Every finding on record at Glendora Grand, Inc

Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents 14 and 124) were called by their legal (official name recognized by government on documents) name or by facility terminology as Assisted Diner. These failures had the potential for Residents 14 and 124 to lose their dignity and individuality.Findings: a. During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including aphasia (a disorder that makes it difficult to speak) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 14's untitled Care Plan (CP) revised on 5/5/2026, the CP indicated Resident 14 needed assistance with Activities of Daily Living (ADLs) including one staff member to assist with eating. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool) dated 5/11/2026, the MDS indicated Resident 14 had severely impaired cognition (ability to understand) and was dependent (helper did all of the effort) from staff with eating. During an interview on 8/12/2026 at 11:59 am with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 14 was a feeder, who was assisted by a Certified Nurse Assistant (CNA) during meals to eat. During an interview on 8/13/2026 at 10:16 am with Registered Nurse Supervisor 1 (RN 1), RN 1 stated it was inappropriate to call a resident a feeder. RN 1 stated, residents who needed assistance to eat were referred to by the facility as assisted diners. During an interview on 8/14/2026 at 9:42 am with the Director of Nursing (DON), the DON stated residents who needed assistance to eat should be called assisted diners or by their names. The DON stated residents should not be called feeders, because it was a dignity issue and labeling the resident would make them feel degraded. b. During a review of Resident 124's AR, the AR indicated Resident 124 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) and lack of coordination. During a review of Resident 124's untitled CP revised on 2/9/2026, the CP indicated Resident 124 needed assistance with Activities of Daily Living, including limited assistance with eating with one staff member. During a review of Resident 124's MDS dated [DATE], the MDS indicated Resident 124 had severely impaired cognition and was dependent from staff with eating. During a review of Resident 124's Order Summary Report (OSR) dated 8/13/2026, the OSR indicated Resident 124 had an active order for Restorative Nursing Assistant (RNA an aid who provides restorative and rehabilitation care to residents) Feeding Program for breakfast and lunch, daily for one month, ordered on 7/28/2026. During an interview on 8/13/2026 at 10:16 am with Registered Nurse Supervisor 1 (RN 1), RN 1 stated it was inappropriate to call a resident a feeder. RN 1 stated residents who needed assistance to eat were referred to by the facility as assisted diners. During an interview on 8/13/2026 at 10:20 am with Restorative Nurse Assistant 1 (RNA 1), RNA 1 stated Resident 124 was a feeder who received assistance being fed and whose progress was monitored. During an interview on 8/14/2026 at 9:42 am with the Director of Nursing (DON), the DON stated residents who needed assistance to eat should be called assisted diners or by their names. The DON stated residents should not be called feeders, because it was a dignity issue and labeling the resident would make them feel degraded. During a review of the facility's Policy and Procedure (P&P) titled, Promoting/Maintaining Resident Dignity, dated 2025, the P&P indicated, it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintained or enhanced a resident's quality of life by recognizing each resident's individuality. The P&P indicated that all staff members were involved in providing care to residents to promote and maintain resident dignity and respect resident rights.

Based on interview and record review, the facility failed to ensure three of three sampled residents' (Residents 9, 13, and 21's) Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment, when:a. The MDS dated [DATE] indicated Resident 9 had invasive mechanical ventilator (a machine pushed air through a tube into the lungs to help someone breathe) when Resident 9 did not have.b. The MDS dated [DATE] indicated Resident 13 had active diagnosis of pneumonia when Resident 13 did not have. c. The MDS dated [DATE] indicated Resident 21 had chemotherapy (medication used to kill cancer cells), radiation (high energy rays used to shrink or kill cancer cells), tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing) care, invasive mechanical ventilator, non-invasive mechanical ventilator (a machine to help a resident breathe using a mask instead of a tube in the throat), intravenous (IV, inside the vein) medication, transfusion (blood or blood products were given through a vein), or hospice (comfort care was provided to resident near the end of life), when Resident 21 did not have any in 6/2026. These deficient practices resulted in inaccurate reporting to the Centers of Medicare and Medicaid Services (CMS, a federal agency that administered the Medicare program and work with state governments to administer the Medicaid and health insurance portability standards) for Residents 9, 13, and 21, and had the potential to result in Residents 9, 13, and 21 not receiving interventions to address specific care concerns. Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted Resident 9 on 5/16/2025 and readmitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (had a long-term breathing problem when the lungs do not get enough oxygen), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 9's History and Physical (H&P) dated 7/13/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool) dated 7/20/2026, the MDS indicated Resident 9 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 9 was dependent (helper did all the effort) on staff with oral hygiene, toileting hygiene, showering/ bathing, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 9 had invasive mechanical ventilator. During an observation on 8/11/2026 at 10:08 am, at Resident 9's bedside, Resident 9 was lying in bed, awake with ongoing oxygen at 2 liters per minute (LPM) via nasal cannula (tube which on one end splits into two prongs which are placed in nostrils to deliver oxygen) tubing. There was no invasive mechanical ventilator at Resident 9's bedside. During an observation on 8/11/2026 at 2:42 pm, at Resident 9's bedside, Resident 9 was lying in bed, awake with ongoing oxygen at 2 LPM via nasal cannula tubing. There was no invasive mechanical ventilator at Resident 9's bedside. During an observation on 8/12/2026 at 10 am, at Resident 9's bedside, Resident 9 was lying in bed, awake with ongoing oxygen at 2 LPM via nasal cannula tubing. There was no invasive mechanical ventilator at Resident 9's bedside. During a concurrent record review and interview on 8/12/2026 at 11:16 am with MDS Assistant 1 (MDSA 1), Resident 9's MDS dated [DATE] was reviewed. MDSA 1 stated the MDS dated [DATE] indicated Resident 9 had an invasive mechanical ventilator. The MDSA 1 stated the MDS was not an accurate assessment and should have been coded No for invasive mechanical ventilator. During an interview on 8/12/2026 at 11:28 am with MDSA 2, MDSA 2 stated it was important to have an accurate MDS assessment because the facility transmit the MDS assessment to CMS. MDSA 2 stated the facility receive Medicare reimbursement from CMS. MDSA 2 stated the facility staff should provide proper care and treatment to address and support residents' needs. MDSA 2 stated when the Registered Nurse (RN) signed the MDS assessment, the RN made sure the information and section were accurate and appropriate to residents according to the nurses' assessments. b. During a review of Resident 13's AR, the AR indicated the facility admitted Resident 13 on 3/17/2022 and readmitted on [DATE] with diagnoses including cerebral atherosclerosis (a condition in which plaque built up inside the arteries of the brain, narrowing them and reducing blood flow) and dementia. During a review of Resident 13's H&P dated 4/10/2026, the H&P indicated Resident 13 did not have the capacity to understand and make decisions. During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had severely impaired cognition. The MDS indicated Resident 13 was dependent on staff with eating, oral hygiene, toileting hygiene, showering/ bathing, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 13 had active pneumonia in the last seven days from assessment date of 5/14/2026. During a concurrent record review and interview on 8/13/2026 at 10:07 am with MDSA 1, Resident 13's entire medical record was reviewed. MDSA 1 stated there was no documentation indicating Resident 13 had active pneumonia in 5/2026. MDSA 1 stated Resident 13's MDS dated [DATE] was not an accurate assessment. MDSA 1 stated MDSA 1 coded the MDS assessment based on the resident's diagnoses list, physician's orders and notes, and the nurses' notes. MDSA 1 stated MDSA 1 should code the active diagnosis instead of the history of diagnosis. During an interview on 8/13/2026 at 12:54 pm with Infection Preventionist Nurse 1 (IPN 1), IPN 1 stated Resident 13 did not have active pneumonia. c. During a review of Resident 21's AR, the AR indicated the facility admitted Resident 21 on 6/10/2024 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (kidney damage), and dependency on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 21's H&P dated 1/21/2026, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's MDS dated [DATE], the MDS indicated Resident 21 had intact cognition. The MDS indicated Resident 21 required setup assistance from staff with eating and oral hygiene. The MDS indicated Resident 21 required moderate assistance (helper did less than half the effort) from staff with personal hygiene and bed-to-chair transferring. The MDS indicated Resident 21 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene and showering/ bathing, The MDS indicated Resident 21 had chemotherapy, radiation, tracheostomy care, invasive mechanical ventilator, non-invasive mechanical ventilator, IV medications, transfusions, and hospice care. During a review of Resident 21's Order Recap Report, dated 6/1/2026 to 6/30/2026, there was no documentation indicating Resident 21 had chemotherapy, radiation, tracheostomy care, invasive mechanical ventilator, non-invasive mechanical ventilator, IV medications, transfusions, or hospice care. During an observation on 8/11/2026 at 10:40 am at Resident 21's bedside, there were no oxygen or any ventilators at bedside. Resident 21 was breathing in room air. Resident 21 did not have a tracheostomy. During an interview on 8/12/2026 at 10:55 am with MDSA 1, MDSA 1 stated Resident 21's MDS assessment dated [DATE] was not accurate. MDSA 1 stated Resident 21 did not have chemotherapy, radiation, tracheostomy care, invasive mechanical ventilator, non-invasive mechanical ventilator, IV medications, transfusions, or hospice care. MDSA 1 stated the person who completed the MDS assessment should sign and verify that the information coded was accurate. MDSA 1 stated the MDS assessment should be accurate to reflect the residents' care, so staff could provide necessary care to the residents. MDSA 1 stated MDSA 1 gathered residents' information by referring to the Resident Assessment Instruction (RAI) manual, reviewing resident's medical diagnoses, H&P, and assessment, interviewing the residents and the CNAs, reviewing residents' medical records such as: physician's orders, nursing assessment, clinical documentation, and physician progress notes. During an interview on 8/13/2026 at 2:03 pm with the Director of Nursing (DON), the DON stated the MDS assessment should accurately reflect the residents' condition, diagnoses, functional status, psychosocial status, and everything about the residents. During a review of the facility's Policy and Procedure (P&P) titled, Conducting an Accurate Resident Assessment dated 2025, the P&P indicated the facility should assure all residents have an accurate assessment to reflect the resident's status at the time of the assessment. The P&P indicated that each individual assessor was responsible for certifying the accuracy of responses relative to the resident's condition. During a review of the facility's P&P titled, Resident Assessment-RAI dated 2025, the P&P indicated the facility should make a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS. The P&P further indicated the assessment process should include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. During a review of the facility's undated MDS Coordinator (MDSC) job description, the job description indicated that the MDSC should ensure accurate completion of all MDS assessments and any supporting assessments or clinical documentation.

Based on interview and record review, the facility failed to meet professional standards of care for two of two sampled residents (Residents 6 and 11) when: a. Licensed staff did not rotate the insulin (a hormone that helps a resident's body use sugar for energy) injection sites for Resident 6 on 6/11/2026, 6/17/2026, and 6/24/2026. b. Licensed staff did not rotate the insulin injection sites for Resident 11 on 7/22/2026. These failures had the potential to compromise Residents 6 & 11's health and safety. Findings: a. During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (when the kidneys are damaged and cannot filter the blood properly), and unspecified dementia (a condition involving memory loss and confusion and the exact cause or type is unknown). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 5/29/2026, the MDS indicated Resident 6 had severe cognitive (thinking ability) impairment. The MDS indicated Resident required moderate assistance (a helper does less than half the effort of the activity) for toileting hygiene, shower/bathing, and upper/lower body dressing. During a review of Resident 6's Doctor's Order (DO) dated 6/14/2026, the DO indicated Resident 6 was ordered to receive 14 units (form of measurement) of Humalog Insulin Lispro (a fast-acting, man-made insulin used to lower blood sugar levels) via subcutaneous (the fatty tissue area located just beneath the skin) injection with breakfast, 14 units with lunch, and 4 units in the evening. The DO dated 6/14/2026 indicated Resident 6 to receive Humalog Insulin Lispro according to a sliding scale (how much insulin to inject based on a resident's blood sugar level) before meals and at bedtime. During a review of Resident 6's DO dated 6/14/2026, the DO indicated Resident 6 was ordered to receive 14 units of Novolog (a fast-acting, man-made insulin) via subcutaneous injection with breakfast, 14 units with lunch, and 4 units in the evening. The DO dated 6/14/2026 indicated Resident 6 to receive Novolog according to a sliding scale before meals and at bedtime. During a review of Resident 6's DO dated 6/29/2026, the DO indicated Resident 6 was ordered to receive 36 units of Insulin Glargine (a long-acting, man-made insulin used once a day to keep blood sugar levels steady over 24 hours) via subcutaneous injection in the morning. During a review of Resident 6's Location of Administration Report (LAR) for the month of 6/2026, the LAR indicated Humalog insulin injection was administered to Resident 6 on 6/11/2026 at 11:02 am to the right arm, and a subsequent Humalog insulin injection on 6/11/2026 at 11:03 also to the right arm. During a review of Resident 6's LAR for the month of 6/2026, the LAR indicated Novolog insulin injection was administered to Resident 6 on 6/17/2026 at 9:32 am to the left lower quadrant (portion) of the abdomen (stomach), followed by an Insulin Glargine injection on 6/17/2026 @ 10:09 am also to the left lower quadrant of the abdomen. During a review of Resident 6's LAR for the month of 6/2026, the LAR indicated Novolog insulin injection was administered to Resident 6 on 6/24/2026 at 8:40 am to the left lower quadrant of the abdomen and an Insulin Glargine injection on 6/24/2026 at 8:40 am also to the left lower quadrant of the abdomen. During a concurrent interview and record review on 8/13/2026 at 10:12 am with Licensed Vocational Nurse 5 (LVN 5), Resident 6's LAR for the month of 6/2026 was reviewed. LVN 5 stated it was professional nursing practice to rotate insulin injection sites and avoid injecting into the same site repeatedly. LVN 5 stated when preparing to administer insulin, the licensed nurse should first review the resident's electronic medication record to determine the insulin injection site that was last used. LVN 5 stated that if the licensed nurse does not rotate an insulin injection site, it was possible for the tissue at that particular site to harden (thicken) over time, which can negatively slow down the insulin's absorption rate (when insulin moves from subcutaneous tissue into the blood) and affect the resident's blood sugar levels. b. During a review of Resident 11's AR, the AR indicated Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and hepatic encephalopathy (a decline in brain function that happens when a damaged liver can no longer filter toxins from the blood). During a review of Resident 11's History and Physical Examination (H&P) dated 9/29/2025, the H&P indicated Resident 11 could make needs known but could not make medical decisions. During a review of Resident 11's Order Summary Report (OSR) dated 9/29/2025, the OSR indicated Resident 11 had a doctor's order to receive Insulin Lispro (a fast-acting, man-made insulin used to lower sudden spikes in blood sugar) via subcutaneous injections before meals and at bedtime according to a sliding scale. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 had severe cognitive impairment. The MDS indicated Resident 11 was dependent (a helper does all of the effort of the activity) on staff with eating, toileting hygiene, and shower/bathing. During a review of Resident 11's LAR dated 7/2026, the LAR indicated that Insulin Lispro was injected into Resident 11's left arm on 7/22/2026 at 11:57 am and subsequently injected also to the left arm on 7/22/2026 at 9:15 pm. During an interview on 8/13/2026 at 10:12 am with LVN 5, LVN 5 stated insulin can be injected into the arms and abdomen. LVN 5 stated that some residents have a preference on the injection's sites, but that licensed nurses need to rotate the injection sites when administering insulin. During an interview on 8/14/2026 at 7:51 am with the Director of Nursing (DON), the DON stated most residents preferred to have insulin injected behind their upper arms and in their abdomen. The DON stated it was professional nursing practice to check the previous insulin injection site used so that the licensed nurse could select a new injection site and ensure the injection sites were rotated. The DON stated the purpose of rotating injection sites was to prevent lipohypertropy (a buildup of fat lumps under the skin caused by injecting insulin to the same sites too many times). During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration Subcutaneous Insulin, dated 2007, the P&P indicated the facility's policy was to administer subcutaneous insulin as ordered and in a safe, accurate and effective manner. The P&P further indicated that the in preparation for injecting insulin, the nurse must check last site of injection and select a new appropriate site for injection.

Based on interview and record review, the facility failed to ensure medications were administered in accordance with physician-ordered parameters (a measurable factor or indicator used to evaluate, track, or define a patient's health status and bodily functions) for one of one sample resident (Resident 12) by failing to: a. Ensure Coreg (medication used to treat high blood pressure and heart failure [HF, a heart disorder which causes the heart to not pump the blood efficiently]) was administered in accordance with physician-ordered parameters on 8/3/2026 and 8/9/2026.b. Ensure Midodrine (medication used to treat low blood pressure) was administered in accordance with physician-ordered parameters on 8/8/2026, 8/11/2026, and 8/13/2026. These failures had the potential to place Resident 12 at risk for medication adverse effects including bradycardia (slow heart rate) and hypotension (low blood pressure).Findings: During a review of Resident 12's admission Record (AR), the AR indicated the facility admitted Resident 12 on 7/20/2018 and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD, irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and atrial fibrillation (a heart rhythm disorder where the heart beats fast and out of sync). During a review of Reside 12's Minimum Data Set (MDS, a resident assessment tool) dated 6/20/2026, the MDS indicated Resident 12 had intact cognition (ability to understand and process information). The MDS indicated Resident 12 required supervision or touching assistance with eating and oral hygiene, partial/moderate assistance (helper did less than half the effort) with personal hygiene and substantial/maximal assistance (helper did more than half the effort) with toileting, shower and upper and lower body dressing. a. During a review of Resident 12's Order Summary Report (OSR), dated 11/21/2025, the OSR indicated Resident 12 had an order for licensed staff to administer Coreg 25 milligrams (mg) by mouth two times a day every Monday, Wednesday, Friday, and Sunday for hypertension (HTN, high blood pressure) and to hold the medication for systolic blood pressure (SBP, the top number in a blood pressure reading) less than (<) 100 or heart rate (HR) < 60 and to hold the medication on Tuesday, Thursday, and Saturday. During a concurrent interview and record review on 8/13/2026 at 1:39 pm with Registered Nurse 1 (RN 1), Resident 12's Medication Administration Record (MAR) for 8/2026 was reviewed. RN1 stated the MAR indicated Resident 12 was administered with Coreg on 8/3/2026 at 7:30 am when Resident 12 had a HR of 58. RN 1 stated the MAR indicated Resident 12 was administered Coreg on 8/9/2026 at 7:30 am when Resident 12 had a HR of 58. b. During a review of Resident 12's OSR, dated 4/16/2026, the OSR indicated Resident 12 had an order for licensed staff to administer Midodrine 5 mg of by mouth in the morning every Tuesday, Thursday, and Saturday and to hold the medication for SBP greater than (>) 110. During a concurrent interview and record review on 8/13/2026 at 1:39 pm with RN 1, Resident 12's MAR for 8/2026 was reviewed. RN 1 stated the MAR indicated Resident 12 was administered with Midodrine on 8/8/2026 at 9:00 am when Resident 12 had a SBP of 112. RN 1 stated the MAR indicated Resident 12 was administered with Midodrine on 8/11/2026 at 9:00 am when Resident 12 had a SBP of 136. RN 1 stated the MAR indicated Resident 12 was administered with Midodrine on 8/13/2026 at 9:00 am when Resident 12 had a SBP of 114. During an interview on 8/13/2026 at 2:29 pm with the Director of Nursing (DON), the DON stated all medications should be given according to the parameters set and according to the physician's order to prevent further drop in the heart rate or changes in the blood pressure and lead to cardiovascular instability. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration General Guidelines, dated 1/24, the P&P indicated, Medications are administered in accordance with written orders of the prescriber. Obtain and record any vital signs as necessary prior to medication administration. Medication administration timing parameters include additional facility specific policies and procedures.

