Every finding on record at Fowler Care Center

Based on observation, interview and record review the facility failed to ensure infection prevention and control practices were followed for cleaning and disinfecting shared resident care equipment for two of five sampled residents (Resident 13 and 6) when Licensed Vocation Nurse 1 used a blood pressure cuff (a medical equipment used to measure blood pressure) to assess Resident 13, and utilized the same blood pressure cuff for Resident 6 without cleaning or disinfecting the device between residents. This failure had the potential risk for Resident 13 and Resident 6 to be exposed to cross-contamination (the unintended transmission of infectious organisms) through shared resident care equipment. Findings:During an observation on 7/1/26 at 8:11a.m., during the medication administration task, Licensed Vocational Nurse (LVN) 1 stated she was going to obtain Resident 13's blood pressure. LVN 1 retrieved a blood pressure cuff from the bottom drawer of the medication cart and obtained Resident 13's blood pressure. After obtaining the blood pressure, LVN 1 returned to the medication cart and placed the used blood pressure cuff on top of the medication cart. After completing medication administration for Resident 13, LVN 1 stated she needed to retrieve a vitamin supplement from another medication stockroom because it was not available in the medication cart. Prior to leaving the medication cart, LVN 1 placed the used blood pressure cuff into the bottom drawer of the medication cart and locked the cart. LVN 1 returned to the medication cart with the supplement, unlocked the cart and stated she was going to administer medications to Resident 6. LVN 1 retrieved the same blood pressure cuff from the bottom drawer of the medication cart without cleaning or disinfecting. LVN 1 entered Resident 6's room and used the same blood pressure cuff to obtain Resident 6's blood pressure. During an interview on 7/1/26 at 8:49 a.m. with LVN 1, LVN 1 stated she would normally clean the blood pressure cuff on all sides, wrap it in a disinfectant wipe, and use another blood pressure cuff while allowing the used cuff to remain wet for the required contact time. LVN 1 stated, I forgot to do that process today. I was nervous. LVN 1 further stated it was important to ensure equipment was clean and sanitary before resident use to promote proper hygiene and resident safety. During an interview on 7/1/26 at 9:16 a.m. with the Infection Preventionist (IP), the IP stated staff were expected to clean shared resident care equipment, including blood pressure cuffs, between resident using the purple disinfectant wipes and allow the blood pressure cuffs to air dry. The IP stated staff received education on cleaning shared resident care equipment through in-service training and ongoing reminders. The IP stated if staff were observed failing to disinfect equipment between resident use, they would be reeducated on the proper cleaning process and required to demonstrate competency. The IP further stated it was important to disinfect blood pressure cuffs between resident use because organisms could be transferred from one resident to another, resulting in spread of infection. During an interview on 7/1/26 at 3:34 p.m. with the Director of Staff Development/Minimum Data Set Nurse (DSD/MDSN), the DSD/MDSN stated staff were expected to clean blood pressure cuffs between resident use using the facilities purple Sani wipes. The DSD/MDSN stated the Sani wipes required a two-minute contact time and the facility had two blood pressure cuff available so staff could alternate their use while allowing the disinfectant to remain on the cuff for the required contact time. The DSD/MDSN further stated it was important to clean blood pressure cuffs between resident use to reduce the risk of infection transmission between residents. During an interview on 7/2/26 at 9:29a.m. with the Director of Nursing (DON), the DON stated staff were expected to clean and disinfect shared resident care equipment, including blood pressure cuffs, between resident use using Sani wipes and allow the disinfectant to remain on the equipment for a two minute contact time before using it with another resident. The DON stated the facility monitored compliance by conducting rounds, during which the IP observed staff performing equipment cleaning and hand hygiene practices. The DON stated nursing staff received education on cleaning shared resident care equipment through in-service training. The DON if a staff member was observed failing to clean equipment between resident use, the staff member would be reeducated. The DON further stated if the behavior became a pattern, disciplinary action would be taken. The DON stated it was important to properly clean shared resident care equipment between resident use to prevent the spread of infection. During a review of facilities policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Equipment, dated 2025, the P&P indicated, reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection.reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs, feeding tube pumps, and oxygen concentrators.each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident.multiple-resident use equipment shall be cleaned and disinfected after each use.During a review of facilities policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 2025, the P&P indicated, all reusable items and equipment requiring special cleaning, disinfection or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.

Based on observation, interview, and record review, the facility failed to ensure food was stored and served safely in accordance with professional standards of food service safety for 41 out of 41 residents eating at the facility when six loafs of unopened bread were not labeled of a use by date (is the deadline after which a product may no longer be safe to use) and a opened 2.26 kilogram (kg-a unit of measurement) canister of sour cream was retained past its use by date.This failure placed residents who consumed food from the kitchen at potential risk to be exposed to foodborne illness (food poisoning). Findings:During a concurrent observation and interview on 6/29/26 at 8:04 a.m. with the Certified Dietary Manger (CDM), in the kitchen, an opened 2.26 kg canister of sour cream was observed labeled with an open date of 6/20/26 and a use by date of 6/27/26. The label indicated the sour cream was 2 days past the use by date. The CDM stated sour cream was a dairy product and per facility policy and procedure all dairy products needed to be used within 7 days of opening. The CDM stated the canister of sour cream had been expired for 2 days and retained within the kitchen. The CDM stated it was important not to retain expired food items in the kitchen to prevent accidental serving of expired food items to residents which could result in foodborne illness. The CDM stated all kitchen staff were responsible for ensuring expired food items were removed on their use by date.During a concurrent observation and interview on 6/29/26 at 8:11 a.m. with the CDM, in the kitchen, six loafs of unopened bread were observed with no labels. The CDM stated the six loafs of bread did not have a label to indicate received by or use by dates. The CDM stated it was important to label all food items to ensure food was rotated on a first in, first out cycle and prevent the serving of expired food items which could result in foodborne illness.During an interview on 6/30/26 at 11:27 a.m. with the Registered Dietician (RD), the RD stated all food items were expected to be labeled with received, opened and use by dates, per facility policy and procedure. The RD stated it was important to label all food items to ensure food was rotated on a first in, first out cycle to prevent expired food items from being served. The RD stated all kitchen staff were responsible for ensuring food items were labeled, per facility policy and procedure, before being stocked on the shelves. The RD stated if food items were not labeled and retained past their use by date there was a risk expired food items would be served to residents. The RD stated consuming expired food items could lead to food borne illness.During an interview on 7/2/26 at 9:28 a.m. with the Director of Nursing (DON), the DON stated kitchen staff were expected to adhere to food safety standards of practice and facility policy and procedure, which included labeling all food items with received, opened and use by dates, and discarding expired food items by the use by date. The DON stated food safety standards of practice and facility policy and procedure were not followed when six loafs of unopened bread were not labeled with a received or use by date and a canister of sour cream was retained 2 days past its use by date. The DON stated residents were placed at risk of being served ecpired food items which could result in foodborne illness.During a review of the facility's document titled, Diet Type Report, dated 7/7/26, the document indicated 41 residents received meals from the kitchen.During a review of the facility's policy and procedure (P&P) titled, Date Marking for Food Safety, dated 2026, the P&P indicated, .the facility adhere to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety of food.the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. the discard day or date may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. The date of opening or preparation counts as day 1.the Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly.During a review of the facility's P&P titled, Food Safety Requirements, dated 2026, the P&P indicated, .labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded.During a review of the facility's P&P titled, Dry Storage Guidelines, undated, the P&P indicated, .bread 5-7 days.During a review of the facility's P&P titled, Refrigerator Storage Guide, undated, the P&P indicated, .dairy products.after opening it may be used for a maximum of 7-days.sour cream.opened: max. of 7 days.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each residents for one of five sampled residents (Resident 13) when Licensed Vocational Nurse (LVN) 1 did not administer physician ordered apixaban (medication used to prevent blood clots [clumps of blood that can block the blood flow through the body]) 5 milligrams (mg-a unit of measurement that was used to show a very small amount of a medication) twice daily on 7/1/26. LVN 1 was aware of the unavailability of Apixaban and did not notify the pharmacy.This failure resulted in Resident 13 not administered physician ordered apixaban and placed Resident 13 at potential risk for sub-therapeutic medications level and subsequent blood clot formation, which could lead to stroke (blood flow to the brain is blocked) and deep vein thrombosis (formation of blood clots in the legs). Findings:During an observation on 7/1/26 at 8:11a.m. during the medication administration observation task, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 13's scheduled apixaban was being held because it was not available in the medication cart. LVN 1 administered the remainder of Resident 13's scheduled morning medications. LVN 1 documented in Resident 13's electronic health record that the scheduled dose of apixaban was not administered. During a review of Resident 13's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 13 was admitted to the facility on [DATE] with a diagnosis which included morbid obesity (had a very high amount of body fat), difficulty walking, heart failure (the heart did not pump blood as well as it should), atrial fibrillation (the heart beat with an irregular rhythm [the heart did not beat in a steady pattern]), and peripheral vascular disease (the blood vessels outside the heart became narrowed and reduced blood flow). During a review of Resident 13's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 13's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 13 out of 15 which indicated Resident 13 had no cognitive deficit.During a review of Resident 13's Order Summary Report, dated July 2026, the Order Summary Report indicated, Resident 13's apixaban oral tablet 5mg oral tablet was ordered to be administered by mouth two times daily. During a concurrent interview and review of Resident 13's electronic health record on 7/1/26 at 8:49 a.m. with LVN 1, LVN 1 stated Resident 13's last dose of apixaban was administered on 6/30/26 at 4 p.m. LVN 1 confirmed Resident 13 was scheduled to receive apixaban twice daily at 8 a.m. and 4 p.m. LVN 1 confirmed Resident 13 did not receive the scheduled 8 a.m. dose because the medication was not available. LVN 1 stated if the facility was completely out of a medication, the pharmacy could be contacted to obtain the medication for the resident's evening dose. LVN 1 stated it was the responsibility of every nurse to ensure medications were ordered and available, and it was important for residents to receive their medications as scheduled. LVN 1 stated apixaban was important for Resident 13 because it was prescribed for anticoagulation (to help prevent blood clots from forming). LVN 1 stated the risk of Resident 13 not receiving the medication as scheduled included blood clots or the medication not remaining at a therapeutic level.During an interview on 7/1/26 at 3:34 p.m. with the Director of Staff Development/Minimum Data Set Nurse (DSD/MDSN), the DSD/MDSN stated if a medication was not available when it was time to administer, the nurse would contact the pharmacy to request a stat [immediately] order and contact the physician to obtain a stat order, if needed. The DSD/MDSN stated the facility's process for obtaining a medication not in stock was to contact the physician, obtain a one-time order of the medication and administer it to the resident. The DSD/MDSN stated nursing staff were responsible for submitting medication refill requests by attaching the medication sticker to the refill document and faxing it to the pharmacy. The DSD/MDSN stated nursing staff were expected to follow up with the pharmacy regarding refill requests. The DSD/MDSN stated when a resident missed a scheduled medication due to the medication not being available, the missed dose would be documented on the Medication Administration Record (MAR) as unavailable, in the medication administration notes, and a progress note would be completed. The DSD/MDSN stated it was important for residents to receive medications as ordered by the physician. The DSD/MDSN stated apixaban was an anticoagulant and it was important for the medication to be administered as ordered to Resident 13. During an interview on 7/2/26 at 9:29 a.m. with the Director of Nursing (DON), the DON stated when Resident 13 prescribed medication, such as apixaban, was unavailable at the scheduled administration time, nursing staff were expected to first check the emergency medication kit (e-kit). The DON stated if medication was not available in the e-kit, nursing staff were expected to contact the physician and the pharmacy to obtain a stat order. The DON stated nursing staff were expected to notify Resident 13 and the responsible party (RP) regarding the unavailable apixaban medication. The DON stated nursing staff were expected to reorder medications when they reached the last row of the bubble pack to ensure an adequate medication supply was maintained. The DON stated when a scheduled medication was unavailable, nursing staff were expected to document the medication as unavailable, document the physician and pharmacy had been contacted, document the resident and RP had been notified, and document the anticipated arrival time of the medication. The DON stated the facility monitored medications that were running low by checking medication carts, conducting random audits to verify medications had been reordered, and providing in-service education to nursing staff regarding timely medication reordering. The DON stated medications could be ordered through the electronic health record or by faxing the order to the pharmacy. The DON stated nursing staff could also check the e-kit and obtain an emergency supply when appropriate. The DON stated it was important for Resident 13 to receive prescribed apixaban medications as ordered to reduce the risk of complications. The DON stated if Resident 13 stopped taking apixaban, Resident 13 could experience coagulation issues (problems with the blood clotting normally) and could experience an adverse reaction if the medication was stopped abruptly. During a review of the facility's Policy and Procedure (P&P) titled, Ordering and Receiving Non-Controlled Medications, 2010, the P&P indicated, timely delivery of new orders is required so that medication administration is not delayed.promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.During a review of the facility's Policy and Procedure (P&P) titled, Unavailable Medications, 2026, the P&P indicated, the facility shall follow established procedures for ensuring residents have a sufficient supply of medications.

Based on observation, interview and record review the facility failed to ensure the daily nurse staffing information publicly posted accurately reflected actual nursing staffing hours. The facility posted projected nursing staffing hours. This deficient practice had the potential to affect all 42 residents residing in the facility upon entrance.This failure had the potential to prevent residents, resident representatives and visitors from accessing accurate daily nurse staffing information intended to inform the public of the facility's actual nurse staffing levels. Findings:During an observation on 6/29/26 at 8:01a.m., the daily nurse staffing information was posted in the facility. The posted document was dated Friday, June 26, 2026. The posting identified a projected resident census of 41, projected staff hours of 156, and a projected Nursing Hours Per Patient Day (NHPPD) of 3.80. The posting reflected projected staffing information for the day rather than the previous day's actual hours worked. No posting reflecting the actual hours worked for the previous day was observed. During an interview on 7/2/26 at 1:07 p.m., with the Director of Staff Development (DSD), the DSD stated he was responsible for preparing and posting the daily nurse staffing information using the daily census and staff schedules. The DSD stated he typically prepared the posting the night before and updated it as needed for staffing changes. The DSD stated the posted staffing information reflected the projected staffing hours for the current day. The DSD further stated the previous day's actual staffing information was maintained behind the current posting. During a concurrent observation of the staffing posting location with the DSD, the previous day's staffing information was not observed behind the current posting. The DSD stated the Human Resources staff member had likely removed the previous day's posting for filing. The DSD stated if staff called in sick or left early, the posting generally remained unchanged because coverage was usually obtained. If coverage could not be secured, he recalculated the staffing hours and posted a revised document. The DSD stated his understanding was that the daily nurse staffing information was required to be posted daily, be accurate, and reflect the current resident census.During an interview on 7/2/26 at 9:37 a.m., with the Director of Nursing (DON), the DON stated the DSD was responsible for preparing and posting the daily nurse staffing information. The DON stated the daily staffing information was expected to be posted each day and that both the projected staffing hours and actual nursing staffing hours were to be posted. When informed the staffing information observed on 6/29/26 reflected Friday's staffing information, the DON stated the posting had not been updated because the DSD had not yet posted the current day's information. The DON further stated the facility only posted projected nursing staffing information and that actual nursing staffing hours were not publicly posted. The DON stated Human Resources verbally communicated the actual nursing staffing hours during the daily stand-up meeting. When asked if she was aware of the facility's written policy directed staff to post projected nursing staffing information rather than actual nursing staffing hours, the DON stated she was not aware the policy referred to projected staffing information. When asked if she was aware the federal requirement was to publicly post actual nursing staffing hours, the DON stated she believed the requirement was to post projected nursing staffing information. The surveyor reviewed Appendix PP, SOM, F732 and 42 CFR S 483.35(g) with the DON. Following review, the DON verbalized understanding that the federal regulation required facilities to publicly post actual nursing staffing hours. The DON further stated that if a resident or family member wanted to know the actual nursing staffing hours, they would have to ask a staff member because the actual nursing staffing hours were not publicly posted. The DON stated it was important for residents and family members to have access to the staffing information so they could know the facility had sufficient staffing to provide resident care.During a review of facilities policy and procedure (P&P) titled, Nurse Staffing Posting Information, dated 2025, the P&P indicated, The nurse staffing sheet will be posted on a daily basis and will contain the following information: d. the total number and projected hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.According to the Electronic Code of Federal Regulations (eCFR), Title 42, Chapter IV, Subchapter G, Part 483.35(g), facilities must publicly post daily nurse staffing information, including the actual hours worked by registered nurses, licensed vocational/practical nurses, and certified nurse aides.Electronic Code of Federal Regulations (eCFR). (2026). Title 42-Public Health, Chapter IV, Subchapter G, Part 483-Requirements for States and Long-Term Care Facilities, S 483.35(g), Nurse Staffing Information. National Archives and Records Administration. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483

Based on observation, interview, and record review the facility failed to meet professional standards of practice for one of ten sampled residents (Resident 41) when Resident 41's physician's order for physical therapy referral was not followed.This failure resulted in Resident 41's physician's order for a physical therapy referral not being implemented, from 3/2/226 to 6/29/26, which could lead to delays in care. Findings:During a concurrent observation and interview on 6/29/26 at 10:02 a.m. with Resident 41, in Resident 41's room, Resident 41 stated he previously received physical therapy services and had been transitioned to the Restorative Nursing Program for ongoing therapy services. Resident 41 stated his provider placed a new physical therapy referral and he had not seen the physical therapist. Resident 41 could not state the date the provider placed the physical therapy referral.During a concurrent interview and record review on 6/30/26 at 11:45 a.m. with the Director of Rehabilitation (DOR), Resident 41's Physical Therapy Notes, dated 6/30/26, were reviewed. The DOR stated physical therapy had not received a referral for Resident 41. The DOR stated physical therapy had not seen Resident 41 since 3/2025, when he completed his therapy service period. The DOR stated a provider could place a physical therapy referral order if requested by the resident or care team for mobility progress. The DOR stated after a provider placed a physical therapy referral, licensed nursing staff were responsible for relaying the referral to the physical therapy department and the physical therapy department would then arrange a date and time to assess the resident, despite insurance coverage. The DOR stated after the resident was assessed, physical therapy would make recommendations for physical therapy, if applicable, and send the request to insurance.During a concurrent interview and record review on 6/30/26 at 10:51 a.m. with the Director of Nursing (DON), Resident 41's electronic medical record (eMAR), dated 6/30/26, was reviewed. The DON stated on 3/2/26 Resident 41 had an order for physical therapy referral. The DON stated Resident 41's physical therapy referral, on 3/2/26, was not sent to the DOR or the physical therapy department. The DON stated there was no documentation or assessment to indicate physical therapy had assessed Resident 41, as per provider orders.During an interview on 7/2/26 at 9:46 a.m. with the DON, the DON stated Resident 41 had a physical therapy referral order on 3/2/26 that was not implemented. The DON stated clinical nursing staff were responsible for ensuring new orders were implemented. The DON stated facility policy and procedure were not followed when Resident 41's provider orders were not followed. The DON stated Resident 41 was at risk for physical mobility decline and delay in plan of care when provider orders were not followed.During a review of the facility's Policy and Procedure (P&P) titled, Telephone/Verbal Orders, dated 2026, the P&P indicated, .follow through with orders by making appropriate contact or notifications .During a review of the facility's P&P titled, Therapy Evaluation, dated 2025, the P&P indicated, .the Licensed Therapist will perform an initial resident evaluation upon physician referral and any re-evaluation where indicated.the Rehabilitation Department will be notified when a physician order is written for therapy.the Licensed Therapist will perform a chart review and initiate the evaluation.evaluations will be documented.During a review of the facility's P&P titled, Reporting of Therapy Services, dated 2025, the P&P indicated, .all specialized rehabilitation services are provided in accordance with physician orders.During a review of the professional reference titled, A Grounded Theory of the Implementation of Medical Orders by Clinical Nurses, retrieved from, https://pmc.ncbi.nlm.nih.gov/articles/PMC10863222/, dated 2/13/24, the professional reference indicated, .The implementation of medical orders is a crucial responsibility for clinical nurses, as they bear legal accountability for the precise implementation of directives issued by medical practitioners.

Based on observation, interview, and record review the facility failed to ensure one of ten sampled residents (Resident 15) were assessed to self-administer and store mediations at bedside when Resident 15 had a bottle of [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9% (over the counter eye drop medication used to treat dry eyes)] eye drops stored at bedside for self-administration with no order or Medication Self-Administration Assessment Form (MSA- an assessment form to determine if a resident is clinically appropriate to safely and securely store and self-administer their own medication at bedside).This failure resulted in Resident 15 self-administering and storing medication at bedside without oversight which could lead to duplicate therapy, medication interactions and adverse effects.Findings:During an observation on 6/29/26 at 8:49 a.m. in Resident 15's room, Resident 15 was observed sitting up in bed. Resident 15 had a clear bin on his bedside nightstand with [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9%] eye drops visible.During an observation on 6/29/26 at 3:04 p.m. in Resident 15's room, Resident 15 was observed sitting up in bed. Resident 15 had a clear bin on his bedside nightstand with [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9%] eye drops visible.During a concurrent observation and interview on 6/29/26 at 3:13 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 15's room, Resident 15 was observed sitting up in bed. Resident 15 had a clear bin on his bedside nightstand with [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9%] eye drops visible. LVN 2 stated Resident 15 had eye drop medication at bedside. Resident 15 stated the eye drops were his and he self-administered them at bedside.During a concurrent interview and record review on 6/29/26 at 3:25 p.m. with LVN 2, Resident 15's electronic medical record (eMAR), dated 6/29/26, was reviewed. LVN 2 stated Resident 15 was confused and confused residents were not candidates to safely and securely store and/or self-administer medication at bedside. LVN 2 stated Resident 15 did not have a provider order for [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9%] eye drops. LVN 2 stated Resident 15 did not have provider orders, a Medication Self-Administration Assessment Form (MSA), or a care plan to store and/or self-administer [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9%] eye drops at bedside. LVN 2 stated all medications required a provider order. LVN 2 stated all medications stored and self-administered at bedside required a provider order, a care plan, and a MSA to ensure oversight. LVN 2 stated Resident 15 was at risk for duplicate therapy, medication interactions and adverse effects when he stored and self-administered [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9%] eye drops at bedside without an order or MSA. During an interview on 7/2/26 at 9:46 a.m. with the Director of Nursing (DON), the DON stated Resident 15 was confused and not an appropriate candidate to safely and securely store and/or self-administer medications at bedside. The DON stated Resident 15 did not have an order for [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9%] eye drops. The DON stated Resident 15 did not have a MSA or care plan completed to store and self-administer [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9%] eye drops at bedside. The DON stated Resident 15 was placed at risk for duplicate therapy, medication interactions, adverse effects and infection from improper eye drop medication administration. The DON stated the facility was responsible for identifying hazards and accidents to ensure resident safety, which included medication stored and self-administered at bedside. The DON stated facility policy and procedures were not followed when Resident 15 had an unidentified medication at bedside with no order, MSA, or care plan which posed a potential risk to Resident 15's safety.During a review of Resident 15's admission Record (AR -a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/30/26 the AR indicated Resident 15 was admitted to the facility on [DATE] with diagnoses of dementia (decline in ability to think), muscle weakness, and encephalopathy (decline in brain function). During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/11/26, the MDS indicated Resident 15 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 10 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 15 was moderately cognitively impaired.During a review of the facility's policy and procedure (P&P) titled, Resident Self-Administration of Medication, dated 2026, the P&P indicated, . a resident may only self-administer medication after the facility's interdisciplinary team has determined which medication may be self-administered safely.the results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record.the following conditions are met for bedside storage to occur.the manner of storage prevents access by other residents.all nurses and aides are required to report to the charge nurse on duty medication found at the bedside not authorized for bedside storage.During a review of the facility's P&P titled, Accidents and Supervision, dated 2025, the P&P indicated, .the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accident. This includes.identifying hazard(s) and risk (s).all staff.are to be involved in observing and identifying potential hazards in the environment.various sources provide information about hazards and risks in the resident environments.these sources may include, but are not limited to.environmental rounds.individual observation.

Based on interview and record review, the facility failed to ensure licensed nurses have the specific competencies necessary to assure residents maintained their highest practicable physical, mental and psychological well-being when Director of Staff Development (DSD) 1 failed to meet the two-year nursing experience qualification. This failure had the potential to result in ineffective staff training, inadequate competency oversight, and negative resident care outcomes. During an interview on 5/7/26 at 11:57 am with DSD 1, DSD 1 stated she had been employed as a Licensed Vocational Nurse as of October 2024 and transitioned to the DSD role on May 1, 2026. During a concurrent interview and record review on 5/7/26 at 1:29 pm with the Director of Nursing (DON), Staff Development Coordinator Job Description (JD) dated 2020 and Director of Staff Development Competency Checklist, not dated were reviewed. The JD indicated, Required Qualifications-Minimum requirements include the following: two years of experience as an LPN/RN. The Checklist indicated, 1. Job Description a. Qualification and Training Requirements (RN or LVN) Option 1: Have one year experience as a licensed nurse providing direct paint care in a long-term care facility, in addition to having one year of experience planning, implementing, and evaluating educational programs in nursing (for a total of two years), Option 2: Have two years of full-time experience as a licensed nurse, at least one of which must be in the provision of direct patient care in a nursing facility was dated 4/28/26 and initialed by the DON. The DON stated DSD 1 does not meet the two-year nursing experience requirement at this time. The DON stated the DSD 1 should not be working as the DSD as she does not meet the requirements for the role. During a concurrent interview and record review on 5/7/26 at 2:35 pm with the Administrator (ADM), Staff Development Coordinator JD, dated 2020 was reviewed. The JD indicated, Required Qualifications-Minimum requirements include the following: two years of experience as an LPN/RN. The ADM stated DSD 1 would not meet the two year's nursing experience until October 2026. The ADM stated DSD 1 did not meet the qualifications of the position and should not be working as the DSD. During a review of Board of Vocational Nursing & Psychiatric Technicians Licensing Details for the DSD 1, dated 5/7/26, the licensing details indicated an issuance date of 9/25/24.

