Every finding on record at Garden View Post Acute Rehabilitation

Based on observation, interview and record review, the facility failed to assess and monitor one of ten sampled residents (Resident 6) in accordance with facility's policy and procedure (P&P) titled, Change in Condition, after discovering an incident on 5/4/2026 that involved Resident 6 and Resident 7. This deficient practice resulted in Resident 6 receiving inadequate care and had the potential to negatively affect Resident 7's psychosocial well-being. a. During a review of Resident 6's admission Record, dated 5/6/2026, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE]. The admission Record indicated Resident 6's diagnoses included morbid obesity (a chronic disease in which a person weighs 100 pounds or more over his/her ideal body weight), acquired absence of right leg above the knee (the surgical removal of the right leg starting somewhere above the kneecap), and muscle weakness. During a review of Resident 6's History and Physical Examination (H&P - a physician's assessment and evaluation of the resident), dated 9/26/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 3/13/2026, the MDS indicated Resident 6 was dependent (helper does all the effort to complete the activity) on staff for toileting hygiene and lower body dressing. During a concurrent observation and interview on 5/4/2026 at 2:18 p.m. with Resident 6, Resident 6 was observed lying in bed in Resident 6's room and Resident 6's various personal belongings were observed on top of Resident 6's bedside tray table. Resident 6 stated on 5/4/2026 at approximately 6:30 a.m., Resident 6 saw Resident 6's roommate (Resident 7) close their room door and then walked toward Resident 6's side of the room. Resident 6 stated Resident 7 was wearing only a diaper that appeared to be soiled and falling off. Resident 6 stated Resident 6 pressed Resident 6's call light so that the nursing staff could assist Resident 7. Resident 6 stated Resident 7 walked closer to Resident 6, grabbed the water pitcher that was on top of Resident 6's bedside tray table and threw it in the direction of Resident 6, who was in bed. Resident 6 stated Resident 7 then grabbed Resident 6's left leg from under the bedsheet but Resident 6 was able to free themselves. Resident 6 stated Resident 7 grabbed a half-filled cannister of potato chips and hit Resident 6 with the cannister which resulted in potato chips landing all over Resident 6 and around the room. Resident 6 stated Certified Nursing Assistant 1 (CNA 1) was the first staff member to come inside the room and separated Resident 7 from Resident 6. During an interview on 5/4/2026 at 4:42 p.m. with Resident 6, Resident 6 stated night shift Registered Nurse 1 (RN 1) came to assist CNA 1 by watching Resident 7 while CNA 1 picked up Resident 6's belongings from the floor and placed them back on Resident 6's bedside tray table. Resident 6 stated CNA 1 cleaned the potato chips off Resident 6's body and off Resident 6's bed. Resident 6 stated when Licensed Vocational Nurse (LVN) 1 arrived in the room shortly after the incident, Resident 6 told LVN 1 that Resident 6 wanted Resident 7 to be taken out of their shared room. b. During a review of Resident 7's admission Record, dated 5/6/2026, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE]. The admission Record indicated Resident 7's diagnoses included repeated falls, unspecified dementia (when a person has symptoms of mental decline, such as memory loss or confusion, but the exact cause is unknown), and Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out basic daily tasks). During a review of Resident 7's Change of Condition (COC - a form of documentation that describes when the condition or care needs of a resident has changed), dated 5/4/2026, the COC indicated at approximately 7:15 a.m. on 5/4/2026, Resident 7 was found walking with only [an] incontinent pad and had went to roommate['s] bedside table and threw all on the floor. The COC indicated Resident 2 was very aggressive / combative, throwing things on the floor, threatening to strike at staff. During an interview on 5/5/2026 at 10:10 a.m. with CNA 1, CNA 1 stated on 5/4/2026 at around 6:40 a.m., CNA 1 heard the bed alarm coming from Resident 6 and Resident 7's shared room. CNA 1 stated CNA 1 saw Resident 6 and Resident 7's room door closed and the call light above the door was lit. CNA 1 stated when CNA 1 opened the door, CNA 1 saw Resident 7 standing at the foot of Resident 6's bed. CNA 1 stated CNA 1 heard Resident 7 verbalized that Resident 6 needed to get out of Resident 7's house. CNA 1 stated Resident 6 looked very agitated, and that Resident 6 reported that Resident 7 was throwing Resident 6's belongings. CNA 1 stated CNA 1 saw potato chips, a water pitcher, and Resident 6's personal items on the floor. CNA 1 stated CNA 1 first moved Resident 7 away from Resident 6's area, and then CNA 1 picked up Resident 6's personal items from the floor and placed them back on Resident 6's bedside tray table. CNA 1 stated CNA 1 also assisted in removing and cleaning the potato chips off Resident 6's body. During a phone interview on 5/5/2026 at 11:04 AM with RN 1, RN 1 stated RN 1 was the assigned night shift nurse for Resident 6 and Resident 7 on 5/4/2026. RN 1 stated on 5/4/2026 at approximately 6:40 a.m., a staff member (unidentified) from the morning shift had asked RN 1 to go to the shared room of Resident 6 and Resident 7 because an incident had occurred. RN 1 stated when RN 1 arrived at Resident 6 and Resident 7's room, RN 1 heard Resident 7 said that the room was Resident 7's house, and Resident 7 was asking why Resident 6 was inside Resident 7's house. RN 1 stated RN 1 saw some of Resident 6's personal belongings on the floor, including a pair of scissors. RN 1 stated RN 1 picked up the scissors and placed them in RN 1's pocket because RN 1 did not want Resident 7 to see the scissors. RN 1 stated he saw Resident 6 looked irritated, and RN 1 heard Resident 6 verbalize that Resident 6 wanted Resident 7 to be removed from their shared room. RN 1 stated RN 1 did not ask Resident 6 what had happened that resulted in Resident 6's belongings all over the floor. RN 1 stated RN 1 did not assess Resident 6 because the morning shift took over handling the incident. When asked what RN 1 would have done if RN 1 was handling the aftermath of any incident, RN 1 stated RN 1 would first make sure the residents involved were safe. RN 1 stated RN 1 would then assess the situation by asking each resident what had happened so that RN 1 can appropriately plan the residents' care. During an interview on 5/5/2026 at 2:55 PM with Resident 6, Resident 6 stated after the incident involving Resident 7 occurred, LVN 1 and RN 1 did not approach Resident 6 to ask Resident 6 the details of what had happened. Resident 6 stated LVN 1 and RN 1 did not check Resident 6's body after the incident. Resident 6 stated sometime in the afternoon of 5/4/2026, Resident 6 noted a discoloration on the back of his right hand that Resident 6 had not noticed prior to the 5/4/2026 dated incident. Resident 6 stated Resident 6 was unsure what caused the discoloration. During an interview on 5/5/2026 at 3:16 p.m. with Director of Social Services (DSS), DSS stated on 5/4/2026 at approximately 2:00 p.m., RN 1 informed DSS that Resident 6 wished to speak with DSS. DSS then spoke with Resident 6 who reported that Resident 7 threw potato chips at Resident 6. DSS stated Resident 6 also reported that Resident 7 was going through Resident 6's belongings, and that Resident 7 had touched Resident 6's left leg. DSS stated Resident 6 expressed a desire to file a grievance regarding the incident involving Resident 7. During a concurrent interview and record review on 5/6/2026 at 8:59 a.m. with LVN 1, Resident 7's electronic medical record was reviewed. LVN 1 stated on 5/4/2026 at around 7:00 AM, LVN 1 was instructed by RN 2 to go to the shared room of Resident 6 and Resident 7 because an incident had occurred. LVN 1 stated when LVN 1 entered the room, LVN 1 saw chips on the floor of the entire room. LVN 1 stated LVN 1 saw CNA 1 standing in between Resident 6 and Resident 7. LVN 1 stated Resident 7 was sitting on Resident 7's bed wearing only a pull-up diaper. LVN 1 stated LVN 1 heard Resident 7 verbalize that Resident 7 wanted Resident 6 to get out of Resident 7's house. LVN 1 stated that RN 2 instructed LVN 1 to assist in transferring Resident 7 to a new room. LVN 1 stated after assisting with the transfer of Resident 7, LVN 1 documented LVN 1's observations in the COC Follow Up Nurses Note, dated 5/4/2026 which indicated Resident 7 was noted with aggressive and combative behavior. LVN 1 stated LVN 1 did not specifically assess Resident 6 because LVN 1 was concentrated on Resident 7. LVN 1 stated LVN 1 only documented LVN 1's assessment of Resident 7. LVN 1 stated LVN 1 should have also assessed Resident 6 by getting information from Resident 6 on what had happened, and by physically checking Resident 6 to see if Resident 6 got injured during the incident. LVN 1 stated it is important to assess each resident involved in any incident to find out what happened, and to determine if there was any injury that resulted from the incident. During an interview on 5/6/2026 at 9:46 AM with RN 2, RN 2 stated on 5/4/2026, RN 2 was doing RN 2's initial morning rounds (when nursing staff check on each resident in the facility) when RN 2 saw Resident 7 standing inside Resident 7's room wearing only a pull-up diaper and verbalizing that Resident 7's room was Resident 7's house. RN 2 stated RN 2 saw Resident 6's personal items on the floor, and CNA 1 was already in the room standing between Resident 6 and Resident 7. RN 2 stated RN 2 instructed CNA 1 not to get too close to Resident 7 because Resident 7 appeared agitated. RN 2 stated RN 2 instructed staff to transfer Resident 7 to a different room, while RN 2 contacted Resident 7's doctor and obtained a medication order to assist in calming Resident 7 down. RN 2 stated after Resident 7 was transferred to a new room and had visibly calmed down, RN 2 completed a COC for Resident 7. During a concurrent interview and record review on 5/6/2026 at 10:08 a.m. with RN 2, Resident 6's electronic medical record was reviewed. RN 2 stated RN 2 did not complete a COC for Resident 6. RN 2 stated Resident 6's medical record contained a COC that was completed by the Director of Nursing (DON) on 5/4/2026 at 2:16 p.m., which was about seven hours after the incident involving Resident 6 and Resident 7 had initially occurred. RN 2 stated RN 2 did not specifically ask Resident 6 what had happened because it was chaos when RN 2 discovered the incident. RN 2 stated on 5/4/2026 RN 2 did not ask Resident 6 about what had happened with Resident 7. RN 2 stated RN 2 did not physically assess Resident 6 after the incident occurred. RN 2 stated RN 2 should have assessed Resident 6 by asking Resident 6 questions about the incident and if Resident 6 felt threatened. RN 2 stated RN 2 should have also competed a body check of Resident 6 after the incident, which is a physical assessment of Resident 6's body to determine if there was any injury. During a phone interview on 5/6/2026 at 11:43 a.m. with the DON, the DON stated a resident has a change of condition if something outside of the normal occurs, whether it be physical or mental changes. When asked what a licensed nurse should do if he/she enters a resident's room and discovers personal belongings all over the floor, DON stated it is standard nursing practice for a licensed nurse to assess the situation and assess the residents involved in the incident. DON stated licensed nurses need to ask residents questions to find out what happened to them during an incident. DON stated nursing assessment is important because it will assist in determining if there was any harm that occurred. DON further stated that licensed nurses needed to assess incidents timely so that the licensed nurses can determine the plan of action and the next steps to take. During a review of the facility's policy and procedure (P&P) titled, Change in Condition, dated 4/2025, the P&P indicated the following: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. The P&P further indicated: If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions.

Based on interview and record review, the facility failed to readmit one of ten sampled residents (Resident 1) to the first available bed in a private room when the General Acute Care Hospital 2 (GACH 2) contacted the facility regarding Resident 1's readmission to the facility on 3/10/2026. This deficient practice resulted in Resident 1 remaining in GACH 2 from 3/10/2026 through 5/7/2026, a total of 59 days, following an inquiry from GACH 2 for Resident 1 to be readmitted to the facility. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses that included pneumonia (an infection that inflames the sacs in one or both lungs), respiratory failure (lungs cannot get enough oxygen into the blood or fail to remove carbon dioxide), and chronic obstructive pulmonary disease (COPD- progressive, long-term lung disease). During a review of Resident 1's History & Physical (H&P, physician assessment and evaluation of the resident), dated 12/4/2025, the H&P indicated Resident 1 had altered level of consciousness (ALOC- a temporary, significant deviation from a person's waking mental state) and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/23/2025, the MDS indicated Resident 1's cognition (ability to understand and process thoughts) was severely impaired and Resident 1 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of the Physician Orders (PO), dated 2/2/2026, the PO indicated Resident 1 was transferred to GACH 1 via 911 on 2/2/2026 due to (d/t) ALOC. During a review of the GACH 2 Case Manager admission Assessment (CMAA), dated 2/17/2026, the CMAA indicated that Resident 1 was admitted to GACH 2 from GACH 1 on 2/16/2026 for continual care with a diagnosis of sepsis (the body's life-threatening response to an infection). During a record review of the GACVH 2 Discharge Plan (DP), dated 5/5/2026, the DP indicated the Case Manager, RN (CMRN) reached out to Admissions (ADM 1) at the facility and ADM 1 stated no isolation bed was available for Resident 1. The CMRN indicated barriers for discharge were isolation bed availability at resident 's previous facility for candida auris (multi-drug-resistant fungus) and CRE (highly drug-resistant bacteria) and no Medi-Care benefit days left. During a phone interview, on 5/5/2026, at 3:48 p.m., with the CMRN, the CMRN stated Resident 1 was admitted to GACH 2 on 2/16/2026 for continued care and continued antibiotic use. The CMRN stated Resident 1 had candida auris (multi-drug-resistant fungus) and CRE (highly drug -resistant bacteria), that was present upon admission to GACH 2. The CMRN stated the CMRN first contacted facility on 3/10/2026 for readmission of Resident 1 to the facility. CMRN stated CMRN communicated with the facility's ADM 1. During a phone interview, on 5/6/2026, at 4:08 p.m., with ADM 1, ADM 1 stated the reason Resident 1 was not readmitted was because Resident 1 had two specific isolations and Resident 1 required a private restroom for Resident 1's isolation. ADM 1 stated GACH 2 had reached out, and the facility had been in contact with GACH 2 and advised GACH 2 that it had been kind of tricky to find a room for Resident 1. ADM 1 stated other residents had been moved around but residents could not be forced to change rooms; and a room for Resident 1 was not created. ADM 1 stated ADM 1's last contact with the CMRN was probably last week. During a phone interview, on 5/6/2026, at 4:33 p.m., with the Infection Preventionist (IP), the IP stated Resident 1 required contact Isolation (infection control measure used to prevent the spread of germs that are transmitted through direct or indirect contact). The IP stated the IP made recommendations to the admissions team, and the admissions team made the determination regarding availability of rooms. During a concurrent interview and record review, on 5/6/2026, at 5:03 p.m., with the Director of Nursing (DON) and the Administrator (ADMIN), the facility Census list was reviewed. The Census indicated there were seven available beds in the facility. During a concurrent interview and record review, on 5/7/2026, at 12:37 p.m., with ADM 1, the facility Admission/Discharge To/From Reports, dated 3/10/2026-5/7/2026, were reviewed. The Reports indicated there was a total of 34 beds available from 3/10/2026. ADM 1 stated eight rooms in the facility had a private bathroom. During an interview, on 5/7/2026, at 2:00 p.m., with the DON, the DON stated in general, when we transfer a resident to the hospital, we would have to take our patient back. The DON stated that Resident 1 is a long-term resident and Resident 1 would have to come back to the facility. The DON stated that according to the facility Policy, readmissions are given the first available bed. During a review of the facility's Policy and Procedure (P&P), titled, Admission/Transfer/Discharge- Bed Hold, revised November 2016, the P&P indicated if the resident's hospitalization or therapeutic leave exceeds the bed-hold period of seven (7) days, the resident may return to the facility to their previous room, if available or immediately upon the first availability of a bed in a semi-private room, if the resident: Requires the services provided by the facility; and Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.