Based on observation, interview, and record review, the facility failed to ensure the smoking policy and procedure (P&P) was implemented for two of four sampled residents (Residents 196 and 274) when Residents 196 and 274 were found with cigarettes in Residents 196 and 274's possession. These failures had the potential to place the facility at risk for fire. Findings: a. During a review of Resident 196's admission Record (AR), the AR indicated the facility admitted Resident 196 on 4/24/2020 and readmitted on [DATE] with diagnoses including extrapyramidal symptoms and movement disorder (EPS, drug-induced movement that affect muscle tone, posture, and involuntary control), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 196's untitled Care Plan (CP) initiated on 2/14/2025, the CP indicated Resident 196 was at risk for self-injury related to smoking. The CP goal included for Resident 196 to abide with house rules on smoking safely. During a review of Resident 196's Smoking Assessment Form (SAF) dated 7/9/2026, the SAF indicated Resident 196 was an unsafe smoker and required constant supervision while smoking. During a review of Resident 196's Minimum Data Set (MDS, a resident assessment tool) dated 7/16/2026, the MDS indicated Resident 196 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 196 required supervision or touching assistance with eating and oral hygiene. The MDS indicated Resident 196 required partial/moderate assistance (helper did less than half the effort) with toileting, shower, upper/lower body dressing and personal hygiene. During a concurrent observation of Resident 196 inside the dining/activity room and interview on 8/11/2026 at 9:29 am with Licensed Vocational Nurse 2 (LVN 2), Resident 196 approached and hand over cigarettes to LVN 2. LVN 2 stated Resident 196 had seven sticks of cigarettes in Resident 196's possession. LVN 2 stated Resident 196 was not allowed to have cigarettes in Resident 196's possession for resident's safety. During an interview on 8/13/2026 at 11:54 am with the Director of Nursing (DON), the DON stated all residents were not allowed to keep cigarettes and to have cigarettes in their possession for the safety of all the residents and staff in the facility. The DON stated cigarettes were a fire hazard. b. During a review of Resident 274's AR, the AR indicated the facility admitted Resident 274 on 7/19/2012 and readmitted on [DATE] with diagnoses including angina pectoris (chest pain), generalized muscle weakness, and schizophrenia (a mental illness characterized by disturbances in thought). During a review of Resident 274's MDS dated [DATE], the MDS indicated Resident 274 had moderately impaired cognition. The MDS indicated Resident 274 required setup assistance from staff with eating. The MDS indicated Resident 274 required moderate assistance from staff with oral hygiene, personal hygiene, toilet transferring, and bed-to-chair transferring. The MDS indicated Resident 274 required maximum assistance (helper did more than half the effort) from staff with toileting hygiene and showering/ bathing. During a review of Resident 274's SAF dated 5/25/2026, the SAF indicated Resident 274 did not understand not to give smoking materials to any other residents or visitors. The SAF indicated Resident 274 was an unsafe smoker and should be supervised at all times while smoking. During a review of Resident 274's History and Physical (H&P) dated 6/26/2026, the H&P indicated Resident 274 had the capacity to understand and make own medical decisions. During a concurrent observation and interview on 8/11/2026 at 10:16 am, inside Resident 274's room, Resident 274 was awake and resting in bed. There was one unlit cigarette on Resident 274's wheelchair at bedside. Resident 274 stated Certified Nurse Assistant 2 (CNA 2) gave the cigarette to Resident 274 during the 10 am smoking time on 8/11/2026. During a concurrent picture review and interview on 8/11/2026 at 10:20 am with Licensed Vocational Nurse 1 (LVN 1), picture dated 8/11/2026 at 10:19 am was reviewed. LVN 1 stated the picture indicated one unlit cigarette on Resident 274's wheelchair at bedside. LVN 1 stated the facility do not allow residents to keep cigarettes to prevent fire. LVN 1 stated it was for safety precaution and CNAs (in general) should do rounds every 15 minutes to ensure no cigarettes were found at resident's bedside and to report to the charge nurse if any. During an interview on 8/13/2026 at 1:46 pm with the DON, the DON stated residents should not have any cigarettes in the resident's possession for safety. The DON stated all staff should ensure residents have no cigarettes in possession, starting with the person distributing the cigarette to the residents. The DON stated the staff disturbing the cigarette should ensure residents did not return to the building with any cigarettes. The DON stated staff should confiscate cigarettes from the residents if seen. During a review of the facility's Policy and Procedure (P&P) titled, Resident Smoking Policy dated 5/5/2023, the P&P indicated that facility should provide a safe and healthy environment for residents, visitors, and employee, including safety as related to smoking. The P&P indicated nursing staff should supervise and maintain residents' smoking materials.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving oxygen therapy (treatment that provided extra oxygen) in accordance with professional standards of practice for four of four sampled residents (Residents 9, 166, 292, and 303) by failing to: a. Ensure Resident 9 received continuous oxygen at 2 liters per minute (LPM) via nasal cannula (a flexible plastic tubing used to deliver oxygen through the nostrils) tubing on 8/11/2026, as ordered.b. Ensure Resident 166's nasal cannula tubing was not touching the floor while in-use on 8/11/2026. c. Ensure Resident 292 received continuous oxygen at 3 LPM via nasal cannula tubing on 8/11/2026, as ordered .d. Ensure Resident 303's nasal cannula tubing was not touching the floor while in-use on 8/11/2026. These deficient practices placed Residents 9, 166, 292, and 303 at risk of complications related to the use of oxygen. Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated the facility initially admitted Resident 9 on 5/16/2025 and readmitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (a long-term breathing problem when the lungs do not get enough oxygen), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 9's History and Physical (H&P) dated 7/13/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool) dated 7/20/2026, the MDS indicated Resident 9 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 9 was dependent (helper did all the effort) on staff with oral hygiene, toileting hygiene, showering/ bathing, personal hygiene, and bed-to-chair transferring. During a review of Resident 9's Order Summary Report (OSR) dated 8/3/2026, the OSR indicated an active order for Resident 9 to receive continuous oxygen at 2 LPM via nasal cannula for chronic respiratory failure with hypoxia every shift. During a review of Resident 9's untitled care plan (CP) for continuous oxygen revised on 8/3/2026, the CP goal was for Resident 9 to maintain highest possible oxygen saturation (O2 sat, a measurement of how much oxygen the blood was carrying as a percentage) daily. The CP indicated a nursing intervention to administer continuous oxygen to Resident 9 as prescribed. During a concurrent observation and interview on 8/11/2026 at 10:08 am with Resident 9, at Resident 9's bedside, Resident 9 was lying in bed, awake with ongoing oxygen running at 2 LPM via nasal cannula tubing. Resident 9's nasal cannula tubing was on Resident 9's left face and not inside the resident's nostrils (external opening of the nose). Resident 9 stated Resident 9 did not know what was on Resident 9's left face. During a concurrent observation and interview on 8/11/2026 at 10:13 am with Certified Nurse Assistant 1 (CNA 1), at Resident 9's bedside, Resident 9 was lying in bed, awake with ongoing oxygen running at 2 LPM via nasal cannula tubing. Resident 9's nasal cannula tubing was on Resident 9's left face and not inside the resident's nostrils. CNA 1 stated Resident 9 was not receiving any oxygen because the nasal cannula was not in Resident 9's nose. During an interview on 8/13/2026 at 2:06 pm with the Director of Nursing (DON), the DON stated the nasal cannula tubing should go inside the resident's nostril. The DON stated the resident was not receiving oxygen if the nasal cannula tubing was on the resident's face and could result in respiratory distress. The DON stated the CNAs, licensed vocational nurses, and the registered nurses should ensure proper placement of the nasal cannula tubing for residents receiving oxygen as ordered. During a review of the facility's undated Policy and Procedure (P&P) titled, Oxygen Administration, the P&P indicated staff should administer oxygen to residents who needed it under orders of a physician, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The P&P indicated staff should place the nasal cannula in resident's nostril to administer oxygen. b. During a review of Resident 166's AR, the AR indicated Resident 166 was admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), respiratory failure (a condition caused by inadequate supply of oxygen and/or the inability to remove carbon dioxide from the lungs), and dementia. During a review of Resident 166's untitled Care Plan (CP) revised on 4/15/2026, the CP indicated Resident 166 had an order for continuous oxygen secondary to COPD diagnosis with an intervention to provide oxygen as ordered. During a review of Resident 166's MDS dated [DATE], the MDS indicated Resident 166 had severely impaired cognition and was on continuous oxygen therapy. During a review of Resident 166's Order Summary Report (OSR dated 8/13/2026, the OSR indicated Resident 166 had an active order for oxygen to be administered at two liters per minute (lpm) via nasal cannula (NC) continuously, ordered on 7/27/2026. During a concurrent observation and interview on 8/11/2026 at 9:28 am with Licensed Vocational Nurse 1 (LVN 1) in Resident 166's room, Resident 166 was receiving oxygen through a NC and the NC tubing was touching the floor. LVN 1 stated Resident 166's NC tubing should not be touching the floor for infection control reasons. During an interview on 8/14/2026 at 9:38 am with the DON, the DON stated the NC tubing should not be touching the floor for infection control. The DON stated the resident could acquire a respiratory infection if the NC tubing was touching the floor. During a review of the facility's undated P&P titled, Oxygen Administration, the P&P indicated oxygen was administered to residents who needed it, consistent with professional standards of practice. The P&P indicated, to change the oxygen tubing and mask/cannula weekly and as needed if it became soiled or contaminated. c. During a review of Resident 292's AR, the AR indicated Resident 292 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including COPD, epilepsy (a brain condition that causes repeated and unexpected seizures), and Parkinson's disease (a slow brain disorder that makes it hard to control body movements). During a review of Resident 292's MDS dated [DATE], the MDS indicated Resident 292's had severely impaired cognition. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, shower/bathe, and upper/lower body dressing. During a review of Resident 292's H&P dated 6/8/2026, the H&P indicated Resident 292 did not have the capacity to understand and make decisions. During a review of Resident 292's OSR dated 6/8/2026, the OSR indicated Resident 292 had a doctor's order to receive continuous oxygen at 3 LPM via nasal cannula for COPD. During an observation on 8/11/2026 at 9:59 am, Resident 292 was lying in bed with eyes closed. Resident 292's nasal cannula tubing was observed inside Resident 292's opened mouth. During a concurrent observation and interview on 8/11/2026 at 10:06 am with LVN 6 at Resident 292's bedside, LVN 6 stated Resident 292's nasal cannula tubing was inside Resident 292's mouth. LVN 6 stated the nasal cannula tubing should have been inside Resident 292's nostril in order to deliver oxygen accurately and properly. LVN 6 stated a resident's oxygen intake could decrease to a harmful level if the nasal cannula is not properly placed inside the resident's nostrils. During an interview on 8/14/2026 at 7:51 am with the DON, the DON stated supplemental (additional) oxygen was given to residents per doctor's orders to prevent respiratory distress (breathing problems). The DON stated supplemental oxygen was primarily administered through a nasal cannula. The DON stated a nasal cannula should be inside a resident's nose, and not inside a resident's mouth, in order to properly and effectively administer supplemental oxygen. During a review of the facility's undated P&P titled, Oxygen Administration, the P&P indicated oxygen is administered to residents who need it, consistent with professional standards of practice. The P&P further indicated the types of delivery systems included nasal cannula where oxygen is administered through plastic cannulas in the nostrils. d. During a review of Resident 303's AR, the AR indicated Resident 303 was admitted to the facility on [DATE] with diagnoses including COPD, depression (persistent feeling of sadness, emptiness, and a loss of interest in activities) and bipolar disorder (mental health condition that causes extreme shifts in mood, energy, and activity levels). During a review of Resident 303's OSR dated 8/11/26, the OSR indicated an order for oxygen at 3L/min via nasal cannula every eight hours as needed for diagnosis of COPD to keep O2 Sat above 92 percent (%). During a review of Resident 303's H&P dated 6/25/2026, the H&P indicated Resident 303 cognition level was unremarkable (the person's mental function, memory, and thinking abilities are normal, typical, or expected for their age). During observation inside Resident 303's room on 8/11/2026 at 9:37 am, Resident 303 was resting in bed. Resident 303's nasal cannula tubing was touching the floor. During an interview with the License Vocational Nurse 4 (LVN 4) on 8/14/2026 at 9:03 am, LVN 4 stated that if a resident was receiving oxygen via nasal cannula, the nasal cannula tubing should not be touching the floor for infection control. LVN 4 stated if the nasal cannula was touching the floor, it would contaminate the tubing. During an interview with the DON on 8/14/2026 at 9:17 AM, the DON stated that the nasal cannula should not be touching the floor for infection control. The DON stated the nasal cannula should be changed and kept clean at all times to protect the residents from bacteria and infections. During a review of the facility's P&P titled, Infection Prevention and Control Program, revised 2023, the P&P indicated, the facility maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure the ice machine dispensing area for one of three facility ice machines was kept clean and sanitary in accordance with the facility's Policy and Procedure (P&P) titled, Ice Machines and Ice Storage Chests. This deficient practice had the potential to result in foodborne illness (illness caused by consuming contaminated food or beverages) for the residents. Findings: During an observation of the ice machine inside the Manor Building and interview with the Dietary Account Manager (DAM) on 8/11/2026 at 8:39 am, the DAM stated that the ice machine dispensing area was not clean. The ice machine dispensing area had black and brown stains. The DAM stated the DAM was unsure if the ice machine dispensing area was dirty or had mold (fungal growth that develops in moist or damp conditions). The DAM stated that the maintenance staff were responsible of ensuring the ice machines were cleaned and sanitized. The DAM stated if the ice machine dispensing area was dirty and if the residents consumed the ice, it could make the residents sick. During an interview with the Maintenance Supervisor (MS) on 8/12/2026 at 11:50 am, the MS stated there were three ice machines throughout the facility. The MS stated that the MS cleaned each ice machine once a week on Mondays and performed deep cleaning every three months. The MS stated the MS did not clean the ice machine inside the Manor Building the previous week on Monday (8/3/2026) because the MS was busy. The MS stated the MS knew it was very important to maintain the ice machines clean at all times. The MS stated if the ice machines were dirty, and the residents consumed the ice, the residents could get sick. During an interview with the Director of Nursing (DON) on 8/12/2026 at 1:43 pm, the DON stated all areas of the ice machine should be cleaned and sanitized. The DON stated if an ice machine dispenser was dirty or had mold, it could contaminate all the ice with harmful bacteria. The DON stated it was unacceptable to have any part of the ice machine dirty and not sanitized. The DON stated it was an infection control issue if the ice machine was dirty. The DON stated that if the ice machine is dirty, it could carry harmful bacteria in the ice that would be distributed to the residents. During a review of the facility's undated P&P titled, Ice Machines and Ice Storage Chests, the P&P indicated, Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. The facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. During a review of the facility's P&P titled, Infection Prevention and Control Program, revised 2023, the P&P indicated, This facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices by failing to:a. Label the food items inside one of two residents' refrigerators with received date and resident's name.b. Ensure one of one sampled resident (Resident 274's) food brought in by family was labeled with the resident's name and date. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) to the residents. Findings: a. During an observation and interview with the Dietary Account Manager (DAM) in the Manor building on 8/11/26 at 8:35 AM, the DAM stated the refrigerator used for the residents' food and snack was located in Station 5. The DAM stated nursing staff were responsible for dating and labelling food items received from family members and placing the food items inside the refrigerator. During an observation in the Manor Building of the resident's refrigerator in Station 5 on 8/11/2026 at 8:35 AM and interview with License Vocational Nurse 2 (LVN2) the following were observed inside the resident's refrigerator: a. One black raspberry flavor sparkling water did not have a date and resident's name b. One strawberry jelly jar did not have a date and resident's name c. One tropical energy drink did not have a date and resident's name d. One orange mango flavored sparkling water bottle did not have a date and resident's name LVN2 stated the items inside the refrigerator were not labeled with the date received or the name of the resident the food item belonged to. LVN2 stated the food inside the resident's refrigerator should be labeled with the resident's name and room number. LVN2 stated that if the resident's family brought food or snacks for the resident, the nursing staff needed to date and write the residents' name on the food item and place the food item inside the refrigerator. LVN2 stated the food item needed to have the resident's name and received date so that staff would know who the food item belonged to. During an interview with the Director of Nursing (DON) on 8/12/2026 at 1:50 PM, the DON stated the food item in the resident's refrigerator must have the resident's name and date when the food item was received. The DON stated it was not acceptable to have unlabeled food items inside the resident's refrigerator. The DON stated if the food item did not have a date, the food item could be expired and should not be given to the resident. The DON stated if the food item was not labeled with a received date or expiration date, the food item needed to be removed or thrown out of the refrigerator. The DON stated if expired food was given to the residents, it could make the residents sick. During a review of the facility's Policy and Procedures (P&P) titled, Food: Safe Handling for Foods from Visitors, dated 2/2023, the P&P indicated, Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. When food items are intended for later consumption, the responsible facility staff member will: label foods with the resident name and the current date. b. During a review of Resident 274's admission Record (AR), the AR indicated the facility admitted Resident 274 on 7/19/2012 and readmitted on [DATE] with diagnoses including type 2 diabetic mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) generalized muscle weakness, and schizophrenia (a mental illness characterized by disturbances in thought). During a review of Resident 274's Order Summary Report (OSR) dated 3/26/2026, the OSR indicated an active order for Regular Diet for Resident 274. During a review of Resident 274's History and Physical (H&P) dated 6/26/2026, the H&P indicated Resident 274 had the capacity to understand and make own medical decisions. During a review of Resident 274's Minimum Data Set (MDS, a resident assessment tool) dated 5/25/2026, the MDS indicated Resident 274 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 274 required setup assistance from staff with eating. The MDS indicated Resident 274 required moderate assistance (helper did less than half the effort) from staff with oral hygiene, personal hygiene, toilet transferring, and bed-to-chair transferring. The MDS indicated Resident 274 needed maximum assistance (helper did more than half the effort) from staff with toileting hygiene and showering/ bathing. During a concurrent observation and interview on 8/11/2026 at 10:16 am, inside Resident 274's room, Resident 274 was awake and resting in bed. The following were observed at Resident 274's bedside: 1. One open and unlabeled bottle of salsa sauce with instructions to refrigerate after opening. 2. Two open and unlabeled bottles of sriracha sauce. Resident 274 stated Resident 274's family brought salsa sauce and sriracha sauce a month ago to the facility.During a concurrent observation and interview on 8/12/2026 at 11:59 am with Certified Nurse Assistant 3 (CNA 3), inside Resident 274's room, Resident 274 was awake and resting in bed. The following were observed at Resident 274's bedside: 1. One open and unlabeled bottle of salsa sauce with instructions to refrigerate after opening. 2. Two open and unlabeled bottles of sriracha sauce. CNA 3 stated the food at bedside was not labeled with resident's name or dates and should have been. CNA 3 stated food should not be stored at bedside for a long time because bacteria would grow and spoil the food. CNA 3 stated food at bedside would attract flies. CNA 3 stated the nurses (in general) should make rounds and check for any food left at the resident's bedside. During an interview on 8/13/2026 at 12:57 pm with Infection Preventionist Nurse 2 (IPN 2), IPN 2 stated nurses (in general) should label outside food with the residents' name and date opened for safety. IPN 2 stated staff (in general) should label outside food with the resident's name so it would not be shared with any other residents. IPN 2 stated the licensed nurse should check and label food brought in by family/ visitor to the facility. During an interview on 8/13/2026 at 2:01 pm with the DON, the DON stated it was infection control to label food brought in by family/visitor for residents to consume later with the resident's name and date. The DON stated the nursing team should ensure food brought in by family/ visitor was labeled and stored in the resident's refrigerator as needed. The DON stated food that needed refrigeration and was left at room temperature would cause gastrointestinal (relating to the stomach and intestines) problems. During a review of the facility's P&P titled, Food: Safe Handling for Foods from Visitors revised 2/2023, the P&P indicated the facility should assist the resident in proper storing and safely consuming food brought into the facility by a visitor. The P&P indicated that the facility staff should label food brought into the facility for residents to consume later with the resident name and the current date.