Based on interview and record review, the facility failed to ensure sufficient supervision to prevent falls for one of six sampled residents (Resident 1), who was assessed as a high fall risk , when Certified Nursing Aide (CNA) 4 left Resident 1 unattended in the restroom while retrieving a diaper and Resident 1 got up from the toilet unassisted, lost his balance and fell. This failure resulted in Resident 1's sustaining a left shoulder fracture.During an interview on 4/2/26 at 2:46 pm with CNA 2, CNA 2 stated CNAs should prepare all necessary supplies before helping residents to the restroom. CNA 2 stated residents must not be left alone in the restroom because they could try to stand up, become unsteady, and fall. CNA 2 stated if additional supplies were needed, CNAs should press the call light button in the restroom and wait for help. During an interview on 4/2/26 at 3:19 pm with CNA 3, CNA 3 stated residents should always be supervised in the restroom to prevent the residents from falling. CNA 3 stated if supplies were needed the CNA should call for help. CNA 2 stated she was taught it was best to stay and supervise the residents. During an interview on 4/2/26 at 3:36 with Licensed Vocational Nurse (LVN), LVN stated it was not safe to leave a resident alone while toileting. LVN stated the CNA would be expected to use the call light to get another staff member to assist with supplies so the residents would not be alone. LVN stated if a resident was left alone in the restroom, they could get up by themselves, fall and get hurt. During a review of the Facility's Declaration Statement dated 3/25/26, the Declaration Statement indicated Resident 1 had loose BM all afternoon and asked CNA 4 to take him to the toilet. CNA 4 wheeled Resident 1 to the restroom and noted Resident 1's diaper was full of stools. CNA 4 decided to grab a diaper that was left on the resident's nightstand. CNA 4 told Resident 1 do not stand up and Resident 1 stated okay, I will unbuckle my shorts till then. When CNA 4 returned, Resident 1 was wobbly on his feet.he hit his left shoulder on the sink. CNA 4 caught Resident 1 and placed him on the toilet. During an interview on 4/2/26 at 3:56 pm with the Minimum Data Set (MDS) nurse, MDS stated the CNA should gather supplies before assisting residents to the restroom. MDS stated if a CNA needed supplies, the CNA should use the emergency call light in the restroom to call for help. MDS stated the CNA should not leave the resident unattended as the resident would be at increased risk for falls/injury. MDS stated Resident 1 had severe cognitive impairment and had difficulty understanding and processing when you speak to him. MDS stated Resident 1 was at high risk for falls, was not good at asking staff for assistance and liked to self-transfer. MDS stated CNA 4 should not have left Resident 1 unattended. During a record review of Resident 1's admission Record (AR), dated 4/10/26, the AR indicated Resident 1 had a history of a broken left arm, type 2 diabetes mellitus (a long-term condition where the body cannot effectively use insulin to manage blood sugar, causing levels to become too high), muscle weakness, broken right shoulder blade, need for assistance with personal care, difficulty walking, alcohol dependence, anemia (lack red blood cells causing people to feel tired, weak, dizzy, or short of breath), conversion disorder with seizures (a condition where a person experiences real, involuntary seizure-like episodes). During a record review of Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life), dated 3/3/26, the BIMS indicated a score of 3 indicating severe impairment (score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). During a concurrent interview and record review with the Director of Nursing (DON), Resident 1's Fall Risk Evaluation dated 3/3/26, OT Discharge summary dated [DATE] and Progress Note Type: IDT Notes dated 3/26/25 were reviewed. The Fall Risk Score of 11.0 indicated at High Fall Risk. The OT Discharge Summary indicated Toilet Transfer Partial/Moderate assistance (the patient can perform 50% of the mobility task while the caregiver assists with 50%). The IDT Note indicated .CNA reported that the resident requested assistance to the bathroom for a bowel movement. CNA assisted the resident onto the toilet and instructed the resident in Spanish to remain seated while she briefly left the room to obtain a brief. Upon returning, CNA observed the resident standing and beginning to lose balance. Before full loss of balance occurred, the resident's left shoulder made contact with the sink. During an interview with the DON, the DON stated Resident 1 required supervision and should not have been left alone. The DON stated she would expect the staff to stay with the resident when toileting a high risk for fall resident. The DON stated Resident 1 was alone when he lost his balance. The DON stated the lack of supervision resulted in Resident 1 having a loss of balance and shoulder injury. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment not dated, the P&P indicated .It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision.to each resident to prevent avoidable accidents. During a review of professional reference review retrieved from https://www.ncbi.nlm.nih.gov/books/NBK43626/table/advances-kline_32.t3/ National Library of Medicine titled, Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment), dated 8/2008 indicated Table 3 Interventions for patients assessed with high risk for falling Standard interventions for high -risk patients.4. Remain with patient while toileting.Additional interventions Physical limitations or motor deficits.3. Supervise and/or assist with toileting. During a review of professional reference review retrieved from https://dudensinglaw.com/nursing-home-obligations-fall-prevention/#:~:text=Toileting%20Plans,Bedrails Dudensing Law titled, Fall Prevention: Nursing Home Obligations, dated 6/30/25 indicated .Unsupervised bathroom use (often due to understaffing) is a common contributor to falls. A scheduled toileting routine tailored to each resident's needs can help minimize the risk of falls.Supervision-Close monitoring is vital for residents at high risk of falling. This can include: .increasing staffing presence during high-risk times or activities.

Based on observation, interview, and record review, the facility failed to ensure food and ice were stored, prepared, and served safely in accordance with professional standards for food service safety for 44 out of 44 residents at the facility when: 1. Honey mustard packets ready for residents' use were expired. 2. Honey mustard packets and frozen sausage pizza toppings were not labeled. 3. A dietary aides personal belonging was observed on the kitchen spice preparation rack. 4. The ice machine water pump (a compartment within the ice machine that carries water) was observed with black spots. These failure resulted to unsafe food handling practices which had the potential risk to caused cross contamination (occurs when harmful bacteria are transferred from one surface or food to anther) and foodborne illness (occurs when a person consume contaminated food or beverages) for the 44 residents at the facility. Findings: 1. During a concurrent observation and interview on [DATE] at 9:32 a.m. with the Certified Dietary Manager (CDM) in the kitchen dry storage room, a brown box filled with individual honey mustard packets was observed to have a use by date (is the last date recommended for the consumption of a product while its at its best quality) of [DATE]. The CDM stated the individual honey mustard packets were expired per the use by date of [DATE] on the brown box. The CDM stated it was the responsibility of the entire kitchen staff to identify expired food items in the kitchen. The CDM stated all expired food items were expected to be removed from the kitchen. The CDM stated she completed kitchen rounds twice a week. The CDM stated the individual honey mustard packets should have been identified during kitchen rounds and removed. 2. During a concurrent observation and interview on [DATE] at 9:32 a.m. with the CDM in the kitchen dry storage room, a brown box filled with individual honey mustard packets was observed to have no open date (refers to the date a product was opened or first used). The CDM could not locate an open date on the box. During an observation with the CDM in the kitchen freezer, frozen sausage pizza topping was observed with no receive date, open date, or use by date. The CDM could not determine the received date, open date, or use by date on the frozen sausage pizza topping. The CDM stated all food items were expected to have a label with the receive date, open date, and use by date. The CDM stated it was the responsibility of the entire kitchen staff to label food items with the receive date, open date, and use by date. The CDM stated it was the responsibility of the entire kitchen staff to identify food items that were not labeled correctly. The CDM stated she completed kitchen rounds twice a week and reviewed food items for accurate labeling. The CDM stated food items were labeled with receive date, open date, and use by dates to prevent the use of expired food items when cooking or serving food to residents. The CDM stated residents were at risk for foodborne illness is they ate expired honey mustard packets or frozen sausage pizza topping. During an interview on [DATE] at 2:36 p.m. with the Registered Dietician (RD), the RD stated she completed monthly kitchen rounds to ensure food items were stored, prepared, distributed and served in accordance with professional standards for food safety. The RD stated the most recent kitchen audit was approximately two weeks ago but could not state the exact date. The RD stated she used the Department of Health and Human Services Centers for Medicare and Medicaid Services, Kitchen/Food Service Observation form to complete monthly kitchen rounds. The RD stated she did not identify the individual honey mustard packets or frozen sausage pizza toppings during her last monthly kitchen round. The RD stated all expired items were expected to be removed during monthly rounds. The RD stated all food items were reviewed during monthly kitchen rounds to ensure all food items were labeled with receive date, open date, and use by dates. The RD stated she expected all staff to remove expired food items when expired and label all food items with a receive date, open date, and use by date, per facility policy and professional standards. The RD stated residents were at risk for foodborne illness if they ate spoiled honey mustard packets or frozen sausage pizza toppings. During an interview on [DATE] at 8:48 a.m. with the CDM, the CDM stated when hired all kitchen staff were trained to label and date food items with the receive date, open date, and use by date. The CDM stated when hired all kitchen staff were trained to discard expired food items. The CDM stated on [DATE] she provided an in-service to all kitchen staff for labeling food items with receive date, open date, and use by dates. During an interview on [DATE] at 8:53 a.m. with the Administrator (ADM), the ADM stated she oversaw the CDM and RD. The ADM stated she did not complete any observations with the CDM and RD during kitchen rounds. The ADM stated the CDM and RD used the Department of Health and Human Services Centers For Medicare and Medicaid Services, Kitchen/Food Service Observation form to complete monthly kitchen rounds together. The ADM stated the most recent kitchen audit completed by the CDM and RD was approximately two weeks ago but could not state the exact date. The ADM stated she was responsible to review the kitchen audit form after it was completed. The ADM stated she expected all kitchen staff to remove expired food items, per facility policy and training. The ADM stated she expected all kitchen staff to label and date food items with the receive date, open date, and use by date, per facility policy and training. During a review of the facility's most recent kitchen audit form titled, Department of Health and Human Services Centers For Medicare and Medicaid Services, Kitchen/Food Service Observation, undated, the form indicated the entire kitchen was assessed. The form indicated, a check mark was placed next to the observation, .Food products are discarded on or before the expiration date .food stored, prepared, distributed, and served in accordance with professional standards for food safety . indicating food storage was reviewed and assessed for expired food items. 3. During a concurrent observation and interview on [DATE] at 9:32 a.m. with the CDM and Dietary Aide (DA) 1 in the kitchen, a cell phone was observed on the kitchen spice preparation rack. The CDM and DA 1 verified the cell phone on the kitchen spice preparation rack. DA 1 stated the cell phone was hers and should not be placed on the kitchen spice preparation rack. The CDM stated no personal belongings were allowed in the kitchen. The CDM stated all personal belongings were expected to be kept in employee lockers or on the designated rack outside of the kitchen. The CDM stated personal items in the kitchen presented an infection control issue and could cause food borne illness. During an interview on [DATE] at 2:36 p.m. with the RD, the RD stated she expected all kitchen staff to maintain a safe, clean and sanitary kitchen environment. The RD stated she expected all staff to follow facility infection control policies. The RD stated a cell phone on the kitchen spice preparation rack did not maintain a safe, clean and sanitary kitchen environment or follow facility infection control policies. The RD stated it was a risk for cross contamination and food borne illness to have a cell phone on the kitchen spice preparation rack. During an interview on [DATE] at 8:48 a.m. with the CDM, the CDM stated when hired all kitchen staff were trained to keep personal items out of the kitchen. The CDM stated she expected all kitchen staff to follow orientation training. The CDM stated on [DATE] she provided an in-service to all kitchen staff regarding cell phone storage outside the kitchen and allowed only on breaks. During an interview on [DATE] at 8:53 a.m. with the ADM, the ADM stated she expected all kitchen staff to keep personal belongings out of the kitchen. The ADM stated no personal belongings should be placed on the kitchen spice preparation rack. The ADM stated it was unsanitary to have a cell phone on the kitchen spice preparation rack and could contaminate food and lead to food borne illness. During an interview on [DATE] at 5:34 p.m. with the Director of Nursing (DON), the DON stated he expected all kitchen staff to follow facility policies which included, infection control, hygiene and food safety. The DON stated he expected all kitchen staff to follow infection control, hygiene and food safety trainings and in-services. The DON stated he expected all food items to be labeled with a receive date, open date and use by date to ensure no food items were served expired. The DON stated all residents who ate at the facility were at risk for receiving an expired food item if left in the kitchen. The DON stated expired food items could cause gastrointestinal (stomach) upset or foodborne illness and make residents sick. 4. During a concurrent observation and interview on [DATE] at 2:24 p.m. with the CDM and Maintenance Supervisor (MS) in the employee breakroom, black dots substance was seen on the water pump in the ice machine. The CDM and MS verified the black dots on the water pump in the ice machine. The MS removed the black dots substance on the water pump with a white napkin. The CDM and MS verified the black substance on the white napkin. The CDM stated she expected the ice machine to be clean, sanitary and free from black substance. During a concurrent observation and interview on [DATE] at 2:36 p.m. with the RD, a picture of the ice machine, dated [DATE], was reviewed. The RD stated she observed black substance as black dots on the water pump. The RD stated she expected the ice machine to be free from black substance. The RD stated the black substance on the water pump contaminated the ice and was a risk for foodborne illness to all 44 residents who ate at the facility. During an interview on [DATE] at 8:53 a.m. with the ADM, the ADM stated she expected the ice machine to always be free from black substance and clean. During a concurrent observation and interview on [DATE] at 5:34 p.m. with the DON, a picture of the ice machine, dated [DATE], was reviewed. The DON stated he observed black substance as black dots on the water pump. The DON stated he expected the ice machine to be clean and free from black substance. During a review of the facility's job description document titled, Dietary Aide, dated 2023, the document indicated, . follows appropriate safety and hygiene measures at all times to protect residents .follows established infection control policies and procedures .as a condition of employment, completes all assigned training and skills competency .maintains food storage areas in a clean and properly arranged manner at all times .assists in inventory and storing in-coming food, supplies, etc., as necessary . During a review of the facility's job description document titled, Dietary Manager, dated 2023, the document indicated, .oversees the budget and purchasing of food and supplies, and food preparation, services, and storage .maintains a clean and sanitary environment .prepares cleaning schedules and maintain equipment to ensure food safety .ensures proper sanitation and safety practices of staff .establishes a culture of compliance by adhering to all facility policies and procedures .follows appropriate safety and hygiene measures at all times to protect residents .follows established infection control policies and procedures . During a review of the facility's job description document titled, Dietician, dated 2023, the document indicated, .performs regular inspections of food service areas for sanitation, order, safety, and proper performance of assigned duties .follows established infection control policies and procedures . During a review of the facility's job description document titled, Maintenance Director, dated 2023, the document indicated, .follows appropriate safety and hygiene measures at all times to protect residents .follows established infection control policies and procedures . During a review of the facility's job description document titled, Administrator, dated 2023, the document indicated, . conducts periodic observations of in-service education to ensure staff members delivering the education are competent with the knowledge and skill set required to accomplish employee learning . During a review of the facility's competency checklist document titled, Dietary Manager Competency, dated [DATE], the document indicated, the CDM received initial training on, .infection control .food storage .meal preparation .tray line/diet card . and demonstrated competency. During a review of the facility's competency checklist document titled, Food & Nutrition: Competency Checklist-Food Service Worker, dated [DATE], the document indicated, DA 1 received initial training on, .infection control practices . sources of food borne illness .correctly label and date foods . and demonstrated competency. During a review of the facility's in-service record document titled, Label/date, Puree Technique, [NAME] Temp vs Holding Temp, Temp Danger Zone, dated [DATE], the document indicated, the document indicated, .All foods must have a label w/ [with] what it is .R: receive date .O: open date .UB: use by date . During a review of the facility's in-service record document titled, Cell Phones, Ear Pods, Breaks, Rest of the time is company time, need to clean or organize or re-stock, dated [DATE], the document indicated, cell phones were only allowed on breaks. During a review of the facility's policy and procedure (P&P) titled, Store/Prepare/Serve Guidelines, dated ,d+[DATE], the P&P indicated, .Food should be provided in a form .that meets each resident's individual needs in accordance with his or her assessment and care plan . During a review of the facility's P&P titled, Food Safety Requirements, dated ,d+[DATE], the P&P indicated, .Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety . food safety practices shall be followed throughout the facility's entire food handling process .storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms .equipment used in the handling of food .and other equipment that comes in contact with food .staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects .additional strategies to prevent foodborne illness include .cleaning and sanitizing the internal competent of the ice machine . During a review of the facility's P&P titled, Ice Machines and Portable Ice Carts, dated ,d+[DATE], the P&P indicated, .it is the policy of this facility to ensure that ice machines/carts are .cleaned, and maintained as per Federal, State, and local, or facility guidance .and current standards of practice . ice machines/carts can be prone to microbial contamination due to .poor cleaning or maintenance of equipment .proper cleaning, maintenance, and infection control in relation to ice machines is important to decrease the risk of illness to residents, staff and visitors .The maintenance director or other designee is responsible for cleaning and maintain the ice machine at the facility . The ice machine(s) or carts will be cleaned at any time contamination may have occurred or when visibly soiled . During a review of the facility's P&P titled, Infection Prevention and Control Program, dated ,d+[DATE], the P&P indicated, .this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment .all staff are responsible for following all policies and procedures related to the program .standard precautions .environmental cleaning and disinfection shall be performed according to facility policy .all staff have responsibilities related to the cleanliness of the facility .

Based on observation and interview, the facility failed to provide a safe, functional, comfortable and homelike environment for residents, staff and the public when: 1. Five of six resident rooms did not have a properly functioning screen doors and one screen door was missing. 2. Three of sixteen resident doors were not functioning properly. These failures had the potential of violating residents' rights to their privacy and at risk of accidents which could lead to serious health condition. Findings: 1. During initial tour a concurrent observation and interview on 3/4/25 at 10:38 a.m. with Resident 42 in his room, Resident 42 was sitting at the edge of his bed. Resident was appropriately dressed and answered questions. Resident 42 stated he had problem with his screen door not working and door to his room was heavy and difficult to closed. Resident 42 stated he reported the concerns to the facility and have not fixed the problem. During a review of Resident 42's Admission Record, dated 3/6/25, the AR indicated Resident 42 was admitted to the facility om 2/6/25 with diagnoses which included muscle weakness and multiple fractures (break in the bones). During a review of Resident 42's Minimum Data Set (MDS-a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 42's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 42 had no cognitive impairment. During an interview on 3/6/25 at 3:40 p.m. with Certified Nurse Aide (CNA) 5, CNA 5 stated she was not aware the screen doors for Rooms' 15, 16, 17, 1, 2, and 3 were not working properly. CNA 5 stated she did not remember resident, or staff complained about the screen doors not working properly. CNA 5 stated when there was building issues needing to be fixed, she reports to the Maintenance Supervisor (MS) in person or enter into their electronic reporting called TELS (Team Electronic Library System- electronic building management). 2. During a concurrent observation and interview on 3/4/25 at 10:40 a.m. with Resident 40, Resident 40 complained about his door being heavy and difficult to open and closed. Resident stated he reported it but no one had tried to fix it. Resident 40 stated it was difficult for him to open and closed his door. During an interview on 3/6/25 at 3:46 p.m. with CNA 6, CNA 6 stated she was not aware of rooms' 15, 1 and 6's door not working properly. CNA 6 stated she did not remember residents or staff complained about rooms' 1, 6 and 15's doors not closing or opening properly. CNA 6 stated she reports building issues to MS in person. CNA 6 stated there was no binder to write building issues needed to be fixed. During a concurrent observation and interview on 3/5/5 at 2:35 p.m. with Maintenance Supervisor (MS), MS walked outside through the sliding door of Resident 40 and checked screen door of Resident 40. The MS stated Resident 40's screen door was not working properly. The MS checked the additional screen doors for Rooms' 16, 17, 1, 2, and 3. The MS stated the screen door for rooms' 16, 17, 1, and 2 were not working properly and room [ROOM NUMBER] did not have a screen door. The MS stated he was not aware room [ROOM NUMBER]'s door was difficult to open and close. The MS stated he was aware of Rooms' 1 and 6's doors were difficult to close and open when the new floors were installed and was in the process of fixing the doors. The MS stated the doors and screen doors should have been working properly because of safety issues which could result in serious health condition. The MS stated he made rounds of the facility at least once a week to ensure facility was safe and doors working properly but did not notice the screen doors were not working properly. During an interview on 3/7/25 at 2:05 p.m. with LVN 3, LVN 3 stated she did not remember any staff or resident complained about screen doors not working properly and missing screen door. LVN 3 stated she was not aware of Rooms' 1, 6 and 15 doors not working properly. LVN 3 stated she reports building issues in person to MS or use TELS system to report issues. During an interview on 3/7/25 at 6:22 p.m. with the Administrator (ADM), the ADM stated her expectation for the MS was to maintain the building. The ADM stated she was not aware the doors and screen doors were not closing or opening properly. ADM stated, All sliding doors should be working properly to keep it as homelike as possible. The ADM stated she was not aware of Rooms' 1, 6 and 15 doors not working properly. The ADM stated it was important to maintain doors in good working condition for safety issue. During a review of facility's policy and procedure (P&P) titled, Safe and Homelike Environment, dated 2024, the P&P indicated, .The facility will provide a safe, clean, comfortable and homelike environment . the physical layout of the facility maximizes resident independence and does not pose a safety risk . Report any furniture in disrepair to Maintenance promptly. Report any unresolved environmental concerns to the Administrator . During a review of the facility's document titled, Maintenance Director, Job Description, dated 2023, the document indicated, . Plans, develops, organizes, implements . Ensures facility remains in compliance with all federal, state and local regulations for Life and Safety Code compliance . Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility, which includes painting, plumbing, carpentry . Develops and implements preventative maintenance tasks, document instructions an procedures for the preventative maintenance of facility .

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for five of six sampled residents (Residents' 1, 39, 40, 41, and 97) when: 1. LVN 1 administered medications to Residents' 39, 40, 41 and 97 without closing the privacy curtain or the door. 2. Licensed Vocational Nurse (LVN) 2 checked Resident 1's blood sugar level (BS-amount of sugar in the blood) without closing the privacy curtain or the door. These failures resulted in Residents' 1, 39, 40, 41, and 97 not provided respect and dignity during care which could potentially impact residents' well-being leading to vulnerability, decreased dignity, anxiety, stress and depression. Findings: 1. During a concurrent observation and interview on 3/6/25 at 7:55 a.m. in Station 1 East Hall with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared Resident 40's medications and entered Resident 40's room. Resident 40 was lying in bed and inside the room was another resident. LVN 1 administered Resident 40's medications without closing the privacy curtain or the door. LVN 1 stated she did not close the privacy curtain or the door when she administered Resident 40's medications and should have. LVN 1 stated it was a dignity issue. During a review of Resident 40's AR, dated 3/6/25, the AR indicated Resident 40 was readmitted to the facility on [DATE] with diagnoses which included hypertension, alcoholic cirrhosis (liver is scarred and damaged permanently) and cellulitis (infection of the skin and tissues beneath the skin). During a review of Resident 40's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 40's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 40 had no cognitive deficit. During a concurrent observation and interview on 3/6/25 at 8:20 a.m. in Station 1 east hall with LVN 1, LVN 1 prepared Resident 39's medications and entered Resident 39's room. Resident 39 was sitting at the edge of the bed playing puzzles and inside the room was another resident. LVN 1 administered Resident 39's medications without closing the privacy curtain or the door. LVN 1 stated she did not close the privacy curtain or the door to give Resident 39 privacy to take her medications and she should have. During a review of Resident 39's Admission Record, dated 3/6/25 the AR indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat), hypertensive heart disease (heart problems caused by prolong high blood pressure) and muscle weakness. During a review of Resident 39's MDS assessment dated [DATE]. Resident 39's BIMS score was 15 out of 15 indicating Resident 39 had no cognitive deficit. During a concurrent observation and interview on 3/6/25 at 8:35 a.m. with LVN 2 in Station two, west hall, LVN prepared Resident 41's medications. Resident 41 was sitting at the edge of the bed and inside the room was another resident. LVN 2 administered Resident 41's medications and did not close the privacy curtain and the door. LVN 2 stated she administered Resident 41's medications and did not close the privacy curtain and the door, and she should have. LVN 2 stated it was Resident 41's resident rights and a dignity issue. During a review of Resident 41's AR dated 3/6/25, the AR indicated Resident 41 was admitted to the facility on [DATE] with diagnoses which included back pain, muscle weakness and hypertension. During a review of Resident 41's MDS assessment dated [DATE], indicated Resident 41's BIMS was 15 out of 15 which indicated Resident 41 had no cognitive deficit. During a concurrent observation and interview on 3/6/25 at 8:42 a.m. with LVN 2 in Station two west wing, LVN 2 prepared Resident 97's medications and entered Resident 97's room. Resident 97 was lying in bed. LVN 2 administered Resident 97's medications and did not close the privacy curtain or door. LVN 2 stated she did not close the privacy curtain and door when she administered Resident 97's medications abd she should have. During a review of Resident 97's AR dated 3/6/25, the AR indicated Resident 97 was admitted to the facility on [DATE] with diagnoses which included kidney failure, hyperlipidemia and dementia (progressive state of decline in mental abilities). During a review of Resident 97's MDS assessment dated [DATE], indicated Resident 97's BIMS assessment score was 10 out of 15 indicating Resident 97 had moderate cognitive deficit. During an interview on 3/7/25 at 10 a.m. with the Director of Staff Development (DSD), the DSD stated the practice was to ensure to provide privacy by closing the privacy curtain and or the door during medication administration including checking of blood sugar level. The DSD stated it was a dignity issue and resident rights to their privacy. During a concurrent observation and interview on 3/6/25 at 7:55 a.m. with LVN 1 in Station 1 west hall, LVN 1 prepared Resident 40's medications. LVN 1 entered Resident 40's room, Resident 40 was lying in bed covered with blanket and answered questions. LVN 1 administered medications to Resident 40 without closing the door or closing the privacy curtain. Residents, staff and visitors walking by and could see Resident 40 taking her medications. 2. During a concurrent observation and interview on 3/6/25 at 11:25 a.m. in east hall cart 2 with LVN 2, LVN 2 entered Resident 1's room. Resident 1 was standing next to his bed located closest to the door and inside the room with Resident 1 was another resident. LVN 2 checked Resident 1's blood sugar without closing the privacy curtain or the door, while the other resident watched LVN 2 performed the blood sugar checked to Resident 1. LVN 2 stated she did not close the privacy curtain or the door when he checked Resident 1's blood sugar and soul have. During a review of Resident 1's Admission Record (AR) dated 3/17/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (high blood sugar level in the blood) and hypertension. During a review of Resident 1's MDS assessment dated [DATE], indicated Resident 1's BIMS assessment did not complete assessment, staff was interviewed for Resident 1's mental status which indicated Resident 1's cognitive skill for daily decision making was modified independence. During an interview on 3/7/25 at 2:15 p.m. with LVN 3, LVN 3 stated it was a facility practice to provide privacy by closing the privacy curtain and doors during medication administration. LVN 3 stated it was the responsibility of the nursing staff to ensure privacy was provided during medication administration. LVN 3 stated there are other residents, staff and visitors walking by and could see residents while taking their medications and fingerstick (a procedure . During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was to ensure privacy was provided to residents during medication administration. The DON stated it was a dignity issue. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2023, the P&P indicated, . The resident has a right to be treated with respect and dignity . During a review of the facility's policy and procedure (P&P) titled, Promoting/Maintaining Resident Dignity, dated 2024, the P&P indicated, . All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Maintain resident privacy . During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 2024, the P&P indicated, . Knock or announce presence . Provide privacy .|