Based on interview and record review, the facility failed to provide dental care and services to two of three sampled residents (Resident 3 and Resident 72) in accordance with the facility's policy and procedure (P&P) titled, Quality of care.This failure had the potential to result in the residents' poor oral health and reduce quality of life.Findings:During a review of Resident 3's face sheet, the face sheet indicated Resident 3 had an initial admission on [DATE] with the diagnoses but not limited to; hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (partial weakness or reduced strength on one side of the body), muscle weakness, chronic obstructive pulmonary disease (chronic lung disease causing difficulty in breathing).During a review of Resident 3's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 12/30/2025, MDS indicated Resident 3 needs substantial/maximal assistance when performing oral hygiene and personal hygiene.During a review of Resident 3's Clinical admission Assessment, dated 11/20/2025, the assessment indicated Resident 3 has own teeth and examination of oral/dental status was not checked.During a review of Resident 72's face sheet, the face sheet indicated Resident 72 had an initial admission on [DATE] with the diagnoses but not limited to; chronic obstructive pulmonary disease (a disease causing difficulty in breathing), protein-calorie malnutrition, essential hypertension (high blood pressure), fracture of right pubis, history of falling and need assistance with personal care.During a review of Resident 72's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 12/29/2025, MDS indicated Resident 72 needs partial/moderate assistance when performing oral hygiene and personal hygiene.During a review of Resident 72's Clinical admission Assessment, dated 12/26/2025, the assessment indicated Resident 72 has his own teeth, but examination of oral/dental status was not checked. The assessment also indicated Resident 72 has difficulty chewing.During an interview on 2/24/2026 at 10:50 am with Resident 3 and Resident 72, Resident 3 and Resident 72 stated, no dentist has seen nor checked their teeth for a long time now.During an interview on 2/25/2026 at 9:10 am with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 3 is dependent on performing oral hygiene. CNA 2 stated that she does not know if Resident 3 has been seen by a dentist.During an interview on 2/24/2026 at 10:40 am with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 72 is dependent on performing oral hygiene and CNA 1 is not aware if Resident 72 had any dental check with the facility's dentist.During an interview on 2/25/2026 at 1:28 pm with the Social Services Director (SSD), SSD stated Resident 3 and Resident 72 have not been seen by the facility dentist to receive a routine dental care since admission. During an interview on 2/27/2026 at 11:20 am with the Director of Nursing (DON), DON stated, residents were not given routine dental care services which should have been coordinated through the facility's SSD. DON stated that routine dental care is very important to the overall health condition of the residents.During a review of the facility's Dental Visit Report for 2025 and 2026, the report did not indicate Resident 3 and Resident 72 had any routine dental care from the facility's dental provider.During a review of the facility's policy and procedure (P&P) titled, Quality of Care, dated 2/2026, the P&P indicated, Social Services will maintain a system to monitor the dental, optometry, podiatry and audiology evaluations. Dental, optometry and audiology evaluations will be scheduled on annual basis and/or as needed.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of two sampled residents (Residents 1 and 50). These failures had the potential to result in Residents 1 and 50 not receiving care or receiving delayed services to meet the residents' needs and could result in a fall or injury. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty walking, history of falling, displaced intertrochanteric fracture of right femur (broken hip occurring at the top of the right thigh bone), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body). During a review of Resident 1's Fall Risk Evaluation (FRE- method of assessing a patient's likelihood of falling) dated 1/19/2026, the FRE indicated Resident 1 had one to two falls in the past three months, was bedbound and had a change in condition in the last 14 days, and recent hospitalization history in the last 30 days. During a review of Resident 1's untitled Care Plan (CP) dated 2/1/2026, the CP indicated Resident 1 was at risk for falls/injury due to generalized weakness related to decline in functional strength and endurance associated with multiple medical condition. The CP interventions included for the nursing staff to ensure Resident 1's call light was within reach and encouraged Resident 1 to use it for assistance as needed. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 1 had moderately impaired cognition (ability to understand and process information) for daily decision making. The MDS indicated Resident 1 needed maximum (helper did more than half the effort) assistance from the staff for eating, oral hygiene, toileting, showering, upper/lower body dressing and putting on/off footwear. During an observation on 2/24/2026 at 9:05 am, Resident 1 was awake, lying in bed with call light stuck on the right side of the bed and rails. During a concurrent observation and interview on 2/24/2026 at 9:06 am, with Responsible Party 1 (RP 1), RP 1 stated Resident 1 had right sided weakness and a fall at home. RP 1 stated Resident 1 could not see and reach Resident 1's call light. During a concurrent observation and interview on 2/24/2026 at 9:07 am, with Treatment Nurse 1 (TN 1), TN 1 stated, Resident 1's call light was not within reach. Resident's call light needed to be accessible at all times in case the resident needed assistance from the staff. b. During a review of Resident 50's AR, the AR indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including difficulty walking, history of falling, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. During a review of Resident 50's FRE dated 1/13/2026, the FRE indicated Resident 50 had one to two falls in the past three months, intermittent confusion, was bedbound, had a change in condition in the last 14 days, and recent hospitalization history in the last 30 days. During a review of Resident 50's untitled CP dated 1/15/2026, the CP indicated Resident 50 was at risk for falls related to confusion, cerebrovascular accident (blood flow to a part of the brain is stopped), right hemiplegia and history of fall. The CP intervention indicated for the nursing staff to ensure Resident 50's call light was within reach and encouraged the resident to use it for assistance as needed. During a review of Resident 50's MDS dated [DATE], the MDS indicated Resident 1 had moderately impaired cognition for daily decision making. The MDS indicated Resident 1 needed maximum assistance to staff for eating, oral hygiene, toileting, showering/bathing self, upper/lower body dressing and putting on/taking off footwear. During an observation on 2/24/2026 at 9:37 am, Resident 50 was awake, sitting in a wheelchair on the bottom right side of the bed with the call light on the left upper side of the bed. During a concurrent observation and interview on 2/24/2026 at 9:38 am with the Director of Staff and Development (DSD), the DSD stated Resident 50 was unable to reach the call light because it was placed on the left upper side of the bed. The DSD stated the purpose of the call light was for the residents to use it to call the staff if they needed help from the staff. The DSD stated the residents' needs would not be met if the call light was not within reach. During an interview on 2/26/2026 at 1:20 pm with Director of Nursing (DON), the DON stated the resident's call light needed to be always accessible to the residents for safety in case they needed assistance from the staff. During a review of the facility's Policy and Procedure (P&P) titled, Call Light, dated 2/2026, the P&P indicated Leave the resident comfortable, ensure the call device is within resident's reach before leaving room.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment and care screening too) reflected accuracy of assessments for two of two sampled residents (Resident 5 and Resident 106) by failing to: a. Ensure Resident 5 was coded in the MDS dated [DATE] taking Rivaroxaban (anticoagulant-blood thinner).b. Ensure Resident 106 was coded in the MDS dated [DATE] as discharged home with home health. These deficient practices resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to negatively affect the resident's care planning and services. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including essential hypertension (elevated blood pressure) and peripheral vascular disease (PVD-a condition involving the narrowing, blockage, or spasm of blood vessels). During a review of Resident 5's Order Summary Report (OSR) dated [DATE], the OSR indicated for licensed staff to administer Rivaroxaban tablet 2.5 mg, give 1 tablet by mouth two times a day for PVD. During a review of Resident 5's History and Physical (H&P) dated [DATE], the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Care Plan Report (CPR) initiated on [DATE], the CPR indicated Resident 5 was on anticoagulant therapy related to history of PVD. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 required substantial/maximal (helper does more than half the effort) assistance for toileting hygiene, shower and bathing. The MDS indicated Resident 5 required partial/moderate (helper does less than half the effort) assistance for oral hygiene, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 5 was independent (setup or clean-up assistance) for eating and personal hygiene. The MDS indicated Resident 5 did not have an anticoagulant medication. During an interview with Registered Nurse Supervisor 1 (RN1) on [DATE] at 7:18 AM, RN1 stated when a resident was on any type of anticoagulants, it should be documented in the MDS to monitor any adverse reactions or risk a resident could have while on high alert medications (such as anticoagulant). During an interview and record review with the MDS Coordinator on [DATE] at 11:40 AM, the MDS Coordinator stated Resident 5's MDS dated [DATE] was not properly documented and no modification to the MDS was submitted or done regarding Resident 5 taking Rivaroxaban. The MDS Coordinator stated the anticoagulant medication Rivaroxaban should have been coded in Resident 5's MDS. During a concurrent interview with the MDS Coordinator on [DATE] at 11:50 AM, the MDS Coordinator stated if the anticoagulant would have been coded in the MDS, it would assist staff to formulate a care plan for Resident 5's use of anticoagulant. The MDS Coordinator stated it was important to code the anticoagulant medication because Resident 5 would not receive services specific to Resident 5's needs. During an interview with the facility's Director of Nursing (DON) on [DATE] at 12:49 PM, the DON stated Resident 5's anticoagulant medication (Rivaroxaban) should be coded correctly in the MDS. The DON stated the MDS Coordinator was responsible for doing the assessment for Resident 5 and submitting the report to CMS (Centers for Medicare & Medicaid Services). The DON stated the MDS must be accurately coded so that staff could formulate a care plan to address Resident 5's needs. The DON stated Rivaroxaban was a high-risk medication and staff needed to monitor Resident 5 for any side effects from taking Rivaroxaban. During a review of the facility's Policies and Procedures (P&Ps) titled, Resident Assessment and Associated Processes, revised 2/2026, the P&P indicated Residents will be assessed, and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. b. During a review of Resident 106's AR, the AR indicated Resident 106 was admitted to the facility on [DATE] with diagnoses including muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (decrease in size or wasting away of a body part or tissue), need for assistance with personal care and non-pressure chronic ulcer (non-healing wound) of other part of right foot with unspecified severity. During a review of Resident 106's Discharge Summary and Post Discharge Plan of Care (DSPDPC) dated [DATE], the DSPDPC indicated Resident 106 will be discharged to home with Home Health services for Nursing, Therapy and wound care. During a review of Resident 106's Physician's Order (PO) dated [DATE], the PO indicated to discharge Resident 106 on [DATE] to home with home health to follow up for Physical Therapy/Occupational Therapy, Registered Nurse for medication and wound care nurse. During a review of Resident 106's MDS dated [DATE], the MDS indicated Resident 106 was discharged to home/community. During an interview on [DATE] at 12:23 pm, with the facility's Minimum Data Set Nurse (MDSN), the MDSN stated Resident 106 was discharged home on [DATE] with home health for RN services, PT/OT and wound care. The MDSN stated Resident 106's MDS assessment dated [DATE] needed to be coded discharged to home with home health services and not just discharged home/community. The MDSN stated Resident 106's MDS assessment should have been coded accurately to give accurate information to CMS. During an interview on [DATE] at 12:47 pm with the facility's DON, the DON stated Resident 106's MDS assessment dated [DATE] was not coded accurately as discharge to home under the care of organized home health service. The DON stated the MDS coordinator was responsible for coding the assessment accurately to give accurate information to CMS. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment and Associated Processed, revised 2/2026, the P&P indicated, The facility will electronically transmit encoded, accurate, and complete MDS data to the CMS system. Transmission of MDS data will include the following documents in addition to those mentioned above, resident's transfer, entry, reentry, discharge, & death.