Based on observation, interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards of practice for two of two sampled residents (Residents 93 and 166) by failing to:a. Document the administration of Resident 93's morning medications on 8/13/2026.b. Accurately document the place and time of Resident 166's transfer on 7/10/2026. These failures had the potential to result in duplication of medication for Resident 93 and overall, negatively impact Residents 93 and 166's care and delivery of services.Findings: a. During a review of Resident 93's admission Record (AR), the AR indicated Resident 93 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 93's Minimum Data Set (MDS, a resident assessment tool) dated 5/19/2026, the MDS indicated Resident 93 had severely impaired cognition (ability to understand).During an observation in Resident 93's room on 8/13/2026 at 8:14 am, Resident 93 was awake, lying in bed. During a concurrent interview and record review on 8/13/2026 at 9:16 am with Licensed Vocational Nurse 3 (LVN 3), Resident 93's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/1/2026 to 8/31/2026 was reviewed. The MAR indicated that the 8/13/2026 - 9am medications for Resident 93 did not have documentation for the following: 1. Famotidine (medication to decrease stomach acid) oral tablet 20 milligrams (mg) 2. Multivitamin oral liquid with minerals 15 milliliters (ml)3. Insulin (a hormone that removes excess sugar from the blood) Aspart Injection Solution 100 unit/ml 4. Amlodipine Besylate (medication to treat high blood pressure) oral tablet 5 mg 5. Buspirone HCl (medication to treat anxiety) oral tablet 5 mg 6. Depakene (medication to stabilize mood) oral syrup 250 mg/5 ml 7. Glucerna (nutritional shake for individuals with diabetes) supplement8. Seroquel (medication to treat the symptoms of mental illness) oral tablet 100mg9. Zyprexa (medication to treat schizophrenia- [a mental illness characterized by disturbances in thought)) oral tablet 7.5mg10. Prostat SF (concentrated liquid protein)LVN 3 stated LVN 3 completed Resident 93's 9 am medication administration but failed to document after the medication administration. LVN 3 stated LVN 3 forgot to complete the documentation and should have completed it after Resident 93's medication administration. LVN 3 stated, documentation was important to show evidence that the resident took medication at that time of medication administration. During an interview on 8/13/2026 at 10:08 am with Registered Nurse Supervisor 1 (RN 1), RN 1 stated documentation in the Medication Administration Record should be completed after the medication(s) were given to the resident to prevent errors from occurring and for resident safety. During an interview on 8/14/2026 at 9:45 am with the Director of Nursing (DON), the DON stated, during the medication administration process documentation should be done immediately after medications were given to the residents to prevent forgetting to document or creating a timing delay. The DON stated, if documentation was not done, the MAR would show the medications were not given and the resident could receive a duplicate dose. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration- General Guidelines, dated 2007, the P&P indicated the individual who administered the medication dose, record the administration on the resident's MAR immediately following the medication being given. During a review of the facility's P&P titled, Charting and Documentation, dated 2025, the P&P indicated all services provided to the resident, or any changes in the resident's medical or mental condition, should be documented in the resident's medical record. The P&P indicated that all observations, medications administered, services performed, etc., must be documented in the resident's clinical records. b. During a review of Resident 166's AR, the AR indicated Resident 166 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dementia. During a review of Resident 166's MDS dated [DATE], the MDS indicated Resident 166 had severely impaired cognition. During a review of Resident 166's Physician Orders (PO) dated 7/10/2026, the PO indicated to transfer Resident 166 to General Acute Care Hospital 1 (GACH 1). During a concurrent interview and record review on 8/12/2026 at 12:58 pm with Licensed Vocational Nurse 3 (LVN 3), Resident 166's Nursing Note (NN) dated 7/10/2026 at 12:58 pm was reviewed. The NN indicated Resident 166 experienced chest pain and was transferred to GACH 1. LVN 3 stated, on 7/10/2026 Resident 166 had chest pain and was transferred to GACH 1 via emergency medical services at 12:43 pm. During a concurrent interview and record review on 8/14/2026 at 11:51 am with the DON, Resident 166's SNF /NF to Hospital Transfer Form (STF), dated 7/10/2026 was reviewed. The STF indicated Resident 166 was sent to GACH 2 on 4/3/2026 at 10:00 pm. The DON stated the nursing staff forgot to change the information when completing the STF on 7/10/2026. The DON stated the STF was incorrectly completed with the wrong transfer date and hospital destination. During a review of the facility's P&P titled, Charting and Documentation, dated 2025, the P&P indicated all services provided to the resident, or any changes in the resident's medical or mental condition, should be documented in the resident's medical record. The P&P indicated entries may only be recorded in the resident's clinical record by licensed personnel in accordance with state law and facility policy. The P&P indicated documentation of procedures and treatments shall include care-specific details and should include at a minimum, the date and time the procedure/treatment was provided.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: a. One of one trash bin located inside the shared bathroom of Room A and Room B was overflowing with used paper towels and had spilled onto the bathroom floor. b. One of one toilet located inside the shared bathroom of Room A and Room B was filled with used toilet paper and feces. c. Five crumpled and used surgical masks (single-use masks worn for general patient care to stop the spread of germs) were found on top of one of one sampled resident (Resident 185's) bedside dresser. These failures had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the spread of infection among residents in the facility. Findings: a. During an observation on 8/11/2026 at 9:35 am inside the shared bathroom between Room A and Room B, the trash bin was overflowing with used paper towels that spilled onto the bathroom floor. During a concurrent observation and interview on 8/11/2026 at 9:46 am with Certified Nursing Assistant 4 (CNA 4) inside the shared bathroom between Room A and Room B, CNA 4 stated the trash bin was filled to the top with used paper towels, and that some of the trash fell onto the bathroom floor. CNA 4 stated trash should not be on the floor because it has germs that could spread infection. During an interview on 8/14/2026 at 7:51 am with the Director of Nursing (DON), the DON stated the majority of resident bathrooms in the facility were shared by two rooms. The DON stated it was possible that multiple residents from each of the two rooms would use the same bathroom. The DON stated having trash spilled onto the shared bathroom floor was an infection control issue that could lead to the spread of germs. b. During an observation on 8/11/2026 at 9:35 am inside the shared bathroom between Room A and Room B, the toilet was filled with used toilet paper and feces. During a concurrent observation and interview on 8/11/2026 at 9:46 am with CNA 4 inside the shared bathroom between Room A and Room B, CNA 4 stated the toilet was not flushed and still contained used toilet paper and feces. CNA 4 stated the toilet should be flushed after every use since multiple residents would use the same toilet. CNA 4 stated a shared bathroom should be kept clean and sanitary to avoid the spread of infection. During an interview on 8/14/2026 at 7:51 am with the DON, the DON stated that when a toilet in a shared bathroom was filled with used tissue and bowel movement, it was an infection control issue because it involved someone's waste. The DON stated an unflushed toilet containing someone's waste could lead to cross-contamination among other residents who use the same bathroom. c. During an observation on 8/11/2026 at 9:35 am inside Resident 185's room, there were multiple crumpled and used surgical masks observed on top of Resident 185's bedside dresser. During a concurrent observation and interview on 8/11/2026 at 9:43 am with CNA 4 near Resident 185's bedside, CNA 4 stated there were five used surgical masks on top of Resident 185's bedside dresser. CNA 4 stated the used surgical masks should have been thrown away in the trash to avoid the possible spread of infection. During an interview on 8/14/2026 at 7:51 am with the DON, the DON stated nursing staff should make rounds (the act of checking on one resident after another) at least every two hours. The DON stated that when nursing staff make rounds, the staff should visually check each resident and the resident's environment for possible infection control issues. The DON stated used surgical masks left on top of a resident's bedside dresser could potentially spread infection because the masks were soiled (dirty), and it was unknown who the masks belonged to. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revised 2023, the P&P indicated the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P further indicated a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, and sanitary environment for two of 24 resident rooms (rooms [ROOM NUMBERS]) in Station Four. These failures had the potential to cause injuries, accidents, and falls to the residents.Findings: a. During a concurrent observation inside room [ROOM NUMBER] and interview on 8/11/2026 at 9:12 am with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the floor inside room [ROOM NUMBER] was sticky and that shoes would stick to the floor when someone walked on it. b. During a concurrent observation inside room [ROOM NUMBER] and interview on 8/11/2026 at 9:14 am with LVN 2, LVN 2 stated the floor outside the bathroom of room [ROOM NUMBER] was wet with red-colored liquid. During an interview on 8/11/2026 at 9:31 am with LVN 2, LVN 2 stated all floors inside the resident rooms should be maintained and kept clean and dry to prevent accidents and cause harm to the residents, visitors and staff. During an interview on 8/13/2026 at 11:54 am with the Director of Nursing (DON), the DON stated residents' rooms should be clutter-free, floors should be dry, clean and not sticky for infection control and for the safety of the residents in the facility During a review of the facility's Policy and Procedure (P&P) titled, Safe and Homelike Environment, revised in November 2017, the P&P indicated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

Based on interview and record review the facility failed to develop an individualized/person- centered care plan (CP) for one of one sampled resident (Resident 190) in accordance with the facility's policy titled Comprehensive Care Plans. This deficient practice had the potential for Resident 190 to not receive appropriate care treatment and/or services.Findings: During a review of Resident 190's admission Record (AR) the AR indicated the facility admitted Resident 190 on 3/13/2026 with diagnoses including bipolar disorder (mental disorder with periods of depression and elevated mood), dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and hyperlipidemia (high level of fat in the blood). During a record review of Resident 190's Order Summary Report (OSR), dated 4/24/2026, the OSR indicated for licensed staff to administer Zyprexa Zydis (antipsychotic medication to treat serious mental disorder) Oral Tablet Disintegrating 5 milligram (mg, unit of measurement) by mouth one time a day manifested by mood swings from happiness to anger related to bipolar disorder, current episode hypomanic (mild-to-moderate burst of high energy). During a review of Resident 190's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/20/2026, the MDS indicated Resident 190 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 190 required supervision (helper provides verbal cues) from staff for oral and toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent interview and record review on 8/12/2026 at 11:13 am with Registered Nurse 2 (RN 2), Resident 190's medical record (PointClickCare - PCC, a cloud-based software used in charting) was reviewed. RN 2 stated a CP was not initiated/implemented to address Resident 190's bipolar disorder diagnosis. RN 2 stated a CP should have been developed and implemented for staff to have a guide on how to provide proper care and treatment to Resident 190. During an interview on 8/13/2026 at 12:01 pm with the facility's Director of Nursing (DON), the DON stated, a CP need to be initiated/developed and implemented upon residents' admission, change of condition or when staff received new orders from the doctor in order to guide staff how to effectively manage and treat the resident's condition. During a review of the facility's undated Policy and Procedure (P&P) titled, Comprehensive Care Plans the P&P indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 69). This failure had the potential for Resident 69 not to receive necessary care or receive delayed services. Findings: During a review of Resident 69's admission Record (AR), the AR indicated the facility initially admitted Resident 69 on 2/28/2014 and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 69's untitled Care Plan (CP) revised on 3/15/2025, the CP indicated Resident 69 needed assistance with activities of daily living (ADL) and the CP interventions included for staff to have the call light within reach of the resident and answering the call light promptly. During a review of Resident 69's Minimum Data Set (MDS, a resident assessment tool) dated 7/14/2026, the MDS indicated Resident 69 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 69 required partial/moderate assistance (helper did less than half the effort) with eating and upper body dressing, substantial/moderate assistance (helper did more than half the effort) with oral hygiene and lower body dressing and dependent (helper did all the effort) with toileting and shower. During a concurrent observation inside Resident 69's room and interview on 8/11/2026 at 9:16 am with Licensed Vocational Nurse 2 (LVN 2), Resident 69 was lying in bed on the right side with the call light on the floor and on the left side of the bed. LVN 2 stated the call light should be placed next to Resident 69 for easy access whenever Resident 69 needed help and in case of an emergency situation. During an interview on 8/13/2026 at 11:54 am with the Director of Nursing (DON), the DON stated the resident's call light should be placed within easy reach of the resident to use when assistance was needed. During a review of the facility's Policy and Procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised in 2021, the P&P indicated, Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 7) had an accurate and complete Acknowledgment of Receipt- Advance Directive/Medical Treatment Decisions (ARAD- form that indicated a resident or resident's representative were informed of their rights regarding medical treatments, Advance Directive [AD, a legal document indicating resident preference on end-of-life treatment decisions] formulation, and whether an AD was created). This failure had the potential for the facility staff to provide medical treatment and services against the will of the resident or responsible party. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 4/1/2023 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 7's History & Physical (H&P) dated 6/8/2026, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a concurrent interview and record review on 8/11/2026 at 10:46 am with Registered Nurse Supervisor 1 (RN 1), Resident 7's ARAD dated 6/9/2026 was reviewed. Resident 7's ARAD did not indicate whether Resident 7 had an Advance Directive and the SSD was written as the surrogate decision maker. RN 1 stated the ARAD was incomplete because it did not indicate whether Resident 7 had an AD which was important for the resident's treatment and to ensure Resident 7's decisions were followed. During a concurrent interview and record review on 8/12/2026 at 3:23 pm with Social Services Director 1 (SSD 1), Resident 7's ARAD dated 6/9/2026 was reviewed. Resident 7's ARAD did not indicate whether Resident 7 had an AD and the SSD was written as the surrogate decision maker. SSD 1 stated Resident 7's ARAD should have a box checked off to indicate if Resident 7 had an AD and the decision maker section should not have been filled out by the SSD, but by the responsible party or surrogate decision maker as indicated. SSD 1 stated, the ARAD was important because it indicated what was chosen for the resident and would help the staff respect the resident's wishes. SSD 1 stated Resident 7's ARAD was incorrectly completed. During an interview on 8/14/2026 at 9:39 am with the Director of Nursing (DON), the DON stated it was necessary that the ARAD was filled out completely and accurately because it was a legal document that indicated whether the resident had an AD or not. The DON stated the ARAD would provide staff the knowledge on how to proceed with resident care during an emergency situation. During a review of the facility's undated Policy and Procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directives, the P&P indicated on admission, the facility would determine if the resident executed an AD and if not, determine whether the resident would like to formulate an AD.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 283) reviewed for changes in Medicare coverage was provided with the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) appeal process in a timely manner while Resident 283 was in the facility. This deficient practice had the potential to result in Resident 283 or responsible party not being able to exercise their right to file an appeal while in the facility. Findings: During a review of Resident 283' s admission Record (AR), the AR indicated the facility admitted Resident 283 on 9/13/2027 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and hypertensive heart disease (problems with the heart that can develop due to high blood pressure). During a review of Resident 283's NOMNC and SNF ABN, the NOMNC indicated Resident 283's last covered day for Medicare Part A Skilled Services was 7/30/2026. There was no documented evidence that Resident 283's representative was given the option to make an informed decision for payment of non-covered services while Resident 283 continued to reside in the facility. During further review of Resident 283's NOMNC, the NOMNC indicated the resident's Skilled Nursing Service end date was 7/30/2026. The NOMNC was not dated when the notice was signed by Resident 283. During a concurrent interview with the Director of Nursing (DON) and record review of Resident 283's SNF ABN Notice on 8/12/2026 at 1:24 pm, the DON stated the DON left a voicemail message to Resident 283's representative on 7/24/2026 but no follow up call was made to get an informed decision from Resident 283's representative. The DON stated the MDS staff and DON needed to do a follow-up call to Resident 283's representative two days before the last covered date of Medicare Part A services so that the resident or resident's representative would be informed of financial responsibility during Resident 283's long term stay in the facility. The DON stated the NOMNC was not dated when it was signed by Resident 283. The DON stated the NOMNC should have been dated when it was discussed with Resident 283. The DON stated the NOMNC should have been discussed with the resident and/or responsible party at least 2 days prior to the last covered date which was on 7/30/2026. During a concurrent interview with the Social Services Director 1 (SSD 1) and record review of Resident 283's SNF ABN Notice on 8/12/26 at 3:18 pm, the SSD stated the SSD called Resident 283's responsible party on 7/24/2026 and did not follow up. The SSD stated that the NOMNC should have been dated to determine when Resident 283 was informed of the last coverage of services. During a review of the facility's Policy and Procedure (P&P) titled, Advance Beneficiary Notices, dated 2026, the P&P indicated, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. To ensure that the resident or representative has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The notices must not be provided while the resident/representative is under duress or in an emergency situation. If the notice cannot be hand-delivered, a telephone notice shall be made, followed up immediately with a mailed, emailed, faxed or hand delivered notice. Documentation shall comply with form instruction regarding telephone notices.

Based on observation, interview, and record review the facility failed to ensure one of one sampled residents (Resident 38) was provided a communication device with the language the resident understood in accordance with the facility's Policy and Procedure (P&P) Communicating with Persons with Limited English Proficiency. This deficient practice had the potential for Resident 38 not to receive necessary care and services and express needs and concerns. Findings: During a review of Resident 38's admission Record (AR), the AR indicated the facility admitted Resident 38 on 11/23/2021 with diagnoses including schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real) and psychosis (severe mental disorder and contact with external reality is lost). During a review of Resident 38's untitled Care Plan (CP) dated 1/24/2025 and revised on 2/24/2025, the CP indicated Resident 38 had impaired communication as evidenced by expressive problem (difficulty finding right words) and receptive problem (difficulty understanding others). The CP intervention indicated for nursing staff to provide interpreter/communication book to Resident 38 as needed. During a review of Resident 38's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/30/2026, the MDS indicated Resident 38 preferred Korean language. The MDS indicated Resident 38 had moderately impaired cognition (ability to think). The MDS indicated Resident 38 needed supervision (helper provides verbal cues) from staff for oral/toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During an observation on 8/11/2026 at 9:15 am, outside Resident 38's room, Resident 38 was talking to Registered Nurse 2 (RN 2) in Resident 38's own dialect. There was no communication tool at Resident 38's bedside. RN 2 stated RN 2 did not understand Resident 38. RN 2 stated there was no communication tool at Resident 38's bedside. RN 2 stated a communication tool should be accessible to Resident 38 and staff to use to effectively communicate with Resident 38 to understand and meet Resident 38's needs. During an observation on 8/12/2026 at 11:22 am, with RN 2, RN 2 stated the facility uses a communication tool to communicate with Resident 38. RN 2 stated the facility staff (unidentified) who spoke Korean was not available to interpret for Resident 38. During an interview on 8/13/2026 at 11:58 am, with the Director of Nursing (DON), the DON stated for a resident who do not speak the English language, a communication tool should be readily accessible inside the resident's room to communicate the resident's needs with the staff. During a review of the facility's undated P&P titled, Communicating with Persons with Limited English Proficiency. the P&P indicated, It is the policy of this facility to take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits. The purpose of this policy is to ensure meaningful communication with LEP residents and their authorized representatives involving their medical conditions and treatment. Notification of the availability of language assistance services will also be provided through one or more of the following: outreach documents, telephone voice mail menus, and/or the facility's website.

Based on interview and record review the facility failed to ensure the binding arbitration agreement (legally binding contract in which parties agree to resolve any future or current disputes out of court) was explained to one of three sampled resident's (Resident 242) representative (RP 1) in a manner that was understandable and be able to acknowledge understanding. This failure had the potential to result in Resident 242 or responsible party to unknowingly giving up their right to settle disputes with the facility through a legal process.Findings: During a telephone interview on 8/13/2026 at 10:28 a.m., RP 1 stated the facility did not explain arbitration or provide paperwork explaining what an arbitration agreement was. The facility had Resident 242's representative to read and sign the document.During an interview on 8/13/2026 at 11:00 a.m. with the admission Coordinator (AC), the AC stated, the arbitration agreement could have been explained more clearly to RP 1. The AC stated, by not having any questions about the arbitration agreement does not mean she fully understood the document and the document should be explained.During an interview with the Director of Nursing (DON) on 8/13/2026 at 12:07p.m., the DON stated arbitration agreement was an alternative to litigation in resolving disputes between residents and the facility.During a review of the facility's policy and procedure (P&P) titled, Binding Arbitration Agreement, revised 2023, the P&P indicated, the person presenting the arbitration agreement to the Resident or representative will: A. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. B. Ensure the resident or his or her representative acknowledges that he or she understands the agreement.