Based on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent. The facility's medication error was 6.9%. 1. Licensed Vocational Nurse (LVN) 1 did not follow medication direction when she administered lactulose solution (medication used to treat constipation) to Resident 40. This failure resulted for Resident 40 not receiving the full therapeutic benefit of the prescribed lactulose solution (medication used to treat constipation) which could lead to constipation or serious health condition. 2. LVN 1 administered metformin (medication used to treat diabetes) medication without food and did not follow the physician's order to administer with food. This failure had the potential risk for Resident 39 to experienced gastrointestinal upset (GI-gastric upset like diarrhea) and could decrease the absorption of Metformin leading to less effective blood sugar control. Findings: 1. During a concurrent medication administration pass observation and interview on 3/6/25 at 8:05 a.m. at the east hall, LVN 1 was preparing Resident 40's medications and poured lactulose solution in a clear medication cup. LVN 1 administered Resident 40's medications. LVN 1 stated she did not administer 30 ml (milliliter-unit of measurement) of lactulose as ordered. LVN 1 stated she should have administered 30 ml. as ordered but instead administered 20 ml to Resident 40. LVN 1 stated Resident 40 did not received the whole medication dose as ordered by MD which could lead to constipation. During a review of Resident 40's Admission Record, dated 3/6/25, the admission record indicated Resident 40 was readmitted to the facility on [DATE] with diagnoses which included alcoholic cirrhosis of liver (permanent scarring of the liver), duodenal ulcer (sore that developed in the lining of the first part of the small intestine) and unsteadiness on feet. During a review of Resident 40's Order Summary Report, (OSR) dated 3/6/25, the OSR indicated, . Lactulose Oral Solution 10GM [gram- unit of measurement]/15ML [milliliter-unit of measurement] (Lactulose) Give 30ml by mouth three times a day . During an interview on 3/7/25 at 9:18 a.m. with LVN 2, LVN 2 stated it was important to follow medication order when administering medications to residents. LVN 2 stated administering medication less than the ordered amount was under dosing and does not help resident. During an interview on 3/7/25 at 10:25 a.m. with the Director of Staff Development (DSD), the DSD stated it was important to follow medication order and give the correct amount of medication as ordered by medical doctor (MD) to be effective. The DSD stated the practice was to administer the correct amount of medication as ordered to be effective. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), The DON stated licensed nurse should have followed the medication order and measured the correct amount of lactulose for Resident 40. The DON stated failing to administer the correct dosage could result in the medication not reaching the required potency. 2. During a concurrent medication administration pass observation and interview on 3/6/25 at 8:15 a.m. at east wing medication cart 1, LVN 1 prepared Resident 39's medications. LVN 1 administered Resident 39's medications without food. LVN 1 stated the medication direction was to administer metformin with food. LVN 1 stated she did not give food to Resident 39 when she administered the metformin. LVN stated the metformin given on an empty stomach could cause GI distress. During a review of resident 39's Admission Record, dated 3/6/25, the admission record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar level in the blood), anemia (body does not have enough healthy red blood cells) and muscle weakness. During a review of Resident 39's Order Summary Report, (OSR) dated 3/6/25, the OSR indicated, . metformin HCl [brand name] [hydrochloride] Oral 500MG [milligram-unit of measurement] Give one [1] tablet by mouth two times a day for Give with meals . During an interview on 3/7/25 at 2:05 p.m. with LVN 3, LVN 3 stated the practice was to always follow the medication order and directions when administering medications. LVN 3 stated if the medication order includes a direction to give with food, it should be followed. LVN 3 stated medications requiring food should be given while the resident was eating, or a snack should be provided if resident was not eating to prevent GI discomfort. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was for the licensed nurse to administer metformin while resident was eating. The DON stated licensed nurse could have offered a snack with the metformin after Resident 39 finished eating to avoid gastrointestinal upset and ensure proper medication absorption. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 11/24, the P&P indicated, .Ensure the that the six rights of medication administration are followed: . Right dose . Administer medication as ordered . Provide appropriate amount of food and fluid . During a review of the facility's policy and procedure (P&P) titled, Medication Error, dated 11/24, the P&P indicated, . Medication administered not in accordance with the prescriber's order . Incorrect dose, route of administration, dosage form . Administering medications without adequate fluids, without food or antacids .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for 10 of 15 sampled residents (Residents 10, 28, 29, 30, 37, 39, 40, 27, 24, and 14) when: 1. Resident's 10, 29, 30, 37, 39, and 40 did not have care plan for enhanced barrier precautions (EBP-infection control strategy, involving use of gowns and gloves during high-contact resident care). These failures placed Residents' 10, 29, 30, 37, 39, and 40 needs not being met. 2. Resident 28 care plan for Enhanced Barrier Precaution (EBP-a set of infection control measures that use personal protective equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]). This failure had the potential for Resident 28's needs being unmet. 3. Resident 27's actives care plan lacked person-centered approach for conversation and socializing. This failure had the potential for missed opportunities for emotional and cognitive stimulation. 4. Resident 24's care plan for impaired cognitive function/dementia was not implemented timely. This failure had the potential for resident 24's needs to not be met and put Resident 24 at an increase for cognitive decline. 5. Resident 14's care plan was not developed to address the use of an anticoagulant (blood thinner) medication. This failure had the potential for Resident 14 to experience severe bruising and bleeding which could lead to serious medical condition and hospitalization . Findings: 1. During a review of Resident 10's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included diabetes (high sugar level in the blood), open wound to right knee, open wound to left knee and muscle weakness. During a review of Resident 10's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 10's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 10 had no cognitive deficit. During a review of Resident 29's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities) and diabetes. During a review of Resident 29's MDS assessment dated [DATE], indicated Resident 29's BIMS assessment was not able to complete and staff assessment was conducted which indicated Resident 29 had a score of 2 indicating Resident 29 was moderately impaired, decisions poor and required cues and supervision. During a review of Resident 30's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included diabetes, surgical aftercare, and chronic ulcer (wounds that fail to heal within a normal time frame) of left foot. During a review of Resident 30's MDS assessment dated [DATE], indicated Resident 30's BIMS assessment score was 13 out of 15 indicating Resident 30 had no cognitive deficit. During a review of Resident 37's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included open wound, non-pressure chronic ulcer (persistent skin wound that fails to heal properly) of right heel and muscle weakness. During a review of Resident 37's MDS assessment dated [DATE], indicated Resident 37's BIMS assessment score was 15 out of 15 indicating Resident 37 had no cognitive deficit. During a review of Resident 39's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included cellulitis ( bacterial skin infection of skin and tissues beneath the skin) of left lower limb, diabetes and muscle weakness. During a review of Resident 39's MDS assessment dated [DATE], indicated Resident 39's BIMS assessment score was 15 out of 15 indicating Resident 39 had no cognitive deficit. During a review of Resident 40's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses which included cellulitis of unspecified part of limb and pressure ulcer of sacral region. During a review of Resident 40's MDS assessment dated [DATE], indicated Resident 40's BIMS assessment score was 15 out of 15 indicating Resident 40 had no cognitive deficit. During a concurrent interview and record review on 3/5/25 at 3:50 p.m. with the IP, Resident's 10, 29, 30, 37, 39, and 40's clinical record were reviewed. The IP stated Resident's 10, 29, 30, 37, 39 and 40 did not have care plans for the EBP. The IP stated care plan should have been initiated as soon as Residents' 10, 29, 30, 37, 39 and 40 were placed on EBP. The IP stated care plan directs staff to care for resident needs. The IP stated all licensed nurses were responsible in creating care plan and she was responsible in creating care plan for residents on EBP. During an interview on 3/7/25 at 10:30 a.m. with Director of Staff Development (DSD), the DSD stated care plan are the responsibilities of licensed nurse. The DSD stated licensed nurses are capable of creating care plan. The DSD stated EBP care plan should have been initiated right away when resident was placed on EBP. During an interview on 3/7/25 at 3:45 p.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated care plan are the responsibility of licensed nurse. LVN 1 stated the IP and DON are responsible in creating EBP care plan to direct staff to care for resident. During an interview on 3/7/25 at 6:15 p.m. with the Director of Nursing (DON), the DON stated the IP was responsible in identifying residents belonging in the EBP and notifying staff of the precautions needed to care for residents. The DON stated care plan should be complete and patient centered. The DON stated IP was responsible in creating care plan and should have initiated care plan right away as soon as resident were determined to be on EBP. During a review of facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 2025, the P&P indicated, . 2. The comprehensive care plan will be developed within 7 days . The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished . b. Any services that would otherwise be furnished . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment . During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, dated 2025, the P&P indicated, . All staff receive training on enhanced barrier precautions upon hire and annually .An order for enhanced barrier precaution will be obtained for residents with any of the following: i. Wounds [ . chronic wounds such as pressure ulcer . urinary catheters . During a review of facility document titled, Infection Preventionist, Job Description dated 2023, the document indicated, . Establishes facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases . Maintains documentation of infection prevention and control program activities . 51284 2. During observation on 3/4/25 at 10:46 a.m. of resident 28's room, resident 28 was not in facility. Resident 28 had Enhanced Barrier precautions (EBP) sign on the door and a dot next to her name. During record review on 3/4/25 at 4:19 p.m. Resident 28's Admission note dated 5/22/24 stated resident had bilateral nephrostomy tubes (a thin, flexible catheter that drains urine from the kidney into a bag outside the body). During a concurrent observation and interview on 3/5/24 at 10:19 a.m. with Resident 28, in Resident 28's room, Resident 28 was observed lying in bed watching television (TV) in her gown. Resident 28 stated she had her nephrostomy tube removed on 3/4/25. Resident 28 stated that she has a surgical site from the procedure. During a concurrent interview and record review on 3/7/25 at 10:11 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 28's Care Plan dated 3/6/25 indicated EBP was initiated on 3/6/25. LVN 3 Stated this was not an appropriate timeframe. LVN 3 stated that care plans are important to provide specific care to that person. During review of Resident 28's Care Plan, dated 3/6/25, the Care Plan indicated, Resident 28 EBP care plan was created on 3/6/25. During interview on 3/7/25 at 3:11 p.m. with Infection Preventionist (IP), the IP stated EBP is determined by the IP. The IP stated EBP are for wounds, catheters, and EBP are important for residents who are at an increased risk for infection. The IP stated it is her responsibility to obtain an order and created the EBP care plan right away. The IP stated the resident 28 did not have a care plan for EBP prior to survey. During an interview on 3/7/25 at 5:40 p.m. with the Director of Nurses (DON), The DON stated the expectation for care plans to be completed and resident centered. DON stated admission care plan are to be completed within 14 days. During a review of facility's job description document titled, Infection Preventionist, dated 2023, the document indicated, .Oversees resident care activities that increase risk infection .use and care of .catheter, wound care, incontinence care .remains current on new developments related to infection prevention .servers as resource for staff regarding infection prevention During a review of the facilities policy and procedure P&P titled, Enhanced barrier precautions dated 2024, the P&P indicated, . an order for enhanced barrier precautions will be obtained for residents with . Unhealed surgical wounds .and or indwelling medical devices . 3. During a review of Resident 27's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 27 was admitted to the facility on [DATE] with a diagnoses absence of left below knee, and blindness, both eyes During a concurrent observation and interview on 3/5/25 at 10:34 a.m. with Resident 27, in Resident 27's room, Resident 27 was lying in bed with cell phone in hand. Resident 27 stated she use to go to actives in the dining room until she got sick. Resident 27 stated she liked to talk to people, she liked to order online. Resident 27 stated she liked to listen to the TV with her roommate. During a concurrent interview and record review on 3/6/25 at 2:57 p.m. with the Activities director (AD), Resident 27's Care plan Room visit/ .activity participation record and Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/17/25 the MDS section F -Preferences for Routine and Activities were reviewed. The AD stated she is responsible for progress notes, care plans, and evaluations. The AD stated Resident 27 is a 1:1 room visit, and each visit is 15 minutes long. The AD stated Resident 27 enjoyed localizing in the large dining hall, talking during the room visits and liked to place online orders. The AD stated Resident 27's activity record and care plan were not person centered or individualized. The AD stated it is important Resident 27's activity record and care plan reflect her interests for her mental, emotion and physical health. During an interview on 3/7/25 at 5:40 p.m. with the Director of Nurses (DON), The DON stated the expectation for care plans to be completed and resident centered. DON stated admission care plan are to be completed within 14 days. During a review of the facility's job description document titled, Activities Director, dated 2023, the document indicted, .Contributing to the .care plan .and approaches that are individualized to match the skills, abilities, and interest/preferences of each resident .activities are to be tailored to the resident's unique requirements and skills . During the review of the facilities policy and procedure (P&P) titled, Comprehensive Care Plans, undated, the P&P indicated, . It's the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and time frames to meet residents medical, nursing and mental and psychosocial needs and all services that are indicated in the resident's comprehensive assessment and meet professional standards of quality . the comprehensive care plan will include measurable objectives and time frames to meet the residents need as identified in the residence comprehensive assessment . 4. During a Review of Resident 24's Admission Record (AR- document containing residents personal information), dated 3/6/25, the AR indicated, Resident 24 was admitted to the facility on [DATE], with diagnoses Type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), Bipolar Disorder (chronic mental health condition characterized by significant and persistent shifts in mood, energy and activity levels), Unspecified Dementia (a diagnosis used when a person has cognitive decline that cannot be attributed to a specific type of dementia). During a review of Resident 24's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/31/25, the MDS section C indicated, Resident 24 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 6, (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 24 severe cognitive impairment. During an observation on 3/4/25 at 10:05 a.m. Resident 24 was sitting in his wheelchair next to a window with light shinning in. During an interview on 3/5/25 at 12:26 p.m. with Resident 24's Family Member (FM) 1, FM 1 stated Resident 24 needs a lot of care, he gets confused. During a concurrent interview and record review on 3/7/25 at 10:11 a.m. with LVN 3, Resident 24's Admission Record and Care Plan, dated 3/7/25 were reviewed. LVN 3 stated Resident 24 was admitted with a diagnosis of dementia, and Resident 24 needs to be redirected with his care. LVN 3 stated Resident 24's Impaired cognitive function/dementia Care plan, dated 10/14/24, indicated care plan was created late. LVN 3 stated nurses are responsible to create a care plan. LVN 3 stated care plans are important to know how to care for the resident. During an interview on 3/7/25 at 5:40 p.m. with the DON, the DON stated admission care plans are done by nurses and within 14 days. DON stated a care plan ensures appropriate resident centered care. During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, undated, the P&P indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care .The admitting nurse, or supervising nurse .shall gather information from the admission physical assessment .and discussion with the resident .A supervising nurse shall verify within 48 hours that a baseline care plan has been developed . During the review of the facilities policy and procedure (P&P) titled, Comprehensive Care Plans, undated, the P&P indicated, . It's the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and time frames to meet residents medical, nursing and mental and psychosocial needs and all services that are indicated in the resident's comprehensive assessment and meet professional standards of quality . the comprehensive care plan will include measurable objectives and time frames to meet the residents need as identified in the residence comprehensive assessment . 51059 5. During a review of Resident 14's Admission Record (AR- document containing resident personal information), dated 3/6/25, the AR indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses which included other nondisplaced fracture of sixth cervical vertebra, subsequent encounter for fracture with routine healing (a break in the sixth bone of the neck where fractured pieces of bone have not moved out of alignment and the fractures healing process is progressing normally with routine care), chronic systolic congestive heart failure (a condition where the left ventricle of the heart is weakened, resulting in reduced pumping ability and fluid buildup in the lungs and other parts of the body), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), unspecified bilateral primary osteoarthritis of hip (a degenerative condition where the cartilage in both hip joints is breaking down, causing pain and stiffness), and muscle weakness generalized. During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/19/25, the MDS assessment indicated Resident 14's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 13 out of 15 which indicated Resident 14 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 14's Order Summary Report, dated 3/6/25, the Order Summary Report indicated, Resident 14 had an active order for .Apixaban Oral Tablet 2.5 [milligrams (MG)- a unit of measurement used to measure the dosage of medication] (Apixaban [ a type of medicine known as an anticoagulant. It decreases the clotting ability of the blood and helps prevent harmful blood clots from forming]) .for anticoagulant. The Order Summary Report indicated .order status active .order date 2/13/25 .start date 2/14/25 . During a review of Resident 14's Care Plan, dated 3/6/25, the Care Plan indicated, Resident 14 did not have an anticoagulant care plan. During an interview on 3/6/25 at 8:15 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated anticoagulant medications were expected to be care planned. LVN 2 stated it was expected all care plans were person centered and included current treatments. LVN 2 stated care plans ensured members of the healthcare team provided ongoing monitoring of medication side effects. LVN 2 stated Resident 14 was at risk for uncontrolled bleeding if she was injured and was not monitored. During a concurrent observation and interview on 3/6/25 at 2:31 p.m. with Resident 14 in Resident 14's room, Resident 14 was observed lying in bed. Resident 14 stated she had not received anticoagulant education since admitted to the facility. Resident 14 stated she was not aware of any side effects or complications of anticoagulant medication to monitor for. During a concurrent interview and record review on 3/6/25 at 2:34 p.m. with LVN 1, Resident 14's Order Summary Report (OSR), Medication Administration Record (MAR) and Care Plan, dated 3/6/25 were reviewed. LVN 1 stated Resident 14 had received .Apixaban .2.5 MG .two times a day for anticoagulant . since 2/14/25. LVN 1 stated Apixaban was an anticoagulant. LVN 1 stated anticoagulants were a blood thinner, and Resident 14 could bruise easily and have uncontrolled bleeding if injured. LVN 1 could not locate an anticoagulant care plan for Resident 14. LVN 1 stated a care plan must be in place for all residents to address the use of an anticoagulant. LVN 1 stated it was important the care plan reflected the use of an anticoagulant to ensure education and monitoring interventions were in place. LVN 1 stated the care plan purpose was to reflect each residents' current conditions and alert staff to individualized treatment, side effects, and monitoring precautions. During an interview on 3/6/25 at 2:40 p.m. with the Director of Nursing (DON), the DON stated all care plans were expected to reflect the residents needs and active orders to ensure appropriate monitoring precautions and goals were in place, per facility policy. The DON stated Apixaban was an anticoagulant and all anticoagulants were expected to be care planned. The DON stated it was expected Resident 14 had an anticoagulant care plan to ensure she was being monitored by all members of the healthcare team. The DON stated a care plan ensured continuing education was provided to the resident regarding anticoagulation therapy. The DON stated without an anticoagulant care plan Resident 14 was not being monitored by all members of the healthcare team and was at risk for bruising and uncontrolled internal bleeding. The DON stated it was important all members of the healthcare were aware Resident 14 was on an anticoagulant to accurately reflect her needs, goals, and interventions. The DON stated it was important each resident had a personalized and individualized care plan. During a review of the facility's job description document titled, Charge Nurse, dated 2023, the document indicated, .Initiates, reviews and updates care plans as required . During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, undated, the P&P indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care .The baseline care plan will .include the minimum healthcare information necessary to properly care for a resident including, but not limited to .physician orders . The admitting nurse, or supervising nurse .shall gather information from the admission physical assessment .physician orders, and discussion with the resident . interventions shall be initiated that address the resident's current needs including . any identified needs for supervision .a written summary of the baseline care plan shall be provided to the resident .the summary shall include, at a minimum .a summary of the resident's medications. During a review of the facility's P&P titled, Comprehensive Care Plans, undated, the P&P indicated, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality .the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress .

Based on observation and interview, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infection for 11 out of 11 sampled residents (Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97) when nursing staff did not provide or assist residents in performing hand hygiene before they were served their lunch tray. This failure to provide hand hygiene placed Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97 at increased risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: During an observation on 3/4/25 at 11:50 a.m. during meal observation in the dining room. Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97 were seen assisted by staff for lunch and staff placed apron on a couple residents. Staff distributed lunch trays to residents and did not provide or offered hand hygiene to residents eating in the dining room. During a review of Resident 8's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 8's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 8 out of 15 which indicated Resident 8 had moderate cognitive deficit. During a review of Resident 9's MDS assessment dated [DATE], the MDS assessment indicated Resident 9's BIMS assessment score was 11 out of 15 which indicated Resident 9 had moderate cognitive deficit. During a review of Resident 23's MDS assessment dated [DATE], the MDS assessment indicated Resident 23's BIMS assessment score was 7 out of 15 which indicated Resident 23 had moderate cognitive deficit. During a review of Resident 24's MDS assessment dated [DATE], the MDS assessment indicated Resident 24's BIMS assessment score was 6 out of 15 which indicated Resident 24 had severe cognitive deficit. During a review of Resident 26's MDS assessment dated [DATE], the MDS assessment indicated Resident 26's BIMS assessment score was 4 out of 15 which indicated Resident 26 had severe cognitive deficit. During a review of Resident 33's MDS assessment dated [DATE], the MDS assessment indicated Resident 33's BIMS assessment score was 10 out of 15 which indicated Resident 33 had moderate cognitive deficit. During a review of Resident 35's MDS assessment dated [DATE], the MDS assessment indicated Resident 35's BIMS assessment score was 5 out of 15 which indicated Resident 35 had severe cognitive deficit. During a review of Resident 39's MDS assessment dated [DATE], the MDS assessment indicated Resident 39's BIMS assessment score was 15 out of 15 which indicated Resident 39 had no cognitive deficit. During a review of Resident 41's MDS assessment dated [DATE], the MDS assessment indicated Resident 41's BIMS assessment score was 15 out of 15 which indicated Resident 41 had no cognitive deficit. During a review of Resident 44's MDS assessment dated [DATE], the MDS assessment indicated Resident 44's BIMS assessment score was 3 out of 15 which indicated Resident 44 had severe cognitive deficit. During a review of Resident 97's MDS assessment dated [DATE], the MDS assessment indicated Resident 97's BIMS assessment score was 10 out of 15 which indicated Resident 97 had moderate cognitive deficit. During an interview on 3/4/25 at 12:15 p.m. with Certified Nurse Aide (CNA) 8, CNA 8 stated she assisted residents in the dining room for meals but did not provide hand hygiene to residents before serving their lunch tray. CNA 8 stated she should have offered and provided hand hygiene to residents because it was an infection prevention and avoid stomach issues. CNA 8 stated she did not know what activities the residents were doing before they had lunch. During an interview on 3/4/25 at 12:30 p.m. with CNA 9, CNA 9 stated, All residents in the dining room were not provided hand hygiene prior to them eating lunch. CNA 9 stated staff should have offered and provided residents hand hygiene before residents were served lunch. CNA 9 stated residents should have been provided hand hygiene to prevent GI upset (gastrointestinal-discomfort or dysfunction in the gastrointestinal tract). During an interview on 3/5/25 at 12:35 p.m. with Activities Assistant (AA), the AA stated several residents participated activities in the dining room before lunch was served. The AA stated activities involved touching papers, tables and other residents. The AA stated residents did not washed or cleaned their hands after activity and before lunch. The AA stated she did not provide hand hygiene to residents after activity. The AA stated she should have provided and offered hand hygiene to residents to prevent cross contamination and stomach upset. During an interview on 3/7/25 at 9:25 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated residents should be offered and assisted with hand hygiene before residents are served meals. LVN 2 stated it was the responsibility of the staff to ensure hand hygiene are provided to residents before each meal for infection prevention and control and prevent GI upset. During an interview on 3/7/25 at 10:25 a.m. with the Director of Staff Development (DSD), the DSD stated CNAs prepares residents before meals. The DSD stated residents are provided with hand wipes for independent residents and staff helped dependent residents with their hand hygiene to prevent GI upset. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was for nursing staff, To ensure resident's hands are cleaned and properly positioned and placed in the dining room. The DON stated it was a sanitation issue which could cause GI problem. During a review of facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 2024, the P&P indicated, . All staff are responsible for following all policies and procedures related to the program . All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted . Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedure . During a review of the facility's job description document titled, Dietary Aide, dated 2023, the document indicated, . follows appropriate safety and hygiene measures at all times to protect residents .follows established infection control policies and procedures .as a condition of employment, completes all assigned training and skills competency .maintains food storage areas in a clean and properly arranged manner at all times .assists in inventory and storing in-coming food, supplies, etc., as necessary .