Based on observation, interview, and record review, the facility failed to provide necessary treatment to prevent pressure ulcer (PU/PI - an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure) development and promote healing for three of four sampled residents (Residents 7, 9, and 46) by failing to: a. & b. Ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries) for Residents 7 and 9 were set to alternating pressure and set correctly to the residents' weights. c. Ensure the LALM was set correctly for Resident 46's weight. These failures had the potential to cause pressure ulcers, worsen, and prevent healing for residents with skin and pressure injuries. Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and difficulty in walking. During a review of Resident 7's Minimum Data Set (MDS – a standardized assessment tool) dated 2/5/2026, the MDS indicated Resident 7 had intact cognition (ability to think). The MDS indicated Resident 7 was independent rolling left and right in bed and used a wheelchair. During a review of Resident 7's History & Physical (H&P) dated 2/28/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 7's Order Summary Report (OSR), the OSR indicated Resident 7 had an active order for a LALM with settings based on weight, to be monitored every shift for placement and function, ordered on 2/23/2026. During a review of Resident 7's Weights and Vitals Summary (WVS) dated 2/23/2026, the WVS indicated Resident 7's weight was 139 pounds (lbs.- unit of measurement). During a review of Resident 7's Skin Check (SC) dated 2/23/2026, the SC indicated a Stage 3 Pressure Injury (St. 3 PI -Full-thickness loss of skin; dead and black tissue may be visible) at the intergluteal cleft (groove between the buttocks) extending laterally (toward the side) to the left buttock. The SC further indicated, a pressure redistribution surface was in place. During a review of Resident 7's untitled Care Plan (CP), revised on 2/23/2026, the CP indicated Resident 7 had a St. 3 PI at the intergluteal cleft extending to the left buttock with an intervention to monitor the LALM settings. During a concurrent observation and interview on 2/24/2026 at 9:11 am with Resident 7 in Resident 7's room, Resident 7 was in bed with the LALM on the static mode (a setting that creates a firm surface) and the weight set at 125 lbs. with a sticker indicating 139. Resident 7 stated, Resident 7 had a wound on Resident 7's buttocks and the mattress felt firm and soft. During a concurrent observation and interview on 2/24/2026 at 9:16 am with the Activity Director (AD) in Resident 7's room, the AD confirmed the LALM setting displayed normal pressure, was on static mode, and was set at about 120 lbs. During an interview on 2/26/2026 at 12:54 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 7 was on a LALM for wound management, which was based on Resident 7's last weight of 139 lbs. LVN 1 stated, the LALM should be set to 139 lbs. to relieve pressure on the resident's wound. LVN 1 stated, LVN 1 did not know what the static setting was and stated the LALM was set by the treatment nurses. LVN 1 stated, it was important for the LALM to be at the correct settings to be therapeutic for Resident 7. During an interview on 2/26/2026 at 12:55 pm with the Director of Nursing (DON), the DON stated licensed nurses needed to follow the physician's order for LALM settings based on the resident's weight to allow the LALM to be therapeutic. The DON stated the LALM should not be on static mode and should be in alternating mode. The DON stated there could be delayed wound healing when the airflow was not alternating. During an interview on 2/26/2026 at 1:13 pm with Treatment Nurse 1 (TN 1), TN 1 stated Resident 7's LALM should be in alternating mode and not in static mode. TN 1 stated the static mode setting made the mattress firmer and was not good for the residents because it was uncomfortable, could impair healing, and easier to develop a PI on the resident. TN 1 stated, Resident 7 received wound care treatments and needed the LALM because Resident 7 had multiple medical issues that could contribute to developing another PI. TN 1 stated the small circular sticker on the LALM device indicated the resident's weight and Resident 7's LALM should be set to 139 lbs. During a review of Drive: Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss Operator's Manual Item #14027, dated 2005, the LALM manual indicated the Med-Aire 8, 14027 System was an air support surface suitable for medium and high-risk pressure ulcer treatment and was specifically designed for the prevention of bedsores (pressure ulcers or injuries). The manual indicated the static/alternating control button was used to shift between alternating and static mode and when in static mode, the mattress would become a firm surface. The manual indicated users could easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. During a review of the facility's policy and procedure (P&P) titled, Low Air Loss, Alternating Pressure Pad or Mattress, revised 2/2026, the P&P indicated it was the policy of the facility to prevent and treat pressure ulcers, alternate pressure under bony prominences and provide resident comfort. The P&P further indicated, Low Air Loss mattress will be set up and serviced according to manufacturer's recommendations. b. During a review of Resident 9's AR, the AR indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing food or liquids), paraplegia (paralysis of the legs and lower body), contracture of muscle, multiple sites, and muscle weakness. During a review of Resident 9's OSR dated 10/9/25, the OSR indicated LALM for wound management; settings to be done based on weight. During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9's cognitive (ability to think and reason) skill for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 9 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 9's WVS dated 2/1/26, the WVS indicated Resident 9's weight was 103 lbs. During an observation inside Resident 9's room on 2/26/26 at 9:43 AM, Resident 9's was resting on a LALM with settings to approximately 125 lbs. During an interview with the Registered Nurse Supervisor (RNS) on 2/26/26 at 7:32 AM, the RNS stated one of the interventions the facility used for residents with pressure ulcers was the use of LALM. The RNS stated LALM was designed to prevent and treat pressure ulcers. The RNS stated LALM provided continuous airflow and pressure redistribution to the residents who had wounds to keep the skin dry and reduce friction. The RNS stated the LALM settings needed to be set according to the resident's weight or doctor's order. The RNS stated inaccurate LALM setting could increase the risk of skin breakdown potentially causing more harm to the residents. During an interview with the Treatment Nurse (TN) on 2/26/2026 at 11:55 AM, the TN stated the LALM was set based on the resident's weight and if the setting was not accurate, it could create complications. The TN stated the LALM was specifically designed to provide cushion and support. The TN stated it would not be acceptable to have inaccurate setting on a LALM that was supposed to provide comfort and support to the resident's pressure areas. During an interview with the facility's DON on 2/26/2026 at 1:25 PM, the DON stated Resident 9's LALM was set to approximately 125 lbs. The DON stated the setting on Resident 9's LALM needed to be in accordance with Resident 9's weight. The DON stated Resident 9's weight was 103 lbs. The DON stated, if the LALM setting was incorrect, it does not serve the purpose to promote wound healing. The DON stated the purpose of a LALM was to prevent and treat pressure ulcers by redistributing pressure and managing moisture on the resident's skin. During a review of the facility's P&P titled, Low Air Loss, Alternating Pressure Pad or Mattress, revised 2/2026, the P&P indicated, It is the policy of the facility to prevent and treat pressure ulcers, alternate pressure under bony prominences and provide resident comfort. c. During a review of Resident 46's AR, the AR indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcer of sacral (large, triangular bone at the base of the spine) region, stage 4 (ulcer that extends into the muscle and bone and causing extensive damage), pressure ulcer of right heel, retention of urine, and acute kidney failure (a sudden decline in kidney function). During a review of Resident 46's MDS dated [DATE], the MDS indicated Resident 46 had intact cognition for daily decision making. The MDS indicated Resident 46 needed maximum assistance (helper does more than half of the effort) from staff for toileting hygiene, shower, lower body dressing, and putting on/off footwear. During a review of Resident 46's untitled CP initiated on 1/10/2026, the CP indicated Resident 46 was at risk for skin breakdown due to multiple scars from old pressure injury at the back and history of pressure injuries. The CP interventions included the use of LAL mattress for Resident 46. During a review of Resident 46's Order Summary Report (OSR) dated 1/10/2026, the OSR indicated LAL mattress for tissue load management, setting set based on weight and to monitor placement and function every shift. During a review of Resident 46's History and Physical (H&P) dated 1/12/2026, the H&P indicated Resident 46 had the capacity to understand and make decisions. During a review of Resident 46's WVS dated 2/23/2026, the WVS indicated Resident 46 weighed 107 lbs. During an observation and concurrent interview on 2/24/2026 at 9:26 am, with the Director of Staff and Development (DSD), Resident 46 was awake and lying on a LAL mattress. The DSD stated Resident 46's LAL setting was set on 125 lbs. The DSD stated, Resident 46's LAL mattress should have been set up according to Resident 46's actual weight of 107 lbs During an interview and record review on 2/24/2026 at 12:40 pm with Treatment Nurse 1 (TN 1) of Resident 46's medical records (PointClickCare - PCC, a cloud-based software) was reviewed. TN 1 stated Resident 46 weighed 107 lbs. on 2/23/2026. TN 1 stated, Resident 46's LAL mattress setting should be based on the actual weight of Resident 46. TN 1 stated the physician's order was not followed for Resident 46 to set the LAL setting based on the resident's actual weight. TN 1 stated Resident 46 could develop a pressure ulcer if the LAL mattress was not set based on the resident's actual weight. During an interview on 2/26/2026 at 12:55 pm with the facility's Director of Nursing (DON), the DON stated, Resident 46's LAL mattress needed to be set based on the resident's actual weight to prevent Resident 46 from developing another pressure ulcer. During a review of Drive: Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss Operator's Manual Item #14027, dated 2005, the LALM manual indicated the Med-Aire 8, 14027 System was an air support surface suitable for medium and high-risk pressure ulcer treatment and was specifically designed for the prevention of bedsores (pressure ulcers or injuries). The manual indicated the static/alternating control button was used to shift between alternating and static mode and when in static mode, the mattress would become a firm surface. The manual indicated users could easily adjust the air mattress to a desired firmness according to the patient's weight and comfort.

Based on observation, interview, and record review, the facility failed to provide necessary care and services in accordance with physician's order and to implement its Policy and Procedure (P&P) on fall management for two of three sampled residents (Residents 6 and 72) by failing to:a. Ensure cushion alarm (safety device designed to alert caregivers immediately when a person at risk of falling would stand up or leave a seated/lying position) for Resident 6 was connected in bed and in the wheelchair.b. Ensure Resident 72 was provided with adequate supervision and had an environment free of accident hazards. These failures placed Residents 6 and 72 at risk for injury from fall and recurrent falls.Findings: a. During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same site of the body), hemiparesis (partial muscle weakness or reduced strength on one side of the body), and anxiety disorder (an emotion characterized by feelings of tension, worried thoughts, and physical changes). During a review of Resident 6's untitled Care Plan (CP) dated 9/30/2024, the CP indicated Resident 6 was at risk for falls. The CP interventions included the use of cushion alarms in bed and in wheelchair to remind Resident 6 not to get up unassisted. During a review of Resident 6's Order Summary Report (OSR) dated 11/21/2024, the OSR indicated Resident 6 had an order for cushion alarm in bed and in wheelchair to remind Resident 6 not to get up unassisted. The OSR indicated to monitor placement and function of the cushion alarm every shift. During a review of Resident 6's Minimum Data Set (MDS – a resident assessment tool) dated 1/2/2026, the MDS indicated Resident 6 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 6 required substantial/maximal assistance (helper did more than half the effort) with oral and personal hygiene. The MDS indicated Resident 6 was dependent (helper did all the effort, resident did none) with eating, toileting, shower, upper and lower body dressing. During a review of Resident 6's Progress Notes (PN) dated 1/2/2026, the PN indicated Resident 6 was at high risk for fall due to intermittent confusion and poor vision. The PN indicated Resident 6 had a Fall Risk score of 17. During a review of Resident 6's Fall Risk Evaluation (FRE) dated 1/4/2026, the FRE indicated a score of 10 or higher indicated the resident is at high risk for falls. During a concurrent observation inside Resident 6's room and interview on 2/25/2026 at 12:26 pm with Licensed Vocational Nurse 4 (LVN 4), Resident 6 was in bed and on Resident 6's back. LVN 4 stated Resident 6 did not have a cushion alarm in bed or in the wheelchair. LVN 4 stated Resident 6 had history of getting out of bed unassisted. During a concurrent interview and record review on 2/25/2026 at 3:56 pm with LVN 3, Resident 6's medical record (chart) and electronic health record (EHR) were reviewed. LVN 3 stated there was no documented record that Resident 6's active order for cushion alarm in bed and in wheelchair was discontinued. LVN 3 stated Resident 6 should have a cushion alarm connected in bed and in wheelchair as ordered, to prevent fall and injury. During an interview on 2/26/2026 at 2:07 pm with the Director of Nursing (DON), the DON stated cushion alarm should be applied as ordered by the physician to alert staff that a resident needed immediate assistance, to prevent fall and for the safety of the residents while in bed or in a wheelchair. During a review of the facility's P&P titled, Fall Management System, revised/reviewed on 2/2026, the P&P indicated, It is the policy of this facility to provide each resident with appropriate assessment and intervention to prevent falls and to minimize complications if a fall occurs. b. During a review of Resident 72's AR, the AR indicated Resident 72 had an initial admission on [DATE] with the diagnoses but not limited to: chronic obstructive pulmonary disease (a lung disease causing difficulty in breathing), protein-calorie malnutrition, essential hypertension (high blood pressure), fracture of right pubis, a history of falling and need assistance with personal care. During a review of Resident 72's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 12/29/2025, the MDS indicated Resident 72 is dependent on lying- to-sitting on side of the bed and had history of fall on admission and had a fracture related to a fall in the six months prior to admission. During a review of Resident 72's Clinical admission Assessment (an initial, comprehensive evaluation of a resident when they are admitted to a facility) dated 12/26/2025, the assessment indicated Resident 72 has weaknesses on right leg, right foot, left leg and left foot. During a review of Resident 72's Nursing Fall Risk Evaluation, dated 12/29/2025, the evaluation indicated Resident 72 is bedbound/incontinent, has a balance problem with standing and walking and is high risk for fall. During a review of Resident 72's care plans initiated on 12/27/2025, the care plan stated Resident 72's bed should be in a low position to minimize the risk for fall. During a concurrent observation on 2/25 /2026 at 10:49 am with Resident 72 inside Resident 72's room, Resident 72 was lying in bed which was not in a low position and no landing pad (a floor pad designed to help prevent injury should a person fall) was in the bedside. During an interview on 2/24/2026 at 10:40 am with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 72 needs supervision in sitting, lying in bed and transferring to bed from a wheelchair and reciprocally. During an interview on 2/26/2026 at 1:00 pm with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 72 was found on the floor on 2/24/2026 at 7:15 pm by the evening shift staff and was sent to the hospital emergency room where they evaluated Resident 72 with no new fracture findings. RN1 stated Resident 72's room should be free from any hazards and nursing assistants should always supervise Resident 72 to prevent any incident. During an interview on 2/27/2026 at 9:52 am with Licensed Vocational Nurse (LVN) 1, LVN stated Resident 72 was found on the floor on 2/24/2026 AT 7:15 pm by the evening shift staff. LVN1 stated Resident 72's bed is not placed in a low position and has no landing pad could help prevent any injury. During an interview on 2/27/2026 at 1:05 pm with the DON (Director of Nursing), DON stated, the evening shift staff wheeled Resident 72 in the resident's room and left the resident, and when the evening shift staff went back to the resident's room, Resident 72 was found on the floor. DON stated that Resident 72 has high risk of falling, staff should have supervised Resident 72 and bed should be in a low position with landing pads should be in place. During a review of the facility's policy and procedure (P&P) titled, Fall Management System, the P&P indicated that the facility provides an environment that remains as free of accident hazards as possible and to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on interview and record review, the facility failed to conduct competencies for two of five sampled staff (Certified Nurse Assistant 4 (CNA 4) and Licensed Vocational Nurse 2 (LVN 2). These failures had the potential for the residents in the facility not to receive appropriate nursing care and services from CNA 4 and LVN 2.Findings: During a concurrent record review and interview on 2/26/2026 at 10:20 am with the Director of Staff and Development (DSD), CNA 4's employee file was reviewed. The DSD stated CNA 4 was a full-time employee in the facility since 11/11/2024. The DSD stated CNA 4 did not have a skills competency on file for 11/2025. The DSD stated, skills competency should be done yearly to ensure staff understand the tasks assigned and remain competent in providing care and treatment for the residents. The DSD stated, staff competency should be completed by the DSD for all CNAs and the Director of Nursing (DON) for all licensed nurses upon hire and annually, thereafter. During a concurrent record review and interview on 2/26/2026 at 10:20 am with the DSD, LVN 2's employee file was reviewed. The DSD stated LVN 2 was a full-time employee in the facility since 5/22/2025. The DSD stated the DON did not sign and date LVN 2's skills check list upon hire. The DSD stated, if it was not signed, it was not done. During an interview on 2/26/2026 at 1:30 pm with the DON, the DON stated, CNA 4's skills competency should have been completed by the DSD upon hire and annually to ensure employees were competent in providing care and services to the residents. During a review of the facility's policy and procedure (P&P) titled, Nursing Staff Competency, reviewed on 2/2026, the P&P indicated, Within 30 days of the date of hire, the nursing staff member shall complete the orientation competency assessment for the appropriate job category in order to meet the needs of the facility's resident population in accordance with the facility assessment.

Based on observation , interview and record review , the facility failed to maintain medication related equipment and storage areas in a clean and appropriate manner, resulting in the presence of contaminated equipment and unsecured, loose medication pills in the medication room.This deficient practice had the potential to cause contamination, medication errors, and unsafe conditions for residents.Findings:During a review of the facility's map, it was noted that the facility has four shower rooms, three nurses' stations (north, center, and south), and two medication rooms located in the center and south stations.During a concurrent observation and interview on 2/26/2026 at 1:15 pm with Registered Nurse Supervisor (RNS) 1 in the center station medication room, crackers were observed stored inside one of the medication room cabinets, and a can of insect repellent spray was observed on top of the cupboard in close proximity to medications. Five unidentified loose medication pills were found on the floor next to the medication destruction container. RNS1 stated food items should not be inside the medication room since these can attract pests. RNS1 stated that any discontinued and expired medications should be placed inside the destruction container.During an interview on 2/27/2026 at 11:29 am with the DON (Director of Nursing), DON stated there should be no food items inside the medication room since these can attract pest infestation. DON stated nurses are responsible for keeping the medication rooms clean to avoid any possible infection that could happen. DON also stated if nurses do not manage the discontinued and expired medications by not placing them in the destruction container, this compromises the safety of our residents. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, the P&P indicated outdated, contaminated, or deteriorated medications are immediately removed from stock , disposed of according to medication disposal and medication storage areas are kept clean and free of clutter.

Based on observation, interview, and record review, the facility failed to maintain a safe and clean areas for residents.This failure had the potential to negatively affect the residents' quality of life.Findings:During a review of the facility's map, it was noted that the facility has four shower rooms, three nurses' stations (north, center, and south), and two medication rooms located in the center and south stations.During a concurrent observation and interview conducted on 2/25/2026 at 8:50 am with Certified Nursing Assistant (CNA) 1 in the shower room near the north nurses' station, CNA 1 reported that most residents follow a shower schedule and that nursing assistants and housekeeping staff are responsible for cleaning the shower rooms. The shower room adjacent to resident rooms in the north station had an exhaust fan with a protective grill that was visibly covered with dust.During an interview on 2/26/2026 at 2:05 PM with Infection Preventionist and Maintenance, Maintenance stated the exhaust fan removes excess moisture inside the shower room and cleaning it helps prevent bacterial growth. Infection Preventionist stated it is important to keep all care areas clean to protect the residents from any source of infection.During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and control Program, the P&P indicated the facility's program addresses detection, prevention and control of infections among residents and personnel including effective cleaning and disinfecting equipment to include bathing areas.

