Every finding on record at Gladstone Sub-Acute and Rehab Center

Based on observation, interview, and record review, the facility failed to ensure one of six exit doors (Door A) remained closed to prevent people from entering the facility without permission.This failure had the potential for a trespassing person with ill intent to enter the facility and harm residents (in general).During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/14/2026 and readmitted Resident 1 on 7/27/2026 with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), hypertensive heart disease with heart failure (condition in which the heart cannot pump enough blood to all parts of the body), and muscle weakness. The AR indicated the facility discharged Resident 1 on 8/10/2026. The AR indicated Resident 1's Responsible Party (often a family member or a power of attorney, who signs paperwork on behalf of a resident) was RP 1.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/19/2026, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort to complete the activity) on staff for lower body dressing, bathing, and toileting hygiene. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort to complete the activity) from staff for upper body dressing. The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort to complete the activity) assistance from staff for personal and oral hygiene.During a review of the facility's Floor Map (FM), titled Fire Alarm Pull Locations, undated, the FM indicated the facility had six exit doors. The FM indicated the exit door on the east side of the facility was the main entrance to the facility. The FM indicated that Door A was next to the Rehab office at the northeast corner of the facility.During a telephone interview on 8/3/2026 at 4:18 PM, with RP 1, RP 1 stated RP 1 was concerned about the safety of Resident 1 and the residents in general at the facility because the exit door next to the Rehabilitation (rehab) office (Door A) was always propped open. RP 1 stated RP 1 had observed the door propped open on 8/2/2026 and 8/3/2026. RP 1 stated the residents (in general) were not safe because unauthorized people had access to the residents (in general) via the open door next to the Rehab office (Door A).During an interview on 8/14/2026 at 9:40 AM with the Director of Nursing (DON), the DON stated the only exit door of the facility that should remain unlocked is the main entrance. The DON stated all other exit doors of the facility should remain locked from the outside.During a concurrent observation and interview on 8/14/2026 at 9:50 AM with the Maintenance Director (MD), all exit doors of the facility were observed. Door A was open about 4 inches. The sign on the window next to Door A indicated, Not an Entrance. The MD stated Door A should be latched closed and locked from the outside. The MD stated that people could exit Door A but should close the door behind themselves. The MD stated staff (in general) left Door A open a crack so they could walk back into the building.During a follow up interview on 8/14/2026 at 11:24 AM with the DON, the DON stated all exit doors of the facility should remain locked from the outside so the facility could keep track of who was coming into the facility. The DON stated all staff, vendors, and visitors needed to be screened by the receptionist at the main entrance. The DON stated if Door A was left open, a stranger could potentially enter the facility and harm staff (in general) and residents (in general). The DON stated the facility has had an issue in the past with staff (in general) leaving Door A cracked open.During a review of the facility's policy and procedure (P&P) titled, Visitor Rules, revised May 2023, the P&P indicated, When entering the Facility, all visitors are required to do the following: 1. Check in at the visitor desk or nursing station in the front lobby. 2. Sign-in on the visitor log and indicate resident being visited.3. Obtain a visitor's badge, if available.

Based on interview and record review, the facility failed to ensure one of four sampled resident (Resident 2) was provided with laboratory services (professional and technical diagnostic tests, such as blood, urine, or tissue analysis) in a timely manner when the facility failed to collect a Complete Blood Count (CBC, measuring cells in the blood) and Basic Metabolic Panel (BMP, measuring chemical balance and kidney function) within four hours of the physician indicating the laboratory order to be STAT (means immediately or without delay).This failure had the potential for Resident 2 not to receive necessary services to meet the medical needs of Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/14/2026 and readmitted Resident 1 on 7/27/2026 with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), hypertensive heart disease with heart failure (condition in which the heart cannot pump enough blood to all parts of the body), and muscle weakness. The AR indicated Resident 2's Responsible Party (RP, often a family member or a power of attorney, who signs paperwork on behalf of a resident) was RP 1. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 7/19/2026, the MDS indicated Resident 2 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 2 was dependent (helper does all the effort) on staff for lower body dressing, bathing, and toileting hygiene. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) from staff for upper body dressing. The MDS indicated Resident 2 required partial/moderate (helper does less than half the effort) assistance from staff for personal and oral hygiene.During a review of Resident 2's physician orders, untitled, dated 7/24/2026, the physician order indicated Resident 2's physician ordered a STAT CBC and BMP for Resident 2. The STAT lab was ordered on 7/24/2026 at 10:06 AM.During a telephone interview on 8/1/2026 at 11:20 AM, with RP 1, RP 1 stated Resident 2's doctor ordered a STAT blood draw for Resident 2 on 7/24/2026 at 10:00 AM. RP 1 stated the person who draws labs never came for Resident 2 and that the facility had to transfer Resident 2 to the hospital at 5:30 PM. During a concurrent interview and record review on 8/1/2026 at 3:56 PM with Registered Nurse (RN) 1, Resident 2's Progress Notes (PN), dated 8/1/2026 was reviewed. The PN indicated Resident 2's doctor ordered a STAT CBC and CMP for Resident 2. The PN indicated the contracted laboratory service provider did not receive the faxed notification of the STAT order from the facility. The PN indicated Resident 2 was transferred to the General Acute Care Hospital (GACH) at 5:30 PM. RN 1 stated the contracted laboratory service provider did not arrive at the facility until after Resident 2 left the facility. RN 1 stated an order for STAT CBC and CMP should be collected for a resident within 4 hours. RN 1 confirmed the STAT order was received from Resident 2's physician at around 10:00 AM. During an interview on 8/1/2026 at 4:58 PM with the Director of Nursing (DON), the DON stated a STAT physician order (in general) should be carried out within four hours.During a review of the facility's policy and procedure (P&P) titled, Laboratory, Diagnostic and Radiology Services, revised November 1, 2017, the P&P indicated, Any orders labeled STAT will be followed up on during the same shift. The P&P indicated, The Facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider.During a review of the contracted laboratory services provider's P&P, untitled, undated, the P&P indicated STAT orders should be collected within 2 hours of the physician's order.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for four of four sampled residents (Residents 10, 16, 17 and Resident 29) who were at risk for falls when the facility failed to ensure Room A and Room B's (Residents 10, 16, 17, and 29's rooms) common door remained open on [DATE].This deficient practice resulted in unheard muffled calls for help by Residents 10, 17, and 29 and had the potential to result in falls to Residents 10, 16, 17 and Resident 29. Findings:During a review of Resident 10's admission Record (AR), the AR indicated the facility admitted Resident 10 on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear).During a review of Resident 10's Care Plan Report (CPR), initiated [DATE], the CPR indicated Resident 10 was at high risk for falls related to confusion, gait/balance problems, and incontinence [involuntary loss of bladder [hollow muscular balloon-like organ that stores urine]or bowel control]. The CPR's interventions indicated to ensure Resident 10's call light was in place and Resident 10 required prompt response to all requests for assistance.During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 10 had severe deficit in cognition (ability to think and make decisions). The MDS indicated Resident 10 was dependent (the resident does none of the effort to complete the activity) with toileting, oral and personal hygiene, and with most mobility such as rolling left and right, sit to lying, and lying to sitting on the side of the bed.During a review of Resident 10's Fall Risk Assessment (FRA), dated [DATE], the FRA indicated Resident 10 was considered a high risk for falls.During a review of Resident 16's AR, the AR indicated the facility admitted Resident 16 on [DATE] with diagnoses that included dementia and generalized muscle weakness.During a review of Resident 16's CPR, initiated [DATE], the CPR indicated Resident 16 was at high risk for falls related to history of falls and desires independence despite physical and cognitive limitations. The CPR's interventions indicated to ensure Resident 16's call light was in place and Resident 16 required prompt response to all requests for assistance.During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 had severe deficit in cognition. The MDS indicated Resident 16 was dependent with toileting hygiene and bed mobility such as sitting to lying, lying to sitting on the side of the bed and with toilet transfers.During a review of Resident 16's FRA, dated [DATE], the FRA indicated Resident 16 was considered a high risk for falls.During a review of Resident 17's AR, the AR indicated the facility admitted Resident 17 on [DATE] with diagnoses that included dementia and epilepsy (a brain disorder in which a person has repeated seizures [convulsions] over time).During a review of Resident 17's CPR, initiated [DATE], the CPR indicated Resident 17 was at risk for falls related to a history of falls. The CPR's interventions indicated to anticipate and meet the resident's needs.During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 had severe deficit in cognition. The MDS indicated Resident 17 required maximal assistance (helper does more than half effort) with toileting hygiene, sit to stand and toilet transfers.During a review of Resident 17's FRA, dated [DATE], the FRA indicated Resident 17 was considered a high risk for falls.During a review of Resident 29's AR, the AR indicated the facility admitted Resident 29 on [DATE], with diagnoses that included dementia and generalized muscle weakness.During a review of Resident 29's CPR, initiated 4/26,2026, the CPR indicated Resident 29 was at high risk for falls related to a new environment, recent hospitalization, being blind, having desires independence despite physical and cognitive limitations. The CPR's intervention indicated to ensure Resident 29's call light was in place and Resident 29 required prompt response to all requests for assistance.During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 had severe deficit in cognition. The MDS indicated Resident 29 was dependent with toileting hygiene and required maximal assistance with rolling left and right, sitting to lying, lying to sitting on the side of the bed.During a review of Resident 29's FRA, dated [DATE], the FRA indicated Resident 29 was considered a high risk for falls.During the following observations on [DATE],At 8:27 AM, Registered Nurse (RN) 2 was at the nurse's station. Rooms A and B were located across the nurse's station and had a common door to enter both rooms. Upon entering, the rooms were divided by partial wall with two beds on the left side of the wall and 2 beds on the right side of the wall. The toilet was located on the right side of the rooms. Resident 17 (Room A) was sitting on the toilet screaming help me repeatedly. The common door was open, and the scream reached the nurse's station, no staff came to assist Resident 17.At 8:30 AM, the common door was closed, and muffled words were heard, help me please. RN 2 was sitting at the nurse's station.At 8:31 AM, RN 2 got up from the nurse's station and walked to the medication cart parked in front of Room A. RN 2 did not enter Rooms A or B or check on the residents inside the rooms. Room A and B's common door remained closed.At 8:32 AM, RN 3 came to the nurse's station and did not check Room A, there were muffled words coming from Rooms A & B, help me that were heard outside of the rooms.At 8:35 AM, Resident 10 was saying help me, the Assistant Director of Nursing (ADON) checked Resident 10's incontinent pad, the incontinent pad was dry, Resident 10 continued to say, help me. At 8:36 AM, Resident 29 was saying Help me to the toilet. RN 3 and ADON replied to Resident 29, the assigned CNA for Room A and B was in the shower room providing a shower to another (unidentified) resident.At 9:05 AM, Certified Nursing Assistant (CNA) 2 opened the common door and entered the rooms, Resident 16 was screaming, help me. CNA 2 exited the rooms.During an interview on [DATE] at 9:05 AM with CNA 2, CNA 2 stated CNA 2 was not the assigned CNA to Rooms A and B, CNA 2 entered to Rooms A and B to look for a mechanical lift (a specialized assistive device used in healthcare to safely move, transfer, or lift residents who have limited mobility). CNA 2 stated when CNA 2 entered the room, Resident 17 was alone sitting on the toilet and was trying to get up from the toilet. CNA 2 stated Resident 17 got up 50 % of the time without asking for assistance from staff. CNA 2 stated Resident 17 self-propelled with the wheelchair to the toilet or the hallway. CNA 2 stated when CNA 2 entered Rooms A and B, Resident 10 was saying help, help. CNA 2 stated Resident 16 was saying something repeatedly and there were no staff inside the room. CNA 2 stated all residents residing in Rooms A and B were at high risk for falling and required so much attention from staff.During an interview on [DATE] at 9:38 AM, CNA 3 stated CNA 3 was assigned to Resident 17 but during the time Resident 17 self-propelled to the toilet, CNA 3 was changing another resident. CNA 3 stated Resident 17 got up without asking for assistance, and self-propelled to the toilet. CNA 3 stated all the residents inside Rooms A and B were at high risk for falls and all staff needed to help the residents inside those rooms when the residents called for help. CNA 3 stated Resident 17 only called for help when Resident 17 really needed help to the bathroom. CNA 3 stated the common door Rooms A and B was left open to at the start of the shift and the common door needed to remain open for the residents' safety.During an interview on [DATE] at 9:54 AM, RN 3 stated Resident 10's behavior was to constantly say help me, help me and when staff asked Resident 10 what she needed, the resident responded, I don't know. Resident 10, 16, 17 and Resident 29 were all placed close to the nurse's station [in Rooms A and B] so all staff could keep an eye on them and for the residents' safety. RN 3 stated when RN 3 arrived at the nurse's station, the door to Rooms A and B was closed and RN 3 thought the CNAs (in general) were changing one of the residents. RN 3 stated Rooms A and B's common door should remain open for the resident's safety.During an interview on [DATE] at 10:20 AM, with RN 2, RN 2 stated RN 2 only heard Resident 10 call for help and that was Resident 10's behavior so RN 2 did not check behind the closed common door. RN 2 stated Room A & B's common door needed to remain open so all staff could check on the residents. RN 2 stated a closed door could result in falls of the residents inside Rooms A and B because staff would not be able to hear when the residents inside the rooms asked for assistance.During an interview on [DATE] at 4:20 PM, with the DON, the DON stated the common door to Rooms A and B needed to remain open so the staff could hear [the residents].During a review of the facility's Policy and Procedure (P&P) titled Fall Management Program dated [DATE], the P&P indicated it is the policy of the facility to provide the highest quality care in the safest environment for the residents residing in the facility. The P&P indicated the nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls.

Based on observation, interview, and record review, the facility failed to provide adequate care and services to 3 of 4 sampled residents (Resident 1, Resident 11 and Resident 92) to promote healing of an existing pressure ulcer/injuries (PI- lesion/wound caused by unrelieved pressure usually over a bony prominence that results in damage of underlying tissue) and prevent the development of new pressure ulcers when the facility failed to: a1. Turn and reposition Resident 1 every 2 hours.a2. Provide a low air-loss mattress (LALM, a mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) to Resident 1 as recommended by the Wound Physician (WP).b. Ensure the LALM was on when Resident 11 was lying in bed as indicated in the physician's order dated [DATE].c. Set the LALM according to Resident 92's weight.These deficient practices resulted in worsening of Resident 1's existing PIs and had the potential to result in the development of new PIs or delayed wound healing to existing PIs for Resident 1, Resident 11, and Resident 92. Findings: a1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE], with diagnoses that included anoxic brain damage (a serious medical condition that happens when the brain is completely cut off from oxygen [a colorless gas essential to living organisms], leading to the death of brain cells within minutes) and dependence on respirator (ventilator, a medical machine that moves air in and out of the lungs when the resident cannot breathe well on their own). During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were severely impaired. The MDS indicated Resident 1 was dependent (the resident does none of the effort to complete the activity) with toileting hygiene, oral hygiene, rolling left and right, and chair/bed-to-chair transfers. During a review of Resident 1's Norton Pressure Ulcer Scales (NPS - a tool used for assessing risk for the development of PIs), dated [DATE], [DATE], [DATE], [DATE], and [DATE], the NPS indicated a score of 3 for Resident 1. The NPS indicated a score of 10 or less indicated a high risk for PIs. During a review of Resident 1's Care Plan Report (CPR), initiated [DATE], The CPR indicated Resident 1 had impaired skin integrity as evidenced by moisture associated skin damage (MASD - caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection) on the left trochanter upon admission. The CPR's interventions indicated to reposition [turn] every 2 hours and as needed. During a review of Resident 1's CPR, initiated [DATE], the CPR indicated Resident 1 was noted with a Deep Tissue Injury (DTI - intact skin with localized area of persistent non-blanchable deep red maroon, purple discoloration due to damage of underlying soft tissue) on the right ischium (buttocks). The CPR's interventions indicated turning and repositioning every 2 hours and as needed. During a review of Resident 1's CPR, initiated [DATE], the CPR indicated Resident 1 noted with left trochanter MASD evolved to an unstageable pressure ulcer. The CPR's interventions indicated turning and repositioning Resident 1 every 2 hours and as needed. During the following observations on [DATE] from 9:13 AM to 10:05 AM; -At 9:13 AM, Certified Nursing Assistant (CNA 5) removed the sheet that was covering Resident 1 and there was a pillow between Resident 1's legs and a dark blue colored wedge under Resident 1's left upper body. CNA 5 turned Resident 1 toward Resident 1's right side and cleaned stool from Resident 1's buttocks area. -At 9:46 AM, Respiratory Therapist (RT) 2 came in with Treatment Nurse (TN) 1, TN 1 removed the dressing from Resident 1's left trochanter site. -At 9:55 AM, TN 1 turned Resident 1 towards Resident 1's left side. TN 1 cleaned the right ischium PI with normal saline, dried with gauze, applied Medi honey to the wound bed and applied a foam dressing on top of the PI. TN 1 stated the black color on the wound bed was necrotic tissue. -At 10:05 AM, CNA 5 positioned Resident 1 slightly toward the right side by placing the dark blue colored wedge pillow under Resident 1's left shoulder down to the waistline. During an observation on [DATE] at 12:40 PM, Resident 1 was positioned with the pillow under Resident 1's left upper body (Resident 1 turned toward the right side), the blue positioning pillow was not covered completely by a sheet and could be seen from Resident 1's doorway. During an observation and interview on [DATE] at 1:10 PM, Restorative Nursing Assistant (RNA) 1 removed the wedge pillow from under Resident 1's left side and removed a second pillow under Resident 1's left leg before initiating range of motion (ROM, how far a person can move a joint or muscle in various directions) exercises. When completed, RNA 1 replaced the wedge pillow under Resident 1 left side (Resident 1 turned toward the right side). During an interview on [DATE] at 2:42 PM, CNA 5 stated CNA 5 did not turn and reposition Resident 1 and CNA 5 usually turned and repositioned Resident 1 at 1 PM but CNA 5 had to assist another resident back to bed at 1:30 PM. CNA 5 stated it was more than 4 hours since the last time CNA 5 turned and repositioned Resident 1. CNA 5 answered no when asked if there was a process in place for someone to provide oversight and follow up on residents that needed turning and repositioning every 2 hours, CNA 5 showed the turning and repositioning guide attached to CNA 5's badge. The guide indicated repositioning Resident 1 on resident's back at 12 noon, CNA 5 stated CNA 5 did not turn and reposition Resident 1 at noon because CNA 5 took a lunch break at 12:30 and assisted other residents before leaving for CNA 5's lunch break. CNA 5 stated Resident 1 needed to be turned and repositioned every 2 hours because Resident 1's PI could worsen. During an interview on [DATE] at 2:54 PM, TN 1 stated CNA 5 reported Resident 1's right ischium DTI to TN 1. TN 1 stated the DTI was dark colored and the skin surrounding the PI was clear with no redness, the PI was discovered on [DATE]. TN 1 stated TN 1 did not turn and reposition Resident 1 after wound care earlier that morning. TN 1 stated turning and repositioning Resident 1 every 2 hours helped with healing of Resident 1's PI. During an interview on [DATE] at 3:48 PM, with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated Resident 1 currently had 2 PIs with interventions to manage the PIs included turning and repositioning Resident 1 every 2 hours and keeping Resident 1 clean. During a review of the facility's documentation on turning and repositioning for the month of [DATE], the documentation indicated CNA 5 documented CNA 5 turned and repositioned Resident 1 on [DATE] at 12:23 PM and at 2:00 PM. The documentation indicated from [DATE] to [DATE], Resident 1 was turned and repositioned from 12 midnight, 2 AM, 4 AM, 6 AM, 8 AM, 10 AM, 10 AM, 12 noon, 2 PM, 4 PM, 6PM, 8PM, and 10 PM was left blank. During a concurrent interview and record review on [DATE] from 2:03 PM to 2:38 PM with TN 2, Resident 1's Skin Observation Tools were reviewed, TN 2 stated a DTI on the right ischium was developed on [DATE] and the left trochanter PI progressed from a MASD to an unstageable PI. TN 2 stated since there was eschar (a thick dry layer of dead tissue that forms over a severe skin wound) on both wounds [PIs], the PIs were classified as unstageable PIs because the extent of injury could not be determined due to the eschar covering the wound beds. TN 2 stated both the right ischial and left trochanter PIs had worsened. During an interview on [DATE] at 2:27 PM, with the WP, the WP stated both the right ischium and the left trochanter PIs were unstageable. The WP stated the WP documented Stage 3 PI instead of unstageable because the system only allowed documentation of surgical debridement for a stage 3 PI but not for an unstageable PI. During an interview on [DATE] at 4:35 PM with the Director of Nursing (DON), the DON stated staff needed to turn and reposition Resident 1 every 2 hours. During a review of the facility's Policy and Procedure (P&P) titled Pressure Ulcer Prevention dated [DATE], the P&P indicated the licensed nurse will develop a care plan specific to the resident's risk factors such as moisture control, pressure reduction, positioning, mobility, and nutrition in consultation with the attending physician, Interdisciplinary Team (IDT) Skin Committee, Registered Dietitian, and the Director of Rehabilitation Services. The P&P indicated nursing staff will monitor interventions for effectiveness and resident tolerance and the care plan will be revised as indicated. During a review of the facility's P&P titled Support Surface Guidelines dated [DATE], the P&P indicated the facility will implement measures to reduce tissue pressure that includes frequent repositioning, protective devices, and the use of support surfaces. The P&P indicated bedbound residents should be turned a minimum of every 2 hours. a2. During an observation on [DATE] at 10:09 AM, Resident 1 was lying in bed on a special mattress attached to a control unit located at the bottom of the bed. The control unit was at comfort level 3, alternate function. During a record review of Resident 1's Order Summary Report (OSR), dated active as of [DATE], the OSR indicated a physician order, dated [DATE], start date [DATE], for a LALM for pressure reducing device while in bed. The order indicated to monitor for placement and to check the settings for resident comfort level 3. During a review of Resident 1's Wound Physician Progress Notes (WPN), the WPN indicated the WP recommended a LALM for Resident 1 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and on [DATE]. During an interview on [DATE] at 4:35 PM, with the Director of Staff Development (DSD), the DSD stated the DSD was not knowledgeable about Resident 1's mattress and did not know if Resident 1's mattress was a LALM. During an interview on [DATE] at 11:31 AM, with the DON, the DON stated Resident 1's mattress was an Air Pressure Mattress (APM) and not a LALM. The DON stated an APM had air in the middle of the bed where a LALM had cells. During a review of the facility's undated Owner's Manual (OM - provided by the facility on [DATE]) for an APM, the OM indicated the APM provides options of alternating pressure.and auto firm. The OM indicated the APM provides pressure management surface for the prevention and treatment of PIs. During a review of the facility's undated OM (provided by the facility on [DATE]) for the LALM, the OM indicated a LALM comes with an air cell mattress that provides low air loss, alternation and static pressure redistribution therapy. During a review of the facility's P&P titled Support Surface Guidelines dated [DATE], the P&P indicated the facility will implement measures to reduce tissue pressure that includes frequent repositioning, protective devices, and the use of support surfaces. The P&P indicated the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The P&P indicated surfaces include alternating-air mattresses, low-air-loss mattresses, and air-fluidized mattresses. The P&P indicated low-air-loss mattresses are giant air-permeable pillows that are continuously inflated with air; the air flow has a drying effect on tissues. Indicated for residents with stage I pressure ulcers who develop hyperemia on static surfaces and for residents with stage Ill or IV pressure ulcers. b. During a review of Resident 11's AR, the AR indicated the facility originally admitted Resident 11 on [DATE] and re-admitted the resident on [DATE] with diagnoses including tracheostomy (a surgical opening in the neck leading directly into the windpipe to help a person get air into the lungs when they cannot breathe normally through their mouth or nose), dependence on ventilator (a medical machine that moves air in and out of the lungs when the resident cannot breathe well on their own), gastrostomy (a medical procedure that creates an opening from the outside of the abdomen directly into the stomach, allows for the placement of a feeding tube), dysphagia (difficulty when swallowing), and functional quadriplegia (paralysis [complete or partial loss of muscle function in a part of the body] from the neck down, including legs, and arms, usually due to spinal cord injury). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 11 was dependent on physical assistance for toileting hygiene and was always incontinent (involuntary loss of bladder [hollow muscular balloon-like organ that stores urine] or bowel control) of bowel and bladder. During a review of Resident 11's OSR, dated active as of [DATE], the OSR indicated a physician order, dated [DATE], start date [DATE], for a LALM for pressure reducing device while in bed. The order indicated to monitor for placement Q shift (every shift) and to check the settings for resident comfort level 3. During a review of Resident 11's CPR, initiated [DATE], target date [DATE], the CPR indicated Resident 11 was using a LALM as a pressure-reducing device while in bed. The CPR indicated predisposing factors included [Resident 11 having] thin and fragile skin, impaired mobility, impaired cognition, being totally dependent with ADLs, transfers, and mobility. The CPR's interventions indicated providing a pressure-reducing device as ordered and to ensure proper function and placement of the LALM. During an observation on [DATE] at 8:48 AM in Resident 11's room, Resident 11's LALM appeared to be off, there were no lights displayed or sound heard on the LALM's control unit. During a concurrent observation and interview on [DATE] at 9:09 AM with CNA 6 in Resident 11's room, CNA 6 traced the LALM's power cord from the control unit to the back of the bed where it was connected to the outlet. CNA 6 moved the control unit and the control unit's lights turned on and had a visible display. CNA 6 stated the LALM was off and stated CNA 6 would contact CNA 6s charge nurse for help with the LALM's settings. During an interview on [DATE] at 9:17 AM with LVN 6, LVN 6 stated Resident 11's LALM's comfort level was a 3. LVN 6 stated the LALM was on this morning and LVN 6 was unsure why it was off. LVN 6 stated it was important for the LALM to function to prevent skin breakdown and allowed for proper circulation [of air]. During a review of the facility's P&P titled, Support Surface Guidelines, dated [DATE], the P&P's support surfaces indicated dynamic surfaces – require electricity to operate. The P&P indicated surfaces included low-air-loss mattresses. The P&P indicated low air loss mattresses are giant air permeable pillows that are continuously inflated with air, the air flow has a drying effect on tissues. The P&P indicated any individual at risk for developing PIs will be placed on a pressure reducing device [such as a LALM]. c. During a review of Resident 92's AR, the AR indicated the facility admitted Resident 92 on [DATE], with diagnoses including reduced mobility, PI, and muscle weakness. During a review of Resident 92's History and Physical (H&P), dated [DATE], the H&P indicated Resident 92 did not have the capacity to understand and make decisions. During a review of Resident 92's MDS, dated [DATE], the MDS indicated Resident 92's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated Resident 92 was dependent (helper does all of the effort) with activities of daily living (AOL, term used in healthcare that refers to self-care activities) and was dependent on mobility. During a review of Resident 92's Weights and Vitals Summary (WVS), dated [DATE], the WVS indicated Resident 92's weight was 150 lbs. (lbs., unit of weight) During an observation on [DATE] at 9:54 AM, Resident 92 was observed lying on the bed on Resident 92's right side on a LALM. The LALM control unit indicated the pressure dial was set to 350 pounds (lbs, unit of weight). During an observation on [DATE] at 9:30 AM, Resident 92 was observed lying in supine (lying flat on the back) position on a LALM. The LALM control unit indicated the pressure dial was set to 350 lbs. During a concurrent interview and observation on [DATE] at 3:10 PM with TN 1 in Resident 92's room, Resident 92's LALM pressure dial was set at 350 lbs. TN 1 stated Resident 92's LALM dial was set at 350 lbs., and this setting was too firm for Resident 92's weight. TN 1 stated the mattress must be set to the resident's actual weight to ensure proper pressure redistribution and comfort. TN 1 stated that an over firm setting could have caused increased pressure, pain, and skin breakdown or the development of new PIs. During a review of the facility's P&P titled, Pressure Ulcer Prevention, revised [DATE], the P&P's purpose indicated, To identifying residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcers and minimize complications. The P&P's policy indicated, The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. During a review of the facility's undated LALM operation manual DynaRest Airfloat 100 Air Mattress with Pump, the manual's Controls and Features indicated: Pressure adjust knob (adjustable by patient's weight): turn the pressure adjust knob to set a comfortable pressure level by using the weight scale as a guide.