Based on observations, interviews, and record reviews, the facility failed to ensure services provided met professional standards of practice of quality for eight of nine sampled residents (Resident 12, 10, 30, 39, 40, 29, 37 and 28) when: 1. Resident 12 had a physician's order for a low air loss machine (a medical device used primarily to prevent or treat pressure ulcer (bedsores) and was not provided to Resident 12 and was unplugged. This failure resulted for Resident 12 not receiving the necessary care which could lead to development of pressure ulcer. 2. Resident 10, 30, 39, 40, 29, 37, and 38 needed Enhanced Barrier Precaution (EBP- an infection control measures to reduce the risk of transmission of infections) and the Infection Preventionist (IP) did not get a physician's order, did not perform a wound assessment and did not initiate a care plan (a personalized, structured document used to outline the care and treatment the residents needs). This failure placed Resident 10, 30, 39, 40, 29, 37, and 38 at increased risk for widespread transmission of infections which could lead to serious health complications. Findings: 1. During a concurrent observation and interview on 3/5/25 at 9:40 a.m. in Resident 12's room, Resident 12 was seen lying in bed, covered with blanket and yelling out. Resident 12 did not answer questions asked. Resident 12's bed was positioned in lowest position and had a low air loss mattress. Resident 12's low air loss mattress was turned off and was unplugged from the wall. During a review of Resident 12's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 12 was readmitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk of the same side of the body) and hemiparesis (is a condition characterized by weakness or paralysis) dementia (the loss of thinking, remembering, and reasoning) and muscle weakness. During a review of Resident 12's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 12's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 10 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 12 had moderate cognitive deficit. During a review of Resident 12's Order Summary Report, dated 3/6/25 indicated, . low air loss mattress r/t [related to] limited mobility . During a concurrent observation and interview on 3/5/25 at 9:42 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 12's care. CNA 1 checked the low air loss machine and found it turned off and unplugged. CNA 1 stated The machine was supposed to be on at all times when a resident has an order to prevent skin breakdown. During an interview on 3/5/25 at 9:50 a.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated she was Resident 12's nurse. LVN 1 stated Resident 12's had a physician's order for low air loss mattress, and it should have been on at all times to prevent pressure ulcer. LVN 1 stated it was the responsibility of the nursing staff to ensure the low air loss mattress machine was on at all times. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was for the low air loss machine to be on at all times when resident was in bed to prevent skin breakdown. The DON stated it was the responsibility of the nursing staff to ensure the low air loss machine was on and functioning properly. The DON stated not having the low air machine on put Resident 12 at risk of developing skin ulcer. During a review of the professional reference from https://www.ncbi.nlm.nih.gov/books/NBK333135/ undated, indicated, The Prevention and Management of Pressure Ulcers in Primary and Secondary Care. Pressure redistributing devices. Pressure relieving and redistributing devices are widely accepted methods of trying to prevent the development of pressure ulcers for people considered as being at risk. The devices used include different types of mattresses, overlays, cushions and seating. These devices work by reducing or redistributing pressure, friction or shearing forces . 2. During a review of Resident 10's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included diabetes (high sugar level in the blood), open wound to right knee, open wound to left knee and muscle weakness. During a review of Resident 10's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 10's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 10 had no cognitive deficit. During a review of Resident 28's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was readmitted to the facility on [DATE] with diagnoses which included retention of urine, hemiplegia and hemiparesis and muscle weakness. During a review of Resident 28's MDS assessment dated [DATE], indicated Resident 28's BIMS assessment score was 15 out of 15 indicating Resident 28 had no cognitive deficit. During a review of Resident 29's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia (a group of symptoms that affects memory, thinking and social abilities) and diabetes [a chronic medical condition that affects how the body process sugar]. During a review of Resident 29's MDS assessment dated [DATE], indicated Resident 29's BIMS assessment was not able to complete and staff assessment was conducted which indicated Resident 29 had a score of 2 indicating Resident 29 was moderately impaired, decisions poor and required cues and supervision. During a review of Resident 30's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included diabetes, surgical aftercare, and chronic ulcer of left foot. During a review of Resident 30's MDS assessment dated [DATE], indicated Resident 30's BIMS assessment score was 13 out of 15 indicating Resident 30 had no cognitive deficit. During a review of Resident 37's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included open wound, non-pressure chronic ulcer of right heel and muscle weakness. During a review of Resident 37's MDS assessment dated [DATE], indicated Resident 37's BIMS assessment score was 15 out of 15 indicating Resident 37 had no cognitive deficit. During a review of Resident 39's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower limb, diabetes and muscle weakness. During a review of Resident 39's MDS assessment dated [DATE], indicated Resident 39's BIMS assessment score was 15 out of 15 indicating Resident 39 had no cognitive deficit. During a review of Resident 40's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses which included cellulitis of unspecified part of limb and pressure ulcer of sacral region. During a review of Resident 40's MDS assessment dated [DATE], indicated Resident 40's BIMS assessment score was 15 out of 15 indicating Resident 40 had no cognitive deficit. During a concurrent interview and record review on 3/5/25 at 3:23 p.m. with IP, IP stated she had been the IP in the facility for over a year. The IP stated her role includes monitoring infection control and antibiotic use. The IP stated there are seven residents on EBP. The IP stated all seven residents on EBP did not have physician's orders. The IP stated according to facility policy and procedure, she should have placed the physician's order on the day Residents' 10, 30, 39, 40, 29, 37 and 28 were placed on EBP. The IP stated Residents' 10, 30, 39, 40, 29, 37 and 28 did not have EBP care plans and should have. The IP stated care plans should be started within 24 hours. The IP stated she did not complete assessment or documentation for the residents' wounds. The IP stated as a result she did not know whether resident wounds were improving or getting worse because there was documentation. During an interview on 3/7/25 at 6:05 p.m. with the Director of Nursing (DON), the DON stated the IP was responsible in identifying residents belonging in the EBP and notifying staff of the precautions needed to care for residents. The DON stated physician order was needed as soon as a resident was placed on EBP. The DON stated the IP should have called Medical Doctor (MD) and get the order. The DON stated his expectation was for the IP to do her job. During a review of facility document titled, Infection Preventionist, Job Description dated 2023, the document indicated, . Establishes facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases . Maintains documentation of infection prevention and control program activities . During a review of the professional reference from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html undated, indicated, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Implementation of Enhanced Barrier Precautions . 19. If a nursing home is receiving a resident known to be colonized with a MDRO from an acute care hospital, do they need to continue Contact Precautions in the facility, or can Enhanced Barrier Precautions be used? The resident should be maintained on Contact Precautions in the nursing home if he or she has acute diarrhea, draining wounds, or other sites of secretions or excretions that are unable to be covered or contained or for a limited period of time during a suspected or confirmed MDRO outbreak investigation. If none of these are present, Enhanced Barrier Precautions would typically be appropriate for the management of this resident, unless otherwise directed by public health authorities . 23. The guidance describes that all residents with wounds would meet the criteria for Enhanced Barrier Precautions. What is the definition of a wound in relation to this guidance? In the guidance, wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. However, the intent of Enhanced Barrier Precautions is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers [are open sores that typically develop on the feet of individuals with diabetes [a chronic medical condition that affects how the body process sugar], and chronic venous stasis ulcers [wound develops on the lower leg as a result of poor blood circulation]. Ostomies [a surgical opening in the body to allow waste to exit], such as colostomies or ileostomies, are not defined as a wound for Enhanced Barrier Precautions .

Based on observation, interview, and record review, the facility failed to ensure care that promoted rights of the resident and enhancement of quality of life for one of six sampled residents (Resident 147) when resident 147 was not allowed to smoke. This failure resulted in Resident 147 not being able to smoke since admission which led to decreased sense of pleasure and increased anxiety. Findings: During a review of Resident 147's Admission Record (AR- document containing resident personal information), dated 3/6/25, the AR indicated, Resident 147 was admitted to the facility on [DATE], with diagnoses which included psychosis not due to a substance or known physiological condition (a mental health condition characterized by a loss of contact with reality. It is a state of altered perception, cognition, and behavior), major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), opioid dependence (physical and psychological reliance on opioids, a substance found in certain prescription pain medications and illegal drugs) and insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and feeling unrested. It can significantly impact daily life, leading to fatigue, irritability, difficulty concentrating, and reduced productivity). During a review of Resident 147's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 3/5/25, the MDS assessment indicated Resident 147's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 14 out of 15 which indicated Resident 147 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 147's Progress Note, dated 3/4/25, the Progress Note indicated, .MD [medical doctor] .was in house and spoke to resident and offered her a nicotine patch, but she declined it .MD . recommended for her to not smoke until she recovers from being intubated (a procedure that involves inserting a tube into a patient's airway to help them breathe) at acute [hospital] . During a concurrent observation and interview on 3/4/25 at 2:14 p.m. with Resident 147 in Resident 147's room, Resident 147 was seen sitting in bed rubbing her hands together and frequently repositioning. Resident 147 stated she had not been allowed to smoke since admitted to the facility. Resident 147 stated, I want to be able to smoke it is the only pleasure I have. Resident 147 stated not being allowed to smoke made her feel anxious. Resident 147 stated she was aware of the MD's recommendation to not smoke. Resident 147 stated the Director of Nursing (DON) provided education to her and her mother on the risks of smoking before her throat was healed. Resident 147 stated she had expressed, since admission, to the DON and facility staff she wanted to smoke despite the recommendation not smoke. During an interview on 3/5/25 at 4:50 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 147 was alert and able to make her needs known. CNA 4 stated she was informed by the licensed nurse; Resident 147 could not smoke until her throat was healed. CNA 4 stated Resident 147 had expressed, despite ongoing education, she wanted to smoke. CNA 4 stated she expected all resident rights and preferences to be upheld. CNA 4 stated it was Resident 147's right to smoke against medical advice. During an interview on 3/6/25 at 8:15 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated smoking was a resident right, and all residents should be allowed to smoke if they wanted. LVN 2 stated the role of the nurse was to educate Resident 147 on the risks and benefits of smoking, potential risks to smoking against medical advice and then uphold Resident 147's choice. During an interview on 3/6/25 at 8:21 a.m. with LVN 1, LVN 1 stated she was aware Resident 147 wanted to smoke, since admission, despite medical recommendation not to. LVN 1 stated it was expected all residents received an admission smoking screen by the Social Services Supervisor (SSS) to determine if each resident was a smoker. LVN 1 stated she did not know if Resident 147 had an admission smoking screen completed. During an interview on 3/6/25 at 8:26 a.m. with the SSS, The SSS stated she was responsible to complete an admission smoking screen on all residents. The SSS stated Resident 147 was not identified as a smoker during the admission smoking screen. The SSS stated after completion of Residents 147's admission smoking screen she was made aware Resident 147 was a smoker and wanted to smoke. The SSS stated Resident 147 was advised not to smoke until her throat was healed. The SSS stated Resident 147 had the right to smoke against medical advice if she wanted. During a concurrent interview and record review on 3/6/25 at 8:30 a.m. with the Activities Director (AD), the facility's Resident Smoking Binder, undated, was reviewed. The AD stated the Resident Smoking Binder was up to date and included all residents within the facility who smoked. The AD stated Resident 147's name was not listed in the Resident Smoking Binder. The AD stated it was her responsibility to complete a Resident Safe Smoking Assessment (an assessment to determine if supervision is required for smoking, or if a resident is safe to smoke at all) on every resident who smoked. The AD stated no Resident Safe Smoking Assessment was completed for Resident 147. The AD stated Resident 147 had expressed to her she wanted to smoke. The AD stated Resident 147 was able to make her needs known and had the right to smoke against medical advice. During an interview on 3/6/25 at 8:36 a.m. with the DON, the DON stated Resident 147 was able to make her needs known and was her own responsible party. The DON stated Resident 147 had the right to make her own healthcare choices. The DON stated he expected all resident healthcare choices and requests to be respected and implemented, per facility policy. The DON stated it was Resident 147's right to smoke. The DON stated Resident 147 was not identified as a smoker on her admission smoking screen. The DON stated he expected all resident admission smoking screens to be completed accurately. The DON stated Resident 147's Resident Safe Smoking Assessment had not been completed. The DON stated he expected the Resident Safe Smoking Assessment to be completed once a resident was identified as a smoker, per facility policy. The DON stated Resident 147's medical team recommended Resident 147 not to smoke until her throat was healed. The DON stated Resident 147 received education from the provider, licensed nurses and himself on the risks and benefits of smoking before her throat was healed. The DON stated he was aware Resident 147 wanted to smoke despite the education. The DON stated Resident 147 had the right to smoke against medical advice. The DON stated Resident 147's rights were violated when she was not allowed to smoke for eight days, since admitted . During a review of the facility's job description document titled, Certified Nursing Assistant, dated 2023, the document indicated, .Promotes and protects all residents' rights . During a review of the facility's job description document titled, Charge Nurse, dated 2023, the document indicated, .Performs rounds to ensure resident needs are being met .collaborates with other members of the interdisciplinary team as needed to ensure residents' needs are holistically met .Promotes and protects all resident's rights . During a review of the facility's job description document titled, Social Services Director, dated 2023, the document indicated, .The Social Services Director ensures that staff members are knowledgeable about Resident's Rights and encourages staff to maintain and enhance each resident's dignity in recognition of each resident's individuality. The Director will also advocate for residents and assist them in assertion of their rights within the facility . Promotes and protects all residents' rights . During a review of the facility's job description document titled, Activities Director, dated 2023, the document indicated, .The Activities Director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program designed to meet the social, psychosocial and therapeutic needs of the resident . this includes .approaches that are individualized to match the skills, abilities, and interest/preferences of each resident .directing the activity program includes scheduling of activities .monitoring the response, reviewing and evaluating the response to the programs to determine is the activities meet the assessed needs of the resident, and making revisions as necessary . During a review of the facility's policy and procedure (P&P) titled, Activities, dated 11/2024, the P&P indicated, .It is the policy of this facility to provide an ongoing program to support residents in their choices of activities based don their comprehensive assessment, care plan, and preferences .to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being .intended to enhance her/his sense of well-being and to promote or enhance physical cognitive, and emotional health .that promote self-esteem, pleasure, comfort .activities will be designed with the intent to .enhance the resident's sense of well-being .reflect resident's interests .reflect choices of the residents . During a review of the facility's P&P titled, Resident Smoking, dated 11/2024, the P&P indicated, .Resident's who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all .The interdisciplinary team, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking .Documentation to support decision making will be included in the medical record, including but not limited to: Resident's wishes .Assessment of relevant functional and cognitive factors affecting ability to smoke safely . During a review of the facility's P&P titled, Resident Right's, dated 11/2024, the P&P indicated, .The resident has the right to a dignified existence .and access to .services inside and outside the facility .The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States .The resident has the right to .request, refuse, and/or discontinue treatment .The resident has a right to choose activities .The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .

Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment for one of two sampled residents when Resident 12's low air loss machine (designed to distribute patient's body weight over a broad surface area and help skin breakdown) was turned off. This failure had the potential for Resident 12 to develop skin breakdown which could result in pressure ulcer development. Findings: During a concurrent observation and interview on 3/5/25 at 9:40 a.m. in Resident 12's room, Resident 12 was seen lying in bed, covered with blanket and yelling out. Resident 12 did not answer questions asked. Resident 12's bed was positioned in lowest position and had a low air loss mattress. Resident 12's low air loss mattress was turned off and was unplugged from the wall. During a review of Resident 12's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 12 was readmitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk of the same side of the body) and hemiparesis (is a condition characterized by weakness or paralysis) dementia (the loss of thinking, remembering, and reasoning) and muscle weakness. During a review of Resident 12's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 12's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 10 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 12 had moderate cognitive deficit. During a review of Resident 12's Order Summary Report, dated 3/6/25 indicated, . low air loss mattress r/t [related to] limited mobility . During an concurrent observation and interview on 3/5/25 at 9:42 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 12's care. CNA 1 checked the low air loss machine of Resident 12 and stated the low air loss machine was off and it was unplugged. CNA 1 stated, The machine was supposed to be on at all times when a resident has an order to prevent skin breakdown. CNA 1 plugged the machine and turned the machine on. During an interview on 3/5/25 at 9:50 a.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated she was Resident 12's nurse. LVN 1 stated Resident 12's has an order for low air loss mattress and should have been on at all times to prevent Resident 12 from developing pressure ulcer (localized skin damage that developed as a result of prolonged pressure). LVN 1 stated it was the responsibility of the nursing staff to ensure the low air loss mattress machine was on at all times. During an interview on 3/5/25 at 10:55 a.m. with CNA 2, she stated she was the CNA assigned to Resident 12 and was familiar with his care. CNA 2 stated the low air loss mattress was off in the morning but did not recall if it was unplugged. CNA 2 stated the machine should have been on at all times. During an interview on 3/7/25 at 5:55 p.m. with the Director of Nursing (DON), the DON stated his expectation was for the low air loss machine to be on at all times when resident was in bed to prevent skin breakdown. The DON stated it was the responsibility of the nursing staff to ensure the low air loss machine was on and functioning properly. The DON stated not having the low air machine on put Resident at risk of developing skin ulcer. During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment, dated 2024, the P&P indicated, . In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . receive care and services safely . and does not pose a safety risk .

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) have the specific competencies, and skill sets necessary to ensure residents who required Enhanced Barrier Precaution (EBP) were properly managed to prevent the risk for infections for seven of seven sampled residents (Residents' 10, 30, 39, 40, 29, 37 and 28) when the IP demonstrated a breakdown in following critical infection control policies and procedures. These failures placed Residents' 10, 30, 39, 40, 29, 37 and 28 at increased risk for infection. Findings: During a review of Resident 10's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included diabetes (high sugar level in the blood), open wound to right knee, open wound to left knee and muscle weakness. During a review of Resident 10's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 10's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 10 had no cognitive deficit. During a review of Resident 28's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was readmitted to the facility on [DATE] with diagnoses which included retention of urine, hemiplegia and hemiparesis and muscle weakness. During a review of Resident 28's MDS assessment dated [DATE], indicated Resident 28's BIMS assessment score was 15 out of 15 indicating Resident 28 had no cognitive deficit. During a review of Resident 29's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia () and diabetes During a review of Resident 29's MDS assessment dated [DATE], indicated Resident 29's BIMS assessment was not able to complete and staff assessment was conducted which indicated Resident 29 had a score of 2 indicating Resident 29 was moderately impaired, decisions poor and required cues and supervision. During a review of Resident 30's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included diabetes, surgical aftercare, and chronic ulcer of left foot. During a review of Resident 30's MDS assessment dated [DATE], indicated Resident 30's BIMS assessment score was 13 out of 15 indicating Resident 30 had no cognitive deficit. During a review of Resident 37's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses which included open wound, non-pressure chronic ulcer of right heel and muscle weakness. During a review of Resident 37's MDS assessment dated [DATE], indicated Resident 37's BIMS assessment score was 15 out of 15 indicating Resident 37 had no cognitive deficit. During a review of Resident 39's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included cellulitis of left lower limb, diabetes and muscle weakness. During a review of Resident 39's MDS assessment dated [DATE], indicated Resident 39's BIMS assessment score was 15 out of 15 indicating Resident 39 had no cognitive deficit. During a review of Resident 40's Admission Record, (AR) dated 3/6/25, the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses which included cellulitis of unspecified part of limb and pressure ulcer of sacral region. During a review of Resident 40's MDS assessment dated [DATE], indicated Resident 40's BIMS assessment score was 15 out of 15 indicating Resident 40 had no cognitive deficit. During a concurrent interview and record review on 3/5/25 at 3:23 p.m. with IP, IP stated she had been the IP in the facility for over a year. The IP stated her role includes monitoring infection control and antibiotic use. The IP stated there are seven residents on EBP. The IP stated all seven residents on EBP did not have physician's orders. The IP stated according to facility policy and procedure, she should have placed the order on the day Residents' 10, 30, 39, 40, 29, 37 and 28 were placed on EBP. The IP stated Residents' 10, 30, 39, 40, 29, 37 and 28 did not have EBP care plans and should have. The IP stated care plans should be started within 24 hours. The IP stated she did not complete assessment or documentation for the residents' wounds. The IP stated as a result she did not know whether resident wounds were improving or getting worse because there was no documentation. During an interview on 3/7/25 at 6:05 p.m. with the Director of Nursing (DON), the DON stated the IP was responsible in identifying residents belonging in the EBP and notifying staff of the precautions needed to care for residents. The DON stated physician order was needed as soon as a resident was placed on EBP. The DON stated the IP should have called Medical Doctor (MD) and get the order. The DON stated his expectation was for the IP to do her job. During a review of facility document titled, Infection Preventionist, Job Description dated 2023, the document indicated, . Establishes facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases . Maintains documentation of infection prevention and control program activities .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 27) were provided special eating equipment when Resident 27's lunch was not served on an adaptive equipment scoop plate per her meal ticket. This failure resulted in Resident 27's individualized care needs not met which led to difficulty eating, delayed in finishing her meals and the potential risk for decreased oral intake. Findings: During a review of Resident 27's Admission Record (AR- document containing resident personal information), dated 3/6/25, the AR indicated, Resident 27 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (complete and partial weakness on the left side of the body following a stroke [blood flow to the brain is decreased, causing brain cells to die]) , chronic obstructive pulmonary disease (COPD-air flow obstruction and inflammation of the airways, leading to difficulty breathing) with acute exacerbation (sudden worsening of COPD symptoms, such as increased breathlessness, cough, and/or sputum production, that requires additional treatment and can worsen health status), type 2 diabetes mellitus with other diabetic ophthalmic complication (high levels of sugar in the blood that have caused vision problems) , muscle weakness and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). During a review of Resident 27's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 1/18/25, the MDS assessment indicated Resident 27's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 15 out of 15 which indicated Resident 27 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). The MDS assessment indicated Resident 27's functional abilities (the capacity to perform daily tasks and activities) had impairments on both sides of her upper extremities. During a concurrent observation and interview on 3/4/25 at 11:55 a.m. with the Certified Dietary Manager (CDM) in the kitchen during tray line (where meals are prepared, organized, and distributed o patients), Resident 27's lunch was seen on a regular plate. Resident 27's meal ticket stated, Adaptive Equipment: Scoop Plate. The CDM stated Resident 27's lunch was on a regular plate. The CDM stated per Resident 27's meal ticket she required a scoop plate. The CDM stated the cook and dietary aide were responsible to plate meals per the meal ticket. The CDM stated occupational therapy (OT) determined Resident 27's need for an adaptive scoop plate and she placed the order on the meal ticket. The CDM stated all adaptive eating equipment devices were listed on the meal ticket. The CDM stated a scoop plate had high plate edges to assist Resident 27 to scoop food on to her utensil. The CDM stated the facility did not have a scoop plate. The CDM stated the facility had one scoop plate and it broke the previous day. The CDM stated a new scoop plate had been ordered and would arrive in one day. During a concurrent observation and interview on 3/4/25 at 12:31 p.m. with Resident 27 in Resident 27's room, Resident 27 was seen eating lunch with her fingers on a regular plate. Resident 27 stated she typically used a special plate that helped her eat. During an interview on 3/5/25 at 12:02 p.m. with the Director of Staff Development (DSD), the DSD stated kitchen staff were responsible to accurately plate each meal per the meal ticket. The DSD stated Licensed Vocational Nurses (LVN) were responsible to ensure each meal ticket matched the plated dish before it was served to the resident. The DSD stated LVN's checked meal trays before serving to residents to ensure the correct diet, texture and adaptive equipment device were present. During an interview on 3/5/25 at 2:36 p.m. with the Registered Dietician (RD), the RD stated she expected all meal ticket orders to be followed. The RD stated the scoop plate made it easier for Resident 27 to eat. The RD stated Resident 27 was at risk for decreased oral intake if she could not easily eat her meal. During an interview on 3/6/25 at 8:15 a.m. with LVN 2, LVN 2 stated adaptive eating equipment devices were listed on the meal ticket. LVN 2 stated the scoop plate was an adaptive eating equipment device. LVN 2 stated all meals were expected to be served per the meal ticket order. LVN 2 stated the scoop plate helped Resident 27 eat with limited assistance and made it easier to scoop food onto utensils using the raised plate edges. LVN 2 stated Resident 27 was at risk for decreased oral intake or frustration if she could not easily eat her meal. LVN 2 stated LVN's were responsible to ensure meal ticket orders were followed before serving every meal. During an interview on 3/6/25 at 8:53 a.m. with the Administrator (ADM), the ADM stated she expected kitchen staff to plate meals accurately per the meal ticket order. The ADM stated the scoop plate was an adaptive equipment device used for eating. The ADM stated Resident 147's meal should have been plated per the meal ticket order. During an interview on 3/6/25 at 10:14 a.m. with Resident 27, Resident 27 stated it took longer to eat her meal with no scoop plate. Resident 27 stated she preferred the scoop plate because it was easier to eat on. During an interview on 3/6/25 at 11:35 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 27 used a scoop plate to eat. CNA 7 stated the scoop plate had raised, curved edges that made it easier for Resident 27 to scoop food onto a utensil. CNA 7 stated Resident 27 had limited mobility in her upper extremities and the scoop plate helped her eat with limited assistance. CNA 7 stated Resident 27 was at risk for decreased oral intake, frustration and decreased independence without the scoop plate. During an interview on 3/7/25 at 5:34 p.m. with the Director of Nursing (DON), the DON stated he expected all meal ticket orders to be followed. The DON stated the scoop plate was an adaptive equipment device. The DON stated he expected all kitchen staff to plate meals per the meal ticket order. The DON stated he expected all LVN's to ensure meal ticket orders matched the plated meal before serving to each resident. The DON stated he expected CNA's to identify any plated meal errors when assisting with meal set up. The DON stated Resident 27's meal should have been plated per the meal ticket order on a scoop plate. The DON stated Resident 27 was at risk for decreased oral intake and weight loss if she could not eat her meal. During a review of the facility's job description document titled, Dietary Cook, dated 2023, the document indicated, .ensures appropriate utensils and equipment are provided with the resident's meal tray . During a review of the facility's job description document titled, Dietary Aide, dated 2023, the document indicated, .sets up meal trays, food carts, dining room, etc., as instructed .assists in checking dietary trays before distribution and delivering food carts to designated areas . During a review of the facility's job description document titled, Dietary Manager, dated 2023, the document indicated, .overseeing safe and timely meal preparation, including the provision of meals and/or supplements in accordance with resident's needs, preferences, and care plan .uses forecasts .inventory, and equipment records to plan the purchase of food, supplies, and equipment .processes new diet orders and diet changes. Keeps diet cards updated . During a review of the facility's job description document titled, Certified Nursing Assistant, dated 2023, the document indicated, .coordinates dining room services at assigned mealtimes, including set-up and clean-up, meal tray delivery, feeding assistance, and documentation of meal intake . During a review of the facility's policy and procedure (P&P) titled, Food Safety Requirements, dated 11/2022, the P&P indicated, .Food will also be .distributed and served in accordance with professional standards for food service safety . During a review of the facility's P&P titled, Adaptive Feeding Equipment, dated 11/2024, the P&P indicated, .The dietary department should be notified of resident's needing adaptive feeding equipment; the equipment is stored and maintained in the dietary department. Appropriate utensils should be placed on the resident's food tray, at each meal, and returned to the dietary department, on the food tray, for sanitization .