Based on observation, interview, and record review, the facility failed to implement its facility's Policy and Procedures (P&P) on the use of cushion pad alarms (safety devices designed to alert caregivers immediately when a person at risk of falling stand up or leave a seated/lying position) for one of one sampled resident (Resident 12). This failure placed Resident 12 at risk of injury and psychological distress related to the use of cushion pad alarms. Findings: During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness (decrease or loss of strength), osteoporosis (weak and brittle bones), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes). During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool) dated 1/23/2026, the MDS indicated Resident had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 12 required partial/moderate assistance (helper did less than half the effort) with eating, oral hygiene, and personal hygiene; substantial/maximal assistance (helper did more than half the effort) with toileting, shower, and upper body dressing; and dependent (helper did all the effort) with lower body dressing. During an observation inside Resident 12's room and interview on 2/24/2026 at 10:29 am with Treatment Nurse 2 (TN 2), Resident 12 was sitting in Resident 12's wheelchair. TN 2 stated Resident 12 had a cushion alarm connected to Resident 12's bed and wheelchair. During a concurrent interview and record review on 2/25/2025 at 12:37 pm with Licensed Vocational Nurse 4 (LVN 4), Resident 12's medical record (chart), electronic health record (EHR) and Order Summary Report (OSR), dated 2/2026, were reviewed. LVN 4 stated Resident 12 did not have an order for cushion pad alarms for bed and wheelchair. LVN 4 stated there was no documented record that consent was obtained prior to the use and application of cushion pad alarms for bed and wheelchair. LVN 4 stated cushion pad alarms were considered as restraints because it restricted the residents' mobility in bed and in the chair. LVN 4 stated the use of cushion pad alarms needed a physician's order for the safety of the residents. LVN 4 stated consent should be obtained prior to the use and application of cushion pad alarms to ensure that the resident or responsible party were aware of the risks and benefits of the use of cushion pad alarms to prevent causing anxiety and discomfort to the resident from hearing the alarm. During an interview on 2/26/2026 at 1:48 pm with the Director of Nursing (DON), the DON stated all cushion pad alarms should have a physician's order and consent should be obtained from the resident and/or responsible party before its use and application to ensure that its use was appropriate and necessary for the safety of the resident. During a review of the facility's P&P titled, Restraint, Physical revised 2/2026, the P&P indicated, Restraints include lab cushions and lap trays the resident cannot remove easily. Any resident using a restraint will have a current order with the following components: The exact type of restraint; The circumstances for usage; The medical reason for usage; A release/exercise statement. Any resident using a physical restraint must have a current signed consent in the clinical chart that identifies the risks/benefits of the restraint, the medical symptom for the restraint usage, and alternatives to the restraint.

Based on interview and record review, the facility failed to ensure for one of six sampled residents' (Resident 108) order for Remeron (a medication to treat depression [a feeling of severe sadness or hopelessness]) included a specific indication for a specific diagnosed condition and the hours of sleep was monitored, as indicated in the facility's policy titled Chemical Restraints and Psychotropic (medications that alter chemical levels in the brain which impact mood and behavior) Medication Management. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to Resident 108.Findings: During a review of Resident 108's admission Record (AR), the AR indicated Resident 108 was admitted to the facility on [DATE] with diagnoses including depression (a feeling of severe sadness or hopelessness) and polyneuropathy (damage or disease affecting peripheral nerves featuring weakness, numbness, and burning pain). During a review of Resident 108's History and Physical (H&P) dated 2/21/2026, the H&P indicated Resident 108 had the capacity to understand and make decisions. During a review of Resident 108's Order Summary Report (OSR) dated 2/21/2026, the OSR indicated for licensed staff to administer Remeron oral tablet as needed manifested by inability to sleep and stay asleep related to insomnia for 14 days. During an interview on 2/24/2026 at 1:58 pm with Registered Nurse 1 (RN 1), RN 1 stated Resident 108 was ordered Remeron and the indication for use was not a specific diagnosis. RN 1 stated Resident 108's hours of sleep were not monitored. RN 1 stated, Resident 108's hours of sleep should have been monitored while on Remeron to determine if the resident was able to sleep or not. During an interview on 2/26/2025 at 12:52 pm with the facility's Director of Nurses (DON), the DON stated psychotropic medications should have been administered with specific diagnosis. The DON stated, Insomnia is not a diagnosis for Remeron use. The DON stated Resident 108's target behavior for inability to sleep should have been monitored by Licensed Nurse to monitor residents' hours of sleep to determine if the medication was effective or not. During a review of the facility's policy and procedure (P&P) titled, Chemical Restraints and Psychotropic Medication Management, revised 4/2025, the P&P indicated, Residents do not receive psychotropic drugs pursuant to an as needed (PRN) order unless medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. The specific condition requiring the use of psychotropic medication(s) is diagnosed and documented in the clinical record. Psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record. Monitoring for adverse consequences and effectiveness of medications are in place. The LN shall review the classification of the drug, the appropriateness of the diagnosis, its indication, behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician.

Based on observation, interview, and record review, the facility failed to update the resident's care plan for one of three sampled residents (Resident 72).This failure had the potential to compromise Resident 72's safety and prevent the provision of necessary care.Findings:During a review of Resident 72's face sheet, the face sheet indicated Resident 72 had an initial admission on [DATE] with the diagnoses but not limited to: chronic obstructive pulmonary disease ( a chronic lung disease causing difficulty in breathing) , protein-calorie malnutrition , essential hypertension (high blood pressure ) , fracture of right pubis , a history of falling and need assistance with personal care.During a review of Resident 72's Minimum Data Set (MDS-a resident assessment tool) dated 12/29/2025, the MDS indicated Resident 72 is dependent on lying- to-sitting on side of the bed and had history of fall on admission and fracture related to a fall prior to admission.During a review of Resident 72's Clinical admission Assessment, dated 12/26/2025, the assessment indicated Resident 72 has weaknesses on the right leg, right foot, left leg and left foot.During a review of Resident 72's Physical Therapy evaluation, dated 12/29/2025, the evaluation indicated Resident 72 exhibited decreased stride length, decreased velocity and uneven step length associated with knee instability.During a review of Resident 72's Nursing Fall Risk Evaluation, dated 12/29/2025, the evaluation indicated Resident 72 is bedbound/incontinent, has a balance problem with standing and walking and is high risk for fall.During a review of Resident 72's medical records, the Situation, background , assessment (SBAR- a structured communication tool used in healthcare) communication form dated 2/24/2026, the form indicated Resident 72 had a fall and a right hip x-ray ( a medical imaging technique that utilizes rays to visualize the interior of the body) was ordered by the physician.During a review of Resident 72's General Acute Care Hospital Emergency Department care note, dated 2/25/2026, the note indicated Resident 72 had no new fracture as a result from the fall.During a review of Resident 72's care plans on 2/25/2026 at 8:45 am, the care plans indicated the fall risk care plan had not been updated following the resident's fall on 2/24/2026.During a concurrent observation and interview on 2/25 /2026 at 10:49 am with Resident 72 inside Resident 72's room, Resident 72 was lying in bed which was not in the lowest position. Resident 72 stated he cannot remember what happened on 2/24/2026 at 7:15PM.During an interview on 2/27/2026 at 9:52 am with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 72 was found on the floor on 2/24/2026 at 7:15 pm by the evening shift staff. LVN 1 stated the care plan was not revised after the incident happened. LVN 1 stated it is important nurses update it so they can better care for the residents after the fall. LVN1 also stated that Resident 72 has no landing pad (a floor pad designed to help prevent injury should a person fall) that could help prevent any injury. During an interview on 2/27/2026 at 1:05 pm with the Director of Nursing (DON), DON stated the nurses did not update Residents 72's care plan to include Resident 72's bed is in a low position and placing a landing pad. DON stated that Resident 72's care plan should have been revised so staff would know how to care for the residents.During a review of the facility's policy and procedure (P&P) titled, Change in condition, the P&P indicated, The nurse will transcribe the treatment and plan of care relative to the change of condition on the resident's Electronic Medical Record (EMR). During a review of the facility's policy and procedure (P&P) titled, Fall Management System, the P&P indicated a fall without injury is still a fall and the resident's care plan will be updated.

Based on observation, interview, and record review, the facility failed to provide required assistance during activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily) for one of one sampled resident (Resident 51).This failure placed Resident 51 at risk of physical injury during bed mobility and overall decline in quality of life.Findings: During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms), left hand contracture (a stiffening/shortening at any point, that reduces the joint's range of motion) and cerebral palsy (condition that affects how the person moves and controls their muscles) During a review of Resident 51's Minimum Data Set (MDS - a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 51 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 51 was dependent (helper did all the effort, resident did none and assistance of 2 or more helpers were required for the resident to complete the activity) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a review of Resident 51's undated/untitled Care Plan (CP), the CP indicated Resident 51 was totally dependent on staff for repositioning and turning in bed and Resident 51 required total assistance with personal hygiene. During a concurrent observation inside Resident 51's room and interview on 2/24/2026 at 9:48 am with Certified Nurse Assistant 5 (CNA 5), CNA 5 was alone while cleaning and turning Resident 51 on Resident 51's left side. CNA 5 stated Resident 51 was totally dependent on staff and required 2-person assistance for shower, toileting, upper/lower body dressing and personal hygiene. CNA 5 stated Resident 51 should be cleaned and turned with the assistance of 2 persons for the safety of the resident and to prevent injury both to the resident and the staff. During an interview on 2/25/2026 at 2:06 pm with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 51 had quadriplegia and hand contracture. LVN 4 stated Resident 51 was dependent on staff for all ADLs. LVN 4 stated Resident 51 could not turn and hold position during toileting and personal hygiene and needed 2-person assistance. LVN 4 stated Resident 51 should not be cared for by one person only to prevent injury to the resident during bed mobility and to ensure Resident 51 was cleaned thoroughly after toileting to prevent skin breakdown. During an interview on 2/26/2026 at 1:53 pm with the Director of Nursing (DON), the DON stated dependent residents required the assistance of 2 or more persons during ADLs to complete the activity to ensure residents were provided adequate care and for the safety of the residents. During a review of the facility's Policy and Procedure (P&P) titled, ADL, Services To Carry Out, reviewed 2/2026, the P&P indicated, It is the policy of this facility that residents are given the appropriate treatment to maintain or improve his/her abilities. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain personal hygiene.

Based on observation, interview and record review, the facility failed to provide necessary care and services for a resident with indwelling catheter (also known as foley catheter {FC}, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) in accordance with the facility's Policy and Procedure (P&P) on urinary catheter care for one of four sampled residents (Resident 46). This failure had the potential for Resident 46 not to receive care or receive delayed care and treatment for urinary tract infection (UTI, an infection in the bladder/urinary tract). Findings: During a review of Resident 46's admission Record (AR), the AR indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcer of sacral (large, triangular bone at the base of the spine) region, stage 4 (ulcer that extends into the muscle and bone and causing extensive damage), pressure ulcer of right heel, retention of urine, and acute kidney failure (a sudden decline in kidney function). During a review of Resident 46's MDS dated [DATE], the MDS indicated Resident 46 had intact cognition for daily decision making. The MDS indicated Resident 46 needed maximum assistance (helper does more than half of the effort) from staff for toileting hygiene, shower, lower body dressing, and putting on/off footwear. During a review of Resident 46's Order Summary Report (OSR) dated 1/12/2026, the OSR indicated Resident 46 had an order for licensed staff to insert an indwelling catheter French (a type of catheter) 16 (size of the catheter) per 10 millimeters (ml, unit of measurement) to closed drainage system (a sterile, self-contained urinary catheter attached to a collection bag to create a sealed circuit). During a review of Resident 46's untitled Care Plan (CP) dated 1/12/2026, the CP indicated Resident 46 was at risk for infection related to indwelling device catheter and history of Multidrug-Resistant Organism (MDRO - refers to bacteria or other germs that have developed resistance to at least three or more classes of antibiotics) infection. The CP interventions included for nursing staff to observe Enhanced Barrier Precautions (EBP - an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at high risk for harboring MDROs) during the provision of close contact care and to monitor for sign and symptoms of active infection and notify physician. During a concurrent observation inside Resident 46's room and interview on 2/24/2026 at 9:31 am with the Director of Staff and Development (DSD), Resident 46 was in bed. Resident 46 had a foley catheter hanging on the right side of the bed. Resident 46's had approximately two inches of white sediments inside the foley catheter tubing. The DSD stated Resident 46's foley catheter tubing should not have white sediments inside. The DSD stated white sediments in the tubing could be a sign of UTI. During an interview on 2/26/2026 at 1:17 pm, with the facility's Director of Nursing (DON), the DON stated licensed nurses should monitor all residents with foley catheter every eight hours for signs and symptoms of infection such as burning upon urination, presence of sediments in the tubing, blood in the urine, fever and alteration in level of consciousness, to prevent UTI. During a review of the facility's policy and procedure (P&P) titled, Indwelling Urinary Catheter Care, revised 2/2026, the P&P indicated, It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition/medication directly to the stomach) site in accordance with the physician's order for one of one sampled resident (Resident 51). This failure had the potential for complications related to tube feedings for Resident 51.Findings: During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms), left hand contracture (a stiffening/shortening at any point, that reduces the joint's range of motion) and gastrostomy (a surgical opening fitted with a device to allow feedings/medication to be administered directly to the stomach). During a review of Resident 51's untitled Care Plan (CP) dated 2/19/2024, the CP indicated Resident 51 had a tube feeding related to dysphagia (difficulty swallowing). The CP had a goal for Resident 51 to remain free of side effects or complications related to tube feeding. During a review of Resident 51's Order Summary Report (OSR) dated 11/29/2025, the OSR indicated Resident 51 had an order for licensed staff to clean GT site with normal saline (NS), pat dry, and apply split gauze dressing (a specialized absorbent, and pre-cut pad designed to fit securely around medical devices that protrude from the skin such as GT) daily and secure with paper tape every shift. During a review of Resident 51's Minimum Data Set (MDS - a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 51 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 51 was dependent (helper did all the effort, resident did none and assistance of 2 or more helpers were required for the resident to complete the activity) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a review of Resident 51's Treatment Administration Record (TAR), dated 2/23/2026, the TAR indicated Resident 51's tube feeding site dressing was changed on 2/23/2026. During a concurrent observation inside Resident 51's room and interview on 2/24/2026 at 9:48 am with Certified Nursing Assistant 5 (CNA 5), Resident 51 was lying in bed on Resident 51's back with gastrostomy tube. CNA 5 stated Resident 51's G-tube dressing was loose and dated 2/22/2026. During an interview on 2/25/2026 at 1:30 pm with Treatment Nurse 1 (TN 1), TN 1 stated g-tube sites needed to be cleaned, pat dry, covered with a split type of gauze daily and as needed and secured with a tape to prevent infection around the g-tube stoma (surgically created opening on the surface of the abdomen that connects an internal organ to the outside of the body) and accidental pulling which might cause injury to the stoma. During an interview on 2/26/2026 at 1:52 pm with the Director of Nursing (DON), the DON stated for Resident 51, the g-tube site should be cleaned daily as ordered by the physician. The DON stated g-tube dressing should be kept clean and in place to prevent infection and tugging during bed mobility. During a review of the facility's policy and procedure (P&P) titled, Gastrostomy Tube Care and Management, revised 4/2025, the P&P indicated, It is the policy of this facility to provide proper care and maintenance of gastrostomy tubes. Clean all stoma sites daily, per MD orders.