Based on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment by not ensuring the room temperature between 71 degrees Fahrenheit ( F, a temperature measurement unit) to 81 F for one of four sampled rooms and two of seven sampled residents (Resident 5 and Resident 6).This deficient practice violated Resident 5's and Resident 6's right to have a comfortable, homelike environment and placed Resident 5 and Resident 6 at risk for health complications due to increased room temperature.1. During a review of Resident 5's admission Record (AR), the AR indicated the facility originally admitted Resident 5 on 3/30/2018 and readmitted Resident 5 on 5/22/2026 with diagnoses which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 5's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 5/22/2026, the H&P indicated Resident did not have the capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 5/13/2026, the MDS indicated Resident 5 had severely impaired cognitive skills (ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 5 was dependent on staff (helper does all the effort or the assistance of 2 or more helpers is required to complete the activity) on lower body dressing and personal hygiene. The MDS indicated Resident 5 required substantial/maximal assistance (helper does more than half the effort to complete the activity) with toileting hygiene, to shower/bathe self, and with putting on/taking off footwear.2. During a review of Resident 6's AR, the AR indicated the facility originally admitted Resident 6 on 12/27/2023 and readmitted Resident 6 on 12/30/2025 with diagnoses which included COPD, chronic kidney disease (a condition in which the kidneys are damaged and can't filter blood as well as they should), UTI, and anxiety disorder (mental health condition that involves excessive fear, worry, or nervousness that interfere with daily life).During a review of Resident 6's H&P, dated 4/18/2026, the H&P indicated Resident 6 did not have the capacity to understand and make decisions.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had severely impaired cognitive skills. The MDS indicated that 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 concurrent observation and interview on 6/17/2026 at 4:05 PM with Maintenance (MT) 1 and MT 2 inside Resident 5's and Resident 6's room, the room temperature was 83.6 F which was checked by MT 1 and MT 2. MT1 and MT 2 stated Resident 5 and 6's room temperature was greater than 81 F.During a concurrent interview and record review on 6/17/2026 at 4:10 PM with MT 1, the facility's policy and procedure (P&P) titled, Safe and Homelike Environment, undated, was reviewed. MT 1 stated that the facility should have made sure that the residents' room temperature was between 71 F and 81 F.During a concurrent interview and record review on 6/18/2026 at 10:55 AM with the Director of Nursing (DON), the facility's P&P titled, Safe and Homelike Environment, undated, was reviewed. The DON stated it was important to keep residents comfortable and to make sure the residents' room temperature was between 71 F and 81 F.During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment, undated, the P&P indicated, The facility will maintain comfortable and safe temperature levels.a. Comfortable and safe temperature levels means that the ambient temperature should be in a range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds.b. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to ensure staff followed the facility's Infection Prevention and Control Program policy and procedure (P&P) for one of eight sampled residents (Resident 3) who was on Enhanced Barrier Precaution (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) when:1. Activity Assistant (AA) 1 came out of Resident 3's room, removed isolation gown and put the isolation gown in the trash outside Resident 3's room.2. Resident 3's used meal tray was taken outside Resident 3's room and placed on top of the cart used to store clean isolation supplies.These deficient practices had the potential to result in widespread infection (the invasion and growth of germs [such as bacteria, fungi, yeast, virus, or other microorganisms]) in the facility.During a review of Resident 3's admission Record (AR), the AR indicated the facility originally admitted Resident 3 on 4/3/2024 and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (a condition in which the kidneys are damaged and can't filter blood as well as they should), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 4/29/2026, the MDS indicated Resident 3 had severely impaired cognitive skills (ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 3 was dependent (helper does all the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff with toileting hygiene and to shower/bathe self. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort to complete the activity) with oral hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 3's Order Summary Report (OSR), dated 6/17/2026, the OSR indicated Resident 3 may have Enhanced Barrier Precaution (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) related to positive Candida Auris (C. Auris, a type of yeast that can cause severe illness and spread easily among very sick patients in healthcare facilities).During a review of Resident 3's Care Plan (CP), initiated 9/18/2024, revised 11/10/2025, the CP indicated Resident 3 had presence of Candida Auris.During a concurrent observation and interview on 6/17/2026 at 11:10 AM with Certified Nursing Assistant (CNA) 1 in front of Resident 3's room in the hallway. Activity Assistant (AA) 1 was observed coming out of Resident 3's room in an isolation gown. AA 1 removed the isolation gown and threw the gown in a trash can in hallway, outside of Resident 3's room. CNA 1 stated that AA 1 should not have taken off the isolation gown outside of Resident 3's room and trash the gown out of the resident's room. CNA 1 stated that staff should remove the gown and gloves and put them in the trash inside the resident's room to prevent spreading the infection.During an observation on 6/17/2026 at 12:42 PM in front of Resident 3's room in hallway, there was a finished uncovered disposable meal tray of Resident 3 on top of a cart for storing clean gowns in hallway.During a concurrent observation and interview on 6/17/2026 at 12:55 PM with Licensed Vocational Nurse (LVN) 1 in front of Resident 3's room in hallway, LVN 1 was observed taking Resident 3's finished and uncovered disposable meal tray from the top of the isolation gown cart in hallway to a soiled room to trash. LVN 1 stated that LVN 1 threw away Resident 3's disposable meal tray because the meal tray was uncovered and left in hallway.During an interview on 6/17/2026 at 3:21 PM with Registered Nurse (RN) 1, RN1 stated staff should remove isolation gown and trash the disposable meal tray inside Resident 3's room to prevent spreading infection.During an interview on 6/17/2026 at 3:55 PM with Infection Preventionist (IP) 1, IP 1 stated staff should take off the gown before passing the resident's room door and trash the gown inside the room for infection control. IP 1 stated staff should trash the disposable isolation meal tray inside the resident's room in a bag, tie the bag, then bring out of the room to prevent infection spread.During an interview on 6/18/2026 at 10:55 AM with the Director of Nursing (DON), the DON stated that it is important to take off the gown after taking care of residents before leaving the room and trash the gown inside of resident's room for infection control. The DON stated that it is important to trash the disposable meal tray inside resident's room to prevent infection spreading out.During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 5/2021, the P&P indicated the facility should have established and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P indicated, All staff are responsible for following all policies and procedures related to the program. The P&P indicated, All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 7/2022, the P&P indicated the facility should implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms. The P&P indicated that Candida Auris is one of the organisms that should be on EBP. The P&P indicated, Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), received appropriate treatment to prevent further decrease in Resident 1's mobility (ability to move) when the facility failed to implement the physician order to have Resident 1 walk five times a week.This failure resulted in Resident 1 experiencing a decrease in the ability to walk. (Cross reference F627 and F842)Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/6/2025 and readmitted Resident 1 on 7/1/2025 with diagnoses including cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), difficulty in walking, and personal history of traumatic brain disorder (damage to the brain caused by an external force, such as a blow, bump, hit, or jolt to the head).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/28/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 supervision or touch assistance from staff for dressing, bathing, and toileting, oral, and personal hygiene.During a review of Resident 1's Order Summary Report (OSR) dated 10/16/2025, the OSR indicated Resident 1 had a physician order for Restorative Nursing Assistant (RNA) to ambulate (walk) Resident 1 five times a week with a front wheel walker (FWW). The physician order was dated 8/28/2025.During a concurrent interview and record review on 10/16/2025 at 1:26 PM with the Director of Rehabilitation (DOR), Resident 1's PT Discharge Summary (DS), dated 8/28/2025, was reviewed. The DS indicated, Patient (Resident 1) is currently able to walk in corridor, and walk in room.patient (Resident 1) will be able to walk in corridor with assist of one, and balance will require the physical support of one, by performing the following Restorative Nursing interventions: provide assistance of one, use gait belt, use walker, encourage participation and allow patient to take his or her time. The DOR stated Resident 1 was discharged from rehab services on 8/28/2025. The DOR stated Resident 1 needed RNA services to include an RNA would walk with Resident 1 in the hallway 5 days out of each week. During a concurrent interview and record review on 10/16/2025 at 2:04 PM with RNA 1, Resident 1's Restorative Nursing Orders (RNO) for August, September, and October 2025, were reviewed. The RNO failed to indicate Resident 1 received the treatment order of ambulating in the hallway 5 times a week. RNA 1 confirmed RNA 1 did not ambulate with Resident 1, 5 times a week. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Programs, dated 2024, the P&P indicated, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received one-on-one supervision (1:1, one staff supervising 1 resident) to prevent fall (move downward, typically rapidly and freely without control, from a higher to a lower level) as indicated in Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals who collaborate to provide comprehensive care for Resident 1) Meeting/Care Conference, dated 5/1/2023. On 6/16/2025 at approximately 5:35 pm, Activity Assistant (AA) 1 left Resident 1 unsupervised in Resident 1's wheelchair inside Resident 1's room. Resident 1 fell from Resident 1's wheelchair and sustained a laceration (a tear or cut in the skin) measured 2 centimeters (cm unit of measurement) in length by (x) 1 cm in width x 0.5 cm in depth on Resident 1's left eyebrow and an abrasion (a surface or superficial wound where the skin was scraped off) to Resident 1's left elbow (size was not indicated) and multiple abrasions on Resident 1's left forearm (sizes were not indicated). On 6/16/2025 at 5:45 pm, the paramedic (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) transferred Resident 1 to General Acute Care Hospital (GACH) 1 for further evaluation. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/24/2019 and readmitted Resident 1 on 12/2/2024 with diagnoses including intellectual disabilities (a condition characterized by significant limitations in both intellectual functioning and adaptive behavior), autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), and schizoaffective disorder (a mental health condition including schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly] and mood disorder symptoms). During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 12/5/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/16/2025, the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from staff for personal hygiene and walking. During a review of Resident 1's Progress Notes (PN), dated 6/16/2025 and timed at 7:02 pm, the PN indicated on 6/16/2025, at approximately 5:35 pm, Resident 1) was found by helper (AA 1) lying on the floor, on Resident 1's left side with profusely bleeding on Resident 1's left eyebrow. The PN indicated Resident 1 was noted with a laceration on Resident 1's left eyebrow, measured 2 cm in length x 1 cm in width x 0.5 cm in depth. The PN indicated Resident 1 had an abrasion to left elbow (size was not indicated) and multiple abrasions to Resident 1's left forearm (sizes were not indicated). The PN indicated (on 6/16/2025) at 5:40 pm, facility's staff (unidentified) called 911 (phone number used to contact the emergency services). The PN indicated (on 6/16/2025) at 5:45 pm, the paramedic arrived and transferred Resident 1 to GACH 1 for further evaluation and (wounds) management. During a review of Resident 1's Emergency Department (ED)Note Physician (EDNP, the documentation created by a physician or other qualified healthcare provider in the ED), dated 6/16/2025 and timed at 6:27 pm, the EDNP indicated Resident 1 was brought into GACH 1 by Emergency Medical Services (EMS, a comprehensive system providing urgent pre-hospital medical care and transportation to individuals experiencing illness or injury). The EDNP indicated Resident 1 had a fall at a Skilled Nursing Facility (SNF). The EDNP indicated Resident 1 had a laceration on Resident 1's forehead and wound care was provided to Resident 1's forehead laceration with Steri-Strips (thin, adhesive bandages used to close and support small cuts, wounds, and incisions). During an observation of Resident 1 inside the facility's activity room, on 6/25/2025 at 11 am, Resident 1 was sitting in a chair with Helper 1 providing 1:1 supervision to Resident 1. Resident 1 was noted to have a scab (a dry, rough protective crust that forms over a cut or wound during healing), measured 2 cm in length x 1 cm in width, over Resident 1's left eyebrow. Resident 1 was noted to have a bruise, the size of a nickel, under Resident 1's left eye. During a telephone interview on 6/25/2025 at 1:09 pm with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 was Resident 1's assigned nurse during the evening shift (from 3pm to 11 pm) on 6/16/2025. LVN 3 stated, on 6/16/2025, at 5:35 pm, Resident 1 fell on the floor in Resident 1's room. LVN 3 stated AA 1 was supposed to be watching/supervising Resident 1 when Resident 1 fell (on 6/16/2025, at 5:35 pm). LVN 3 stated an assigned staff (AA 1) needed to always watch/supervise Resident 1 due to Resident 1 was impulsive (acting without forethought) and would also throw tantrums (having an uncontrolled outburst of anger, often involving loud crying, screaming, or other physical displays) when Resident 1 became upset. LVN 1 stated Resident 1 would bang Resident 1's head against things (objects, material things that can be seen and touched) when Resident 1 became upset. During a telephone interview on 6/25/2025 at 2 pm with AA 1, AA 1 stated, on 6/16/2025, before Resident 1 fell (unable to recall exact time), LVN 4 had instructed AA 1 to watch/supervise Resident 1 while AA 1 was also supervising other residents (unidentified) in the smoking patio next to the activity room. AA 1 stated Resident 1 was watching television in the activity room when Resident 1 told AA 1 that Resident 1 was going back to Resident 1's room. AA 1 stated Resident 1's room was next to the activity room. AA 1 stated Resident 1 wheeled Resident 1 (in the wheelchair) from the activity room to Resident 1's room and closed Resident 1's room door behind Resident 1. AA 1 stated, after 30 seconds, AA 1 opened Resident 1's room door, went into Resident 1's room and found Resident 1 lying on the floor next to Resident 1's bed. AA 1 stated Resident 1 was bleeding over Resident 1's eyes and there was blood on the floor in Resident 1's room. During an interview on 6/25/2025 at 2:35 pm with LVN 1, LVN 1 stated Resident 1 required 1:1 supervision from facility's staff (in general). LVN 1 stated assigned staff (staff assigned to provide 1:1 supervision) needed to be with Resident 1 to supervise Resident 1 because Resident 1 had behaviors of throwing tantrums when Resident 1 got upset. During an interview on 6/25/2025 at 3:02 pm with Registered Nurse (RN) 1, RN 1 stated Resident 1 needed 1:1 supervision from staff (facility's staff). RN 1 stated Resident 1 should not have been in Resident 1's room alone and unsupervised when Resident 1 fell on 6/16/2024 (at 5:35 pm). RN 1 stated, It was not safe for Resident 1 to be left unattended by AA 1. During a concurrent interview and record review on 6/26/2025 at 11:40 am with the Director of Nursing (DON), Resident 1's IDT Meeting/Care Conference, dated 5/1/2023, was reviewed. The IDT notes indicated, Due to resident's (Resident 1) impaired cognition and medications, resident (Resident 1) will be closely monitored for falls. The IDT notes indicated effective 5/9/2023, the IDT team and the Regional Center's (a private, non-profit corporation that provided services for individual with developmental delay or disability) staff (RCS) determined that Resident 1 would be provided with helpers to perform 1:1 supervision for Resident 1 daily, for 10 hours a day (time frame was not indicated). The DON stated on 6/16/2025, Resident 1 should have been provided with 1:1 supervision from staff until 7:00 pm (from 9 am to 7 pm). The DON stated after dinner (around 7 pm), Resident 1 would calm down, go to bed and would not need a 1:1 supervision. The DON stated Resident 1 required 1:1 supervision from staff for 10 hours daily since 5/9/2023. During a telephone interview on 6/26/2025 at 12:05 pm with LVN 4, LVN 4 stated LVN 4 was responsible to make the staffing assignment for the evening shift (3 pm to 11 pm) on 6/16/2025. LVN 4 stated LVN 4 had instructed/assigned AA 1 to supervise Resident 1 on 6/16/2025 (from 3 pm to 11 pm). LVN 4 stated AA 1 was supposed to keep an eye on Resident 1 at all times. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated, The interdisciplinary care team shall target interventions to reduce the potential for accidents. The P&P indicated Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. ensuring that interventions are implemented; and e. documenting interventions.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 assessed/checked one of two sampled residents (Resident 1) ' s body on 3/20/2025 and 3/21/2025 to prevent injury/wound (an injury to living tissue, specifically a break or disruption in the skin or other body tissues caused by an external force) from embedded (implanted, an object fixed firmly and deeply in a surrounding mass) bracelets (ornamental/decorative band, hoop, or chain worn on the wrist or arm). These failures resulted in Resident 1 developing an infected wound (a wound that harbors harmful bacteria, leading to symptoms like increased redness, pain, swelling, and pus) to Resident 1 ' s left wrist. Cross Reference: F656 and F726 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 4/30/2015 with diagnoses including mild intellectual disabilities (limitations on intelligence, learning and everyday abilities) and abnormalities of gait (walk) and mobility. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 1/26/25, the MDS indicated Resident 1's cognition was moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with showering/bathing, upper body dressing, The MDS indicated Resident 1 did not have any skin conditions. During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 3/28/2025, the H&P indicated Resident 1 was able to make needs known but could not make medical decisions. During a review of Resident 1's Nursing Weekly Assessment (NWA), dated 3/19/2025, the NWA indicated Resident 1 ' s skin was intact. During a review of Resident 1 ' s EMS run report (a standardized document used by emergency medical service care providers), dated 3/21/2025 and timed at 11:25 a.m., the report indicated, the emergency medical technicians (EMTs) arrived at the facility on 3/21/2025 at 11:30 a.m., and was at Resident 1 ' s bedside to evaluate Resident 1 at 11:31 a.m. The EMS run report indicated, the EMTs noticed swelling to (left) arm, upon exposing arm, EMT noted a hospital bracelet and personal bracelets cutting into Resident 1 ' s skin and showing signs and smell of infection with discharge coming from the wound (on the left wrist). During a review of Resident 1 ' s GACH 1 ' s Emergency Department Provider Notes (EDPN), dated 3/21/2025, the EDPN indicated Skin: Rubber band embedded in the left wrist that appears infected. During a review of GACH 1 History of Present Illness (HPI), dated 3/21/2025 at 1:04 p.m., the HPI indicated Resident 1 had an infection (on Resident 1 ' s left wrist) related to embedded bracelets. During an interview on 4/9/2025 at 1:00 p.m. with LVN 1, LVN 1 stated LVN 1 was assigned to Resident 1 on 3/20/2025. LVN 1 stated LVN 1 noticed a foul smell coming from Resident 1 ' s body, but did not know where the smell was coming from. LVN 1 stated a full body assessment of a resident was not within LVN 1 ' s scope of practice. LVN 1 stated LVN 1 did not check/assess other area on Resident 1 ' s body nor notify Resident 1 ' s foul smell to LVN 1 ' s supervisor/Registered Nurse (RN). LVN 1 stated Resident 1 was given a shower on 3/20/2025. LVN 1 stated LVN 1 noticed the smell from Resident 1 the following day (3/21/2025). LVN 1 stated LVN 1 notified RN 1 of the smell, so LVN 1 and RN 1 went to Resident 1 ' s room. LVN 1 stated LVN 1 was instructed by RN 1 to give Resident 1 a shower. LVN 1 stated LVN 1 notified RN 1 that a shower was given to Resident 1 on 3/20/2025 but the smell did not go away. During a concurrent interview and record review on 4/9/2025 at 2:20 p.m. with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, Skin Assessment, was reviewed. The P&P indicated the procedural guidelines in performing the full body skin assessment. The policy explanation and compliance guidelines indicated a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and as needed. The policy indicated the assessment may also be performed after a change of condition or after any newly identified pressure ulcer/ (localized damage to the skin and underlying tissue caused by sustained pressure) wound. The DON stated the policy indicated, it is the facility ' s policy for staff (LVNs and RNs) to perform a full body skin assessment as part of our systematic approach for pressure ulcer/wound prevention and for the promotion of healing of various skin conditions. The DON stated the LVN 1 and RN 1 did not assess/check Resident 1 ' s skin condition as indicated in the facility ' s policy. During an interview and record review on 4/10/2025 at 3:00 p.m. with LVN 1, LVN 1 stated, LVN 1 was to assess Resident 1 further on 3/20/2025 when LVN 1 first noticed the smell coming from Resident 1 ' s body. LVN 1 stated when the EMS arrived at the facility on 3/21/2025, one of the members from the EMS (EMT 1) asked where the smell was coming from. LVN 1 stated EMT 1 was preparing to take Resident 1 ' s blood pressure when EMT 1 noticed Resident 1 ' s bracelets (on Resident 1 ' s left wrist). LVN 1 stated the beaded bracelets, and the hospital arm band (on Resident 1 ' s left wrist) were cut off and LVN 1 witnessed the items (the beaded bracelets and the hospital arm band) falling to the floor. LVN 1 stated LVN 1 did not see Resident 1 ' s wrist due to all the EMS staff huddling around Resident 1, but LVN 1 heard them (EMS staff) said, oh this is where the smell is coming from, and LVN 1 saw EMT 1 wrap Resident 1 ' s left arm with gauze. LVN 1 stated once the EMT 1 cut the bracelets off from Resident 1 ' s left wrist the smell got stronger, and it smelled like an infected wound.