Based on observation and interview, during the survey period of 3/4/25 to 3/7/25, the facility failed to provide and maintain a minimum of at least 80 square feet per resident room for 10 out of 16 rooms (Rooms 1, 2, 5, 6, 11, 12, 14, 15, 16 & 17). This failure had the potential to place residents at risk for not having sufficient space to accommodate their needs, privacy, and comfort. Findings: Resident rooms 1, 2, 5, 6, 11, 12, 14, 15, 16 & 17 did not meet the required square footage requirements; however, the residents had privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver did not adversely affect the health and safety of any of the residents residing in these rooms. Room # Square Feet Number of Residents 1 155.32 sq ft 2 2 157.25 sq ft 2 5 218.41 sq ft 3 6 215.63 sq ft 3 11 218.55 sq ft 3 12 218.01 sq ft 3 14 219.46 sq ft 3 15 157.83 sq ft 2 16 157.54 sq ft 2 17 157.09 sq ft 2 Recommend waiver continue. Don [NAME], HFES Health Facilities Evaluator Supervisor Date Request waiver continue in effect. ____________________________________

Based on observations, interviews, and record reviews, the facility failed to employ and maintain a Registered Dietitian (RD) to implement and sustain a comprehensive, coordinated, and systematic process for nutrition care to identify residents at nutrition risk and provide nutritional interventions to 10 of 10 sampled Residents (9, 19, 10, 22, 16, 17, 20, 21, 23, 22, and 18) with severe and/or significant weight loss when: 1. Resident 9 experienced a severe unplanned weight loss of 23.4 pounds (lbs. - measurement of weight) (14.7%) from January to May 2022 (five months). Weights were obtained and recorded but weight loss was not consistently communicated to the Physician or RD to determine effective interventions. Resident 9 was diagnosed with nine pressure ulcers (a severe injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin), one of which was unstageable (deeply damaged skin ulcer wound) on his left hip. The facility's Interdisciplinary Team (IDT- an interdisciplinary team comprised of professionals from various disciplines who work in collaboration to address a Resident with multiple physical and psychological needs) did not meet to discuss the severe unplanned weight loss or the unstageable pressure ulcer, and interventions were not implemented to address the severe unplanned weight loss. Resident 9 did not have a comprehensive nutrition assessment completed by an RD to reflect the severe weight loss, pressure ulcers, or recent laboratory tests ordered by the facility since 11/16/21. Laboratory test results would assist the facility's clinical team in monitoring the health and nutritional status of Resident 9. 2. Resident 19 experienced a severe unplanned weight loss of 27 lbs. (18.75%) from January to May 2022 in five months. Weights were obtained and recorded but the weight loss was not communicated to the Physician to assist in determining effective interventions. Resident 19 was diagnosed with type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints) and dysphagia (difficulty swallowing) and is on a tube-feeding (liquid nutrition through a tube) for his nutrition because he does not eat food by mouth. The RD's nutrition assessment indicated the goal was no significant weight changes in 30, 90, 180 days. The IDT did not meet to discuss interventions to address the severe weight loss, tube feeding formula tolerance, or other concerns which may have prevented Resident 19's further decline in nutrient status. 3. Resident 20 experienced a severe unplanned weight loss of 23 lbs. (14.2%) from January to May 2022 in five months. Weights were obtained and recorded but weight loss was not communicated to the Physician to determine effective interventions. Resident 20 was diagnosed with type 2 diabetes, hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone and typically causes weight gain), and hyperlipidemia (condition in which there are high levels of fat particles in the blood). The IDT did not meet to discuss the severe unplanned weight loss and interventions were not implemented to address the weight loss. The RD's nutritional assessment recommendation intervention on 4/13/22 to add fortified foods to Resident 20's Regular diet was not communicated to the physician and the diet order did not change to reflect the recommendation. 4. Resident 10 experienced a severe unplanned weight loss of 22 lbs. (12.1%) from January to May 2022 in five months. Weights were obtained and recorded but weight loss was not communicated to the Physician and RD to determine effective interventions. Resident 10 was diagnosed with a stage 4 pressure ulcer (where the wound extends deep through the skin and exposes underlying muscle, tendon, cartilage, or bone). The IDT did not discuss the severe unplanned weight loss or the pressure ulcer to develop interventions that would address the severe weight loss or stage 4 pressure ulcer. The RD failed to address the weight loss in a 4/13/22 progress note and the nursing intervention to increase nutritional supplement and physician order was not transcribed and added to the diet until 5/16/22 until 33 days later. Resident 10 did not have routine laboratory tests to assist in developing appropriate interventions to address the severe unplanned weight loss and stage 4 pressure ulcer to prevent further decline in nutrient status. 5. Resident 16 experienced a severe unplanned weight loss of 19 lbs. (13.7%) from January to May 2022, in five months. Weights were obtained and recorded but weight loss was not communicated to the Physician to determine effective interventions. Resident 16 was diagnosed with hypothyroidism and cyst of kidney (round pouch of fluid on the kidney). The IDT did not meet to discuss the severe unplanned weight loss to develop interventions that would address or prevent further weight loss. The RD's recommendation for nursing to provide supplemental nutrition was not communicated to the physician or transcribed, and the resident did not receive the necessary nutrition. 6. Resident 17 experienced a severe unplanned weight loss of 12 lbs. (10.2%) from January to May 2022, in five months. Weights were obtained and recorded but weight loss was not communicated to the Physician to determine effective interventions. Resident 17 was diagnosed with protein-calorie malnutrition (low availability of nutrients such as protein and energy in the body), hypothyroidism, hypocalcemia (a condition where the blood has too little calcium), and anemia (low levels of healthy red blood cells that carry oxygen throughout the body). The IDT did not meet to discuss the significant unplanned weight loss to develop interventions that would address the weight loss. The RD's nutrition assessment dated ,d+[DATE] indicated the Resident's weight was 119 lbs. and the goal was Weight maintenance due to desirable weight gain of 12 lbs. in six months. The RD's progress notes indicated No significant weight changes in 30 days But no other nutrition interventions were recommended to address Resident 17's severe insidious (slow and progressive) weight loss in five months. 7. Resident 21 experienced a severe unplanned weight loss of 13 lbs. (10.9%) from March to May 2022 in three months. Resident 21 was admitted weighing 119 lbs. in March 2022 but weighed 106 lbs. in May 2022, a loss of 13 lbs. in three months. Resident 17 was diagnosed with hyperlipidemia and later diagnosed with protein-calorie malnutrition. The RD's nutrition assessment recommendation on 4/13/22 to provide fortified foods and the physician's order to weigh weekly as of 4/6/22 were not implemented for Resident 21. The IDT did not meet to discuss the significant unplanned weight loss to develop interventions that would address the weight loss. 8. Resident 23 experienced a significant unplanned weight loss of 9 lbs. (6.5%) from January to May 2022, and a severe unplanned weight loss of 10 lbs. (7.2%) in one month, from April to May 2022. Weights were obtained and recorded but weight loss was not communicated to the Physician to assist in determining effective interventions. The IDT did not meet to discuss the significant unplanned weight loss to develop interventions that would address the weight loss. Resident 23 was diagnosed with vitamin D deficiency and gastroesophageal reflux disease (GERD - a condition when stomach acid frequently flows back into the tube connecting the mouth and the stomach). Resident 23 did not have recent laboratory tests ordered by the facility in 2021, which occurred May 2022. Laboratory test results would assist the facility's clinical team in monitoring the health and nutritional status of Resident 23 to minimize nutrition risk. 9. Resident 22 experienced a severe unplanned weight loss of 11 lbs. (10.1%) from January to May 2022, in five months Weights were obtained and recorded but weight loss was not discussed by the IDT to determine possible effective interventions. Resident 22 was diagnosed with protein-calorie malnutrition and is on 100% tube feeding. Without a comprehensive recommendation from the RD's nutrition assessment and communication with the Resident 22's physician, the resident will continue to experience progressive weight loss. 10. Resident 18 experienced a significant unplanned weight loss of 9 lbs. (6.5%) from January to May 2022. Weights were obtained and recorded but weight loss was not communicated to the Physician to determine effective interventions. The RD's nutrition assessment on 2/2/22 for Resident 18 indicated the goal was .no significant weight changes, goal weight range: 145-160# (pounds). Resident 18's weight was 148 lbs. on 1/17/22 and 139 lbs. on 5/12/22. No other nutrition intervention recommendations were made by the RD for Resident 18, and the resident continued to lose weight. As a result of these failures, Residents (9, 19, 10, 22, 16, 17, 20, 21, 23, 22, and 18) nutritional and health status was compromised and resulted in severe or significant weight loss in one, three, or five months and led to, or had the potential to further complicate chronic conditions including but not limited to dehydration (the body does not have enough water and other fluids to carry out its normal functions), loss of lean muscle and body mass, and decreased mobility. The facility also failed to ensure a qualified Dietary Manager provided oversight of the operational functions of the food and nutrition services department according to state regulation and facility policy, from April 13, 2022- May 12, 2022. Because of the significant and severe unplanned weight loss for Residents (9, 19, 10, 22, 16, 17, 20, 21, 23, 22, and 18), the facility's lack of a comprehensive nutritional assessment system process to consistently respond to residents severe and significant weight loss, assess, identify residents at nutritional risk in order to maintain acceptable parameters of nutrition, and resident with severe wounds did not receive adequate nutrition to promote wound healing, an Immediate Jeopardy (IJ- a condition where the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called on 5/17/22, at 4:25 P.M. The IJ was called under Code of Federal Regulations (CFR) S483.25 Nutrition/Hydration Status Maintenance (F692) with the Administrator (ADM) and Director of Nursing (DON in attendance. The Centers for Medicare & Medicaid Services (CMS- a federal agency that administers the nation's major healthcare programs) IJ Template was provided to the facility and an explanation given that the facility obligation was to submit a written Action Plan based on the need for immediate actions as listed on the IJ Template. The facility submitted an acceptable IJ Plan of Action (POA), Version 4 on 5/20/22, at 3:27 P.M. The Plan of Action included but was not limited to the following: 1) The Registered Dietitian (RD) will complete comprehensive nutrition assessments to accurately assess 10 out of 10 residents with unplanned weight loss- 3 residents (Residents 9,10, and 19) with severe unplanned weight loss and 7 residents (Residents 22,16, 17,18,20,21, and 23) with significant unplanned weight loss during change of condition and on admission. 2) Implement a system to accurately calculate meal consumption percentage and immediate training of Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) staff to measure it. 3) Develop and implement an electronic system to order, monitor, and respond to nutritional lab values for 10 of 10 residents with unplanned significant and severe weight loss. 4) Notify the Physicians for Residents 9, 19, 10, 22, 16, 17, 20, 21, 23, 22, and 18 of significant or severe weight change to prevent further health decline. 5) Complete a root cause analysis by the facility's Interdisciplinary Team (IDT) and revision of facility weight policy to ensure residents are consistently and accurately weighed. 6) Obtain full-time, onsite Registered Dietitian coverage for 35 or more hours per week to conduct in-person nutrition and health assessments of all residents. 7) Conduct a new baseline weight for all residents, particularly the affected Residents 9, 19, 10, 22, 16, 17, 20, 21, 23, 22, and 18 with unplanned significant and severe weight loss. 8) Develop a system to consistently communicate resident weights to nursing staff, physicians, and the RD. The survey team validated each of the items on the IJ POA by observation, interview, and record review. The IJ for F 692 was removed on 5/24/22 at 11:49 A.M. with the ADM in attendance. Cross reference F725, F686 Findings: During a review of professional reference in the Journal of the American Society on Aging, titled Weight Issues in Later Years. Generations, dated 2004, retrieved from https://www.jstor.org/stable/26555322. The article indicated, A combination of many factors can lead to geriatric failure to thrive, defined by the National Institute on Aging as a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol . Early intervention is important in preventing progression of this condition. During a review of professional reference in the Journal of the American Dietetic Association titled, Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, dated October 2010, the position paper indicated, . In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost .that may trigger sarcopenia (a condition characterized by loss of skeletal muscle mass and function) and functional decline (a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living). During a review of professional reference titled, Involuntary Weight Loss can lead to Muscle Wasting . Depression and an increased rate of Disease Complications (www.aafp.org/afp American Family Physician), dated 2/15/02, the reference indicated, .Various studies demonstrated a strong correlation between weight loss .morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost five percent of their body weight in one month were found to be four times more likely to die within one year . During a review of a professional reference publication titled, Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated, . The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight . During a review of professional reference titled, The Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines dated 2007-2009, indicated, . The Registered Dietitian should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT) . 1. During a review of Resident 9's Face Sheet (FS) undated, Resident 9 was admitted to the facility on [DATE] with diagnoses which included epilepsy (A condition of the brain when nerve activity is impaired leading to seizures) and hyperlipidemia (condition in which there are high levels of fat particles in the blood), and readmitted on [DATE] with a new diagnosis of protein-calorie malnutrition (low availability of nutrients such as protein and energy in the body). During a record review of the facility's document titled Monthly Weight Report, dated 5/16/22, the weight report indicated the following weights in lbs. (pounds) from January - May 2022 for Resident 9: January 2022 - 160 lbs.; February 2022 -148.9 lbs.; March 2022 - 143.6 lbs.; April 2022 - 145.2 lbs.; and May 2022 - 136.6 lbs. According to the Monthly Weight Report, Resident 9 experienced a 14.7% severe unplanned weight loss. During a review of the RD's nutrition assessment document titled CANM (Comprehensive Assessment Nutrition Management)- Nutritional Risk Quarterly, dated 11/16/21, the nutrition assessment indicated Resident 9's weight was 161 lbs., planned goal weight: 155-165# (lbs.), and planned weight goal was No significant weight changes for 1 mo., 3 mos., or 6 mos.; skin intact, no labs available or reviewed . A review of a limited RD nutrition progress note on 4/13/22 indicated resident [9] weight loss of 11 lbs. in 30 days was .highly likely to variable meal intake, recommend nursing to provide MedPass 2.0 supplement [high calorie, nutritional supplement, 90 mL [milliliters- unit of measurement], BID [Two times a day]. During a concurrent observation and interview on 5/16/22 at 9:15 A.M. with RD1 about Resident 9, RD1 stated she was unaware of Resident 9's prior history of pressure ulcers or recent weight loss. Resident 9 was lying in bed resting. RD1 stated residents with pressure ulcers or wounds should have appropriate dietary modifications such as increased protein, vitamin C, and Zinc to promote wound healing. RD1 acknowledged this recommendation should have been part of the previous RD's notes and a RD consult should have been communicated to the facility's RD. During an interview on 5/16/22 at 11:05 AM with the Administrator (ADM), the ADM stated the facility did not have an RD after the previous one left in April until one was hired in May 2022. The ADM stated the last RD was hired to work part-time to cover the facility residents' nutrition care issues, and provide oversight of kitchen/dietary operations. The ADM further stated the RD's position is important to the facility because they are supposed to ensure the nutrition needs of the residents are taken care of. During an interview on 5/16/22 at 11:45 A.M. with Dietary Service Supervisor (DSS)1 about Resident 9's meals and snacks, DSS1 stated he was unaware of any dietary preferences or meal concerns for Resident 9 to address pressure ulcers. The DSS1 stated he never met the facility's RD in person or communicated with her about any resident meals/snack concerns, or kitchen related issues before her last day of work with the facility in April 2022. The DSS1 stated, The former RD worked part-time remotely here. The DSS1 further stated nursing would inform him or DSS2 (in his absence) of any dietary meal or snack preferences and changes so him or DSS2 could implement them. During a concurrent interview and record review on 5/17/22 at 10:00 A.M. with DSS1, the DSS1 stated Resident 9 was recently added back to the resident daily nourishment list on 5/6/22 for the resident to receive Med pass 2.0 at 10 A.M., 2 P.M. and 7 P.M. DSS1 stated he was removed back in February 2022 but was not readded in March 2022. During an interview on 5/19/22 at 10:33 A.M. with Physician (PHYS) 1, PHYS1 stated Resident 9 was very fragile and had multiple pressure ulcers when he returned from a medical facility. PHYS1 stated she was unaware a wound consult and dietary consult were not sent to nursing or the RD for an evaluation of Resident 9's pressure ulcers and weight loss. PHYS1 stated she was unaware the facility did not have an RD for over a month. PHYS1 stated for residents with weight loss, the RD completes an assessment, and the facility sends recommendations to the physician. PHYS 1 stated she did not recall receiving recommendations to address Resident 9's pressure ulcers and wounds. PHYS 1 stated using Remeron, vitamin D, vitamin C, Zinc and protein supplements is a standard nutrition protocol for addressing pressure ulcers. PHYS1 further stated laboratory values are important to review for residents with chronic medical conditions. PHYS 1 stated she was unaware Resident 9 did not have recent labs in 2022, especially since he had severe weight loss and unstageable pressure ulcers. PHYS1 stated she normally ordered prealbumin, thyroid, B12, vitamin C and vitamin D labs to check Resident 9's health status. PHYS 1 stated the RD's role is hugely important in the wound healing process and reducing weight loss to ensure the appropriate nutrition recommendations are implemented. During a review of the facility's document titled Situation Background Appearance Review and Notify (SBAR) Communication Form, dated 3/30/22, the SBAR indicated at 4:30 P.M., .CNA informed nursing of Resident 9's open skin area on right hip . at 6:00 P.M., MD 1 made aware relayed findings, new order for RD referral . During a review of the facility's document titled Pressure Sore Management Record dated May 2022, the facility document indicated Resident 9 had a total of eight pressure ulcers, on the right hip, left ankle, left knee, right inner shin, right heel, left hip upper and lower left hip. During a record review of Resident 9's meal intake consumption percentage report titled Follow up Question Report dated 4/1/22-4/30/22, the report indicated Resident 9 had an average daily meal consumption of 76-100%. A review of May 2022 meal intake percentage indicated an average daily meal consumption of 51%-100%. During a record review of an undated facility document of Resident 9's meal intake consumption, the document indicated .Question 4 .Amount Eaten .4/28/22 .Yes/No . During an interview with the DON on 5/18/22 at 2:30 P.M., the DON stated she was unaware Resident 9 had recently restarted receiving the MedPass 2.0. The DON further stated it was important for the dietary department and nursing staff provide residents with their nutrition supplements, according to their diet order. The DON also stated it was important for nursing staff to receive the proper training on how to correctly calculate the facility residents' meal intake consumption in amounts, not yes/no. During an interview on 5/19/22 at 6:00 P.M. with RD 1, RD 1 stated the RD is responsible for conducting nutrition assessments of the resident to determine their nutrition status and ensure their needs are met. RD 1 stated it was important for the RD to check the following parameters when conducting a comprehensive nutrition assessment on a resident: medical diagnoses, fractures, weight, height, calorie/energy and protein needs, how much they're eating, physician ordered medications, labs, supplements, previous weight loss that was identified, edema (swelling of skin caused by extra fluid trapped in skin). The RD also works with the kitchen supervisor to make sure food safety and sanitation measures are carried out. During an interview on 5/20/22 at 4:23 P.M. with RD2, RD 2 stated I was told there were missing assessments and large amount of residents with weight loss. There was also no kitchen oversight . During a subsequent interview with RD 2 on 5/23/22 at 5:05 PM, RD2 stated an RD is needed to check residents on tube feeding (TF) to make sure they have the correct formula and rate, check residents with weight loss/weight gain routinely to determine the root cause of the weight changes and develop a plan for the resident with the interdisciplinary team (IDT). During a review of the facility's electronic medical record (EMR) on 5/19/22, under the Results tab for laboratory tests, indicated Resident 9 did not have laboratory tests in 2022. During a review of the Resident 9's Diet Order, dated 5/16/22, .the diet and diet texture indicated Regular, Dental Soft (mechanical soft), Fortified (the addition of foods like butter or pudding to increase calories and protein in a meal). During an interview with RD1 on 5/23/22 at 2:54 P.M., RD 1 acknowledged Resident 9 did not have current routine labs and stated Resident 9 should have been reassessed and new labs drawn when the pressure ulcers were identified. RD 1 further stated it was important for nursing staff to correctly enter the resident's meal intake consumption into the resident's chart because it helps the RD to develop proper nutrition interventions during an assessment. During a review of the facility's policy and procedure (P&P) titled, Nourishments and Snacks, dated 12/20, the P&P indicated .PROCEDURE: I. Nourishments A. Residents who may receive nourishments include, but are not limited to, the following: i. Residents who are underweight or have experienced weight loss, .iii. Residents with poor intake, .iv. Residents with skin problems, .v. Residents who have low albumin . During a review of the facility's P&P titled, House Supplements, dated 12/2020, the P&P indicated, PURPOSE: To ensure that the facility provides house supplements to residents that meet nutritional guidelines .At least 6 grams of protein and 180 calories will be provided in all products used as house supplements . During a review of facility P&P titled Wound Management dated 6/2020, the P&P indicated .POLICY: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing .PROCEDURE: .C. An assessment of care needs for pressure injury and wound management will be made with an emphasis on .v. nutritional status . During a review of the facility's P&P titled, Assessment and Management of Resident Weights, dated 06/20, the P&P indicated, .PROCEDURE: .II. If the weight is less than or greater than 5# (# stands for pounds) from the previous weight, immediately re-weigh and have licensed nurse verify accuracy of the weight; .V.Significant weight changes are: .5% in one (1) month, .7.5% in three (3) months, .10% in six (6) months; .B. Report weight change in the medical record and on the 24 hour report; ii. Notify the physician and dietitian of significant weight changes; .C. The registered dietitian will: i. Complete a nutritional assessment on all residents with a significant weight change; and ii. Document the nutritional assessment and weight management recommendations in the medical record; D. The licensed nurse will notify the physician of the dietitian's recommendations and notify the family/health care decision maker of the weight change .E. If the physician does not implement the dietitian's recommendations, they will document the rationale for non-implementation in the medical record .; F. Residents with significant weight change will be weighed at least weekly and discussed at the Resident at Risk or other clinical meeting to determine possible causes of weight gain or loss including goals for care . During a record review of the facility's RD Consultant Contract document titled CONSULTING AGREEMENT, dated 9/23/21, the contract indicated .CLIENT .and CONSULTANT .The RD will provide consultation as follows .Assess the resident's nutritional needs .Document nutritional information according to the policies of the facility and accepted professional practices. This task is performed by the RD for initial assessments, annuals, and change of condition . 2. During a review of the facility's FS dated 5/16/22, Resident 19 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, dysphagia (difficulty swallowing), and gout. During a record review of the facility's document titled Monthly Weight Report, dated 5/16/22, the weight report indicated the following weights in lbs. (pounds) from January - May 2022 for Resident 19: January 2022 - 144 pounds; February 2022 -117 pounds; March 2022 - 120 pounds; April 2022 - 106.2 pounds; and May 2022 - 117 pounds. According to the Monthly Weight Report, Resident 19 experienced a 18.75% severe unplanned weight loss. During a review of the RD's nutrition assessment titled CANM Nutritional Risk Assessment- Admission/Annual, dated 11/16/21, the assessment indicated the Resident 19's weight was 135 lbs., the goal was weight maintenance, and tube feed rate was three times a day Bolus [fluid given over a short period of time] feedings of Glucerna 1.2 (2 cans 474 ml) to provide 1422 ml/1706 kcals (kilocalories or calories)/85 gm protein, 1146 ml free water, Water flushes 180 ml pre/post bolus feedings to provide 1080 ml water TID (three times a day). During a review of the RD's nutrition assessment for Resident 19 dated 2/10/22, the assessment indicated the goal was to continue TF [tube feeding- Administering nutrition or other fluids by means of a tube surgically inserted directly into the stomach] tolerance, no significant weight changes in 30, 90, 180 days, and RD will monitor . During a review of the RD's nutrition progress note dated 4/1/22, the RD recommended to change the tube feed formula to Glucerna 1.5 two cans, three times a day from Glucerna 1.2 two cans four times a day to provide 2496 kcal instead of 1896 kcal per day. During a review of Resident 19's Diet Orders and Enteral Feeding in the EMR on 5/19/22, the Diet Orders indicated Diet Type: NPO (nothing by mouth) . There was no Enteral Feeding Orders in the EMR for Resident 19's tube feeding. During a concurrent observation and interview on 5/23/22 at 12:04 p.m. LVN5 stated she was familiar with resident 19 and that he gets Jevity 1.4, 4 times a day. LVN5 checked the EMR system and confirmed resident 19 receives Glucerna 1.5, seven cans total per day. LVN 5 stated the tube feed order was recently changed. During a concurrent interview and record review on 5/23/22 at 2:54 P.M. with RD1, RD1 acknowledged that the former RD's recommendation in April 2022 to increase the tube feed formula to Glucerna 1.5 had not been completed. However, RD 1 further stated she observed Resident 19 is receiving Glucerna 1.2 but was not sure where the physician's diet order was in the EMR for it. RD1 further stated a comprehensive nutrition assessment should have been completed for Resident 19 and discussed with the IDT to revise the feeding to continuous instead of bolus which may improve the resident's nutrition status. During an interview on 5/23/22 at 5:05 P.M. with RD2, RD 2 stated when completing a nutrition assessment on residents on tube feeding, especially who has lost weight or look very lean, she would review their labs and recommend an increase in formula rate. During a review of the facility's electronic medical record (EMR) on 5/19/22, under the Results tab, the Laboratory Results indicated Resident 19's last lab tests were dated 11/23/21 and no new labs until 5/3/22. During a concurrent interview and record review with RD 1 on 5/19/22 at 4:50P.M., RD 1 stated laboratory values, particularly nutrition status labs such as albumin, are important to have for an RD to conduct a comprehensive nutrition assessment of a resident. RD 1 acknowledged lab tests were not drawn for Resident 19 from December 2021-May 2022. During a review of the facility's P&P titled, Nutrition/Hydration Management, dated 06/20, the P&P indicated, PURPOSE: To ensure each resident maintains acceptable parameters of nutritional status, such as body weight and protein levels .based on the resident's comprehensive assessment .; POLICY: I. The concept of nutrition management is an interdisciplinary process .key components of this system are .A. Maintaining nutritional status as indicated by clinical measures such as body weight, biochemical measure, and hydration; B. Developing an individual nutrition/hydration program based on individual assessed needs; C. Implementing the nutrition/hydration program; D. Identifying new instances of unplanned weight loss .; E. Ongoing assessment, monitoring, and evaluation of the effectiveness of the nutrition/hydration management program. II. The goal of any nutrition/hydration management process is to improve quality of life .; PROCEDURE: II. A registered dietitian completes a thorough nutritional assessment providing a [NAME][TRUNCATED]