Based on observation, interview, and record review the facility failed to ensure one of seven sampled residents (Resident 109) was free from significant medication error by failing to administer Morphine Sulfate Contin (MS Contin- controlled medication used for pain) Oral Tablet Extended Release (ER-long acting) 15 milligrams (mg- unit of measurement) at the correct administration time. The medication was administered too early than the ordered scheduled time of administration. This failure had the potential to place Resident 109 at risk for adverse side effects related to overdosing, such as lethargy, respiratory depression (slow breathing and carbon dioxide retention) and hypotension (low blood pressure).Findings: During a review of Resident 109's admission Record (AR), the AR indicated Resident 109 was admitted to the facility on [DATE] with diagnoses including cutaneous abscess (pocket of pus in the skin from an infection) of the left upper arm and pain in the left shoulder. During a review of Resident 109's History & Physical (H&P) dated 2/23/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 109's Order Summary Report (OSR), the OSR indicated an active order for MS Contin Oral Tablet ER 15 mg to be given by mouth every 12 hours as needed for severe pain of 7-10 (on a pain rating scale of zero being no pain, and 10 being the worst possible pain, severe pain was rated as 7-10 on a 1-10 scale), ordered on 2/25/2026. During a review of Resident 109's untitled Care Plan (CP) dated 2/20/2026, the CP indicated the resident had acute pain due to an open wound to the left shoulder, with interventions for MS Contin on 2/25/2026 and to administer medications/treatments as ordered. During a medication pass observation on 2/26/2026 at 8:51 am, Licensed Vocational Nurse 1 (LVN 1) administered oral tablet of MS Contin ER 15 mg to Resident 109 for nine out of ten (9/10) left arm abscess pain. LVN 1 charted the medication administration in the electronic medication administration records (eMAR- a daily documentation record used by a licensed nurse to document medications and treatments given) and then in the Controlled Drug Record (CDR). During a review of the Resident 109's eMAR, dated 2/1/2026 through 2/28/2026, the eMAR indicated MS Contin oral tablet ER 15 mg was documented as given on 2/25/2026 at 4:20 pm and on 2/26/2026 at 8:50 am. During a review of Resident 109's Controlled Drug Record (CDR-a controlled drug record/accountability record of medications that are considered to have a strong potential for abuse), dated 2/25/2026, the CDR indicated, Morphine sulfate ER tablet 15 mg was previously administered on 2/26/2026 at 4:20 am and LVN 1 administered the tablet again at 8:50 am. During an interview on 2/26/2026 at 8:56 am with LVN 1, LVN 1 stated the pill count matched the doses given in the CDR and the bubble pack showed that a total of three doses had been given to Resident 109, but the dose given at 2/26/26 at 4:20 am was not charted in the eMAR. During a concurrent observation and interview on 2/26/2026 at 8:59 am with Resident 109 in Resident 109's room, Resident 109 was alert and sitting up in bed. Resident 109 stated Resident 109 received medication around 4 am (today) for the pain in Resident 10's arm. Resident 109 could not recall the name of the medication. During a follow up interview on 2/26/2026 at 9:03 am with LVN 1, LVN 1 stated the licensed nurses should document every time a medication was administered, follow medication rights, and check if given. LVN 1 stated LVN 1 gave the MS Contin ER 15 mg tablet before it was due which could cause resident 109 to become lethargic, experience low blood pressure and heart rate, and cause a change in condition. During an interview on 2/26/2026 at 11:12 am with Registered Nurse 3 (RN 3), RN 3 stated RN 3 took care of Resident 109 the night prior and gave Resident 109 MS Contin ER 15 mg on 2/25/2026 at 4:20 am for severe pain. RN 3 stated, RN 3 admitted RN 3 had forgotten to document the medication administration in the eMAR. RN 3 stated the CDR and eMAR should be checked before giving the medication and because the dose was given too early, Resident 109 could experience adverse side effects, decreased respirations, and cardiac issues. During an interview on 2/26/2026 at 2:02 pm with the Director of Nursing (DON), the DON stated for medication administration, the nurses must follow the five rights of medication administration and review the prior administration by checking the CDR and the eMAR. The DON stated, Resident 109's medication administration of the MS Contin ER 15 mg on 2/26/2026 at 8:50 am was a medication error. The DON stated licensed nurses should document on both the CDR and eMAR for controlled drugs so the following nurse would know when the next medication was available to the resident to prevent medication errors from occurring for resident's safety. The DON stated, Resident 109 could experience lethargy, altered mental status, and decreased respiration and would be monitored for 72 hours. During a review of the facility's policy and procedure (P&P) titled, Controlled Medications-Storage and Reconciliation, revised 4/2025, the P&P indicated, it was the policy of the facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse. The P&P indicated, the facility would maintain a process for monitoring, administration, documentation, reconciliation, and destruction of controlled substances. During a review of the facility's P&P titled, Medication Administration, dated 1/2019, the P&P indicated, medications were administered within 60 minutes of scheduled time. The P&P further indicated, the individual who administered the medication dose recorded the administration on the resident's MAR directly after the medication was given. The P&P further indicated, at the end of each medication pass, the person who administered the medications reviewed the MAR to ensure necessary doses were administered and documented.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 66) was assisted with eating at eye level and called by Resident 66's legal (official name recognized by government on documents), proper and preferred name. These failures had the potential for Residents 66 to lose dignity and individuality.Findings: During a review of Resident 66's admission Record (AR), the AR indicated Resident 66 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), asthma (a chronic lung disease that causes inflammation and muscle tightening of the airways, making it harder to breathe), and dysphagia (difficulty swallowing). During a review of Resident 66's Order Summary (OS), the OS indicated Resident 66 had an active order for a no-added salt fortified diet, pureed texture meals with thin liquids, ordered on 11/7/2025. During a review of Resident 66's History & Physical (H&P) dated 11/28/2025, the H&P indicated the resident had intellectual disability. During a review of Resident 66's untitled Care Plan (CP) revised on 12/23/2025, the CP indicated Resident 66 had an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility, impaired balance, confusion, with a goal to maintain Resident 66's current level of functions, including eating. During a review of Resident 66's Minimum Data Set (MDS) assessment dated [DATE], the MDS indicated Resident 66 had severely impaired cognition (ability to think) and required partial/moderate assistance (helper does less than half the effort) for eating. During an observation on 2/24/2026 at 12:20 pm in the dining room, Resident 66 was being fed by Treatment Nurse 2 (TN 2). TN 2 was sitting on a black stool about 1/2 foot above Resident 66 on the resident's right side. TN 2 was side to side with Resident 66 and looking down at the resident during feeding. During an interview on 2/24/2026 at 12:38 pm with TN 2, TN 2 stated Resident 66 was a feeder, someone who needed assistance with feeding. TN 2 stated, TN 2 was seated higher up since Resident 66's wheelchair was low and TN 2 was unable to lower the stool. TN 2 stated TN 2 could have used a lower chair to assist Resident 66 with eating at eye-level. TN 2 stated TN 2 was not at eye-level and was not facing Resident 66 because TN 2 was paying attention to the other residents in the dining room. During an interview on 2/26/2026 at 1:58 pm with the Director of Nursing (DON), the DON stated, for resident safety and engagement, residents should be fed by the nursing staff at eye-level and facing the resident to monitor how the resident tolerated the feeding. The DON stated labeling residents as feeders and feeding the resident while looking down on them was a dignity issue. During a review of the facility's policy and procedure (P&P) titled, Dignity and Privacy, revised 2/2026, the P&P indicated, it was the policy of the facility that all residents be treated with kindness, dignity, and respect. The P&P indicated, the staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.

Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for one of four sampled residents (Resident 80) by failing to ensure the resident's nasal cannula (NC- a flexible tube with two small prongs that sits in the nostrils to deliver oxygen) was not touching the floor. This deficient practice had the potential to result in infection to Resident 80. Findings: During a review of Resident 80's AR, the AR indicated Resident 80 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing food or liquids) and gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube [GT], through the abdomen and into the stomach for medication/feeding). During a review of Resident 80's MDS dated [DATE], the MDS indicated Resident 80's cognitive (ability to think and reason) skill for daily decision making was severely impaired (never/rarely made decisions). The MDS also indicated Resident 80 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review or Resident 80's Order Summary Report (OSR) dated 1/12/26, the OSR indicated continuous Oxygen at 2 liter per NC to keep oxygen at 92% every shift. During an observation inside Resident 80's room on 2/24/26 at 9:43 AM, Resident 80's NC tube was touching the floor. During a concurrent observation inside Resident 80's room on 2/24/26 at 1:57 PM, Resident 80's NC tube was still touching the floor. During an interview with the Infection Control Nurse (IPN) on 2/25/26 at 11:37 AM, the IPN stated if Resident 80's NC was touching the floor, it could result in an infection. The IPN stated the NC should not be touching the floor. The IPN stated, when not in use, the NC should be placed inside a bag and safely stored so it will not be touching the floor. During an interview with the Registered Nurse Supervisor (RNS) on 2/26/2026 at 7:18 AM, the RNS stated if Resident 80's NC was touching the floor, it was an infection control issue and was not sanitary. The RNS stated the resident's NC should not touch the floor and change every week or as needed. During an interview with the facility's Director of Nursing (DON) on 2/26/2026 at 1:32 PM, the DON stated Resident 80's NC should not be touching the floor for infection control. During a review of the facility's Policies and Procedures (P&P) titled, Use of Oxygen, revised 5/2007, the P&P indicated, It is the policy of this facility to promote resident safety in administering oxygen. The following guidelines will be observed in oxygen administration: The tubing should be kept off the floor.

Based on observation, interview, and record review the facility failed to provide and maintain dignity for two of two sampled residents (Residents 138 and 238) by failing to: a. Close Resident 138's privacy curtain and Resident 138's body was exposed and can be seen from the hallway. b. Close Resident 238's privacy curtain and Resident 238's upper extremities were exposed when Minimum Data Set Nurse (MDSN) checked the resident's surgical site. These deficient practices violated Residents 138 and 238's right to privacy. Findings: a. During a review of Resident 138's Admission Record (AR), the AR indicated Resident 138 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) and generalized muscle weakness. During a review of Resident 138's History and Physical (H&P, a formal assessment that a doctor performs for information about a patient's health) dated 11/28/2024, the H&P indicated Resident 138 had the capacity to understand and make decisions. During a review of Resident 138's Minimum Data Set (MDS, a resident assessment tool) dated 11/30/2024, the MDS indicated Resident 138 had clear speech, had the capacity to understand others and make self understood and had intact cognition. The MDS indicated Resident 138 was dependent (helper does all of the effort) for toilet hygiene and rolling left and right. During a concurrent interview and observation on 1/7/2025 at 9:28 am, in Resident 138's room, Resident 138 was lying in bed and the resident's above the knee to chest area was exposed. Resident 138's privacy curtain was not closed and Resident 138's exposed body part could be seen from the hallway. Certified Nursing Assistant 6 (CNA6) stated, CNA 6 forgot to close Resident 138's privacy curtain after CNA 6 prepared Resident 138 for a bed bath. CNA 6 stated, when providing bed bath, staff should close the privacy curtain for resident's privacy and to respect their dignity. 42781 b. During a review of Resident 238's AR, the AR indicated Resident 238 was admitted to the facility on [DATE] with diagnoses that included fracture (broken bone) of unspecified part of the neck of the right femur (thigh bone). During a concurrent interview and observation in Resident 238's room on 1/7/2025 at 9: 43 am, Resident 238 was awake, lying in bed. The MDSN opened Resident 238's gown to check Resident 238's surgical site on the right upper thigh. The MDSN did not close the privacy curtain to provide Resident 238 privacy exposing Resident 238's thigh. The MDSN stated, the resident's privacy curtain needed to be closed to provide privacy to Resident 238. During an interview on 1/8/2025 at 11:30 am with the facility's Director of Nursing (DON), the DON stated the resident's privacy curtain needed to be closed during resident care to maintain Resident 238's dignity and privacy. During a record review of the facility's Policy and Procedure (P&P) titled, Resident Rights reviewed on 1/2024, the P&P indicated residents shall be examined and treated in a manner that maintains the privacy of their bodies. The P&P indicated a closed door or drawn curtain shields the residents from passers-by.