Based on interview and record review, the facility failed to provide foot care and treatment to one of eight sampled residents (Resident 4) according to Resident 4's Care Plan (CP) titled, Care Plan Report, and the facility's policies and procedures (P&P) titled, Podiatry Services, and Comprehensive Care Plans, by failing to ensure: 1. Licensed Nurses (all licensed nurses that assigned to care for Resident 4) notified Resident 4's physician(s) and Resident 4's family and/or responsible party (RP) when Resident 4 repeatedly refused to be treated by the podiatrist (medical doctor who specializes in the treatment of disorders of the foot, ankle, and the lower leg), for the year of 2024. 2. Licensed Nurses implemented Resident 4's CP when Resident 4 refused to receive podiatrist care and treatment for multiple times in one year. 3. Licensed Nurses notified Resident 4's physician regarding the condition of Resident 4's toenails. These failures resulted in Resident 4 to be transferred and admitted to the General Acute Care Hospital (GACH) 1, on 2/13/25, for intravenous (IV, given directly into the blood stream through the vein) antibiotic (medications used to treat infections) to treat right toe osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Cross reference: F580, F656, and F684 Findings: During a review of Resident 4's Admission Record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and dementia (a progressive state of decline in mental abilities). During a review of Resident 4's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 12/10/24, the H&P indicated Resident 4 could make needs known but could not make medical decisions. During a review of Resident 4's CP titled, Care Plan Report. dated 12/10/24, the CP indicated Resident 4 was at risk for clinical or social decline due to Resident 4's refusal to shower, refusal of assistance with Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), and refusal of treatment and medications. The CP's goal indicated for Resident 4's family members and/or staff to assist in making decisions for health and personal care and to inform Resident 4 of risks and consequences of the choices Resident 4 made daily. The CP's interventions included for staff (in general) to monitor Resident 4 for episodes of noncompliance and to notify the physician for possible treatment, and to refer Resident 4 for psychological (related to the mental and emotional state of a person) and/or psychiatric (relating to mental illness or its treatment) consultation as ordered by the primary physician. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/25, the MDS indicated Resident 4's cognition (ability to remember and process information) was moderately impaired. The MDS indicated Resident 4 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral (having to do with the mouth or speaking) hygiene, toileting hygiene, lower body dressing, and personal hygiene. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with showering/bathing, upper body dressing, and with putting on/taking off footwear. During a review of Resident 4's Nursing Weekly Assessment (NWA), dated 1/14/25, 1/22/25, 1/28/25, and 2/5/25, the NWA indicated Resident 4 had mycotic (infection or disease caused by fungus [a type of organism that feeds from decaying material or other living things]), hypertrophic (a nail disorder that causes fingernails or toenails to grow abnormally thick) toenails. The NWA indicated no treatment was provided to Resident 4 on 1/14/25, 1/22/25, 1/28/25, and 2/5/25 due to Resident 4's refusal of podiatric treatment. During a review of Resident 4's Nursing Progress Notes (NPN), dated 2/10/25, timed at 7:15 pm, the NPN indicated Certified Nursing Assistant (CNA) 8 reported to Licensed Vocational Nurse (LVN) 9 Resident 4 had mycotic toenails. LVN 9 notified Nurse Practitioner (NP- a registered nurse with advanced training who can diagnose and treat patients) 1 regarding Resident 4's mycotic toenails, and NP 1 recommended for Resident 4 to be seen by the podiatrist and to have an X-ray (imaging study that takes pictures of bones and soft tissues) of both feet. During a review of Resident 4's X-ray report, dated 2/11/25, the X-ray report indicated Resident 4 had suspicious osteomyelitis on the right second (the long toe) distal phalanx (the bone at the tip of the toes) and right fourth (the second-to-last toe on the foot, located between the third [middle] and fifth [pinky] toes) distal phalanx. During a review of Resident 4's Podiatric Consultation Notes (PCN), dated 2/12/25, the PCN indicated Resident 4 refused and had a history of refusing toenail debridement. During a review of Resident 4's SBAR (Situation, Background, Assessment, Recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 2/13/25, the SBAR indicated Resident 4 had a change of condition. The SBAR indicated Resident 4's right foot X-ray showed possible osteomyelitis. The SBAR indicated NP 1 was informed of Resident 4's X-ray results on 2/13/25 at 9 am and recommended to send Resident 4 to GACH 1 for evaluation. During a review of Resident 4's NPN, dated 2/13/25, timed at 9:34 am, the NPN indicated Resident 4 was picked up by the ambulance and was transported to GACH 1. During a review of Resident 4's GACH 1's H&P, dated 2/13/25, the H&P indicated Resident 4's assessment indicated osteomyelitis of the right foot and a plan to give Resident 4 intravenous Rocephin (medication used to treat infections) and Vancomycin (medication used to treat infections) and pain medication as needed (specific pain medication was not indicated). During an interview on 2/25/25 at 1:59 pm with the Social Service Director (SSDR), the SSDR stated all residents in the facility were seen by a podiatrist every two months or as needed. The SSDR could not remember when Resident 4 was last seen by the podiatrist. The SSDR stated in general when a resident refused podiatry care, the podiatrist would ask for staff assistance, and if the resident continued to refuse, the podiatrist would document the refusal on the PCN. The SSDR stated it was Resident 4's right to refuse podiatry care, but the facility could not let Resident 4 refuse for too long because it could cause residents to sustain harm and or injury. During a concurrent interview and record review, on 2/25/25 at 2:34 pm, with the SSDR, Resident 4's PCNs, dated 1/16/24, 3/18/24, 5/29/24, 8/8/24, 10/21/24, 12/26/24, and 2/12/25, were reviewed. Resident 4's PCNs dated 1/16/24, 3/18/24, 5/29/24, 8/8/24, 10/21/24, 12/26/24, and 2/12/25 indicated all of Resident 4's toenails on both feet were discolored, elongated, incurvated (ingrown toenail- a toenail that has grown curved with corners that have grown into the skin), dystrophic (deformed, thickened or discolored), hypertrophic , and painful (unrated) with subungual debris (buildup of skin cells and dead tissue under the nail caused by a fungal infection). The PCNs indicated Resident 4 refused toenail debridement (medical procedure that removes damaged or infected nail tissue) on both feet. The SSDR stated Resident 4 refused podiatry care for the whole year of 2024. The SSDR stated whenever the SSDR became aware a resident had refused treatment three times, the SSDR would inform the licensed nurses (licensed nurses that assigned to take care Resident 4) and asked the licensed nurses what else can be done for Resident 4. The SSDR stated the SSDR did not inform the licensed nurses when Resident 4 continued to refuse podiatry care for more than one year. During a concurrent interview and record review, on 2/25/25 at 2:52 pm, with the Director of Nursing (DON), Resident 4's PCNs dated 1/16/24, 3/18/24, 5/29/24, 8/8/24, 10/21/24, 12/26/24, and 2/12/25 were reviewed. Resident 4's PCNs dated 1/16/24, 3/18/24, 5/29/24, 8/8/24, 10/21/24, 12/26/24, and 2/12/25 indicated Resident 4 refused toenail debridement on both feet. The DON stated the DON was unaware Resident 4 had refused podiatry care for the whole year of 2024. The DON stated the SSDR and/or Social Services Designee (SSD) must notify licensed nurses whenever a resident refused podiatry care so the nursing department could try other interventions like having a staff that had a good rapport (a harmonious relationship between people, characterized by mutual understanding, trust, and agreement) with the resident be present during treatment. The DON stated, the licensed nurses (in general) could also notify the primary physician, the psychiatrist (a medical doctor who specializes in the diagnosis and treatment of mental illness) and/or the psychologist (a person who specializes in the study of mind and behavior or treatment of mental, emotional, and behavioral disorders), and the family or responsible party to coordinate care and for diagnostic studies. The DON stated the licensed nurses must also check the resident's fingernails and toenails during the weekly nursing assessment of the resident and notify the resident's physician(s) once they found any change in the resident's condition. During a telephone interview on 2/25/25 at 4:20 pm with CNA 8, CNA 8 stated when CNA 8 showered Resident 4 on 2/10/25, Resident 4's toenails were thick and long (unable to specify size/measurement), and the big toenail on Resident 4's right foot was curving up. CNA 8 stated CNA 8 informed LVN 9 regarding Resident 4's long toenails because Resident 4's toenails were not supposed to be that long. During a telephone interview on 2/25/25 at 4:34 pm with LVN 9, LVN 9 stated after CNA 8 reported to LVN 9 about Resident 4's toenails on 2/10/25, LVN 9 assessed Resident 4's toenails. LVN 9 stated Resident 4's toenails were long, thick, and were dark yellowish green in color. LVN 9 stated Resident 4's toenails did not look normal so LVN 9 called NP 1 on 2/10/2025. NP 1 ordered a podiatry consultation and an X-ray of Resident 4's feet on 2/10/2025. LVN 9 stated LVN 9 should have done an SBAR for Resident 4's change of condition on 2/10/25 when CNA 8 first reported about Resident 4's toenails and not to wait until 2/13/25. LVN 9 stated long nails could cause residents discomfort and pain and put residents at risk for nails infections. During an interview on 2/26/25 at 9:28 am with the DON, the DON stated an SBAR must be completed on the same day when Resident 4 had a change of condition. The DON stated LVN 9 should have completed an SBAR on 2/10/25 regarding Resident 4's toenails and not wait until 2/13/25 (3 days later). During a concurrent record review and interview, on 2/26/25 at 3:41 pm, with the DON, the DON could not recall if Resident 4's family was informed of Resident 4's repeated refusals for podiatry care. Resident 4's last 4 Interdisciplinary Team (IDT, CP conferences, a team of health care professions who work together to establish plans of care for residents) were reviewed with the DON, the DON was unable to find documentation indicating Resident 4's family was informed of Resident 4's repeated refusal for podiatry care. The DON stated after a resident refused treatment three times, the primary physician, the psychologist/psychiatrist, and the family must be informed. The DON stated licensed nurses were not aware Resident 4 was refusing podiatry care and, probably did not inform (Resident 4's) physicians. During a review of the facility's P&P titled, Podiatry Services, undated, the P&P indicated, It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. The P&P indicated, Employees should refer any identified need for foot care to the social worker or designee. During a review of the facility's P&P titled, Comprehensive Care Plans, undated, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The P&P indicated, The facility will attempt alternative methods of refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, undated, the P&P indicated, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .refusal of treatment or medications .A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacts more than one area of the resident's health status, requires interdisciplinary review and/or revision to the care plan and ultimately is based on the judgment of the clinical staff .Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when .there is a significant change in the resident's physical, mental, or psychosocial status .

Based on observation, interview, and record review, the facility failed to provide supervision to prevent elopement (when an individual leaves the healthcare facility unsupervised and/or undetected) for one of five sampled residents (Resident 1) who was assessed as at risk for elopement as indicated in the facility's policy and procedure titled, Elopements and Wandering Residents, by failing to: 1. Ensure Janitor 1 ([DATE]) did not unlock the door of the facility's secured unit (any area in the facility designed and operated to ensure that all its entrances and exits are locked to prevent residents from leaving the facility without permission and/or supervision) to allow Resident 1 to leave the facility without a staff chaperone (a person who goes with and looks after another person or group of people) or helper. 2. Ensure a staff chaperone or helper was present to accompany Resident 1 before allowing Resident 1 to leave the facility with the rideshare (a car service that allows a person to use a smartphone application to arrange a ride in a privately owned vehicle usually driven by its owner) driver to go to Resident 1's ophthalmologist's (a medical doctor who specializes in treating and caring for the eyes) appointment scheduled on 8/13/24 at 8 am. As a result, on 8/13/24 at 7:07 am, Resident 1 left the facility unsupervised to go to Resident 1's ophthalmologist appointment scheduled on 8/13/24 at 8 am. Resident 1 did not check in at the ophthalmologist's office for Resident 1's scheduled appointment. The facility staff were unable to locate Resident 1 and the facility filed a missing person report with the local police department on 8/13/24 at 11:17 am. As of 8/16/24 at 11 am, Resident 1 had not been found. This failure had the potential to put Resident 1 at risk for serious injury, harm, and/or death due to not receiving diabetic medication (medication used to treat diabetes mellitus [disease that results in too much sugar in the blood due to the body's inability to process carbohydrates [one of the basic food groups]), psychotropic medication (medication that affects behavior, mood, thoughts, or perception), not having food and shelter, and being exposed to hot weather. On 8/15/24 at 5:15 pm, while onsite at the facility, the surveyor identified an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) due to Resident 1 left the facility's secured unit without a staff chaperone. The surveyor called an IJ in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to monitor and supervise Resident 1, under 42 Code of Federal Regulations Section 483.25(d) Accidents, including providing adequate (acceptable in quality or quantity) supervision to prevent accidents to Resident 1 who was at risk for elopement and had a history of attempting to leave the facility. On 8/16/24 at 9:17 am, the facility submitted an acceptable IJ Removal Plan (IJRP, a list of steps taken to correct the deficient practices). While onsite at the facility, the surveyor verified the facility provided in-service training to [DATE] and all staff regarding safety to ensure staff (all staff) did not unlock the secured unit's door for any reason without the approval of the charge nurse (Licensed Vocational Nurse) or the supervisor (Registered Nurse) and confirmed the implementations of the IJRP through observation, interview, and record review. The surveyor determined an IJ situation was no longer present and removed the IJ on 8/16/24 at 9:50 am, in the presence of the ADM and the DON. The IJ removal plan, dated 8/16/24, included the following: a. On 8/15/24, the ADM provided [DATE] with one-on-one in-service training regarding safety to ensure [DATE] did not unlock the locked door of the secured unit without the approval of the charge nurse or the supervisor for any reason. b. On 8/15/24, the DON initiated in-service training to all staff regarding safety to ensure staff did not unlock the locked door of the secured unit without the approval of the charge nurse or the supervisor for any reason. Any staff that were off or on vacation would be in-serviced upon return and would not be assigned to the secured unit until staff completed the in-service. c. On 8/15/24, the DON initiated in-service training to all licensed nurses to ensure residents in the secured unit had a staff chaperone or helper for every appointment. d. On 8/15/24, the DON initiated in-service training to all licensed nurses regarding new Appointment Log to ensure licensed nurses logged driver information and staff chaperone or helper assigned (to accompany [go somewhere with someone as a companion] the resident to his/her appointment) before releasing the resident. e. On 8/15/24, a sign indicating Before exiting with any resident please obtain clearance from the charge nurse and or supervisor, was posted on every entrance and exit doors in the secured unit. f. The DON or Director of Staff Development (DSD) and/or designee would provide in-service regarding safety, supervision, and elopement Prevention every 10th of the month. The DON and/or designee would monitor the new Appointment Log in the secured unit weekly to ensure residents with appointments had a helper or staff chaperone assigned and no resident would leave for an appointment without a helper. Findings: During a review of Resident 1's Face Sheet (FS, document that contains a patient's personal and contact information, diagnoses, and medical history), the FS indicated, the facility admitted Resident 1 on 9/7/22, with diagnoses which included diabetes mellitus and schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others). The FS indicated, the responsible party for Resident 1 was the facility's Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care). During a review of Resident 1's Wandering Risk Assessment (WRA, tool used to evaluate a resident's risk of wandering and elopement), dated 12/16/22, the WRA indicated, Resident 1 was at risk for wandering outside the facility. The WRA indicated, the facility tried multiple alternatives but Resident 1 continued to attempt to wander out of facility premises due to Resident 1's delusional thoughts (fixed false beliefs that are based on an inaccurate interpretation of reality). During a review of Resident 1's Physician Order (PO), dated 12/16/22, the PO indicated, an order for the facility to admit Resident 1 to the secured unit after Resident 1 attempted multiple times to wander out of the facility. During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 9/12/23, the H&P indicated, Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's untitled Care Plan (CP), dated 9/13/23, the CP indicated, Resident 1 was at risk for elopement due to wandering behavior and confusion. The CP indicated, Resident 1 exhibited exit-seeking behavior. The CP interventions indicated for the staff to allow Resident 1 to wander within the secured unit and assure that Resident 1's environment was safe and secured. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/13/24, the MDS indicated, Resident 1 communicated verbally and required supervision or touching assistance (helper provided verbal cues and/or touching/steadying assistance as resident completed activity) from staff for oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and walking 150 feet. During a review of Resident 1's PO, dated 7/12/24, the PO indicated, an order for an ophthalmologist appointment scheduled on 8/13/24 at 8 am at ophthalmologist's office address. During a review of Resident 1's Licensed Personnel Progress Notes (LPPN), dated 8/13/24, timed at 8 am, the LPPN indicated, Licensed Vocational Nurse (LVN) 1, who worked the night shift (on 8/12/2024 from 11 pm to 7 am), informed LVN 3 that Resident 1 left the facility with the rideshare driver at 7:10 am (on 8/13/24). During a review of Resident 1's LPPN, dated 8/13/24, timed at 12:30 pm, the LPPN indicated, LVN 3 informed LVN 7 that Resident 1 was not at the ophthalmologist's office. The LPPN indicated, Resident 1 was dropped off by the rideshare driver at the ophthalmologist's office at 7:58 am (on 8/13/24). The LPPN indicated LVN 7 called the ophthalmologist's office on 8/13/24 at 8:20 am and was unable to speak with anyone. The LPPN indicated, Activities Assistant (AA) 1 and the facility's driver (Van Driver [DRV] 1) followed Resident 1 to the ophthalmologist's office but Resident 1 was not there. The LPPN indicated, staff at the ophthalmologist's office (unidentified) told AA 1 and DRV 1 Resident 1 did not check in at the ophthalmologist's office (on 8/13/24 at 8 am). The LPPN indicated, the facility filed a missing person report with the local police department on 8/13/24 at 11:17 am. During a review of Resident 1's Situation, Background, Appearance, Review Communication Form (SBAR, a standardized communication tool between healthcare providers), dated 8/13/24, untimed, the SBAR indicated, (on 8/13/24, at 8 am), Resident 1 did not go to Resident 1's scheduled ophthalmologist appointment. The SBAR indicated, facility staff (unidentified) called hospitals, shelters, stores, and nearby areas (to locate Resident 1), and involved the local police department (on 8/13/24 at 11:17 am). During an interview on 8/15/24 at 10:18 am with the ADM, the ADM stated the rideshare driver picked up Resident 1 on 8/13/24 (at 7:10 am) for an appointment with the eye doctor (ophthalmologist). The ADM stated LVN 1 gave the needed paperwork to the rideshare driver for Resident 1's scheduled eye appointment and told the rideshare driver to wait for the staff helper assigned to accompany Resident 1. The ADM stated after LVN 1 gave the paperwork to the rideshare driver, LVN 1 and another staff (unable to identify) in the secured unit could not find the driver and Resident 1 inside the secured unit. The ADM stated DRV 1 and AA 1 drove to Resident 1's ophthalmologist's office (on 8/13/24 at 8:20 am) but did not find Resident 1 there. The ADM stated DRV 1 and AA 1 checked all the offices around Resident 1's ophthalmologist's office and the surrounding areas but were unable to find Resident 1. The ADM stated AA 1 went inside Resident 1's ophthalmologist's office and the ADM called the ophthalmologist's office, and the ophthalmologist's office receptionist told the ADM Resident 1 did not show up for Resident 1's appointment. The ADM stated the facility filed a missing person report with the local police department (on 8/13/24 at 11:17 am). The ADM stated Resident 1 was moved to the secured unit in 2022 because Resident 1 tried to leave the facility without staff supervision. The ADM stated AA 1 needed to accompany Resident 1 to Resident 1's eye appointment. During an interview on 8/15/24 at 10:55 am with the Director of Nursing (DON), the DON stated Resident 1 was admitted to the facility on [DATE], and was moved to the secured unit on 12/16/22, because Resident 1 was confused and tried to leave the facility without staff supervision. During a concurrent observation of the facility's secured unit, and interview on 8/15/24 at 11:05 am with the DON, in the facility's secured unit, the DON stated Resident 1 and the rideshare driver exited through the locked door of the secured unit located between the Manor (name of a building in the facility) and the Center (name of secured unit building in the facility). The DON stated the facility did not know who opened the locked door of the secured unit to let Resident 1 and the rideshare driver out. The DON stated all the entrance and exit doors in the secured unit were locked and could only be opened with a passcode. A security camera (a video camera used to monitor activity in an area) was observed above the secured unit's locked door. The DON stated AA 1, who was the helper assigned to accompany Resident 1 to Resident 1's appointment, needed to be in the secured unit with Resident 1 before the scheduled pick-up time (on 8/13/24 at 7 am), but AA 1 was not there at that time. During an interview on 8/15/24 at 11:10 am with the Social Services Designee (SSD), the SSD stated Resident 1's pick-up time for the ophthalmologist's appointment was scheduled for 8/13/24 at 7 am and AA 1 needed to be in the facility by 7 am. During an interview on 8/15/24 at 11:13 am with LVN 2, LVN 2 stated all residents in the secured unit were at risk for elopement and had to be accompanied by a facility staff for any outside appointment. LVN 2 stated any staff in the secured unit must not unlock the door to let any resident and any rideshare driver out without a staff helper. LVN 2 stated only facility staff knew the passcode to open doors in the secured unit. During an interview on 8/15/24 at 11:36 am with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated all residents in the secured unit were at risk for elopement and needed a chaperone when a resident (any resident) goes out for any appointment. RNS 1 stated staff in the secured unit must not unlock the door until the chaperone or helper was with Resident 1. During an interview on 8/15/24 at 11:52 am with LVN 3, LVN 3 stated all residents in the secured unit needed constant supervision and monitoring because they wandered and at risk for elopement. LVN 3 stated residents in the secured unit were not allowed to go out without a staff helper to ensure residents' safety and to prevent elopement. During a concurrent review of the facility's secured unit's video surveillance and interview on 8/15/24 at 12:05 pm with the Director of Maintenance (DOM) and the DON, the surveyor reviewed the facility's secured unit's video surveillance dated 8/13/24 and timed at 7:07 am to 7:08 am with the DOM and the DON. The video surveillance showed a male staff entering the passcode to unlock the door to allow Resident 1 and the rideshare driver to go outside the secured unit on 8/13/24 at 7:07 am. The DON stated the male staff who unlocked the door was [DATE]. During a concurrent review of the facility's secured unit's video surveillance and interview on 8/15/24 at 12:32 pm with [DATE], [DATE] stated the doors to the secured unit were always locked with a passcode and staff (any staff in general) could not let residents out without a staff chaperone/helper. [DATE] watched the recorded video surveillance, dated 8/13/24 timed at 7:07 am to 7:08 am, and stated the male staff on the video surveillance who let Resident 1 and the rideshare driver leave the secured unit was [DATE]. [DATE] stated [DATE] thought the rideshare driver with Resident 1 was a facility staff. During an interview on 8/15/24 at 2:46 pm with LVN 3, LVN 3 stated on 8/13/24 at 7:40 am, the SSD informed LVN 3 that Resident 1 left the facility with the rideshare driver and without a staff chaperone. LVN 3 stated on 8/13/24, unable to recall time, LVN 3 asked LVN 7 to call the ophthalmologist's office to verify if Resident 1 checked in for Resident 1's appointment, but LVN 7 was unable to speak with anyone at the ophthalmologist's office (on 8/13/24 at 8:20 am). LVN 3 stated the ADM informed LVN 3 at 8:51 am (on 8/13/24) that Resident 1 never made it to Resident 1's appointment. During an interview on 8/15/24 at 3:10 pm with the DON, the DON stated Resident 1 had an eye appointment on 8/13/24 (at 8 am). The rideshare driver arrived at the facility's secured unit to pick up Resident 1 (on 8/13/24 at 7:07 am) but AA 1, who was the assigned helper to accompany Resident 1, was not in the facility yet. The DON stated LVN 1 told the rideshare driver to wait for AA 1 to arrive, but the rideshare driver did not wait and left the facility with Resident 1. During an interview on 8/15/24 at 3:36 pm with AA 1, AA 1 stated on 8/13/24 (at 7 am) AA 1 was supposed to go with Resident 1 to the ophthalmologist's office but AA 1 did not wake up on time and was running late. AA 1 stated DRV 1 called AA 1 at 7 am to remind AA 1 of Resident 1's appointment, and AA 1 informed DRV 1 that AA 1 was running late. AA 1 stated as soon as AA 1 arrived at the facility on 8/13/24, unable to recall time, DRV 1 told AA 1 they had to follow Resident 1 to the ophthalmologist's office. AA 1 stated as soon as they (DRV 1 and AA 1) got to the ophthalmologist's office on 8/13/24 at 8:20 am, the receptionist told them Resident 1 did not check in for Resident 1's appointment. AA 1 checked all the offices in the building and DRV 1 drove around the streets near the ophthalmologist office. AA 1 stated when they (DRV 1 and AA 1) could not find Resident 1 they notified the SSD and an LVN (unidentified). AA 1 stated AA 1 usually accompanied residents to their appointments and that was the first time AA 1 was late. During an interview on 8/15/24 at 4:29 pm with the SSD, the SSD stated on 8/13/24 at 7:30 am LVN 3 called the SSD and informed the SSD that Resident 1 left the facility to go to the ophthalmologist's office with the rideshare driver without a staff helper. The SSD stated the SSD called Resident 1's insurance company, on 8/13/24 at 7:35 am, to find out how to get a hold of the rideshare driver because Resident 1's insurance company was the one who arranged the rideshare service. The SSD stated Resident 1's insurance representative informed the SSD that Resident 1 was dropped off by the rideshare driver at the ophthalmologist's office at 7:58 am. The SSD stated the receptionist at the ophthalmologist's office verified Resident 1 had an appointment but Resident 1 never checked in. The SSD stated residents in the secured unit were not allowed to go outside the building without a staff chaperone/helper or a family member. During a phone interview on 8/16/24 at 11:30 am with LVN 1, LVN 1 stated Resident 1 had a doctor's appointment on 8/13/24 (at 8 am) and the rideshare driver arrived to pick up Resident 1 between 7:05 am to 7:10 am. LVN 1 told the rideshare driver to wait inside the secured unit so LVN 1 could find out where AA 1 was. LVN 1 stated Resident 1 and the rideshare driver were standing in the hallway by the secured unit's door between the Manor and the Center, while LVN 1 called the supervisor's office to find out where AA 1 was. LVN 1 stated when LVN 1 hung up the phone, Resident 1 and the rideshare driver were no longer standing in the hallway by the door. LVN 1 stated LVN 1 alerted LVN 3 and LVN 2. LVN 1 stated this happened during shift change, and nurses were coming in and out of the secured unit's door. LVN 1 stated Helper (HLP) 1 looked outside the facility for Resident 1 and the rideshare driver, but HLP 1 did not find Resident 1 and the rideshare driver. LVN 1 stated staff were not supposed to let residents out without staff supervision. LVN 1 stated residents in the secured unit were at risk for elopement and it was important to have a staff helper with them whenever the residents went outside so they would not wander away. During a review of the facility policy and procedure (P&P) titled, Elopements and Wandering Residents, dated 2/2020, the P&P indicated, the facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate (sufficient/enough) supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The P&P indicated, the facility established and utilized a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The P&P indicated, adequate supervision would be provided to help prevent accidents or elopement.