Based on observation, interview and record review, the facility failed to provide sufficient staffing with appropriate competencies and skill sets to meet the needs of the residents when: 1. The facility leadership scheduled one registry (staffing agency) Licensed Vocational Nurse (LVN) to perform medication administration and provide nursing services for 42 of 42 residents from 5/1/22 to 5/10/22 during the morning and evening shifts without completing facility orientation or skills competencies. The facility did not employee a registered nurse (RN) to provide resident care and provide RN oversight of LVN in accordance with the California Board of Vocational Nursing and Psychiatric Technicians (BVNPT). The facility did not employee a Director of Nursing (DON) to oversee resident nursing services in accordance with healthcare law and regulations. The facility did not employ a Director of Staff Development (DSD) in accordance with state law. The facility did not employee a Registered Dietician (RD) to oversee kitchen staff and resident dietary services and conduct resident comprehensive medical nutrition assessments for resident experiencing significant and server weight loss living in the facilities. These failures resulted in 6 of 42 residents (Residents 18, 26, 19, 28, 11, and 29) receiving medications over one hour late and placed resident at risk for medication errors, serious negative effects from low blood sugar, high blood pressure, unrelieved pain, experience a decline in resident mental health condition, and experience seizures (a burst of uncontrolled electrical activity between brain cells). The failure of not employing a RN resulted in LVN ' s not having RN oversight, administering medications late, resident experiencing significant and server weight loss, not receiving RN assessment, residents developed and worsening of pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) and not receiving RN assessments. The failure of not employing a DSD resulted in LVNs not receiving facility orientation and not receiving nursing care skills check evaluation prior to providing resident care which resulted in multiple residents experiencing significant and severe weight loss, residents developed pressure ulcers and wounds worsened and developed infections because of wound care not being done. The failure of not employing a DON resulted in resident nursing services to have no DON oversight and consequently a decline in multiple resident ' s health status which resulted in multiple resident experiencing significant and severe weight loss, residents developed pressure ulcers and pressure ulcers worsened and developed infections because of wound care not being done in accordance with the physicians order, and as a result of noncompliance, and in consideration of the facility resident ' s physical, mental, psychosocial (individual thought and behavior) or health needs, and/or vulnerabilities, experienced serious adverse outcome, serious injury, and placed all resident at risk of serious harm, serious impairment and/or death. 2. The facility had nine resident-to-resident verbal and physical abuse altercations between 1/1/22 and 5/3/22. The facility did not evaluate staffing needs and ensure sufficient nurses were scheduled to provide care and interventions to prevent continued abuse and scheduled one LVN for 42 of 42 residents. The facility failed to conduct timely resident to resident abuse investigations to determine abuse triggers and did not perform timely resident assessments, did not develop, revise, and implement effective care plan interventions to prevent further resident-to-resident abuse altercations for five of 10 residents (Residents 15, 2, 26, 25, and 24). These failures placed residents at risk of serious injury, and serious harm, serious impairment and/or death. 3. One of 4 sampled residents (Resident 9) was admitted on [DATE] with four stage 2 (a shallow open ulcer/blister), and two unstageable pressure ulcers (Full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green, or brown] and/or eschar [tan, brown or black] in the wound) and assessments and services to promote pressure ulcer healing were not provided. Resident 9 developed two additional pressure ulcers in the facility by 3/30/22, and the facility did not employ a qualified and competent nurse to conduct weekly skin assessments, wound treatments, follow professional standards for staging of pressure ulcers (determining how serious the bed sore is) and follow physician ordered treatments to promote healing of wounds. The facility did employee a registered dietician to perform a nutritional assessment and to implement nutrition interventions to promote wound healing. These failures resulted in the significant decline, serious harm of Resident 9 ' s clinical status and worsening of pressure ulcers; and contributed to Resident 9 ' s severe unplanned weight loss and the need to transfer Resident 9 to an acute care hospital (higher level of care) for six days and placed Resident 9 at risk for serious impairment and/or death. Because of the serious harm to Resident 9 and potential serious harm to all residents related to not providing sufficient number of qualified staff, Nursing and RD with appropriate level of skills and competencies to provide care to facility residents, administer medications on time, evaluate and implement effective nurse interventions to address resident safety, prevent resident to resident abuse altercations and not providing care and services to meet resident needs. The actual serious harm to Resident 9 related to not providing competent and qualified nurses to assess and treat pressure ulcers and prevent worsening pressure ulcers, an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called on 5/11/22 at 3:40 p.m. in the area of Code of Federal Regulations (CFR) 483.35 (a) (F725) Nursing ServicesS483.35(a) Sufficient Staff with the facility Administer (ADM), Assistant Administrator (AA) and Director of Nursing (DON).The IJ template was provided to the ADM that documented the Need for Immediate Actions and the explanation to the facility was provided to submit a written plan to address the IJ situation. The facility submitted Version three Plan of Removal that was accepted on 5/13/22 at 2:10 p.m. which included bringing in an additional Licensed Vocational Nurse (LVN) for each shift so that a minimum of 2 Licensed Nurses are in the facility to allow for medications to be given on time and to provide oversight of resident-to resident interactions, physical assessments were completed on all residents, and orientation, education and training was provided to each staff member before they were given an assignment each shift. While onsite, the surveyors verified through observations, interviews and record reviews and confirmed the implementation of interventions to address the IJ situation on version three Plan of Removal were fully implemented. The IJ was removed on 5/18/22 at 5:09 p.m. with the Administrator. Findings: 1.During an interview on 5/3/22 at 9:30 a.m., with the Administrator (ADM) and the Assistant Administrator (AA), the ADM stated There currently isn ' t a DON . the LVNs are currently covering for the DON. We do not currently have a DSD. The LVNs are covering for the DSD also. The AA stated, We have our own nurses for PM (evening) and night shifts, but the day shift is covered by registry. The ADM stated, We do not have a full time RN (registered nurse) currently on staff to cover the regulation of 8 hours per day 7 days a week .we are fortunate, so far nobody has needed an RN assessment. During a review of the facility document titled, Daily Census dated 5/3/22, the document indicated, .Total Residents - 42. During an observation and interview in the west hallway on 5/3/22 at 1 p.m., with LVN 3, LVN 3 was observed to be the only nurse working that shift. LVN 3 stated, I work for registry and have been here for four days. There is no DON that I am aware of. LVN 3 stated there was no DSD that she was aware of and, They [the facility] expect me to work alone on day shift, so I cancelled all of my shifts for the rest of the month. LVN 3 stated the Assistant Administrator (AA) told her they cannot afford to pay another nurse, and she [the AA] wanted me to work alone for all 42 Residents. LVN 3 stated there was no consistent oversight from an RN. During an interview on 5/3/22 at 2 p.m. with the AA, the AA stated PM nurses work alone. Sometimes noc (night shift) nurses work alone. Sometimes the noc nurses will come in early to help the PM nurses. During an interview on 5/3/22 at 3:25 p.m. with LVN 4, LVN 4 stated he has worked the PM shift at this facility for almost a year. LVN 4 stated, There is only one nurse on PM. They do it on purpose; I have asked the administration for more help. It ' s just me and 42 Residents. I manage with the medications, but I can ' t get to charting sometimes . the Administrator ' s answer is that registry is expensive. During an interview on 5/3/22, at 3:57 p.m. with the Infection Prevention Nurse (IP) 2, IP 2 stated there was not enough staff on duty to keep all the residents safe. During an interview on 5/12/22 at 11:45 a.m. with the Registry Owner (RO) LVN, the RO/LVN stated, My nurses are independent contractors. It depends on the facility if they want the competencies on file before the nurses start onsite. The competencies are done by the nurses themselves. They rate themselves on how competent they are on different tasks, how much time they have spent doing a task, comfort level. It is a self-screen competency. There is no hands-on testing or oversite to verify competency. The facilities in [other facilities] require proof of competencies but [this facility] has not requested any of it. During an interview on 5/11/22 at 8:41 a.m. with LVN 7, LVN 7 stated, When registry comes into the facility there is no orientation. Last night when I came in, I went straight to work passing meds. Besides the quick walking rounds with [LVN 4], I didn ' t meet with anyone. We are expected to just come in start. No orientation or anything from the facility. During an interview on 5/12/22 at 11:52 a.m., with the AA, The AA stated the facility did not receive any proof or verification of the nurses ' competency from the registry before hiring them. The AA stated the facility has not required proof of competency for nurses coming into the building and nobody at this facility has tested their competency either. The AA stated that the registry nurses have not been proven to be competent to perform any nursing duties. During a concurrent interview and record review on 5/12/22, at 10:44 a.m., with the DON, the DON stated there had not been enough people to care for the residents in the facility, prevent altercations, or improve nutrition. The DON stated there was a need for the staff to be trained. During an interview on 5/3/22, at 4:38 p.m., with the ADM, the ADM stated she would hire a DON as soon as possible. The ADM would not comment on what were the possible effects on residents ' care if there is no RN with clinical oversight for the licensed nurses. The ADM declined to comment when asked what issues could arise from the lack of licensed nurses, such as director of staff development, minimum data set coordinator (a registered nurse who does the assessments for all residents) or director of nurses onsite to cover the charge nurses if needed. During an interview with the DON on 5/9/22 at 2:45 p.m. the DON stated today, 5/9/22 was her first day working at this facility and this is her first assignment with the company that owns this facility. During a concurrent observation and interview on the east wing on 5/9/22 at 10:11 a.m. with LVN 5, LVN 5 was observed to be passing her medications that were due at 9 a.m. LVN 5 stated she knew that her medication pass was late and that the medications were due at 9:00 a.m. LVN 5 stated she was not done with all of the west wing (15 residents) yet and that she had been the only licensed nurse there all morning. LVN 5 stated, I didn ' t know I was going to be by myself. During an interview on 5/9/22 at 10:51 a.m. with the Registry Owner LVN (RO/LVN), she stated she is the owner of the Registry service used by the facility to staff LVNs and Certified Nursing Assistants (CNAs). The RO/LVN stated that she, Just came in to help LVN 5. RO/LVN stated, I am passing late medications that were due at 8 a.m. and 9 a.m. I am passing medications like metformin (a drug used to treat diabetes), lorazepam (a drug used to prevent seizure and anxiety), Depakote (a drug used to prevent seizure). RO/LVN stated, the Residents could have adverse effects from not getting their medications timely. It could affect their blood sugar and cause it to be elevated. Someone on a seizure medication could have seizures if they wait too long between doses. Their [meaning the residents] medications are really late . During an interview on 5/9/22 at 11:24 a.m., with LVN 5, LVN 5 stated the medications were late because she was by herself. LVN 5 stated, There are so many Residents and just one nurse, it isn ' t safe. During an interview on 5/9/22 at 4:35 p.m. with RO/LVN, RO/LVN stated, I was having a hard time staffing this facility only because the nurses did not want to work alone with 42 Residents. The facility wanted only one nurse on days [6:45 a.m. to 3:15 p.m.]. and PMs [2:45 p.m. to 11:15 p.m.]. They had nurses coming in for 4 hours (in addition to the scheduled 8-hour nurse) for a while, but then they called me and cancelled the contract for the 4 hour nurse. RO/LVN stated if the facility wanted two 8-hour LVNs to cover the facility her registry business could have provided the nurses and would have no trouble staffing the facility. During an interview on 5/10/22 at 3:04 p.m. with the Corporate Clinical Officer (CCO) regarding having only one licensed nurse in the building and no Director of Nursing, the CCO stated, That responsibility lies with me. This hasn ' t been fair to this facility .We haven ' t had the right oversight at [this facility] . We are committed to correcting this .I accept responsibility for that oversight. The CCO stated she is aware that there have been multiple incidents regarding Resident-to-Resident abuse, elopements, and other concerns. If you have your head down and you ' re passing meds, it ' s hard to do anything proactive as far as Resident-Resident interactions, elopements, and so on. During a concurrent interview and record review on 5/9/22 at 3:50 p.m. with the AA, the facility document titled Licensed Nurse Schedule . May-22 was reviewed. The schedule indicated from May 1, 2022, through May 10, 2022, there was only one licensed nurse scheduled for the facility on day shift, one licensed nurse on the PM shift, and one licensed nurse on the night shift. The AA stated they did not have a Director of Nursing (DON) during this time. The schedule had a space for a second 8-hour licensed nurse and a 4-hour licensed nurse on the day shift and PM shift, but no names were listed and no indication that registry nurses had been requested. The AA stated, We call them in if we need them. A facility document, untitled, was reviewed with the AA that included names and a schedule. The AA stated this was the CNA schedule for May 2022. The schedule indicated there were two to six CNAs working each day from 5/1/22 - 5/9/22 on day shift, three to four CNAs working on PM shift, and two to three working on night shift. During an interview on 5/12/22 at 8:41 a.m., the DON stated there had not been enough people to care for the residents in the facility, prevent altercations, or improve nutrition. The DON stated there was a need for the staff to be trained. During a review of the facility ' s P&P titled, Staffing, dated 10/2017, the P&P indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .2. Facility shall use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .3. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident ' s care plan . During a review of the facility document titled Licensed Practical Nurse/Licensed Vocational Nurse, (undated) the document indicated, Below are the job duties that are required of every Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN). POSITION SUMMARY - The Licensed Practical Nurse or Licensed Vocational Nurse as defined by state, is responsible to the Director of Nursing, and is to be clinically competent, delivers care to patients utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation, and effectively interacts with patient, significant others and other health team members while mainlining standards of professional nursing. Limitations of assessment as designated by scope and state. The LPN has the primary responsibility for providing medical services, counseling, supervision, and program plan implementation to clients during scheduled shifts within known scope of practice. Direct client care involves the following duties: POSITION RESPONSIBILITIES/STANDARDS - . assess the patient, collect and document the patient ' s current health status and medical history, complete and/or review Admission Data Record .make accurate and ongoing assessment of patient ' s status and respond appropriately . evaluate; nurse can input assessment and revise plan of care based on new data and patient ' s condition, document patient response to care provided, patient needs, problems, capabilities, limitations, and progress toward goals .communicate with physician regarding patient needs . administer medications according to policy and procedure . During a concurrent interview and record review on 5/18/22 at 10:31 a.m. with the DON, the facility document titled Medication Administration Audit Report (MAAR) dated 5/17/22 was reviewed. The document indicated 6 of 41 residents (Residents 18, 26, 19, 28, 11, 29,) received their medications more than one hour after the ordered time on 5/17/22. The MAARs for 5/2/22 through 5/10/22 were reviewed and indicated late medications over one hour for all days. The MAAR dated 5/17/22 indicated Resident 18 was scheduled at 8:00 a.m. to receive metoprolol (for high blood pressure), rivaroxaban (a blood thinner to prevent blood clots and stroke), sertraline HCI (for depression) digoxin (for heart failure), and Acetaminophen (for pain), and these medications were given at 10:03 a.m. on 5/17/22. The MAAR dated 5/17/22 indicated Resident 26 was scheduled at 8:00 a.m. to receive fluoxetine (for depression), gabapentin (for pain and to prevent seizures), fluticasone propionate (for difficulty breathing), and clonazepam (for seizures and anxiety) and these medications were given at 10:09 a.m. on 5/17/22. The MAAR dated 5/17/22 indicated Resident 19 was scheduled at 8:00 a.m. to receive lorazepam (for anxiety) and to have his liquid dietary formula started (his only means of nutrition), and the lorazepam was given at 9:23 a.m. The document indicated his liquid dietary formula was started at 9:21 a.m. on 5/17/22. The MAAR dated 5/17/22 indicated Resident 28 was scheduled at 8:00 a.m. to receive omeprazole (to keep stomach acid from flowing back into the esophagus (esophagus - the tube that connects the mouth to the stomach), lamotrigine (for a serious mental disorder), and clonazepam (for seizures and anxiety), and these medications were given at 9:49 a.m. on 5/17/22. The MAAR dated 5/17/22 indicated Resident 11 was scheduled at 8:00 a.m. to receive quetiapine (for serious mental disorder), and Bactrim DS (for infections); Resident 11 was also scheduled to receive Novolog (short acting insulin for diabetes blood sugar control) at 11:00 a.m., and these medications were given at 12:07 p.m. on 5/17/22. The MAAR dated 5/17/22 indicated Resident 29 was scheduled at 4 p.m. to receive vitamins and calcium, and these medications were given at 5:34 p.m. on 5/17/22. The DON stated the medications should not be given late because a lot of them were psychiatric and seizure medications. The DON stated if the medication is given too late and the next dose is too close together, they run a risk of toxicity of the medications and the level running too high. If they are given too far apart then the full therapeutic effect will not be met. During an interview on 5/18/22 at 12:05 p.m. with the ADM, the ADM stated, The staff did not relay that the meds (medications) were late to the nursing administration. During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated 12/2018, the P&P indicated, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .b. Administer within 60 minutes prior to after scheduled time unless otherwise ordered by the physician . During a professional reference review from https://www.ncsbn.org/Medication_Administration_in_Nursing.pdf, titled Medication Administration in Nursing Homes ., dated October 2021, the professional reference indicated, The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP, 2011) defines medication error as any preventable medication-related event that may cause or lead to patient harm. Medication errors can take place at any point from prescribing a drug to monitoring its effects . medication errors most commonly result from faulty systems and processes, including nurse staffing . During a professional reference review from https://govt.westlaw.com/calregs/Browse/Home/California/CaliforniaCodeofRegulations, titled Chapter 3. Skilled Nursing Facilities, 22 CCR S 72311, S 72329. Nursing Service - Staff, updated 2022, indicated, .(a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The Department may require a facility to provide additional staff as set forth in Section 72501(g). S 72327. Nursing Service -Director of Nursing Service. (a) The director of nursing service shall be a registered nurse and shall be employed eight hours a day, on the day shift five days a week. S 72329.1. Nursing Service - Staff.(a)Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The staffing requirements required by this section are minimum standards only. Skilled nursing facilities shall employ, and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant state and federal staffing requirements. The Department may require a facility to provide additional staff as set forth in Section 72501(g) . (1) Skilled nursing facilities shall employ and schedule additional staff to ensure patients receive nursing care based on their needs . (3) Unless granted a waiver pursuant to subsection (j), facilities shall use the following ratios: (A) On the day shift, the ratio shall be at least one direct caregiver for every 5 patients or fraction thereof;(B) On the evening shift, the ratio shall be at least one direct caregiver for every 8 patients or fraction thereof; and,(C) On the night shift, the ratio shall be at least one direct caregiver for every 13 patients or fraction thereof.(D) There shall be one licensed nurse for every 8 or fewer patients, based on the facility census for the 24 hour period. These are not in addition to the requirements in subparagraphs (A) through (C) above and may be assigned to shifts as required by the facility, subject to other statutory and regulatory requirements. (4) Day shift refers to the 8-hour period during which a facility's patients require the greatest amount of care. Evening shift refers to the 8-hour period when the facility's patients require more than minimal care. Night shift refers to the 8-hour period during which a facility's patients require the least amount of care. A facility that uses other than 8-hour shifts for its direct caregivers shall seek a waiver under subsection (j) to continue that practice. (5) A shift is defined as the working period of one direct caregiver, or the full time equivalent of one direct caregiver, who performs eight hours of nursing services, as defined in section 72038. Other than time spent on normal rest periods required by section 11020 of Title 8 of the California Code of Regulations, or in the in-service training at the facility required by section 71847, time not spent providing nursing services, such as that spent at meal periods, may not be included in calculating a shift. A facility that uses fractions of a shift to meet the ratios must ensure that the posting required by subsection (i) contains this information in a form that will enable all interested persons to verify that the required staffing is provided, and the ratios are met .S 72517. Staff Development. (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (1) Problems and needs of the aged, chronically ill, acutely ill and disabled patients. (2) Prevention and control of infections. (3) Interpersonal relationship and communication skills. (4) Fire prevention and safety. (5) Accident prevention and safety measures. (6) Confidentiality of patient information. (7) Preservation of patient dignity, including provision for privacy. (8) Patient rights and civil rights. (9) Signs and symptoms of cardiopulmonary distress. (10) Choking prevention and intervention. (b) In addition to (a) above, all licensed nurses shall have training in cardiopulmonary resuscitation. (c) At least once every two years, a facility shall ensure that each registered nurse, licensed vocational nurse, certified nurse assistant, and medical director directly employed by a facility receives training .(e) Each facility shall have a written orientation program for all newly hired employees. Each employee shall receive orientation to the facility, the employee's job description and duties, the patient population, the pertinent policies and procedures and the facility staff. (f) Consultants employed by the facility shall participate in the staff development program . During a professional reference review from https://www.bvnpt.ca.gov/ titled, BUSINESS AND PROFESSIONS CODE - BPC . CHAPTER 6.5. Vocational Nursing [2840 - 2895.5] .ARTICLE 2. Scope of Regulation [2859 - 2873.6] dated 1/1/22 indicated, .license Vocational Nurse .practiced under the direction of a licensed registered Nurse .License vocational nurse . shall be supervised by a registered nurse 2. During a record review of facility document titled, SOC [State of California] 341 LOG (a log that describes actual or alleged abuse that has occurred in the facility) dated December 2021-December 2022, the document indicated from 12/16/21 to 5/3/22 the facility reported nine incidents of Resident to Resident altercations ranging from verbal altercations to physical altercations. Four of the incidents involved Resident 1. During an observation and interview on 5/3/22 at 12:04 p.m. with Resident 1, Resident 1 was walking in the hallway. Resident 1 spoke clearly but could not carry on a conversation, speaking about different things, and sentences did not make sense. She stated she gets along with everyone. During an observation on 5/3/22 at 2:57 p.m., Res 1 approached the housekeeping cart and started pushing the cart and attempted to remove items from the top of the cart. Housekeeper (HSK) 2 redirected Res 1 and Res 1 continued down the hallway. During an observation on 5/3/22 at 3:22 p.m. in the west hallway, Resident 1 was observed taking the medication binder (a paper copy of information and instructions for nurses). LVN 4 got up and took Resident 1 another piece of paper to trade her for the binder and redirected her from the binder. During observations on 5/3/22 from 9:30 a.m. to 3:22 p.m., Resident 1 was observed wandering around the facility throughout the day. During an interview on 5/3/22 at 3:25 p.m. with LVN 4, LVN 4 stated he has worked the PM shift at this facility for almost a year. LVN 4 stated Resident 1 gets aggressive with staff and other Residents . she needs 1:1 (meaning one staff member assigned to be with this one resident at all times), that would be the only way to manage her behavior. She is on every 15-minute monitoring by the CNAs (Certified Nursing Assistants) . when the CNAs have a lot of other Residents, the 15-minute monitoring gets thrown away (meaning it doesn ' t occur.) During an interview on 5/12/22, at 10:44 a.m., with the DON, the DON stated there had not been enough people to care for the residents in the facility, prevent altercations, or improve nutrition. The DON stated there was a need for the staff to be trained. During an interview on 5/3/22, at 3:57 p.m. with the Infection Prevention Nurse (IP) 2, IP 2 stated there was not enough staff on duty to keep all the residents safe. During a concurrent observation and interview on 5/13/22 at 9:10 a.m. with the AA, Resident 1 was observed standing at the bedside of Resident 8. Resident 1 was holding the hand of Resident 8 and talking softly to her. The attendant who was assigned to provide 1:1 care for Resident 1 was inside the room, but near the door, approximately 10 feet from the bed. The AA stated the attendant needed to be closer to Resident 1 if she was expected to intervene in the event of a physical altercation. The AA stated the attendant had not had specific training on how close she should be to Resident 1 when assigned as a 1:1 attendant. The AA stated the attendant should be the closest person to the Resident at all times. During a review of facility document titled SOC 341 LOG, the log indicated Resident 1 had physical altercations with other Residents since 2/27/22 as follows: 2/27/22 - physical altercation with another Resident 3/1/22 - physical altercation with Resident 12 3/2/22 - physical altercation with staff member 4/25/22 - physical altercation with Resident 2 During a review of document titled Care Plan Detail for Resident 1, an entry dated 3/1/22 indicated Resident 1 shoved a Resident without any reason and slapped another Resident. The interventions listed on the care plan were separate both Residents immediately and continue to monitor Resident q (every) 15 minutes for 72 hours. During a concurrent interview and record review on 5/9/22 at 2:45 p.m. with the DON, care plans were reviewed for residents who had been involved in resident-to-resident altercations from 1/1/22 - 5/9/22 (residents 1, 12, 20, 27, 6, 15, 2, 26, 25, and 24). Residents 15, 2, 26, 25, and 24 did not have nursing assessments, updates, or revised care plans for resident-to-resident altercations. The DON stated, obviously updating care plans hasn ' t been the focus. The nurses are concentrating on giving medications. The DON stated nurses don ' t have time to watch the other residents to intervene before situations escalate, because there aren ' t enough nurses in the facility. During a review of the facility ' s P&P titled, Resident-to-Resident Altercations, dated 12/2016, the P&P indicated, .1. Facility staff wil[TRUNCATED]