Based on observation, interview, and record review the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures by failing to: Record medication storage area room temperature on a temperature monitoring log for July 2026, for one (1) of two (2) inspected Medication Rooms (Medication Room SNF.) Ensure externally (eye drops) medications were stored separately from internally (orally) administered medications, in one (1) of six (6) inspected Medication Carts (Medication Cart 2.) These deficient practices increased the risk for residents in the facility to receive medication that had become ineffective or toxic due to improper storage and increase the risk of contamination and receiving medications via the wrong route (internal versus external routes) possibly leading to adverse health consequences resulting in in the negative impact to their health and well-being or hospitalization.Findings: a. During an observation and concurrent interview on 7/21/2026 at 11:14 a.m., with Registered Nurse (RN) 1, the Medication Room SNF contained medication bottles for facility stock and residents. The room temperature monitoring log for the storage of medications in Medication Room SNF for July 2026 was not available. RN 1 stated the room temperature log for the storage of medication in Medication Room SNF for July 2026 was not available, and without a log containing documentation for room temperatures, it was implied that the room temperature for medication storage area in Medication Room SNF was not monitored. RN 1 stated the room temperature should be monitored and documented every day, similar to the refrigerator temperature monitoring, to ensure medications are properly maintained at an acceptable temperature range, and their potency (the strength of medication required to produce an effect) not affected. RN 1 stated if the room temperature was not monitored it was unknown if the temperatures were maintained within the acceptable range and if the medications were affected negatively. RN 1 stated using improperly stored medications can harm the residents and not help in treating their condition. During an interview, on 7/21/2026 at 12:15 p.m., with the Director of Nursing (DON), the Assistant DON (ADON) and the Administrator (ADMIN), the ADON stated that the temperature of medication rooms should be documented once a day for the room temperature and twice daily for the refrigerator temperature. The ADON stated that failing to document the temperature could indicate a lack of monitoring, potentially resulting medications being stored outside acceptable temperature ranges, lose efficacy, and be ineffective in treating the residents' conditions. The ADON stated that Medication Room SNF contained several medication bottles for facility stock and residents did not have temperature monitoring log for July 2026. b. During an observation on 7/21/2026 at 11:30 a.m., in Medication Cart 2, with Licensed Vocational Nurse (LVN) 1, the following medications were stored in a manner contrary to the facility's P&P: One (1) nitroglycerin (an orally administered medication) oral tablet bottle was stored with three (3) artificial tear eye drops bottle, one (1) brimonidine (an eye drop medication) eye drop bottle and two (2) latanoprost (an eye drop medication) eye drop bottles, in the same bin/compartment of the medication cart. One (1) Systane (an eye drop medication) eye drop bottle was stored with one (1) icosapent (an orally administered medication) oral tablet bottle, one (1) magnesium (an orally administered medication) oral tablet bottle, one (1) calcium (an orally administered medication) oral tablet bottle, in the same bin/compartment of the medication cart. During a concurrent interview, LVN 1 stated that internally administered medications, such as oral tablets, and externally administered medications, such as eye drops, ear drops, creams, and nasal sprays, should be stored separately in their own sections/bins and not together, to prevent errors in wrong route administration and possible infections/contaminations. LVN 1 acknowledged one (1) nitroglycerin oral tablet bottle was stored with three (3) artificial tear eye drops bottle, one (1) brimonidine eye drop bottle and two (2) latanoprost eye drop bottles, in the same bin/compartment. LVN 1 acknowledged one (1) Systane eye drop bottle was stored with one (1) icosapent oral tablet bottle, one (1) magnesium oral tablet bottle, one (1) calcium oral tablet bottle together in the other bin/compartment. LVN 1 stated the facility failed to store eye drop medications separate from oral medications. During an interview with the ADON on 7/21/2026 at 12:15 p.m., the ADON stated internally (such as oral medications) and externally (such as medications for the eyes, ears, nose, skin) administered medications should be stored separately to prevent wrong route administration, infections and contaminations. The ADON stated the facility failed to store eye drop mediations in Medication Cart 2 separate from oral medications. During a review of facility's Policy and Procedures (P&P) titled, Storage of Medications, dated 2023, the P&P indicated Medication and biological are stored properly, following manufacturer's recommendations or those of the supplier to maintain their integrity and to support safe administration. Internally administered medications are kept separate from externally used medications.Medications requiring storage at room temperature are kept at temperatures ranging from 59 degrees Fahrenheit to 86 degrees Fahrenheit.

Based on observation, interview, and record review the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures by failing to: Reconcile (the process of comparing transactions and activity to supporting documentation) three (3) medication eKITs (Emergency Kit or Emergency Dispensing Kit, a secure, on-site supply of critical medications used to provide immediate treatment when a patient cannot wait for a standard pharmacy delivery) containing controlled medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) with an inventory count at each shift change for July 2026, in one (1) of two (2) inspected Medication Rooms (Medication Room SNF.) Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled Drug Record accountability logs for six (6) of 15 sampled records awaiting disposal (removal, destroying) in the DON's office. As a result, availability of medications for continuity of care and control and accountability of CSs did not follow state and federal regulations and facility policy and procedures (P&P.) These failures increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and exposure of harmful medications to residents in the facility, possibly leading to physical and psychosocial harm, and hospitalization.Findings: a. During a concurrent observation and interview on 7/21/2026 at 11:14 a.m., with Registered Nurse (RN) 1, in Medication Room SNF there was: One (1) medication eKIT stored in the refrigerator containing CMs, labeled 68, without an accountability log for the inventory reconciliation of CMs at every shift change for July 2026. Two (2) medication eKITs stored at room temperature containing CMs, labeled 18 and 100, without an accountability log for the inventory reconciliation of CMs at every shift change for July 2026. During a concurrent interview, RN 1 stated that all CMs, including medication eKITs containing CMs, should be reconciled at every shift. RN 1 stated that the eKIT labeled 68 in the refrigerator and 18 and 100 in the cabinet of Medication Room SNF contained CMs and were not reconciled with an inventory count at every shift in July 2026. RN 1 stated it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an interview, on 7/21/2026 at 12:15 p.m., with the DON, the Assistant DON (ADON) and the Administrator (ADMIN), the ADON stated that medication eKITs containing CMs needed inventory count and reconciliation at every shift change, similar to CMs stored in medication carts, to ensure accountability and prevent CM diversion. The ADON stated the eKITs containing CMs in Medication Room SNF refrigerator labeled 68 and in the cabinet labeled 18 and 100 were not accounted for with an inventory count on an accountability log at each shift change in July 2026. The ADON stated that the facility will immediately implement an accountability log for reconciliation of eKIT inventory count at each shift change in Medication Room SNF. b. During a concurrent interview and record review on 7/21/2026 at 1 p.m. in the DON's office, with the DON, two (2) Controlled Drug Record accountability logs dated 7/20/2026 and three (3) Controlled Drug Record accountability logs dated 7/21/2026 for CS's awaiting final disposition did not contain verifying witness's signature. During a concurrent interview, the DON stated the DON was unable to locate her verifying signature as the witness on the five (5) Controlled Drug Record accountability logs. The DON stated the DON failed to sign the Controlled Drug Record accountability logs upon receipt of the CSs from the Licensed Vocational Nurses (LVNs). The DON stated the DON counts the CSs with the LVNs upon receipt of the accountability logs, however there was no consistent process to sign the logs as a witness. The DON stated the DON understood the importance of CS accountability to ensure each CS dose was accounted for until disposed throughout the process of CS accountability. The DON stated it was important to verify and sign these logs to prevent medication diversions and accidental exposure of harmful substances to residents. During a review of facility's Policy and Procedures (P&P) titled, Controlled Medication Storage, dated 2023, the P&P indicated Medication included in the state and federal Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the care center in accordance with federal, state and other applicable laws and regulations.The DON and the consultant pharmacist maintain the care center's compliance with federal and state laws and regulations in the handling of controlled medications.At each shift change.a physical inventory of all controlled medications is conducted by two licensed nurses per state regulation and is documented on the controlled substance accountability record. During a review of facility's P&P titled, Disposal of Medications, dated 2023, the P&P indicated: Medication included in the Drug Enforcement Administration (DEA) classification as controlled substances. are subject to special handling, storage, disposal and record keeping in the care center in accordance with federal and state laws and regulations.c. A controlled medication disposition log, or equivalent form, shall be used for documentation.This log shall contain the following information:Signatures of the two witnesses.

Based on interview and record review the facility failed to ensure two of four sampled kitchen cooks (Cook [CK] 1 and CK 2) had competency for cooling potentially hazardous foods (PHF, items that require time and temperature control to prevent the rapid growth of harmful germs).This deficient practice had the potential to result in food born illness (an illness caused by eating contaminated food) to the residents consuming the PHF.Findings: During a review of the facility's Dietary Inservice Training/Meeting, (DITM), dated 2/2/2026, the DITM indicated the instructional content was to check food temperature and Cooling Log procedure/ Log sheet. The DITM indicated the facility's policy and procedure (P&P) titled Hazardous Foods Cooling Monitor, dated 1/31/2018, was part of the DITM. The P&P indicated PHFs should be cooled from 140 degrees Fahrenheit ( F, unit of temperature) to 70 F within two hours and cooled from 70 F to 41 F or lower in an additional four hours. The P&P indicated, if the temperatures were not reached in the appropriate time, corrective action was to throw away the food.During a review of the facility kitchen's Cooling Log, (CL), dated 6/2026, the CL indicated that food that is cooked and will not be used for immediate service will be cooled to the appropriate temperatures within the allotted time to prevent microbial growth. The CL indicated meats must reach 70 F in two hours, and 40 F within four more hours (6-hour total).During a concurrent interview and record review on 7/22/2026 at 11:32 AM, with the Dietary manager (DM), the facility kitchen's CL, dated 6/2026, was reviewed with the DM. The CL indicated the cooling times and temperatures of roast turkey on 6/22/2026 and roast beef on 6/29/2026. The CL indicated on 6/22/2026, the roast turkey was 185 F when removed from the oven and was 145 F at 12 PM. The CL did not indicate any further times or temperatures for the roast turkey. On 6/29/2026, the CL indicated the roast beef was 188 F when removed from the oven. The CL indicated the following times and temperatures for the roast beef:At 11:30 AM the roast beef had an internal temperature of 135 F.At 1:40 PM the roast beef had an internal temperature of 68 F.At 4:15 PM the roast beef had an internal temperature of 55 F.At 6:35 PM the roast beef had an internal temperature of 38 F.The DM stated the DM did not know why the roast turkey did not have any further cooling times or temperatures. The DM stated the CL indicated the roast beef cooled longer than six total hours and stated it was likely that a staff member wrote something on the log incorrectly.During a concurrent interview and record review on 7/22/2026 12:21 PM with CK 1, the kitchen's CL, dated 6/2026, was reviewed with CK1 and CK 2. When asked CK 1 how staff cooled meat to be used later, CK 1 stated cooked meat was taken out of the oven, placed into an ice bath, and staff took the temperature of the meat every two hours. When asked CK 1 how long it took for cooked meat to cool, CK 1 stated the meat's temperature was checked every 2 hours until it reached 41 degrees F according to the CL. CK 1 stated CK 1 usually went home before the meat was finished cooling and CK 2 followed up to complete the CL.During an interview on 7/22/2026 at 12:21 PM with CK 2, CK 2 stated the meat was not finished cooling until it reached 41 F. When asked CK 2 how long it took for the meat to cool, CK 2 stated the meat must reach 41 F by 6:30 PM because that is the end of the shift. CK 2 stated if the meat was removed at 11:30 AM, then sometimes it was done cooling by 6 PM but if not, then the meat was kept out longer until it reached 41 F.During an interview on 7/23/2026 at 1:23 PM with the DM, the DM stated it was important for staff to know how to properly cool PHF to prevent the growth of bacteria (microscopic, single celled living organism some can cause disease) on the food.During a review of the facility's updated P&P titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, the P&P indicated Cooked PHF or Time/Temperature Control for Safety (TCS) food shall be cooled and reheated in a method to ensure food safety. The P&P further indicated when cooked PHF or TCS food will not be served right away, it must be cooled as quickly as possible with the two-stage method. The two-stage method indicated to cool cooked food from 140 F to 70 F within two hours and then cool from 70 F to 41 F or less in an additional four hours for a total cooling time of six hours.

Based on observation and interview, the facility failed to ensure lids were fully closed and garbage was properly contained in two of four dumpsters on 7/21/2026 and on 7/23/2026.This deficient practice had the potential to result in unwanted pests inside the facility and the potential to result in health complications to the residents residing at the facility.Findings: During an observation on 7/21/2026 at 1:22 PM, two grey dumpsters were positioned side by side in the back parking lot of the facility, their lids were not fully closed and trash was pushing up against both lids. There was visible trash on the floor and there was trash on top and in between both dumpster's handles. The observed trash included a disposable adult brief, disposable gloves, and an empty body of cleansing wash.During an observation on 7/23/2026 at 12:58 PM, the two grey dumpsters positioned side by side in the back parking lot of the facility. One dumpster was observed with the lid not fully closed and propped open with a Coca-Cola cardboard box. The second dumpster lid was not fully closed and kept open by clear trash bags. There were disposable gloves on the floor by the dumpsters.During an interview on 7/23/2026 at 1:26 PM with the Director of Maintenance (DM), the DM stated the facility's garbage was picked up daily in the mornings. The DM stated the dumpster lids needed to be closed to prevent unwanted smells and flies from gathering and attracting unwanted pests near the facility.During an interview on 7/23/2026 at 3:00 PM with the Medical Records (MR), the MR stated the facility did not have a policy related to the facility's dumpster or proper maintenance of garbage.

Based on observation, interview, and record review, the facility failed to implement infection control practices for two of two sampled residents (Resident 84 and 95) by:a. Failing to ensure Licensed Vocational Nurse (LVN) 4 wore Personal Protective Equipment (PPE, special gear or clothing worn to protect from health and safety hazards) while handling Resident 95's gastrostomy tube (G-tube, soft flexible tube surgically inserted directly into the stomach through a small opening in the abdomen, used to deliver liquid nutrition, hydration, and medications for people who cannot eat or swallow safely) who was on Enhanced Barrier Precautions (EBP- extra measures, like wearing gowns and gloves, used during high-contact care activities for residents who are at a higher risk of having or spreading germs that are hard to treat, like multidrug-resistant organisms [MDRO], and antibiotics (medications used to treat infections [the invasion and growth of germs in the body]) can no longer be used to control or kill the bacteria]). b. Failed to ensure Certified Nursing Assistant (CNA) 9 and CNA 10 wore PPE during a transfer back to bed for Resident 84 who was on EBP.This deficient practice had the potential to result in the spread of infections amongst the facility's residents. Findings: a. During a review of Resident 95's admission Record (AR), the AR indicated Resident 95 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (a sudden worsening of a pre-existing breathing problem where there is not enough oxygen in the body), encounter for attention to gastrostomy (Gtube, soft flexible tube surgically inserted directly into the stomach through a small opening in the abdomen, used to deliver liquid nutrition, hydration, and medications for people who cannot eat or swallow safely), and type 2 diabetes mellitus (a common form of diabetes in which the body cannot properly store or use glucose [sugar], the body's main source of energy). During a review of Resident 95's Minimum Data Set (MDS- a resident assessment tool), dated 6/19/2026, the MDS indicated Resident 95 had impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort, the resident does none of the effort to complete the activity) on staff for toileting and personal hygiene. During a review of Resident 95's Order Summary Report (OSR), dated active as of 7/30/2026, the OSR indicated Resident 95 had a physician order, dated 2/18/2025, indicating to observe EBP per Centers of Disease Control and Prevention (CDC, a national public health agency of the United States). During a review of Resident 95's Care Plan Report (CPR), initiated on 3/31/2026, the CPR indicated Resident 95 was on enhanced standard precautions for the duration of Resident 95's stay in the facility due to the presence of enteral feeding (a method of delivering liquid food and medications directly into the stomach via a feeding tube). The CPR interventions indicated all staff will observe appropriate precautions during high-contact resident care activities requiring gown and glove use among residents that trigger EBP use including: dressing, bathing/showering, transferring, providing hygiene care, changing linens, changing briefs, or assisting with toileting. The interventions further included to instruct family/ visitors/ caregivers to wear disposable gown and gloves during physical contact with the resident. During an observation on 7/22/2026 at 1:50 PM, inside Resident 95's room, there was EBP signage. During an observation on 7/22/2026 at 2:03 PM in Resident 95's room with LVN 4, LVN 4 was observed administering a medication via Resident 95's G-tube without the use of a gown. During an interview on 7/23/2026 at 11:43 AM with the Infection Preventionist (IP), the IP stated nurses (in general) needed to wear gowns and gloves while administering medications via a G-tube to protect the wearer from bodily fluids that could escape via the G-tube and onto the staff. b. During a review of Resident 84's AR, the AR indicated the facility admitted Resident 84 on 3/14/2025, with diagnoses that included chronic (long standing) respiratory failure with hypoxia and tracheostomy (a surgical opening in the neck leading directly into the windpipe to help a person get air into the lungs when they cannot breathe normally through their mouth or nose). During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84 had intact cognition. The MDS indicated Resident 84 was dependent on all activities of daily living such as toileting hygiene, oral hygiene, and eating. During a review of the CPR, initiated 9/21/2025, target goal 9/22/2026, the CPR indicated Resident 84 was on EBP secondary to [having a] gastric tube (a medical device placed directly through the skin into the stomach used to deliver food, liquids, and medications when eating by mouth is not safe or possible), tracheostomy, and ventilator. The CPR's interventions indicated all staff will observe appropriate precautions during high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: dressing, bathing/showering, transferring, providing hygiene care, changing linens, changing briefs or assisting with toileting. During an observation on 7/23/2026 at 4:34 PM, Resident 84 was lying in bed and CNA 9 and CNA 10 were repositioning Resident 84. CNA 9 and CNA 10 were not wearing PPE. During a concurrent observation and interview on 7/23/2026 at 4:36 PM, there was signage posted near Resident 84's doorway indicating Resident 84 was on EBP. CNA 9 stated CNA 9 and CNA 10 just transferred Resident 84 back to Resident 84's bed using the mechanical lift (a specialized assistive device used in healthcare to safely move, transfer, or lift residents who have limited mobility). CNA 9 stated CNA 9 and CNA 10 did not wear PPE while transferring Resident 84 inside Resident 84's room. CNA 9 stated staff (in general) needed to wear PPE during Resident 84 transfers to protect Resident 84 and themselves during close physical contact. During a review of the facility's policy and procedure (P&P) titled, Standard and Enhanced Precautions, revised 4/1/2024, the P&P indicated gloves are worn when direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material is anticipated. The P&P indicated a gown is worn to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing. The P&P further indicated for residents whom EBP is indicated, EBP should be used when performing the following high-contact resident care activities: vii. Device care or use: feeding tube.

Based on observation, interview, and record review, the facility failed to ensure call lights were answered promptly for three of three sampled residents (Resident 28, Resident 13, and Resident 76).This deficient practice had the potential to result in unmet needs to Resident 28, Resident 13, and Resident 76 due to the residents being unable to call for assistance from staff or alert staff during an emergency. Cross Reference F550Findings:1. During a review of Resident 28's admission Record (AR), the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that included encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems), generalized muscle weakness, reduced mobility, depression (a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition marked by excessive fear, constant worry, and physical tension that do not go away and make it hard to live your normal daily life).During a review of Resident 28's History and Physical (H&P), dated 11/14/2026, the H&P indicated Resident 28 did not have the capacity to understand and make decisions.During a review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 7/13/2026, the MDS indicated Resident 28 had moderately impaired cognitive (the ability to think and process information) skills for daily decision making. The MDS indicated Resident 28 was dependent (helper does all of the effort, the resident does none of the effort to complete the activity) on physical assistance for toileting hygiene and was always incontinent (involuntary loss of bladder [hollow muscular balloon-like organ that stores urine] or bowel control) of bowel and bladder.During an observation on 7/20/2026 at 2:11 PM in Resident 28's room, Resident 28 was sitting in the wheelchair, repeating incomprehensible words and kept pressing the call light.During a concurrent observation and interview on 7/20/2026 at 2:33 PM with Certified Nursing Assistant (CNA) 4 in Resident 28's room, Resident 28 continued to repeat incomprehensible words and pointed to her abdomen. CNA 4 stated when Resident 28 pointed to her G-tube (soft flexible tube surgically inserted directly into the stomach through a small opening in the abdomen, used to deliver liquid nutrition, hydration, and medications for people who cannot eat or swallow safely), Resident 28 wanted to be disconnected and to go to the activities room.2. During a review of Resident 13's AR, the AR indicated Resident 13 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including acquired absence of left leg above knee, muscle weakness, depression, anxiety disorder, and legal blindness.During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13's cognition was intact.During a concurrent observation and interview on 7/20/2026 at 2:53 PM in Resident 13's room, Resident 13 stated Resident 13 had told a female CNA (unidentified) Resident 13 had pain and wanted Tylenol (medication used to relive pain). Resident 13 stated Resident 13 had been waiting 20-30 minutes for the medication. Resident 13 was observed pressing Resident 13's call light. During an observation on 7/20/2026 at 3:04 PM in Resident 13's room, CNA 4 entered the room, turned off the call light, and walked away from Resident 13 and toward the door. Licensed Vocational Nurse (LVN) 3 was standing on Resident 13's doorway and asked CNA 4 what Resident 13 needed. CNA 4 stated, I don't know, turned back toward Resident 13, and asked what Resident 13 needed. Resident 13 stated Resident 13 wanted Tylenol. 3. During a review of Resident 76's AR, the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait, mobility, and muscle weakness.During a review of Resident 76's H&P, dated 7/1/2026, the H&P indicated Resident 76 had the capacity to understand and make decisions.During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76's cognition was intact. The MDS indicated Resident 76 was dependent on physical assistance for toileting hygiene and was frequently incontinent of bowel and bladder.During a review of Resident 76's Concern/Grievance Report, dated 7/9/2026, the grievance report indicated Resident 76 had turned on Resident 76's call light at 4:28 AM for assistance and then called the facility at 5:05 AM because no one [staff] answered Resident 76's call light. The report indicated Resident 76 was told someone would be sent to assist Resident 76. The report indicated a CNA (unidentified) came to assist Resident 76 at 5:30 AM. The report indicated the CNA seemed bothered and said, What, I'm busy. I have other patients. You're not the only one.During an interview on 7/21/2026 at 9:40 AM with Resident 76, Resident 76 stated Resident 76 had been in the facility for 21 days and recently (no date recall) Resident 76 pressed Resident 76's call light to ask for an adult brief change and Resident 76's call light was not answered for three hours. Resident 76 stated Resident 76 took herself to the bathroom using the bedside table. Resident 76 stated Resident 76 was told by the Director of Staff Development (DSD) any CNA (in general) could answer Resident 76's call light. Resident 76 stated staff (in general) had told Resident 76 they were not Resident 76's CNAs but to be patient while they located Resident 76's assigned CNA. Resident 76 stated, how can I be patient when I have been waiting 2-3 hours?!During a concurrent observation and interview on 7/22/2026 at 1:15 PM, Resident 76's call light was turned on (light outside of Resident 76's room). Upon entering Resident 76's room, Resident 76 stated Resident 76 had pressed her call light 20 minutes ago and was also calling the nurses station but Resident 76's call light and phone call were not being answered.During a concurrent observation and interview on 7/22/2026 at 1:26 PM, with LVN 5 and in nursing station 2, a call light was beeping and the surveyor asked LVN 5, what is that noise? LVN 5 stated it was the ventilator (a medical machine that moves air in and out of the lungs when the residents cannot breathe well on their own) alarm, a Respiratory Therapist (RT, unidentified) standing in the nursing station stated [the beeping sound] was a call light. There was an unidentified staff member walking by the nursing station and LVN 5 asked the staff to look for the call light and answer the call light immediately. During a review of the facility's policy and procedure (P&P) titled, Communication - Call System, dated 11/1/2017, the P&P indicated the purpose was to provide a mechanism for residents to promptly communicate with the nursing staff. The P&P indicated nursing staff will answer call bells promptly, in a courteous manner. The P&P indicated when answering a request, nursing staff will return to resident with the item or reply promptly.