Based on observation, interview, and record review, the facility failed to provide care and services for three of three sampled residents (Residents 228, 231 and 80 ) to prevent the development of a pressure ulcer (PU, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and failed to provide treatment to the PU. 1. For Resident 228 who was assessed as at risk for developing PU, the facility failed to: a. Ensure Treatment Nurses (TXN 1 and TXN 3) provided treatment to Resident 228's right hip opened scratches (areas of damage on the surface of the skin)/open wounds (injuries that involve a break in the skin and leave the internal tissue exposed) on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 as ordered by Resident 228's Medical Doctor (MD) 1. b. Ensure TXN 1 and TXN 3 provided treatment to Resident 228's right and left hips' unstageable PU (full thickness tissue loss where the depth of the wound was covered by eschar [collection of dry, dead tissue within a wound]) on 7/29/2024 as ordered by MD 1. c. Ensure TXN 3 notified MD 1 of Resident 228's development of the avoidable (able to be prevented) unstageable PU on the right and left hips when Physician Assistant 1 (PA 1) identified those PUs on 7/24/2024. d. Ensure TXN 3 carried out PA 1's verbal order to clean Resident 228's unstageable PU on Resident 228's right and left hips with Normal Saline (NS, mixture of water and salt) and Betadine (medication used to prevent infection in wounds), and to cover (the PU) with dressing (unspecified) on 7/24/2024. e.Ensure TXN 1 and TXN 3 implemented Resident 228's Care Plan (CP) dated 5/30/2024 for impaired skin integrity and risk of worsening of a PU and to provide wound care treatment to Resident 228 as ordered by MD 1 and to report further skin breakdown to MD 1. As a result, on 7/24/2024, Resident 228 developed an avoidable unstageable PU on the right hip and worsened left hip unstageable PU. The unstageable PU on the right hip measured 5.5-centimeter (cm, measurement unit in length) length by 5 cm width with a depth of 0.2 cm, and the unstageable PU on the left hip measured 7 cm length by 4 cm width with a depth of 0.2 cm. 2. For Resident 231, the facility staff failed to ensure the Low Air Loss mattress (LAL - tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float) was set at accurate setting based on the resident's weight. Resident 231's LAL mattress was set at 325 pounds (lbs. - unit of measurement) static mode and the resident currently weighed 158 pounds. This failure had the potential for skin breakdown for Resident 231. 3. For Resident 80, the facility failed to ensure facility Treatment Nurses (TXN) provided treatment for Resident 80's Stage 4 Pressure Ulcer (Stage 4 PU, full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer; slough and/or eschar may be visible on some parts of the wound bed) on the Sacro coccyx (tailbone) from 7/25/24 to 7/30/24. This failure had the potential to delay healing of Resident 80's PU. Cross reference F657 Findings: 1. During a review of Resident 228's Admission Record (AR), the AR indicated the facility admitted Resident 228 on 2/23/2024 and readmitted on [DATE] with diagnoses that included type two diabetes mellitus (occurs when there was too much sugar in the blood), End Stage Renal Disease (ESRD- kidneys were damaged and unable to filter blood), and dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood). During a review of Resident 228's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/4/2024, the MDS indicated Resident 228 had moderately impaired cognition (ability to think, learn, and understand). The MDS indicated Resident 228 was at risk for developing PU due to occasionally moist skin and very limited mobility (ability to change and control body position). During a review of Resident 228's Admission Body Assessment ([NAME]) dated 5/30/2024, the [NAME] indicated Resident 228 was admitted to the facility with an unstageable PU on the left hip which measured 1 cm. length by 1.5 cm width. The [NAME] indicated Resident 228 had contractures (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the body part) of bilateral (both) knees, left elbow, and left wrist. During a review of Resident 228's Braden Scale (BS, tool used to assess resident's risk for developing a PU) form, dated 5/30/2024, the BS form indicated Resident 228 was at risk to develop a PU due to occasionally moist skin and very limited mobility. During a review of Resident 228's untitled CP for impaired skin integrity and risk of worsening of a PU dated 5/30/2024, the CP indicated for staff to provide treatment to Resident 228's PU as ordered by MD 1 and to report further skin breakdown to MD 1. During a review of Resident 228's Non-Pressure Sore Skin Problem Report (NPSSPR) of the right hip dated 6/22/2024, the NPSSPR indicated there was open red and moist scratches on Resident 228's right hip. During a review of Resident 228's Physician's Order (PO) dated 6/22/2024, the PO indicated for licensed staff (TXN 1 and TXN 3) to cleanse Resident 228's right hip open scratches/wounds with NS, pat (the wounds) dry and apply calmoseptine (moisture barrier) and cover (the wound) with Optifoam (non-adhesive dressing to create a proper environment for wound healing) every day for 14 days and re-evaluate. During a review of Resident 228's PO dated 7/22/2024, the PO indicated for licensed staff (TXN 1 and TXN 3) to paint Resident 228's right hip's open wounds with Betadine and cover (the wound) with Optifoam every day for 14 days and re-evaluate. During a review of Resident 228's Physician's Assistant Wound Assessment Notes (PAWAN) dated 7/24/2024 at 3:06 PM, the PAWAN indicated the following: Resident 228's left hip had one unstageable PU, which measured 7 cm length by 4 cm width with a depth of 0.2 cm. Resident 228's right hip had one unstageable PU which measured 5.5 cm length by 5 cm width with a depth of 0.2 cm. Resident 228's PAWAN indicated PA 1 recommended for licensed staff (TXN 1 and TXN 3) to cleanse Resident 228's right and left unstageable PU with NS and Betadine, cover the PUs with dry dressing (wound dressing make of dry material such as gauze or absorbent cotton), offload (relieve the PU from pressure) and reposition. During a review of Resident 228's PO dated 7/26/2024, the PO indicated for licensed staff (TXN 1 and TXN 3) to clean Resident 228's left hip red scab (unstageable PU) with NS, paint (the unstageable PU) with Betadine, and cover (the unstageable PU) with Optifoam for 14 days. During a review of Resident 228's PO, dated 7/27/2024, the PO indicated for licensed staff (TXN 1 and TXN 3) to clean Resident 228's right hip PU with NS, apply Santyl ointment (ointment used to remove damaged tissue) daily, and cover (the right hip PU) with Optifoam for 14 days. During a review of Resident 228's Skin and Wound Progress Report (SWPR) for the right hip dated 7/27/2024, the SWPR indicated Resident 228 had an unstageable PU on the right hip. The SWPR indicated unstageable PU on Resident 228's right hip had increased in size and color. During a concurrent observation of Resident 228 in Resident 228's room and an interview with Resident 228 on 7/31/2024 at 9:15 AM, Resident 228 was lying on Resident 228's right side with bilateral (both) knees, left elbow, and left wrist contracted (tissue shortened). Resident 228 stated Resident 228 did not know how Resident 228 developed the unstageable PU on Resident 228's right and left hips. During an interview on 7/31/2024 at 10:49 AM with Registered Nurse 3 (RN 3), RN 3 stated the unstageable PU on Resident 228's right hip was a new PU, and the PU was developed in the facility. RN 3 stated the right hip unstageable PU started as a scratch on 6/22/2024. RN 3 stated Resident 228 was admitted with a left hip PU. During a concurrent interview with TXN 1 on 7/31/2024 at 3:58 PM and record review of Resident 228's Treatment Administration Record (TAR) dated from 7/26/2024 to 7/31/2024 for the left hip, Resident 228's TAR indicated missing treatment for the unstageable PU on 7/29/2024. TXN 1 stated the TAR for 7/29/2024 was blank. TXN 1 stated TXN 1 was unsure if Resident 228 received treatment for the unstageable PU on 7/29/2024. TXN 1 stated there was no documented evidence on Resident 228's clinical record to indicate why the treatment was missed. TXN 1 stated missing the treatment would result in worsening of Resident 228's left hip unstageable PU. During a concurrent interview with TXN 1 on 7/31/2024 at 4 PM and record review of Resident 228's TAR dated from 6/1/2024 to 7/31/2024 for the right hip and the CP for impaired skin integrity and risk of worsening of PU dated 5/30/2024, Resident 228's TAR for the right hip indicated blank spaces on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 and 7/29/2024. TXN 1 stated Resident 228 missed five days of treatment (7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 and 7/29/2024). The CP indicated for licensed staff (TXN 1 and TXN 3) to provide wound care treatment as ordered and to report further skin breakdown to MD 1. TXN 1 stated Resident 228's right hip started as a scratch on 6/22/2024. TXN 1 stated not providing treatment as ordered would cause the right hip unstageable PU to worsen. TXN 1 stated Resident 228's CP was not implemented because treatment for the open wound on the right hip was not provided to Resident 228 as per MD 1's order. TXN 1 stated missing treatments would contribute to the development of an avoidable PU. During a concurrent observation of Resident 228's right and left hip unstageable PU in Resident 228's room and interview with the facility's Director of Nursing (DON) and RN 3 on 8/1/2024 at 10:32 AM, the DON and RN 3 assessed Resident 228's right and left unstageable PUs. The DON stated the wound bed (base of the wound) for the left hip unstageable PU was moist, pink, and purple with yellow slough (yellow or white material which consist of dead cells that accumulate in the wound) surrounded the PU. The DON stated the left hip unstageable PU had no tunneling (narrow opening that extends from the wound's surface into deeper tissue). The DON stated Resident 228's left hip PU had gotten worse because there was drainage and slough on the wound bed. The DON stated the wound bed for Resident 228's right hip unstageable PU was pale, red, moist, and surrounded with yellow slough. The DON stated the right hip unstageable PU had gotten worse due to the slough on the wound bed. During a concurrent interview with RN 3 and record review of Resident 228's TAR on 8/1/2024 at 2:34 PM, Resident 228's TAR for the right hip dated from 6/1/2024 to 7/31/2024 was reviewed. Resident 228's TAR indicated blank spaces on 7/6/2024,7/20/2024,7/21/2024,7/25/2024 and 7/29/2024. RN 3 stated Resident 228 missed treatment for the right hip open wound on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024, and for unstageable PU on 7/29/2024. RN 3 stated five days of missed treatments would result in worsening of the PU. During a concurrent interview with the DON on 8/2/2024 at 8:14 AM and record review of Resident 228's PAWAN dated 7/24/2024, the DON stated the DON received the PAWAN dated 7/24/2024 from PA 1 in the morning of 8/2/2024. The DON stated PA 1 determined the PUs on Resident 228's left, and right hip were unstageable on 7/24/2024. The DON stated, TXN 1 notified MD 1 on 7/27/2024 (three days after the PA 1 assessed the PU on 7/24/2024) regarding Resident 228's right hip because the right hip PU had increased in size. The DON stated, not having the PAWAN for Resident 228 in Resident 228's medical record timely (assessment date) resulted in the delay in treatment for Resident 228's right and left hip unstageable PU and the PU got worsen. During a concurrent interview with the DON on 8/2/2024 at 11:40 AM, and record review of Resident 228's TAR for the right hip wound dated from 6/1/2024 to 7/31/2024 indicated blank spaces on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 and 7/29/2024. The DON stated, unfilled boxes on the TAR indicated treatment for the right hip open wound was not done on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024, and 7/29/2024. The DON stated not providing treatment as ordered would result in the development of new PU and worsening of the current PU. The DON stated the DON was made aware of Resident 228's right unstageable PU on 7/29/2024 but was not aware the left hip unstageable PU worsened. The DON stated, the right hip PU could have been prevented by providing the wound treatment as ordered and implementing the CP. During an interview with TXN 3 on 8/2/2024 at 1:03 PM, TXN 3 stated TXN 3 accompanied PA 1 on 7/24/2024. TXN 3 stated orders were not initiated because staff were waiting for PA 1 to fax or email the PAWAN to the facility. TXN 3 stated the PA 1's notes should have been in Resident 228's chart. TXN 3 stated it was not acceptable for the TXNs (TXN 1 and TXN 3) to not provide treatment for three days. TXN 3 stated she did not follow up with PA 1 for the PAWAN when she did not receive the PAWAN from PA 1. TXN 3 stated the risk of delaying treatment would result in the development of new PU and or worsening of the current PU. During an interview with PA 1 on 8/2/2024 at 3:10 PM, PA 1 stated PA 1 assessed Resident 228 for treatment for the left and right hip wounds on 7/24/2024. PA 1 stated PA 1 was accompanied by TXN 3 and stated Resident 228 had an unstageable PU on the left and right hip. PA 1 stated PA 1 gave verbal orders to TXN 3 for repositioning Resident 228, cleaning the PUs with NS and Betadine, cover the PU with dry dressing. PA 1 stated the expectation for staff when receiving a verbal order was to implement the order as soon as possible (the same day). PA 1 stated PA 1 had computer glitches/email problems, so facility staff (DON) did not receive PA 1's PAWAN of Resident 228's PUs on the right and left hips until 8/2/2024. During a review of the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention and Management, the P&P indicated the facility will establish and utilize a systematic approach for pressure ulcer prevention and management, starting with a prompt assessment and treatment. The P&P indicated the attending physician will be notified of the presence, progression towards healing, or lack of healing upon identification of injuries. The P&P indicated interventions will be documented in the care plan and communicated to all relevant staff. 45064 2. During a review of Resident 231's AR, the AR indicated Resident 231 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included spinal stenosis (a tightening of the spinal canal that causes nerve pain), muscle weakness and cellulitis (infection of the skin and tissues) of the right and left lower extremities. During a review of Resident 231's Physician Orders (PO) dated 6/14/24, the PO indicated for Resident 231 to have LAL mattress for skin integrity maintenance. During a review of Resident 231's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition. The MDS indicated, the resident was at risk of developing pressure ulcer (PU). The MDS indicated, Resident 231 required substantial/maximal assistance (helper did more than half the effort and lifted or held trunk or limbs) for toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 231's Monthly Weight Record (MWR) for the month of July 2024, the MWR indicated Resident 231 weighed 158 lbs. During an observation on 7/30/24 at 10:46 am in Resident 231's room, Resident 231's LAL mattress was set at 325 lbs. and in static mode. During an observation and interview on 7/30/24 at 10:48 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 231 was at high risk for PU and that the resident was unable to move independently in bed. LVN 1 stated, the current LAL mattress setting was set at 325 lbs. in static mode which was inaccurate setting for Resident 231 that could potentially cause PU for the resident. LVN 1 stated the LAL mattress setting needed to be set according to Resident 231's current weight of 158 lbs. During an interview on 8/2/24 at 10:35 am with the Director of Nursing (DON), the DON stated licensed nurses were responsible to check the LAL mattress setting every shift to ensure accurate setting for the residents. The DON stated the setting of the LAL mattress was based on the resident's current weight. The DON stated, static mode means the maximum firmness of the mattress, and only used during resident care such as transfer, or repositioning. The DON stated, inaccurate setting of the LAL mattress could potentially cause the resident to develop PU. During a review of the undated manufacturer's manual titled Alternating Pressure and Low Air Loss Mattress System, the manual indicated it was recommended to turn the pressure-adjust knob . adjust the air mattress to a desired firmness according to the patient's weight .In static mode, the mattress provides a firm surface that make it easier for the patient to transfer or reposition. During a review of the facility's undated P&P titled Use of Support Surfaces the P&P indicated, Support surfaces will be utilized in accordance with manufacturer recommendation. 40913 3. During a review of Resident 80's Face Sheet, the face sheet indicated the facility initially admitted the resident on 4/4/15 and readmitted the resident on 6/6/24, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and dysphagia (difficulty swallowing.) During a review of Resident 80's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment. The MDS indicated Resident 80 was dependent with all activities of daily living. During a review of Resident 80's Skin and Wound Progress Notes indicated on 6/6/24, Resident 80 was readmitted to the facility with unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) wound on the sacrococcyx area and on 6/8/24, Resident 80's was assessed by the Wound Consultant and the wound was identified as a Stage 4 PU measuring 1 centimeter (cm) in length, 1 cm in width and 0.1 cm depth. During a review of Resident 80's TAR for the month of July 2024, the TAR indicated treatment order dated 7/17/24 to cleanse Resident 80's Stage 4 PU with normal saline, to pat dry and apply a wound gel and then cover with bordered gauze daily for 14 days. The TAR indicated from 7/17/24 to 7/24/24, the TAR was signed off, and treatment was provided. The TAR was blank from 7/25/24 to 7/30/24. During an interview on 8/1/24 at 3:45 pm, LVN 9 stated she did not remember performing wound care treatment to Resident 80. During a concurrent review of the TAR, LVN 9 stated she worked in the Red Zone (area of facility for residents on isolation precautions for COVID-19 [ an illness caused by a virus that can spread from person to person]) on 7/31/24 but did not know about the pressure ulcer treatment for Resident 80. LVN 9 stated the signature on TAR would indicate the treatment was provided and if not signed the PU treatment was not provided. During a wound care observation on 8/1/24 at 4:12 pm, Treatment Nurse 3 (TXN 3) measured Resident 80's Stage 4 sacrococcyx PU which measured 0.5 cm in length, 0.5 cm in width and 0.6 cm in depth. During an interview on 8/2/24 at 10:00 am, LVN 7 stated she worked in the Red Zone on 7/30/24. LVN 7 stated she did not remember performing wound care treatment to Resident 80 when she was at the Red Zone. During a concurrent review of the TAR, LVN 7 stated she did not sign the TAR because she missed the wound care treatment for Resident 80. During an interview on 8/2/24 at 10:45 am, the Director of Nursing (DON) stated licensed staff (TXNs) needed to continue PU treatment in the Red Zone.