Based on observation, interview, record review, the facility failed to provide pain management for one of seven sampled residents (Resident 1). For Resident 1, who had a language barrier, cancer and a broken spine, the facility did not provide the needed pain relief by: 1. Failing to implement Resident 1's pain plan of care by not assessing Resident 1's daily pain, not evaluating effectiveness of the pain medication, not administering pain medication as ordered, and not notifying Resident 1's attending physician (MD 1) about the uncontrolled pain, and the lack of ordered routine pain relief medication. 2. Failing to develop effective strategies to address Resident 1's need for pain management. 3. Failing to attend to Resident 1's calls for pain relief medication. 4. Failing to conduct an Interdisciplinary Team (IDT- a group of healthcare professionals from diverse healthcare fields providing care to the resident) meeting to discuss management of Resident 1's continuous unrelieved pain. As a result, on [DATE], at 12:45 p.m., after experiencing uncontrolled pain, Resident 1 committed suicide (intentionally causing one's own death) by placing a plastic bag over his head and suffocating (process of dying from being deprived of air or unable to breathe). Findings: A review of Resident 1's Record of Admission (Face Sheet) indicated Resident 1 was a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Record of Admission indicated Resident 1 spoke his primary (native) language and his English was poor. Resident 1's responsible party (DPOA 1) had a Durable Power of Attorney (DPOA - a legal document that grants an individual agent the legal authority to make decisions on behalf of another individual) for healthcare decisions. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's Care Plan, developed on [DATE], indicated Resident 1's risk for alteration in comfort related to episodes of pain or generalized discomfort associated with multiple medical conditions and diagnosis. The goal was for Resident 1 to have a resolution of pain or reach the pain level of comfort within 30 minutes of intervention. The care plan indicated Resident 1 verbalized pain and the occasion when pain was most likely to occur was during activities of daily living (ADLs - bathing, transfers, walking, repositioning, and personal hygiene) and during exercises. The care plan interventions included assessing pain intensity level, frequency, site, and factors that triggered the pain each shift; handling him gently during care, administering medications as ordered, monitoring and documenting effectiveness of pain medication, and documenting and notifying the physician of increasing or unrelieved pain. A review of Resident 1's care plan, developed on [DATE], for Resident 1's at risk for pathological fracture (bone brake caused by disease that led to weakness of the bone structure) had interventions that included handling Resident 1 gently during care, assessing pain, providing two-person assist during care, and answering Resident's call light promptly. A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-planning tool), dated [DATE], indicated Resident 1 needed and wanted an interpreter (a translator) to communicate with the healthcare staff in his preferred language, had clear speech, was usually able to understand others, and could make himself understand. Resident 1 was unable to walk, and needed extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's physician's orders [REDACTED].#3 (300 mg of [MEDICATION NAME] with 30 mg [MEDICATION NAME], a narcotic pain medication), one tablet, by mouth every six hours PRN for severe pain. On [DATE] at 4:38 p.m., during an observation, Resident 1 was in bed, covered with a white sheet. There were handwritten notes in Resident 1's native language on the bedside table. Police Officer 1, who was present at Resident 1's bedside, stated that Resident 1's body was covered with a white sheet. Registered Nurse 1 (RN 1), who was at Resident 1's bedside, stated that the handwritten notes belonged to Resident 1. On [DATE] at 4:41 p.m., during an interview, the Administrator and the Director of Nursing (DON) were asked to find a staff member to read and translate Resident 1's handwritten notes but both stated there was no staff that could understand and read Resident 1's language. The Administrator and DON stated the facility had only Licensed Vocational Nurse 5 (LVN 5), who was able to read and speak Resident 1's language but LVN 5 was not available at the time. On [DATE] at 4:47 p.m., during an interview, Resident 7 (Resident 1's roommate) stated he (Resident 7) heard Resident 1 moaning and complaining of pain every day and staff would take over twenty minutes to attend to Resident 1's request for pain relief medication. A review of Resident 7's MDS, dated [DATE], indicated Resident 7's cognitive pattern was moderately impaired, his hearing was adequate, was able to make his needs known, and was able to understand others. A review of Resident 1's handwritten notes translated into English by Evaluator 2 indicated: - [DATE]. The mean on duty woman purposely delayed delivering the medicine for 75 minutes. Whatever I encountered and endured it is only in this life. I just want to write down a word to the living people ---SAD! -[DATE]. There was a new male worker with diamond earring who suddenly came to my bedside (around 5 p.m.) found my bed controller and put my head to the lowest point (I was suffering, and it was painful). I thought he was going to examine something, but he left right away. Twenty some minutes later he delivered dinner without saying anything. -19th around 4 a.m., there was a tall, strong female worker in green clothes who brought me pain medication and a small cup of cold water. She said there is no hot water, but in fact, there is hot water 24 hours a day in the facility. - 23rd 4 a.m. They were supposed to bring my pain medication, but this bad-hearted nurse just did not want to bring the pain medication. I waited for 70 minutes then I modeled what other people do - I yelled aloud saying, Where's my pain medication? For sure, the bad-hearted woman came with pain medication right away and blamed me for using the call bell and yelling aloud. Does this kind of young woman work as a nurse? These young girls will get what they deserved. Abusing a sick old man is illegal and they will go to jail. A review of the facility's Device (call light) Activity Report, dated [DATE], and timed at 8:45:25 p.m., indicated Resident 1's call light was on until 9:14:23 p.m. (28 minutes and 58 seconds). On [DATE] at 5:11 p.m., during an interview, Restorative Nursing Assistant 1 (RNA 1) stated that on [DATE] at 11:55 a.m., she found Resident 1 lying in bed with a clear color plastic bag over his head. She called for help and LVN 1 removed the plastic bag from Resident 1's head. On [DATE] at 5:35 p.m., during an interview, LVN 1 stated that Resident 1 was a quiet person and spoke very little English. LVN 1 stated that she used hand gestures to communicate. LVN 1 stated Resident 1 could answer yes or no to questions. LVN 1 stated Resident 1 like hot water when taking his medications. LVN 1 stated she was not aware if Resident 1 was sad or had [MEDICAL CONDITION]. On [DATE] at 7:07 p.m., during an interview, DPOA 1 stated Resident 1 complained about the delay in the administration of pain relief medication and pain not controlled. DPOA 1 stated he requested MD 1 to prescribe routine pain relief medication (could not remember the date) but this was not done. On [DATE] at 8 p.m., a review of the facility's video footage with the Administrator, dated [DATE], timed at 4:56.55 p.m., showed that a male certified nursing assistant (CNA) wearing earrings, a baseball cap, and regular clothes entered Resident 1's room. The Administrator identified the male CNA as CNA 1. The ADM stated that CNA 1 wore earrings as indicated in Resident 1's handwritten notes. On [DATE] at 7 a.m., during an interview, CNA 3 stated that Resident 1 had pain every time he was repositioned and he (CNA 3) notified the licensed nurses about Resident 1's complaints of pain. On [DATE] at 8:20 a.m., during an interview, LVN 2 stated Resident 1 used his call light to request for pain relief medication and that staff was supposed to answer the call lights as soon as possible. On [DATE] from 12:35 p.m. to 1:03 p.m., during an interview, CNA 1 stated that he wore earrings on [DATE]. CNA 1 stated that he entered Resident 1's room on [DATE] to reposition Resident 1 in bed. CNA 1 stated that he put Resident 1's bed flat, Resident 1 was in pain, and that Resident 1 had facial grimacing and was moaning. CNA 1 stated that he repositioned Resident 1 without help. CNA 1 stated that Resident 1 was always in pain and that it was usual for Resident 1 to have pain. CNA 1 stated that on [DATE], he (CNA 1) did not inform the licensed nurses of Resident 1's pain. On [DATE] at 3:36 p.m., during a telephone interview, MD 1 stated the licensed nurses did not inform him of Resident 1's daily pain. MD 1 stated DPOA 1 requested routine pain relief medication (date when request was made not mentioned) but that he did not order it because Resident 1 was not in pain and routine pain medication could cause constipation (difficulty in emptying the bowels). On [DATE] at 3:52 p.m., during an interview with RN 2 and a concurrent review of Resident 1's Medication Administration Record [REDACTED]. Resident 1 received 38 doses of [MEDICATION NAME] but there was no documentation if the [MEDICATION NAME] was effective each time it was given. On [DATE] at 5:21 a.m. and on [DATE] at 4:39 a.m., Resident 1 received [MEDICATION NAME] 650 mg for moderate pain instead of 1000 mg as ordered. RN 2 stated, after reviewing Resident 1's clinical record, there was no documentation the licensed nurses reported to MD 1 the lack of pain control and daily complaints of pain. RN 2 stated the licensed nurses did not give the correct dose of [MEDICATION NAME] based on Resident 1's pain rate. RN 2 stated the IDT did not address Resident 1's unmanaged pain. On [DATE] at 2:20 p.m., during a telephone interview, Medical Director 2 (MD 2), stated the licensed nurses have to address every resident's pain and inform the physician when pain is not controlled. A review of Resident 1's Certificate of Death indicated Resident 1 died on [DATE] at 12:45 p.m. with asphyxia (condition caused by insufficient intake of oxygen) and suffocation (process of dying from being deprived of air or unable to breathe) as the immediate cause of death. The manner of death was suicide, self-inflicted suffocation by placing a plastic bag over the head. A review of the facility's policy and procedure titled, Pain-Clinical Protocol, with a revised date of ,[DATE], indicated the physician and staff would identify individuals who have pain and who are at risk for having pain including a review of each person's known [DIAGNOSES REDACTED]. Nursing staff would assess each individual for pain upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain. Staff would evaluate and report how much and how often the individuals asked for PRN pain medication and depending on the severity and location of pain. Staff would reassess the individual's pain and related consequences at regular intervals, and review frequency and intensity of pain, ability of performing activities of daily living (ADLs), sleep patterns, mood, behavior, and participation in activities. A review of the facility's policy and procedure titled, Nursing Services, with a revised date of [DATE], indicated medications and treatments should be administered as prescribed and recorded in the resident's record. A review of the undated facility's policy and procedure titled, Pain Management, indicated the facility was dedicated to a pain management program that was individualized according to the resident's needs and updated as needed. Care planning was an interdisciplinary effort that should include the resident, family members or significant others, the physician, and other members of the healthcare team. A review of the facility's undated policy and procedure titled, Call System, indicated to answer call bells promptly, listen to resident's request, and return to resident with item or reply promptly.

Based on interview and record review, the facility failed to inform the Physician of a change in condition for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure. For Resident 1, the resident displayed an increase in confusion, restlessness manifested by trying to get out of wheelchair, and nursing staff failed to inform the resident's Physician regarding the change in condition for an evaluation of the current treatment plan. As the result, on 1/14/19, Resident 1 fell after getting out of the wheelchair, sustaining a head injury with bleeding. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where the resident had a repair of the scalp laceration with four staples. Findings: A review of the Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's Care Plan developed on 6/2/18 for the resident's fall risk indicated for staff to move Resident 1 close to the Nurses' Station for easy visibility and added safety. A review of the Minimum Data Set (MDS - a standardized assessment and care-planning tool) dated 12/6/18, indicated Resident 1 had severe impairment in cognition (impaired memory and inability to make decisions), needed extensive assistance (resident involved in actives and staff provide weight-bearing- support) with bed mobility, transfers, walking, dressing, toilet use, and personal hygiene with one-person assist. Resident 1's balance during transitions and walking was not steady and was only able to stabilize with staff assistance. A review of the Fall Risk Assessment, dated 12/6/18, indicated Resident 1 was at a high risk for falls with the score of 18 (total score above 10 represents high risk). A review of the Medication Administration Record [REDACTED] 1/1/19 - 1 episode during the 11 p.m. to 7 a.m. shift 1/5/19 - 2 episodes during the 11 p.m. to 7 a.m. shift 1/6/19 - 4 episodes during the 11 p.m. to 7 a.m. shift and 2 episodes during the 3 p.m. to 11 p.m. shift 1/9/19 - 1 episode during the 11 p.m. to 7 a.m. shift and 2 episodes during 3 p.m. to 11 p.m. shift 1/10/19 - 3 episodes during 3 p.m. 11 p.m. shift 1/11/19 - 10 episodes during the 11 p.m. to 7 a.m. shift. 1/12/19 - 12 episodes during the 11 p.m. to 7 a.m. shift. 1/14/19 - 1 episode during the 11 p.m. to 7 a.m. shift, and 6 episodes during 3 p.m. to 11 p.m. shift A review of the Advanced Situation, Background, Assessment, and Recommendation (SBAR) Change of Condition Documentation, dated 1/14/19, timed at 1:10 a.m., indicated Resident 1 had a fall with altered level of consciousness. Resident 1 got up unassisted from the wheelchair and fell to the floor, sustaining a [MEDICAL CONDITION]. A review of Resident 1's Physician Order, dated 1/14/19, indicated to transfer Resident 1 to GACH 1 Trauma Center via paramedics for status [REDACTED]. A review of the GACH's Discharge Documentation, dated 1/14/19, indicated Resident 1 had a right scalp laceration. The documentation indicated Resident 1 received four staples in the Emergency Department to repair the scalp laceration. Resident 1 was readmitted to the facility on the same day. A review of Resident 1's Physician order [REDACTED]. 1. Provide non-pharmacological interventions such as music, activity, exercise 1:1 conversation, verbal cues to decrease Resident 1's anxiety. 2. Administer [MEDICATION NAME] (medication to treat anxiety), 0.5 milligram, one tablet by mouth every shift as needed for anxiety manifested by inability for Resident 1 to relax. 3. Provide physical therapy (the treatment of [REDACTED]. During an interview on 2/22/19 at 8:18 a.m., Certified Nursing Assistant 3 (CNA 3) stated Resident 1 did not have a behavior of trying to get out of bed and wheelchair until about one to two weeks before the fall. Resident 1 started to have more confusion and increased restlessness manifested by attempting to get up from the wheelchair. During an interview on 2/22/19 at 11:12 a.m., Licensed Vocational Nurse 1 (LVN 1) stated few days prior to the fall incident, Resident 1 was getting more agitated and kept looking for a family member, who had passed away. On 2/22/19 at 11:52 a.m., during a review of the Medication Administration Record [REDACTED]. RN 1 stated since there have been changes in the usual number of Resident 1 attempting to get up from wheelchair, the Physician should have been notified to re-evaluate and to develop new interventions such as providing 1:1 supervision (staff member can only leave the resident if there is another person to relieve them) for safety measures. During a telephone interview on 2/27/19 at 1:32 p.m., CNA 7 stated on 1/14/19, prior to the fall incident, he was monitoring Resident 1 in the hallway but he left the resident to attend to the call light of another resident. CNA 7 stated about five minutes later, Resident 1's wheelchair alarm went off and the resident was seen lying on the floor. CNA 7 stated he was not aware that Resident 1 had an increase in episodes of getting up from the wheelchair. During a telephone interview on 2/28/19 at 11 a.m., RN 2 stated Resident 1 was notably confused, thinking there was flooding in the facility, during the start of shift on 1/14/19 and Resident 1 should have been supervised while sitting on the wheelchair. During a telephone interview on 2/28/19 at 1:42 p.m., LVN 5 stated Resident 1 had an increase in confusion two to three days prior to the fall incident. LVN 5 stated she should have called Resident 1's Physician to obtain a new order for a medication that could have alleviated Resident 1's confusion and restlessness, and to increase supervision. On 3/1/19 at 2 p.m., during a review of the 11 p.m. to 7 a.m. shift staff assignment dated 1/13/19 -1/14/19 and a concurrent interview, the Director of Staff Development (DSD) stated CNA 7 was assigned to take care of 18 residents. On 3/1/19 at 3:24 p.m., during a review of Resident 1's medical record and concurrent interview with the Assistant Director of Nursing (ADON), she stated facility's staff (in general) should have provided supervision to Resident 1 due to Resident 1's increased episodes of getting up from the wheelchair. The ADON stated there was no documented evidence that Resident 1's Physician was notified and the care plan was updated to include new interventions when Resident 1 had a change in condition. A review of the facility's policy and procedures, titled Falls and Fall Risk, Managing, dated 12/2007, indicated staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling based on previous evaluations and current data. The policy indicated staff would identify and implement relevant interventions to try to minimize serious consequences of falling in conjunction with the Attending Physician. A review of the facility's policy and procedures, titled Change in Resident Condition, dated 6/17/10, indicated all changes in resident condition must be documented in the medical record and communicated to the physician and resident/responsible party. The policy also indicated the physician's recommendations must be documented on the Advanced SBAR Change in Condition Documentation form and the current care plan must be updated. A review of the facility's policy and procedures, titled, Safety and Supervision of Residents, dated 12/2007, indicated the type and frequency of resident supervision may vary among residents and over time for the same resident. The policy indicated resident supervision might need to be increased when there is a change in resident's condition.