Based on observation, interview, and record review, the facility failed to ensure a dignified environment when call lights were not answered promptly for two of three sampled residents (Resident 28 and Resident 76).This deficient practice resulted in Resident 28 feeling upset and sad and Resident 76 feeling ignored, frustrated, and stressed. Additionally, the deficient practice had the potential to affect Resident 28 and 76's psychosocial wellbeing. Cross Reference F919Findings:1. During a review of Resident 28's admission Record (AR), the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that included encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), generalized muscle weakness, reduced mobility, depression (a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition marked by excessive fear, constant worry, and physical tension that do not go away and make it hard to live your normal daily life).During a review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 7/13/2026, indicated Resident 28's had moderately impaired cognitive (the ability to think and process information) skills for daily decision making. The MDS indicated Resident 28 was dependent (helper does all of the effort, the resident does none of the effort to complete the activity) on physical assistance for toileting hygiene and always incontinent (involuntary loss of bladder [hollow muscular balloon-like organ that stores urine]or bowel control) of bowel and bladder.During a review of Resident 28's History and Physical (H&P), dated 11/14/2026, the H&P indicated, Resident 28 does not have the capacity to understand and make decisions.During an observation on 7/20/2026 at 2:11 PM in Resident 28's room, Resident 28 was sitting in the wheelchair, repeating incomprehensible words and kept pressing the call light. Resident 28 appeared upset when Resident 28 had Resident 28's eyebrows scrunched and her nose was wrinkled. Resident 28 touched Resident 28's abdomen, her eyes appeared watery, and Resident 28 wiped her eyes with a tissue. During a concurrent observation and interview on 7/20/2026 at 2:33 PM with Certified Nursing Assistant (CNA) 4 in Resident 28's room, Resident 28 continued to repeat incomprehensible words and pointed to her abdomen. CNA 4 stated when Resident 28 pointed to her G-tube (soft flexible tube surgically inserted directly into the stomach through a small opening in the abdomen, used to deliver liquid nutrition, hydration, and medications for people who cannot eat or swallow safely), Resident 28 wanted to be disconnected and to go to the activity room.2. During a review of Resident 76's AR, the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including abnormalities of gait, mobility, and muscle weakness.During a review of Resident 76's H&P, dated 7/1/2026, the H&P indicated Resident 76 had the capacity to understand and make decisions.During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76's cognition was intact. The MDS indicated Resident 76 was dependent on physical assistance for toileting hygiene and was frequently incontinent of bowel and bladder.During a review of Resident 76's Concern/Grievance Report, dated 7/9/2026, the grievance report indicated Resident 76 had turned on Resident 76's call light at 4:28 AM for assistance and then called the facility at 5:05 AM because no one [staff] answered Resident 76's call light. The report indicated Resident 76 was told someone would be sent to assist Resident 76. The report indicated a CNA (unidentified) came to assist Resident 76 at 5:30 AM. The report indicated the CNA seemed bothered and said, What, I'm busy. I have other patients. You're not the only one.During an interview on 7/21/2026 at 9:40 AM with Resident 76, Resident 76 stated she has been in the facility for 21 days and has been left in a wet diaper for 3 hours despite using her call light for assistance. Resident 76 stated she felt ignored and frustrated and took herself to the bathroom using the bedside table. Resident 76 stated when the call light was finally answered Resident 76 was told by the unidentified staff answering the call light that it was better to urinate in Resident 76's diaper than risking a fall on the way to the bathroom. Resident 76 raised her voice and stated, how can I be patient when I have been waiting 2-3 hours?! Resident 76 stated, when Resident 76's door was open, she saw staff (in general) pass by and ignored Resident 76's call light until she yelled hello! to get that staff's attention. Resident 76 stated she also called the facility operator to connect her to the nurse's station [to get assistance form staff] and the phone rang and rang, sometimes they answer and sometimes they don't. Resident 76 stated this had caused Resident 76 a lot of stress.During a review of the facility's policy and procedure (P&P) titled, Communication - Call System, dated 11/1/2017, the P&P indicated the purpose was to provide a mechanism for residents to promptly communicate with the nursing staff. The P&P indicated nursing staff will answer call bells promptly, in a courteous manner.During a review of the facility's P&P, titled Privacy and Dignity, dated 11/1/2017, the P&P indicated the purpose was to ensure care and services provided to the facility promote and/or enhance privacy, dignity and overall quality of life. The P&P's procedure indicated staff assists the residents in maintaining self-esteem and self-worth. The P&P indicated staff treats residents with respect including respecting their social status, speaking respectfully, and listening carefully.

Based on observation, review and record review, the facility failed to provide reasonable accommodation and preferences of one of one sampled resident (Resident 97) by not having a working television in Resident 97's room.This deficient practice had the potential to put Resident 7's activity need was not met.Findings:During a review of Resident 97's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities) with psychotic disturbance (a mental disruption where a person loses touch with reality, mainly through hallucinations, delusions and confused thinking) and mood [affective] disorder (a mental health condition that causes long-lasting extreme shifts in a person's emotional state, primarily depression, mania, or both).During a review of Resident 97's History and Physical (H&P), dated 9/13/2025, the H&P indicated, Resident 97 does not have the capacity to understand and make decisions.During a review of Resident 97's Activities Progress Note, dated 5/13/2026, the note indicated Resident 97's current activity preferences include 9. Watching TV/Movies in a group, 1:1, Independent, and with Family. Additional Notes/Comments indicate Resident 97 continues with room visits 2 to 3 times per week such as soothing music and sensory stimulation (vision, hearing and mental) W/EBP (with Evidence-Based Practice, the intentional, systematic application of environmental or physical inputs-targeting auditory, visual, olfactory, gustatory, or tactile modalities-guided by empirical research to promote behavioral responsiveness, neural arousal, or emotional self-regulation) at all times.During a review of Resident 97's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 5/18/2026, the MDS indicated Resident 97's cognitive (the ability to think and process information) skills for daily decision-making were severely impaired; making self rarely/never understood and the ability to sometimes understand others. The MDS indicated Resident 97 was dependent on assistance from staff for transfer, dressing, toilet use, and bathing.During an observation on 7/20/2026 at 2:00 PM in Resident 97's room, the TV was powered on with a black background and white lines on the left corner of the TV screen.During a concurrent observation and interview on 7/23/2026 at 11:37 AM with the Activities Assistant (AA) in Resident's 97's room, Resident 97's TV was powered on with a black background and white lines on the left corner of the TV screen. The AA stated that she was unaware of the television not working.During a concurrent interview and Record Review on 7/23/2026 at 11:37 AM with the Activities Director (AD) (at the same time with the interview with the AA), Resident 97's Daily Activities Attendance, dated July 2026, was reviewed. The Daily Activities Attendance indicated the last documented day when Resident 97 watched TV in her room was on 7/7/2026. The AD stated, the last recorded time Resident 97 watched TV in her room was on 7/7/2026. The AD stated watching TV is important for Resident 97's sensory stimulation. During a review of the facility's policy and procedure (P&P) titled, Resident Rights - Accommodation of Needs, dated 5/31/2023, the P&P indicated, VI. Facility Staff interacts with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains each resident's dignity.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan with goals and interventions for one of one sampled resident (Resident 4), after Resident 4 was diagnosed with pneumonia (PNA, an infection that inflames the small air sacs (alveoli) in one or both lungs) and received antibiotic (powerful medicines that treat bacterial infections by killing bacteria or stopping them from growing).This deficient practice had the potential to result in delay and ineffective care and treatment for Resident 1.Findings:During a review of Resident 4's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included chronic respiratory failure (a long-term condition where the lungs cannot properly move oxygen into the blood or remove carbon dioxide from it) with hypoxia (a medical condition where your body tissues do not get enough oxygen to work properly) and tracheostomy (a surgical procedure that creates a small opening in the neck and windpipe to insert a breathing tube).During a review of Resident 4's History and Physical (H&P), dated 5/14/2026, the H&P indicated, Resident 4 does not have the capacity to understand and make decisions.During a review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 6/11/2026, the MDS indicated Resident 4 had limited abilities to make self-understood and is usually understands. During a review of Resident 4's Order Summary Report (OSR) for July 2026, the OSR indicated Cefepime HCL Solution 2GM (gram)/100ML (milliliter). Use 2 gram intravenously (IV, within a vein. It refers to the delivery of liquid medicines, fluids, blood, or nutrients directly into a person's bloodstream through a tube or needle) every 8 hours for PNA for 7 days. The OSR indicated the order status was completed with an order date of 7/14/2026. The OSR indicated the start date for the medication administration was on 7/14/2026 and the end date was on 7/21/2026.During a review of Resident 4's Medication Administration Record (MAR) from Registered Nurses (RNs), for July 2026, the MAR-RN indicated Cefepime HCL Solution 2 GM/100ML Use 2 gram intravenously every 8 hours for PNA for 7 days. The MAR-RN indicated the first dose of the medication was given on 7/14/2026 at 2200 and the last dose was given on 7/21/2026 at 1400 without any missed doses noted.During a review of Resident 4's SBAR Communication Form (a structured communication tool that stands for Situation, Background, Assessment, and Recommendation) and Progress Note, dated 7/14/2026, the SBAR indicated, PNA as per CXR (chest x-ray) result (IVABX [intravenous antibiotics] Cefepime 2G Q8 x 7 days).During an interview on 7/22/2026 at 1:20PM with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated she was unable to see any mention of pneumonia or antibiotic medications in Resident 4's care plan besides a care plan for the peripheral IV site, dated 7/20/2026 for Resident 4.During an interview on 7/22/2026 at 1:30 PM with LVN 5, LVN 5 stated she was able to find a care plan for the peripheral IV site dated 7/20/2026 and a care plan for a previous diagnosis of pneumonia with amoxicillin (comment prescription oral [taken by mouth] antibiotic medication). LVN 5 stated the license nurses (LVNs and RN supervisors) would complete the care plans (in general, all care plans). LVN 5 continued to state that the importance of having a care plan is to coordinate how to care for the patient/resident. LVN 5 stated the care plan for Resident 4's most current pneumonia should have been done due to Resident 4's respiratory risk. LVN 5 stated the IV antibiotic medication administration also needed an individualized care plan.During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 10/24/2022, the P&P indicated, Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to obtain a physician order prior to the use of a low air loss mattress (LALM- special type of mattress used for the prevention and treatment of [pressure injuries (PI, lesion/wound caused by unrelieved pressure usually over a bony prominence that results in damage of underlying tissue)], prioritizes moisture control and temperature regulation to prevent skin breakdown) for one of five sampled residents (Resident 92).This deficient practice resulted in an incorrect LALM setting and had the potential to result in further skin breakdown and a physical decline to Resident 92.Cross Reference F656Findings:During a review of Resident 92's admission Record (AR), the AR indicated the facility admitted Resident 92 on 7/9/2026 with diagnoses including reduced mobility, pressure ulcer (PI), and muscle weakness.During a review of Resident 92's History & Physical (H&P), dated 7/10/2026, the H&P indicated Resident 92 did not have the capacity to understand and make decisions.During a review of Resident 92's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2026, the MDS indicated Resident 92's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated Resident 92 was dependent (helper does all of the effort) with activities of daily living (AOL, term used in healthcare that refers to self-care activities) and was dependent on mobility.During a review of Resident 92's Weights and Vitals Summary (WVS), dated 7/19/2026, the WVS indicated Resident 92's weight was 150 lbs.During a review of Resident 92's Order Summary Report (OSR), dated active as of 7/22/2026, the OSR indicated a physician order for Resident 92's LALM indicating to check for placement and functionality for wound management or skin maintenance management. The physician order start date was 7/22/2026. During an observation on 7/20/2026 at 9:54 AM, Resident 92 was observed lying on the bed on Resident 92's right side on a LALM. The LALM control unit indicated the pressure dial was set to 350 pounds (lbs, unit of weight).During a concurrent interview and record review on 7/22/2026 at 3:10 PM, with Treatment Nurse (TN) 1, Resident 92's OSR was reviewed. TN 1 stated Resident 92 was placed on a LALM without a physician order. TN 1 emphasized that obtaining an order was important to confirm medical necessity, program the correct settings [by following the order], and to ensure proper monitoring. TN 1 stated Resident 92's LALM was not set according to Resident 92's actual weight and stated that a mattress that was too firm could cause increased pressure, pain, and skin breakdown or the development of new PIs to Resident 92.During a review of the facility's policy and procedure (P&P) titled, Physician Orders, revision date 5/1/2019, the P&P indicated treatment orders will include the following:A description of the treatment, including the treatment site, if applicable;The frequency of treatment and duration of order (when appropriate); andThe condition/diagnosis for which the treatment is ordered.

Based on interview and record review, the facility failed to ensure the tracheostomy tube (TT-a curved hollow tube placed through a surgical opening in the neck into the windpipe to help a person breathe) was changed monthly for one of four sampled residents (Resident 1), This failure had the potential to result in a respiratory infection (an illness affecting the airways or lungs) to Resident 1. During a review of Resident 1's admission Record (AR). the AR indicated an initial admission to the facility on [DATE], and readmission on [DATE] with diagnoses of paraplegia (loss of movement and feeling in the lower half of the body), pressure injury to left buttock stage 4 (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore), chronic respiratory failure (a condition where the lungs cannot move enough oxygen in or carbon dioxide out, leading to low oxygen or high carbon dioxide I the blood), TT, and diabetes mellitus (elevated blood glucose levels). During a review of History and Physical Examination (H&P) dated 11/03/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of the treatment administration record (TAR), dated January 2026, the TAR indicated no signature documented for TT change in the month of January 2026. During a review of Resident 1's Minimum Data Set (MDS: a standardized assessment and care planning screening tool) dated 05/05/2026, the MDS indicated Resident 1 had no cognitive impairment. The MDS indicated Resident 1 was totally dependent with two-person assist with toilet use and required extensive assistance (2 staff provide weight bearing support) with eating, bed mobility, transfers, dressing, and personal hygiene. The MDS indicated Resident 1 had unhealed pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin). During an interview on 07/20/2026 at 10:25 a.m. with Respiratory Therapist 1 (RT 1-a specialized healthcare professional who cares for patients with breathing disorders, managing tasks like oxygen therapy, mechanical ventilators, and diagnostic lung testing), RT 1 stated, there was a standing order for changing the whole TT system once a month and as needed. RT 1 stated the the initial TT change was scheduled during the day shift, upon admission, either on the initial admission, or re-admission from GACH. During an interview on 07/22/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated TT change is completed monthly per standing order and as indicated in the facility's policy and procedure (P&P). The DON stated, during the month of January, Resident 1's TT was not changed. the DON stated the RTs did not follow the facility's P&P. The DON stated not changing Resident 1's TT monthly would put Resident 1 as increased risk of respiratory infection. During a review of the facility's P&P titled, Tracheostomy Tube - Change, Dated May 1, 2024, the P&P indicated, Purpose to reduce the incidence of infection, to replace defective tubes, to replace tubes after accidental extubation, and/or to change style of size upon the physician's order. Residents' tracheostomy tubes will be routinely changed monthly by a licensed Nurse of Respiratory Therapist.

Based on interview and record review, facility's nursing staff failed to follow the facility's policies and procedure (P&P) on medication administration for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 did not swallowing the pain medication that was administered and ineffective pain management for Resident 1.During a review of Resident 1's admission Record (AD), the AD indicated an initial admission to the facility on [DATE], and readmission on [DATE] with diagnoses of paraplegia (loss of movement and feeling in the lower half of the body), pressure injury to left buttock stage 4 (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore), chronic respiratory failure (a condition where the lungs cannot move enough oxygen in or carbon dioxide out, leading to low oxygen or high carbon dioxide I the blood), TT, and diabetes mellitus (elevated blood glucose levels). During a review of History and Physical Examination (H&P) dated 11/03/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS: a standardized assessment and care planning screening tool) dated 05/05/2026, the MDS indicated Resident 1 had no cognitive impairment. The MDS indicated Resident 1 was totally dependent with two-person assist with toilet use and required extensive assistance (2 staff provide weight bearing support) with eating, bed mobility, transfers, dressing, and personal hygiene. The MDS indicated Resident 1 had unhealed pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin). A review of Resident 1's physician order dated 06/28/2026, the order indicated Ibuprofen oral tablet 800 milligrams (mg), give 1 tablet by mouth every 6 hours as needed for pain management (pain scale of 4-6). The order indicated for Resident 1 to take the medication with food and full glass of water. A review of the Medication Administration Record (MAR) dated June 2026, the MAR indicated Ibuprofen was given on 06/28/2026 at 6:30 a.m. for a pain level of 3 out of 10. A review of situation background, assessment, and recommendation (SBAR) note dated 06/28/2026 at 9:29 a.m., the note indicated during rounds [on 6/28/2026] at 8:00 a.m. Resident 1 addressed concern to the charge nurse that Resident 1 has asked the NOC shift nurse for pain medication, and the pain medication was given to him. The note indicated Resident 1 removed a pill from speaking valve container and showed the charge nurse a pill. During an interview on 7/16/2026 at 3:00 p.m. with Resident 1, Resident 1 stated, about 2 weeks ago I asked for a pain pill and Licensed Vocational Nurse 2 (LVN 2) made a mistake and gave me a different pill. Resident 1 stated I saved it and gave it to my next nurse. During a telephone interview on 07/21/2026 at 10:10 a.m. with LVN2, LVN 2 stated, LVN 2 gave Resident 1 pain medication. LVN 2 stated I did not explain what the name of the medication was, and I did not verify Resident 1 swallowed the medication. LVN 2 stated I did not follow the policy and procedure. During an interview on 7/22/2026 at 3:00 p.m. with the Director of Nursing (DON), the DON stated LVN 2 did not explain to Resident 1 what medication he was administering nor did he wait for Resident 1 to swallow the medication. The DON stated the negative outcome could be Resident 1 was in pain or Resident 1 could hold the medication and consume it with all at once with other pain medication. The DON stated LVN 2 did not follow the facilities P&P on medication administration. During a review of the facility's P&P titled, Medication - Administration, dated November 01, 2017, the P&P indicated, Purpose to provide practice standards for safe administration of medications for residents in the facility. Medication will not be left at the bedside, and the resident has the right to know what the medication does.