Based on interview and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) to two of three sampled residents (Resident 1 and Resident 5) who had a full code status (when the resident's heart stopped beating and/or the resident stopped breathing, the resident or their representative wishes for all lifesaving procedures to be provided to keep them alive) by failing to ensure: 1. Registered Nurse Supervisor (RNS) 1, Licensed Vocational Nurse (LVN) 1, Certified Nurse Assistant (CNA) 1, CNA 2, and CNA 3 immediately provided CPR to Resident 1 after Resident 1 became unresponsive while being provided the Heimlich Maneuver (HM, a first aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure was applied on the abdomen, between the navel and the rib cage) after Resident 1 choked on his dinner. As a result, on [DATE] at 7:01 pm, Resident 1 was pronounced (noticeable or certain) dead after the paramedics (emergency medical technicians [EMTs] who provided emergency medical services) provided unsuccessful CPR to Resident 1 in Resident 1's room. 2. LVN 6 immediately provided CPR to Resident 5 after LVN 6 found Resident 5 in the dining room unresponsive with no palpable pulse and no visible chest rise. As a result, on [DATE] at 12:05 pm, Resident 5 did not receive immediate CPR and was pronounced dead after paramedics provided unsuccessful CPR to Resident 5 in an unknown resident room in the facility. On [DATE] at 7:17 pm, while onsite at the facility, an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) regarding the facility's failure to provide immediate and continuous CPR to Resident 1 on [DATE] and Resident 5 on [DATE] who had a full code status and the risk for 283 other residents who were residing in the facility with full code status not receiving CPR when those residents' hearts stopped beating and/or when they stopped breathing. The IJ was called in presence of the facility's ADM and DON. On [DATE] at 9:40 am, the facility submitted an acceptable Plan of Action (POA, a list of steps taken to correct the deficient practices). While onsite at the facility, the survey team verified and confirmed the facility's implementations of the POA through observation, interview, and record review. The survey team determined an IJ situation was no longer present and removed the IJ while onsite on [DATE] at 3:35 pm, in the presence of the ADM and the DON. The IJ removal plan, dated [DATE] included the following: a. On [DATE], the CPR instructor provided CPR class training for RNS 1, LVN 1, CNA 1, 2, and 3. b. On [DATE], the DON, Social Service Department (SSD), and Nursing Supervisors (NS) initiated chart review audit to all current residents to check code status (described the type of emergent procedures a person would like the health care team to conduct when his/her heart stopped beating and/or he/she stopped breathing). There were 283 residents with FULL CODE status and 31 residents with NO CPR (NO CODE, an order that instructed the medical team to not resuscitate the patient if either the heart stopped beating or the individual stopped breathing). c. On [DATE], the Continuous Quality Improvement Registered Nurse Consultant (CQI RNC) and the DON initiated a Mock Code Blue (pretend emergency situations in which a pretend patient had no pulse and/or not breathing and had to be provided CPR) to all licensed nurses and CNAs. d. On [DATE], Certified CPR Instructor provided in-person CPR class training for all licensed nurses and CNAs. e. On [DATE], the CQI RNC and the DON initiated an in service regarding NO CODE and FULL CODE status and placed the record of each resident's code status in the residents MARs for easy reference. f. The DON and or Designee and the Director of Staff Development (DSD) would conduct random Mock Code Blue to licensed nurses and CNAs monthly. Any issues will be addressed and corrected immediately. Findings will be reported to the quarterly Quality Assessment and Assurance (QA&A, a continuous process based on identifying quality problems assessment of data collection and analysis) meetings for 6 months. Cross reference F689 Findings: 1. During a review of Resident 1's Face Sheet (FS), the FS indicated, the facility initially admitted Resident 1 to the facility on [DATE] and readmitted Resident 1 on [DATE] with diagnoses that included autistic disorder (a developmental disability caused by differences in the brain) and Alzheimer's disease (a brain disorder that affected memory, thinking, and behavior severe enough to interfere with daily task). During a review of Resident 1's Physician Orders for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner, or a physician assistant which specified what a patient's lifesaving treatment wishes were), dated [DATE], the POLST indicated, Resident 1 wanted CPR and full treatment (primary goal of prolonging life by all medically effective means) if Resident 1's heart stopped and/or if Resident 1 stopped breathing. During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated, Resident 1 required partial/moderate assistance (helper provided less than half the effort and helper lifted, held, or supported trunk or limbs) from staff with eating. During a review of Resident 1's EMT run report (a standard document used by emergency medical service care providers), dated [DATE] and timed at 6:27 pm, the report indicated, the EMTs arrived at the facility on [DATE] at 6:33 pm and was at Resident 1's bedside to evaluate Resident 1 at 6:34 pm. The report indicated, the EMTs found Resident 1 in bed unresponsive, apneic (breathing stopped or had almost no airflow), and pulseless (without a pulse/heart rate) and the EMTs started CPR at 6:37 pm. The report indicated, Resident 1's first monitored heart rhythm (electrical activity of the heart seen on a screen) was asystole (no heartbeat) at 6:42 pm. The report indicated, on [DATE], Resident 1's heart rate was 68 at 6:43 pm, asystole at 6:52 pm and 6:53 pm, 27 at 6:54 pm, 28 at 6:55 pm, and asystole from 6:58 pm to 7:02 pm. The report indicated, Resident 1 remained with no heart rate and no change in heart rhythm while providing CPR. The report indicated, Resident 1 was pronounced dead on scene on [DATE] at 7:01 pm. During a review of Resident 1's Licensed Personnel Progress Notes (LPPN), dated [DATE] and timed at 11:15 pm, the LPPN indicated, at 6:20 pm, CNA 1 set up Resident 1's dinner tray on Resident 1's table in front of Resident 1. The LPPN indicated, CNA 1 left Resident 1's room to get a towel from the linen room. At 6:22 pm, CNA 1 returned to Resident 1's room to feed Resident 1 and noted Resident 1 with both hands to his mouth, coughing, and with some ground meat particles on Resident 1's hands. The LPPN indicated, CNA 1 tapped Resident 1's back three times and performed HM but Resident 1 continued to cough. The LPPN indicated, CNA 1 immediately yelled for help by calling LVN 1. LVN 1 promptly responded into Resident 1's room. The LPPN indicated, LVN 1 observed Resident 1 to be non-responsive and coughing. LVN 1 continued the HM a couple of times, swept out Resident 1's mouth, and was able to remove tiny brown food particles (from Resident 1's mouth). CNA 1 immediately informed RNS 1 on duty who responded promptly, and additional staff arrived who assisted with ongoing HM. During an interview on [DATE] at 4 pm with CNA 1, CNA 1 stated, on [DATE], Resident 1 was assigned to CNA 1 and Resident 1 was on the feeding assistance list. CNA 1 stated Resident 1 was a choking risk because Resident 1 swallowed his food without chewing it. CNA 1 stated on [DATE] (unable to recall the time), CNA 1 left Resident 1's meal tray on the table in front of Resident 1 because CNA 1 did not have a towel and had to get one from the linen closet. CNA 1 stated when CNA 1 returned to Resident 1's room, Resident 1 was coughing and holding both hands with closed fists to his mouth. CNA 1 stated CNA 1 called Resident 1's name, gave Resident 1 three back blows, and CNA 1 observed ground meat come out of Resident 1's mouth. CNA 1 stated Resident 1 continued coughing so CNA 1 began the HM while Resident 1 was sitting on the wheelchair. CNA 1 stated Resident 1 continued to cough so CNA 1 yelled for LVN 1. CNA 1 stated CNA 1 continued performing HM until LVN 1 arrived. CNA 1 stated when LVN 1 entered Resident 1's room, Resident 1 was bent over on the wheelchair, not moving, and not coughing. CNA 1 stated LVN 1 took over the HM but Resident 1 was no longer coughing or moving. CNA 1 stated LVN 1 told CNA 1 to call for help. CNA 1 stated LVN 3 came in Resident 1's room, and CNA 1 called CNA 2 and CNA 3. CNA 1 stated when CNA 2 and CNA 3 arrived in Resident 1's room, CNA 1 ran to get RNS 1 and returned to Resident 1's room with RNS 1. CNA 1 stated LVN 1, LVN 3, and CNA 3 were in Resident 1's room performing the HM. CNA 1 stated Resident 1 was still slumped forward on the wheelchair not responding and not coughing. During an interview on [DATE] at 5:07 pm with LVN 2, LVN 2 stated LVN 5 notified her of the code blue (call for medical personnel and equipment to attempt to resuscitate a patient in cardiac or respiratory arrest) involving Resident 1. LVN 2 stated on [DATE] (unable to recall the time) she entered Resident 1's room and saw CNA 2 and CNA 3 providing HM on Resident 1. LVN 2 stated CNA 3 was holding Resident 1 in a standing position while providing HM. LVN 2 stated Resident 1's face was blue, and Resident 1 was unresponsive. LVN 2 stated she instructed CNA 3 and CNA 2 to put Resident 1 back in bed to start CPR. During an interview on [DATE] at 5:10 pm with RNS 1, RNS 1 stated CNA 1 notified her that Resident 1 was choking. RNS 1 stated CNA 1 and RNS 1 entered Resident 1's room and observed Resident 1 was unresponsive to verbal stimuli and Resident 1's face was blue. RNS 1 stated LVN 1 was behind Resident 1's wheelchair performing the HM on Resident 1, while CNA 2 and CNA 3 were in the room. RNS 1 stated RNS 1 returned to the Nurses' Station to overhead page code blue, call 911 (phone number used to contact emergency services in the event of a medical emergency), and check Resident 1's code status in Resident 1's chart (medical record). RNS 1 stated when RNS 1 returned to Resident 1's room, staff (unidentified, unable to remember) was performing CPR on Resident 1, while Resident 1 continued to be unresponsive. RNS 1 stated staff (unidentified) attempted to get vital signs (measuring the basic functions of your body temperature, blood pressure, pulse, and respirations) with no readings. RNS 1 stated the paramedics arrived within five minutes. During an interview on [DATE] at 5:39 pm with CNA 3, CNA 3 stated CNA 2 asked for help in Resident 1's room. CNA 3 stated he entered Resident 1's room and saw Resident 1 in the wheelchair, slumped over, not moving, and not coughing. CNA 3 stated LVN 1 was providing HM on Resident 1 while Resident 1 was in the wheelchair. CNA 3 stated he stood Resident 1 up from the wheelchair and provided HM at least seven times while lifting Resident 1 up. CNA 3 stated he switched with CNA 2 and CNA 2 started HM again. During an interview on [DATE] at 5:50 pm with CNA 2, CNA 2 stated on [DATE] (unable to recall the time), CNA 1 called CNA 2 for assistance due to Resident 1 choking. CNA 2 stated when CNA 2 arrived in Resident 1's room, CNA 1 and LVN 1 were in the room, and Resident 1 was sitting in his wheelchair, slumped over, not responding. CNA 2 stated LVN 1 was giving Resident 1 back blows. CNA 2 stated CNA 2 immediately attempted the HM on Resident 1 and tapped Resident 1 but Resident 1 continued to be unresponsive to verbal stimuli and slumped over his chair with eyes open. CNA 2 stated CNA 2 continued providing the HM four to five times. CNA 2 stated CNA 3 entered Resident 1's room within seconds behind CNA 2 and CNA 3 began taking turns with CNA 2 providing the HM. CNA 2 stated LVN 2 came in after CNA 3 to check Resident 1's pulse and instructed LVN 1, CNA 2, CNA 3 to put Resident 1 on the bed and start CPR. CNA 2 stated they (CNA 2 and CNA 3) should have checked Resident 1's pulse when Resident 1 became unresponsive and began CPR. CNA 2 stated they should have begun the CPR instead of continuing the HM on Resident 1 because Resident 1 was unresponsive. During a phone interview on [DATE] at 7:56 pm with LVN 1, LVN 1 stated, on [DATE] at 6:15 pm to 6:20 pm, LVN 1 heard CNA 1 shouting for help. LVN 1 stated when LVN 1 entered Resident 1's room, LVN 1 saw Resident 1 unresponsive, and Resident 1 was sitting in his wheelchair facing the wall. LVN 1 stated LVN 1 began providing the HM on Resident 1, and LVN 1 told CNA 1 to call RNS 1. LVN 1 stated LVN 1 heard Resident 1 coughing right before LVN 1 entered Resident 1's room. LVN 1 stated once LVN 1 entered Resident 1's room, LVN 1 did not hear Resident 1 coughing. LVN 1 stated Resident 1 was not moving and not responding to touch. LVN 1 stated CNA 2 and CNA 3 came in Resident 1's room and attempted the HM on Resident 1. LVN 1 stated CNA 2, CNA 3, and LVN 1 took turns providing the HM on Resident 1, and before CNA 3 began the HM, LVN 1 checked Resident 1's pulse on Resident 1's neck. LVN 1 stated Resident 1 had a pulse and then CNA 3 took over the HM. LVN 1 stated another staff (LVN 2) told LVN 1 to lay Resident 1 in bed then LVN 1 provided a full set of CPR compressions. LVN 1 stated CPR continued until the paramedics arrived and took over. LVN 1 stated when a resident was choking and had a weak pulse, CPR needed to be done instead of HM. LVN 1 stated LVN 1 forgot about what LVN 1 learned from the CPR training. LVN 1 stated LVN 1 could not remember if Resident 1 had a pulse or not. During an interview on [DATE] at 10:30 am with the DSD, the DSD stated, CPR was reviewed during the competency training in [DATE]. The DSD stated all staff had CPR certification and all staff were up to date. The DSD stated staff needed to perform HM on a resident who was choking. The DSD stated when a choking resident became unresponsive, staff needed to stop HM and begin chest compression. During an interview on [DATE] at 11 am with the DON, the DON stated when a resident (any resident) was choking and became unresponsive the expectation was for staff (any nursing staff) to begin CPR. 2. During a review of Resident 5's FS, the FS indicated, the facility readmitted Resident 5 on [DATE], with diagnoses that included schizophrenia (a disorder that affected a person's ability to think, feel, and behave clearly) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). During a review of Resident 5's H&P, dated [DATE], the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a Review of Resident 5's POLST dated [DATE], the POLST indicated, Resident 5 wanted CPR and all lifesaving procedures to be provided to Resident 5 if Resident 5's heart stopped and/or if Resident 5 stopped breathing. During a review of Resident 5's s EMT run report, dated [DATE], the report indicated, EMTs arrived at the facility on [DATE] at 11:39 am and was at Resident 5's bedside to evaluate Resident 5 at 11:40 am. The report indicated the EMTs found Resident 5 in bed unresponsive, apneic, and pulseless and the EMTs started CPR at 11:42 am. Resident 5's first monitored heart rhythm was asystole. Resident 5's heart rate at 11:44 am was 212, at 11:46 am was 141, from 11:46 am to 12:02 pm was asystole. The report indicated, Resident 5 was pronounced dead at on [DATE] at 12:02 pm. During a review of Resident 5's LPPN dated [DATE] and timed at 11:27 am, the LPPN indicated, the activity staff (AS) reported the AS was unable to wake up Resident 5 when the AS approached Resident 5 (undated and untimed) on the dining table in the activities room. The LPPN indicated, the AS asked for nurse assistance. The LPPN indicated, LVN 6 immediately attended to Resident 5 and noted Resident 5 leaning onto Resident 5's right side, Resident 5's skin was warm/dry to touch, and LVN 6 was unable to see Resident 5's chest rise due to Resident 5's positioning. The LPPN indicated, Resident 5 was unresponsive with no palpable pulse. The LPPN indicated, LVN 6 called for additional assistance, LVN 6 was unable to obtain Resident 5's vital signs and LVN 6 called code blue. The LPPN indicated, staff (unidentified) transferred Resident 5 to bed (unidentified bed in a room closest to the dining room) and initiated CPR. The LPPN indicated, at 11:32 am, facility's staff (unidentified) called 911, and staff (unidentified) at bedside continuing with CPR approximately for 20 cycles. The LPPN indicated, paramedics arrived at 11:40 am and took over CPR. The LPPN indicated, the paramedics continued to provide CPR for Resident 5, and Resident 5 had no pulse detected. The LPPN indicated, CPR stopped at 12:05 pm. During an interview on [DATE] at 5:25 pm with LVN 6, LVN 6 stated Resident 5 died (on [DATE] at 12:02 pm). LVN 6 stated the AS could not wake up Resident 5 while Resident 5 was in the dining room. LVN 6 stated AS asked LVN 6 to check Resident 5 in the front dining room. LVN 6 stated LVN 6 found Resident 5 in the wheelchair with head tilted to the side. LVN 6 stated LVN 6 touched Resident 5's arm, shook Resident 5, and Resident 5 flinched but LVN 6 did not see chest rise. LVN 6 stated LVN 6 could not remember if LVN 6 checked Resident 5's pulse. LVN 6 stated LVN 6 pushed Resident 5's wheelchair to the first resident room closest to the dining room (dining room, public restroom, office, first resident room) then called for help and got the crash cart. LVN 6 stated she called the code blue and all staff rushed to help with oxygen tank and CPR was initiated. LVN 6 stated LVN 6 should have performed CPR in the dining room/activity room and should have provided CPR sooner. LVN 6 stated LVN 6 did not know Resident 5's code status at that time and was unsure if activity staff was trained and allowed to move Resident 5. During a review of the facility's policy and procedure (P&P) titled, Cardiopulmonary Resuscitation (CPR), undated, the P&P indicated, facility adhered to residents' right to formulate advance directives (legal documents that provided instructions for medical care and only go into effect if the person cannot communicate his/her own wishes). In accordance with these rights, the facility implemented guidelines regarding cardiopulmonary resuscitation (CPR). The P&P indicated, the facility followed current American Heart Association (AHA) guidelines regarding CPR. The P&P indicated, if a resident experienced cardiac arrest, facility staff provided basic life support, including CPR, prior to the arrival of emergency medical services, and if the resident showed obvious signs of clinical death. During a review of the CPR Select website titled, What to Do If a Person is Choking and First Aid Treatment, updated on [DATE], choking due to severe upper airway obstruction was life-threatening medical emergency requiring fast, appropriate action by anyone available. The website indicated, if a choking victim became unconscious, CPR must be performed to save the person's life. The website indicated, treating an unconscious choking person was a critical and potentially life-saving situation. In such cases, CPR must be performed. The website indicated, time was crucial in such situations, so do not delay. [Choking Emergency First Aid: Steps to Save a Life (mycprcertificationonline.com)]

