed the MDS assessment to acknowledge and verify assessment accuracy. During a review of the facility's P&P titled, Minimum Data Set (MDS) dated 5/2017, the P&P indicated that MDS coding should accurately reflect the resident's status during the assessment reference period. The P&P further indicated the MDSC was responsible for reviewing assessments for accuracy. c. During a review of Resident 83's AR, the AR indicated the facility admitted Resident 83 on 3/12/2026 with diagnoses including osteoporosis (weak and brittle bones), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 83's MDS dated [DATE], the MDS indicated Resident 83 was admitted from a short-term general hospital (acute hospital) and discharged back to the acute hospital. During a review of Resident 83's Physician Order (PO) dated 3/14/2026, the PO indicated Resident 83 was discharged home against medical advice (AMA, occurs when a resident chooses to depart before treatment team recommends discharge). During a review of Resident 83's Discharge Summary (DS) dated 3/14/2026, the DS indicated Resident 83 was discharged to home AMA as requested by Resident 83's daughter. During a concurrent interview and record review on 6/3/2026 at 2:44 pm with the MDSC, Resident 83's MDS dated [DATE] was reviewed. The MDSC stated the MDS was incorrectly coded with Resident 83's discharge destination to the acute hospital. The MDSC stated Resident 83 was discharged home on 3/14/2026. The MDS C stated the MDS assessment should be coded accurately to reflect Resident 83's current assessment and for accurate reporting to CMS. During an interview on 6/4/2026 at 11:47 am with the DON, the DON stated the MDS assessment should be coded correctly to reflect the resident's overall current health condition and to report accurate information to CMS. During a review of the facility's P&P titled, Minimum Data Set (MDS) Accuracy, dated 5/2017, the P&P indicated, The Nursing Home shall maintain an MDS process that ensures resident assessments accurately reflect each resident's condition, strengths, needs, services provided, and functional status. MDS assessments shall be completed using current clinical documentation and interdisciplinary input and shall be submitted within required timeframes.

Based on interview and record review, the facility failed to meet professional standards of care by not rotating the insulin (a hormone that helps a resident's body use sugar for energy) administration site for three of three sampled residents (Residents 3, 8, and 53). These failures had the potential to compromise Residents 3, 8, and 53's health and safety.Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 1/9/2026 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (type 2 DM, a disorder characterized by difficulty in blood sugar control) and legal blindness. During a review of Resident 3's History and Physical (H&P) dated 3/26/2026, the H&P indicated Resident 3 could make needs known but could not make medical decisions. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 4/6/2026, the MDS indicated Resident 3 had intact cognition (ability to understand and process information). The MDS indicated Resident 3 required supervision from staff with eating. The MDS indicated Resident 3 required maximum assistance (helper did more than half the effort) from staff with oral hygiene, toileting hygiene, showering/ bathing, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 3 received insulin injection daily. During a review of Resident 3's Physician Order (PO) dated 4/19/2026, the PO indicated Resident 3 had an active order for licensed staff to administer HumuLIN R insulin (a short acting insulin that helps a resident control blood sugar) 100 unit/milliliter (ml- unit of measurement) and inject as per sliding scale (a way to give insulin based on a resident's blood sugar level) subcutaneously (the fatty tissue area located just beneath the skin) before meals and at bedtime. During an interview on 6/3/2026 at 11:13 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the licensed nurse should rotate the insulin injection site for each injection to minimize pain, bleeding, redness, and discoloration. During a concurrent record review and interview on 6/4/2026 at 1:23 pm with the Director of Nursing (DON), Resident 3's Medication Administration Record (MAR) dated 5/1/2026 to 5/31/2026 was reviewed. The MAR indicated the licensed nurses administered HumuLIN R insulin to Resident 3 at the same injection sites and did not rotate the injection site on the following dates: 5/1/2026, 5/2/2026, 5/4/2026, 5/5/2026, 5/6/2026, 5/7/2026, 5/17/2026, 5/18/2026, 5/19/2026, 5/20/2026, and 5/31/2026. The DON stated the MAR indicated the licensed nurse did not rotate the insulin injection site and should have. The DON stated the resident would have skin hardening and pain with the same insulin injection site. The DON stated the licensed nurse should check the last insulin injection site and rotate the site each time. During a concurrent record review and interview on 6/4/2026 at 1:23 pm with the DON, Resident 3's MAR dated 6/1/2026 to 6/30/2026 was reviewed. The MAR indicated the licensed nurse administered HumuLIN R insulin to Resident 3 at the same injection sites and did not rotate the injection site on the following dates: 6/1/2026, 6/2/2026, and 6/3/2026. The DON stated the MAR indicated the licensed nurse did not rotate the insulin injection site and should have. b. During a review of Resident 8's AR, the AR indicated the facility admitted Resident 8 on 5/5/2026 with diagnoses including type 2 DM and hypertension (HTN, high blood pressure). During a review of Resident 8's H&P dated 5/6/2026, the H&P indicated Resident 8 did not have the capacity to understand and make decisions. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 had severely impaired cognition. The MDS indicated Resident 8 required supervision from staff with eating. The MDS indicated Resident 8 required moderate assistance (helper did less than half the effort) from staff with oral hygiene. The MDS indicated Resident 8 required maximal assistant from staff with toileting hygiene, showering/bathing, and personal hygiene. The MDS indicated Resident 8 was dependent (helper did all the effort) on staff with toilet transferring, tub/ shower transferring, and car transferring. During a review of Resident 8's PO dated 5/22/2026, the PO indicated Resident 8 had an active order for licensed staff to administer HumuLIN R insulin 100 unit/ml and inject as per sliding scale before meals and at bedtime. During a concurrent record review and interview on 6/4/2026 at 1:23 pm with the DON, Resident 8's MAR dated 5/1/2026 to 5/31/2026 was reviewed. The MAR indicated the licensed nurse administered HumuLIN R insulin to Resident 8 at the same injection sites and did not rotate the injection site on the following dates: 5/24/2026, 5/25/2026, 5/26/2026, 5/27/2026, 5/28/2026, 5/29/2026, 5/30/2026, and 5/31/2026. The DON stated the MAR indicated the licensed nurse did not rotate the insulin injection site and should have. During a concurrent record review and interview on 6/4/2026 at 1:23 pm with the DON, Resident 8's MAR dated 6/1/2026 to 6/30/2026 was reviewed. The MAR indicated the licensed nurse administered HumuLIN R insulin to Resident 8 at the same injection sites and did not rotate the injection site on the following dates: 6/1/2026 and 6/2/2026. The DON stated the MAR indicated the licensed nurse did not rotate the insulin injection site and should have. c. During a review of Resident 53's AR, the AR indicated the facility admitted Resident 53 on 2/14/2017 and readmitted on [DATE] with diagnoses including type 2 DM and HTN During a review of Resident 53's PO dated 12/7/2023, the PO indicated Resident 53 had an active order for licensed staff to administer insulin Aspart (rapid-acting insulin) 100 unit/ml and inject per sliding scale subcutaneously before meals and at bedtime. During a review of Resident 53's PO dated 8/21/2025, the PO indicated Resident 53 had an active order for licensed staff to administer insulin Glarigine (long-acting insulin) 100 unit/ml and inject 16 units subcutaneously at bedtime. During a review of Resident 53's H&P dated 11/30/2025, the H&P indicated Resident 53 could not make decisions. During a review of Resident 53's MDS dated [DATE], the MDS indicated Resident 53 had severely impaired cognition. The MDS indicated Resident 53 required setup assistance from staff with eating. The MDS indicated Resident 53 required supervision from staff with toileting hygiene. The MDS indicated Resident 53 required moderate assistance from staff with oral hygiene and bed-to-chair transferring. The MDS indicated Resident 53 required maximal assistant from staff with showering/bathing and personal hygiene. The MDS indicated Resident 53 received insulin injection daily. During a concurrent record review and interview on 6/4/2026 at 1:23 pm with the DON, Resident 53's MAR dated 5/1/2026 to 5/31/2026 was reviewed. The MAR indicated the licensed nurse administered insulin Aspart to Resident 53 at the same injection sites and did not rotate the injection site on the following dates: 5/14/2026, 5/15/2026, 5/18/2026, 5/19/2026, 5/25/2026, and 5/26/2026. The MAR indicated the licensed nurse administered insulin Glargine to Resident 53 at the same injection site and did not rotate the injection site on the following dates: 5/5/2026, 5/6/2026, 5/7/2026, 5/17/2026, 5/18/2026, and 5/19/2026. The DON stated the MAR indicated the licensed nurse did not rotate the insulin injection site and should have. During a concurrent record review and interview on 6/4/2026 at 1:23 pm with the DON, Resident 53's MAR dated 6/1/2026 to 6/30/2026 was reviewed. The MAR indicated the licensed nurse administered insulin Aspart to Resident 53 at the same injection sites and did not rotate the injection site on the following dates: 6/1/2026, 6/2/2026, and 6/3/2026. The DON stated the MAR indicated the licensed nurse did not rotate the insulin injection site and should have. During a review of the facility's Policy and Procedure (P&P) titled Insulin Administration, dated 9/2018, the P&P indicated the facility should administer insulin in accordance with accepted nursing standards to ensure safe insulin administration to minimize the risk of adverse events. The P&P indicated the licensed nurse should rotate the insulin injection sites according to accepted nursing practice.

Based on observation, interview, and record review, the facility failed to provide residents on Enhanced Barrier Precaution (EBP, a set of infection control practices that use personal protective equipment [PPE, clothing and equipment used to provide protection] to reduce the spread of multi-drug resistant organisms [MDRO, a bacteria that is resistant to antibiotics]) a safe and sanitary environment to help prevent the development and transmission of communicable diseases for two of eight sampled residents (Residents 13 and 36) by failing to: a. Ensure the Minimum Data Set Coordinator (MDS C) wore the required PPE when touching Resident 13's gastrostomy tube (GT, a medical device inserted through the abdomen directly into the stomach).b. Ensure Restorative Nurse Assistant 1 (RNA 1) wore the required PPE while transferring Resident 36 from the wheelchair to the bed. These failures had the potential to expose Resident 13, Resident 36 and other residents in the facility to infection.Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated the facility initially admitted Resident 13 on 2/7/2023 and readmitted on [DATE] with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach), history of urinary tract infections (UTI, an infection in the bladder/urinary tract) ), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 3/19/2026, the MDS indicated Resident 13 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 13 required partial/moderate assistance (helper did less than half the effort) with eating and oral hygiene. The MDS indicated Resident 13 required substantial/maximal assistance (helper did more than half the effort) with toileting, shower, upper/lower body dressing and personal hygiene. The MDS indicated Resident 13 was on feeding tube for nutrition. During a review of Resident 13's untitled Care Plan (CP) dated 5/28/2026, the CP indicated Resident 13 was at risk for MDRO related to GT feeding. The CP approach included placing Resident 13 on EBP and wearing gloves, gown and hand hygiene during high contact resident care activity (dressing, showering, transferring, providing hand hygiene, changing briefs with toileting, device care and wound care). During a review of Resident 13's Order Summary Report (OSR) dated 5/29/2026, the OSR indicated Resident 13 was placed on EBP related to GT feeding and pressure injury (PU, localized damage to the skin and/or underlying tissue usually over a bony prominence). During a concurrent observation inside Resident 13's room and interview on 6/2/2026 at 9:06 am with MDS C, Resident 13 was lying in bed. The MDS C checked and touched Resident 13's G-tube catheter and site. The MDS C was wearing only gloves and not wearing a gown. The MDS C stated the MDS C needed to wear gown and gloves before checking and touching Resident 13's GT catheter and site to prevent the spread of infection. b. During a review of Resident 36's AR, the AR indicated the facility initially admitted Resident 36 on 2/3/2024 and readmitted on [DATE] with diagnoses including open wound on the right thigh, history of UTI, and stage 3 pressure ulcer (full-thickness loss of skin. Dead and black tissue may be visible) on the upper left back. During a review of Resident 36's untitled CP dated 3/19/2026, the CP indicated Resident 36 had a right thigh wound and stage 3 pressure injury on the left deltoid (large, triangular muscle that covers the shoulder). The CP approach included placing Resident 36 on EBP during high contact resident care activity. During a review of Resident 36's MDS dated [DATE], the MDS indicated Resident 36 had moderately impaired cognition. The MDS indicated Resident 36 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) with eating. The MDS indicated Resident 36 required substantial/maximal assistance with oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a review of Resident 36's OSR dated 3/26/2026, the OSR indicated Resident 36 was placed on EBP related to right thigh wound and left deltoid with stage 3 pressure injury. During a concurrent observation inside Resident 36's room and interview on 6/3/2026 at 10:15 am with Restorative Nurse Assistant 1 (RNA 1), RNA 1 transferred Resident 36 from the wheelchair to Resident 36's bed. RNA 1 was only wearing gloves and not wearing a gown. RNA 1 stated Resident 36 was on EBP and RNA 1 should have worn a gown and gloves before transferring Resident 36 from the wheelchair to the bed for infection control. During an interview on 6/4/2026 at 8:50 am with the Infection Prevention Nurse (IPN), the IPN stated all staff should wear gowns and gloves during high-contact care activities including transferring and touching of feeding tubes of residents placed on EBP to avoid contamination and spread of infection. During an interview on 6/4/2026 at 11:47 am with the Director of Nursing (DON), the DON stated staff must wear proper/necessary PPE when touching, transferring and caring to residents on EBP to prevent the spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precaution. dated 6/2021, the P&P indicated, EBP may be implemented for residents who: have wounds requiring ongoing treatment or dressing changes; have indwelling medical devices, including: urinary catheters, central venous catheters, tracheostomies, feeding tubes and other devices as identified by the IP or physician. Staff shall wear gloves and gown during high-contact resident care activities - dressing residents, bathing or showering, transferring residents, changing linens, wound care, device care, assisting with toileting and other activities involving extensive physical contact.