Based on interview and record review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 1) who was high risk for developing pressure injuries (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore) by failing to ensure Resident 1 was turned every 2 hours on 06/11/2026 at 4:00 p.m., 6:00 p.m., and 10 p.m. This deficient practice had the potential to cause further skin breakdown and delay of wound healing for Resident 1. During a review of Resident 1's admission Record (AR). the AR indicated an initial admission to the facility on [DATE], and readmission on [DATE] with diagnoses of paraplegia (loss of movement and feeling in the lower half of the body), pressure injury to left buttock stage 4 (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore), chronic respiratory failure (a condition where the lungs cannot move enough oxygen in or carbon dioxide out, leading to low oxygen or high carbon dioxide I the blood), and diabetes mellitus (elevated blood glucose levels). During a review of History and Physical Examination (H&P) dated 11/03/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Care Plan (CP) for repositioning needs dated 05/04/2026, the CP indicated Patient will be repositioned at lease every 2 hours and as requested. During a review of Resident 1's Minimum Data Set (MDS: a standardized assessment and care planning screening tool) dated 05/05/2026, the MDS indicated Resident 1 had no cognitive impairment. The MDS indicated Resident 1 was totally dependent with two-person assist with toilet use and required extensive assistance (2 staff provide weight bearing support) with eating, bed mobility, transfers, dressing, and personal hygiene. The MDS indicated Resident 1 had unhealed pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin). During a review of Resident 1's initial Braden Scale Assessment for Predicting Pressure Sore Risk on readmission dated 06/04/2026, the assessment indicated Resident 1 was assessed as high risk in developing a pressure related injury. During an interview on 07/16/2026 at 3:00 pm with Resident 1, Resident 1 stated there was a day I was not turned but I can't remember the date, you should look at binder. During a concurrent interview and record review on 07/22/2026 at 3:00 pm with Director of Nursing (DON), the DON stated residents should be turned every 2 hours and the turning binder for Resident 1 is missing turning times on 06/11/2026 at 4:00 pm, 6:00 pm, and 10:00 pm. The DON stated according to the documentation, Certified Nurse Assistant (CNA) 8 did not follow the facility's Policy and Procedure (P&P). The DON stated not following the P&P puts Resident 1 at risk for more skin break down. During a review of the facility's P&P titled, Positioning and Body Alignment, dated November 1, 2017, the P&P indicated, Purpose to improve or maintain the resident's self-performance in moving to and from a laying position, turning side to side, and positioning while in bed. Positioning and body alignment activities are individualized to the resident's needs, planned, monitored, evaluated and documented in the resident's medical record. Techniques E. Change the resident's position every 2 hours, or as otherwise indicated or ordered by the attending Physician.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident's (Resident 4) head of the bed (HOB) was kept between 30 to 45 degrees when Resident 4's gastrostomy tube (GT - a tube inserted into an artificial external opening in the stomach for nutritional support) feeding was running (Resident 4 received nutrition), the facility failed to turn off Resident 4's GT feeding when Resident 4's HOB was lowered to a flat position.This deficient practice had the potential to result in aspiration pneumonia (a serious complication of GT feeding when food, liquid, or other materials enter the lungs causing an infection) and a physical decline to Resident 4.Findings:During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 5/12/2025, with diagnoses that included chronic respiratory failure (long lasting condition that requires ventilatory support or supplemental oxygen [colorless odorless gas] due to inadequate gas exchange) and dysphagia (difficulty swallowing).During a review of Resident 4's Minimum Data Set (MDS -a resident assessment tool), target date 5/1/2026, the MDS indicated Resident 4's cognitive (the ability to think and process information) was severely impaired. The MDS indicated Resident 4 was dependent on staff for activities of daily living.During an observation on 6/10/2026 at 1:20 PM, Certified Nursing Assistant (CNA) 1 entered Resident 4's room and lowered Resident 4's HOB to a flat position. CNA 1 prepared items needed for pericare (process of gently washing a person's private parts, performed daily), removed the nasal cannula (NC, lightweight flexible plastic tube with two prongs that sit in the nostrils to deliver supplemental oxygen) prongs from Resident 1's nose, removed Resident 1's gown, and began wiping Resident 1's face. Resident 1's GT feeding remained running during pericare.During a concurrent observation and interview on 6/10/2026 at 1:30 PM, with Licensed Vocational Nurse (LVN) 1, Resident 4's HOB was in a flat position, LVN 1 stated the GT feeding needed to be turned off [due to the lowered HOB]. LVN 1 turned off Resident 4's GT feeding. During an interview on 6/10/2026 at 3:05 PM, CNA 1 stated CNA 1 did not ask the licensed nurse (in general) to turn off Resident 4's GT feeding prior to lowering Resident 4's HOB. CNA 1 stated CNA 1 thought Resident 4's GT feeding was already off. CNA 1 stated GT feedings needed to be turned off when the HOB was lowered to prevent food (GT feeding) from going back up the throat and into the lungs.During an interview on 6/11/2026 at 11:10 AM, with the Director of Staff Development (DSD), the DSD stated GT feedings needed to be turned off when the HOB was lowered during paricare.During a review of Resident 1's Order Summary Report (OSR) that include a physician's order, initiated on 3/9/2026, the order indicated to elevate the HOB 30-45 degrees at all times while feeding was on [running].During a review of the facility's Policy and Procedure (P&P) titled Bolus Feeding, dated 5/1/2026, the P&P indicated to limit the risk for aspiration and reflux (stomach acid comes back up to the back of the throat), raise the HOB 30-45 degrees during [GT] feeding and for 1 hour after feeding.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment for one of one sampled resident (Resident 1) when Certified Nursing Assistant 1 provided pericare (process of gently washing a person's private parts, performed daily) to Resident 1 and used the sink instead of a wash basin in accordance with the facility's Policy and Procedure (P&P) titled Perineal Care. This deficient practice had the potential to result in the development and spread of infections (the invasion and growth of germs in the body) and the potential to result in a urinary tract infection (UTI - an infection in the bladder/urinary tract) to Resident 1. Findings:During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 5/12/2025, with diagnoses that included chronic respiratory failure (long lasting condition that requires ventilatory support or supplemental oxygen [colorless odorless gas] due to inadequate gas exchange) and dysphagia (difficulty swallowing).During a review of Resident 4's Minimum Data Set (MDS -a resident assessment tool), target date 5/1/2026, the MDS indicated Resident 4's cognitive (the ability to think and process information) was severely impaired. The MDS indicated Resident 4 was dependent on staff for activities of daily living.During an observation on 6/10/2026 at 1:20 PM, CNA 1 entered Resident 4's room and lowered Resident 4's head of the bed. CNA 1 prepared items needed for pericare, took a large towel from the bedside table, placed the towel inside the bathroom sink and ran the water. CNA 1 poured liquid body wash onto the towel and the water in the sink became bubbly. CNA 1 removed Resident 4's gown and used the wet towel from the sink to clean Resident 4's face. Next, CNA 1 removed Resident 4's diaper, squeezed the same wet towel and soapy water dripped to Resident 4's perineal (private) area. CNA 1 went back to the bathroom dipped the towel in the sink's soapy water, returned to Resident's bedside, and squeezed the same towel dripping water on Resident 4's perineal area. CNA 1 continued pericare by drying Resident 4's perineal area with a dry towel.During an interview on 6/11/2026 at 11:10 AM with the Director of Staff Development (DSD), the DSD stated the DSD followed the CNAs (in general) during the completion of the orientation's Competency Evaluation Checklist. The DSD stated, through this evaluation, the CNAs demonstrated perineal care that included gathering supplies such as a basin, towels, wash cloths. The DSD stated CNA's should not put pericare towels (used during pericare) directly on the bathroom sinks. The DSD stated the sink became dirty and the sink was shared by other residents (multi resident room).During an interview on 6/11/2026 at 2:54 PM, CNA 1 stated CNA 1 did not use a wash basin and stated Resident 4 did not have a wash basin. CNA 1 stated CNA 1 had never used a basin for Resident 4's pericare and CNA 1's practice was to always use the sink. CNA 1 stated CNA 1 needed to use a basin because the sink was dirty.During a review of the facility's P&P titled Perineal Care dated November 1, 2017, the P&P indicated the purpose of Perineal Care was to maintain cleanliness of the genital area, to reduce odor and to prevent infection or skin breakdown. The P&P indicated to prepare the following equipment for Perineal Care that included a washbasin, soap, washcloths, bath towel, pad, gloves.to put on gloves, wash the pubic area, wash the penis from the urethral opening or tip of the penis, wash the scrotum, rinse and dry.During a review of the facility's P&P titled Infection Prevention and Control Program (IPCP) dated October 24, 2022, the P&P indicated the purpose of the IPCP was to ensure the facility established and maintained an Infection Control Program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection in accordance with federal and state requirements.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 6) with tracheostomy tube (a curved tube inserted into a surgically created opening in the neck [stoma] and into the windpipe [trachea] to provide an alternative airway for breathing) received necessary care and services when:1. The cause of Resident 6's accidental decannulation (accidental removal of tracheostomy tube from the stoma) on [DATE] was not investigated.2. A care plan (CP - summary of a person's health condition, care needs, treatments, goals of treatment, and specific interventions for each identified condition or care need) regarding Resident 6's accidental decannulation was not developed and implemented.These failures placed Resident 6 and other residents with tracheostomy tube at risk for accidental decannulation which could negatively affect the residents' health and well-being.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 acute respiratory failure with hypoxia (when the lungs suddenly cannot get enough oxygen into the blood or remove carbon dioxide [waste gas made in the body's cells] from the blood) and pulmonary embolism (a blood clot that blocks and stops blood flow to the lungs). The AR indicated Resident 6 had a tracheostomy tube.During a review of Resident 6's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 6 had fluctuating capacity to understand and make decisions.During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 6 had mildly impaired cognitive skills (ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 6 was dependent on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 6's Care Plan Report (CPR), initiated on [DATE], the CPR indicated Resident 6 had a tracheostomy related to impaired breathing mechanics. The CPR interventions included ensuring tracheostomy ties are secured at all times.During a review of Resident 6's SBAR Communication Form (SBAR- situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated [DATE] and timed at 8:04 AM, the SBAR indicated Resident 6 had an accidental decannulation while being red capped (process of placing a plug [red cap] to cover the opening of a tracheostomy tube to test if the individual can breathe on their own without the tracheostomy tube) on [DATE]. The SBAR indicated Resident 6 complained of pain at the tracheostomy site after being red capped and restorative nursing assistant (RNA, certified nursing assistant who had special training in ambulation, range of motion exercises, applying and removing splints, and positioning) (unidentified) and charge nurse (unidentified) immediately observed Resident 6's tracheostomy tube was out of place.During a review of Resident 6's Respiratory Therapy Note (RTN), dated [DATE] and timed at 9:25 AM, the RTN indicated Resident 6 had an episode of decannulation around 8:40 AM on [DATE]. The RTN indicated Resident 6's tracheostomy tube was reinserted, and the tracheostomy tie was secured.During a review of Resident 6's medical record, there was no documentation regarding how Resident 6's tracheostomy tube accidentally came out on [DATE].During a review of Resident 6's current care plans (CPs), there was no care plan regarding Resident 6's episode of accidental decannulation on [DATE].During an interview on [DATE] at 1:46 PM with Resident 6, Resident 6 stated Resident 6's tracheostomy tube had been accidentally disconnected while being repositioned and cared for by a CNA (unidentified) once before. Resident 6 was unable to remember when the incident happened.During a phone interview on [DATE] at 2:57 PM with RNA 1, RNA 1 stated on the morning of [DATE] Resident 6 told RNA 1 Resident 6's tracheostomy felt uncomfortable. RNA 1 stated RNA 1 did not know Resident 6 had an accidental decannulation on [DATE].During a phone interview on [DATE] at 4:35 PM with Respiratory Therapist (RT) 1, RT 1 stated Resident 6 had an accidental decannulation on [DATE]. RT 1 stated Resident 6 told RT 1 on [DATE] that Resident 6's tracheostomy came out after certified nursing assistants (CNAs) (unidentified) repositioned and changed Resident 6.During a phone interview on [DATE] at 2:14 PM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated licensed nurses should have developed and implemented a care plan after Resident 6 had an accidental decannulation. LVN 5 stated LVN 5 did not know the reason and the details regarding Resident 6's accidental decannulation on [DATE].During a phone interview on [DATE] at 4:25 PM with Registered Nurse (RN) 2, RN 2 stated RN 2 should have developed and implemented a care plan after Resident 6 had an accidental decannulation on [DATE] to provide care, to monitor for respiratory distress and vital signs (measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature), and to prevent accidental decannulation again. RN 2 stated RN 2 did not know the reason or details that caused Resident 6's accidental decannulation on [DATE].During a concurrent interview and record review on [DATE] at 3:40 PM with the Assistant Director of Nursing (ADON), Resident 6's SBAR, dated [DATE], and current CPs were reviewed. The ADON stated licensed nurses should have developed and implemented a CP regarding Resident 6's accidental decannulation on [DATE]. The ADON stated it was important to create a care plan regarding Resident 6's accidental decannulation to prevent decannulation again and to maintain the resident's well-being.During an interview on [DATE] at 4:55 PM with the Director of Nursing (DON), the DON stated the facility did not investigate Resident 6's accidental decannulation on [DATE] and did not know the cause of the accidental decannulation. The DON stated it was important to investigate the accidental decannulation to find the cause and create a care plan regarding resident's accidental decannulation to provide care to prevent decannulation again and maintain resident's well-being.During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, revised [DATE], the P&P indicated that the facility should ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The P&P indicated, A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed bases.During a review of the facility's P&P titled, Change of Condition Notification, dated [DATE], the P&P indicated when there is an accident involving a resident a licensed nurse must Update the Care Plan to reflect the resident's current status and A Licensed Nurse will document each shift for at least seventy-tow (72) hours.

Based on interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two sampled residents, (Resident 1) who was assessed as needing contact guard assistance (CGA, place one or two hands on the resident's body to help with balance) with ambulation, by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA) 1, CNA 2, Licensed Vocational Nurse (LVN) 1, and LVN 2, who were assigned to take care of Resident 1, were made aware by Physical Therapist 1 (PT 1, a licensed medical professional who helps patients/residents improve their ability to move and function) that Resident 1 required touching assistance (helper provides verbal cues and/or tactile [touch] cues or contact guard assistance while the resident completes activity) with ambulation on level surfaces and walking ten feet. 2. Provide touching assistance to Resident 1 while Resident 1 walked in the room, from the closet to Resident 1's bed. As a result, on 8/23/24 at around 9 pm, Resident 1 fell while walking from the closet to Resident 1's bed. Resident 1 experienced 10/10 pain (on a scale of 0 to 10 [0 representing no pain and 10 representing the worst pain imaginable]) on the right groin area (area where the lower abdomen meets the inner thigh). The facility transferred Resident 1 to General Acute Hospital 1 (GACH 1) for further evaluation. At GACH 1, Resident 1 was found to have a fracture (a break in a bone) through the transcervical region (the middle portion) of the right femoral neck (the part of the thigh bone that connects the femoral head [the top of the thigh bone] to the femoral shaft [the long, straight part of the thigh bone]). Resident 1 was hospitalized at the GACH 1 for 20 days (from 8/23/24 to 9/12/24). On 8/26/24, Resident 1 underwent a partial right hip arthroplasty (a surgical procedure to replace part of the hip joint with a prosthetic [artificial] implant). Cross reference F656 Findings: During a review of Resident 1's Admission Record, the admission record indicated the facility admitted Resident 1 on 7/19/24, with diagnoses that included hemiplegia (weakness and paralysis of one side of the body) affecting the right dominant side, gout [a type of arthritis (joint inflammation) that causes pain and swelling in the joints), difficulty in walking, generalized muscle weakness, and epilepsy (brain disorder in which a person has repeated seizures [a sudden, uncontrolled episode of abnormal electrical activity in the brain that can cause physical changes in behavior and movement] over time). During a review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 7/20/24, the PT Evaluation and Plan of Treatment indicated Resident 1 was assessed as feeling unsteady when walking and Resident 1 was worried about falling. The PT Evaluation and Plan of Treatment indicated Resident 1 had impaired right and left lower extremity strength and required contact guard assistance with transfers and gait (manner of walking or moving on foot) on level surfaces. The PT Evaluation and Plan of Treatment indicated Resident 1 presented with impaired mobility (ability to move) and impaired coordination (a condition that makes it difficult to control your body's movements), due to the documented physical impairments, and Resident 1 was at risk for falls. During a review of Resident 1's History and Physical (H&P) dated 7/22/24, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's untitled care plan (CP), initiated on 7/22/24, the CP indicated Resident 1 was at risk for falls due to hemiplegia. The CP interventions included for staff to anticipate Resident 1's needs, explain the call system if appropriate, and assess ability to use the call light. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 7/25/24, the MDS indicated Resident 1 had intact cognition (ability to think and process information). The MDS indicated Resident 1 required touching assistance with toilet transfer and to walk 10 feet. During a review of Resident 1's Physical Therapy Encounter Notes (PT EN) dated 8/21/24, the PT EN indicated Resident 1 had compromised [unable to function optimally (in the best way)] balance, coordination, functional activity tolerance, postural support/control (appliance or device used to achieve proper body position and balance, to improve a resident's mobility and independent functioning), safety awareness and strength. The PT EN indicated Resident 1 required contact guard assistance with gait on level surfaces and standby assistance (when someone is present to help prevent injury or falls but does not provide physical assistance or touch the person they are helping) with transfers. During a review of Resident 1's Physical Therapy Discharge Summary (PT DS), dated 8/21/24, the PT DS indicated Resident 1 required contact guard assistance with ambulation on level surfaces using a two-wheeled walker (a rolling walker that has wheels on the front two legs and rubber tips on the back two legs). The PT DS indicated Resident 1 required standby assistance with functional (having a special purpose or task) transfers. During a review or Resident 1's Situation, Background, Assessment and Recommendation (SBAR, a structured communication framework to share information about the condition of a resident) dated 8/23/24, timed at 10:01 pm, the SBAR indicated on 8/23/24, at around 9 pm, Resident 1 was found lying on the floor on Resident 1's back and Resident 1 complained of discomfort in the right groin area. The SBAR indicated Resident 1 stated Resident 1 tripped over the wheelchair footrest while the resident was walking back to her bed from the closet. The SBAR indicated there was a bone protruding (location was not indicated). The SBAR indicated LVN 2 notified Resident 1's Attending Physician/Medical Doctor 1 (MD 1) of the fall and MD 1 ordered to transfer Resident 1 to GACH 1 for further evaluation. During a review of Resident 1's Physician Order (PO) dated 8/24/24, timed at 12:15 am, the PO indicated to transfer Resident 1 to GACH 1's emergency room for further evaluation. During a review of Resident 1's GACH 1 Emergency Department (ED) Narrative dated 8/24/24, timed at 12:41 am, the ED Narrative indicated Resident 1 reported a mechanical fall (an external force that caused the resident to fall) resulting in Resident 1 hitting her head on the door. The ED Narrative indicated Resident 1experienced an onset of right groin pain radiating down Resident 1's right leg which began immediately after the fall. During a review of Resident 1's GACH 1 Computed Tomography Scan (CT scan, an imaging test that uses X-ray techniques to create detailed images of the body) Report dated 8/24/24, timed at 3:53 am, the CT scan report indicated a fracture through the transcervical region of the right femoral neck. During a review of Resident 1's Operative Report (OR) dated 8/27/24, the OR Report indicated on 8/26/24, Resident 1 had an Open treatment of right femoral neck fracture using partial hip arthroplasty. During an interview on 9/4/24 at 2:27 pm with CNA 1, CNA 1 stated when assigned to Resident 1 (unable to recall date and time) CNA 1 had observed Resident 1 get up and walk by herself to the bathroom. CNA 1 stated CNA 1 was not aware Resident 1 needed assistance with ambulation. During an interview on 9/4/24 at 3:20 pm with LVN 1, LVN 1 stated Resident 1 was alert, and oriented to person, place, and time. LVN 1 stated Resident 1 did not use the call light. LVN 1 stated Resident 1 was very independent and would like to do things on her own. LVN 1 stated Resident 1 had been getting up and walking independently (by oneself/all alone) to the bathroom since admission to the facility. During a concurrent interview with the Director of Rehabilitation (DOR) and record review on 9/4/24 at 3:31 pm, Resident 1's PT EN, dated 8/21/24 was reviewed. The PT EN indicated Resident 1 required CGA with gait on level surfaces and standby assistance with transfers. The DOR stated there were different levels of functions, starting with independent, set-up, supervised assist, standby assist, CGA, and dependent. The DOR stated CGA required a little contact with the resident to keep the resident steady during the activity. The DOR stated Resident 1 required CGA for safety. During a phone interview on 9/4/24 at 4:07 pm with CNA 2, CNA 2 stated she was assigned to Resident 1 the night the resident fell (8/23/24 at). CNA 2 stated Resident 1 would get up every morning independently. CNA 2 stated CNA 2 would see Resident 1 get up while CNA 2 assisted Resident 1's roommate with incontinent (having no or no voluntary control over urination or defecation [discharge of feces from the body]) care. CNA 2 stated Resident 1 would walk slowly, would hold the bed and the table, and Resident 1would hold the wall towards the bathroom. CNA 2 stated Resident 1 was able to walk independently. During an interview on 9/4/24 at 5:25 pm with LVN 2, LVN 2 stated LVN 2 had observed Resident 1 walk by herself and was steady. LVN 2 stated Resident 1 was able to ambulate independently. LVN 2 stated Resident 1 never pressed the call light when Resident 1 went to the bathroom. LVN 2 stated during the night of the fall (8/23/24 at 9 pm), LVN 2 heard a thud while LVN 2 was passing medications and LVN 2 immediately checked Resident 1. LVN 2 stated LVN 2 found Resident 1 lying on the floor. LVN 2 stated Resident 1 told LVN 2 Resident 1 tripped on the footrest of the wheelchair while Resident 1 was walking from the closet to Resident 1's bed LVN 2 stated it was not the nurses' practice to refer to the PT EN. LVN 2 stated LVN 2 did not know Resident 1 required contact guard assistance with ambulation. During an interview on 9/5/24 at 11:20 am with CNA 3, CNA 3 stated the licensed nurses (in general) need to communicate to the CNA (assigned CNA) whether Resident 1 would need assistance or not with ambulation. During a concurrent interview with PT 1 and a record review on 9/5/24 at 12:20 pm, the PT EN dated 8/21/24 was reviewed. The PT EN indicated Resident 1 required contact guard assistance with gait on level surfaces and standby assistance with transfers. PT 1 stated Resident 1 had slight weakness to both lower extremities (legs). PT 1 stated the PT EN dated 8/21/24, indicated Resident 1 was unsteady with transfers and gait, and had decreased safety awareness. PT 1 stated PT 1 would not consider Resident 1 independent (able to ambulate by oneself). During a follow-up interview on 9/5/24 at 12:39 pm, the DOR stated when licensed nurses (all licensed nurses) or CNAs (all CNAs) asked regarding Resident 1's mobility, the DOR would verbally inform them (licensed nurses and CNAs) if the resident required assistant from staff or an assistive device. The DOR stated the safety report and any changes in the resident's condition would be discussed during huddle meeting (a short meeting where a team comes together to address residents' goals and challenges). The DOR stated the PT EN were available in Resident 1's chart (medical record) for the nurses' reference. During an interview on 9/5/24 at 12:50 pm with LVN 1, LVN 1 stated Resident 1 was not considered at risk for fall. LVN 1 stated Resident 1 had a slight limp and would take small, steady steps while walking inside the room and the resident would use the wheelchair to move around the facility. LVN 1 stated LVN 1 did not refer to the PT notes/assessments in Resident 1's medical record. LVN 1 stated CGA meant staff needed to be close to Resident 1 to guide and redirect Resident 1 when the resident was unsteady. During a concurrent interview and record review on 9/5/24 at 1 pm with RN 1, Resident 1's care plan for fall dated 7/22/24 was reviewed. The care plan did not indicate Resident 1 required contact guard assistance with ambulation. RN 1 stated RN 1 did not speak to PT 1 about Resident 1 requiring CGA. RN 1 stated CGA required staff to be close to Resident 1 so staff could grab or guide Resident 1 when Resident 1 was unsteady. RN 1 stated Resident 1's fall risk care plan indicated no documentation that Resident 1 required CGA with ambulation. During a concurrent record review and interview with the Director of Nursing (DON) on 9/5/24 at 3:07 pm, the MDS dated [DATE], PT DS dated 8/21/24, and Resident 1's fall care plan dated 7/22/24, were reviewed. The MDS indicated Resident 1 required CGA with toilet transfer and to walk 10 feet. The PT DS indicated Resident 1 required CGA with ambulation on level surfaces using a two-wheeled walker. The DON stated Resident 1 required CGA with ambulation. The DON stated Resident 1 told staff Resident 1 could do things by herself. The DON stated, this resident (Resident 1) will do whatever she wants to do. The DON stated the care plan did not indicate any interventions based on the PT assessments of Resident 1's level of functional mobility and level of assistance required. During a review of the facility's Policy and Procedure (P&P) titled, Fall Management Program, dated 11/1/2017, the P&P indicated, it is the policy of this facility to provide the highest quality of care in the safest environment for the residents residing in the facility. The P&P indicated, based on the information gathered from the history and assessment of the resident, the nursing staff, and Interdisciplinary Team (IDT, a group of health care professionals working collaboratively to accomplish a common goal), with input from the Attending Physician, will identify and implement interventions to reduce the risk of falls.

Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program, led by the Infection Preventionist (IP) Nurse, to provide a safe and sanitary environment by having: 1. A cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen for 92 of 92 sampled residents (Residents 1- 92) who reside in the facility. 2. Harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls and floors and on different surfaces in the kitchen for 92 of 92 sampled residents (Residents 1- 92) who reside in the facility. These deficient practices placed the 92 sampled residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches, mosquitos, ticks, and fleas) and had the potential for the 92 sampled residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On 12/21/2021, at 8:03 pm, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents), in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) in regards to the potential for the residents in the facility to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death On 12/23/2021, at 3:00 pm, two days after identifying the IJ situation, the SSA removed the IJ situation, while at the facility, in the presence of the ADM, DON, Assistant Director of Nursing (ADON), and Clinical Services (CS), after confirming on-site that the facility had implemented the acceptable written plan of action (POA, action to correct the deficient practices) as follows: 1. The facility called the pest control company and the pest control company arrived at the facility on 12/21/2021 at 5pm and did a full kitchen inspection and performed an intensive crack and crevice treatment in the dishwashing area. 2. On 12/23/2021, Maintenance staff sealed all cracks and crevices in the kitchen. 3. On 12/21/2021, the clinical care consultant created care plans for all the residents regarding gastrointestinal (GI, relating to the stomach and the intestines) discomfort. 4. On 12/21/2021, Licensed nurses were in-serviced to monitor for (gastrointestinal) GI discomfort and signs and symptoms of food intoxication from ingesting food containing toxins from bacteria. 5. On 12/21/2021, the facility contacted outside vendors to provide dinner for the residents and continued to provide food services. Cross Reference F925 Findings: A review of the facility's census report, dated December 20, 2021, indicated there were 91 residents residing in the facility. On 12/21/2021, at 3:07 pm, during an interview, the Chief Environmental Health Specialist (EHS) 1 from the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) reporting cockroach infestation in the facility's kitchen to the State Survey Agency (SSA). EHS 1 stated that EHS 2 closed the kitchen on 12/21/2021 at 3 pm. At 4:55 pm, three live cockroaches were observed in the dish washing section of the kitchen. On December 21, 2021, at 4:40 pm, a complaint investigation was initiated regarding cockroaches in the kitchen. ADM was informed of the visit. On 12/21/2021, at 4:43 pm, during an interview, EHS 2 stated he saw seven German cockroaches (German cockroaches are known to carry disease-producing organisms, such as bacteria, protozoans, and viruses) on 12/21/2021. These cockroaches also spread different forms of gastroenteritis [food poisoning, dysentery, diarrhea, and other illnesses], plus they carry different allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma.). EHS 2 stated he saw the cockroaches in the dishwashing section of the kitchen, underneath the automatic dish washing machine, and under the drainboard. EHS 2 stated the cockroaches were under the washing machine, on the wall, and in the cracks and gaps in the wall where the drainpipes enter the wall. EHS 2 stated he closed the kitchen on 12/21/2021 at 3 pm. On 12/21/2021, at 4:55 pm, during an observation of the kitchen with EHS 2, there were three live German cockroaches moving on the wall under the counter where the automatic dishwasher was placed. Gaps were observed around the pipes coming out of the walls. Tile on the wall near the floor were cracked and peeling back from the wall. On 12/21/2021, at 5:56 pm, during an interview, the facility's Infection Preventionist (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), stated she provided in-service training to everyone including kitchen staff and housekeeping (unidentified date). IP stated she did not in-service the staff on pest control. IP stated it was important for the staff to know about pest control. IP stated cockroaches in the kitchen could cause different infections to the residents. On 12/21/2021, at 6:02 pm, during an interview, Dietary Supervisor (DS 2) stated he had worked in the kitchen as a dishwasher for one year. DS 2 stated he did not receive any in-services training on identifying vermin and pest in the kitchen. On 12/21/2021, at 6:19 pm, during an interview with the IP, a review of the Infection Control Checklist for September, October, November, and December of 2021 indicated she did not assess for pests or conditions that harbor pests. IP stated she conducted rounds regarding infection control every week in the kitchen. IP stated she did not focus on pest control. She stated she did not check underneath the sink for pests. IP stated it was important to look for pests because pests could bring infection or spread disease that could make the residents sick. On 12/21/2021, at 6:26 pm, during an interview, Maintenance Supervisor (Maintenance 1) stated he did not provide in-service training on pest control to the kitchen staff. On 12/22/2021, at 9 am, during a telephone interview, Dietary Supervisor (DS 1) stated she saw cockroaches about three months ago and she told Maintenance Supervisor (Maintenance 1). During a concurrent telephone interview on 12/22/2021 at 9:01 am, ADM stated he was never notified about the cockroaches. On 12/22/2021, at 3:10 pm, during a telephone interview, Registered Dietitian (RD 1) stated she did not provide an in-service training on pest control to the kitchen staff. On 12/22/2021, at 3:44 pm, during an interview, the facility's Janitor stated she saw cockroaches at the facility in May or June 2021. The Janitor stated she saw about eight cockroaches when cleaning a resident (unidentified) room and stated she informed her supervisor (unidentified). On 12/22/2021, at 4:10 pm, during a telephone interview, Pest Control (PC) stated he started providing pest control services in September 2021. PC stated that he saw cockroaches before in the dishwasher area and inside some residents' rooms (unidentified). PC stated he saw dead cockroaches in the dishwasher area of the kitchen in September 2021. PC stated the facility had an infestation of cockroaches in September 2021. PC stated an infestation was more than five cockroaches. On 12/22/2021, at 3:42 pm, during an interview with DS 1, a review of the in-service meeting minutes indicated Registered Dietitian 1 (RD 1) or RD 2 did not provide an in-service on pest control for kitchen staff. DS 1 stated RD 1 or RD 2 did not provide an in-service on pest control for kitchen staff. A review of Resident 16's Admission Record (Face Sheet) indicated the facility admitted the resident, a 66-years-old female, on 8/17/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 11/3/2021, indicated Resident 16 was independent with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making, was able to communicate needs, had no memory problems, and required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. On 12/22/2021, at 4:26 pm, during an interview, Resident 16 stated she heard staff and residents talking in the hallway about seeing cockroaches in the shower room. On 12/22/2021, at 4:35 pm, during an interview and observation with Maintenance 1, the shower room was observed. There was a dead cockroach in the second shower stall. There was a dead cockroach in the third shower stall. Maintenance 1 stated it was a cockroach. A review of the Director of Maintenance Job Description, Revised October 2020, indicated the Director of Maintenance ensures the facility is maintained to protect the health and safety of residents. The Job Description indicated the Director of Maintenance will coordinate the training of all staff in infection prevention. The Job Description indicated the Director of Maintenance will supervise staff for adherence with all approved safety protocols and facility policies and procedures to ensure compliance with existing safety regulations. A review of the facility's Infection Prevention and Control Program policy, revised October 2008, indicated that the infection prevention and control program (IPCP) Is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated July 1, 2019 (retrieved on 12/30/2021, from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html) indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens from one living organism to other living organisms). A review of the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation (retrieved on 12/30/2021, from publichealth.alcounty.gov/eh/docs/specializedvencor_management/cockroachmgmt.pdf) indicated that cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with animal fecal matter, they have the potential to transmit bacteria that cause food poisoning if they enter the structures.