Based on observation, interview, and record review, the facility failed to implements it's infection control policy and procedure for 12 of 49 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) by failing to: 1. Establish a surveillance system that allows the facility to track, analyze and interpret the data, and identify a concern that there was an unusual increasing number of residents, including newly admitted residents, with new and ongoing rashes every month from (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). 2. Screen newly admitted residents for scabies (a contagious skin disease marked by itching and small raised spots, caused by the itch mite) during the initial assessment (especially if admitted from another healthcare facility) and place the newly admitted residents in contact isolation until examined for scabies. According to the Director of Nursing (DON 1), the facility did not have a policy to screen newly admitted residents for scabies. 3. Identify and prepare a line listing (a list that includes information about time, person, and place to be organized and reviewed to keep track of different categories of cases) of symptomatic (showing characteristic signs of an illness) residents (Residents 2 and 3) and healthcare workers. According to DON 1, that the facility did not prepare a line listing for Residents 2 and 3, after the residents were diagnosed with [REDACTED]. 4. Identify and prepare a line listing of all residents who had direct contact to residents diagnosed with [REDACTED]. Evaluate contacts for scabies. According to DON 1, the facility did not prepare a line listing of Residents 1, 2 and 3's contacts after acquiring information of the residents' [DIAGNOSES REDACTED]. 5. Assess the skin of the residents (Residents 4, 8, 9, 10, 11, and 12), who resided in the same ward (North Station) as Resident 1, 2, and 3 and document the skin assessments on the residents' medical records. According to DON 1, the facility did not do a skin assessment sweep (head to toe skin assessment involving all residents on a certain location) on the affected units when Residents 2 and 3 were diagnosed with [REDACTED]. 6. Identify an outbreak when at least two clinically suspect (included as a probable case affected in an outbreak) cases (Residents 5, 6, and 7) were treated with [MEDICATION NAME] cream 5% (a scabicide or a medication used to treat scabies. Brand name is [MEDICATION NAME]) during a two (2) week period of time. Resident 5 was treated with [MEDICATION NAME] 5% cream on 5/25/18, and Resident 6 and Resident 7 on 5/26/18. 7. Report an outbreak to the Public Health Morbidity Unit (control unit responsible in receiving and reporting cases of communicable diseases and outbreaks). According to DON 1, the occurrences of rashes were not reported because there was only one resident (Resident 3), who was a confirmed case of scabies through skin scraping (removal of a skin tissue indicated to screen for infectious organisms). 8. Administer [MEDICATION NAME] cream 5% on Resident 4 on 1/17/18 as ordered. These deficient practices resulted in unrelieved itching for Residents 1, 2, 3, 4, 5, 6, and 7; increased agitation and aggressiveness for Resident 2; development of excoriations (a damage to the skin due to skin picking) to hands, bilateral upper extremities, back, and flank of Resident 3; and inability or loss of sleep of Resident 7 because of the terrible itch; and spread of infection. An immediate jeopardy (IJ) was identified for the facility's failure to establish and ensure implementation of an infection control program that prevented the spread of infection for the residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49). On 6/8/18, at 5:30 PM, an immediate jeopardy was declared and the administrator and DON 1 were verbally notified of the serious findings that resulted in the immediate threat to the health and safety for all residents in the facility when the facility failed to identify the increasing number of residents with rashes for the past seven months (November (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR)) and report an outbreak when three residents (Residents 5, 6, and 7) were treated with [MEDICATION NAME] 5% cream during a two week period. On 6/9/18, at 4:30 PM, the IJ was abated after the administrator and DON 1 presented their immediate plan of correction (P[NAME]): a. Skin sweep conducted to all residents on 6/9/18. b. Existing residents with rash identified using the facility skin rash tracking. c. Dermatologist contacted. Skin condition of identified residents discussed and obtained orders for skin scraping and treatment of [REDACTED]. d. Roommates of residents with rash informed of need for [MEDICATION NAME] treatment related to possible exposure to scabies. treatment of [REDACTED]. e. [MEDICATION NAME] treatment of [REDACTED]. f. Started the contact line listing for residents and healthcare workers to track scabies case/contact utilizing the contact line listing form provided in the CDC guidelines. g. Facility mapping for rashes was started on 6/8/18. h. Facilitate screenings of newly admitted residents for scabies to promote early identification and immediate treatment of [REDACTED]. i. In-services was conducted regarding scabies prevention and control per CDC guidelines and Unusual Occurrence reporting. j. Daily documentation of skin assessments to all residents until no new cases for four weeks. k. All facility employees denying treatment would be documented with signature and date. Findings: During an interview, on 6/7/18, at 2 PM, the facility's Infection Preventionist 1 (IP 1) stated the treatment nurses tracks and documents the residents with symptoms of rashes in the facility. During an interview, on 6/7/18 at 4:20 PM, DON 1 was asked if a contact line listing was developed after Resident 3 was tested positive for scabies on 12/12/17 by skin scraping and Resident 2 was clinically diagnosed (a [DIAGNOSES REDACTED]. DON 1 stated there was no contact line listing developed for Residents 2 and 3. DON 1 provided a handwritten list of residents in a piece of paper titled, Rashes, for the months of (MONTH) (YEAR) (5 residents), (MONTH) (YEAR) (11 residents), (MONTH) (YEAR) (7 residents), (MONTH) (YEAR) (10 residents), (MONTH) (YEAR) (12 residents), (MONTH) (YEAR) (10 residents), and (MONTH) (YEAR) (6 residents). DON 1 handed a record titled, Skin Rashes Tracking, dated 5/30/18 with 12 residents on the list. During an interview, on 6/8/18, at 5:38 PM, DON 1 stated she did not believe Resident 2's rashes had a definitive [DIAGNOSES REDACTED]. DON 1 stated that the GACH treated Resident 2's rashes with a scabicide (a medication used to treat scabies) agent (on 1/17/18) because this was the easiest thing to do in the GACH. During an interview, on 6/9/18, at 2:15 PM, DON 1 stated that Resident 3's skin scraping was performed (on 12/12/17) in the facility and the test result was positive for scabies. DON 1 was asked if the facility conducted a skin assessment sweep for all residents when Resident 3 was tested positive for scabies on 12/12/17. DON 1 stated that the treatment nurse conducted body checks (skin assessments) once a week. DON 1 stated that the facility continued to conduct weekly skin assessments after Resident 2 was transferred and clinically diagnosed with [REDACTED]. During an interview, on 6/9/18 at 2:15 PM, DON 1 stated the facility received a telephone call on 2/14/18, from Resident 1's family complaining that Resident 1 had a worsening skin condition. Resident 1's medical records indicated Resident 1 developed rashes on the chest area two days before discharged home from the facility on 1/20/18. Resident 1's family informed the DON that Resident 1 was (clinically) diagnosed with [REDACTED]. There was no documented evidence that the facility conducted daily skin assessments and evaluate the facility's surveillance system after Resident 3 was tested positive for scabies on 12/12/17 in the facility, and after learning that Resident 2 was clinically diagnosed with [REDACTED]. During an interview, on 6/9/18, at 2:15 PM, DON 1 stated the facility did not have a separate tracking log for residents with skin rash prior to 5/30/18. DON 1 stated a previous visit by an evaluator prompted her to develop a separate tracking for skin rashes titled, Skin Rashes Tracking, on 5/30/18. During an interview, on 6/9/18, at 3:36 PM, DON 1 was asked if the facility had a system of analyzing information if the number of residents with rashes were increasing or decreasing. DON 1 stated the facility meet every week for an interdisciplinary team (IDT, a team of professionals from different fields) meeting to discuss a particular resident's general skin condition. A review and analysis of the facility's handwritten list of residents with rashes and residents' individual medical records from (MONTH) (YEAR) to (MONTH) (YEAR) (11/2017 to 6/2018) indicated that the handwritten list contained inaccurate information. Residents 4 and 11 were not included in the 11/2017 to 6/2018 handwritten list. The list indicated: a. On (MONTH) (YEAR), five residents had rashes (Residents 2, 6, 14, 15, and 16). The list did not include Resident 3. Resident 3 received [MEDICATION NAME] 5% cream on 11/30/17. b. On (MONTH) (YEAR), 11 residents had rashes (Residents 2, 3, 6, 10, 12, 17, 18, 19, 20, 21, and 22). The list indicated there were nine new residents with rashes and one resident with ongoing rash. A review of the individual residents' medical records indicated there should be 3 residents with ongoing rash (Resident 2, 3 and 6). c. On (MONTH) (YEAR), seven residents had rashes (Residents 1, 2, 3, 10, 13, 19, and 23). The list indicated there were three new residents with rashes and four residents with ongoing rashes. d. On (MONTH) (YEAR), ten residents had rashes (Residents 5, 24, 25, 26, 27, 28, 29, 30, 31, and 32). The list indicated there were three new residents with rashes and seven residents with rashes present upon admission to the facility. There were no documentation how many residents with ongoing rashes on (MONTH) (YEAR). e. On (MONTH) (YEAR), 12 residents had rashes (Residents 5, 10, 24, 25, 31, 33, 34, 35, 36, 37, 38, and 39). There were two new residents with rashes, six residents with rashes present on admission to the facility, and five residents with ongoing rashes. f. On (MONTH) (YEAR), 10 residents had rashes (Residents 7, 8, 26, 40, 41, 42, 44, 45, 46, and 47). There were five new residents with rashes, four residents with rashes present on admission, and two residents with ongoing rashes. The (MONTH) list did not include Resident 4 whose first appearance of rashes were documented on 4/24/18 and records did not indicate that [MEDICATION NAME] (an action taken to prevent a disease) treatment of [REDACTED]. g. On (MONTH) 30, (YEAR), 12 residents had rashes (Residents 6, 7, 25, 26, 30, 31, 39, 40, 42, 43, 48, and 49). There were one new resident with a rash, one resident with a rash present on admission, and eight residents with ongoing rashes. The (MONTH) list did not include Resident 4 who had ongoing rash in May. There were two residents, (Residents 6 and 7) who received [MEDICATION NAME] cream 5% and Ivermectin (a medication in tablet form that is used to treat scabies) for suspicious rashes in (MONTH) with a dermatology consult on 5/25/18. Resident 6 and 7 received [MEDICATION NAME] on 5/26/18, within a two week period. h. On (MONTH) (YEAR), six residents had ongoing rashes (Residents 25, 26, 42, 43, 44, and 48). The (MONTH) list did not include Resident 4 who had ongoing rash, had an order for [REDACTED]. During an interview, on 6/7/18 at 4:30 PM, the DON 1 stated the facility did not have its own policy and procedure for investigation and controlling outbreaks (scabies), which included screening newly admitted residents for scabies during the initial assessment. The DON stated the facility follows the guidelines set by the Communicable Disease Control (CDC), dated (MONTH) 2008 and a Scabies Fact Sheet, dated Year 1999. The DON stated that it was not reported to the Department or the local health officer (Public Morbidity Unit) because there was only one confirmed case of scabies through skin scraping. A review of the scabies outbreak guideline provided by the facility titled Management of Scabies Outbreaks in California Healthcare Facilities, dated (MONTH) 2008, received from DON 1 on 6/7/18, indicated the following information: a. An Outbreak can be defined as an increase in the incidence of new cases above baseline within a defined period of time and within a defined geographical location. An Outbreak of Scabies is defined as two or more confirmed (positive skin scraping) cases of scabies identified during a two week period of time. One confirmed case and at least two clinically suspect cases identified during a two week period of time. At least two clinically suspect cases identified during a two week period of time. b. All outbreaks should be reported immediately to both the local health officer and to the Licensing and Certification District Office. c. All hospitals should develop, implement, and periodically evaluate a scabies prevention policy and procedure. d. It may take as long as two to six weeks following exposure before symptoms of scabies infestation are apparent. d. All hospitals should have a scabies outbreak management plan in writing, reviewed, and approved by the hospital's infection control committee. e. The infection control practitioner should develop a surveillance data collection form for specifically investigating the scabies outbreak. f. Analysis of the surveillance data collected on healthcare workers and patients who were diagnosed may assist the infection control committee in making the decision about what method of [MEDICATION NAME] (preventive measure) is most applicable to the situation. 1. Resident 2 A review of Resident 2's Record of Admission indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident 2 was discharged from the facility on 1/29/18. A review of Resident 2's Minimum Data Set (MDS, a care area assessment and screening tool), dated 10/20/17, indicated that Resident 2 was not able to communicate. The MDS indicated that Resident 2 presented with a worsening wandering behavior and required limited supervision with walking and locomotion (how resident moves in between locations). A review of Resident 2's Advanced SBAR (Situation; Background; Assessment; Recommendation) Change of Condition Documentations indicated the following conditions: a. On 10/28/17, Resident 2 was observed with rashes to the chest and back area. A review of Resident 2's Treatment Records dated 10/29/17, indicated Resident 2 was treated with an antifungal cream for the chest and back rashes ordered for 21 days. b. On 11/24/17, Resident 2 was observed with raised rashes to bilateral thighs and the resident had complaints of itchiness. A review of Resident 2's Non-Pressure Sore Skin Progress Report dated 11/4/17 and 11/11/17, indicated Resident 2 was observed scratching and itchiness to the scattered raised rashes to the chest and back areas. c. On 12/14/17, Resident 2 was observed with rashes to the chest area extending to both shoulders. The Interdisciplinary (involving more than one expert) Progress Notes, dated 12/13/17, indicated that Resident 2 had been observed with increased episodes of scratching. The Interdisciplinary Progress Notes dated 12/21/17, indicated Resident 2 wandered in other resident's rooms and laid in their beds (scabies mites could be transmitted from infested items such as bedding, clothes, and furniture). d. On 1/17/18, Resident 2 was observed with increased agitation and aggressiveness. The SBAR indicated that the resident was placed on contact isolation for body rashes. A review of Resident 2's Physician and Telephone Orders, dated 1/17/18, indicated an order to apply one time on Resident 2's neck to toe [MEDICATION NAME] cream 5%, leave the [MEDICATION NAME] cream for eight hours, and then wash out for [MEDICATION NAME]. A review of Resident 2's Interdisciplinary Progress Notes, dated 1/17/18, indicated Treatment Nurse 1 (Tx 1) applied the [MEDICATION NAME] cream 5% at 5 PM. The progress notes indicated that Resident 2 was observed with increased agitation and aggressiveness with staff. Resident 2 was transferred to GACH for evaluation of increased agitation and aggressiveness (since Resident 2 was not able to communicate coherently). A review of Resident 2's GACH History and Physical (H&P), dated 1/17/18, indicated a chief complaint of agitation and confusion. The H&P indicated that Resident 2 arrived in GACH ambulating in agitated fashion. The assessment and plan indicated [DIAGNOSES REDACTED]. The plan indicated Resident 2 would be treated for [REDACTED]. A review of Resident 2's Interdisciplinary Progress Notes, dated 1/20/18, indicated that Resident 2 was readmitted to the facility on [DATE]. The interdisciplinary notes indicated that the resident continued to have episodes of wandering around the facility and into other residents' rooms. During an interview, on 6/7/18, at 4 PM, Registered Nurse 1 (RN 1) stated that Resident 2 was completely confused and speaks Spanish only. RN 1 stated that Resident 2 had behavioral issues of wandering around the facility and other residents' rooms. RN 1 stated, during a concurrent record review, that Resident 2 did not have rashes when originally admitted to the facility on [DATE], and appearance of rashes to the chest and back areas were first observed on 10/29/17. RN 1 stated that when the physician ordered [MEDICATION NAME] cream for both Residents 2 and 3 for [MEDICATION NAME], the physician was suspecting the generalized rashes could be scabies. 2. Resident 4, roommate of Resident 2 A review of Resident 4's Record of Admission indicated Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record indicated that Resident 4 was a roommate of Resident 2 when Resident 2 was clinically diagnosed with [REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated Resident 4's cognition was intact and the resident required extensive assistance (resident involved in activity, staff provided weight bearing support) with bed mobility and transfer. The MDS indicated Resident 4 required limited assistance for wheelchair movement. A review of Resident 4's Physician and Telephone Orders, dated 1/17/18, indicated an order to apply on Resident 4 one dose of [MEDICATION NAME] cream 5% topically (apply on the affected skin area) from neck to toes for [MEDICATION NAME]. There was no documented evidence on Resident 4's Treatment Records and Interdisciplinary Progress Notes that [MEDICATION NAME] 5% cream was applied on Resident 4 on 1/17/18. During a concurrent interview and record review of Resident 4's medical records with RN 3, there was no documented evidence that Resident 4 had skin rashes on (MONTH) (YEAR). The records did not indicate ongoing skin assessments was conducted by licensed nurses to determine signs and symptoms of scabies after the physician ordered the [MEDICATION NAME] treatment of [REDACTED]. RN 3 stated that the facility's practice was to monitor the resident after the application of the [MEDICATION NAME] 5% cream for side effects and appearance of rashes. A review of Resident 4's Interdisciplinary Progress Notes, dated 4/24/18, indicated that a certified nurse assistant (unknown) reported an observation of scattered raised brown rashes in Resident 4's bilateral lower extremities. A review of Resident 4's Physician order [REDACTED]. Patients often present with multiple excoriated [MEDICAL CONDITION] caused by scratching) to the right thigh and knee area. The dermatologist's Physician order [REDACTED]. On 6/12/18, the dermatologist's Physician order [REDACTED]. A review of Resident 4's Physician Telephone Orders, dated 6/9/18, indicated an order for [REDACTED]. A review of Resident 4's Laboratory Report, dated 6/9/18, indicated there was no sarcoptes scabei (scabies mites) seen on Resident 4's skin sample. 3. Resident 3 A review of Resident 3's Record of Admissions indicated Resident 3's readmitted s of 10/24/17 and 12/6/17, with [DIAGNOSES REDACTED]. The record indicated that Resident 3 was discharged to the facility on [DATE]. A review of Resident 3's MDS, dated [DATE], indicated that Resident 3 was able to communicate and had a moderately impaired cognition (decisions poor; cues/supervision is required). The MDS indicated that Resident 3 required extensive assistance with activities of daily living. A review of Resident 3's Non-Pressure Sore Skin Problem Report, dated 11/12/17, indicated that Resident 3 had slightly raised rashes to her left upper arm. On 11/16/17, Resident 3 had more rashes on her left breast. The report indicated on 11/18/17, Resident 3 had rashes on the left side of her chest and the rashes were reclassified to [DIAGNOSES REDACTED] after a dermatology consult. A review of Resident 3's Physician and Telephone Orders, dated 11/30/17, indicated to apply [MEDICATION NAME] 5% cream one time, topically from neck to toes, leave on for 12 hours, then rinse, for [MEDICATION NAME]. A review of Resident 3's Interdisciplinary Progress Notes, dated 11/30/17, indicated that the resident received [MEDICATION NAME] cream 5% for the spread of pruritic [MEDICAL CONDITION] in different areas of resident's body. The Treatment Record also indicated that [MEDICATION NAME] cream was applied to Resident 3 on 11/30/17. During an interview, on 6/7/18, at 2:10 PM, RN 1 was asked why Resident 3's physician ordered [MEDICATION NAME] cream 5% to be applied topically for [MEDICATION NAME], on 11/30/17. RN 1 stated that the physician ordered [MEDICATION NAME] cream for Resident 3's generalized rashes because he was suspicious of the resident having scabies. A review of Resident 3's Non-Pressure Sore Skin Problem Report, dated 12/7/17, indicated that Resident 3 was observed with multiple pustules (a bulge in the skin containing a yellowing fluid called pus) to her right hip up to her right lower back. The report, dated 12/11/17, indicated that the attending wound care physician stated that the resident's generalized body rashes were suspicious for scabies with resident complaining of itching. The report indicated Resident 3 received [MEDICATION NAME] cream 5%, which was applied from her neck to her toes. A review of Resident 3's Surgical and Wound Care Progress Note Details, dated 12/11/17, indicated that Resident 3 had excoriations (a damage to the skin due to skin picking) to hands, bilateral upper extremities, back, flank, and had complaints of itchiness. The progress note indicated that Resident 3 received [MEDICATION NAME] cream two weeks ago (on 11/30/17) secondary to suspicious for scabies. The progress note indicated the wound care physician recommended skin scraping (a skin test to diagnose parasitic infections, such as scabies) and [MEDICATION NAME] treatment, including contact isolation until skin-scraping test results was available. A review of the facility's Isolation Tracking Log for the month of (MONTH) (YEAR) indicated Resident 3 was placed on contact isolation because of a suspicious rash on 12/11/17 and was treated with [MEDICATION NAME] cream on the same day. A review of Resident 3's Laboratory Report, dated 12/12/17, indicated the skin scraping test result indicated Resident 3's skin sample had sarcoptes scabiei (scabies mites). 4. Resident 1 A review of Resident 1's Record of Admission indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Initial Assessment, dated 10/4/17, indicated Resident 1 did not have a rash at admission. A review of Resident 1's MDS, dated [DATE], indicated Resident 1's communication and cognition was intact. The MDS indicated Resident 1 required extensive assistance with bed mobility, transfers, dressing, and locomotion in and out of her room. A review of Resident 1's Interdisciplinary Progress Notes, dated 1/20/18, indicated that Resident 1 developed scattered, slightly raised red rashes on her chest area. The progress note indicated that the attending physician ordered to apply [MEDICATION NAME] 1% ointment topically daily for 14 days. On 1/22/18, the progress note indicated Resident 1 had multiple discoloration to bilateral upper extremities, including the chest area. A review of Resident 1's medical records indicated Resident 1 was discharged to home with home health care on 1/22/18. A review of the home health care provider's document titled Resumption of Care dated 2/5/18, indicated Resident 1's Integumentary Status (skin condition) was dry and had rashes. The notes indicated that resident was observed with rashes to the buttocks and low back that appeared to be [MEDICAL CONDITION] (skin inflammation) in nature. A review of Resident 1's home health care provider's document titled, Home Health Aide Visit Note, dated 2/14/18, indicated that Resident 1 was observed with rashes to the chest, arms, and back area. A review of Resident 1's home health care provider's document titled, Communication Note, dated 2/19/18, indicated that Resident 1 was agitated and itching from a rash. A review of Resident 1's Skilled Nursing Visit documentation from the home health care provider's registered nurse (unidentified HHRN), dated 2/23/18, indicated that Resident 1's attending physician visited the resident's home on 2/22/18 and ordered to apply [MEDICATION NAME] cream 5% for the rashes. The HHRN indicated in the notes that Resident 1 had itching and scabies all over the body. A review of Resident 1's home health care provider's document titled, Physician Order, indicated Resident 1 was diagnosed with [REDACTED]. 5. Resident 7 A review of Resident 7's Record of Admission indicated Resident 7 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 7's MDS dated [DATE], indicated Resident 7's communication and cognition were intact. The MDS indicated Resident 7 required extensive assistance with activities of daily living. A review of Resident 7's Dermatology Consultation, dated 3/28/18, indicated Resident 7 had [DIAGNOSES REDACTED] to lower back, abdomen, legs, and right upper extremities. The consultation report indicated an order for [REDACTED]. A review of Resident 7's Non-Pressure Sore Skin Problem Report, dated 3/29/18, indicated Resident 7 was observed with pink, raised skin rashes described as [DIAGNOSES REDACTED] to the bilateral lower extremities, right upper extremity, back, and abdominal areas with complaints of itchiness. A review of Resident 7's Interdisciplinary Progress Notes, dated 3/29/18, indicated Resident 7 received [MEDICATION NAME] cream 5% ordered. A review of Resident 7's Dermatology Consultation, dated 5/25/18, indicated generalized unspecified [MEDICAL CONDITION]. The consultation report indicated an order for [REDACTED]. A review of Resident 7's Non-Pressure Sore Skin Problem Report, dated 5/26/18, indicated the dermatologist reclassified Resident 7's [DIAGNOSES REDACTED] rashes to generalized unspecified [MEDICAL CONDITION]. A review of Resident 7's Interdisciplinary Progress Notes, dated 5/26/18, indicated Resident 7 received [MEDICATION NAME] cream 5% as ordered. A review of the Treatment Records indicated that Resident 7 received the treatment orders ([MEDICATION NAME] cream 5%) on 5/26/18. During an interview, on 6/8/18, at 3:10 PM, in the presence of Treatment Nurse 1 (TN 1), Resident 7 stated that she had not been out of the facility since the start of (YEAR). Resident 7 stated, So if I got any infectious rash, I got it from here. Resident 7 stated, It itch terribly when it first started especially at night. During a subsequent interview with Resident 7 at 4:40 PM, Resident 7 stated that before she was treated with the [MEDICATION NAME] cream 5%, she would wake up in the middle of the night around 3 to 4 AM because of the terrible itchiness and she was unable to go back to sleep. Resident 7 stated that the itchiness was, Mostly in my back, because I could not reach my back to scratch it. It was not comfortable. Resident 7 was observed with red rashes in the right upper extremity, abdomen, and back area. 6. Resident 5, roommate of Resident 7 A review of the facility's handwritten list of residents with rashes for (MONTH) (YEAR), indicated that Resident 5 was included in the list with rash to the left plantar foot. The handwritten list indicated Resident 5's rash was facility acquired. A review of the (MONTH) (YEAR) handwritten list included Resident 5's name and indicated Resident 5 was admitted with rashes to the left plantar foot. A review of Resident 5's individual medical record indicated that the facility's handwritten list contained inaccurate information. A review of Resident 5's Record of Admission indicated Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's Initial History and Physical, dated 8/18/17, indicated Resident 5 did not have the capacity to understand and make decisions. A review of Resident 5's Dermatology Consultation, dated 5/25/18, indicated a treatment order of [MEDICATION NAME] cream 5% for Resident 5 to receive for [MEDICATION NAME]. A review of Resident 5's Physician's Telephone Orders, dated 5/26/18, indicated to give Resident 5 a shower first, then apply [MEDICATION NAME] cream 5% topically at bedtime from neck to toes, leave for 12 hours and rinse, for [MEDICATION NAME]