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for two of two sampled residents (Residents 3 and 28) in accordance with the facility's policy and procedure (P&P) when: a. The facility did not provide Resident 3 who was on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) had failed) an emergency kit (E-kit, containing the main items needed in an emergency) at bedside.b. The facility did not properly dispose of a shaver, leaving the shaver unattended on top of the hand soap dispenser inside Room A's restroom.c. Resident 28 who required supervision while smoking (breathing in smoke from cigarettes [tobacco wrapped in paper]) had a lighter in possession. These deficient practices had the potential to increase the risk of injury, accidental fire and harm for the residents, staff and visitors in the facility. Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 1/9/2026 and readmitted on [DATE] with diagnoses including acute kidney failure (kidneys suddenly stopped working), dependence on renal dialysis (treatment for kidney failure that removes unwanted toxins, waste products and excess fluids by filtering the blood), and legal blindness. During a review of Resident 3's History and Physical (H&P) dated 3/26/2026, the H&P indicated Resident 3 could make needs known but could not make medical decisions, During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 4/6/2026, the MDS indicated Resident 3 had intact cognition (ability to understand and process information). The MDS indicated Resident 3 required supervision from staff with eating. The MDS indicated Resident 3 required maximum assistance (helper did more than half the effort) from staff with oral hygiene, toileting hygiene, showering/ bathing, personal hygiene, and bed-to-chair transferring. During a review of Resident 3's care plan (CP) for hemodialysis, revised 6/2026, the CP indicated Resident 3 was at risk of bleeding secondary to the Perma catheter (a tube placed into a large vein so the resident could get dialysis) on Resident 3's left upper chest. The CP goal was for Resident 3 to not have complications related to hemodialysis. The CP intervention indicated to monitor Resident 3's skin condition daily. During a concurrent observation and interview on 6/3/2026 at 11:13 am with Licensed Vocational Nurse 1 (LVN 1) inside Resident 3's room, Resident 3 was awake, lying in bed with Perma catheter on Resident 3's left upper chest. LVN 1 stated Resident 3 did not have a dialysis E-kit at bedside. LVN 1 stated it was important to have a dialysis E-kit at bedside for emergencies such as active bleeding at the resident's Perma catheter site. During an interview on 6/4/2026 at 1:23 pm with the Director of Nursing (DON), the DON stated the purpose of the dialysis E-kit was to apply pressure in the event of bleeding during an emergency. The DON stated the facility should have the dialysis E-kit available for Resident 3 who had a Perma catheter. The DON stated the DON forgot to place the dialysis E-kit inside Resident 3's bedside drawer. The DON stated the dialysis E-kit included gauze, tape, and bandage. During a review of the facility's undated Policy and Procedure (P&P) titled, Hemodialysis, Care of Resident, dated 5/2016, the P&P indicated the facility should ensure safe and effective care for residents receiving hemodialysis and to promote their health, safety, comfort, and quality of life. b. During an observation on 6/2/2026 at 9:14 am inside Room A's restroom, a blue shaver was on top of the hand soap dispenser unattended by staff. During an observation on 6/2/2026 at 11:25 am, inside Room A's restroom, a blue shaver was on top of the hand soap dispenser unattended by staff. During an observation on 6/2/2026 at 1:00 pm, inside Room A's restroom, a blue shaver was on top of the hand soap dispenser unattended by staff. During an observation on 6/3/2026 at 9:21 am, inside Room A's restroom, a blue shaver was on top of the hand soap dispenser unattended by staff. During a concurrent observation and interview on 6/3/2026 at 11:13 am with LVN 1, inside Room A's restroom, LVN 1 stated there was a shaver on top of the hand soap dispenser without any staff supervision. LVN 1 stated the shaver should never be in a resident's restroom. LVN 1 stated staff should dispose of the shaver into the sharp disposal container (a tough, hard plastic box used to safely throw away sharp medical objects) for safety and prevent the residents from injury/cutting themselves. During an interview on 6/4/2026 at 1:23 pm with the DON, the DON stated the shaver should not be placed unattended in the resident's restroom for safety. The DON stated the certified nurse assistant was responsible for assisting residents to shave in the restroom. The DON stated the facility should ensure environmental safety. During a review of the facility's undated Policy and Procedure (P&P) titled, Resident Safety, dated 1/2019, the P&P indicated the facility should provide a safe and secure environment for residents through ongoing assessment, supervision, staff education, environmental safety measures, and prompt response to identified risks. The P&P indicated the facility should take reasonable precautions to prevent accidents and injuries while encouraging residents to maintain their highest practicable level of independence. The P&P indicated that the staff should implement appropriate interventions to minimize the risk of accidents and injuries. c. During a review of Resident 28's AR, the AR indicated the facility admitted Resident 28 on 9/30/2019 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow), hyperlipidemia (high level of fats in the blood), and hypertension (high blood pressure). During a review of Resident 28's untitled Care Plan (CP) dated 2/3/2026, the CP indicated Resident 28 was at risk for injury due to smoking and the resident was capable of smoking in a designated area with supervision only. The CP intervention indicated for nursing staff to monitor Resident 28's whereabouts, especially during smoking time. During a review of Resident 28's Smoking Safety Assessment (SSA) dated 2/3/2026, the SSA indicated Resident 28 was independent for decision making and interventions included smoking safely with minimal supervision and supervised smoking by staff. During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 had intact cognition. The MDS indicated Resident 28 was independent for eating and needed moderate assistance (helper does less than half the effort) from staff for oral hygiene, toileting hygiene, shower, lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation and interview on 6/2/2026 at 9:08 am, inside Resident 28's room, Resident 28 was awake, lying in bed and stated Resident 28 had smoked 2 weeks ago and kept a lighter in Resident 28's possession. Resident 28 stated Resident 28 had the lighter and took the lighter from Resident 28's left pocket. During a concurrent observation and interview on 6/2/2026 at 9:08 am, inside Resident 28's room together with Registered Nurse 1 (RN 1), RN 1 stated, lighters and smoking paraphernalia should not be in Resident 28's possession and should be kept in a box in the Activity Department for safety of the residents and prevent potential fire. During an interview on 6/3/2026 at 1:28 pm, with the Activity Director (AD), the AD stated Resident 28 smoked once a week at night and AD did not know Resident 28 had a lighter in possession. The AD stated residents who smoke were not allowed to keep cigarettes and lighters in their possession to prevent the residents from lighting up cigarettes. During an interview on 6/4/2026 at 11:47 am with the facility's Director of Nursing (DON), the DON stated, residents were not allowed to keep lighters in their possession due to risk of fire. The DON stated, smoking paraphernalia should be secured in the AD's office during daytime and handed over to the licensed nurse in the afternoon for safety. During a review of the facility's P&P titled, Smoking Policy, updated 2/16/2022, the P&P indicated All cigarettes and lighters will be kept at the Activities office from 8am to 3pm and the Nursing Stations from 3pm to 8pm. Smoking in bed shall not be permitted.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of one sampled resident (Resident 5) to address the resident's refusal for podiatry care. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 5. Findings: During a review of Resident 5's admission Record (AR) the AR indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness and lack of coordination. During a review of Resident 5's Order Summary Report (OSR) dated 2/6/2026, the OSR indicated an active order for Resident 5 to have podiatry care every two months and as needed for hypertrophic or mycotic nails (thick, discolored, brittle nails). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 3/19/2026, the MDS indicated Resident 5 had severely impaired cognition (ability to understand) for daily decision making and needed partial/moderate assistance (helper does less than half the effort) for putting on or taking off footwear. During a review of Resident 5's Podiatry Evaluation and Treatment (PET), dated 4/16/2026, the PET indicated Resident 5 refused treatment. During a concurrent observation and interview on 6/2/2026 at 9:39 am with Certified Nurse Assistant 2 (CNA 2) in Resident 5's room, Resident 5 was awake in bed and had long toenails on all five toes of the right foot and the first, second and third toe of the left foot. CNA 2 stated, Resident 5 was confused and had long toenails. During a concurrent observation and interview on 6/2/2026 at 9:49 am with Registered Nurse 1 (RN 1) in Resident 5's room, Resident 5 was awake in bed and had long toenails. RN 1 stated Resident 5's toenails on both feet were long. RN 1 stated toenails should not be kept long to avoid anything getting caught on them and to prevent dirt from getting under the nails. During a review of Resident 5's entire Care Plans (CP), there was no CP developed to address Resident 5's podiatry care or refusal. During an interview on 6/3/2026 at 3:09 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated a care plan should have been developed for Resident 5's refusal of podiatry care, grooming, and Activities of Daily Living (ADL). During a concurrent interview and record review on 6/3/2026 at 3:12 pm with Registered Nurse 1 (RN 1), Resident 5's entire current care plans were reviewed. RN 1 stated there was no CP developed for Resident 5's podiatry refusal in the medical record. During an interview on 6/3/2026 at 3:15 pm with the Director of Nursing (DON), the DON stated Resident 5 did not have a CP for non-compliance for podiatry care. The DON stated CPs were created to meet the residents' needs and provide necessary care. The DON stated Resident 5 had a risk for infection with long toenails, and a CP should have been developed. During a review of the facility's policy and procedure (P&P) titled, Care Plan Revision, dated August 2005, the P&P indicated the CP included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psycho-social needs. The P&P indicated, the CP was updated as the resident's conditions changed and was revised as needed.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls for one of three sampled residents (Resident 1) who was identified as a high risk (high possibility of happening) for a fall, by failing to monitor Resident 1's location as often as possible.This failure had the potential to result in Resident 1 falling and sustaining injuries.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3 /12/2026, with diagnoses which included dementia (a progressive state of decline in mental abilities), major depressive disorder (a serious mental health condition that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's untitled care plan (CP), dated 3/12/2026, the CP indicated Resident 1 was at high risk for injury, accidents, and falls related to fall risk. The care plan goal indicated Resident 1 would have no injuries/accidents or falls in the next 3 months. The care plan interventions included maintaining a safe and hazard free environment, placing the bed in low position with bilateral floor mat to reduce the risk of injury related to fall risk, and to monitor residents' location as often as possible.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/14/2026, the MDS indicated Resident 1's cognitive skills (mental process of thinking and understanding) for daily decision-making was moderately impaired. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and required supervision or touching assistance (helper provides verbal cues and/or touching, steadying and/or contact guard assistance as resident completes activity) for transfers and walking.During a review of Resident 1's Fall Risk Evaluation (FRE - tool that predicts the likelihood that a resident will fall), dated 3/12/2026, the FRE indicated Resident 1 had intermittent confusion, had balance problems while standing and while walking, had decreased muscular coordination, had gait problems, and required the use of assistive devices. The FRE also indicated Resident 1 had 3 or more predisposing diseases (diseases that make the resident more likely to fall). The FRE indicated a total score of 10 or above represents high risk for a fall. Resident 1's total FRE score was 20.During a phone interview with Family Member (FM) 1 on 3/20/2026 at 10:10 AM, FM 1 stated when FM 1 visited the facility on 3/14/2026, Resident 1 was walking alone in the hallway without staff supervision and there were no staff (in general) present in the immediate area monitoring Resident 1. FM 1 stated FM 1 attempted to locate staff (in general) and when FM 1 encountered a certified nursing assistant (CNA) (unidentified) and informed the CNA Resident 1 was walking alone, the CNA did not immediately intervene.During an interview on 3/20/2026 at 2:45 PM with CNA2, CNA 2 stated CNA 2 took care of Resident 1 on 3/14/2026. CNA 2 stated CNA 2 was covering the break of the CNA (unidentified) assigned to the dining area during the shift. CNA 2 stated that while covering the dining area, CNA 2 was unable to visually observe all the residents. CNA 2 stated she did not observe Resident 1 when Resident 1 was ambulating in the hallway on 3/14/2026.During an interview on 3/20/2026 at 2:45 PM with Registered Nurse 1 (RN 1), RN 1 stated monitoring of residents was conducted through frequent checks and staff awareness. RN 1 stated monitoring was not continuous. RN 1 stated RN 1 was on break on 3/14/2026 at the time the concern (Resident 1 walking unsupervised) was reported. RN 1 stated Resident 1 was new to the facility and staff may not have been fully familiar with Resident 1's needs at that time.During an interview on 3/20/2026 at 3:20 PM with Director of Nursing (DON), DON stated staff were expected to follow care plans and provide monitoring. DON stated Resident 1 was alert but confused, ambulatory, and required assistance with walking.During a review of facility's Policy and Procedure (P&P) titled, Fall Prevention Falling Star Program, revised on 9/19, the P&P indicated residents identified as at risk for falls are to be monitored closely. The policy further indicated that staff are to observe residents for ambulation and attempts to transfer and provide supervision and assistance as needed.