Based on observation, interview, and record review, the facility failed to remain free of pests by not having an effective pest control for 92 of 92 sampled residents (Residents 1- 92) who are residing in the facility consuming food, receiving fluids, and using tableware from the kitchen, by failing to: 1. Eradicate (destroy/kill) a cockroach (small insects that carry and spread infectious diseases) infestation (presence of an unusually large number of cockroach population) in the kitchen. 2. Eliminate harborage conditions (locations and conditions where pests can live, thrive [grow strong], reproduce, and feed) such as holes, gaps, cracks, crevices (narrow openings) in the walls, floors, and different surfaces in the kitchen. These deficient practices placed the 92 sampled residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches, mosquitos, ticks, and fleas) and had the potential for the 92 sampled residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On 12/21/2021, at 3:07 pm, during an interview, the Chief Environmental Health Specialist (EHS) 1 from the Los Angeles County (LAC) Department of Public Health (DPH) Environmental Health (EH) District Surveillance and Enforcement (DSE) Branch (department responsible for ensuring food provided for human consumption is safe and free of contamination) reported cockroach infestation in the facility's kitchen to the State Survey Agency (SSA). EHS 1 stated that EHS 2 closed the kitchen on 12/21/2021 at 3 pm. On 12/21/2021, at 8:03 pm, the SSA called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents), in the presence of the facility's Administrator (ADM) and Director of Nursing (DON). On 12/23/2021, at 3:00 pm, two days after identifying the IJ situation, the SSA removed the IJ situation, while at the facility, in the presence of the ADM, DON, Assistant Director of Nursing (ADON), and Clinical Services (CS), after confirming on-site that the facility had implemented the acceptable written plan of action (POA, action to correct the deficient practices) as follows: 1. Pest Control company was immediately called and arrived at the facility on 12/21/21 at 5:00pm to do a full kitchen inspection and performed an intensive crack and crevice treatment in the dishwashing area. 2. On 12/23/2021, Maintenance staff sealed all cracks and crevices in the kitchen. 3. On 12/21/2021, care plans for (gastrointestinal) GI discomfort for all residents in place were created by the clinical care consultant. 4. On 12/21/2021, Licensed nurses were in-serviced to monitor for GI discomfort and signs and symptoms of food intoxication from ingesting food containing toxins from bacteria. Cross Reference F880 Findings: A review of the facility's census report, dated December 20, 2021, indicated there were 91 residents residing in the facility (the facility had one new admission). On December 21, 2021, at 4:40 pm, a complaint investigation was initiated regarding cockroaches in the kitchen. ADM was informed of the visit. On 12/21/2021, at 4:43 pm, during an interview, EHS 2 stated he saw seven live German cockroaches (German cockroaches are known to carry disease-producing organisms, such as bacteria, protozoans, and viruses. These cockroaches also spread different forms of gastroenteritis [food poisoning, dysentery, diarrhea, and other illnesses], plus they carry different allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma.). EHS 2 stated he saw the cockroaches in the dishwashing section of the kitchen, underneath the automatic dish washing machine, and under the drainboard. He stated the cockroaches were under the washing machine, on the wall, and in the cracks and gaps in the wall where the drainpipes enter the wall. EHS 2 stated he closed the kitchen at 3 pm. On 12/21/2021, at 4:50 pm, during an interview with Maintenance 2, Maintenance 2 was observed patching cracks and gaps in the wall underneath the sink in the dishwashing section of the kitchen. Maintenance 2 stated that he had just started sealing cracks and gaps in the wall. On 12/21/2021, at 4:55 pm, during an observation of the kitchen with EHS 2, there were three live German cockroaches moving on the wall under the counter that the automatic dishwasher was sitting on. Gaps were observed around the pipes coming out of the walls. Tile on the wall near the floor were cracked and peeling back from the wall. On 12/21/2021, at 6:26 pm, during an interview, Maintenance Supervisor (Maintenance) 1 stated the facility had a company that did pest control. Maintenance 1 stated the pest control company did not tell him about the breaks in the kitchen wall. Maintenance 1 stated sometimes he did not follow the pest control person while he was servicing the facility. On 12/22/2021, at 9 am, during a telephone interview, Dietary Supervisor (DS) 1 stated she saw cockroaches about three months ago. She stated she told the Maintenance 1. On 12/22/2021, at 9:01 am, during a telephone interview with ADM and EHS 1, ADM stated he was never notified about the cockroaches. ADM stated the pest control company came out monthly to provide service. He stated the pest control personnel were unaccompanied by facility staff during some of their visits. EHS 1 stated pest control personnel should always have a facility escort to ensure the pest control services were done. On 12/22/2021, at 3:44 pm, during an interview, Janitor stated that she saw cockroaches at the facility in May or June. She stated she saw about 8 cockroaches when cleaning a resident's room. She stated she informed her supervisor. On 12/22/2021, at 4:10 pm, during a telephone interview, Pest Control (PC) stated that he started providing pest control services in September 2021. PC stated that he had seen cockroaches before in the dishwasher area and some resident rooms. He stated he saw dead cockroaches in the dishwasher area of the kitchen in September. He stated the facility had an infestation of cockroaches in September 2021. PC stated an infestation was more than five cockroaches. A review of Resident 16's Admission Record (Face Sheet) indicated the facility admitted the resident, a 66-years-old female, on 8/17/2017 with diagnoses including hypertension (a condition in which the force of the blood against the artery walls is too high), [CONDITION(S)] (The wearing down of the protective tissue at the ends of bone) of the hip, and [CONDITION(S)] (excessive body fat). A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 11/3/2021, indicated Resident 16 was independent with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making, was able to communicate needs, had no memory problems, and required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. On 12/22/2021, at 4:26 pm, during an interview, Resident 16 stated she heard staff and residents (unidentified) talking in the hallway about seeing cockroaches in the shower room. On 12/22/2021, at 4;35 pm, during an interview with Maintenance 1, the surveyor conducted an observation of the shower room. There was a dead roach in the second shower stall. There was a dead roach in the third shower stall. Maintenance 1 stated it was a cockroach. A review of the facility's Pest Control policy, revised May 2008, indicated the facility would maintain an on-going pest control program to ensure the building is kept free of insects and rodents. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms (living thing that is too small to be seen with the naked eye) which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease-causing) microorganisms that are transmissible through food. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated July 1, 2019 (retrieved on 12/30/2021, from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html) indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens from one living organism to other living organisms). A review of the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation (retrieved on 12/30/2021, from publichealth.alcounty.gov/eh/docs/specializedvencor_management/cockroachmgmt.pdf) indicated that cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. When cockroaches that live outdoors come into contact with human excrement in sewers or with animal fecal matter, they have the potential to transmit bacteria that cause food poisoning if they enter the structures.

Based on observation, interview, and record review, the facility failed to provide evidence that all allegations of verbal abuse (mocking, insulting, ridiculing; yelling, with the intent to intimidate), sexual abuse (non-consensual sexual contact of any type or sexual harassment), and physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) were thoroughly investigated for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). 1. Provide evidence that all allegations of abuse were thoroughly investigated as alleged by Residents 1, 2, 3, 4, and Family Member 1 (FAM 1). As a result of the noncompliance described above, the abuse allegations were not reported and not investigated. These deficient practices resulted in Residents 1, 2, 3, 4, 5, and 6 to experience sexual, verbal, or physical abuse. Because of the serious potential harm related to not protecting the residents from abuse, not reported, and not providing evidence that all abuse allegations were thoroughly investigated, on 9/9/2021, at 7:55 pm, the State Agency (SA) declared an Immediate Jeopardy (IJ) situation (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON). On 9/12/2021, three days later, the facility provided an acceptable Plan of Action (POA). While onsite, the survey team confirmed implementation of the immediate corrective actions through observation, interview, and record review, and on 9/12/2021, at 6:10 pm, the SA abated the IJ situation in the presence of the ADM and the DON. The POA included: a. Residents 1, 4, and 6 were transferred to a general acute care hospital (GACH) due to a medical condition not related to abuse. b. The facility-initiated abuse investigation of all alleged abuse and made the necessary reports to police and Ombudsman Program. c. CNA 1 was terminated, HA 1 was removed from the facility, CNAs 3, and 4 were counseled and imposed disciplinary actions. d. The facility conducted in-service trainings on abuse prevention starting on 9/9/2021 for all staff. e. The facility conducted a meeting with residents (Residents' Council Meeting) with sixteen residents on 9/10/2021 addressing abuse. Cross Reference F600, F607, and F609 Findings: 1. On 9/8/2021 at 10 am, during a telephone interview, the complainant stated Resident 1 reported on 9/5/2021, a male staff entered her room (date and time were not specified) to provide personal hygiene despite having requested female staff. The male staff touched the resident's clitoris. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, a 55-years-old female, on 8/25/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 9/1/2021, indicated Resident 1 was independent with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making, was able to communicate needs, had no memory problems, and was totally dependent on staff for bed mobility, eating, toilet use, and personal hygiene. A review of Resident 1's nursing Progress Notes, dated 9/3/2021, timed at 6:47 pm, indicated the facility transferred Resident 1 to GACH 1 due to right leg pain and swelling. A review of Resident 1's clinical record indicated there was no documentation regarding any abuse allegation or incident. On 9/8/2021 at 10:51 am, during a telephone interview, Resident 1 stated that on 8/26/2021 at around 10:30 pm, she was in bed, alone in her room, when a man came into her room and stood on her left side. Resident 1 stated this man said he was there to clean her up. Resident 1 stated the man took his right hand and lifted her gown and with his left hand touched her clitoris area and rubbed her for about 30 seconds. Resident 1 stated that it felt like he was not wearing gloves. Resident 1 told him to stop touching her, he stopped, and stood next to the bed. Resident 1 stated later when LVN 1 came into the room, she reported to LVN 1 what had happened. During an interview on 9/8/2021 at 5:42 pm, ADM stated Resident 1's clinical record did not include the sexual abuse allegation documentation because an abuse report was not made, and he was not notified. ADM was unable to provide documentation other residents were assessed to identify if they were subject of abuse and measures taken to prevent sexual abuse from occurring. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident, a forty-eight-year-old female, on 6/21/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This long-term (chronic) condition results in too much sugar circulating in the bloodstream). A review of Resident 2's MDS dated [DATE], indicated the resident was independent with cognitive skills for daily decision-making, was able to communicate needs, and had no memory problems. On 9/8/2021 at 11 am, during an interview with the Director of Staff Development (DSD) and a concurrent review of CNA 1's employee file indicated there were two Notices of Disciplinary Action, one dated 11/23/2020, which indicated CNA 1 was suspected of sexual abuse reported anonymously to the Ombudsman Program. The victim's name (resident) was not included in the report. The action taken was termination of employment. A second Notice of Disciplinary Action, dated 8/12/2021, indicated a resident (unidentified) reported CNA 1 provided peri care (cleaning the resident's private areas) and asked, Do you like the way (her name) touches you? CNA 1 was to be suspended for three days during the investigation of the alleged sexual abuse. DSD explained on 8/12/2021 Resident 2 made the report but did not remember the date and time of the incident but reported CNA 1 was cleaning her private area and asked her if she liked the way she (CNA 1) was touching her. Resident 2 did not like the way CNA 1 asked her the question. DSD stated ADM decided to terminate CNA1's employment and asked her to call CNA1 to inform her but DSD could not remember the date she called CNA 1. On 9/8/2021 at 2:15 pm, during an interview with DON and concurrent review of the Concern/Grievance Report indicated on 8/12/2021 Resident 2's sexual abuse allegation was investigated and reported. DON also reviewed the Notices of Disciplinary Actions dated 11/23/2020 and 8/12/2021 and could not explain why the Notice dated 11/23/2020 indicated CNA 1 was terminated when she was still employed on 8/12/2021. DON stated she was not working at the facility on 8/2020. On 9/8/2021 at 3 pm, during an interview with ADM and concurrent review of the Notice of Disciplinary Action dated 11/23/2020, ADM stated the sexual allegation was investigated and unsubstantiated. ADM stated he was not aware the action taken indicated CNA 1 was terminated. ADM was unable to provide documentation Resident 2 was protected from further abuse inflicted by CNA 1, if other residents were evaluated to determine if they were abused by CNA 1, and what measures were taken to prevent residents from being abused by CNA 1. On 9/9/2021 at 6:45 pm, during an interview, Resident 2 stated she had diarrhea on 8/11/2021 and CNA 1 was caring for her. Resident 2 stated when CNA 1 was cleaning her private area, CNA 1 asked, Do you like the way (CNA 1's name) is touching you? Resident 1 replied to her You are not touching me; you are cleaning me. Resident 2 stated she felt weird and uncomfortable. Resident 2 stated she asked CNA 1 to give her the wipes and she would clean herself. Resident 2 was crying while telling the incident to the Evaluator. Resident 2 stated she reported the incident to SSD the following day. 3. A review of Resident 3's Admission Record indicated the facility admitted the resident, a fifty-nine-year-old female, on 10/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS dated [DATE], indicated the resident had moderate impairment in cognitive skills (difficulty with daily decision-making and remembering things). On 9/8/2021 at 10:35 am, during an interview with SSD and concurrent review of the facility's Concern/Grievance Report dated 8/4/2021, indicated Resident 2 reported CNA 1 was bullying her roommate (Resident 3) by calling her Ms. Piggy when interacting with her. The Summary of Findings indicated SSD spoke with CNA 1 about not nickname calling. SSD stated grievances and abuse allegations were documented on the same form, the Concern/Grievance Report. SSD stated she did not report the bullying allegation as abuse because she was very familiar with CNA 1 and was aware CNA 1's way of talking was a cultural thing. SSD stated, Ms. Piggy was a simple nickname and not hurtful and was not verbal or mental abuse. On 9/8/2020 at 11 am, during an interview, DSD stated the staff should not be calling residents nicknames and Ms. Piggy, was not a documented preferred nickname for Resident 3. DSD stated CNA 1's behavior was a form of verbal abuse. DSD was unable to provide documentation Resident 3 was protected from further abuse from CNA 1 and should have been reported. DSD was unable to provide documentation Resident 3 was protected from further abuse inflicted by CNA 1, if other residents were evaluated for abuse by CNA 1, and measures taken to prevent residents from being abused by CNA 1. On 9/9/2021 at 7:30pm, during an observation and interview Resident 3 was inside her room lying in bed and stated she felt awful after CNA 1 called her Miss Piggy. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident, an eighty-two-year-old male, on 6/20/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated the resident had memory problems, clear speech, and usually understood others and was understood. A review of Resident 4's nursing Progress Notes, dated 7/15/2021, no time specified, indicated Resident 1 informed SSD that HA 1 hit Resident 4 on the side of his head. Registered Nurse 1 (RN 1) informed the resident's physician the resident (Resident 4) called the police reporting HA 1 had pistol whipped him on the side of his head. Police arrived at the facility to investigate. On 8/25/21 at 12:22 pm, during an interview the DSD stated on 7/15/2021 on or around 12 pm, she heard commotion and Resident 4 was yelling and informed her that HA 1 hit him on the side of his head. DSD stated she immediately reported the allegation to the Nurse Supervisor 1 (RN 1). On 9/9/2021 at 4:30 pm, during an interview, ADM stated on 7/15/2021 around 12 pm, Resident 4 was yelling saying HA 1 hit him on the side of his head. ADM stated on 8/11/2021, another facility (where the resident currently resided) notified them in writing about Resident 4's alleging HA 1 on 7/15/2021, hit him on the side of his face. ADM was unable to provide documentation Resident 4 was protected from further abuse inflicted by HA 1, if other residents were evaluated to determine if they were abused by HA 1, and what measures were taken to prevent HA1 to abuse the residents. 5. A review of Resident 5's Admission Record indicated the facility admitted the resident, a seventy-seven-year-old female on 2/24/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's MDS dated [DATE] indicated Resident 2 was moderately cognitively impaired, had memory problems, difficulty making daily decision and required extensive assistance with transfers, walking, dressing, toileting, and personal hygiene. On 9/9/2021 at 4:30 pm, during an interview with SSD and ADM, and concurrent review of the Concern/Grievance Report, indicated on 3/29/2021 FM 1 reported observing through the window on 3/28/2021, a staff member (no name indicated) was repositioning Resident 5 in bed and felt the staff was handling the resident 5 in a rough manner. SSD stated the incident was handled as a grievance because CNA 3 (the staff member FM 1 observed) was apologetic and agreed to treat the resident gently. SSD stated the incident was not investigated as a physical abuse. SSD and ADM were unable to provide documentation Resident 5 was protected from further physical abuse (rough handling) inflicted by CNA 3, if other residents were evaluated to determine if they were abused by CNA 3, and what measures were taken to prevent CNA 3 to abuse the residents. 6. A review of Resident 6's Admission Record indicated the facility readmitted a sixty-three-year-old resident on 11/17/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review or Resident 6's MDS dated [DATE], indicated the resident had severe cognitive impairment with cognitive skills (unable to understand and make decisions). Resident 6 had a gastrostomy tube (GT - soft tubing surgically inserted into the stomach through the abdominal wall to administer food and medication) and was also given oral diet. A review of the facility's Concern/Grievance Report, with a date received of 8/4/2021 indicated Resident 2 reported witnessing CNA 1 get upset at Resident 6 for throwing a cup from her meal tray, CNA 1 cussed while cleaning up the spilled food, and took Resident 6's tray away-stating, she's not eating today. CNA 4 assisted with taking Resident 6's tray away. A review of the CNA 4's Notice of Disciplinary Action dated 8/4/2021, indicated CNA 4 was assigned to Resident 6, who threw her cup across the room. CNA 1 removed the tray. CNA 4 did not offer a meal replacement to Resident 6. The action to be taken was to give CNA 4 a written notice and a suspension. A review of CNA 1's Notice of Disciplinary Action, dated 8/6/2021, indicated CNA 1 was swearing and using inappropriate language and was noted to be calling residents nicknames. On 9/8/2021 at 10:25 am, during an interview, LVN 1 stated she was the charge nurse on the morning shift on 8/4/2021 and remembered Resident 2 asked her to get Resident 6 a sandwich. LVN 1 stated Resident 2 told her she did not want to get anyone in trouble and wanted to keep quiet and just asked for the sandwich. LVN 1 stated she did not ask Resident 2 what happened and just got the sandwich. LVN 1 stated Resident 6 would communicate not liking her food by pushing the tray away. On 9/8/2021 at 10:35 am, during an interview, SSD stated she did not feel CNA 1 was abusive towards Resident 6 because cussing was not towards the resident. SSD stated CNA1 taking Resident 6's tray away was not abusive because Resident 6 kept throwing the tray away and why keep giving her ammunition. On 9/8/2021 at 11 am, during an interview, DSD stated she interviewed Resident 2 and did not feel that CNA 1 taking away Resident 6's tray was a punishment, because the resident had the behavior of pushing away her tray. DSD stated Resident 2 could get nourishment from her GT. DSD explained to Resident 2 CNA 1's behavior and way of speaking was cultural. DSD reviewed the Concern/Grievance Report dated 8/4/2021 and stated it was the first one she had completed and as written, taking the tray away from a resident would be considered punishment. On 9/8/2021 at 3 pm, during an interview, ADM stated he was the abuse coordinator for the facility and oversaw all abuse allegations. ADM stated the incident on 8/4/2021 about the removal of Resident 6's lunch tray was a grievance and not an abuse allegation. ADM was unable to provide documentation Resident 6 was protected from further abuse from CNAs 1 and 4, if other residents were evaluated to determine if they were abused by CNAs 1 and 4, and what measures were taken to prevent them from being abused by CNAs 1 and 4. On 9/9/2021, at 6:45 pm, during an interview, Resident 2 was tearful and stated she had been sad because the incidents of abuse had affected her so much. A review of the facility's policy and procedure titled Abuse Investigation and Reporting, revised on 7/2017, indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property would be reported by the facility Administrator, or his/her designee, to the following persons or agencies: the State Licensing/certification agency responsible for surveying/licensing the facility, local/State Ombudsman, .local law enforcement officials. The policy indicated all alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: two (2) hours if the alleged violation involved abuse or resulted in serious bodily injury. A review of the facility's Elder/Dependent Adult Abuse Policy, updated October 2020, indicated the facility would protect the residents from any type of abuse and the facility was to report all alleged violations involving abuse, neglect, exploitation, or mistreatment. The policy indicated the facility was to report the alleged abuse immediately, but not later than two hours. The policy indicated the facility should make the report to the Department, Ombudsman, and local law enforcement.