Based on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and facility policy and procedure, for three of four sampled residents (Residents 9, 10, and 11) when: 1.Resident 9 was admitted on [DATE] with four stage 2 (a shallow open ulcer/blister), and two unstageable pressure ulcers (Full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green, or brown] and/or eschar [tan, brown or black] in the wound) and assessments and services to promote pressure ulcer healing were not provided causing Resident 9 to develop two additional pressure and previously stage 2 pressure ulcers worsened to unstageable pressure ulcers to right heel by 3/30/22. Nurses did not assess and measure wounds weekly according to facility policy and procedure and did not follow physician orders for wound care. Nurses were not trained and competent to assess the skin for staging (process used to determine tissue damage severity) pressure ulcers in accordance with professional standards of practice. Nurses lack of assessment delayed identifying signs of wound infection. Nurses did not communicate deterioration of wounds to the physician. Facility did not have routine interdisciplinary Team (IDT- an approach to healthcare that integrates multiple disciplines through collaboration to ensure that patients receive the best care) meetings to evaluate the effectiveness of the pressure ulcer treatment and healing. Resident 9 ' s nutritional needs were not addressed to promote or improve pressure ulcer healing. Nurses did not assess Resident 9 ' s pain and did not administer pain relief prior to providing wound care. These failures resulted in Resident 9 developing two additional pressure ulcers, diagnosed on [DATE] as a stage 3 to left metatarsal (long bone on the outside of the foot that connects to the little toe) ulcers and a stage 4 to the right hip, worsening of pressure ulcers to stage 4 and unstageable pressure ulcers. Resident had a total of 8 pressure ulcers with necrotic tissue (dead tissue that cannot be salvaged), slough (necrotic tissue that needs to be removed from the wound for healing to take place), eschar (dry, dark, or falling away of dead skin tissue) and copious (large quantity) amounts of foul smelling purulent (thick, yellow milky discharge from a wound) drainage. Resident 9 was diagnosed with a wound infection on 5/11/22 which required oral antibiotic therapy. Resident 9 experienced a severe unplanned weight loss of 23.4 pounds (lbs. -measurement of weight) from January to May 2022 which further affected his health status and the ability for his wounds to heal. Resident 9 was transferred on 5/19/22 and admitted to the General Acute Care Hospital (GACH for seven days for Pneumonia (PNA- lung infection) and while at the GACH, Resident 9 ' s wounds of the left hip were assessed to had visible exposed metal artificial joint (Resident 9 had a history of hemiarthroplasty [joint surface replaced with an artificial material, usually metal] of the left hip in 2019) and vancomycin-resistant enterococci (VRE- germs that develop resistance to vancomycin, an antibiotic that is used to treat some drug-resistant infections- some VRE infections may be life-threatening) infection in the pressure ulcer wounds. 2. Resident 10 developed a stage three pressure ulcers to right lateral (outer side of the) foot on 3/3/22. Pressure ulcers worsened to a stage 4 pressure ulcer to the right tuberosity fifth metatarsal bone (bone area on the side of the foot) and a DTI (Deep Tissue Injury- a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue) to right outer foot. Nursing staff did not perform accurate skin assessments. Resident 10 experienced a 22 lb. severe unplanned weight loss from January to May 2022 which affected her nutritional status for wound healing. 3. Resident 11 ' s weekly skin assessment dated [DATE] documented no pressure ulcers and skin assessment dated [DATE] identified a Deep Tissue Injury (DTI) to the right outer heel. Nursing staff did not perform daily skin assessment in accordance with Resident 11 care plan intervention. Resident 11 experiences 18.3 lb. significant unplanned weight loss from January 2022 to May 2022 and nutritional assessment was not conducted by the Registered Dietitian to ensure nutritional support was provided to prevent pressure ulcer development. These failures resulted in Resident 9, Resident 10 and Resident 11 ' s pressure ulcer deterioration, and the development of new Pressure ulcers. For Resident 9 he developed two additional stage 3 pressure ulcer and worsening of pressure ulcers to stage 4 and unstageable pressure ulcers. Resident had a total of 8 pressure ulcers with necrotic tissue (dead tissue that cannot be salvaged), slough (necrotic tissue that needs to be removed from the wound for healing to take place), eschar (dry, dark, or falling away of dead skin tissue) and copious (large quantity) amounts of foul smelling purulent (thick, yellow milky discharge from a wound) drainage. Resident 9 was diagnosed with a wound infection on 5/11/22 which required oral antibiotic therapy. Resident 9 experienced a severe unplanned weight loss of 23.4 pounds (lbs. -measurement of weight) from January to May 2022 which further affected his health status and the ability for his wounds to heal. Resident 9 was transferred on 5/19/22 and admitted to the General Acute Care Hospital (GACH for seven days for Pneumonia (PNA- lung infection) and while at the GACH, Resident 9 ' s wounds of the left hip were assessed to had visible exposed metal artificial joint (Resident 9 had a history of hemiarthroplasty [joint surface replaced with an artificial material, usually metal] of the left hip in 2019) and vancomycin-resistant enterococci (VRE- germs that develop resistance to vancomycin, an antibiotic that is used to treat some drug-resistant infections- some VRE infections may be life-threatening) infection in the pressure ulcer wounds and placed Resident 9. 10 and 11 at risk for further development of pressure ulcers, infection, compromise their health and subsequent death. Because of the serious actual harm and potential for serious injury and/or death to Resident 9 due to unassessed, incorrectly treated, and infected pressure wounds, and serious potential harm, serious injury and/or death to Residents 10 and Resident 11 and system failure to prevent pressure ulcer development and worsening, accurately assess pressure ulcer wounds and provide wound care in accordance with professional standards of practice, an Immediate Jeopardy (IJ) situation was called on 5/12/22 at 5:30 p.m. in the area of Code of Federal Regulations (CFR) 483.25 (b), F686 with the facility Administer (ADM), Assistant Administrator (AA) and Director of Nursing (DON). On 5/12/22, at 5:30 p.m. The IJ template was provided to the ADM and an explanation provided that the facility must submit an acceptable Action Plan to address the need for immediate action related to the IJ. The facility submitted a IJ Plan of Removal Version 1 on 5/12/22 at 8:23 p.m. and was unacceptable. Version 4 of the IJ Plan of Removal was accepted on 5/18/22, at 6 a.m. and addressed all the elements of the IJ situation, which included educating nursing staff on the identification, assessment and staging of pressure ulcer wounds. The facility would conduct wound assessment, wound care and pressure ulcer staging competencies of the nursing staff, facility would hire an RN supervisor to provide resident care oversight and employees competency supervision. The facility would educate nursing staff on conducting appropriate and accurate skin/wound assessments for each affected resident with the oversight of a trained and certified wound specialist. While onsite, the surveyors verified by observations, interview and record reviews and confirmed the implementation of interventions to address the IJ situation on Version four IJ Plan of Removal were fully implemented. The IJ was removed on 5/20/22, at 2:44 p.m. with the ADM. Findings: 1.During a review of a professional reference found at: https://www.hopkinsmedicine.org/gec/series/wound_care.html, Titled Wound and Pressure Ulcer Management, undated, the professional reference indicated, .Wound management involves a comprehensive care plan with consideration of all factors contributing to and affecting the wound and the patient. No single [staff person] can meet all the needs of a patient with a wound . Significance of the problem . Pressure ulcer (Pr U) incidence is associated with an increased Morbidity [a specific illness or condition] & Mortality [the number of deaths due to a specific illness or condition] . Pr U incidence is increasing in long term care . a pressure ulcer is the result of damage caused by pressure over time causing an ischemia (inadequate blood supply) of underlying body structures. Bony prominences (Areas where bones are close to the surface) are the most common sites and causes . Contributing factors include . Malnutrition [lack of proper nutrition] . Impaired mobility . Decreased LOC (level of consciousness) . Infection . External contributing factors include . Pressure . Friction [motion of one body rubbing or sliding against another surface] . Moisture . Incontinence [lack of bladder and bowel control] . How Do You Prevent a Pressure Ulcer . Managing pressure is also necessary and the following is recommended . Reposition every two hours in bed .Do not position directly on trochanter [bony prominences toward the near end of the thighbone (the femur)] . An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: [identifying] location, class/stage, size, base tissues, exudates [fluid from the wound], odor, edge/perimeter, pain and an evaluation for infection . Location . Documentation of location indicating which extremity [arms or legs], nearest bony prominence or [location] is necessary for appropriate monitoring of wounds . Class/Stage . Pressure ulcers are classified by stages . Originally there were four stages (I-IV) but in February 2007 these stages were revised and two more categories were added, deep tissue injury [Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] and unstageable [Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed] . Pressure Ulcer Staging . Stage I - Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area . Stage II - Partial thickness loss of dermis [thick layer of living tissue below the first skin layer] presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum [ is the fluid and solute component of blood] filled blister . Stage III - Full thickness skin loss. Subcutaneous fat [found directly under the skin] may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include .tunneling . Stage IV - Full thickness skin loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining [cutting that extend in all directions into the subcutaneous tissue under the skin] and tunneling . Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed . Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue . [wound] Measurement . Length-from top edge to bottom edge (head to toe) at longest point . Width-from edge-to-edge perpendicular to the length at the widest point . Depth-straight in, perpendicular to the base, at deepest point . Using the clock concept (12 o ' clock is in the direction of the patient ' s head and 6 o ' clock is toward the feet) . Where does it start and where does it end (clockwise direction) . Tunnel depth is at its deepest point . Location of deepest point . Base Tissues . Assessing the appearance of tissue in the wound bed is critical for determining appropriate treatment strategies and to evaluate progress toward healing . Necrosis/Eschar - Black, brown or tan devitalized [dead] tissue that adheres to the wound bed or edges and may be firmer or softer than the surrounding skin . Slough - Soft, moist . tissue that adheres to the wound bed in strings or thick clumps; may be white, yellow, tan or green . Exudates (wound drainage) . Amount . None - base and dressing dry . Slight - small amount in center of dressing . Moderate - contained within the dressing . Copious - extends beyond dressing onto clothing or bed linen . Type [of exudate] . Serous - thin, watery, clear or straw colored . Serosanguineous - thin, pale red to pink . Purulent - thick, opaque [cloud], tan, yellow to green and may have an offensive odor . Consider treatment . and frequency of dressing changes . Odor . Extreme malodor [unpleasant smell], especially if accompanied by purulent exudates is suggestive of infection . Pain . A critical aspect of local wound assessment both from the perspective of the patient and as a clinical indicator (measure, process, or outcome used to judge a particular clinical situation and indicate whether the care delivered was appropriate) of infection Include location, type/cause, rating (use validated scale), patient description and nonverbal signs . Evaluation of infection . Infection - Signs and Symptoms . Redness, warmth, and induration [hardening of an area] of adjacent tissues . Pain or tenderness . Unusual odor . Purulent exudates . When to Culture [testing of the drainage] . When signs of infection are present or when a clean wound fails to heal .assess . Adequate nutrition & hydration . Encourage protein, calorie-dense foods and fluids . Monitor [food] intake, weight and skin turgor . Assess and address impairments in dentition and swallowing . Assist patients with meals if needed . Dietary consult . Eliminate or Minimize Pain . Address the cause (remove the source if external, treat the infection or medicate based on physiological stimulus [anything that can trigger a physical change]) . Prevent and Manage Infection . Critical colonization [presence of bacteria] can result in failure to heal, poor quality tissue, increased friability [easily crumbled] and increased drainage . Determining whether the wound has a bacterial imbalance . is of primary importance to healing . Removal of Nonviable [dead] Tissue . Removes bacterial growth medium (contains chemicals that allow some types of bacteria to grow), controls/ prevents infection, defines extent of the wound and stimulates the healing process . Control Odor . Appropriate frequency of dressing changes . Cleanse with each dressing change . Debridement [removal of damaged tissue] and antimicrobials [destructive to or inhibiting the growth of microorganisms] as indicated . Exudates [fluid that has seeped out ] . The volume and type of exudates are significant determinants in selection of primary and secondary dressings [primary dressing -Therapeutic or protective covering applied directly to wounds and secondary dressing must hold the primary dressing in place] . Adequate containment of exudate [action of keeping wound drainage under control] is critical to manage increased bioburden [spread of bacterial or viruses], protect the peri-wound [area round the wound] skin, control odor . Odor . Commonly associated with an infected wound . Odor may cause considerable patient/ caregiver stress and embarrassment . During a review of the clinical record for Resident 9, the Admission Record (record containing resident demographic information), undated, the Admission Record indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included Mild Protein-Calorie Malnutrition (condition that occurs when the body does not get enough protein which can lead to muscle loss, fat loss, and the body not working as it usually would), Need for Assistance with Personal Care, Personal History of Transient ischemic Attack (TIA- blood supply to part of the brain is briefly blocked) and Cerebral Infarction (a stroke which resulted from an extended disrupted blood flow to the brain), Dysphagia (difficulty swallowing) following Cerebral Infarction, Unspecified Dementia (loss of mental functions that is severe enough to affect your daily life and activities), Pressure Ulcer of Left Hip . unstageable Pressure Ulcer of Right Hip. During a review of Resident 9's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical functional level) assessment dated [DATE], indicated Resident 9's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 8 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderate impairment, and 00-07 indicates severe impairment) indicating Resident 9 had moderate cognitive deficits. During a review of Resident 9 ' s Skin/Wound Note, dated 3/24/22, at 6:25 p.m., the note indicated, .Described description, site, dimensions with PHYS 1 . R [right] heel, unstageable, with DTI (deep tissue injury) in middle of pressure sore and fluid filled blister, [measured] 6.5 [centimeters (cm) - a unit of measurement} x (by) 10 [cm] x5 [cm] . L lateral [side of] ankle stage 2, 2.5 [cm] x2 [cm] . L lower hip stage 2, 9.5 [cm] x 4.5 [cm] . L upper hip area stage 2, 2 [cm] x7 [cm] . L upper calf stage 2, 2.5 [cm] x1 [cm] . R inner calf, unstageable, 6.5 [cm] x 2 cm] . [nurse] Will follow up when [PHYS 1] when she is ready to give orders . During a review of Resident 9 ' s Skin/Wound Note, dated 5/12/22, at 12:00 p.m., documented by the DON, the wound note indicated, .Wound Assessment: Completed by DON and LVN (licensed Vocational Nurse] . [had] Left Upper hip Unstageable pressure ulcer: 3 cm x 5.5 cm x UTD (unable to determine), 90 % [percent] thick yellow/green slough 10% epithelial tissue, 1.5 cm undermining 100% peri-wound, copious amounts of purulent drainage . Lower left hip unstageable pressure ulcer: 5 cm x 5 cm x UTD, 80% slough and 20% eschar 10% epithelial tissue, copious amounts of purulent drainage . Left medial [situated in the middle] hip unstageable pressure ulcer 1 cm x 2 cm x UTD 100% yellow slough . Left lateral hip unstageable pressure ulcer 2.5 cm x 3 cm x UTD 100% eschar . Left lateral ankle unstageable pressure ulcer 2.5 cm x 3 cm by UTD, 100% eschar dry, no drainage . Left Medial Great Toe Metatarsal Unstageable pressure ulcer 2 cm x 2 cm x UTD 90% sloth [sic], 10% epithelial tissue . Right hip abrasion [surface layers of the skin (epidermis) has been broken] 0.8 cm x 0.1 cm x 0.1 cm 100% epithelial tissue . Right heel dry, scaly skin . During a concurrent interview and record review on 5/11/22, at 8:41 a.m., with LVN 7, LVN 7 stated she worked for the staffing agency, and it was her second day at the facility. Resident 9 ' s Treatment Administration Record (TAR) was reviewed. LVN 7 stated Resident 9 was scheduled for wound treatment to nine wounds which included, .R (right) hip abrasion . Left ankle Stage 3 . Left lower hip . unstageable necrosis . Left metatarsal Stage 3 . Left upper hip, unstageable necrosis . Right hip. Stage 4 pressure sore . Right outer and lateral heel open blister . Right upper medial leg (by calf) Stage 3 pressure sore . Treatment to right hip open skin area . LVN 7 stated she passed medications for 42 resident and did not have time to perform wound care and stated, I wouldn ' t have known I had wound care to do this morning if you hadn ' t asked about it. I wouldn ' t have been able to look at the [TAR] until later because the [medication] pass is so heavy and takes up so much time. LVN 7 stated she had to start the med pass as soon as she began her shift and did not have time to review residents plan of care for wound treatments. LVN 7 stated she did not have time to sit down and complete the nursing documentation for residents that required monitoring of medical conditions until later in the day and that was when she would check to see if there were wound treatments due. LVN 7 reviewed Resident 9 ' s Skin/Wound Note, dated 3/24/22, at 6:25 p.m. LVN 7 stated the note indicated Resident 9 was admitted to the facility with six pressure wounds. LVN 7 stated Resident 9 had pressure wounds to his left lateral ankle, left lower hip, left upper hip, and left upper calf and the wounds were stage 2 on admission. LVN 7 stated Resident 9 ' s wounds had worsened from a stage 2 to stage 3, 4 and unstageable pressure ulcers since admission. During a concurrent interview and record review with LVN 7, Resident 9 ' s SBAR [Situation, Background, Appearance, Review] Communication Form, dated 3/30/22, at 7:00 p.m., was reviewed, the SBAR indicated, .Situation . This started on: 3/30/22 . Around 4:30 p.m. [Certified Nursing Assistant] CNA informed nurse that resident had a new skin change to right hip area . Open skin area measuring about 3cm (centimeters- unit of measurement) long . Review and Notify . Recommendations of Primary Clinician . new order for RD [nutritional] referral and clean [wound] site with NS (normal saline-medical salt water) and apply clean [wound] dressing [bandage] . LVN 7 stated Resident 9 developed a new pressure wound on his right hip on 3/30/22 after his admission. LVN 7 stated pressure injuries were caused when bedbound residents were not turned frequently enough. LVN 7 reviewed Resident 9 ' s weekly nurse summaries for 4/23/22, and stated the weekly summary indicated skin was not intact (healthy) but provided no further explanation. Weekly summary for 5/1/22 indicated skin intact [marked] yes, no wounds. Weekly summary dated 5/7/22 indicated skin intact [without wounds] yes, no wounds. LVN 7 stated the weekly summaries indicated Resident 9 had no skin wounds and that was not an accurate assessment. LVN 7 stated the nurses did not accurately assess Resident 9 skin. During an interview on 5/11/22, at 8:58 a.m., with CNA 7, CNA 7 stated she was familiar with Resident 9. CNA 7 stated Resident 9 had a lot of wounds on his right hip and left hip, both heels and ankles. CNA 7 stated Resident 9 ' s wounds oozed and had worsened. CNA 7 stated the wounds on his hips were big and the wound on his lower left hip had green and yellow skin on it. During a concurrent observation and interview on 5/11/22, at 10:13 a.m., with LVN 7 and LVN 8, in Resident 9 ' s room, a foul odor was noted when the door to Resident 9 ' s room was opened. Resident 9 was on his bed, made eye contact and slow to respond when greeted. LVN 8 stated she had not assessed Resident 9 ' s pain prior to his wound care. LVN 8 stated Resident 9 ' s wounds did not seem to bother him, and he received Tylenol twice a day routinely. Resident 9 was noted closing his eyes. LVN 8 stated she noticed foul wound odor when the door was opened. LVN 8 stated, We have masks and [face] shields on and it [wound] still smells that strong, the wound needs to be swabbed [meaning culture laboratory sample taken to test for infection]. The undated wound bandage on the upper left hip was observed to be heavily soiled with drainage (fluid seeps from a wound). The wound on the lower left hip was observed to be soiled with large amount of multicolored drainage. LVN 8 stated the dressing appeared to have not been changed recently. The lower left hip wound had three 4-inch (in) X 4 (in) wound dressings on it. LVN 7 stated it appeared the nurse didn ' t have a larger wound dressing to cover the wound and they overlapped three on the wound. LVN 7 stated those dressings (meaning the 4(in) X 4 (in) dressings) were not meant to be used like that. LVN 7 stated the wound drainage was running out of the dressings. LVN 8 removed the dressing from left lower hip wound. A 4 (in) X 4 (in) dressing covered the top of the wound and was soiled with drainage. LVN 8 stated the wound was covered with calcium alginate (dressing known for absorbing excess wound exudate and forming a non-adherent gel) and this was not the prescribed wound treatment for Resident 9 ' s wound. LVN 8 removed the calcium alginate and exposed Resident 9 ' s lower hip wound. Resident 9 ' s lower hip wound had a large circular area of hardened tissue with yellow liquid surrounding the edges of the wound. LVN 8 stated, This needs to be debrided, all of this. The middle is necrotic and surrounded by slough. LVN 8 stated there is tunneling at the edges and inserted a cotton swab around the edge of the wound underneath the wound edges. LVN 8 stated, This needs to be debrided. The wound was measured by LVN 7, the lower left hip wound was 5 cm X 5 cm X 1 cm. LVN 8 stated there was a 1.7 cm tunnel under the edges of the wound. Two smaller wounds were noted above the lower left hip wound, and each wound was covered with slough. LVN 7 measured the wound that was superior (above) and anterior (towards the Resident ' s head) to the lower left hip wound at 2.5 cm X 1 cm X 0 cm and the superior posterior wound measured 1 cm X 1 cm X 0 cm. LVN 7 stated the facility did not have a trained wound nurse and needed a wound nurse to take care of all the wounds. LVN 7 asked LVN 8 if she had wound training. LVN 8 responded she did not. LVN 7 stated she would like to have wound training. LVN 7 stated the wounds needed a lot of care and she had not seen a progress note which indicated Resident 9 ' s physician had been notified of the severity of the wound conditions. LVN 8 stated she hoped the physician had been notified because the wounds needed debridement and smelled bad. LVN 8 removed the dressing from Resident 9 ' s upper left hip wound. LVN 8 stated, This one [wound] has calcium alginate on it too. LVN 8 stated calcium alginate was not the dressing the physician prescribed for the wound treatment. When LVN 8 removed the calcium alginate, copious amount of thick purulent soul odorous drainage came out of the wound. The wound bed was filled with slough and necrotic tissue. LVN 8 cleaned the wound with normal saline (NS) and gauze, the necrotic area was lifted, and this action exposed a large amount of slough underneath. LVN 8 stated the wound was unstageable because the wound bed was not visualized. LVN 7 measured the wound and stated it was 4cm X 5cm X 0cm. Resident 9 ' s wound to his left outer ankle was covered by a piece of calcium alginate dressing and no cover dressing. LVN 8 stated, It [wound] should not have calcium alginate on it either. LVN 8 attempted to remove the calcium alginate, but the dressing was stuck to the wound. LVN 8 stated she was having a hard time getting the calcium alginate off the wound. LVN 8 wet the dressing with NS and was able to remove the dressing. LVN 7 measured the wound 1.1 cm X 0.3 cm X 0 cm. The dressing to the right lateral ankle dated 5/10/22 and initialed. Resident 9 did not have a dressing on his right hip wound. The wound was pink and had a small open area in the middle. LVN 7 measured the wound, 0.8 cm X 1 cm X 0 cm. LVN 8 stated Resident 9 ' s fresh dressing to the left lower hip wound was already saturated with drainage. LVN 8 stated the wound was draining a lot. During an interview on 5/12/22, at 10:16 a.m., with the Director of Nursing (DON), in Resident 9 ' s room, the DON stated LVN 8 had just finished Resident 9 ' s wound care. The DON stated she looked at Resident 9 ' s wounds and notified the facility ' s medical director because the appearance and wound order had signs of infection. The DON stated the medical director prescribed oral antibiotics (medication to treat infection) for Resident 9 ' s wound infection. The DON stated the facility did not have a wound committee (IDT meeting to discuss resident needs for wound healing) to review wound healing in the facility. The DON stated she reviewed Resident 9 ' s clinical record and noticed Resident 9 had lost weight and the weight loss would complicate and delay wound healing. The DON stated she called Resident 9 ' s conservator to discuss the condition of his wounds and options to improve Resident 9 ' s nutrition, such as a feeding tube. The DON stated the facility did not have a weight committee to review weight loss and needed to have monthly weight meetings to discuss Resident 9 (IDT meeting to discuss nutritional needs) ongoing weight loss. The DON stated the facility did not have a Registered Dietician (RD) on staff to assess and evaluate Resident 9 or other residents nutritional needs (amount of nutrients needed to support health, growth and development) or weight loss. The DON stated an RD would be able to identify specific national needs to promote wound healing of Resident 9 wounds. During a concurrent interview and record review on 5/12/22, at 10:44 a.m., with the DON, Resident 9 ' s wound pictures and measurements dated 5/11/22 were reviewed. The DON stated it looked like, His treatments are not consistently being done. The DON stated with the short staffing she did not see how one nurse could pass medication and perform wound care for 42 residents. The DON provided documents with the wound measurements and description performed when she and the LVN 8 performed wound care for Resident 9 on 5/12/22. The DON stated Resident 9 ' s wounds were all unstageable and a wound physician needed to come in to examine and debride his wounds. The DON stated from a clinical standpoint the facility had Resident care which needed to improve care. The DON stated, I don ' t think not having an RN for clinical assessment has helped him [Resident 9] at all. He would have benefited from having an RN here to do assessment. He had a lot going on. The DON stated without a DON or RN the facility did not have the oversight required to ensure they had enough staff to care for the residents needs prevent wounds or nutrition issues. The DON stated the facility did not have a nurse to ensure LNs were trained and competent to perform wound assessment, perform competed wound care, evaluate wounds for infection and assess residents ' nutritional status to promote wound healing and prevent further wounds and infection. During a concurrent observation and interview on 5/12/22, at 3:45 p.m. with CNA 4, CNA 4 stated Resident 9 frequently had pain when he was turned. CNA 4 stated when they would turn him, sometimes he would say ow or his face would tighten. Resident 9 laid in bed and would not respond when spoken to. CNA 4 stated she had just changed him. CNA stated she did not know if Resident 9 was given pain medication to help his pain. During an interview on 5/17/22, at 9:12 a.m., with CNA 5, CNA 5 stated Resident 9 appeared to feel better and was responding better since he started on the antibiotic last week. CNA 5 stated Resident 9 had been eating better and more alert since he started the antibiotic. CNA 5 stated prior to the antibiotic Resident 9 would lay in bed and rarely respond to the staff. During a concurrent interview and record review on 5/17/22, 11:40 a.m., with the DON, Resident 9 ' s laboratory (lab) results were reviewed. The DON stated she was unable to locate Resident 9 ' s lab results in his electronic medical record (EMR) or in the chart. The DON stated Resident 9 had a complete blood count drawn on 5/17/22 but was unable to locate any previous lab results. The DON stated Resident 9 should have other nutritional lab tests drawn due to his multiple wounds. The DON [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse for one of two sampled residents (Resident 31) when: 1. The Administrative staff did not evaluate the risk of resident-to-resident abuse prior to rooming Resident 31, who was assessed with known inability to speak and was totally dependent on staff for mobility and assistance, with Resident 2, who had known aggressive behaviors and a history of resident-to-resident physical altercations with other residents and roommates. This failure resulted in Resident 31 being found by staff on 1/21/22, on his bed with bruising, and swelling to left side of face upper cheek, left upper side of the lip and facial expressions of pain that required treatment seven days to heal. Internal investigation by staff determined the injuries suffered by Resident 31 were purposefully inflicted by Resident 2. Resident 2 had injuries to his hand consistent with striking Resident 31. 