Based on interview and record review, the facility failed to complete a Notice of Proposed Transfer/Discharge (NPTD) and failed to inform the long-term care Ombudsman (a representative who assists residents with issues related to day-to-day care, health, safety, and personal preferences) of a transfer for one of three sampled residents (Resident 1), when Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 2/24/2026.This deficient practice placed Resident 1 at risk for an inappropriate and unsafe discharge and violated Resident 1's rights.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome (pain that lasts longer than three months).During a review of Resident 1's History and Physical (H&P), dated 8/25/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 1 had intact cognition (ability to understand). The MDS indicated Resident 1 was independent with daily activities and mobility.During a review of Resident 1's Physician Order (PO), dated 2/24/2026, the PO indicated to transfer Resident 1 to another General Acute Care Hospital (GACH) via paramedic (a highly trained healthcare professional who provides emergency medical care and transportation).During a review of Resident 1's Progress Notes (PN), dated 2/24/2026 and timed at 8:50 PM, the PN indicated Resident 1 was transferred to the GACH 1 via paramedic for pain.During an interview on 2/26/2026 at 2:50 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the licensed nurse who discharged Resident 1 should have completed an NPTD during Resident 1's transfer process.During a concurrent interview and record review on 2/26/2026 at 3:31 PM with the Director of Nursing (DON), Resident 1's medical records were reviewed. The DON was unable to find an NPTD for Resident 1's hospital transfer on 2/24/2026. The DON stated the facility should have completed the NPTD for Resident 1's transfer on 2/24/2026. The DON stated the NPTD must be completed and kept in Resident 1's medical record.During an interview on 2/27/2026 at 12:38 PM with Registered Nurse 1 (RN 1), RN 1 stated the licensed nurse should have completed the NPTD upon transferring the resident to GACH 1. RN 1 stated the purpose of the NPTD was to inform the resident where the resident would be transferred to and the reason for the transfer. RN 1 stated it was the facility's practice to place the NPTD in the resident's medical record as proof the NPTD was completed.During a review of the facility's Policy & Procedure (P&P) titled Proposed Transfer and Discharge Notice, dated 1/2004, the P&P indicated, A written notice was to be provided to the resident and, if known, a family member or resident's personal representative, of the reasons for the transfer or discharge as soon as practicable before the transfer or discharge takes place.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal, mental(emotional) and physical abuse for two of three sampled residents (Residents 1 and 2).This deficient practice resulted in Resident 1 being subjected to physical abuse and Resident 2 being subjected to verbal and mental abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Chronic atrial fibrillation (AFib- a condition where the upper chambers of the heart (atria) beat irregularly and rapidly ), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control). During a review of Resident 1's Nursing admission Assessment (NAA) dated 1/17/25, the NAA indicated Resident 1had clear speech, normal hearing, and level of consciousness was oriented, awake/alert and confused. During a review of Resident 1's History and Physical (H&P) dated 1/18/25, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 7/28/25, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 was independent in eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 1's Physician Orders (POs), the POs indicated the following orders:1. Monitor behavior manifested by verbally abusive to staff every shift and tally by hashmark (Order date: 4/8/25).2. Monitor any signs of emotional or psychological distress every shift (Start date: 9/5/25).3. Scratch on neck - Cleanse with Normal Saline. Pat dry, apply bacitracin ointment every day shift for 14 days (Start date: 9/5/25). During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included other intervertebral disc degeneration, thoracic region and primary osteoarthritis, right hand (two separate conditions: degenerative disc disease in the mid-back (thoracic region) and primary osteoarthritis in the right hand which are both age-related wear and tear conditions), COPD and DM. During a review of Resident 2's NAA dated 3/9/23, the NAA indicated Resident 2 had clear speech, normal hearing, and level of consciousness was oriented, and awake/alert. During a review of Resident 2's H&P dated 2/28/25, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition for daily decision making. The MDS indicated Resident 2 was independent with eating and required set-up or clean-up assistance with oral hygiene, toileting hygiene, upper/lower body dressing, putting on/taking off footwear and personal hygiene; supervision was required for shower/bathe self. During a review of Resident 2's Physician Orders (POs), the POs indicated the following orders:1. Monitor behavior manifested by verbally abusive to staff every shift, tally by hash marks (Start date: 12/1/24).2. Monitor episodes of hallucination (seeing, hearing, smelling, tasting, feeling things that are not present), memory loss, aggressiveness, violent behavior, dizziness, headache, shortness of breath, restlessness every shift, tally by hash marks (Start date: 12/1/24).3. Monitor episodes of hitting another resident every shift, tally by hash marks (Start date: 12/1/24).4. Monitor behavior m/b yelling and screaming at staff every shift Tally by hash marks (Start date: 12/1/24). During a review of Resident 1's Change of Condition (COC)/Interact Assessment Form (SBAR, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) dated 9/5/25, the COC indicated on 9/5/25 Resident 1 stated, I was leaving Nursing Station 2 from signing out for OOP (temporarily absent from the facility, or Out on Pass), then I was coming back to my room down the hallway, I saw [former resident's name], the ex-patient, was in Resident 2's room when he exited, I said, Hello [former resident's name] , how are you doing? and then Resident 2 stated, He needs to put some [f-king] socks in his mouth so he can shut up. Resident 2 was in the wheelchair, in the middle of the hallway with [former resident's name], so I passed her [Resident 2] up cause she was cursing me out and taking long to move out of the way, so I turned around and she [Resident 2] got up from her wheelchair, and put both hands behind my back and she [Resident 2] grabbed by my neck and choked me, and then she socked me on the right cheek, and she punched me in my stomach too. She [Resident 2] then said, I don't give a damn. then I walked away towards my room. The COC further indicated the charge nurse (CN) was sitting at Nursing Station 2 and heard yelling down the hallway and CN immediately went towards room [number] & saw that Resident 2 was standing up from Resident 2's wheelchair and had Resident 2's left hand on Resident 1's neck, choking Resident 1. During a review of Resident 2's Nursing Progress Notes (NPN) dated 9/5/25, the NPN indicated, Resident to resident physical altercation: Resident 2 stated Resident 1 said to her, You need to wash that a_ _, that stinky a_ _, crack head. Resident 2 stated, And I just wanted him [Resident 1] to get away from me, and I said, Somebody come over here please quickly before I kill him. Then I put my left hand around his neck and then I squeezed it, and then I stopped doing it to him [Resident 1], and then I punched him in the stomach. During a review of Resident 1's Social Services Note dated 9/5/25, the note indicated Resident 1 stated to the Social Services Director (SSD), while Resident 1 was on Resident 1's way to Nursing Station 2 to sign for out on pass, Resident 1 saw [former resident's name] at the facility's lobby and greeted [former resident's name] and said Hello, Hi and without a warning Resident 2 stood up from Resident 2's wheelchair and said profanity words and continued cursing at Resident 1. Resident 2 stood up from Resident 2's wheelchair and placed Resident 2's hand on Resident 1's neck trying to choke Resident 1 and when Resident 2 removed Resident 2's hand from Resident 1's neck there was a scratch mark on Resident 1's neck. Resident 1 stated he did not retaliate or hit Resident 2 back because Resident 1 said, I don't hit women. During a review of Resident 2's Social Services Note dated 9/5/25, the note indicated Resident 2 stated to the SSD, while Resident 2 and [former resident's name] were walking towards the smoking patio, Resident 1 greeted [former resident's name], then Resident 1 claimed and told Resident 2 that Resident 2 was an addict and crack head and Resident 2 used drugs. Resident 2 stated Resident 1 provoked Resident 2 and that Resident 2 was tired of being called a crack head. During an interview on 9/11/25 at 2:13 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 2 was often loud and yelling and confrontational with staff. During an interview on 9/11/25 at 3:35 p.m. with Resident 2, Resident 2 stated Resident 1 called Resident 2 crack head many times over the course of a year. Resident 2 stated she told Resident 1 to stop calling Resident 2 crack head because it was insulting and not true. Resident 2 stated Social Services had talked to Resident 1 at least 3 times about Resident 1's behavior and the inappropriate language Resident 1 used against Resident 2. Resident 2 stated being called crack head all the time and taken off medications so quickly were contributing factors why Resident 2 attacked and hit Resident 1. Resident 2 stated, On Friday [9/5/25], I heard cussing at Station 2, and it was Resident 1 yelling at the staff. Resident 2 stated the staff didn't do anything to Resident 1. Resident 2 stated as Resident 1 walked down the hall from the Nursing station towards Resident 2, Resident 2 said to Resident 1, Somebody should wash your mouth out with soap. Resident 2 stated Resident 1 started to speak friendly with [former resident's name, who is Resident 2's boyfriend]. Resident 2 stated, There you go talking to [former resident's name] again like you know him. Resident 2 stated Resident 1 called Resident 2 a fatso and crack head, and then got up close to Resident 2's personal space. Resident 2 stated, I told him to move out of my personal space. Resident 2 stated when Resident 1 didn't move, Resident 2 stood up from Resident 2'swheel chair and grabbed Resident 1's neck then punched Resident 1 in the stomach. Resident 2 stated staff heard what was happening then Resident 2 was separated from Resident 1. Resident 2 stated several incidents happened prior to this most recent incident and this has been ongoing, well over a year to 1 1/2 years. During an interview on 9/11/25 at 3:54 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated, Resident 1 liked to tease other residents and bother them. CNA 2 stated CNA 2 told Resident 1 to stop with his inappropriate language towards residents, but Resident 1 would do it again to other residents. During an interview on 9/11/25 at 4:02 p.m. with Social Services Director (SSD), SSD stated Resident 1 loved to tease the residents. SSD stated, Some [residents] will respond to him others will be quiet. SSD stated, I was there that day [incident between Resident 1 and Resident 2], went out to see, and asked Resident 1 what happened. SSD stated Resident 1 told SSD Resident 1 did nothing to Resident 2. During an interview on 9/11/25 at 4:45 p.m. with Registered Nurse 2 (RN 2), RN 2 stated yelling at someone and saying hurtful and cruel things and teasing someone and calling the person a crack head is a form of verbal abuse. RN 2 stated, name calling was a form of abuse if the resident verbalized that he or she was not comfortable about it. During an interview with the facility's Director of Staff Development (DSD), the DSD stated, Verbal abuse is not acceptable. It falls under abuse. Verbal can mentally hurt and damage the resident's morale. Physical abuse, it hurts, damages you mentally and physically. During a review of the facility's current Policy & Procedure (P&P) titled, Abuse Prevention and Response Policy, revised 3/21/25, the P&P indicated the facility would ensure the safety and well-being of all residents by preventing, identifying, reporting, and responding to any form of abuse, neglect, or exploitation. The P&P indicated abuse is not limited to physical, emotional, sexual, and financial abuse, as well as neglect and exploitation. Each type of abuse is defined as follows:Verbal Abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.Emotional Abuse: Verbal or non-verbal actions causing emotional pain or distress.

Based on observation, interview, and record review, the facility failed to implement infection control guidelines by failing to: a. Ensure to change the nasal canula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) weekly for one of one sampled resident (Resident 76). b. Ensure personal toiletry was labeled and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms) of Residents 65, 48, 30, 78, 43 and 23. These failures had the potential to result in the spread of infection in the facility. Findings: a. During a review of Resident 76's Admission Record (AR), the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool) dated 1/29/2025, the MDS indicated Resident 76 had an intact cognition (ability to understand) and required setup or clean-up assistance (helper sets up or clean up, resident completes activity) with toileting hygiene and upper and lower body dressing. During an observation on 4/1/2025 at 10:45 am, in Resident 76's room, Resident 76 was sitting at bedside. Resident 76 had NC in the nostrils, receiving 2 liters of oxygen per minute. Resident 76's NC bag was dated 3/8/2025. During a concurrent interview, Licensed Vocational Nurse 3 (LVN 3) stated, resident's NC should be changed weekly and as needed for infection control purposes. During an interview on 4/2/2025 at 9:33 am with the Infection Preventionist Nurse (IPN), the IPN stated the resident's NC should be changed weekly to prevent bacteria accumulating and for infection control. During a review of Resident 76's Order Summary Report (OSR) dated 4/1/2025, the OSR indicated Resident 76 had an active order for oxygen inhalation 2 liters per minute via (through) NC as needed for shortness of breath (SOB), congestion (an excessive accumulation of blood or mucus), wheezing (abnormal lung sound) and comfort needs. During a review of the facility's Policy and Procedure tilted Oxygen Use of, dated 8/2025, the P&P indicated Oxygen equipment will be maintained in the following manner: humidifier bottle will be changed every 7 days (s) and PRN. Equipment will be changed as needed. 42307 b. During a review of Resident 65's AR, the AR indicated Resident 65 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), mild, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality, leading to distorted perceptions, thoughts, and behaviors), mood disturbance (a significant change in a person's emotional state that persists for an extended period), and anxiety (persistent, excessive fear or worry that significantly interferes with daily life) and personal history of urinary (tract) infections (UTI, an infection in the bladder/urinary tract). During a review of Resident 65's History and Physical (H&P) dated 12/25/24, the H&P indicated Resident 65 did not have the capacity to understand and make decisions. During a review of Resident 65's MDS dated [DATE], the MDS indicated, Resident 65 had severely impaired cognition. The MDS indicated Resident 65 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self and personal hygiene. During a review of Resident 48's AR, the AR indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including COPD, unspecified and schizophrenia (a mental illness that is characterized by disturbances in thought), unspecified. During a review of Resident 48's H&P dated 10/20/24, the H&P indicated Resident 48 could make needs known but could not make medical decisions. During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48's had severely impaired cognition. The MDS indicated Resident 48 required substantial/maximal assistance with toileting hygiene and shower/bathe self. During a review of Resident 30's AR, the AR indicated Resident 30 was originally admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar type (mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 30's H&P dated 11/28/24, the H&P indicated Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's MDS dated [DATE], the MDS indicated Resident 30's had intact condition. The MDS indicated Resident 30 required setup or clean-up assistance with toileting hygiene and shower/bathe self. During a review of Resident 78's AR, the AR indicated Resident 78 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction leading to symptoms like confusion, altered consciousness) and type 2 diabetes mellitus (DM) with diabetic neuropathy (a type of nerve damage that can occur with DM), unspecified. During a review of Resident 78's H&P dated 2/17/25, the H&P indicated Resident 78 had the capacity to understand and make decisions. During a review of Resident 78's MDS dated [DATE], the MDS indicated Resident 78 had intact cognition. The MDS indicated Resident 78 required substantial/maximal assistance with toileting hygiene and shower/bathe self. During a review of Resident 43's AR, the AR indicated Resident 43 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder, unspecified. During a review of Resident 43's H&P dated 11/12/24, the H&P indicated Resident 43 had the capacity to understand and make decisions. During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 had intact cognition. The MDS indicated Resident 43 required substantial/maximal assistance with toileting hygiene and shower/bathe self. During a review of Resident 23's AR, the AR indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including essential (primary) hypertension (HTN, high blood pressure) and anxiety disorder, unspecified. During a review of Resident 23's H&P dated 1/7/25, the H&P indicated Resident 23 did not have the capacity to understand and make decisions. During a review of Resident 23's MDS dated [DATE], the MDS indicated Resident 23 had moderately impaired cognition. The MDS indicated Resident 23 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and shower/bathe self. During a concurrent observation and interview on 4/1/25 at 11:20 a.m. with Certified Nursing Assistant 7 (CNA 7), inside the [NAME] and [NAME] restroom shared by Residents 65, 48, 30, 78,43 and 23, there was an opened, unlabeled 8 fl. oz. (fluid ounce, a unit of volume) of moisturizing shampoo & body wash stored on the window sill. CNA 7 stated, resident's personal toiletries should not be stored inside the restroom and should be labeled with the resident's name and kept at the bedside for resident's personal use. CNA 7 stated the moisturizing shampoo & body wash shouldn't be in the restroom for safety reasons and to prevent cross contamination among residents. During an interview on 4/1/25 at 11:29 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated personal toiletries were supposed to be labeled with resident's name and stored in the resident's drawer because other residents might use it (personal toiletry) to prevent cross contamination, for infection control. During a record review of the facility's Policy and Procedure (P&P) titled, Personal Hygiene Items, dated 4/16, the P&P indicated each resident would have their own toothbrush, toothpaste, comb, and other personal hygiene items to prevent cross-contamination. During a record review of the facility's undated P&P titled, Infection Control Program, the P&P indicated the facility should establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection.