Based on observation, interview, and record review, the facility failed to implement its policies and procedures to prohibit, prevent, and investigate allegations of sexual abuse (non-consensual sexual contact of any type or sexual harassment), physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish), or verbal abuse (mocking, insulting, ridiculing; yelling, with the intent to intimidate) for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). The facility failed to: 1. Protect Resident 1 from sexual abuse when an unknown staff male allegedly touched Resident 1's clitoris (part of the female genitalia) for 30 seconds on 8/26/2021. Resident 1 reported the incident of abuse to Licensed Vocational Nurse 1 (LVN 1) the same day it occurred, 8/26/2021. LVN 1 did not report the abuse allegation. 2. Protect Resident 2 from sexual abuse from Certified Nursing Assistant 1 (CNA 1) when on 8/11/2021 (time not specified) while cleaning the resident's perineal (around the genital [private parts] area, asked Resident 2, Do you like the way (CNA 1's name) touches you? Resident 2 stated she felt weird and uncomfortable, and was crying while talking about the incident to the Evaluator. Resident 2 reported the allegation on 8/12/2021, to the Social Services Designee (SSD), who treated the allegation as a grievance (an official statement of a complaint over something believed to be wrong or unfair) instead of an abuse allegation. 3. Protect Resident 3 from verbal and mental abuse when CNA 1 called the resident Miss Piggy. On 8/4/2021, Resident 3 reported the incident to the Director of Staff Development (DSD). Resident 3 stated she felt awful being called Miss Piggy. CNA 1 continued to care for Resident 3. On 8/4/2021, Resident 2 witnessed CNA 1 called Resident 3 Miss Piggy and reported to the SSD. 4. Protect Resident 4 from Health Aide 1 (HA 1) when Resident 4 alleged HA 1 physically abused him. On 7/15/2021 DSD entered Resident 4's room after heard some commotion from the room, and determined it was not abuse. 5. Protect Resident 5 from physical abuse from CNA 3. On 3/28/2021 Resident 5's Family Member 1 (FM 1) witnessed, through the resident's room window, CNA 3 being rough while repositioning Resident 5 in bed and reported the abuse to the facility. 6. Protect Resident 6 when, on 8/4/2021, Resident 2 reported witnessing CNAs 1 and 4 removing Resident 6's lunch tray as punishment after Resident 6 spilled the juice. These deficient practices resulted in Residents 1, 2, 3, 4, 5, and 6 experiencing sexual, verbal, mental, psychological harm, and physical abuse, placed the six residents at risk of repeated abuse, and placed other ninety one residents who resided at the facility at risk for abuse. Because of the serious potential harm related to not protecting the residents from abuse, on 9/9/2021, at 7:55 pm, the State Agency (SA) declared an Immediate Jeopardy (IJ) situation (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON). On 9/12/2021, three days later, the facility provided an acceptable Plan of Action (POA). While onsite, the survey team confirmed implementation of the immediate corrective actions through observation, interview, and record review, and on 9/12/2021, at 6:10 pm, the SA abated the IJ situation in the presence of the ADM and the DON. The POA included: a. Residents 1, 4, and 6 were transferred to a general acute care hospital (GACH) due to a medical condition not related to abuse. b. The facility-initiated abuse investigation of all alleged abuse and made the necessary reports to police and Ombudsman Program. c. CNA 1 was terminated, HA 1 was removed from the facility, CNAs 3, and 4 were counseled and imposed disciplinary actions. d. The facility conducted in-service trainings on abuse prevention starting on 9/9/2021 for all staff. e. The facility conducted a meeting with residents (Residents' Council Meeting) with sixteen residents on 9/10/2021 addressing abuse. Cross Reference F600, F609, and F610 Findings: 1. On 9/8/2021 at 10 am, during a telephone interview, the complainant stated Resident 1 reported on 9/5/2021, a male staff entered her room (date and time were not specified) to provide personal hygiene despite having requested female staff. The male staff touched the resident's clitoris. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, a [AGE] year-old female, on 8/25/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 9/1/2021, indicated Resident 1 was independent with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making, was able to communicate needs, had no memory problems, and was totally dependent on staff for bed mobility, eating, toilet use, and personal hygiene. A review of Resident 1's nursing Progress Notes, dated 9/3/2021, timed at 6:47 pm, indicated the facility transferred Resident 1 to GACH 1 due to right leg pain and swelling. A review of Resident 1's clinical record indicated there was no documentation regarding any abuse allegation or incident. On 9/8/2021 at 10:51 am, during a telephone interview, Resident 1 stated that on 8/26/2021 at around 10:30 pm, she was in bed, alone in her room, when a man came into her room and stood on her left side. Resident 1 stated this man said he was there to clean her up. Resident 1 stated the man took his right hand and lifted her gown and with his left hand touched her clitoris area and rubbed her for about 30 seconds. Resident 1 stated that it felt like he was not wearing gloves. Resident 1 told him to stop touching her, he stopped, and stood next to the bed. Resident 1 stated later when LVN 1 came into the room, she reported to LVN 1 what had happened. During an interview on 9/8/2021 at 5:42 pm, ADM stated Resident 1's clinical record did not include the sexual abuse allegation documentation because an abuse report was not made, and he was not notified. ADM was unable to provide documentation other residents were assessed to identify if they were subject of abuse and measures taken to prevent sexual abuse from occurring. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident, a forty-eight-year-old female, on 6/21/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This long-term (chronic) condition results in too much sugar circulating in the bloodstream). A review of Resident 2's MDS dated [DATE], indicated the resident was independent with cognitive skills for daily decision-making, was able to communicate needs, and had no memory problems. On 9/8/2021 at 11 am, during an interview with the Director of Staff Development (DSD) and a concurrent review of CNA 1's employee file indicated there were two Notices of Disciplinary Action, one dated 11/23/2020, which indicated CNA 1 was suspected of sexual abuse reported anonymously to the Ombudsman Program. The victim's name (resident) was not included in the report. The action taken was termination of employment. A second Notice of Disciplinary Action, dated 8/12/2021, indicated a resident (unidentified) reported CNA 1 provided peri care (cleaning the resident's private areas) and asked, Do you like the way (her name) touches you? CNA 1 was to be suspended for three days during the investigation of the alleged sexual abuse. DSD explained on 8/12/2021 Resident 2 made the report but did not remember the date and time of the incident but reported CNA 1 was cleaning her private area and asked her if she liked the way she (CNA 1) was touching her. Resident 2 did not like the way CNA 1 asked her the question. DSD stated ADM decided to terminate CNA1's employment and asked her to call CNA1 to inform her but DSD could not remember the date she called CNA 1. On 9/8/2021 at 2:15 pm, during an interview with DON and concurrent review of the Concern/Grievance Report indicated on 8/12/2021 Resident 2's sexual abuse allegation was investigated and reported. DON also reviewed the Notices of Disciplinary Actions dated 11/23/2020 and 8/12/2021 and could not explain why the Notice dated 11/23/2020 indicated CNA 1 was terminated when she was still employed on 8/12/2021. DON stated she was not working at the facility on 8/2020. On 9/8/2021 at 3 pm, during an interview with ADM and concurrent review of the Notice of Disciplinary Action dated 11/23/2020, ADM stated the sexual allegation was investigated and unsubstantiated. ADM stated he was not aware the action taken indicated CNA 1 was terminated. ADM was unable to provide documentation Resident 2 was protected from further abuse inflicted by CNA 1, if other residents were evaluated to determine if they were abused by CNA 1, and what measures were taken to prevent residents from being abused by CNA 1. On 9/9/2021 at 6:45 pm, during an interview, Resident 2 stated she had diarrhea on 8/11/2021 and CNA 1 was caring for her. Resident 2 stated when CNA 1 was cleaning her private area, CNA 1 asked, Do you like the way (CNA 1's name) is touching you? Resident 1 replied to her You are not touching me; you are cleaning me. Resident 2 stated she felt weird and uncomfortable. Resident 2 stated she asked CNA 1 to give her the wipes and she would clean herself. Resident 2 was crying while telling the incident to the Evaluator. Resident 2 stated she reported the incident to SSD the following day. 3. A review of Resident 3's Admission Record indicated the facility admitted the resident, a fifty-nine-year-old female, on 10/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS dated [DATE], indicated the resident had moderate impairment in cognitive skills (difficulty with daily decision-making and remembering things). On 9/8/2021 at 10:35 am, during an interview with SSD and concurrent review of the facility's Concern/Grievance Report dated 8/4/2021, indicated Resident 2 reported CNA 1 was bullying her roommate (Resident 3) by calling her Ms. Piggy when interacting with her. The Summary of Findings indicated SSD spoke with CNA 1 about not nickname calling. SSD stated grievances and abuse allegations were documented on the same form, the Concern/Grievance Report. SSD stated she did not report the bullying allegation as abuse because she was very familiar with CNA 1 and was aware CNA 1's way of talking was a cultural thing. SSD stated, Ms. Piggy was a simple nickname and not hurtful and was not verbal or mental abuse. On 9/8/2020 at 11 am, during an interview, DSD stated the staff should not be calling residents nicknames and Ms. Piggy, was not a documented preferred nickname for Resident 3. DSD stated CNA 1's behavior was a form of verbal abuse. DSD was unable to provide documentation Resident 3 was protected from further abuse from CNA 1 and should have been reported. DSD was unable to provide documentation Resident 3 was protected from further abuse inflicted by CNA 1, if other residents were evaluated for abuse by CNA 1, and measures taken to prevent residents from being abused by CNA 1. On 9/9/2021 at 7:30pm, during an observation and interview Resident 3 was inside her room lying in bed and stated she felt awful after CNA 1 called her Miss Piggy. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident, an eighty-two-year-old male, on 6/20/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated the resident had memory problems, clear speech, and usually understood others and was understood. A review of Resident 4's nursing Progress Notes, dated 7/15/2021, no time specified, indicated Resident 1 informed SSD that HA 1 hit Resident 4 on the side of his head. Registered Nurse 1 (RN 1) informed the resident's physician the resident (Resident 4) called the police reporting HA 1 had pistol whipped him on the side of his head. Police arrived at the facility to investigate. On 8/25/21 at 12:22 pm, during an interview the DSD stated on 7/15/2021 on or around 12 pm, she heard commotion and Resident 4 was yelling and informed her that HA 1 hit him on the side of his head. DSD stated she immediately reported the allegation to the Nurse Supervisor 1 (RN 1). On 9/9/2021 at 4:30 pm, during an interview, ADM stated on 7/15/2021 around 12 pm, Resident 4 was yelling saying HA 1 hit him on the side of his head. ADM stated on 8/11/2021, another facility (where the resident currently resided) notified them in writing about Resident 4's alleging HA 1 on 7/15/2021, hit him on the side of his face. ADM was unable to provide documentation Resident 4 was protected from further abuse inflicted by HA 1, if other residents were evaluated to determine if they were abused by HA 1, and what measures were taken to prevent them from being abused by HA 1. 5. A review of Resident 5's Admission Record indicated the facility admitted the resident, a seventy-seven-year-old female on 2/24/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's MDS dated [DATE] indicated Resident 5 was moderately cognitively impaired, had memory problems, difficulty making daily decision and required extensive assistance with transfers, walking, dressing, toileting, and personal hygiene. On 9/9/2021 at 4:30 pm, during an interview with SSD and ADM, and concurrent review of the Concern/Grievance Report, indicated on 3/29/2021 FM 1 reported observing through the window on 3/28/2021, a staff member (no name indicated) was repositioning Resident 5 in bed and felt the staff was handling Resident 5 in a rough manner. SSD stated the incident was handled as a grievance because CNA 3 (the staff member FM 1 observed) was apologetic and agreed to treat the resident gently. SSD stated the incident was not investigated as a physical abuse. SSD and ADM were unable to provide documentation Resident 5 was protected from further physical abuse (rough handling) inflicted by CNA 3, if other residents were evaluated to determine if they were abused by CNA 3, and what measures were taken to prevent them from being abused by CNA 3. 6. A review of Resident 6's Admission Record indicated the facility readmitted a sixty-three-year-old resident on 11/17/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's MDS dated [DATE], indicated the resident had severe cognitive impairment with cognitive skills (unable to understand and make decisions). Resident 6 had a gastrostomy tube (GT - soft tubing surgically inserted into the stomach through the abdominal wall to administer food and medication) and was also given oral diet. A review of the facility's Concern/Grievance Report, with a date received of 8/4/2021 indicated Resident 2 reported witnessing CNA 1 get upset at Resident 6 for throwing a cup from her meal tray, CNA 1 cussed while cleaning up the spilled food, and took Resident 6's tray away-stating, she's not eating today. CNA 4 assisted with taking Resident 6's tray away. A review of the CNA 4's Notice of Disciplinary Action dated 8/4/2021, indicated CNA 4 was assigned to Resident 6, who threw her cup across the room. CNA 1 removed the tray. CNA 4 did not offer a meal replacement to Resident 6. The action to be taken was to give CNA 4 a written notice and a suspension. A review of CNA 1's Notice of Disciplinary Action, dated 8/6/2021, indicated CNA 1 was swearing and using inappropriate language and was noted to be calling residents nicknames. On 9/8/2021 at 10:25 am, during an interview, LVN 1 stated she was the charge nurse on the morning shift on 8/4/2021 and remembered Resident 2 asked her to get Resident 6 a sandwich. LVN 1 stated Resident 2 told her she did not want to get anyone in trouble and wanted to keep quiet and just asked for the sandwich. LVN 1 stated she did not ask Resident 2 what happened and just got the sandwich. LVN 1 stated Resident 6 would communicate not liking her food by pushing the tray away. On 9/8/2021 at 10:35 am, during an interview, SSD stated she did not feel CNA 1 was abusive towards Resident 6 because cussing was not towards the resident. SSD stated CNA1 taking Resident 6's tray away was not abusive because Resident 6 kept throwing the tray away and why keep giving her ammunition. On 9/8/2021 at 11 am, during an interview, DSD stated she interviewed Resident 2 and did not feel that CNA 1 taking away Resident 6's tray was a punishment, because the resident had the behavior of pushing away her tray. DSD stated Resident 2 could get nourishment from her GT. DSD explained to Resident 2 CNA 1's behavior and way of speaking was cultural. DSD reviewed the Concern/Grievance Report dated 8/4/2021 and stated it was the first one she had completed and as written, taking the tray away from a resident would be considered punishment. On 9/8/2021 at 3 pm, during an interview, ADM stated he was the abuse coordinator for the facility and oversaw all abuse allegations. ADM stated the incident on 8/4/2021 about the removal of Resident 6's lunch tray was a grievance and not an abuse allegation. ADM was unable to provide documentation Resident 6 was protected from further abuse from CNAs 1 and 4, if other residents were evaluated to determine if they were abused by CNAs 1 and 4, and what measures were taken to prevent them from being abused by CNAs 1 and 4. On 9/9/2021, at 6:45 pm, during an interview, Resident 2 was tearful and stated she had been sad because the incidents of abuse had affected her so much. A review of the facility's policy and procedure titled Abuse Investigation and Reporting, revised on 7/2017, indicated All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: the State Licensing/certification agency responsible for surveying/licensing the facility, local/State Ombudsman, .local law enforcement officials. The policy also indicated all alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: two (2) hours if the alleged violation involved abuse OR results in serious bodily injury. A review of the facility's Elder/Dependent Adult Abuse Policy, updated 10/2020, indicated the facility will protect the rights, safety and wellbeing of each resident. Against any and all forms of abuse. The policy indicated the facility was to report all alleged violations involving abuse, neglect, exploitation, or mistreatment. The policy indicated that the facility is to report the alleged abuse immediately, but not later than 2 hours. The policy indicated the facility should make the report to the Department, LTC Ombudsman, and local law enforcement.

Based on observation, interview, and record review, the facility failed to ensure six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6) were free from sexual abuse (non-consensual sexual contact of any type or sexual harassment), physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish), or verbal abuse (mocking, insulting, ridiculing; yelling, with the intent to intimidate). The facility failed to: 1. Protect Resident 1 from sexual abuse when an unknown staff male allegedly touched Resident 1's clitoris (part of the female genitalia) for 30 seconds on 8/26/2021. Resident 1 reported the incident of abuse to Licensed Vocational Nurse 1 (LVN 1) the same day it occurred, 8/26/2021. 2. Protect Resident 2 from sexual abuse from Certified Nursing Assistant 1 (CNA 1) when on 8/11/2021 (time not specified) while cleaning the resident's perineal (around the genital [private parts]) area, asked Resident 2, Do you like the way (CNA 1's name) touches you? Resident 2 stated she felt weird and uncomfortable, and was crying while talking about the incident to the Evaluator. Resident 2 reported the allegation on 8/12/2021, to the Social Services Designee (SSD), who treated the allegation as a grievance (an official statement of a complaint over something believed to be wrong or unfair) instead of an abuse allegation. 3. Protect Resident 3 from verbal and mental abuse when CNA 1 called the resident Miss Piggy. On 8/4/2021, Resident 3 reported the incident to the Director of Staff Development (DSD). Resident 3 stated she felt awful being called Miss Piggy. CNA 1 continued to care for Resident 3. On 8/4/2021, Resident 2 witnessed CNA 1 called Resident 3 Miss Piggy and reported to the SSD. 4. Protect Resident 4 from Health Aide 1 (HA 1) when Resident 4 alleged HA 1 physically abused him. On 7/15/2021 DSD entered Resident 4's room after she heard some commotion from the room, and determined it was not abuse. 5. Protect Resident 5 from physical abuse from CNA 3. On 3/28/2021 Resident 5's Family Member 1 (FM 1) witnessed, through the resident's room window, CNA 3 being rough while repositioning Resident 5 in bed and reported the abuse to the facility. 6. Protect Resident 6 when on 8/4/2021, Resident 2 reported witnessing CNAs 1 and 4 removing Resident 6's lunch tray as punishment after Resident 6 spilled the juice. These deficient practices resulted in Residents 1, 2, 3, 4, 5, and 6 experiencing sexual, verbal, mental, and physical abuse, placed the six residents at risk of repeated abuse, and placed ninety one residents who resided at the facility at risk for abuse. Because of the serious potential harm related to not protecting the residents from abuse, on 9/9/2021, at 7:55 pm, the State Agency (SA) declared an Immediate Jeopardy (IJ) situation (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON). On 9/12/2021, three days later, the facility provided an acceptable Plan of Action (POA). While onsite, the survey team confirmed implementation of the immediate corrective actions through observation, interview, and record review, and on 9/12/2021, at 6:10 pm, the SA abated the IJ situation in the presence of the ADM and the DON. The POA included: a. Residents 1, 4, and 6 were transferred to a general acute care hospital (GACH) due to a medical condition not related to abuse. b. The facility-initiated abuse investigation of all alleged abuse and made the necessary reports to police and Ombudsman Program. c. CNA 1 was terminated, HA 1 was removed from the facility, CNAs 3, and 4 were counseled and imposed disciplinary actions. d. The facility conducted in-service trainings on abuse prevention starting on 9/9/2021 for all staff. e. The facility conducted a meeting with residents (Residents' Council Meeting) with sixteen residents on 9/10/2021 addressing abuse. Cross Reference F607, F609, and F610 Findings: 1. On 9/8/2021 at 10 am, during a telephone interview, the complainant stated Resident 1 reported on 9/5/2021, a male staff entered her room (date and time were not specified) to provide personal hygiene despite having requested female staff. The male staff touched the resident's clitoris. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, a 55-years-old female, on 8/25/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 9/1/2021, indicated Resident 1 was independent with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making, was able to communicate needs, had no memory problems, and was totally dependent on staff for bed mobility, eating, toilet use, and personal hygiene. A review of Resident 1's nursing Progress Notes, dated 9/3/2021, timed at 6:47 pm, indicated the facility transferred Resident 1 to GACH 1 due to right leg pain and swelling. A review of Resident 1's clinical record indicated there was no documentation regarding any abuse allegation or incident. On 9/8/2021 at 10:51 am, during a telephone interview, Resident 1 stated that on 8/26/2021 at around 10:30 pm, she was in bed, alone in her room, when a man came into her room and stood on her left side. Resident 1 stated this man said he was there to clean her up. Resident 1 stated the man took his right hand and lifted her gown and with his left hand touched her clitoris area and rubbed her for about 30 seconds. Resident 1 stated that it felt like he was not wearing gloves. Resident 1 told him to stop touching her, he stopped, and stood next to the bed. Resident 1 stated later when LVN 1 came into the room, she reported to LVN 1 what had happened. During an interview on 9/8/2021 at 5:42 pm, ADM stated Resident 1's clinical record did not include the sexual abuse allegation documentation because an abuse report was not made, and he was not notified. ADM was unable to provide documentation other residents were assessed to identify if they were subject of abuse and measures taken to prevent sexual abuse from occurring. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident, a forty-eight-year-old female, on 6/21/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This long-term (chronic) condition results in too much sugar circulating in the bloodstream). A review of Resident 2's MDS dated [DATE], indicated the resident was independent with cognitive skills for daily decision-making, was able to communicate needs, and had no memory problems. On 9/8/2021 at 11 am, during an interview with the Director of Staff Development (DSD) and a concurrent review of CNA 1's employee file indicated there were two Notices of Disciplinary Action, one dated 11/23/2020, which indicated CNA 1 was suspected of sexual abuse reported anonymously to the Ombudsman Program. The victim's name (resident) was not included in the report. The action taken was termination of employment. A second Notice of Disciplinary Action, dated 8/12/2021, indicated a resident (unidentified) reported CNA 1 provided peri care (cleaning the resident's private areas) and asked, Do you like the way (her name) touches you? CNA 1 was to be suspended for three days during the investigation of the alleged sexual abuse. DSD explained on 8/12/2021 Resident 2 made the report but did not remember the date and time of the incident but reported CNA 1 was cleaning her private area and asked her if she liked the way she (CNA 1) was touching her. Resident 2 did not like the way CNA 1 asked her the question. DSD stated ADM decided to terminate CNA1's employment and asked her to call CNA1 to inform her but DSD could not remember the date she called CNA 1. On 9/8/2021 at 2:15 pm, during an interview with DON and concurrent review of the Concern/Grievance Report indicated on 8/12/2021 Resident 2's sexual abuse allegation was investigated and reported. DON also reviewed the Notices of Disciplinary Actions dated 11/23/2020 and 8/12/2021 and could not explain why the Notice dated 11/23/2020 indicated CNA 1 was terminated when she was still employed on 8/12/2021. DON stated she was not working at the facility on 8/2020. On 9/8/2021 at 3 pm, during an interview with ADM and concurrent review of the Notice of Disciplinary Action dated 11/23/2020, ADM stated the sexual allegation was investigated and unsubstantiated. ADM stated he was not aware the action taken indicated CNA 1 was terminated. ADM was unable to provide documentation Resident 2 was protected from further abuse inflicted by CNA 1, if other residents were evaluated to determine if CNA 1 abused them, and what measures were taken to prevent CNA 1 from abusing the residents. On 9/9/2021 at 6:45 pm, during an interview, Resident 2 stated she had diarrhea on 8/11/2021 and CNA 1 was caring for her. Resident 2 stated when CNA 1 was cleaning her private area, CNA 1 asked, Do you like the way (CNA 1's name) is touching you? Resident 2 replied to her You are not touching me; you are cleaning me. Resident 2 stated she felt weird and uncomfortable. Resident 2 stated she asked CNA 1 to give her the wipes and she would clean herself. Resident 2 was crying while telling the incident to the Evaluator. Resident 2 stated she reported the incident to SSD the following day. 3. A review of Resident 3's Admission Record indicated the facility admitted the resident, a fifty-nine-year-old female, on 10/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS dated [DATE], indicated the resident had moderate impairment in cognitive skills (difficulty with daily decision-making and remembering things). On 9/8/2021 at 10:35 am, during an interview with SSD and concurrent review of the facility's Concern/Grievance Report dated 8/4/2021, indicated Resident 2 reported CNA 1 was bullying her roommate (Resident 3) by calling her Ms. Piggy when interacting with her. The Summary of Findings indicated SSD spoke with CNA 1 about not nickname calling. SSD stated grievances and abuse allegations were documented on the same form, the Concern/Grievance Report. SSD stated she did not report the bullying allegation as abuse because she was very familiar with CNA 1 and was aware CNA 1's way of talking was a cultural thing. SSD stated, Ms. Piggy was a simple nickname and not hurtful and was not verbal or mental abuse. On 9/8/2021 at 11 am, during an interview, DSD stated the staff should not be calling residents nicknames and Ms. Piggy, was not a documented preferred nickname for Resident 3. DSD stated CNA 1's behavior was a form of verbal abuse. DSD was unable to provide documentation Resident 3 was protected from further abuse from CNA 1 and should have been reported. DSD was unable to provide documentation Resident 3 was protected from further abuse inflicted by CNA 1, if other residents were evaluated for abuse by CNA 1, and measures taken to prevent CNA 1 from abusing the residents. On 9/9/2021 at 7:30pm, during an observation and interview Resident 3 was inside her room lying in bed and stated she felt awful after CNA 1 called her Miss Piggy. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident, an eighty-two-year-old male, on 6/20/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated the resident had memory problems, clear speech, and usually understood others and was understood. A review of Resident 4's nursing Progress Notes, dated 7/15/2021, no time specified, indicated Resident 1 informed SSD that HA 1 hit Resident 4 on the side of his head. Registered Nurse 1 (RN 1) informed the resident's physician the resident (Resident 4) called the police reporting HA 1 had pistol whipped him on the side of his head. Police arrived at the facility to investigate. On 8/25/2021 at 12:22 pm, during an interview the DSD stated on 7/15/2021 on or around 12 pm, she heard commotion and Resident 4 was yelling and informed her that HA 1 hit him on the side of his head. DSD stated she immediately reported the allegation to the Nurse Supervisor 1 (RN 1). On 9/9/2021 at 4:30 pm, during an interview, ADM stated on 7/15/2021 around 12 pm, Resident 4 was yelling saying HA 1 hit him on the side of his head. ADM stated on 8/11/2021, another facility (where the resident currently resided) notified them in writing about Resident 4's alleging HA 1 on 7/15/2021, hit him on the side of his face. ADM was unable to provide documentation Resident 4 was protected from further abuse inflicted by HA 1, if other residents were evaluated to determine if HA 1 had abused them, and what measures were taken to prevent HA 1 from abusing them. 5. A review of Resident 5's Admission Record indicated the facility admitted the resident, a seventy-seven-year-old female on 2/24/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's MDS dated [DATE] indicated Resident 5 was moderately cognitively impaired, had memory problems, difficulty making daily decision and required extensive assistance with transfers, walking, dressing, toileting, and personal hygiene. On 9/9/2021 at 4:30 pm, during an interview with SSD and ADM, and concurrent review of the Concern/Grievance Report, indicated on 3/29/2021 FM 1 reported observing through the window on 3/28/2021, a staff member (no name indicated) was repositioning Resident 5 in bed and felt the staff was handling Resident 5 in a rough manner. SSD stated the incident was handled as a grievance because CNA 3 (the staff member FM 1 observed) was apologetic and agreed to treat the resident gently. SSD stated the incident was not investigated as a physical abuse. SSD and ADM were unable to provide documentation Resident 5 was protected from further physical abuse (rough handling) inflicted by CNA 3, if other residents were evaluated to determine if CNA 3, and what measures were taken to prevent CNA 3 from abusing the residents. 6. A review of Resident 6's Admission Record indicated the facility readmitted a sixty-three-year-old resident on 11/17/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review or Resident 6's MDS dated [DATE], indicated the resident had severe cognitive impairment with cognitive skills (unable to understand and make decisions). Resident 6 had a gastrostomy tube (GT - soft tubing surgically inserted into the stomach through the abdominal wall to administer food and medication) and was also given oral diet. A review of the facility's Concern/Grievance Report, with a date received of 8/4/2021 indicated Resident 2 reported witnessing CNA 1 get upset at Resident 6 for throwing a cup from her meal tray, CNA 1 cussed while cleaning up the spilled food, and took Resident 6's tray away-stating, she's not eating today. CNA 4 assisted with taking Resident 6's tray away. A review of the CNA 4's Notice of Disciplinary Action dated 8/4/2021, indicated CNA 4 was assigned to Resident 6, who threw her cup across the room. CNA 1 removed the tray. CNA 4 did not offer a meal replacement to Resident 6. The action to be taken was to give CNA 4 a written notice and a suspension. A review of CNA 1's Notice of Disciplinary Action, dated 8/6/2021, indicated CNA 1 was swearing and using inappropriate language and was noted to be calling residents nicknames. On 9/8/2021 at 10:25 am, during an interview, LVN 1 stated she was the charge nurse on the morning shift on 8/4/2021 and remembered Resident 2 asked her to get Resident 6 a sandwich. LVN 1 stated Resident 2 told her she did not want to get anyone in trouble and wanted to keep quiet and just asked for the sandwich. LVN 1 stated she did not ask Resident 2 what happened and just got the sandwich. LVN 1 stated Resident 6 would communicate not liking her food by pushing the tray away. On 9/8/2021 at 10:35 am, during an interview, SSD stated she did not feel CNA 1 was abusive towards Resident 6 because cussing was not towards the resident. SSD stated CNA1 taking Resident 6's tray away was not abusive because Resident 6 kept throwing the tray away and why keep giving her ammunition. On 9/8/2021 at 11 am, during an interview, DSD stated she interviewed Resident 2 and did not feel that CNA 1 taking away Resident 6's tray was a punishment, because the resident had the behavior of pushing away her tray. DSD stated Resident 2 could get nourishment from her GT. DSD explained to Resident 2 CNA 1's behavior and way of speaking was cultural. DSD reviewed the Concern/Grievance Report dated 8/4/2021 and stated it was the first one she had completed and as written, taking the tray away from a resident would be considered punishment. On 9/8/2021 at 3 pm, during an interview, ADM stated he was the abuse coordinator for the facility and oversaw all abuse allegations. ADM stated the incident on 8/4/2021 about the removal of Resident 6's lunch tray was a grievance and not an abuse allegation. ADM was unable to provide documentation Resident 6 was protected from further abuse from CNAs 1 and 4, if other residents were evaluated to determine if they were abused by CNAs 1 and 4, and what measures were taken to prevent them from being abused by CNAs 1 and 4. On 9/9/2021, at 6:45 pm, during an interview, Resident 2 was tearful and stated she had been sad because the incidents of abuse had affected her so much. A review of the facility's policy and procedure titled Abuse Investigation and Reporting, revised on 7/2017, indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property would be reported by the facility Administrator, or his/her designee, to the following persons or agencies: the State Licensing/certification agency responsible for surveying/licensing the facility, local/State Ombudsman, .local law enforcement officials. The policy indicated all alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: two (2) hours if the alleged violation involved abuse or resulted in serious bodily injury. A review of the facility's Elder/Dependent Adult Abuse Policy, updated October 2020, indicated the facility would protect the residents from any type of abuse and the facility was to report all alleged violations involving abuse, neglect, exploitation, or mistreatment. The policy indicated the facility was to report the alleged abuse immediately, but not later than two hours. The policy indicated the facility should make the report to the Department, Ombudsman, and local law enforcement.