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent avoidable pressure sore (localized injury to the skin and or underlying tissue as a result of pressure or pressure in combination with shear and/or friction) development to one of five residents observed for pressure sores (Resident 1) in a total of 20 sampled residents by failing to: 1. Revise the plan of care to address the frequency in which the resident should be turned as well as the positioning of the resident. 2. Ensure the resident was not lying on her back directly on the pressure sore. 3. Develop a care plan to address prevention and or progression of pressure sore on the resident's right buttock while sitting in wheelchair during physical and occupational therapy in the rehabilitation room. 4. Accurately assess the skin condition of the right buttock. These failures resulted in Resident 1 developing an avoidable Stage III pressure sore (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) to the right buttock with suspected deep tissue injury (DTI- 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) to the periwound (tissue surrounding the wound itself). Findings: A review of the admission face sheet indicated Resident 1 was readmitted to the facility on [DATE], with a Stage I pressure sore (intact skin with non-blanchable redness over a bony prominence) to her coccyx (tailbone). The resident's [DIAGNOSES REDACTED].= inadequate blood flow to a part of a brain or hemorrhage (bleeding) into the brain that results in death of brain cells) with right sided weakness. The pressure sore to the coccyx was healed on 1/13/16. A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 1/2/16, indicated Resident 1 was assessed with [REDACTED]. A review of the Braden Scale Assessment (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure sore) dated 1/8/16, indicated Resident 1 scored 14 which indicated the resident was at moderate risk of developing pressure sore. On 1/20/16 at 3:37 p.m., a review of the Non -Pressure Sore Skin Problem Report with Treatment Nurse 1 indicated on 1/8/16, Resident 1's right buttock had an excoriation (an open wound usually caused by something rubbing against the skin). The excoriation of the right buttock had progressed on 1/15/16, to Stage II pressure sore (partial thickness skin loss involving epidermis, dermis or both). The wound doctor assessed the resident's right buttock on 1/15/16, as Stage II pressure sore that measured 4 cm in length (L) by (x) 4 cm in width (W) (2.5 cm centimeters (cm) = 1 inch). The Weekly Pressure Sore report dated 1/20/16 indicated the pressure sore to the right buttock had progressed to deep tissue injury (DTI). A review of the wound assessment done by the wound doctor dated 1/22/16 indicated Stage III pressure sore to right buttock that measured 2.9 cm x 4 cm with 0.1 cm depth, 5 percent (%) slough (dead tissue). Also, the wound doctor assessed the resident's sacral coccyx ((sacral) - a triangular shaped bone at the base of the spine) on 1/22/16, as deep tissue injury that measured 5 cm L x 6 cm W. A review of Resident 1's initial care plan dated 12/26/15 indicated the resident was assessed at risk for skin breakdown due to decreased mobility and activity, bowel and bladder incontinence, dependent on bed mobility and transfer. The care plan goal was for Resident 1 not to have skin breakdown by the next review due in March 2016. The care plan for Stage II pressure sore to right buttock dated 1/15/16 indicated the care plan goal was to decrease the size of the pressure sore to 0.5 centimeter every week by the next review on 2/5/16. However, both care plans dated 12/26/15 and 1/15/16, did not contain nursing care approaches such as turning and repositioning the resident while in bed, the frequency and which specific side the resident's body should be turned and repositioned to promote healing of the pressure sore and to prevent further skin breakdown. According to Medical Surgical Nursing Ninth Edition pages 186-187 indicated: Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure ulcer. A review of the Service Log Matrix for Occupational Therapy (OT) and Physical Therapy (PT) indicated Resident 1 stayed in the rehabilitation room for 100 minutes (one hour and 40 minutes) each day during her physical and occupational therapy on 1/15/16, 1/18/16, 1/19/16 and 1/20/16. On 1/19/16 at 2:00 p.m., Resident 1 was observed sitting in a semi-recliner wheelchair while in the rehabilitation room during her physical therapy. Resident 1 was confused and non-interviewable. On 1/19/16, at 2:50 p.m., Resident 1 was observed being transferred back to bed using a Hoyer lift by Certified Nursing Assistant (CNA1), Physical Therapy Assistant (PTA) and Registered Occupational Therapist (OTR). CNA 1 positioned Resident 1 on her back in bed. On 1/19/16, at 3:07 p.m., 4:00 p.m., and 5:00 p.m., the resident was observed on the same position lying on her back. On 1/20/16 at 7:40 a.m., 8:45 a.m., Resident 1 was observed lying on her back while in bed. During the treatment observation on 1/20/16 at 11:20 a.m., Resident 1 was observed with Stage III pressure sore to the right buttock with deep tissue injury to periwound that was purple and maroon in color. The pressure sore to the right buttock measured 4 cm L x 4.5 cm W (open wound). The combined measurement of the right buttock pressure sore open area and deep tissue injury to periwound was 7 cm L x 6 cm W. The Treatment Nurse 1 cleansed the right buttock wound bed with normal saline, applied Benelex (castor oil and balsam Peru) ointment and calcium alginate (absorbent and non-adherent dressing. The periwound was cleansed with Sure Prep and covered the pressure sore with dry dressing. During an interview on 1/20/16 at 4:00 p.m., CNA 1 stated he was aware Resident 1 had a pressure sore to her right buttock. CNA 1 stated, I turned and repositioned the resident side to side and on her back when she's in bed. CNA 1 was asked why the resident was lying on her back when the resident had pressure sore to her right buttock. CNA 1 stated he was not informed by any staff member Resident 1 should not be turned and repositioned on her back while in bed. During an interview on 1/20/16 at 4:50 p.m., the Registered Physical (RPT) Therapist/Rehabilitation director stated he was aware Resident 1 had Stage II pressure sore to her right buttock. RPT/ Rehab director was unable to provide documented evidence a plan of care was developed to address prevention and or progression of pressure sore on the resident's right buttock while sitting in wheelchair during her physical and occupational therapy in the rehabilitation room. On 1/21/16 at 2:00 p.m., the Director of Nursing (DON), Treatment Nurse 2, and Registered Nurse Supervisor 2 were interviewed. They stated staff did not have a written or visual monitoring system to ensure a resident with pressure sore was not turned and repositioned on a pressure sore while in bed. Treatment Nurse 2 stated the pressure sore was inaccurately assessed as DTI instead of Stage III pressure sore with DTI to periwound of the right buttock.