Based on observation, interview, and record review, the facility failed to follow safe food handling and proper storage practices for one of one facility kitchen in accordance with professional standards of food service safety and the facility's Policy and Procedure (P&P) by failing to: 1. Label/date food items. 2. Store dishware and kitchenware under sanitary conditions. 3. Wear hair restraints in the kitchen food preparation area. These deficient practices could result in a risk for serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability (taste) of food for the residents. Findings: During a concurrent observation and interview on 4/1/25 at 9:22 a.m. with the Dietary Supervisor (DS), during the initial tour of the kitchen, Freezer 2 had a signage posted on the door indicating a Reminder: . Observed inside Freezer 2 were: 1. One opened box of 24 count of individual three oz (ounce, a unit of weight) cups of frozen pineapple sherbet and one three oz cup of frozen pineapple sherbet outside of the box on the shelf. The box was marked with a black marker indicating, R 3.24.25 and was not labeled with an opened date. 2. One opened box of 24 count of individual three oz cups of frozen strawberry ice cream. The box was marked with a black marker indicating, R 3.31.25 and was not labeled with an opened date The DS stated, the R on the boxes meant received. The DS stated the boxes should have been labeled with an opened date. During a concurrent observation inside the walk-in refrigerator and interview on 4/1/25 at 9:40 a.m. with the DS and [NAME] 1 (CK 1), CK 1 was asked what kind of eggs to use if a resident wanted either a soft boiled egg or over easy, CK 1 showed a 36-count of white eggs stored on top of a box of 150 count of eggs that had no indication or label that the eggs were pasteurized. The DS stated, staff should use pasteurized eggs to prevent food borne illness. The DS stated, the facility catered to the elderly who were easy to get infection (the invasion and growth of germs in the body) and bacteria. During a concurrent observation in the kitchen and interview with the DS on 4/1/25 at 9:42 a.m. the following were observed: 1. Three stacks of clean white colored dinner plates stored on the shelf above the tray line 2. Six stacks of clean maroon colored and clean blue colored plastic plate covers stored on the shelf above the tray line 3. Three stacks of clean cream colored plastic compartment plates stored on the shelf above the tray line 4. One stack of clean stainless steel colander and two stainless steel mixing bowls stored on the bottom shelf of a utility cart. The dishware and kitchenware were stored face up and not covered. The DS stated, dishware and kitchenware should be stored upside down to avoid contamination that could cause food borne illness. During an observation in the kitchen and interview on 4/4/25 at 7:34 a.m. with CK 1, CK 1 was inside the kitchen without a hair restraint. CK 1 stated, it was important to wear a hairnet for sanitization and to maintain cleanliness. CK 1 stated, a hair could fall into the food and contaminate the food and could get the residents sick. During a concurrent observation in the kitchen and interview on 4/4/25 at 10:20 a.m. with the DS, the Dishwasher (DW) was in the dishwashing station without a hair restraint and was tossing and fixing her long, thick hair. The DS stated, staff should wear a hair restraint once staff entered the kitchen to prevent contamination. The DS stated, the facility provided staff with hair net located by the kitchen door. During a record review of the facility's signage posted (SP) on the door of Freezer 2 titled, Reminder:, the SP indicated, to label with the date the package or container was opened. During a record review of the facility's P&P titled, Food Storage, Handling, Dishwashing, Shelf Life, and Hair Restraint Policy, dated 4/16, the P&P indicated, the P&P ensured all food stored, handled, prepared, and served within the facility was safe and sanitary and included measures to prevent contamination, including proper use of hairnets and other restraints in food service areas. The P&P indicated, the P&P applied to all employees involved in food service operations, including procurement, preparation, dishwashing, serving, and storage. The P&P indicated, the facility would enforce hygiene standards, including the mandatory use of hairnet or head coverings to prevent hair contamination in food preparation and storage areas. Staff would follow food safety procedures and maintained a clean, safe environment. The P&P indicated, one of the procedures was to label and seal opened packages and use the FIFO (first-in, first-out) method. The P&P indicated, all staff must wear hairnets or approved hair restraints (e.g., caps) when in food prep, dishwashing, or storage areas. The P&P indicated, under the Kitchenware Storage section, to store clean dishes in dry, covered, clean areas. During a record review of the facility's P&P titled, Policy on Pasteurized Eggs, dated 3/17, the P&P indicated, to minimize the risk of Salmonella (type of bacteria) and other foodborne illnesses, the facility should only use pasteurized eggs or pasteurized egg products in any dish requiring raw or undercooked eggs. The P&P indicated, only commercially pasteurized eggs or egg products should be purchased and stored in the facility.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 4 and 34) were treated with dignity when Certified Nursing Assistant 2 (CNA 2) and CNA 4 stood over Residents 4 and 34 while assisting Residents 4 and 34 to eat. This deficient practice had the potential to result in psychosocial (mental and emotional well-being) decline and lowered self-esteem and self-worth for Residents 4 and 34. Findings: a. During a review of Resident 4's Admission Record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movement), without mention of fluctuations and unspecified dementia (a progressive state of decline in mental abilities), mild, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality), mood disturbance (a significant change in a person's emotional state that persists for an extended period), and anxiety (a mental health condition characterized by persistent, excessive fear or worry that significantly interferes with daily life). During a review of Resident 4's History and Physical Examinations (H&P) dated 7/24/24, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Care Plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions and evaluation plan), titled, Weight (Wt.) loss of 7 pounds (lbs.) for 30 days, dated 9/15/24, the CP interventions included for staff to provide assistance with meals as needed. During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 2/18/25, the MDS indicated Resident 4's cognitive skills (ability to think and process information) for daily decision making was severely impaired. The MDS indicated Resident 4 required set up or clean-up assistance (helper sets up or cleans up) with eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). During a concurrent observation in Resident 4's room and interview on 4/1/25 at 12:16 p.m. with Certified Nursing Assistant (CNA) 7, Resident 4 was in bed at a high fowler's position (bed is elevated 60-90 degrees) while being fed lunch by CNA 2. CNA 2 was feeding Resident 4 while CNA 2 was standing over Resident 4 on the left side of Resident 4's bed. Resident 4's head was at CNA 2's waist level. CNA 7 stated staff needed to sit down while feeding residents (in general) at eye level of the resident for staff to be engaging and make residents feel comfortable. During an interview on 4/2/25 at 8:08 a.m. with the Director of Nursing (DON), the DON stated, staff should be sitting down when feeding residents for body mechanics (coordinated movement to maintain balance and posture) for the staff and to be able to feed the residents correctly. During a review of the facility's Policy and Procedure (P&P) titled, Feeding Program Policy, effective 2/2018, the P&P indicated the purpose of the policy was to establish guidelines for the feeding program at the facility to ensure that all residents received proper nutrition, hydration, and individualized feeding assistance in a safe and dignified manner. The P&P indicated, proper feeding assistance should be provided to residents who required help with eating and drinking to maintain their health and quality of life. The P&P indicated, staff should assist residents who required help with feeding in a patient, respectful, and dignified manner. 40438 b. During a review of Resident 34's AR, the AR indicated Resident 34 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness on one side of the body). During a review of Resident 34's MDS dated [DATE], the MDS indicated Resident 34 had severely impaired cognition. The MDS indicated Resident 34 required partial/moderate assistance (helper did less than half the effort) with eating and dependent (helper did all of the effort, resident did none of the effort to complete the activity) with oral and toileting hygiene, shower, upper and lower body dressing and personal hygiene. During an observation inside Resident 34's room on 4/1/2025 at 10:41 am, Resident 34 was in bed on her back and the head of the bed was elevated. CNA 4 was standing on the left side of Resident 34. CNA 4 was feeding Resident 34 with vanilla pudding. During an interview on 4/2/2025 ay 9:53 am with CNA 2, CNA 2 stated residents should be fed with the staff sitting next to resident and at eye level of the resident for the resident be able to eat comfortably and in a relaxed pace. During an interview on 4/4/2025 at 9:44 am with the Director of Nursing (DON), the DON stated, staff feeding a resident should be sitting at an eye level of the resident for the health, safety and dignity of the resident. During a review of the facility's policy and procedure (P&P) titled, Feeding Assistance Procedures, dated 5/2017, the P&P indicated, Sit at eye level with the resident to encourage engagement. Avoid rushing and maintain a calm, pleasant dining environment.

Based on interview and record review, the facility failed to designate a member of the facility's Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their patients) who was responsible for working with Hospice (a program designed to provide comfort care and emotional support to the terminally ill) representatives to coordinate care for one of one sampled resident (Resident 3). This deficient practice had the potential to affect Resident 3's quality of while on Hospice Care. Findings: During a review of Resident 3's Admission Record (AR), the AR indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses including adult failure to thrive (a decline in physical and cognitive function) and rhabdomyolysis (a medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream). During a review of Resident 3's active Physician Order (PO) dated 3/19/2025, the PO indicated Resident 3 was admitted under Hospice Service (H 1). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 3/30/2025, the MDS indicated Resident 3 had unclear speech, rarely/never understood others and made self-understood. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for personal hygiene and upper and lower body dressing. During a review of H1's visitation calendar for 3/2025, the visitation calendar indicated H1's Certified Home Health Aid (CHHA) was scheduled to visit Resident 3 on 3/26/2025 and 4/2/2025. During a review of H1's Staff Sign in Log (SSIL) from 3/19/2025 to 4/2/2025, the sign in log indicated there was no CHHA who signed in on 3/26/2025 and 4/2/2025. During an interview and concurrent record review on 4/2/2025 at 3:10 pm with the Director of Nursing (DON), the DON stated the facility did not have a designated staff who was responsible to work with H1 and coordinate care to Resident 3, provided by the facility staff and H1 staff. The DON stated, the facility had a binder for H1 for Resident 3. The DON stated there was monthly calendar in hospice binder with H1's visitation schedules. The DON stated CHHA was scheduled to visit Resident 3 on 3/26/2025 and 4/2/2025 according to H1's March 2025 schedule. The DON stated hospice staff should sign in on the SSIL every time they come and provide care to Resident 3. The DON stated there was no sign in by CHHA for 3/26/2025 and 4/2/2025. The DON stated the facility cannot verify if CHHA came on 3/26/2025 and 4/2/2025 to provide necessary care to Resident 3 because the facility did not have a designated person to monitor and follow up with H1's scheduled visit. The DON stated it was important to have a designated staff for hospice residents to ensure no missed visitations from hospice staff and ensure Resident 3's hospice care was provided in order to maintain Resident 3's quality of life. During an interview with the DON on 4/3/2025 at 10:55 am, the DON stated the facility did not have a policy and procedure indicating the facility assigning a designated staff to coordinate with hospice services.

Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) on Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) for one of one sampled resident (Resident 76) by failing to ensure the Advance Directive Acknowledge (ADA) Form was completed on admission for Resident 76. This failure had the potential risk for facility staff to provide medical treatment and services against the will of Resident 76. Findings: During a review of Resident 76's Admission Record (AR), the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool) dated 1/29/2025, the MDS indicated Resident 76 had an intact cognition (ability to understand) and required setup or clean-up assistance (helper sets up or clean up, resident completes activity) with toileting hygiene and upper and lower body dressing. During a review of Resident 76's ADA, the ADA did not indicate if Resident 76 had or had not executed an ADA. The ADA was not dated when it was signed by Resident 76. The ADA had missing signature from the facility. During an interview on 4/1/2025 at 1:03 pm with Social Service Director (SSD), the SSD stated Resident 76's ADA form was considered incomplete because there was no indication if Resident 76 executed an AD. The SSD stated Resident 76 did not execute an AD. The SSD stated, an AD indicated the resident's care and treatment choices, and it was important to follow the residents' wishes. The SSD stated, if the ADA form was incorrectly completed, the nurses would not know the resident's choices during an emergency. During a review of the facility's undated P&P titled Advanced Directives Policy and Procedure, the P&P indicated Advanced Directive acknowledgement forms must be completed within 7 days from admission by Social Services director or designee.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of three sampled residents (Resident 47). This failure had the potential for Resident 47 not to receive necessary care or receive delayed services, placing the resident at risk for falls or injury. Findings: During a review of Resident 47's Admission Record (AR), the AR indicated Resident 47 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), dementia (a progressive state of decline of mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 47's Fall Risk Assessment (FRA) dated 1/31/2025, the FRA indicated Resident 47 was assessed as high risk for fall. During a review of Resident 47's Minimum Data Set (MDS, a resident assessment tool) dated 2/26/2025, the MDS indicated Resident 47 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 47 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene and lower body dressing and substantial/maximal assistance (helper did more than half the effort) with shower. During a review of Resident 47's untitled Care Plan (CP), dated 2/25/2025, the CP indicated, Resident 47 was high risk for injury /accident and falls related to episode of getting out of bed unassisted. The CP interventions included for staff to ensure the call light was within reach and to answer promptly. During a concurrent observation inside Resident 47's room and interview on 4/1/2025 at 11:17 am with Certified Nurse Assistant 3 (CNA 3), Resident 47 was in bed on her back with call light stuck behind Resident 47's personal belongings. CNA 3 stated Resident 47 would not be able to find and reach the call light. CNA 3 stated the resident's call light should be placed next to the resident and within the reach of the resident to be able to call staff when help was needed. During an interview on 4/4/2025 at 9:53 am with the Director of Nursing (DON), the DON stated the resident's call light should be placed next to the resident's strong arm and hand so that the resident could call for assistance and staff could address the resident's needs timely. During a review of the facility's Policy and Procedure (P&P) titled, Call Lights and Use of the Call Cord System, dated 8/2005, the P&P indicated, Assure that the call light is within the resident's reach when in their room or on the toilet. Placement of the call cord within the resident's reach.

Based on observation, interview and record review, the facility failed to provide wound care services to prevent pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and failed to promote healing of the existing pressure injury for one of two sampled residents (Resident 1) by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) followed Resident 1's care plan and notified Treatment Nurse 1 (TN 1) so TN 1 could notify Physician 1 (MD 1) of the changes in Resident 1's skin condition, on the resident sacral coccyx (tailbone, the bottom of the spine), on 11/1/21, 11/2/21, 11/4/21, and 11/5/21. 2. Ensure Resident TN 1 revised Resident 1's Care Plan for stage 4 pressure injury (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures such as tendon, joint capsules) to address the frequency in which Resident 1 should be turned and repositioned in bed and avoided positioning the resident on the pressure injury site. 3. Ensure Resident 1 was not lying on the resident's back directly on her pressure injury site. 4. Ensure Nursing Staff (in general) followed the facility's policy and procedure to avoid the use of plastic backed chux (under pad with plastic backing to protect the mattress from getting wet) and thick linen on the low air loss mattress (a mattress that provides a flow of air to assist in managing the heat and humidity of the skin). As a result, Resident 1 developed an avoidable unstageable pressure injury [full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. When the slough or eschar is removed, a stage 3 (full-thickness loss of skin in which adipose/fat is visible in the ulcer/open sore) or stage 4 pressure will be revealed] on the resident's sacral coccyx extending to right and left buttocks (back of a hip that forms two rounded fleshy parts on which a person sits). Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 1/26/12. The record indicated Resident 1 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Care Plan titled, Pressure Injury Prevention, initiated on 12/12/20 and revised on 9/19/21, indicated the resident was assessed at risk for development of pressure injury due to impaired mobility and incontinence of bowel and bladder (lack of voluntary control over urination or defecation). The nursing interventions included daily body checks for open areas, skin redness and to notify the physician for any changes in skin condition. A review of Resident 1's Braden Scale for Predicting Pressure Sore Risk (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure injury), dated 9/3/21, indicated Resident 1 scored 17 (a total score of 15-18 indicated Resident 1 was at mild risk for developing a pressure injury). A review of Resident 1's Nursing Admission Assessment, dated 9/17/21, indicated Resident 1 had a healed scar on the sacral coccyx. The assessment indicated Resident 1 was readmitted to the facility without a pressure injury. A review of the Resident 1's Transfer Record, dated 11/6/21, indicated Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) via 911 (call for emergency services) due to weakness and declined in activity of daily living function. The transfer record did not indicate Resident 1 has an unstageable pressure injury. A review of GACH 1's Admission Record, dated 11/6/21, indicated Resident 1 admitted to GACH 1 on 11/6/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of GACH 1's Operative Report, dated 11/11/21, indicated Resident 1 received excisional debridement (surgically removal of dead tissues) of the pressure injury on the sacral coccyx with ostectomy (surgically removal of the bone) in preparation for future wound closure. The operative report indicated a total area of debridement was 14 x 8 centimeters (cm). The operative report indicated Resident 1 has a stage 4 pressure injury on the sacral coccyx with necrosis (death tissues) and infection. A review of GACH 1's Wound Care Nurse (WCN) Report, dated 1/16/21, indicated Resident 1 was admitted to GACH 1's on 11/6/21 due to [CONDITION(S)] and unstageable pressure injury. The report indicated the Transfer Summary from the Skilled Nursing Facility (SNF) did not mention of Resident 1's pressure injury or treatment. The report indicated on 11/9/2021 WCN spoke to SNF's Director of Nursing (DON) and the DON was not able to provider further information regarding Resident 1's pressure injury. The report indicated on 11/11/21, Resident 1 received debridement of the pressure injury on the sacral coccyx and the unstageable pressure injury became a stage 4 pressure injury. A review of GACH 1's Discharge Instruction, dated 11/16/21, indicated Resident 1's sacral coccyx unstageable pressure injury was debrided (removal of dead tissue from a wound) on 11/11/21. The discharged instruction indicated Resident 1 was discharged back to SNF on 11/16/21 with a stage 4 pressure injury of the sacral coccyx extending to the right and left buttocks. A review of Resident 1's Care Plan for stage 4 pressure injury on the sacral coccyx extending to right and left buttocks, dated 11/16/21, indicated the goal was for Resident 1's pressure injury to heal in 30 days. The nursing interventions included for staff to assist the resident with turning/repositioning for skin pressure relief and provide low air loss mattress. The nursing interventions did not address the frequency of turning/repositioning of Resident 1 in bed or to avoid positioning the resident on the pressure injury A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/22/21, indicated the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 required extensive assistance (staff provide weight-bearing support) for bed mobility with two persons physical assist. The MDS indicated Resident 1 was incontinent of bowel and bladder. During multiple observations of Resident 1 on 11/29/21 at 11:30 a.m., 11:45 a.m., 12:45 p.m., 1:20 p.m., and 2:22 p.m., Resident 1 was lying in bed on her back. During and observation of Resident 1's pressure injury treatment on 11/29/21 at 11:45 a.m., the resident had a stage 4 pressure injury to her sacral coccyx extending to right and left buttocks. TN 1 measured the pressure injury as 9 cm in length by 17 cm in width, 3.2 cm in depth with undermining (destruction of tissue extending under the skin edges so that the pressure injury is larger at its base than at the skin surface) of 1.7 cm at 8-11 o'clock. The wound bed (base of the wound) had large amount of yellow slough (dead tissues). TN 1 cleansed the pressure injury with Normal Saline (sterile mixture of salt and water), applied Santyl ointment (medicine that removes dead tissues from wound so the wound can start to heal), applied collagen powder (medicine that helps accelerate the healing of pressure injury), packed the pressure injury with calcium alginate (absorbent wound dressing) and covered the pressure injury with foam dressing (dressing that absorb fluid from pressure injury wounds). Resident 1 was lying on a plastic backed chux with a thick folded linen on low air loss mattress. During an interview on 11/29/21 at 2:28 p.m., CNA 1 stated he was the caregiver assigned to Resident 1 on the morning shift of 11/01/21, 11/2/21, 11/4/21, 11/5/21 and 11/6/21. CNA 1 stated Resident 1's skin on her sacral coccyx and buttocks were black in color and the surrounding skin was brown when he conducted the resident's body check on those dates. CNA 1 stated he did not report the changes in Resident 1's skin color on the sacral coccyx and buttocks until 11/6/21 when he observed the opened skin on Resident 1's sacral coccyx. CNA 1 stated he thought Resident 1's normal skin color on the sacral coccyx and buttocks were black. CNA 1 stated he turned and repositioned Resident 1 on a side lying position by placing a thin pillow under the resident's shoulder and waist area. CNA 1 stated he did not fully turn the resident to her side as the lower back (sacral coccyx and buttocks) of the resident remained on contact with the mattress. CNA 1 stated he was not informed by any nursing staff members that Resident 1 should be fully turned to a side lying position to offload (take pressure off) the pressure injury on the sacral coccyx and buttocks to promote pressure injury healing. CNA 1 stated he did not receive training to avoid using plastic backed chux and thick linen on Resident 1's low air loss mattress for pressure management. CNA 1 stated he was unable to turn and reposition Resident 1 every two hours in bed as he was busy taking care of other residents. During an interview and concurrent review of Resident 1's Nursing Admission Assessment, on 11/29/21 at 3:05 p.m., the DON stated on 11/6/21, she transferred Resident 1 to GACH 1 due to the resident had shortness of breath. The DON stated during the transfer process, Registered Nurse 1 (RN 1) found out that Resident 1 had an unstageable pressure injury on the sacral coccyx extending to right and left buttocks. The DON stated RN 1 did not measure Resident 1's pressure injury as the resident was leaving the facility via 911. The DON stated on 11/1/21, CNA 1 did not immediately report the changes in Resident 1's skin color (black color) on the sacral coccyx and buttocks to RN 1. The DON stated Resident 1 did not receive appropriate nursing interventions for the pressure injury from 11/1/21 to 11/6/21. The DON stated Resident 1's pressure injury could have been prevented. A review of Resident 1's Nursing Admission Assessment, dated 11/16/21, indicated Resident 1 was readmitted from GACH 1 with a stage 4 pressure injury of the sacral coccyx extending to right and left buttocks. During an observation and concurrent interview on 11/29/21 at 3:45 p.m., Resident 1 was lying on her right side and speaking in Vietnamese. Resident 1 stated she was always lying on her back on all shifts. Resident 1 stated this afternoon was the first time that her lower back (sacral coccyx and buttocks) was not on contact with the mattress after her caregiver positioned her on her side. Resident 1 stated she felt good when her wound (pressure injury) was not pressing on the mattress A review of the facility's Policy and Procedure (P&P), titled Body Check Daily Report, dated 8/5/2021, indicated for Certified Nursing Assistants to conduct daily body check to each assigned resident, complete the daily body check form and submit the form to Treatment Nurses for review. The policy indicated for Treatment Nurse to monitor areas of skin breakdown noted on daily body check report and responsible for the treatment. A review of the facility's P&P, titled Prevention and Care of Pressure Ulcers, dated 8/05/2021, indicated for staff to: a. Identify residents who at risk for the development of pressure injuries. b. Identify the potential skin problems on the residents' care plan. c. Turn and reposition the resident as often as needed for the individual resident. d. Ensure proper bed making such as no wrinkles in bed linen, no excess padding of bed for incontinent residents. A review of the facility's P&P, titled Skin Assessment, dated 7/17/21, indicated for staff to continually observes and monitor resident for changes and implement revisions to the plan of care as needed. Develop comprehensive, interdisciplinary plan of care including preventions and would treatments as have indicated. The policy indicated for staff to provide safe and effective care to prevent the occurrence of pressure injuries. A review of the facility's P&P, titled Alternating Pressure, Low Air Loss, Gel, Water Mattress, use of, dated 8/5/21, indicated for staff not to stuck sheet under mattress. According to an article titled, A Laboratory Study Examining the Impact of Linen Use on Low-air-loss Support Surface Heat and Water Vapor Transmission Rates Volume 59 - Issue 8 - August 2013 ISSN 1943-2720 indicated the use of multiple layers of linen, plastic backed chux and plastic backed diaper can adversely affect the ability of the low air loss bed to manage the microclimate (temperature and humidity of the skin). This will block the airflow and may potentially trap heat and moisture against the patient's skin that may increase the risk of skin breakdown.