Based on interview and record review, the facility failed to report allegations of either verbal abuse (mocking, insulting, ridiculing; yelling, with the intent to intimidate), sexual abuse (non-consensual sexual contact of any type or sexual harassment), or physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6) to the Department, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement and in accordance with the facility's policy and procedure, by failing to: 1. Report to the Department, Ombudsman, and to the local police Resident 1's allegations that an unknown man touched her clitoris (part of the female genitalia) for 30 seconds on 8/26/2021. Resident 1 reported the allegation to Licensed Vocational Nurse 1 (LVN 1) on 8/26/2021. 2. Report to the Department, Ombudsman, and to the local police Resident 2's allegation on 8/11/2021 (no time specified) when Certified Nursing Assistant 1 (CNA 1) asked Resident 2, Do you like the way (CNA 1's name) touches you? while providing perineal (involves cleaning the private areas of a resident) care to Resident 2. Resident 2 stated she felt weird and uncomfortable, and was crying while talking about the incident to the Evaluator. Resident 2 reported the allegation to the Social Services Designee (SSD), who treated the allegation as a grievance (an official statement of a complaint over something believed to be wrong or unfair) instead of an abuse allegation. 3. Report to the Department, Ombudsman, and to the local police when CNA 1 called the Resident 3 Miss Piggy. On 8/4/2021, Resident 3 reported the incident to the Director of Staff Development (DSD). Resident 3 stated she felt awful being called Miss Piggy. CNA 1 continued to care for Resident 3. On 8/4/2021, Resident 2 witnessed CNA 1 called Resident 3 Miss Piggy and reported to the SSD. 4. Report to the Department, Ombudsman, and to the local police when Resident 4 alleged a facility contracted Health Aid (HA, observes the care, and reporting on conditions to a registered nurse or other health care professional) punched him on the side of the head on 7/15/2021, DSD entered Resident 4's room after she heard some commotion from the room, and determined it was not abuse. 5. Report to the Department, Ombudsman, and to the local police on 3/28/2021 when Resident 5's Family Member 1 (FM 1) witnessed, through the resident's room window, CNA 3 being rough while repositioning Resident 5 in bed and reported the abuse to the facility. 6. Report to the Department, Ombudsman, and to the local police when CNA 1 told CNA 4 to remove Resident 6's tray away as a punishment on 8/4/2021 during lunch time after Resident 6 spilled juice, and the DSD was made aware as witnessed by Resident 2. 7. Investigate and report the results of the investigation of the above alleged allegations to the Department within five (5) working days of the alleged incidents. These deficient practices resulted in the facility to not report the abuse allegations and resulted for Residents 1, 2, 3, 4, 5, and 6 to experience abuse, and were at risk of repeated abuse, and placed ninety residents who currently resided at the facility at risk for abuse. Because of the serious potential harm related to not protecting the residents from abuse, not reporting, not investigating the alleged abuse allegations, on 9/9/2021, at 7:55 pm, the State Agency (SA) declared an Immediate Jeopardy (IJ) situation (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON). On 9/12/2021, three days later, the facility provided an acceptable Plan of Action (POA, interventions to correct the deficient practices). While onsite, the survey team confirmed implementation of the immediate corrective actions through observation, interview, and record review, and on 9/12/2021, at 6:10 pm, the SA abated the IJ situation in the presence of the ADM and the DON. The POA included: a. Residents 1, 4, and 6 were transferred to a general acute care hospital (GACH) due to a medical condition not related to abuse. b. The facility-initiated abuse investigation of all alleged abuse and made the necessary reports to the police and Ombudsman Program. c. CNA 1 was terminated, HA 1 was removed from the facility, CNAs 3, and 4 were counseled and imposed disciplinary actions. d. The facility conducted in-service trainings on abuse prevention starting on 9/9/2021 for all staff. e. The facility conducted a meeting with residents (Residents' Council Meeting) with sixteen residents on 9/10/2021 addressing abuse. Cross Reference F600, F607, and F610 Findings: 1. On 9/8/2021 at 10 am, during a telephone interview, the complainant stated Resident 1 reported on 9/5/2021, a male staff entered her room (date and time were not specified) to provide personal hygiene despite having requested female staff. The male staff touched the resident's clitoris. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, a 55-years-old female, on 8/25/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 9/1/2021, indicated Resident 1 was independent with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making, was able to communicate needs, had no memory problems, and was totally dependent on staff for bed mobility, eating, toilet use, and personal hygiene. A review of Resident 1's nursing Progress Notes, dated 9/3/2021, timed at 6:47 pm, indicated the facility transferred Resident 1 to GACH 1 due to right leg pain and swelling. A review of Resident 1's clinical record indicated there was no documentation regarding any abuse allegation or incident. On 9/8/2021 at 10:51 am, during a telephone interview, Resident 1 stated that on 8/26/2021 at around 10:30 pm, she was in bed, alone in her room, when a man came into her room and stood on her left side. Resident 1 stated this man said he was there to clean her up. Resident 1 stated the man took his right hand and lifted her gown and with his left hand touched her clitoris area and rubbed her for about 30 seconds. Resident 1 stated that it felt like he was not wearing gloves. Resident 1 told him to stop touching her, he stopped, and stood next to the bed. Resident 1 stated later when LVN 1 came into the room, she reported to LVN 1 what had happened. During an interview on 9/8/2021 at 5:42 pm, ADM stated Resident 1's clinical record did not include the sexual abuse allegation documentation because an abuse report was not made, and he was not notified. ADM was unable to provide documentation other residents were assessed to identify if they were subject of abuse and measures taken to prevent sexual abuse from occurring. 2. A review of Resident 2's Admission Record indicated the facility admitted the resident, a forty-eight-year-old female, on 6/21/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This long-term (chronic) condition results in too much sugar circulating in the bloodstream). A review of Resident 2's MDS dated [DATE], indicated the resident was independent with cognitive skills for daily decision-making, was able to communicate needs, and had no memory problems. On 9/8/2021 at 11 am, during an interview with the Director of Staff Development (DSD) and a concurrent review of CNA 1's employee file indicated there were two Notices of Disciplinary Action, one dated 11/23/2020, which indicated CNA 1 was suspected of sexual abuse reported anonymously to the Ombudsman Program. The victim's name (resident) was not included in the report. The action taken was termination of employment. A second Notice of Disciplinary Action, dated 8/12/2021, indicated a resident (unidentified) reported CNA 1 provided peri care (cleaning the resident's private areas) and asked, Do you like the way (her name) touches you? CNA 1 was to be suspended for three days during the investigation of the alleged sexual abuse. DSD explained on 8/12/2021 Resident 2 made the report but did not remember the date and time of the incident but reported CNA 1 was cleaning her private area and asked her if she liked the way she (CNA 1) was touching her. Resident 2 did not like the way CNA 1 asked her the question. DSD stated ADM decided to terminate CNA1's employment and asked her to call CNA1 to inform her but DSD could not remember the date she called CNA 1. On 9/8/2021 at 2:15 pm, during an interview with DON and concurrent review of the Concern/Grievance Report indicated on 8/12/2021 Resident 2's sexual abuse allegation was investigated and reported. DON also reviewed the Notices of Disciplinary Actions dated 11/23/2020 and 8/12/2021 and could not explain why the Notice dated 11/23/2020 indicated CNA 1 was terminated when she was still employed on 8/12/2021. DON stated she was not working at the facility at that time. On 9/8/2021 at 3 pm, during an interview with ADM and concurrent review of the Notice of Disciplinary Action dated 11/23/2020, ADM stated the sexual allegation was investigated and unsubstantiated. ADM stated he was not aware the action taken indicated CNA 1 was terminated. ADM was unable to provide documentation Resident 2 was protected from further abuse inflicted by CNA 1, if other residents were evaluated to determine if CNA 1 abused them, and what measures were taken to prevent CNA 1 to abuse the residents. On 9/9/2021 at 6:45 pm, during an interview, Resident 2 stated she had diarrhea on 8/11/2021 and CNA 1 was caring for her. Resident 2 stated when CNA 1 was cleaning her private area, CNA 1 asked, Do you like the way (CNA 1's name) is touching you? Resident 1 replied to her You are not touching me; you are cleaning me. Resident 2 stated she felt weird and uncomfortable. Resident 2 stated she asked CNA 1 to give her the wipes and she would clean herself. Resident 2 was crying while telling the incident to the Evaluator. Resident 2 stated she reported the incident to SSD the following day. 3. A review of Resident 3's Admission Record indicated the facility admitted the resident, a fifty-nine-year-old female, on 10/19/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS dated [DATE], indicated the resident had moderate impairment in cognitive skills (difficulty with daily decision-making and remembering things). On 9/8/2021 at 10:35 am, during an interview with SSD and concurrent review of the facility's Concern/Grievance Report dated 8/4/2021, indicated Resident 2 reported CNA 1 was bullying her roommate (Resident 3) by calling her Ms. Piggy when interacting with her. The Summary of Findings indicated SSD spoke with CNA 1 about not nickname calling. SSD stated grievances and abuse allegations were documented on the same form, the Concern/Grievance Report. SSD stated she did not report the bullying allegation as abuse because she was very familiar with CNA 1 and was aware CNA 1's way of talking was a cultural thing. SSD stated, Ms. Piggy was a simple nickname and not hurtful and was not verbal or mental abuse. On 9/8/2020 at 11 am, during an interview, DSD stated the staff should not be calling residents nicknames and Ms. Piggy, was not a documented preferred nickname for Resident 3. DSD stated CNA 1's behavior was a form of verbal abuse. DSD was unable to provide documentation Resident 3 was protected from further abuse from CNA 1 and should have been reported. DSD was unable to provide documentation Resident 3 was protected from further abuse inflicted by CNA 1, if other residents were evaluated for abuse by CNA 1, and measures taken to prevent residents from being abused by CNA 1. On 9/9/2021 at 7:30pm, during an observation and interview Resident 3 was inside her room lying in bed and stated she felt awful after CNA 1 called her Miss Piggy. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident, an eighty-two-year-old male, on 6/20/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated the resident had memory problems, clear speech, and usually understood others and was understood. A review of Resident 4's nursing Progress Notes, dated 7/15/2021, no time specified, indicated Resident 1 informed SSD that HA 1 hit Resident 4 on the side of his head. Registered Nurse 1 (RN 1) informed the resident's physician the resident (Resident 4) called the police reporting HA 1 had pistol whipped him on the side of his head. Police arrived at the facility to investigate. On 8/25/21 at 12:22 pm, during an interview the DSD stated on 7/15/2021 on or around 12 pm, she heard commotion and Resident 4 was yelling and informed her that HA 1 hit him on the side of his head. DSD stated she immediately reported the allegation to the Nurse Supervisor 1 (RN 1). On 9/9/2021 at 4:30 pm, during an interview, ADM stated on 7/15/2021 around 12 pm, Resident 4 was yelling saying HA 1 hit him on the side of his head. ADM stated on 8/11/2021, another facility (where the resident currently resided) notified them in writing about Resident 4's alleging HA 1 on 7/15/2021, hit him on the side of his face. ADM was unable to provide documentation Resident 4 was protected from further abuse inflicted by HA 1, if other residents were evaluated to determine if they were abused by HA 1, and what measures were taken to prevent them from being abused by HA 1. 5. A review of Resident 5's Admission Record indicated the facility admitted the resident, a seventy-seven-year-old female on 2/24/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's MDS dated [DATE] indicated Resident 5 was moderately cognitively impaired, had memory problems, difficulty making daily decision and required extensive assistance with transfers, walking, dressing, toileting, and personal hygiene. On 9/9/2021 at 4:30 pm, during an interview with SSD and ADM, and concurrent review of the Concern/Grievance Report, indicated on 3/29/2021 FM 1 reported observing through the window on 3/28/2021, a staff member (no name indicated) was repositioning Resident 5 in bed and felt the staff was handling the resident 5 in a rough manner. SSD stated the incident was handled as a grievance because CNA 3 (the staff member FM 1 observed) was apologetic and agreed to treat the resident gently. SSD stated the incident was not investigated as a physical abuse. SSD and ADM were unable to provide documentation Resident 5 was protected from further physical abuse (rough handling) inflicted by CNA 3, if other residents were evaluated to determine if they were abused by CNA 3, and what measures were taken to prevent CNA 3 to abuse the residents. 6. A review of Resident 6's Admission Record indicated the facility readmitted a sixty-three-year-old resident on 11/17/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review or Resident 6's MDS dated [DATE], indicated the resident had severe cognitive impairment with cognitive skills (unable to understand and make decisions). Resident 6 had a gastrostomy tube (GT - soft tubing surgically inserted into the stomach through the abdominal wall to administer food and medication) and was also given oral diet. A review of the facility's Concern/Grievance Report, with a date received of 8/4/2021 indicated Resident 2 reported witnessing CNA 1 get upset at Resident 6 for throwing a cup from her meal tray, CNA 1 cussed while cleaning up the spilled food, and took Resident 6's tray away-stating, she's not eating today. CNA 4 assisted with taking Resident 6's tray away. A review of the CNA 4's Notice of Disciplinary Action dated 8/4/2021, indicated CNA 4 was assigned to Resident 6, who threw her cup across the room. CNA 1 removed the tray. CNA 4 did not offer a meal replacement to Resident 6. The action to be taken was to give CNA 4 a written notice and a suspension. A review of CNA 1's Notice of Disciplinary Action, dated 8/6/2021, indicated CNA 1 was swearing and using inappropriate language and was noted to be calling residents nicknames. On 9/8/2021 at 10:25 am, during an interview, LVN 1 stated she was the charge nurse on the morning shift on 8/4/2021 and remembered Resident 2 asked her to get Resident 6 a sandwich. LVN 1 stated Resident 2 told her she did not want to get anyone in trouble and wanted to keep quiet and just asked for the sandwich. LVN 1 stated she did not ask Resident 2 what happened and just got the sandwich. LVN 1 stated Resident 6 would communicate not liking her food by pushing the tray away. On 9/8/2021 at 10:35 am, during an interview, SSD stated she did not feel CNA 1 was abusive towards Resident 6 because cussing was not towards the resident. SSD stated CNA1 taking Resident 6's tray away was not abusive because Resident 6 kept throwing the tray away and why keep giving her ammunition. On 9/8/2021 at 11 am, during an interview, DSD stated she interviewed Resident 2 and did not feel that CNA 1 taking away Resident 6's tray was a punishment, because the resident had the behavior of pushing away her tray. DSD stated Resident 2 could get nourishment from her GT. DSD explained to Resident 2 CNA 1's behavior and way of speaking was cultural. DSD reviewed the Concern/Grievance Report dated 8/4/2021 and stated it was the first one she had completed and as written, taking the tray away from a resident would be considered punishment. On 9/8/2021 at 3 pm, during an interview, ADM stated he was the abuse coordinator for the facility and oversaw all abuse allegations. ADM stated the incident on 8/4/2021 about the removal of Resident 6's lunch tray was a grievance and not an abuse allegation. ADM was unable to provide documentation Resident 6 was protected from further abuse from CNAs 1 and 4, if other residents were evaluated to determine if they were abused by CNAs 1 and 4, and what measures were taken to prevent them from being abused by CNAs 1 and 4. On 9/9/2021, at 6:45 pm, during an interview, Resident 2 was tearful and stated she had been sad because the incidents of abuse had affected her so much. A review of the facility's policy and procedure titled Abuse Investigation and Reporting, revised on 7/2017, indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property would be reported by the facility Administrator, or his/her designee, to the following persons or agencies: the State Licensing/certification agency responsible for surveying/licensing the facility, local/State Ombudsman, .local law enforcement officials. The policy indicated all alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: two (2) hours if the alleged violation involved abuse or resulted in serious bodily injury. A review of the facility's Elder/Dependent Adult Abuse Policy, updated October 2020, indicated the facility would protect the residents from any type of abuse and the facility was to report all alleged violations involving abuse, neglect, exploitation, or mistreatment. The policy indicated the facility was to report the alleged abuse immediately, but not later than two hours. The policy indicated the facility should make the report to the Department, Ombudsman, and local law enforcement.