2. The facility failed to provide Resident 1 with adequate supervision, effective interventions, and Registered Nurse (RN) clinical assessments to evaluate aggressive behaviors and prevent Resident 1 from initiating four resident-to-resident abusive altercations between February 2022 and May 2022. These failures placed facility residents' safety at risk for bodily harm and serious injuries. Findings: During a review of Resident 31's Admission Record (AR, a document containing Resident demographic information and medical diagnosis), undated, the AR indicated, Resident 31 was admitted to the facility with diagnoses that included, Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and Contracture (permanent shortening of a muscle or joint, limiting mobility). During a review of Resident 31's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive (mental processes) and physical functional level) assessment, dated 9/13/21, the MDS indicated Resident 31's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 3 out of 15 (0-15 scale [0-6-severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 31 was severely impaired. Resident 31's section G (assessment of functional abilities) assessment indicated Resident 31 required extensive assistance with bed mobility, dressing and personal hygiene and two [staff] persons physical assistance with transfers from bed to chair. During a review of Resident 2's AR, undated, the AR indicated, Resident 2 was admitted on [DATE] to the facility, with diagnoses that included, Unspecified Dementia with Behavioral Disturbance, Unspecified Psychosis (a mental condition causing the person to experience false beliefs, seeing or hearing things that others do not see or hear), and Bipolar Disorder with Psychotic Features (a mental condition marked by alternating periods of elation and depression [medical illness that negatively affects how a person feels, thinks and how the person acts], and inability to recognize what is real in the world around them). During a review of Resident 2's MDS assessment, dated 9/19/21, the MDS BIMS assessment indicated Resident 2's was moderately impaired and was able to independently walk and transfer with staff supervision and setup help only. During an observation on 1/28/22, at 1:46 p.m., in Resident 31's room, Resident 31 was laying on his back in bed. Resident 31 was staring at the ceiling and did not respond verbally when greeted but moved his eyes from side to side. Resident did not move his arms or legs during observation. Resident 31 had no visible bruising or swelling to the left side of face, upper cheek and left upper side of the lip. During a review of Resident 31's Treatment Administration Record (TAR), dated 1/1/22 to 2/28/22, the TAR indicated, . Apply ice compress to affected area Q[every]15 minutes Q shift or as needed for 14 days [for bruising and swelling to left side of face and left upper lip] . Start Date 1/21/22 . During a review of Resident 31's TAR, dated 1/1/22 to 2/28/22, the TAR indicated, . Monitor redness/mild swelling to left cheek for s/s [signs/symptoms] of infection such as swelling, redness, warm, discharge, odor. Notify physician of significant findings . Start Date 1/21/22 . During a review of Resident 31's TAR, dated 1/1/22 to 2/28/22, the TAR indicated, . Monitor small hematoma [a solid swelling of clotted blood within the tissues] to left upper lip for s/s of infection, such as swelling, redness, warm, discharge, odor. Notify physician of significant findings . Start Date 1/21/22 . During an interview on 1/28/22, at 1:55 p.m., with Resident 2, in the facility hallway outside of his room, Resident 2 stated, I don't want to talk right now. Resident 2 appears uneasy and was observed walking towards the nursing station. During a concurrent interview and record review on 1/28/22, at 6:51 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes (PN), dated 1/21/22 was reviewed. The PN indicated, . 09:00 [9:00 a.m.] . Received report from nursing r/t [related to] resident [31] having bruising and swelling to left side of face upper cheek and left upper side of the lip. Upon assessment, resident [31] is noted to have bruising and swelling to left side of face upper cheek and bruising and swelling and bleeding to left upper side of lip, . Resident [31] nonverbal unable to describe occurrence of event. Resident is now transferred to a new room with new roommate . ice compress applied to resident's injury to relieve swelling and bruising as well as PRN [as needed] pain medication. DON [Director of Nursing], Administrator, MD [Medical Doctor] made aware. Per MD with orders for resident [31] injury to be monitored for 72 hours and report of any changes. Emer [Emergency] [Responsible Party] contacted . LVN 1 stated Resident 31 was bedbound, required total staff care in all areas of Activities of Daily Living (ADLs), and unable to move his upper and lower extremities without staff assistance. LVN 1 reviewed Resident 31's nursing noted dated 1/20/22 and 1/21/22 and stated Resident 31 did not have any documented fall or accident the day prior (1/20/22) or from the previous shift. During a concurrent interview and record review on 1/28/22, at 6:56 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 31's PN, dated 1/18/22 was reviewed. The PN indicated, . 20:52 [8:52 p.m.] . LVN 1 stated Resident 31's most recent progress note was on 1/18/22 and prior to the reported left face and upper left lip injury on 1/21/22, Resident 31 had no injuries prior to the reported left face and left upper lip injury on 1/21/22. During a review of the facility's document titled, Declaration Statement, dated 1/21/22, the document indicated, . 1/21/22 [no time] . I did not receive report on [Resident 31] last night before I left PM shift at 11:10 p.m., he was fine and upon coming into AM [morning shift] at 7:08 a.m., he had a red area [face] . Signed [CNA 2] During a review of Resident 31's Care Plan (CP), dated 1/21/22, the CP indicated, . Focus . Altered skin integrity non pressure [injury] related to: left upper lip, has a small hematoma with mild swelling . Goal . Affected area will heal without complications . Interventions . Monitor for signs and symptoms of infection such as swelling, redness, warm discharge, odor notify physician of significant findings . During a review of Resident 31's PN, dated 1/21/22, the PN indicated, . 22:00 [10:00 p.m.] . Monitoring resident for facial injury, resident stable slight left cheek discoloration noted, . area iced . During a review of Resident 31's PN, dated 1/22/22, the PN indicated, . 5:56 [5:56 a.m.] . Resident alert charting to monitor .injury bruising/swelling to L [left]-upper cheek and L-upper side of lip . Continue ice compress . During a review of Resident 31's PN, dated 1/23/22, the PN indicated, . 15:11 [3:31 p.m.] Monitoring bruising and swelling to L [left face] side . facial injury. Mild discoloration noted, no s/s [signs/symptoms] of pain or discomfort, ice compress to affected area . During a review of Resident 31's PN, dated 1/23/22, the PN indicated, . 17:00 [5:00 p.m.] Medication Administration Note [name of medication] Tablet 325 mg (milligram - unit of measurement) Give 1 tablet by mouth every 4 hours as needed for mild pain . During a review of Resident 31's PN, dated 1/23/22, the PN indicated, . 21:52 [9:52 p.m.] Monitor for facial injury, resident stable facial grimacing noted [name of medication] given PRN [as needed] for comfort. [affected] Area iced. Face with slight swelling and discoloration . During a concurrent interview and record review on 1/28/22, at 7:15 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's (Resident 31's roommate on 1/21/22) Progress Notes (PN), dated 1/21/22 was reviewed. The PN indicated, . 09:00 [9:00 a.m.] . Resident [2] reporting to this nurse about his right-hand index finger hurting and swelling, upon assessment resident's right hand index finger is noted to be swollen . Notified MD . ordered x-ray (device used to picture inside the body) of the right hand . DON, administrator, and RP made aware . LVN 1 stated LVN 1 stated Resident 2 had a history of hitting other residents and does not like sharing room with other residents. LVN 1 stated Resident 2 should be left alone in his room and not have roommates because of Resident 2's aggressive behavior. During a review of Resident 2's X-ray Interpretation Report, dated 1/22/22, the report indicated, . Date of Exam: 1/22/2022 . Multiple views of the right hand do not show evidence of fracture [broken bone], dislocation . During a review of Resident 2's Treatment Administration Record (TAR), dated 1/1/22 to 2/28/22, the TAR indicated, . Apply ice compress to affected area Q15 minutes Q shift or as needed for 14 days . Start Date 1/21/22 . During an interview on 1/28/22, at 7:20 p.m., with LVN 1, LVN 1 stated the Resident 31 had physical injuries to his face on 1/21/22. LVN 1 stated the facility failed to protect Resident 1 from harm and abuse by Resident 2. During an interview on 1/31/22, at 10:00 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 31 was bedbound, required total care in all areas of ADLS and unable to communicate his needs. CNA 1 stated she received a verbal report from another CNA during a shift change on 1/21/22 that Resident 31 was struck by Resident 2. CNA 1 stated Resident 31's left face was swollen and bruised for a few days. CNA 1 stated Resident 31 was moved into Resident 2's room on 1/13/22 when the facility had a COVID-19 infection outbreak. CNA 1 stated Resident 2 had a history of physical and verbal aggression towards other residents and staff. CNA 1 stated the facility failed to protect Resident 31 from abuse by Resident 2. During a concurrent interview and record review on 1/31/22, at 10:23 a.m., with the Director of Staff Development (DSD), Resident 31's Progress Notes (PN), dated 1/21/22 was reviewed. The PN indicated, . 09:00 [9:00 a.m.] . Received report from nursing r/t resident [31] having bruising and swelling to left side of face upper cheek and left upper side of the lip . DSD stated Resident 2 has a documented history of hitting former roommates and other residents. DSD stated she talked to the Assistant Administrator (AA) on 1/13/22 and voiced her concern about the aggressive behavior of Resident 2 and that the planned room change for Resident 31 was not safe. DSD stated the AA did not listen to her concerns. DSD stated she voiced her concern of Resident 31's inappropriate room move to the former Social Services Director (SSD), but her concern was not acknowledged. DSD stated the facility failed to protect Resident 31 from abuse from Resident 2. During a concurrent interview and record review on 1/31/22, at 10:30 a.m., with the SSD, Resident 2's Progress Notes (PN), dated 4/11/21 was reviewed. The PN indicated, . 15:53 [3:53 p.m.] . [Resident 2] had a grip of [Resident 3 (a different resident abuse altercation)] right arm. Residents were immediately separated. Res [Resident] 2 was placed on q [every] 15-minute checks. Body assessment was performed on both residents . New orders given to send to ER [Emergency Department] for eval [evaluation] of altered mental status . DSD stated Resident 2 has a documented history of hitting former roommates and other residents. SSD reviewed Resident 1 and Resident 2's clinical record and was unable to find a risk for abuse assessment that should have been completed by the Interdisciplinary Team (IDT- a group of dedicated healthcare professionals who work together to provide residents with the care you need, when you need it) for Resident 31 prior to moving Resident 31 into Resident 2's room. During a concurrent interview and record review on 1/31/22, at 10:34 a.m., with the Director of Staff Development (DSD), Resident 2's Progress Notes (PN), dated 4/17/21 was reviewed. The PN indicated, . 8:39 [8:39 a.m.] . Resident approached a peer in hallway and struck him with closed fist in the chest . During a concurrent interview and record review on 1/31/22, at 10:38 a.m., with the Director of Staff Development (DSD), Resident 2's Progress Notes (PN), dated 4/17/21 was reviewed. The PN indicated, . 12:37 [12:37 p.m.] . Resident [2] is being monitored s/p [status post] altercation. Resident [2] was alert, [with confusion]. No change from baseline noted . During an interview on 1/31/22, at 2:36 p.m., with LVN 2, LVN 2 stated he verbalized his concern to the AA on 1/13/22 regarding moving Resident 31 in the same room with Resident 2. LVN 2 stated the AA told him that both Resident 31 and Resident 2 would be monitored for 72 hours after the move for any concerns. LVN 2 stated Resident 2 had a history of verbally and physically abusing residents and staff. LVN 2 stated Resident 31 was physically abused by Resident 2. LVN 2 stated the facility failed to protect Resident 31's rights to be free from abuse and being injured. During an interview on 1/31/22, at 2:36 p.m., with the Director of Nursing (DON), the DON stated the facility leadership failed to consult and gather Resident 2 aggressive abusive history towards other residents from licensed nurses before moving Resident 31 into Resident 2's room. The DON stated the facility failed to protect Resident 31's rights to be free from abuse. During an interview on 1/31/22, at 4:00 p.m., with the AA, the AA stated she was told by LVN 2 on 1/13/22 that moving Resident 31 to Resident 2's room was, Not a good idea. The AA stated she told LVN 2 to proceed with the room transfer and monitor both residents [adjustment to a new room and roommate]. The AA stated moving Resident 31 to Resident 2's room was not a good decision. The AA stated the facility failed to protect Resident 31's rights to be free from abuse from Resident 2. During an interview on 1/31/22, at 5:30 p.m., with the Administrator (ADM), the ADM stated the facility leadership failed to consult and gather input from direct care staff before moving Resident 31 into Resident 2's room. The ADM stated the facility failed to implement effective interventions to protect Resident 31's rights to be free from abuse. During a review of the facility's document titled, Report of suspected dependent adult/elder abuse [SOC 341 form], dated 2/1/22, the document indicated, . On 1/21/2022 approx [approximately] at 9AM [9:00 a.m.] the Licensed Nurse on duty [LVN 3] reported that the resident [Resident 31] having swelling and bruising to left upper cheek and left upper side of lip. Resident in [sic] nonverbal and unable to verbalize what happened . Cool compress and pain medication PRN was .given . Resident MD and family notified. Investigation in process . During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 11/2021, the P&P indicated, . Our residents have the right to be free from abuse, neglect . 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents . 42123 2. During a review of the clinical record for Resident 1, the Admission Record (record containing resident demographic and medical diagnosis information), undated, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included Dementia (loss of cognitive functioning-thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) with Behavioral Disturbance (repetitive pattern of behavior that seriously impairs a person's functioning), Restlessness (inability to rest or relax as a result of anxiety) and Agitation (disturbance, excitement, inner unrest, uneasiness, or apprehension) and Psychotic Disorder (mental disorder characterized by a disconnection from reality) with Hallucinations (perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there). During a review of Resident 1's MDS assessment dated [DATE], was reviewed. The MDS BIMS assessment indicated Resident 1's cognition was severely impaired. During a review of Resident 1's Nursing Notes, dated 4/25/22, at 9:17 p.m., the note indicated, Patient [Resident 1] was noted to have been walking in the hallway patient [Resident 1] saw another patient [Resident 2] walking towards her and patient [Resident 1] pushed the patient [Resident 2] which happened to be a male. The male which [sic] raised his hand at the patient but did not hit the patient [Resident 1]. Patients [Resident 1 and Resident 2] are being monitored for behaviors and delayed injuries. Non[e] noted at this time . During a concurrent interview and record review on 5/3/22, at 9:30 a.m., with the Administrator (ADM) and Assistant Administrator (AA), The AA stated the facility kept track of (Resident abuse) incidents on a document titled [NAME] Care Center SOC 341 (a document for the information given by a reporting party on a suspected incident of abuse or neglect) Log. The Log was reviewed and indicated, Resident 1 was involved in altercations on 2/27/22, 3/1/22, 3/2/22, 4/25/22. The AA stated she was aware Resident 1 was frequently involved in resident abuse altercations. The ADM stated she was a new employee and her first day at the facility was on 4/28/22. The ADM stated the facility did not have a Director of Nursing (DON) or a Director of Staff Development (DSD) to oversee nursing services and resident care. The ADM stated the LVNs were currently covering for the DON and DSD positions in addition to their nursing duties. The ADM stated the facility did not have a full time Registered Nurse (RN) on staff to oversee LVNs and conduct Resident assessments. The ADM stated the facility had been fortunate because none of the residents had needed an RN clinical assessment. During an interview on 5/3/22, at 11:06 a.m., with CNA 2, CNA 2 stated Resident 1 had a known history of aggressive behaviors towards other residents. CNA 2 stated when Resident 1 was agitated she would become more agitated with the staff spoke to her to divert her attention away from another resident. CNA 2 stated she had worked at the facility since September 2021 and Resident 1's aggressive behaviors had worsened and become more frequent. CNA 2 stated it was difficult to have time to care for Resident 1 and properly care for other residents when the facility did not have sufficient staff. During a concurrent interview and observation on 5/3/22, at 12:04 p.m., Resident 1 was observed walking steadily in the hallway without assistive walking devises. Resident 1 was approached and she was noted to be alert with confusion and unable to carry on a conversation. During a concurrent interview and record review on 5/3/22, at 1:00 p.m., with LVN 3, LVN 3 stated the facility did not have a DON to oversee resident care or supervise the clinical department and staff. LVN 3 stated the facility did not have enough Licensed Nursing (LN) coverage at the facility to meet resident needs. LVN 3 stated she was the only LN in the facility to care for 42 residents. LVN 3 stated the LN coverage was not safe for the residents when the facility had aggressive residents. LVN 3 stated it was difficult to prevent abuse altercations because the nurses were too busy to intervene before the abuse happened. LVN 3 stated the facility did not have RN clinical oversight without a DON to perform assessments when needed. LVN 3 stated she was familiar with Resident 1. LVN 3 stated Resident 1 would frequently get agitated. LVN 3 stated [she] hasn't gotten physical with anyone yet today. LVN 3 stated Resident 1 would grab things off the counters and would become loud and aggressive when staff tried to retrieve the items back from her. LVN 3 stated she had locked her medication (med) book in the medication cart because Resident 1 would take it and become angry when the nurses tried to get the book back. LVN 3 stated You never know what will set her off. Resident 1's Order Summary Report, dated 4/26/22 was reviewed. LVN 3 stated there were no new physician orders after the abuse altercation on 4/25/22. LVN 3 stated abuse behavior monitoring was ordered by the physician on 10/7/21 and was not done and should the monitoring nneeded be performed according to physician's order. LVN 3 stated the facility was understaffed and the Licensed Nurses (LNs) could only focus on the medication pass and document if there was time. Resident 1's aggressive behavior care plan dated 3/1/22 was reviewed by LVN 3, the care plan indicated, .Focus . An altercation with other resident . Resident shoved resident without any reason . 3/1/22-Slapped another resident . Goal . Will have no complications from this altercation . Will have no episodes of physical aggression towards any resd. (resident) or staff. x [for] 2 weeks . Interventions . Give support and reassurance . SOC 341 will submit by the DON within 24 hours . The facility will submit the summary investigation within 5 calendar days . put on 1:1 (one to one) monitoring starting today on 3/4/22 @ [at] PM shifts, then AM&PM shift on the weekend then the IDT (Interdisciplinary team- different healthcare disciplines working collaboratively toward a common goal) will review the 1:1 intervention on Monday [3/7/22] if the resident still requires it . On 15 minutes monitoring x 72 hours . Continue with monitor resident Q (every) 15 minutes x 72-hour whereabouts and ensure the resident is not close to another resident that involved with the aggression . LVN 3 stated the 1:1 and every 15-minute monitoring were the only interventions to prevent another altercation. LVN 3 stated the other interventions would not prevent future altercations. LVN 3 stated the intervention indicated Resident 1 would be on 1:1 monitoring until IDT met. LVN 3 stated Resident 1 was not on 1:1 monitoring. LVN 3 stated she was unable to locate an IDT meeting after the 3/1/22 and 3/2/22 altercations. LVN 3 stated SBAR (a communication form documenting Situation, Background, Review and Notify) notes were completed for resident change of condition. Resident 1's SBAR note, dated 4/25/22, was reviewed by LVN 3. LVN 3 stated the SBAR was poorly documented and did not address Resident 1's abuse altercation or interventions to prevent further abuse. During a concurrent observation and interview on 5/3/22, with Housekeeper (HSK) 2, HSK 2 stated Resident 1 walked around the facility often and would walked up to the housekeeping cart and started to push the cart, attempted to take things off the cart. HSK 2 stated she frequently had to distract Resident 1 from her cart and supplies to keep Resident 1 safe. During an interview on 5/3/22, at 3:07 p.m., with CNA 3, CNA 3 stated she had witnessed Resident 1 and Resident 2's abuse altercation on 4/25/22. CNA 3 stated Resident 2 had tried to walk around Resident 1 in the hallway and Resident 1 aggressively pushed him against the wall. CNA 3 stated Resident 1 was aggressive with other residents and the staff. CNA 3 stated Resident 1 had frequent abuse altercations and her moods were very up and down. CNA 3 stated every 15-minute checks was the only intervention implemented for Resident 1 to prevent further abuse altercation. CNA 3 stated she tried to check on Resident 1 every 15 minutes but was unable to because she also had other residents take care of and did not have time. CNA 3 stated, I am not able to truly check her every 15 minutes. CNA 3 stated she would sign off the documentation as done when she had not checked on Resident 1's whereabouts. CNA 3 stated the facility staff only one licensed nurse on the evening shift and the CNAs would try to wait until the LVN completed the medication pass to ask the LN for help, they would interrupt the LVN if they had an emergency, because the facility did not have other nurses. CNA 3 stated one LN instead of two was one less person to watch Resident 1. CNA 3 stated when Resident 1 would get mad the staff would try to direct her anger at the staff to protect the other residents. CNA 3 stated I watch my back [around Resident 1]. CNA 3 stated Resident 1 was unpredictable and was difficult to manage at the facility without more staff. During a concurrent observation, interview, and record review on 5/3/22, at 3:25 p.m., Resident 1 was observed taking a binder off the medication cart. LVN 4 handed Resident 1 a piece of paper to redirect her from the binder. LVN 4 stated Resident 1 needed constant supervision and redirection to keep the other residents safe. LVN 4 stated Resident 1 had pleasant days and other days she would get aggressive with staff and residents. LVN 4 stated Resident 1 had frequent abuse altercations and 1:1 supervision would be the best way to manage her behavior. LVN 4 stated Resident 1 was supposed to be monitored every 15 minutes. LVN 4 stated, when the CNAs have a lot of other residents the 15-minute monitoring gets thrown away. LVN 4 stated since he was the only nurse] the priority for me is emergencies and passing meds [medications]. Resident 1's abuse altercation care plan dated 3/1/22, was reviewed. LVN 4 stated the interventions indicated to redirect, give snacks and remove her from the hallway. LVN 4 stated the abuse prevention interventions were not always appropriate. LVN 4 stated Resident 1 would sometimes get angry when the staff tried to redirect her away from other residents. LVN 4 stated Resident 1's mood fluctuated frequently and was unpredictable. LVN 4 stated when Resident 1 was pleasant he felt like the other residents were safe. LVN 4 stated her aggressive behaviors would change quickly which made it difficult to anticipate when she would become angry. LVN 4 stated there was an order to check Resident 1 every 15 minutes which had not been effective. LVN 4 stated I have suggested a 1:1. But again it goes back to staffing. LVN 4 stated, There have been so many abuse occurrences [altercations] something else needs to be done. During an interview on 5/3/22, at 3:57 p.m., with IP (infection Preventionist) 2, IP 2 stated the facility did not have enough licensed nurses to meet the care needs of the residents. IP 2 stated there was one licensed nurse in charge of 42 residents on day shift and evening shift. IP 2 stated Resident 1 would become aggressive and combative and there was not enough staff to keep the residents and staff safe. IP 2 stated Resident 1 would hit the nurses when they tried to get the items that Resident 1 would take from the medication cart. During an interview on 5/3/22, at 4:08 p.m., with the Social Services Director (SSD), the SSD stated Resident 1's aggressive moods would fluctuate. The SSD stated Resident 1's needs for supervision made it difficult for the staff assigned to care for Resident 1 and the other residents at the same time. The SSD stated Resident 1 was aggressive towards everyone. The SSD stated Resident 1's moods were very unpredictable which made it difficult to anticipate her behaviors. The SSD stated Resident 1 frequently had angry, aggressive outbursts. The SSD stated the facility's lack of sufficient staffing played a big part in Resident 1's aggressive behavior. The SSD stated, The CNAs have more residents, it is hard to concentrate on residents like [Resident 1] that have more [aggressive] behaviors. The SSD stated the facility scheduled only one licensed nurse to care for all the facility residents and did not have sufficient staff to focus on Resident 1's aggressive behaviors. The SSD stated the LVNs could only focus on med pass or wounds. The SSD stated the LVNs would not have the time to realize what was going on outside of the med pass. The SSD stated the facility did not have effective abuse preventing interventions in place for Resident 1. The SSD stated [in the past] she [Resident 1] had grabbed my shirt and thrown me into the med cart. The SSD stated she did not think the other residents were safe with Resident 1 in the building. During an interview on 5/3/22, at 4:38 p.m., with the ADM, the ADM stated she was a new employee and had only worked at the building since 4/28/22. The ADM stated she was told about Resident 1's multiple abuse altercations by the AA on 5/3/22. The ADM stated the facility wanted to move Resident 1 to another facility. The ADM stated Resident 1 had so many abuse altercations they needed to be investigated properly. The ADM stated Mostly the DON normally takes the lead for resident-to-resident altercations. They [DON] notify the doctor and follow up with psych [medications to teat mental health problems] meds, labs and what is triggering the resident [aggressive behavior]. The ADM stated she was aware the facility did not have a DON, RN to oversight resident care and nursing services and would hire a DON as soon as possible. The ADM was unable to answer the potential negative effect on the residents by the facility not hiring a Registered Nurse for clinical oversight and conduct resident assessments. During an interview on 5/9/22, at 11:39 a.m., with the DON, the DON stated she was hired on 5/9/22 and was a new employee. The DON stated one licensed nurse for 42 residents was not a safe staffing ratio for the facility's resident population. The DON stated the low staffing ratio affects resident safety. The DON stated the expected process after an altercation was an RN assessment needed to be done within 24 to 72 hours, a medication review, and the IDT should meet after the RN assessment was completed to discuss the resident's needs to prevent a future abuse altercation. During a review of the facility's policy and procedure (P&P) titled Resident-to-Resident Altercations, dated December 2016 was reviewed, The P&P indicated, .All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator . Policy Interpretation and Implementation . 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff . shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator . 2. If two residents are involved in an altercation, staff will . a. Separate the resident, and institute measures to calm the situation . b. Identify what happened, including what might have led to aggressive conduct . d. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents . g. Document in the resident's clinical record all interventions and their effectivenes [TRUNCATED]