Based on observation, interview, and record review, the facility failed to supervise outside the facility's building a resident at risk for elopement in accordance to the resident's care plan and facility's policy and procedure for 1 of 2 sampled residents (Resident 1). Certified Nursing Assistant 1 (CNA 1) left Resident 1 unattended outside the facility without supervision to call for help when Resident 1 refused to go back inside the facility. This deficient practice resulted in Resident 1 eloping. The police found Resident 1 and took the resident to the general acute care hospital (GACH). The resident sustained [REDACTED]. Findings: A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility on [DATE] and readmitted , on 3/3/17, with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 8/10/17, indicated Resident 1 had a [DIAGNOSES REDACTED]. The MDS indicated the resident required supervision on transfer, mobility, and eating. A review of Resident 1's care plan titled, Resident Care Plan: Wanderguard, initiated on 3/3/17, indicated the resident was at risk for wandering. The resident was on wanderguard (a device placed on the dominant wrist to prevent a resident from leaving a facility unnoticed) due to confusion and history of leaving the facility unattended. The interventions included for facility staff to stay alert when the alarm goes on to monitor or prevent the resident from leaving the facility unattended and provide frequent (the frequency was not specified) monitoring as needed. A review of Resident 1's Elopement Risk Assessment, dated 11/9/17, indicated Resident 1 was at risk for elopement. The facility applied a Wanderguard on the resident and the facility staff would continue monitoring the resident. A review of Resident 1's change of condition (C[NAME]) Nursing Progress Notes, dated 1/31/18 at 6:42 a.m., indicated Resident 1 was asleep at 3 a.m. At 3:10 a.m., a certified nursing assistant (CNA, the specific CNA was not identified by the progress notes) reported, while making rounds, that Resident 1 left the facility. During an interview on 2/15/18 at 4:15 p.m., Administrator 1 stated Resident 1 eloped on 1/31/18 (at 3:10 a.m.). Administrator 1 stated a resident who wanders or has a history of elopement wears a Wanderguard bracelet. Administrator 1 stated CNA 1 was in the hallway Location A when CNA 1 heard the main entrance door closing. Administrator 1 stated she did not know the reason why CNA 1 left Resident 1 unattended outside the facility to call for help after Resident 1 refused to go back inside the facility. During a telephone interview, on 2/23/18 at 7:50 a.m., CNA 1 stated that on 1/31/18 around 3 a.m., she was in Location A when she heard the front door (main entrance door) close. CNA 1 stated she did not hear any door alarm at that time. She followed Resident 1 to the main (entrance) door. CNA 1 stated she saw Resident 1 on the side walk in front of the facility swinging his hands when asked to come back in. CNA 1 stated Resident 1 started to fight back, resistive, and swinging his hand with no physical contact. CNA 1 stated she did not have her cell phone with her to call for help and she did not want to go outside the facility by herself. She stated she went back inside the facility to get help from another staff, leaving Resident 1 alone outside the building. CNA 1 stated when she and other two staff returned outside, Resident 1 was gone. During a telephone interview, on 2/26/18 at 8:30 a.m., Licensed Vocational Nurse 2 (LVN 2) stated he was told by someone (he was unable to recall the staff's name) that Resident 1 got out of the facility (on 1/31/18). LVN 2 stated he went outside and then inside the facility to look for Resident 1 but he was unable to find the resident. During a telephone interview, on 2/26/18 at 11:31 a.m., LVN 3 stated that on 1/31/18 (at 3:10 a.m.), Resident 1 went outside the facility. LVN 3 stated she would be able to hear the alarm the moment it goes off. LVN 3 stated that morning (on 1/31/18 at 3:10 a.m.) she did not hear the alarm going off. LVN 3 stated she drove around the street and back to the facility but she was unable to locate the resident. A review of Resident 1's History and Physical from the general acute care hospital (GACH), dated 1/31/18 at 9 p.m. (18 hours after being identified as missing), indicated Resident 1 was found outside a home located in another city and the property owner called the police when Resident 1 would not leave the homeowner's property. Resident1 was brought in by police to GACH. Resident 1 had a large ecchymosis (bleeding under the skin) of the left hand/wrist. Resident 1 was notably wearing a Wanderguard bracelet. Resident 1 was also noted to have skin rashes and [MEDICAL CONDITION] (abnormal change in structure caused by injury) on the back and a large plaque (substance that grow inside the body with certain diseases) over the left forearm. A review of Resident 1's GACH Radiologic (the science that uses medical imaging to diagnose and sometimes also treat diseases within the body) test, dated 1/31/18, indicated an avulsion fracture first proximal phalanx (a broken thumb/finger occurs when one or more of these bones breaks).

Based on interview and record review, the facility failed to have a physician order to discontinue an indwelling urinary catheter (a flexible tube that passes through the urethra (a tube by which urine is conveyed out of the body from the bladder) and into the bladder to drain urine), accurately monitor the fluid intake and output (I & O) according to facility's policy and procedure, and monitor the weekly weights as ordered by the physician for one of three sampled resident (Resident 1). These deficient practices resulted inaccurate assessment and monitoring of Resident 1's fluid intake and output and weight loss. Facility transferred resident to general acute care hospital (GACH 1) for low blood pressure of 80/42 (systolic blood pressure (SBP) less than 90 millimeters of mercury (mm Hg, measured used to measure blood pressure) or diastolic (DBP) less than 60 mm Hg is considered low). Resident 1 had admitting [DIAGNOSES REDACTED]. Findings: A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility, on 10/3/2017, and readmitted , on 10/14/2017, with [DIAGNOSES REDACTED]. of infection), and dementia (a condition affecting memory, personality, and reasoning abilities). A review of Resident 1's Minimum Data Set (MDS, an assessment and care planning tool), dated 10/23/2017, indicated Resident 1 had severe impairment in cognition (a mental action of acquiring knowledge and understanding) and needed extensive assistance (resident involved in activity; staff provide weight bearing support) with one-person assist with the activities of daily living with transfers, eating, toileting, dressing, and bathing. Resident's height was 69 inches and weight was 128 pounds. A review of Resident 1's admission orders [REDACTED]. A review of Resident 1 Physician's Telephone Orders, dated 10/5/17 noted at 3:30 p.m., indicated, Discontinue (D/C) previous order of Foley catheter. On 3/8/18 at 6:06 p.m., during an interview and concurrent record review of Resident 1's Physician's Telephone Orders, dated 10/5/17 noted at 3:30 p.m., the Director of Nursing (DON) stated the physician order should have been to discontinue the Foley catheter not discontinue previous order of a Foley catheter. A review of Resident 1's Nursing Notes, dated 10/5/17 at 1:44 a.m., indicated resident's F/C was intact and patent. Resident 1's Nursing Notes, dated 10/5/17 at 4:22 p.m., indicated the resident was on monitor for status [REDACTED]. A review of Resident 1's Intake and Output Record, indicated the licensed nurses did not document Resident 1's shift total intake and output for 10/3/17 (shift: 3 p.m. to 11 p.m.) and 10/4/17 (shifts: 11 p.m. to 7 a.m. and 3 p.m. to 11 p.m.). Resident 1's Intake and Output Record indicated the licensed nurses did not document the total fluid intake (by mouth/ IV (intravenous, within a vein) [MEDICATION NAME] (other than the mouth)) and output for 24 hours for 10/3/17, and 10/4/17. The document did not indicate the resident's fluid intake range, output range, appearance of urine, clinical evaluation, and had no signature of the evaluator (the licensed nurse), which were required information on the facility Intake and Output Record form. A review of the facility policy and procedures, dated 8/05, titled Intake and Output, indicated the purpose of intake and output (I & O) records was to maintain an accurate record of the resident's fluid balance and influence the physician's choice of therapies. The document indicated residents with indwelling catheters require measurement and documentation of I & O every shift, including a 24-hour total and weekly evaluation on residents with a Foley catheter. The document indicated the physician must be notified and corrective action taken if the weekly evaluation determined inadequate or excessive I & O for the physical condition of the resident. The Intake and Output policy of procedure indicated nursing assistants must total the amount of fluid consumed with each meal and record and report the nourishments and fluids taken between meals. The document indicated nursing assistants must empty the resident's collection bag and record and report the amount at the end of shift. A review of Resident 1's Change of Condition, dated 10/7/17, indicated resident had abdominal pain, distended abdomen, decreased urine output, and complained of difficulty urinating. A review of the Resident 1's Physicians Order, dated 10/7/2017, indicated Resident 1 transferred to the GACH 1 for placement of F/C due to [MEDICAL CONDITION]. A review of Resident 1's GACH 1 record from a urology consultation note, dated 10/7/17, indicated the physician documented Resident 1's F/C was removed at nursing home a few days ago and the resident was unable to void. Resident's bladder scan and computerized tomography scan (CT scan, a diagnostic test to view inside the body) showed a mildly distended bladder. A review of Resident 1's admission orders [REDACTED]. A review of the facility policy and procedures, dated 8/05, titled Weight Loss Policy, indicated all residents must be weighed and measured on admission and weekly for four weeks. It also indicated all 3-pound weight loss or gain must be reported to the physician and recorded in the nurses notes and Monthly Weights and Vital Signs form. The document indicated any significant weight loss or gain must be reviewed in the interdisciplinary team conference and must trigger a care plan entry to specify appropriate interventions and needed complete reassessment. On 3/8/18 at 5:12 p.m., during an interview and concurrent record review of facility's policy and procedures, dated 8/05, titled Weight Loss Policy, the DON stated facility had a form in each residents chart to monitor resident's weight and vital signs. DON provided the form titled Vital Sign Flow Sheet. A review of Resident 1's Vital Sign Flow Sheet, dated 10/14/17, indicated blood pressure of 110/68 and weight of 128 pounds. The document had no other weight and vital signs. A review of the facility's Weekly Resident Height and Weight Log from 10/3/17 to 11/7/17 and the facility's Resident Height and Weight Log for (YEAR) indicated no height and weight written for Resident 1. A review of Resident 1's care plan, titled Dehydration/Fluid Maintenance, dated 10/14/2017, indicated Resident 1 was at risk for dehydration due to renal (kidney) disease, UTI, and use of diuretics (medications designed to increase the amount of water and salt expelled from the body as urine) and cardiovascular agents (medications that affects the heart). The care plan indicated interventions, such as, encouraging the resident to increase the fluid intake as tolerated, monitoring the resident's intake, monitoring and reporting the signs and symptoms of dehydration to the physician, and monitoring the resident's weight. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's Intake and Output Record indicated the licensed nurses did not document the shift's total intake and output for 10/15/17 (shifts: 7 a.m. to 3 p.m. and 3 p.m. to 11 p.m.), 10/16/17 (shift: 3 p.m. to 11 p.m.), 10/18/17 (shift: 3 p.m. to 11 p.m.), 10/19/17 (shifts: 3 p.m. to 11 p.m.), 10/20/17 (shift: 7 a.m. to 3 p.m.), 10/21/17 (shift 3 p.m. to 11 p.m.), and 10/26/17 ( 3 p.m. to 11 pm.). Resident 1's Intake and Output Record indicated the licensed nurses did not document the total fluid intake and output for 24 hours on 10/15/17, 10/16/17, 10/17/17, 10/18/17, 10/19/17, 10/20/17, 10/21/17, 10/23/17, 10/25/17, and 10/26/17. The document did not indicate the resident's fluid intake range, output range, appearance of urine, clinical evaluation, and had no signature of evaluator, which were required information on the facility Intake and Output Record form. A review of Resident 1's Change of Condition (C[NAME]) progress note, dated 10/27/17 at 3:18 p.m., indicated the resident was transferred to GACH 1. Resident 1 had a blood pressure of 80/42 mmHg, generalized weakness, and decreased urine output. A review Resident 1's Emergency Department (ED) Provide Note, dated 10/27/17 at 5:31 p.m., indicated resident had a blood pressure of 62/50 mmHg and weighed 45 kilogram (kg)/ 99 pounds. A review of Resident 1's GACH 1 History and Physical, dated 10/28/17, indicated Resident 1 findings included UTI, rule [MEDICAL CONDITION], and dehydration. A review of Resident 1's Nephrology Consultation note from GACH 1, dated 10/27/17, indicated Resident 1 was admitted in the emergency room with altered mentation. The nephrologist (a special type of physician who [DIAGNOSES REDACTED]. The nephrologist's assessment included Resident 1 had UTI, acute kidney injury and severe dehydration. The nephrologist documented treat with aggressive IV (intravenous, within a vein) hydration (a process by which fluids are replaced through sterile water solutions containing small amounts of salt or sugar being injected into the body through a tube attached to a needle which is inserted into a vein), and close monitoring of resident's renal function. On 11/16/17 at 3:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated the signs of dehydration include poor skin turgor, dry oral mucosa, and concentrated urine. LVN 1 stated nursing interventions include offering fluids to the resident, notifying the physician, and obtaining an order for [REDACTED]. On 12/14/17 at 9:02 a.m., during an interview, LVN 2 stated she did not complete the I & O form attached to the MAR unless the resident was on fluid restrictions with a physician order. LVN 2 did not know that I & O must be assessed and monitored for facility residents with a Foley catheter. On 2/1/18 at 4:40 p.m., during an interview, LVN 4 stated he only filled out the I & O form for residents on [MEDICAL TREATMENT] and if ordered by the physician. LVN 4 stated he did not know that I & O monitoring must be done for all residents with a Foley catheter. On 2/1/18 at 5:03 p.m., during an interview, LVN 5 stated she did not fill out the I & O form if there was no physician order to monitor the I & O. LVN 5 stated she did not know that I & O monitoring must be done for all residents with a Foley catheter. On 12/14/17 at 10:41 a.m., during an interview and concurrent record review of Resident 1's medical records, Registered Nurse 1 (RN 1) stated there was a physician's order to obtain Resident 1's weekly weights upon admission and four times subsequently, but there was no documentation in the MAR indicated [REDACTED]. RN 1 stated I & O of residents with Foley catheter must be monitored and documented in the MAR per facility policy. During the interview, RN 1 stated amounts of fluid intake monitored came from the fluids drank from the resident's trays, water pitchers at the bedside, water provided to the residents as requested, and water used with the medication administration. RN 1 stated the licensed nurses I did not complete Resident 1's I & O. RN 1 stated the RN did not evaluated Resident 1's I & O weekly. On 2/1/18 at 3:45 p.m., during an interview, Certified Nursing Assistant 6 (CNA 6) stated he only checked the fluids served in the meal trays of all the residents but not the fluid drank from other sources. CNA 6 was not aware that fluids between meals and from nourishments must also be recorded. On 2/1/18 at 4:03 p.m., during an interview, CNA 7 stated she did not record the consumed fluids served with the resident snacks. CNA 7 stated she was not aware that fluids taken between meals and from nourishments must also be recorded. On 2/2/18 at 9 a.m., during an interview, CNA 9 stated she not know that the urine output of residents with a Foley catheter drainage bag must be recorded. On 2/2/18 at 9:34 a.m., during an interview, CNA 10 stated she did not monitor and record residents' fluid intake with snacks, bedside water pitcher, and fluids offered during the activities. CNA 10 did not know that fluids taken between meals and from nourishments must also be recorded for residents with a Foley catheter. On 2/2/18 at 10:42 a.m., during an interview and concurrent record review of Resident 1's Nutritional Assessment form, dated 10/19/2017, with the Registered Dietitian (RD). The RD stated Resident 1 was determined to have a fluid requirement of 1,745 milliliters per day based on his weight. RD stated the average fluid provision in the dietary trays equaled to 1200 - 1500 milliliters per day based on the diet ordered by the physician. RD stated Resident 1 would meet his fluid intake needs from the water offered at the bedside (water pitcher), between meals (snacks), while in the Activity Room, and water given with Resident 1's medications. On 2/2/18 at 11:37 a.m., during an interview, RN 1 stated Resident 1's hospitalization could have been prevented with accurate I & O assessment. RN 1 stated Resident 1 could have been encouraged to drink more fluids or given IV fluid hydration if the urine output was decreased. RN 1 stated accurate assessment and monitoring of Resident 1's weekly weights would indicate significant weight losses and gain. RN 1 stated a weight loss indicated poor intake and the physician would be notified. On 2/7/18 at 9:55 a.m., during an interview, Resident 1's Physician 1 stated some of the signs and symptoms of dehydration would include a change in the resident's mental status, low urine output, and a decrease in blood pressure. Physician 1 stated it was very important to assess and monitor the I & O of residents with a Foley catheter for possible catheter obstruction and/or need to replace the catheter for decrease output. During the interview, Physician 1 stated IV hydration therapy could be ordered under close monitoring by the licensed nurses for residents needing fluid hydration. Physician 1 stated residents on diuretics and have chronic kidney problems need to have monitoring of weekly weights and I & O because of the higher risk to lose excessive amounts of fluid.