Based on observation, interview and record review, the facility failed to assess and monitor skin discolorations to the resident's inner thigh, lower and mid part of the resident's abdomen, right hip, right groin (the area between the abdomen and the thigh on either side of the body), anus (the hole in the resident's bottom), and the right side of the resident's genitals (vagina) for one of three sampled residents (Resident 1) who was on anticoagulant therapy (treatment with anticoagulant medications to reduce the risk of the formation of blood clots) to ensure proper treatment was provided in accordance with the resident's care plan and facility's policy and procedure. As a result of this deficient practice, on 5/12/2021, at 8:10 am, Resident 1 was transferred to a general acute care hospital (GACH) via 911 (emergency services) due to diaphoresis (extreme sweating), and rapid heart rate of 150 beats per minute (normal range 60-100 rate per minute). Resident 1 was admitted to the Intensive Care Unit (ICU, an area in the GACH where patients with life threatening condition are cared for) for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross Reference F757 and F710 Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 5/19/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/19/2021 Resident 1 was transferred to General Acute Care Hospital (GACH) and was admitted to the emergency room (ER) due to [CONDITION(S)], diaphoresis (sweating, especially to an unusual degree as a symptom of disease or a side effect of a drug), and [CONDITION(S)] (low blood pressure), which required admission to the ICU. On 3/24/2021 Resident 1 was readmitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool, dated 3/1/2021, indicated Resident 1 was totally dependent (full staff performance all the time) with one person assistance on bed mobility, transfers, toilet use and personal hygiene. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] ([MEDICATION(S)]-medication used to prevent and treat blood clots) Solution 100 mg (milligrams per milliliter mg/ml, a unit of measurement) subcutaneously injected (injected with the needle under the skin) every twelve hours for deep vein [CONDITION(S)] (DVT, blood clot formation in the veins) prophylaxis (prevention). b. [MEDICATION(S)] 75 mg (medication used to treat blood clots) via gastrostomy tube (G tube, inserted into the stomach to deliver fluids and medications) for [CONDITION(S)] ([CONDITION(S)] or stroke, an interruption of blood flow to the brain due to blood clot or bleeding) prophylaxis. A review of Resident 1's care plan titled [MEDICATION(S)] Therapy, dated 3/26/2021, indicated the resident was at risk for skin discoloration, bruising, and bleeding, and the interventions included to monitor the resident for adverse reaction of anticoagulation therapy. A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan titled, Alteration of Skin Integrity Due to Skin Discoloration, dated 5/1/2021, indicated the resident's risk factors included usage of blood thinner, and the interventions were for nursing staff to monitor Resident 1's discolored areas for increase in size, skin breakdown tenderness and or swelling, and to notify attending physician as needed. A review of Resident 1's Nursing Progress Notes, dated 5/1/2021, timed at 5:20 pm, indicated MD 1 was informed regarding Resident 1's right upper posterior and inner lateral (side) thigh being swollen, warm, and with bluish purplish discoloration. MD 1 ordered [MEDICATION(S)] (an antibiotic or medication to treat infection) 500 mg one tablet via GT for 10 days for [CONDITION(S)] (a skin infection). The progress notes indicated MD 1 ordered ultrasound (uses high-frequency sound waves to create an image of the inside of the body), venous (vein) and arterial (artery) doppler (an imaging test that uses sound waves to show blood moving through blood vessels) of the right upper thigh due to swelling. A review of Resident 1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes also indicated the doppler study was not indicative of DVT and to repeat arterial doppler (study test that uses high-frequency sound waves to measure the amount of blood flow through your arteries and veins). A review of Resident 1's Nursing Progress Notes dated 5/12/2021, and timed at 7:35 am, indicated Resident 1 looked pale (a faintness or absence of color) and diaphoretic (sweating heavily) and with a heart rate of 154 beats per minute. The notes indicated that at 7:50 am, the facility called 911, and at 8:10 am, Resident 1 was transferred to the GACH. A review of Resident 1's GACH record, dated 5/12/2021, at 9 am indicated the following laboratory tests and results: a. Hgb (hemoglobin-the red blood cells that carry oxygen to the cells) results were 7.9 grams/deciliter (g/dl) (normal range 11.0-15.0) below the normal range laboratory tests b. Hct (hematocrit-a measure of the percentage of red blood cells in the body) results were low at 26.6 % (normal range 33-45 %) A review of Resident 1's GACH's physician record, dated 5/12/2021, timed at 10:16 am, indicated Resident 1's condition required urgent complex decision-making to assess and prevent vital organ system failure (organ failure) and to prevent imminent or life-threatening deterioration in the resident's condition. The GACH physician record also indicated management of Resident 1's condition included frequent assessment of the critical values, vital signs and response to interventions. A review of Resident 1's GACH photographs, dated 5/12/2021, and timed at 10:25 pm, indicated hematoma on the following: a. Right buttocks and near the anal opening measured 5 cm (length) x 7cm (width) b. Right abdomen measure 8 cm length X 7 cm (width) A review of Resident 1's computerized tomography scan (CT scan, uses computers and rotating X-ray machines to create cross-sectional images of the body) of the pelvis and right thigh result, dated 5/13/21 indicated the following: a. 10.1 x 6.1 x 19.4 cm (centimeter [cm]) intramuscular (in the muscle) hematoma within the left gluteus maximus (buttocks) and medius (hip) muscle extending inferiorly (bottom) into the posterior (back) compartment of the left thigh. b. 9.4 cm x 7.2 x 22.9 cm intramuscular hematoma in the posterior compartment of the right thigh and subcutaneous (under the skin) [CONDITION(S)] throughout the right lower extremity. During an observation at the GACH on 5/14/2021 at 1:30 pm, Resident 1 was observed inside the ICU room lying in bed, unresponsive and was on a ventilator machine (a machine use to assist with breathing) connected to a [CONDITION(S)] tube (a tube surgically inserted into the throat to deliver oxygen into the lungs). In a concurrent interview, Registered Nurse (RN 1) stated Resident 1 was admitted to the ER and immediately transferred to the ICU due to critical condition. RN 1 stated Resident 1 was observed with multiple bruises and hematoma in the abdomen, inner thighs, and buttocks. RN 1 stated Resident 1 received intravenous (into the vein) fluids and three units of blood transfusion due to low blood count. During an observation on 5/14/2021 at 2:15 pm, conducted with RN 2, Resident 1 was observed with purplish skin discolorations on the lower and mid part of the resident's abdomen, dark purple skin discoloration on the right hip, both lateral inner and posterior thighs, right groin, anus, and right side of the vagina. Resident 1's both arms were observed swollen. During an interview on 5/14/2021 at 3:30 pm, Director of Nursing (DON) stated, Resident 1's bruises could be from the use of [MEDICATION(S)] and [MEDICATION(S)] (anticoagulant, blood thinner) therapy. DON stated, she was not aware how extensive Resident 1's bruises or skin discolorations were prior to Resident 1's transfer to GACH. During a concurrent record review of Resident 1's clinical records and interview with DON, on 5/14/2021 at 4:31 pm, DON stated the resident's skin assessment form, dated 5/1/2021, indicated Resident 1's skin was intact. DON stated Resident 1 had purple bluish skin discoloration on the posterior (back) upper thigh. DON stated the skin assessment form, dated 5/7/2021 indicated Resident 1's inner thigh was intact and swollen with purplish bluish discoloration. DON stated the skin assessment did not indicate the size and exact locations of the skin discolorations. DON stated Resident 1's skin discoloration should have been adequately assessed and measured every week or when worsened to determine if the discoloration or swelling had worsened or improved. DON stated there was no documented evidence in Resident 1's clinical record that MD 1 ordered any laboratory test. During a concurrent record review and interview on 5/14/2021 at 4:45 pm, DON stated the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated, the physician's progress notes did not indicate if the resident's right thigh [CONDITION(S)] (infection of the skin) or the skin discoloration was improving or getting worse. DON stated according to Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the licensed staff failed to document in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 5/26/2021 at 4:35 pm, MD 1 stated Resident 1's decrease in the blood count hemoglobin and hematocrit could be due to bleeding, or a hematoma that erupted. MD 1 stated this resulted for Resident 1 to receive blood [CONDITION(S)]. MD 1 stated he prescribed [MEDICATION(S)] and [MEDICATION(S)] after Resident 1 was diagnosed with PE in March 2021. MD 1 stated he based the dosage of [MEDICATION(S)] prescribed to Resident 1 according to the resident's weight of 100 mgs per kilogram (Resident 1's weight was 96 kgs on 3/1/2021). MD 1 stated he did not recall if he consulted the Pharmacy Consultant to ensure correct dosage of [MEDICATION(S)] with the combination of [MEDICATION(S)]. MD 1 stated he observed Resident 1 with the small bruise during his visit at the facility (MD 1 stated he could not recall the date). MD 1 stated a CBC should had been ordered when bruises were observed. MD 1 stated he relied on the licensed staff to report Resident 1 had skin redness and he determined it was due to [CONDITION(S)]. MD 1 stated he ordered [MEDICATION(S)] to treat the [CONDITION(S)]. MD 1 stated when he saw Resident 1 at the hospital on 5/12/2021, he observed Resident 1 with a large hematoma in the upper inner thighs, buttocks, and abdomen, which was not [CONDITION(S)]. During a telephone interview on 7/6/2021 at 10:23 am, Treatment Nurse (TN 1) stated she observed Resident 1 's right inner thigh intact, swollen with dark purple skin discoloration on 5/1/2021.TN 1 stated the resident's skin discoloration extended to the back of the thigh with redness surrounding Resident 1's anal area. TN 1 stated she reported the resident's skin condition to RN 1 who obtained an order to administer [MEDICATION(S)] for [CONDITION(S)] of the right thigh to be given for 10 days.TN 1 stated Resident 1's skin discoloration did not improve and remained dark and purple.TN 1 stated she failed to document the size or the condition of the discoloration since 5/7/2021 and prior to Resident 1's transfer to the hospital on 5/12/2021. During a telephone interview on 7/6/2021 at 10:52 am, the Pharmacy Consultant stated, residents who received a combination of [MEDICATION(S)] and [MEDICATION(S)] were at high risk for bleeding. Pharmacy Consultant stated if the facility's staff observed the Resident 1 with bruises, bleeding, or skin discoloration, it should be reported to the physician. Pharmacy Consultant stated this would ensure the physician to evaluate the resident and adjust the dosage of the medication. A review of the facility's policy and procedure (P&P) titled, Clinical Protocol-Anticoagulation, dated 9/2012, indicated the physician would assess the resident for any signs and symptoms related to adverse reactions due to a medication or combination of other medications. The P&P indicated the physician would also assess for side effects related to sub-therapeutic (not within the effective dosage of medication) or greater than therapeutic (excessive dose) drug level related to drug and will prescribe anticoagulation according to the recognized guidelines. The P&P indicated the physician would order appropriate laboratory testing to monitor anticoagulation therapy and potential complications. The P&P indicated the staff, and the physician would monitor the individual for signs and symptoms of excessive bruising or other evidence of bleeding, the nurse would discuss the situation with the physician before giving the next dose of anticoagulant.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary medications when the facility failed to: 1. Assess and monitor Resident 1 for the side effects (unwanted effects of medication) of [MEDICATION(S)] (a medication that prevents blood clot formation) and [MEDICATION(S)] (blood thinner to prevents blood clot to form) for the presence of skin discolorations and or bleeding. 2. Ensure Resident 1's Medical Doctor 1 (MD1) ordered a complete blood count (CBC, group of tests to evaluate the cells that circulate in blood for the detection of a variety of diseases and conditions) and other appropriate laboratory testing to monitor anticoagulation therapy (treatment with anticoagulant medications to reduce the risk of the formation of blood clots) and potential complications in accordance with the facility's policy and procedure. 3. Assess and monitor Resident 1's skin discolorations to the resident's inner thigh, lower and mid part of the resident's abdomen, right hip, right groin (the area between the abdomen and the thigh on either side of the body), anus (the hole in the resident's bottom), and the right side of the resident's genitals (vagina), prior to prescribing and administering [MEDICATION(S)] (an antibiotic or medication to treat infection) for [CONDITION(S)] (a skin infection) that was described and documented as purplish skin discoloration, swollen, and intact skin breakdown. As a result of these deficient practices, on 5/12/2021, at 8:10 am, Resident 1 was transferred to a general acute care hospital (GACH) via 911 (emergency services) due to diaphoresis (extreme sweating), and rapid heart rate of 150 beats per minute (normal range 60-100 rate per minute). Resident 1 was admitted to the Intensive Care Unit (ICU, an area in the GACH where patients with life threatening condition are cared for) for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross Reference F684 and F710 Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 5/19/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/19/2021 Resident 1 was transferred to General Acute Care Hospital (GACH) and was admitted to the emergency room (ER) due to [CONDITION(S)], diaphoresis (sweating, especially to an unusual degree as a symptom of disease or a side effect of a drug), and [CONDITION(S)] (low blood pressure), which required admission to the ICU. On 3/24/2021 Resident 1 was readmitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool, dated 3/1/2021, indicated Resident 1 was totally dependent (full staff performance all the time) with one person assistance on bed mobility, transfers, toilet use and personal hygiene. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] ([MEDICATION(S)]) Solution 100 mg (milligrams per milliliter mg/ml, a unit of measurement) subcutaneously injected (injected with the needle under the skin) every twelve hours for deep vein [CONDITION(S)] (DVT, blood clot formation in the veins) prophylaxis (prevention). b. [MEDICATION(S)] 75 mg via gastrostomy tube (Gtube, inserted into the stomach to deliver fluids and medications) for [CONDITION(S)] ([CONDITION(S)] or stroke, an interruption of blood flow to the brain due to blood clot or bleeding) prophylaxis. A review of the Drug Regimen Review (DRR, a review of all medications the resident is currently using in order to identify any potential adverse effects and drug reactions) conducted by the Pharmacy consultant, dated 3/25/2021, indicated Resident 1's concurrent use of [MEDICATION(S)] and [MEDICATION(S)] could result in increased risk of bleeding. There was no documented evidence in Resident 1's clinical record of the physician's response to the DRR to prevent or minimize adverse consequences to related to anticoagulation therapy. A review of Resident 1's care plan titled [MEDICATION(S)] Therapy, dated 3/26/2021, indicated the resident was at risk for skin discoloration, bruising, and bleeding, and the interventions included to monitor the resident for adverse reaction of anticoagulation therapy. A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the DRR conducted by the Pharmacy consultant, dated 4/15/2021, indicated for the facility to clarify the duration of Resident 1's use of [MEDICATION(S)]. The DRR indicated [MEDICATION(S)] was not for long term use. The DRR indicated the usual duration for the use of [MEDICATION(S)] was for 10 days to 12 weeks maximum for prevention and or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's Physician Order, dated 4/18/2021, indicated for the resident to receive [MEDICATION(S)] 100 mg subcutaneously injected every twelve hours for PE with a duration until 6/20/2021. A review of Resident 1's care plan titled, Alteration of Skin Integrity Due to Skin Discoloration, dated 5/1/2021, indicated the resident's risk factors included usage of blood thinner, and the interventions were for nursing staff to monitor Resident 1's discolored areas for increase in size, skin breakdown tenderness and or swelling, and to notify attending physician as needed. A review of Resident 1's Nursing Progress Notes, dated 5/1/2021, timed at 5:20 pm, indicated MD 1 was informed regarding Resident 1's right upper posterior and inner lateral (side) thigh being swollen, warm, and with bluish purplish discoloration. MD 1 ordered [MEDICATION(S)] 500 mg one tablet via GT for 10 days for [CONDITION(S)]. The progress notes indicated MD 1 ordered ultrasound (uses high-frequency sound waves to create an image of the inside of the body), venous (vein) and arterial (artery) doppler (an imaging test that uses sound waves to show blood moving through blood vessels) of the right upper thigh due to swelling. A review of Resident 1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes also indicated the doppler study was not indicative of DVT and to repeat arterial doppler (study test that uses high-frequency sound waves to measure the amount of blood flow through your arteries and veins). A review of Resident 1's Nursing Progress Notes dated 5/12/2021, and timed at 7:35 am, indicated Resident 1 looked pale (a faintness or absence of color) and diaphoretic (sweating heavily) and with a heart rate of 154 beats per minute. The notes indicated that at 7:50 am, the facility called 911, and at 8:10 am, Resident 1 was transferred to the GACH. A review of Resident 1's GACH record indicated the following laboratory tests and results: a. On 5/12/2021, at 9 am indicated Resident 1's Hgb (hemoglobin-the red blood cells that carry oxygen to the cells) results were 7.9 grams/deciliter (g/dl) (normal range 11.0-15.0) below the normal range laboratory tests, and Resident 1's Hct (hematocrit-a measure of the percentage of red blood cells in the body) results were low at 26.6 % (normal range 33-45 %) A review of Resident 1's GACH's physician record, dated 5/12/2021, timed at 10:16 am, indicated Resident 1's condition required urgent complex decision-making to assess and prevent vital organ system failure (organ failure) and to prevent imminent or life-threatening deterioration in the resident's condition. The GACH physician record also indicated management of Resident 1's condition included frequent assessment of the critical values, vital signs and response to interventions. A review of Resident 1's GACH photographs, dated 5/12/2021, and timed at 10:25 pm, indicated hematoma on the following: a. Right buttocks and near the anal opening measured 5 cm (length) x 7cm (width) b. Right abdomen measure 8 cm length X 7 cm (width) A review of Resident 1's computerized tomography scan (CT scan, uses computers and rotating X-ray machines to create cross-sectional images of the body) of the pelvis and right thigh result, dated 5/13/21 indicated the following: a. 10.1 x 6.1 x 19.4 cm (centimeter [cm]) intramuscular (in the muscle) hematoma within the left gluteus maximus (buttocks) and medius (hip) muscle extending inferiorly (bottom) into the posterior (back) compartment of the left thigh. b. 9.4 cm x 7.2 x 22.9 cm intramuscular hematoma in the posterior compartment of the right thigh and subcutaneous (under the skin) [CONDITION(S)] throughout the right lower extremity. During an observation at the GACH on 5/14/2021 at 1:30 pm, Resident 1 was observed inside the ICU room lying in bed, unresponsive and was on a ventilator machine (a machine use to assist with breathing) connected to a [CONDITION(S)] tube (a tube surgically inserted into the throat to deliver oxygen into the lungs). In a concurrent interview, Registered Nurse (RN 1) stated Resident 1 was admitted to the ER and immediately transferred to the ICU due to critical condition. RN 1 stated Resident 1 was observed with multiple bruises and hematoma in the abdomen, inner thighs, and buttocks. RN 1 stated Resident 1 received intravenous (into the vein) fluids and three units of blood transfusion due to low blood count. During an observation on 5/14/2021 at 2:15 pm, conducted with RN 2, Resident 1 was observed with purplish skin discolorations on the lower and mid part of the resident's abdomen, dark purple skin discoloration on the right hip, both lateral inner and posterior thighs, right groin, anus, and right side of the vagina. Resident 1's both arms were observed swollen. During an interview on 5/14/2021 at 3:30 pm, Director of Nursing (DON) stated, Resident 1's bruises could be from the use of [MEDICATION(S)] and [MEDICATION(S)] (anticoagulant, blood thinner) therapy. DON stated, she was not aware how extensive Resident 1's bruises or skin discolorations were prior to Resident 1's transfer to GACH. During a concurrent record review of Resident 1's clinical records and interview with DON, on 5/14/2021 at 4:31 pm, DON stated the resident's skin assessment form, dated 5/1/2021, indicated Resident 1's skin was intact. DON stated Resident 1 had purple bluish skin discoloration on the posterior (back) upper thigh. DON stated the skin assessment form, dated 5/7/2021 indicated Resident 1's inner thigh was intact and swollen with purplish bluish discoloration. DON stated the skin assessment did not indicate the size and exact locations of the skin discolorations. DON stated Resident 1's skin discoloration should have been adequately assessed and measured every week or when worsened to determine if the discoloration or swelling was worsened or improved. DON stated there was no documented evidence in Resident 1's clinical record that MD 1 ordered any laboratory test. During a concurrent record review and interview on 5/14/2021 at 4:45 pm, DON stated the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated, the physician's progress notes did not indicate if the resident's right thigh [CONDITION(S)] (infection of the skin) or the skin discoloration was improving or getting worse. DON stated according to Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the licensed staff failed to document in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 5/26/2021 at 4:35 pm, MD 1 stated Resident 1's decrease in the blood count hemoglobin and hematocrit could be due to bleeding, or a hematoma that erupted. MD 1 stated this resulted for Resident 1 to receive blood [CONDITION(S)]. MD 1 stated he prescribed [MEDICATION(S)] and [MEDICATION(S)] after Resident 1 was diagnosed with PE in March 2021. MD 1 stated he based the dosage of [MEDICATION(S)] prescribed to Resident 1 according to the resident's weight of 100 mgs per kilogram (Resident 1's weight was 96 kgs on 3/1/2021). MD 1 stated he did not recall if he consulted the Pharmacy Consultant to ensure correct dosage of [MEDICATION(S)] with the combination of [MEDICATION(S)]. MD 1 stated he observed Resident 1 with the small bruise during his visit at the facility (MD 1 stated he could not recall the date). MD 1 stated a CBC should had been ordered when bruises were observed. MD 1 stated he relied on the licensed staff to report Resident 1 had skin redness and he determined it was due to [CONDITION(S)]. MD 1 stated he ordered [MEDICATION(S)] to treat the [CONDITION(S)]. MD 1 stated when he saw Resident 1 at the hospital on 5/12/2021, he observed Resident 1 with a large hematoma in the upper inner thighs, buttocks, and abdomen, which was not [CONDITION(S)]. During a telephone interview on 7/6/2021 at 10:23 am, Treatment Nurse (TN 1) stated she observed Resident 1 's right inner thigh intact, swollen with dark purple skin discoloration on 5/1/2021.TN 1 stated the resident's skin discoloration extended to the back of the thigh with redness surrounding Resident 1's anal area. TN 1 stated she reported the resident's skin condition to RN 1 who obtained an order to administer [MEDICATION(S)] for [CONDITION(S)] of the right thigh to be given for 10 days.TN 1 stated Resident 1's skin discoloration did not improve and remained dark and purple.TN 1 stated she failed to document the size or the condition of the discoloration since 5/7/2021 and prior to Resident 1's transfer to the hospital on 5/12/2021. During a telephone interview on 7/6/2021 at 10:52 am, the Pharmacy Consultant stated, residents who received a combination of [MEDICATION(S)] and [MEDICATION(S)] were at high risk for bleeding. Pharmacy Consultant stated if the facility's staff observed the Resident 1 with bruises, bleeding, or skin discoloration, it should be reported to the physician. Pharmacy Consultant stated this would ensure the physician to evaluate the resident and adjust the dosage of the medication. A review of the facility's policy and procedure (P&P) titled, Clinical Protocol-Anticoagulation, dated 9/2012, indicated the physician would assess the resident for any signs and symptoms related to adverse reactions due to a medication or combination of other medications. The P&P indicated the physician would also assess for side effects related to sub-therapeutic (not within the effective dosage of medication) or greater than therapeutic (excessive dose) drug level related to drug and will prescribe anticoagulation according to the recognized guidelines. The P&P indicated the physician would order appropriate laboratory testing to monitor anticoagulation therapy and potential complications. The P&P indicated the staff, and the physician would monitor the individual for signs and symptoms of excessive bruising or other evidence of bleeding, the nurse would discuss the situation with the physician before giving the next dose of anticoagulant. A review of the facility's P&P titled Physician's Services, dated 4/2013, indicated the medical care of the residents was under the supervision of the Licensed Physician. The P&P indicated the resident's attending physician participated in the resident's assessment and care planning, monitoring changes in the resident's medical status. providing consultation or treatment when called by the facility and overseeing the relevant plan of care for the resident. A review of the facility's P&P titled, Medication Regimen Review, dated 5/2019, indicated the Consultant Pharmacist reviewed the medication regimen of each resident at least monthly. The P&P indicated the MRR involved a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities. The P&P indicated the attending physician documented in the resident's medical record that the irregularity had been reviewed and what (if any) action was taken to address it.

Based on observation, interview and record review, the facility failed to ensure the care of one of three sampled residents (Resident 1) was supervised by a physician when the facility failed to: 1. Ensure Resident 1's Medical Doctor 1 (MD1) ordered a complete blood count (CBC, group of tests to evaluate the cells that circulate in blood for the detection of a variety of diseases and conditions) and other appropriate laboratory testing to monitor anticoagulation therapy (treatment with anticoagulant medications to reduce the risk of the formation of blood clots) and potential complications in accordance with the facility's policy and procedure. 2. Ensure Resident 1's MD 1 assess Resident 1's skin discoloration to the resident's inner thigh, lower and mid part of the resident's abdomen, right hip, right groin (the area between the abdomen and the thigh on either side of the body), anus (the hole in the resident's bottom), and the right side of the resident's genitals (vagina), prior to prescribing and administering [MEDICATION(S)] (an antibiotic or medication to treat infection) for [CONDITION(S)] (a skin infection). As a result of these deficient practices, on 5/12/2021, at 8:10 am, Resident 1 was transferred to a general acute care hospital (GACH) via 911 (emergency services) due to diaphoresis (extreme sweating), and rapid heart rate of 150 beats per minute (normal range 60-100 rate per minute). Resident 1 was admitted to the Intensive Care Unit (ICU, an area in the GACH where patients with life threatening condition are cared for) for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross Reference F684 and F757 Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 5/19/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/19/2021 Resident 1 was transferred to General Acute Care Hospital (GACH) and was admitted to the emergency room (ER) due to [CONDITION(S)], diaphoresis (sweating, especially to an unusual degree as a symptom of disease or a side effect of a drug), and [CONDITION(S)] (low blood pressure), which required admission to the ICU. On 3/24/2021 Resident 1 was readmitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool, dated 3/1/2021, indicated Resident 1 was totally dependent (full staff performance all the time) with one person assistance on bed mobility, transfers, toilet use and personal hygiene. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] ([MEDICATION(S)]) Solution 100 mg (milligrams per milliliter mg/ml, a unit of measurement) subcutaneously injected (injected with the needle under the skin) every twelve hours for deep vein [CONDITION(S)] (DVT, blood clot formation in the veins) prophylaxis (prevention). b. [MEDICATION(S)] 75 mg via gastrostomy tube (Gtube, inserted into the stomach to deliver fluids and medications) for [CONDITION(S)] ([CONDITION(S)] or stroke, an interruption of blood flow to the brain due to blood clot or bleeding) prophylaxis. A review of Resident 1's care plan titled [MEDICATION(S)] Therapy, dated 3/26/2021, indicated the resident was at risk for skin discoloration, bruising, and bleeding, and the interventions included to monitor the resident for adverse reaction of anticoagulation therapy. A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan titled, Alteration of Skin Integrity Due to Skin Discoloration, dated 5/1/2021, indicated the resident's risk factors included usage of blood thinner, and the interventions were for nursing staff to monitor Resident 1's discolored areas for increase in size, skin breakdown tenderness and or swelling, and to notify attending physician as needed. A review of Resident 1's Nursing Progress Notes, dated 5/1/2021, timed at 5:20 pm, indicated MD 1 was informed regarding Resident 1's right upper posterior and inner lateral (side) thigh being swollen, warm, and with bluish purplish discoloration. MD 1 ordered [MEDICATION(S)] 500 mg one tablet via GT for 10 days for [CONDITION(S)]. The progress notes indicated MD 1 ordered ultrasound (uses high-frequency sound waves to create an image of the inside of the body), venous (vein) and arterial (artery) doppler (an imaging test that uses sound waves to show blood moving through blood vessels) of the right upper thigh due to swelling. A review of Resident 1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes also indicated the doppler study was not indicative of DVT and to repeat arterial doppler (study test that uses high-frequency sound waves to measure the amount of blood flow through your arteries and veins). A review of Resident 1's Nursing Progress Notes dated 5/12/2021, and timed at 7:35 am, indicated Resident 1 looked pale (a faintness or absence of color) and diaphoretic (sweating heavily) and with a heart rate of 154 beats per minute. The notes indicated that at 7:50 am, the facility called 911, and at 8:10 am, Resident 1 was transferred to the GACH. A review of Resident 1's GACH record, dated 5/12/2, timed at 9am, indicated the following laboratory tests and results: a. Hgb (hemoglobin-the red blood cells that carry oxygen to the cells) results were 7.9 grams/deciliter (g/dl) (normal range 11.0-15.0) below the normal range laboratory tests b. Hct (hematocrit-a measure of the percentage of red blood cells in the body) results were low at 26.6 % (normal range 33-45 %) A review of Resident 1's GACH's physician record, dated 5/12/2021, timed at 10:16 am, indicated Resident 1's condition required urgent complex decision-making to assess and prevent vital organ system failure (organ failure) and to prevent imminent or life-threatening deterioration in the resident's condition. The GACH physician record also indicated management of Resident 1's condition included frequent assessment of the critical values, vital signs and response to interventions. A review of Resident 1's GACH photographs, dated 5/12/2021, and timed at 10:25 pm, indicated hematoma on the following: a. Right buttocks and near the anal opening measured 5 cm (length) x 7cm (width) b. Right abdomen measure 8 cm length X 7 cm (width) A review of Resident 1's computerized tomography scan (CT scan, uses computers and rotating X-ray machines to create cross-sectional images of the body) of the pelvis and right thigh result, dated 5/13/21 indicated the following: a. 10.1 x 6.1 x 19.4 cm (centimeter [cm]) intramuscular (in the muscle) hematoma within the left gluteus maximus (buttocks) and medius (hip) muscle extending inferiorly (bottom) into the posterior (back) compartment of the left thigh. b. 9.4 cm x 7.2 x 22.9 cm intramuscular hematoma in the posterior compartment of the right thigh and subcutaneous (under the skin) [CONDITION(S)] throughout the right lower extremity. During an observation at the GACH on 5/14/2021 at 1:30 pm, Resident 1 was observed inside the ICU room lying in bed, unresponsive and was on a ventilator machine (a machine use to assist with breathing) connected to a [CONDITION(S)] tube (a tube surgically inserted into the throat to deliver oxygen into the lungs). In a concurrent interview, Registered Nurse (RN 1) stated Resident 1 was admitted to the ER and immediately transferred to the ICU due to critical condition. RN 1 stated Resident 1 was observed with multiple bruises and hematoma in the abdomen, inner thighs, and buttocks. RN 1 stated Resident 1 received intravenous (into the vein) fluids and three units of blood transfusion due to low blood count. During an observation on 5/14/2021 at 2:15 pm, conducted with RN 2, Resident 1 was observed with purplish skin discolorations on the lower and mid part of the resident's abdomen, dark purple skin discoloration on the right hip, both lateral inner and posterior thighs, right groin, anus, and right side of the vagina. Resident 1's both arms were observed swollen. During a concurrent record review of Resident 1's clinical records and interview with DON, on 5/14/2021 at 4:31 pm, DON stated the resident's skin assessment form, dated 5/1/2021, indicated Resident 1's skin was intact. DON stated Resident 1 had purple bluish skin discoloration on the posterior (back) upper thigh. DON stated the skin assessment form, dated 5/7/2021 indicated Resident 1's inner thigh was intact and swollen with purplish bluish discoloration. DON stated the skin assessment did not indicate the size and exact locations of the skin discolorations. DON stated Resident 1's skin discoloration should have been adequately assessed and measured every week or when worsened to determine if the discoloration or swelling was worsened or improved. DON stated there was no documented evidence in Resident 1's clinical record that MD 1 ordered any laboratory test. During a concurrent record review and interview on 5/14/2021 at 4:45 pm, DON stated the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated, the physician's progress notes did not indicate if the resident's right thigh [CONDITION(S)] (infection of the skin) or the skin discoloration was improving or getting worse. DON stated according to Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the licensed staff failed to document in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 5/26/2021 at 4:35 pm, MD 1 stated Resident 1's decrease in the blood count hemoglobin and hematocrit could be due to bleeding, or a hematoma that erupted. MD 1 stated this resulted for Resident 1 to receive blood [CONDITION(S)]. MD 1 stated he prescribed [MEDICATION(S)] and [MEDICATION(S)] after Resident 1 was diagnosed with PE in March 2021. MD 1 stated he based the dosage of [MEDICATION(S)] prescribed to Resident 1 according to the resident's weight of 100 mgs per kilogram (Resident 1's weight was 96 kgs on 3/1/2021). MD 1 stated he did not recall if he consulted the Pharmacy Consultant to ensure correct dosage of [MEDICATION(S)] with the combination of [MEDICATION(S)]. MD 1 stated he observed Resident 1 with the small bruise during his visit at the facility (MD 1 stated he could not recall the date). MD 1 stated a CBC should had been ordered when bruises were observed. MD 1 stated he relied on the licensed staff to report Resident 1 had skin redness and he determined it was due to [CONDITION(S)]. MD 1 stated he ordered [MEDICATION(S)] to treat the [CONDITION(S)]. MD 1 stated when he saw Resident 1 at the hospital on 5/12/2021, he observed Resident 1 with a large hematoma in the upper inner thighs, buttocks, and abdomen, which was not [CONDITION(S)]. During a telephone interview on 7/6/2021 at 10:23 am, Treatment Nurse (TN 1) stated she observed Resident 1 's right inner thigh intact, swollen with dark purple skin discoloration on 5/1/2021.TN 1 stated the resident's skin discoloration extended to the back of the thigh with redness surrounding Resident 1's anal area. TN 1 stated she reported the resident's skin condition to RN 1 who obtained an order to administer [MEDICATION(S)] for [CONDITION(S)] of the right thigh to be given for 10 days.TN 1 stated Resident 1's skin discoloration did not improve and remained dark and purple.TN 1 stated she failed to document the size or the condition of the discoloration since 5/7/2021 and prior to Resident 1's transfer to the hospital on 5/12/2021. During a telephone interview on 7/6/2021 at 10:52 am, the Pharmacy Consultant stated, residents who received a combination of [MEDICATION(S)] and [MEDICATION(S)] were at high risk for bleeding. Pharmacy Consultant stated if the facility's staff observed the Resident 1 with bruises, bleeding, or skin discoloration, it should be reported to the physician. Pharmacy Consultant stated this would ensure the physician to evaluate the resident and adjust the dosage of the medication. A review of the facility's policy and procedure (P&P) titled, Clinical Protocol-Anticoagulation, dated 9/2012, indicated the physician would assess the resident for any signs and symptoms related to adverse reactions due to a medication or combination of other medications. The P&P indicated the physician would also assess for side effects related to sub-therapeutic (not within the effective dosage of medication) or greater than therapeutic (excessive dose) drug level related to drug and will prescribe anticoagulation according to the recognized guidelines. The P&P indicated the physician would order appropriate laboratory testing to monitor anticoagulation therapy and potential complications. The P&P indicated the staff, and the physician would monitor the individual for signs and symptoms of excessive bruising or other evidence of bleeding, the nurse would discuss the situation with the physician before giving the next dose of anticoagulant. A review of the facility's P&P titled Physician's Services, dated 4/2013, indicated the medical care of the residents was under the supervision of the Licensed Physician. The P&P indicated the resident's attending physician participated in the resident's assessment and care planning, monitoring changes in the resident's medical status. providing consultation or treatment when called by the facility and overseeing the relevant plan of care for the resident.