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers (localized injury to the skin and underlying tissue caused from a prolonged pressure to the skin, which decreases blood flow into the area) from developing for one of three sample residents (Resident 2) with pressure ulcers. The facility failed to: 1. Ensure Resident 2's right heel pressure ulcer did not redevelop. 2. Implement Resident 2's plan of care to float the resident's right heel with a pillow when in bed. 3. Ensure Resident 2's right heel was not directly in contact with the mattress or any pillows. 4. Inform Resident 2's physician that Resident 2's right heel pressure ulcer had redeveloped and did not provide any treatment to the right heel pressure ulcer for 5 days. These deficient practices led to Resident 2 to redevelop a pressure ulcer to the right heel. Findings: A review of Resident 2's Record of Admission, indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's Nursing Admission assessment dated [DATE] indicated Resident 2 had the following pressure ulcers (Pressure ulcer stages (National Pressure Ulcer Advisory Panel (NPUAP)) include: Stage I-presents as intact skin with non-blanchable redness (redness does not go away when pressure is relieved) of a localized area, usually over a bony prominence.) Stage II-characterized by partial-thickness loss of dermis presenting as a shallow open ulcer. Stage III-characterized by a full-thickness tissue loss. Fat under the skin may be visible but bone, tendon, or muscle is not exposed. Stage IV-presents with full-thickness tissue loss with exposed bone, tendon, or muscle exposed.) 1. Right heel- Stage III pressure ulcer on the right heel 2. Sacro-coccyx- Stage IV pressure ulcer 3. Left mid buttock- Stage IV 4. Left lower buttock- Stage III 5. Left medial thigh- Stage III A review of Resident 2's Braden Scale- for Predicting Pressure Sore Risk dated 1/11/2017 indicated Resident 2's score was 14 indicating a moderate risk for developing a pressure ulcer. A review of Resident 2's MDS dated [DATE] indicated Resident 2 had five unhealed pressure ulcers and was totally dependent on staff for bed mobility, transfer, toilet use, and personal hygiene. A review of Resident 2's Alteration in skin integrity/ Potential for development of pressure ulcers care plan dated 1/11/2017 included the following interventions: 1. Daily body checks for redness, open areas, etc. 2. Turn and reposition resident every 2 hours, or more for dependent residents. 3. Use pillows for support (e.g. back, between knees, and to other bony prominence). 4. Provide support surface for heels. Elevate heels off bed surface. 5. Notify MD promptly for any skin breakdown. A review Resident 2's Nurses Progress Notes indicated Resident 2's: 1. Right heel pressure ulcer healed on 1/20/17. 2. Left lower buttock pressure ulcer healed on 1/27/17. A review of Resident 2's wound care specialist notes dated 2/24/17 indicated Resident 2's: 1. Sacral coccyx pressure ulcer had healed. 2. Treatments to Resident 2's left buttock and left medial thigh pressure ulcers continued. On 4/4/17, at 12:10 p.m., an observation and concurrent interview with Resident 2 was done. Resident 2 was observed in lying in a flat position with legs curled up in bed. Both heels were observed resting directly on the mattress. Resident 2 stated he had problems extending his legs to make them straight. Resident 2 stated he had a sore on his left hip, could not get up by himself, and had limited mobility in bed. On 4/4/17 at 12:30 p.m., 12:50 p.m., 1:45 p.m., 2:45 p.m., and on 4/6/17 at 2:30 p.m., 3:40 p.m., 4:15 p.m. and 4:30 p.m., Resident's 2 was observed still lying in the same position on his back with his legs curled up in bed and with his heels resting on the mattress. On 4/6/17, at 11:50 a.m., an interview was conducted with Certified Nurse Assistant (CNA 1). CNA 1 stated the facility staff turned residents who are bedridden every 2 hours. CNA 1 also stated she reports any unusual skin observation to the treatment nurse (TN), Charge Nurse (CN) and to the DON. On 4/6/17, at 2:30 p.m. a treatment observation of Resident 2's wound care was conducted with the TN. The TN proceeded with the treatments to Resident 2's medial thigh and left buttocks pressure ulcers. Resident 2's right heel was exposed and was observed with a purplish maroon color and the skin at the ball of the heel had partially peeled off. At the end of the treatment, TN did not assess Residents 2's other parts of the body. On 4/6/17, at 3:15 p.m. an interview was conducted with the TN. The TN stated she did not observe any discoloration on Residents 2's right heel and she would re-assess Resident 2. On 4/6/17, at 3:40 p.m., an observation and concurrent interview was conducted with the DON at Resident 2's bedside. The DON confirmed Resident 2's heels were resting directly on the mattress. The DON stated Resident 2's right heel had discoloration and an open skin area The DON also stated Resident 2 was contracted (chronic loss of joint movement) on both lower extremities and both heels had to be offloaded (kept off the mattress, no pressure to the heels). The DON asked Resident 2 if there was pain on his right heel and Resident 2 responded it is tender to the touch. On 4/6/17, at 4:00 p.m., an interview was conducted with CNA 2. CNA 2 stated the facility used a turning clock to remind staff to reposition the residents every 2 hours. CNA 2 also stated that residents who had pressure ulcers to their heels, the heels need to be elevated off the mattress. On 4/11/17 a review of Resident 2's clinical record indicated that there was no documentation of the following: 1. Resident 2's right heel pressure ulcer had been assessed, 2. Resident 2's physician had been notified of the new right heel pressure ulcer. 3. Resident 2's right heel pressure ulcer received any treatments. On 4/11/17, at 1:15 p.m., an interview was conducted with the DON. The DON stated she had discussed with the TN Resident 2's right heel condition on 4/6/17. The DON stated and confirmed TN did not assess Resident 2's right heel condition, inform Resident 2's physician, and had not done any treatments to Resident 2's right heel. A review of the facility policy titled Guidelines for Assessing Potential for Pressure Sores dated 8/2005, indicated: 1. The nurse documents on the comprehensive nursing assessment and nurse's notes all skin problems identified. 2. All pressure points are checked for redness; Turning and repositioning are noted in the daily nurse assistant notes in the residents' charts. 3. When pressure ulcers developed the charge nurse immediately contacts the physician for an order.

Based on observation, interview, and record review, the facility's Infection Control Program failed the following for one of 15 sample residents (Resident 12): 1. Maintain a record of residents with rashes, conduct surveillance and tracking of residents with rashes to identify an outbreak of scabies (contagious skin infestation caused by mites (small bugs) that burrow into the skin causing severe itching). 2. Follow the physician's orders [REDACTED]. 3. Failed to report the outbreak of scabies to the Department of Public Health to obtain further recommendations to treat Resident 12's rash that was not responding to topical therapy. These failures resulted in Resident 12 having severe skin irritation which caused uncontrollable scratching of her infested skin areas; and developed secondary skin infections due to her scratching. The delay in identifying and treating Resident 12's scabies had the potential to spread the scabies infestation to all residents, staff and visitors in the facility. In addition, the facility staff failed to communicate with an outside agency that Resident 4 was on isolation precautions and staff repeating place a linen back on the linen cart after falling on the floor. These failures had the potential of resulting in the spread of infection. Findings: a. A review of the admission record indicated that Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), a standardized assessment tool, dated 9/13/16, indicated Resident 12 had clear speech when speaking to others. The MDS functional status (activities of daily living), under Section G indicated Resident 12 required extensive assistance (one-person physical assist) for dressing, personal hygiene, bathing, and walking. A review of Resident 12's Treatment Record from 6/16 to 10/16 indicated Resident 12 had itching for five months and on 10/24/16, Resident 12 developed an infection to the right upper back rash. During an interview with the Infection Control Nurse (ICN), on 11/9/16, at 9:30 a.m., a list of all residents with rashes in the last three months was requested. ICN was instructed to indicate if any of the residents on the list were treated with [MEDICATION NAME] (a medication applied to the skin to kill the mites that cause scabies, a contagious skin infestation). The ICN was unable to provide the requested lists. A second request for the list was done the following day on, 11/10/16, at 10:49 a.m. Both the ICN and Treatment Nurse (TN) were unable to provide the requested lists of residents with skin rashes. Further review of Resident 12's clinical record indicated a primary physician's orders [REDACTED]. The physician ordered to place Resident 12 on contact isolation precautions (use of gown, gloves and proper handwashing when in contact with resident to prevent the spread of the infection); and ordered to apply the first treatment for [REDACTED]. According to the dermatologist evaluation dated 7/1/16, Resident 12 continued to itch. The dermatologist ordered to apply [MEDICATION NAME] (a type of skin cleanser used to kill germs) wash once a day for 10 days; Okay to apply second [MEDICATION NAME] treatment in 6 days. The dermatologist also ordered [MEDICATION NAME] (medication used to treat allergy symptoms such as itching) 10 milligrams (mg) once a day for 3 weeks. The dermatologist's note dated 7/5/16, indicated Resident 12's chief complaint was skin rashes, dry and pruritus (itching). The plan indicated to treat with second [MEDICATION NAME] treatment, continue current treatment, follow-up in seven days. On 8/5/16, there was an order for [REDACTED]. On 8/25/16, the physician ordered [MEDICATION NAME] (medication used to treat infection) 100 mg twice a day for 10 days for pimples-like skin rash infection on Resident 12's back due to itching. On 9/5/16, the physician continued the antibiotic of [MEDICATION NAME] 100 mg twice a day for 10 more days for the pimples-like skin rash infection on her back. A review of a physician order [REDACTED]. On 10/13/16, the dermatologist ordered the following: 1. Perform skin scraping. 2. Bathe resident with [MEDICATION NAME] wash daily for 10 days. 3. Then apply the fourth [MEDICATION NAME] treatment one time per week for two weeks. 4. [MEDICATION NAME] 10 mg once a day for 4 weeks; and apply Eloncon cream (medication used to treat inflammation and itching) 0.1% twice a day for 4 weeks to body rashes. On 10/23/16, Resident 12 ' s primary physician order [REDACTED]. The physician ordered [MEDICATION NAME] ointment (antibiotic medication) once a day for 21 days to treat boil to right upper back and right 2nd finger pustule (small collection of pus under the skin). Resident 12 developed a second skin infection due to itching. During a subsequent interview with ICN, on 11/10/16, at 11:15 a.m., when asked about the facility's infection control program, ICN stated tracking was done for infections which required antibiotics. ICN reviewed the facility's Infection Control Surveillance log for the months of 9/16, 10/16 and 11/16, and stated the log was used to track or monitor infections of the skin, respiratory, eye, ear and intestine that required antibiotics. A review of the tracking logs for 9/16, 10/16 and 11/16 failed to indicate skin rashes were treated with [MEDICATION NAME] (a medication applied to the skin to kill the mites that cause scabies, a contagious skin infestation). ICN stated she would ask the TN if she kept a list of residents. During an interview with the Acting Director of Nursing (ADON), on 11/10/16, at 1:35 p.m., when asked for a list of residents with skin rashes, she stated she did not have one. A review of the list provided by the pharmacy on 11/10/16 indicated the following residents were dispensed [MEDICATION NAME]: For Resident 12, on 10/13/16; For Resident 8, on 8/30/16 and 10/13/16; For Resident 6, on 10/14/16; For Randomly Selected Resident (RSR 16), on 10/31/16, and For RSR 17, on 11/9/16. Three residents (6, 8, and 12) had shown signs and symptoms of scabies and were treated by the facility with [MEDICATION NAME] within two days of each other. According to Prevention and Control Of Scabies In California Long-Term Care Facilities California Department of Public Health Division of Communicable Disease Control in Consultation with Licensing and Certification dated March 2008, outbreaks should be reported to the local health officer and to the California Department of Public Health, Licensing and Certification District Office. Two (2) suspect cases occurring among residents, health care workers, visitors or volunteers during a 2 week period should be considered an outbreak for reporting purposes. During an interview with the ADON, on 11/10/16, at 1:53 p.m., ADON stated in 6/2016 the facility reported an outbreak of scabies but were cleared by the local Health Department. The last outbreak reported was in 6/2016 and no outbreak had been identified or reported to the Health Department in 10/2016. Failed to report the outbreak of scabies to the Department of Public Health to obtain further recommendations to treat Resident 12's rash that was not responding to topical therapy. During a body check and concurrent interview of Resident 12, with the ADON, on 11/10/16, at 1:39 p.m., Resident 12 had pin point skin rashes with scratches to the chest and a skin abscess (a painful swollen area on the skin caused by an accumulation of pus-liquid inflammation caused by infection) to the right hand between the 1st and 2nd fingers. Resident 12 stated she had intense itching all day and night since admission and felt like she wanted to tear her skin off. In an interview with the TN on 11/10/16, at 2:42 p.m., she stated the evening shift nurse applied the [MEDICATION NAME] cream to Resident 12 on 10/14/16 and 10/20/16. TN stated that the skin scrapings were done on 10/26/16 (after [MEDICATION NAME] treatment) and the results were negative for scabies. According to the Los Angeles County Department of Public Health Acute Communicable Disease Control Program, Scabies Prevention and Control Guidelines for Care Facilities, 2009, indicated for Management of Symptomatic Cases the following are required: 1. Identification of an outbreak, defined as increase in the incidence of new cases above baseline within a defined period of time and within a defined geographical location, specifically, at least two (2) clinically suspect cases identified in residents during a two (2) week period of time. 2. Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic residents. 3. Treat symptomatic residents with an approved Scabicide. Ivermectin is an antiparasitic agent shown to be safe and effective for infestations that do not respond to topical therapy ([MEDICATION NAME]). 4. All outbreaks of scabies are required to be reported to Los Angeles County Department of Public Health to obtain further recommendations to treat and prevent the spread of the infection. <https://admin.publichealth.lacounty.gov/acd/docs/ScabiesGuidelinesFinal8.20.09_1.pdf> b. During initial tour on 11/7/16, at 1:50 p.m., Resident 4 was observed in her room on her wheelchair being assisted by the transportation driver with no personal protective equipment (PPE). There was an isolation cart outside Resident 4's room with gowns and a sign indicating contact isolation. In an interview on 11/7/16 at 1:52 p.m., with the transportation driver and the Acting Director of Nursing (ADON), he stated he was not aware Resident 4 was on contact isolation. The ADON reviewed the communication record form to the outside agency and verified the facility staff failed to documented Resident 4 was placed on contact isolation for an infected abscess. A review of Resident 4's record of admission, indicated Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician order, dated 11/6/16, indicated to placed Resident 4 on contact isolation for [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) to gallbladder abscess. A review of the undated policy, Infection Control, indicated it is the facility's policy to implement infection control measures to prevent the spread of communicable diseases and conditions. c. During an observation on November 9, 2016, at 9:43 a.m., Certified Nursing Assistant (3) was observed in the hallway getting towels and linens from the clean linen cart. As CNA 3 pulled some towels and linens from the cart, a wash cloth fell on the floor. CNA 3 was observed picking up the wash cloth from the floor and returning it back to the linen cart. Upon further observation, the wash cloth fell on the floor again and CNA 3 picked it up and returned it back to the linen cart. During an interview on November 9, 2016, at 9:43 a.m., CNA 3 stated I made a mistake. CNA 3 was then observed getting the possibly contaminated wash cloth from the linen cart and putting it in the dirty linen barrel.

Based on record review and interview, the facility failed to provide adequate supervision to one of one resident (Resident A) with a [DIAGNOSES REDACTED]. Resident A was found on the floor with her head hanging against the side rail with a piece of cloth around her neck unresponsive and not breathing, on [DATE], at 2:55 p.m. Resident A was pronounced dead, on [DATE], at 3:10 p.m. Findings: On [DATE], at 1:10 p.m., an investigation was initiated regarding Resident A, who strangled herself and expired at the facility. Staff 1 was informed of the nature of the visit. Record reviews with Staff 1 indicated Resident A was originally admitted to the facility, on [DATE], having a history of two suicide attempts as follows: On [DATE], Resident A was admitted to an acute hospital (Hospital 1) due to attempted suicide by ingesting toilet bowl cleaner and trying to cut her wrist. On [DATE], while at Hospital 1, Resident A made another attempt to commit suicide by using an IV (intravenous-flexible plastic tubing) tubing to strangle herself. On [DATE], Resident A was transferred from Hospital 1 to a psychiatric hospital (hospitals specializing in the treatment of [REDACTED]. The psychiatric report from Hospital 2, dated [DATE], indicated Resident A needed continued psychiatric care. The discharge summary from Hospital 2, dated [DATE], indicated Resident A had severe depression with suicide attempt. The report indicated Resident A stated she could not guarantee that she would not try to harm herself again. Resident A was admitted to the skilled nursing facility, on [DATE]. On [DATE], she was discharged to an acute hospital due to another suicide attempt. According to a Discharge Summary from the hospital, dated [DATE], Resident A was transferred to Hospital 3 due to a suicide attempt. On [DATE], a review of the psychiatric evaluation(is a process of gathering information about a person within a psychiatric or mental health services with the purpose of making a diagnosis) conducted at Hospital 3, dated [DATE],, indicated Resident A tried to use clothes or a bed sheet to try and strangle herself in her bathroom and there were strangle marks over the resident's neck. Resident A was brought to the emergency room , was placed on 72-hour hold for danger to self and was transferred to a psychiatric unit for acute psychiatric care and treatment. The psychiatric evaluation indicated Resident A heard voices telling her she has to kill herself and that was why she went to the bathroom and tried to strangle herself. The record reflected that the Resident A felt depressed, hopeless, useless and with some bizarre delusions (false belief) that her family members, her son and daughter were going to kill themselves. The evaluation further indicated there were also auditory hallucinations (perception of something not present) telling her to kill herself or her family members are going to do so. The resident was placed on suicidal precautions and due to major depressive disorder with psychotic (insane) feature and suicidal attempt. Hospital 3 discharged Resident A back to the skilled nursing facility, on [DATE]. The skilled nursing facility ' s admission face sheet indicated Resident A was readmitted to the facility from Hospital 3, on [DATE], with [DIAGNOSES REDACTED]. Resident A's physician's orders [REDACTED]. for psychosis (severe mental disorder in which thoughts and emotions are impaired), manifested by auditory hallucinations hearing voices saying someone will kill her son so she has to leave to save him; and Lorazepam 0.5 mg, by mouth, as needed every 6 hours, for anxiety manifested by agitation. On [DATE], a review of the comprehensive care plan, dated [DATE], indicated the facility identified Resident A was at risk for further self-harm related to self-strangulation. The listed approaches included to monitor, document and report resident potential for suicide, monitor the resident's whereabouts, and monitor behavior manifestations daily. The plan also included to encourage religious functions. There was another care plan, dated [DATE], indicating Resident A had depression manifested by the resident's verbalization of feeling depressed; and having auditory hallucinations such as hearing voices saying her son will be killed and she has to leave to save him. The listed approaches included to monitor the resident's behaviors each shift and report any changes to the physician. The plan did not include specific measures of monitoring. The interventions failed to indicate environmental checks to remove objects the resident could use to harm or strangle herself again. There was an activity care plan re-evaluated, on [DATE], indicating Resident A attended group activities of choice, but preferred to stay in her room when not in the activity room. The interventions included to invite/encourage the resident to attend participate in group activity, be patient and give simple instructions, and call resident by her name. The plan failed to indicate precautions of not providing objects that may be used to harm herself. A nursing progress note, dated [DATE], indicated Resident A left the facility undetected. When asked about what happened to her Wander Guard (security system worn as a bracelet), Resident A showed the staff the Wander Guard bracelet that was cut and hidden under her pillow. The staff also found scissors inside Resident A ' s sewing kit and was removed from the sewing kit with the resident's permission. However, the care plans, including the activity plan were not revised to ensure the resident was not provided anything that she could use to harm herself. The Minimum Data Set (a standardized assessment and care planning tool), dated [DATE], indicated that Resident A spoke clearly, made herself understood, able to understand others, needed supervision (cueing, oversight, encouragement) for activities of daily living. The current [DIAGNOSES REDACTED]. On [DATE], a review of the social work progress notes, dated February 26, 2015, indicated Resident A had an increased behavior of auditory hallucinations such as hearing voices, someone is going to kill her son so she has to leave to save him. The social worker documented that the physician and the psychiatrist (a medical doctor who specializes in mental health) were made aware and the son was made aware of resident's increased behavior and encouraged to visit resident for emotional support and reassurance. The note indicated the psychiatrist would visit the resident during the first week in March. There was no evidence the Social Worker coordinated with the nursing staff to revise Resident A's plans of care for closer monitoring. There was no evidence the nursing staff monitored the resident's depression and potential for suicide, in accordance with the plan of care. The licensed nurses ' weekly notes and the licensed progress notes, from [DATE] to [DATE], did not indicate licensed nurses assessed Resident A for suicidal ideation related to depression. On [DATE], a psychiatric progress note indicated that Resident A was depressed, paranoid, but denied suicidal thoughts. This progress note also stated the resident said she just wanted to go to church to see if her son was safe or not. The nurses ' progress notes indicated that, on [DATE], at 12:30 p.m., when the CNA was about to serve lunch, the Resident A was not in the room. The staff searched all over and they found the resident at the Buddhist Temple about 50 yards away from the facility. On [DATE], at 2:30 p.m., Staff 2 indicated during visual rounds Resident A and found crying and the resident refused to eat. There was no indication the staff identified the behavior exhibited as signs of depression. The staff did not conduct environmental check and supervision to ensure the resident was safe and not voicing suicidal thoughts. At 2:55 PM, Staff 2 indicated seeing Resident A on the floor with her head hanging against the side rail with a piece of cloth around her neck. Nursing staff removed the piece of cloth and started CPR (cardio-pulmonary resuscitation) and called 911. On [DATE], at 1:30 p.m., during an interview, Staff 2 stated that, on [DATE], at 2:30 p.m., she checked Resident A, who was in her room located across the nursing station. She observed Resident A was lying in bed, crying and the privacy curtain was not drawn. Resident A told Staff 2 that she was worried about her son. On [DATE], at 2:55 p.m., Staff 2 returned to Resident A's room, and observed the resident's privacy curtain was drawn. As Staff 2 entered the resident's room, Staff 2 saw the resident lying on the floor (next to her bed) with the resident's upper body leaning against the bed. Staff 2 opened the resident's privacy curtain and saw Resident A's face was blue and not breathing. Staff 2 immediately called Code Blue (a medical emergency code). In less than a minute, another nursing staff came into the room and tried to assist Staff 2 to place Resident A on her bed. Staff 2 explained that two staff were not able to move the resident because there was a cloth belt tied around Resident A's neck. Staff 2 released the belt, placed the resident on her bed and initiated CPR (Cardiopulmonary Resuscitation-An emergency procedure performed manually to restore spontaneous blood circulation and breathing in a person who is in cardiac distress.) Within a couple of minutes, paramedics arrived and took over the CPR, but they were not able to revive the resident. On [DATE], at 3:10 p.m., Resident A expired. During an interview with Staff 1, on [DATE], at 3 p.m., when asked about how the staff were monitoring Resident A, Staff 1 stated they were monitoring every hour, but was not able to show evidence this was done. When asked about the how the resident got a cloth belt tied around Resident A ' s neck, Staff 1 stated the activity staff (not available for an interview) gave a sewing kit to Resident A as an individual activity. The resident had sewn a cloth belt with buttons on it. On [DATE], at 3:30 p.m., a review of the facility's suicide threats policy and procedure, dated [DATE], with Staff 1 was conducted. According to the policy, the charge nurse is responsible for removing any dangerous objects from the resident's possession (i.e., glass objects, shoelaces, razors and/or blades, nail clippers or files, metal eating utensils, cords or belts, or excess linen). Residents under suicide precaution are allowed to use these articles only with constant and ample supervision. On [DATE], at 3:10 p.m., a review of the medical examiner's autopsy report, dated [DATE], was conducted. According to the medical examiner, Resident A's cause of death was asphyxia (a condition caused by lack of oxygen to the body due to choking which can lead to coma or death) due to hanging. It indicated the resident's manner of death was suicide.