Based on interview and record review, the facility failed to provide supervision during meal time to prevent choking (a person who has severe difficulty in breathing because of a constricted or obstructed throat or a lack of air) accident (any unexpected or unintentional incident, which resulted or may result in injury or illness to a resident) for one of three sampled residents (Resident 1) who was at risk for choking by failing to: Ensure Certified Nursing Assistant (CNA) 1 did not leave Resident 1's dinner tray unattended in Resident 1's room with Resident 1 and supervised/monitored Resident 1 during mealtime as indicated in Resident 1's Care Plan (CP) titled, Resident Care Plan for Risk for Choking, and the facility's policy and procedure (P&P) titled, Meal Supervision and Assistance. As a result, on [DATE] at 6:22 pm, Resident 1 consumed his dinner unsupervised, choked on his dinner and became unresponsive (not reacting or responding to an action, question, or suggestion). On [DATE] at 7:01 pm, Resident 1 was pronounced (noticeable or certain) dead after the paramedics (emergency medical technicians [EMTs] who provide emergency medical services) provided unsuccessful cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breathe], performed when the heart stops beating or beats ineffectively and/or to restore breathing) on Residents 1 in Resident 1's room. On [DATE] at 7:17 pm, while onsite at the facility, an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) regarding the facility's failure to monitor and supervise Resident 1 who was at risk for choking during dinner on [DATE], as indicated in Resident 1's CP and facility's policy and procedure and the risk for 17 other residents who were residing in the facility not being monitored and supervised during meals. The IJ was called in the presence of the facility's ADM and DON on [DATE] at 7:17 pm. On [DATE] at 9:40 am, the facility submitted an acceptable Plan of Action (POA, a list of steps taken to correct the deficient practices). While onsite at the facility, the survey team verified and confirmed the facility's implementations of the POA through observation, interview, and record review. The survey team determined an IJ situation was no longer present and removed the IJ on [DATE] at 3:35 pm, in the presence of the ADM and the DON. The IJ removal plan, dated [DATE] included the following: a. On [DATE], the DON provided CNA 1 with one-to-one in-service regarding supervision for assisted feeding including proper feeding techniques to prevent choking. b. On [DATE], the Continuous Quality Improvement Registered Nurse Consultant (CQI RNC) provided CNA 1 with a follow up in service regarding supervision for assisted feeding including proper feeding techniques to prevent choking. c. On [DATE], the Speech Therapist (ST, a health professional who diagnosed and treated communication and swallowing problems) screened 132 residents on mechanical soft diet (a type of texture-modified diet for people who had difficulty chewing and swallowing), with diagnosis of dysphagia (difficulty swallowing), and/or edentulous (lacking teeth) to ensure the residents were provided with the appropriate diet for safety. This will be completed on [DATE]. d. On [DATE], the DON and the Registered Nurse Supervisor (RNS) reviewed all 17 residents requiring a special diet or any special needs to ensure the residents were being monitored/supervised properly during meals. e. On [DATE], the DON and/or designee interviewed all CNAs and licensed nurses regarding residents with behavior of eating fast, gulping food (swallowing food quickly), and resisting feeding assistance. The DON and/or designee identified 17 residents, updated, and completed the care plans of these 17 residents on [DATE]. f. On [DATE], the CQI RNC, DON, and the Director of Staff Development (DSD) initiated an in-service to 127 staff including licensed nurses and CNAs regarding supervision for assisted feeding residents including proper feeding techniques to prevent choking and not to leave meal trays unattended. g. On [DATE], the CQI RNC, DON, the DSD, and/or designee, initiated skills competency with return demonstration regarding assisted feeding and proper feeding techniques to 37 CNAs. h. On [DATE], the DON and/or designee updated the list of residents that required feeding assistance. i. On [DATE], the DON and/or designee initiated an in-service regarding feeding assistance monitoring log to licensed nurses and CNA's. A feeding assistance monitoring log was implemented for all shifts with a list of residents that required feeding assistance. The RNSs will sign and check off each resident to ensure residents were supervised during mealtimes and to report any unusual observation while resident was eating. j. The DON, the licensed staff, and department managers will monitor residents during rounds at mealtime to ensure residents who required assistance with feeding were supervised and monitored. k. The DON and/or designee would monitor using an audit tool with list of residents who required feeding assistance to ensure they were supervised during mealtimes daily. l. The DON will be responsible for the compliance review and follow up findings would be reported during the quarterly Quality Assessment and Assurance (QA&A, a continuous process based on identifying quality problems assessment of data collection and analysis) meetings for further review and follow up for 6 months. Cross reference F678 Findings: During a review of Resident 1's Face Sheet (FS, admission record), the FS indicated, the facility initially admitted Resident 1 to the facility on [DATE] and readmitted Resident 1 on [DATE] with diagnoses that included autistic disorder (a developmental disability caused by differences in the brain) and Alzheimer's disease (a brain disorder that affected memory, thinking, and behavior severe enough to interfere with daily task). During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated, Resident 1 required partial/moderate assistance (helper provided less than half the effort and helper lifted, held, or supported trunk or limbs) from staff with eating. During a review of Resident 1's CP titled, Resident Care Plan for Risk for Choking, dated [DATE], the CP indicated, Resident 1 was at risk for choking and/or aspiration (a condition in which food, liquids, saliva, or vomit was breathed into the airways) because Resident 1 was edentulous. The CP goal indicated, Resident 1 would have less frequent episodes of choking with food and/or fluids. The CP approached interventions included for staff to monitor Resident 1 during meals and observe Resident 1 for any difficulty in swallowing, pocketing of food (food was held in the mouth, especially in the cheeks, without being swallowed). During a review of Resident 1's EMT run report (a standard document used by emergency medical service care providers), dated [DATE] and timed at 6:27 pm, the report indicated, the EMTs arrived at the facility on [DATE] at 6:33 pm and was at Resident 1's bedside to evaluate Resident 1 at 6:34 pm. The report indicated, the EMTs found Resident 1 in bed unresponsive, apneic (breathing stopped or had almost no airflow), and pulseless (without a pulse/heart rate) and the EMTs started CPR at 6:37 pm. The report indicated, Resident 1's first monitored heart rhythm (electrical activity of the heart seen on a screen) was asystole (no heartbeat) at 6:42 pm. The report indicated, Resident 1's heart rate was 68 at 6:43 pm, asystole at 6:52 pm and 6:53 pm, 27 at 6:54 pm, 28 at 6:55 pm, and asystole from 6:58 pm to 7:02 pm. The report indicated, Resident 1 remained with no heart rate and no change in heart rhythm while providing CPR. The report indicated Resident 1 was pronounced dead on scene at 7:01 pm. During a review of Resident 1's Licensed Personnel Progress Notes (LPPN), dated [DATE] and timed at 11:15 pm, the LPPN indicated, at 6:20 pm, CNA 1 set up Resident 1's dinner tray on Resident 1's table in front of Resident 1. The LPPN indicated, CNA 1 left Resident 1's room to get a towel from the linen room. At 6:22 pm, CNA 1 returned to Resident 1's room to feed Resident 1 and noted Resident 1 with both hands to his mouth, coughing, and with some ground meat particles on Resident 1's hands. The LPPN indicated, CNA 1 tapped Resident 1's back three times and performed Heimlich Maneuver (HM, a first aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure was applied on the abdomen, between the navel and the rib cage) but Resident 1 continued to cough. The LPPN indicated, CNA 1 immediately yelled for help by calling LVN 1. LVN 1 promptly responded to CNA 1 and entered Resident 1's room. The LPPN indicated, LVN 1 observed Resident 1 to be non-responsive. LVN 1 continued the HM a couple of times, swept out Resident 1's mouth, and was able to remove tiny brown food particles (from Resident 1's mouth). CNA 1 immediately informed RNS 1 on duty who responded promptly, and additional staff arrived who assisted with ongoing HM. During an interview on [DATE] at 2:44 pm with Resident 10 in Resident 10 room, which was across the hall from Resident 1's room, Resident 10 stated at 6:25 pm, three or four nights ago ([DATE]), Resident 10 was standing at the door in Resident 10's room when Resident 10 heard the commotion across the hall in Resident 1's room. Resident 10 stated, Resident 1 had passed away sitting in the chair. Resident 10 stated Resident 1 needed assistance with meals because Resident 1 always shoves all the food in his (Resident 1's) mouth. Resident 10 stated Resident 10 had seen him (Resident 1) drink a coke in one shot, not burping, no rest. Resident 10 stated Resident 1 always needed assistance with feeding. During an interview on [DATE] at 3 pm with CNA 6, CNA 6 stated Resident 1 was on the list for feeding assistance and supervision. CNA 6 stated all staff (in general) in the morning shift were aware not to pass out meal trays to Resident 1 who was on the feeding assistance list until assigned staff was ready to physically assist with feeding Resident 1. CNA 6 stated Resident 1's meal tray needed to stay in the meal cart until staff was ready to physically assist Resident 1 with feeding. CNA 6 stated CNA 6 would pass out towels to use as bibs in residents' rooms before mealtime started. CNA 6 stated it was the rule in the facility. CNA 6 stated when there was no towel in Resident 1's room, CNA 6 would remove the meal tray from Resident 1's room, get a towel, and return to Resident 1 room with the meal tray and towel to begin assisting Resident 1 with eating. During an interview on [DATE] at 3:30 pm with LVN 4, LVN 4 stated LVN 4 was familiar with Resident 1 (LVN 4 used to work with Resident 1). LVN 4 stated LVN 4 gave Resident 1's medication one at a time, and Resident 1 would get upset about it. LVN 4 stated LVN 4 made sure that Resident 1 did not pocket the medication in Resident 1's mouth. LVN 4 stated Resident 1 was at risk for aspiration and had to be assisted with feeding. LVN 4 stated LVN 4 would assist Resident 1 with feeding at times. LVN 4 stated LVN 4 always made sure that there was a towel in Resident 1's room. LVN 4 stated staff (in general) should never leave the meal tray at the bedside for any resident who was on the feeding assistance list until there was a staff to monitor or supervise the residents. During an interview on [DATE] at 4 pm with CNA 1, CNA 1 stated, on [DATE], Resident 1 was assigned to CNA 1 and Resident 1 was on the feeding assistance list. CNA 1 stated Resident 1 was a choking risk because Resident 1 swallowed his food without chewing it. CNA 1 stated on [DATE] (unable to recall the time), CNA 1 left Resident 1's meal tray on the table in front of Resident 1 because CNA 1 did not have a towel and had to get one from the linen closet. CNA 1 stated when CNA 1 returned to Resident 1's room, Resident 1 was coughing and holding both hands with closed fists to Resident 1's mouth. CNA 1 stated CNA 1 called Resident 1's name, gave Resident 1 three back blows, and CNA 1 observed ground meat come out of Resident 1's mouth. CNA 1 stated Resident 1 continued coughing so CNA 1 began the Heimlich Maneuver (HM, a first aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure was applied on the abdomen, between the navel and the rib cage) while Resident 1 was sitting on the wheelchair. CNA 1 stated Resident 1 continued to cough so CNA 1 yelled for LVN 1. CNA 1 stated CNA 1 continued performing HM until LVN 1 arrived. CNA 1 stated when LVN 1 entered Resident 1's room, Resident 1 was bent over on the wheelchair, not moving, and not coughing. CNA 1 stated LVN 1 took over the HM but Resident 1 was no longer coughing or moving. CNA 1 stated LVN 1 told CNA 1 to call for help. CNA 1 stated LVN 3 came in Resident 1's room, and CNA 1 called CNA 2 and CNA 3. CNA 1 stated when CNA 2 and CNA 3 arrived in Resident 1's room, CNA 1 ran to get RNS 1 and returned to Resident 1's room with RNS 1. CNA 1 stated LVN 1, LVN 3, and CNA 3 were in Resident 1's room performing the HM. CNA 1 stated Resident 1 was still slumped forward on the wheelchair not responding and not coughing. During an interview on [DATE] at 5:10 pm with RNS 1, RNS 1 stated CNA 1 notified her that Resident 1 was choking. RNS 1 stated CNA 1 and RNS 1 entered Resident 1's room and observed Resident 1 was unresponsive to verbal stimuli (provide stimulation in the form of verbal communication) and Resident 1's face was blue. RNS 1 stated LVN 1 was behind Resident 1's wheelchair performing the HM on Resident 1, while CNA 2 and CNA 3 were in the room. RNS 1 stated RNS 1 returned to the Nurses' Station to overhead page code blue, call 911 (phone number used to contact emergency services in the event of a medical emergency), and check Resident 1's code status (described the type of emergent procedures a person would like the health care team to conduct when his/her heart stopped beating and/or he/she stopped breathing) in Resident 1's chart (medical record). RNS 1 stated when RNS 1 returned to Resident 1's room, staff (unidentified, unable to remember) was performing CPR on Resident 1, while Resident 1 continued to be unresponsive. RNS 1 stated staff (unidentified) attempted to get vital signs (measuring the basic functions of your body temperature, blood pressure, pulse, and respirations) with no readings. RNS 1 stated the paramedics arrived within five minutes. RNS 1 stated staff (in general) needed to get everything ready for residents on the feeding assistance list before taking the meal tray inside the resident's room. RNS 1 stated staff should never leave the tray unsupervised/unmonitored at the bedside for residents who were at risk for aspiration/choking or needed feeding assistance. During an interview on [DATE] at 10:20 am with the DSD, the DSD stated the facility provided in-service training to all staff regarding following residents' diet and how to care and feed residents with dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), and choking risk. The DSD stated staff must always be present to monitor and supervise residents at risk for choking during mealtimes. The DSD stated meal tray for Resident 1 who required assistance with feeding must stay in the food cart until the assigned CNA (CNA 1) was ready to sit down with the Resident 1 and assist Resident 1 with feeding. During an interview on [DATE] at 11:28 am with the DON, the DON stated Resident 1 required assistance with feeding because Resident 1 had poor coordination. The DON stated CNA 1 must ensure all the needed feeding supplies were in Resident 1's rooms before taking meal trays into Resident 1's room and placing the meal tray at Resident 1's bedside. The DON stated meal trays should not be left unattended with choking risk residents at any time. During a review of the facility's policy and procedure (P&P) titled, Meal Supervision and Assistance, undated, the P&P indicated, the resident was prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents including identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring effectiveness and modifying interventions when necessary. The P&P indicated, the facility developed and implemented an individualized care plan to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during mealtime. The P&P indicated, staff assembled equipment and supplies needed and did not serve the meal until the attendant was ready to assist the resident.

Based on observation, interview, and record review, the facility failed to provide services to maintain Range of Motion [ROM, full movement potential of a joint (where two bones meet)] for one of six sampled residents (Resident 271) with mobility (ability to move) concerns, by failing to: a. Provide Resident 271 with ambulation (the act of walking) with handheld assistance (HHA, helper places their hands on the resident to perform the task) from two persons in accordance with the physician's order, dated 2/27/23. b. Provide Resident 271 ambulation with a front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) in accordance with the physician's order, dated 3/2/23. c. Provide Resident 271 Active Assistive Range of Motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) to both legs (on 5/3/23 to 6/8/23) in accordance with the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge recommendations and physician's order, dated 4/3/23. d. Report Resident 271's decline in ROM on both legs and increased difficulty to perform sit to stand transfers to the rehabilitation staff (in general) in accordance with Resident 271's care plan for the Restorative Nursing Program (RNP, nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility). These deficient practices resulted in Resident 271 to develop left hip moderate joint mobility limitation (50-75 percent [%] available ROM, 25-50% loss of motion), right hip minimal joint mobility limitation (75-100% available ROM, 0-25% loss of motion) and moderate joint mobility limitations on both knees which caused Resident 271 not able to stand upright. Findings: During a review of Resident 271's Face Sheet (admission record), the Face Sheet indicated the facility admitted Resident 271 on 8/31/21 and readmitted Resident 271 on 12/7/22 with diagnoses including left neck of femur (thigh bone), presence of left artificial hip joint, unspecified dementia (decline in mental ability severe enough to interfere with daily life), difficulty in walking, and muscle weakness. During a review of Resident 271's Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 12/8/22, the JMA indicated, Resident 271's ROM in both arms and both legs were Within Functional Limits (WFL, sufficient movement without limitation). During a review of Resident 271's PT Evaluation and Plan of Treatment, dated 12/8/22, the PT Evaluation and Plan of Treatment indicated Resident 271 had a left femoral (relating to thigh bone) neck fracture (break in the bone) and underwent a left hip hemiarthroplasty (surgical procedure that involves replacing part of the hip). The PT Evaluation and Plan of Treatment indicated Resident 271's ROM in both arms and both legs were WFL. The PT Evaluation and Plan of Treatment indicated Resident 271 required maximum assistance (MAX-A, required 51-75% physical assistance to perform tasks) from two persons for bed mobility (moving to either side in bed and moving from lying in bed to the edge of bed), total dependence (required more than 75% physical assistance to perform the task) for transfers, and Resident 271 was unable to ambulate (walk). The PT Evaluation and Plan of Treatment included exercises and gait (manner of walking) training for Resident 271 five times per week for four weeks. During a review of Resident 271's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 12/11/2022, the MDS indicated Resident 271 had clear speech, difficulty communicating some words or finishing thoughts, and had severely impaired cognition (unable to think and process information).The MDS indicated Resident 271 required extensive assistance (resident involved in activity while staff provided support) for bed mobility, transfers between surfaces, and walking. The MDS also indicated Resident 271 did not have any ROM limitations in both arms and both legs. During a review of Resident 271's PT Discharge Summary, dated 2/21/23, the PT Discharge Summary indicated Resident 271 required supervision for bed mobility, required moderate assistance (MOD-A, requires 25-50% physical assistance) for transfers, and ambulation of 30 feet using the FWW. The PT Discharge Summary indicated Resident 271 was referred to the Restorative Nursing Program (RNP, nursing program that uses restorative nursing aides [RNAs] to help residents maintain the residents' function and mobility) for Active Range of Motion (AROM, performance of ROM of a joint without any assistance or effort of another person). During a review of Resident 271's Physician's Orders, dated 2/21/23 (untimed), the physician's order indicated for RNA to provide AROM exercises to Resident 271's both arms and both legs, five times a week as tolerated. During a review of Resident 271's Physician's Orders, dated 2/23/23, timed at 12:00 PM, the physician's order indicated to discontinue RNA for AROM to both arms and both legs for Resident 271. The physician's order indicated for RNA to provide Resident 271 with Active Assistive Range of Motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) to both legs, every day, five times a week as tolerated. During a review of Resident 271's Physician's Orders dated 2/27/23 at 10:30 AM, the physician's order indicated for RNA to ambulate Resident 271 with HHA from two persons, five times per week. During a review of Resident 271's Restorative Nursing Records (RNA Flow Sheet- record of RNA sessions) for 2/2023, the RNA Flow Sheet indicated Resident 271 received RNA for AAROM exercise to both legs on 2/24/23 to 2/28/23. Resident 271's RNA Flow Sheet did not indicate Resident 271 received RNA for ambulation with HHA of two persons from 2/27/23 to 2/28/23. During a review of Resident 271's Physician's Orders, dated 3/2/23 (untimed), the physician's orders indicated to discontinue RNA for Resident 271 and to ambulate Resident 271 with the FWW as tolerated, every day, five times a week. During a review of Resident 271's entire clinical record, the clinical record did not have an RNA Flow Sheet for Resident 271's ambulation with the FWW as tolerated, every day, five times a week for the month of 3/2023. During a review of Resident 271's Physician's Order, dated 3/7/23 (untimed), the physician's order indicated to discharge the RNA program and provide PT evaluation and treatment for Resident 271. During a review of Resident 271's PT Evaluation and Plan of Treatment, dated 3/7/23, the PT Evaluation and Plan of Treatment indicated a referral to PT for Resident 271's new onset decreased strength, decreased mobility, decreased transfers, reduced ability to safely ambulate, and increased need for assistance from others. The PT Evaluation and Plan of Treatment indicated Resident 271's ROM in both arms and both legs were WFL. The PT Evaluation and Plan of Treatment also indicated Resident 271 required minimum assistance (MIN-A, requires less than (<)25% physical assistance to perform the task) for bed mobility and between MOD-A and MAX-A for ambulation of five feet using the FWW. The PT Evaluation and Plan of Treatment included exercises and gait training for Resident 271 three times a week for four weeks. During a review of Resident 271's PT Discharge Summary, dated 4/3/23, PT Discharge Summary indicated, Resident 271 required MIN-A for bed mobility, MOD-A for sit to stand transfers, and between MOD-A and MAX-A for ambulation of 50 feet using the FWW. The PT Discharge Summary included recommendations for transfers and ROM for Resident 271. During a review of Resident 271's Physician's Order, dated 4/3/23 (untimed), the physician's order indicated to discontinue PT for Resident 271 and to provide Resident 271 with RNA services for AAROM of both legs, five times per week, and practice sit to stand using handrail, five times per week. During a review of Resident 271's RNA Program Care Plan, initiated on 4/3/23, the RNA Program Care Plan indicated Resident 271 needed an RNA maintenance program for AAROM of both legs, five times a week, and practice sit to stand using the handrail, five times per week. The RNA Program Care Plan for Resident 271 indicated to notify the rehabilitation staff (unidentified) if Resident 271 showed a decline in function. During a review of Resident 271's RNA Flow Sheet for 5/2023, the RNA Flow Sheet indicated Resident 271 received sit to stand exercises using the handrail from 5/1/23 to 5/31/23. The RNA Flow Sheet indicated Resident 271 received RNA for AAROM exercises to both legs on 5/1/23 and 5/2/23. The RNA Flow Sheet indicated AAROM exercises to Resident 271's both legs were stopped on 5/3/23. During an observation on 6/8/23 at 9:14 AM of Resident 271 in the hallway, Resident 271 was fully dressed wearing socks and shoes while sitting in a wheelchair. Restorative Nursing Aide 4 (RNA 4) placed a gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 271's waist and moved the wheelchair forward toward the hallway railing. RNA 4 was positioned on the left side of Resident 271's wheelchair. Resident 271 used both arms to pull up onto the railing while RNA 4 assisted Resident 271 to transfer from sit to stand. The heel of Resident 271's left foot lifted off the floor and both knees and hips remained in a bent position. Resident 271 did not fully stand upright. RNA 4 assisted Resident 271 back to sit in the wheelchair. Licensed Vocational Nurse 4 (LVN 4) came to assist RNA 4 and stood on Resident 271's right side. LVN 4 and RNA 4 assisted Resident 271 from sitting to standing while Resident 271 pulled up onto the railing. Resident 271 was not able to fully stand upright and continued to have both knees and hips in a bent position. Certified Nursing Assistant 5 (CNA 5) came to the hallway and replaced LVN 4. Resident 271 used both arms to pull up onto the railing while RNA 4 and CNA 5 assisted Resident 271 to transfer from sitting to standing. Both of Resident 271's hips and knees continued to be in a bent position while attempting to stand. Resident 271 was not able to fully stand upright. RNA 4 and CNA 5 assisted Resident 271 back to sitting in Resident 271's wheelchair. During a concurrent observation and interview on 6/8/23 at 9:14 AM with RNA 4 in the hallway, RNA 4 stated Resident 271 had ROM limitations on the left knee. RNA 4 attempted to straighten Resident 271's left knee while Resident 271 was seated in the wheelchair. RNA 4 stated it would be better for Resident 271 to be in bed to stretch both of Resident 271's legs. CNA 5 and RNA 4 brought Resident 271 back to Resident 271's room and transferred Resident 271 from the wheelchair to the bed. While Resident 271 was lying in bed, RNA 4 was unable to straighten both of Resident 271's knees, which continued to be in a bent position. RNA 4 stated Resident 271's knees did not straighten which prevented Resident 271 to fully stand upright. During a concurrent interview and a review of Resident 271's PT evaluation, dated 12/7/22, on 6/8/23 at 3:10 PM with Physical Therapist 2 (PT 2), PT 2 stated Resident 271 received a PT Evaluation on 12/7/22. PT 2 stated Resident 271's ROM in both legs was WFL. PT 2 stated WFL meant Resident 271 had the full ROM necessary to transfer or walk. PT 2 stated Resident 271 was discharged from PT on 2/21/23, requiring MOD-A for transfers and MOD-A for ambulation of 30 feet. PT 2 stated the PT Discharge recommendations for Resident 271 included an RNP program for AROM for both legs. PT 2 stated ambulation was not recommended since Resident 271's movements were unpredictable and unsafe. PT 2 stated Resident 271 had a decline in function, and PT 2 re-evaluated Resident 271 on 3/7/23. PT 2 stated Resident 271's ROM in both legs were WFL, required MOD-A for sit to stand transfers and between MOD-A and MAX-A for walking. PT 2 stated Resident 271 was discharged from PT on 4/3/23, requiring MOD-A for sit to stand transfers and between MOD-A and MAX-A for walking 50 feet. PT 2 stated Resident 271 pulled up to stand, leaned backward while standing, and stood up completely when Resident 271 was discharged from PT. PT 2 stated PT Discharge recommendations for Resident 271 included a RNP program for sit to stand transfers holding on to the handrail and ROM to both legs. PT 2 stated two people would need to be present for sit to stand transfers for safety since Resident 271's movements were unpredictable. During an interview on 6/8/23 at 3:50 PM with the Director of Rehabilitation (DOR), the DOR stated the DOR, Director of Nursing (DON), Director of Staff Development (DSD), and the RNAs met weekly to discuss any changes to report for residents (in general) on RNA program. The DOR stated RNAs need to inform the rehabilitation staff (in general) if there was a change in Resident 271's status. During an interview on 6/9/23 at 8:31 AM with Restorative Nursing Aide 6 (RNA 6), RNA 6 stated, Resident 271's RNA program used to include ROM exercises and standing. RNA 6 stated Resident 271's current RNA program included standing. RNA 6 stated Resident 271 required MAX-A to stand and could not completely stand for the past three weeks (from the time of the interview). During a concurrent observation and interview on 6/9/23 at 9:02 AM with PT 2 in the dining room, Resident 271 was fully dressed while sitting in a wheelchair. PT 2 wheeled Resident 271 back to Resident 271's room and transferred Resident 271 to bed in lying position to perform a brief ROM assessment of both arms and both legs. Resident 271's right knee was in a bent position. PT 2 provided a forceful downward pressure to straighten Resident 271's right knee, causing Resident 271 to scream in pain, [NAME] both eyebrows, and reach toward PT 2 as if trying to stop PT 2 from pushing down. Resident 271's right knee was still in bent position despite PT 2's attempts to straighten Resident 271's right knee. Resident 271's left knee was also in a bent position. PT 2 assessed Resident 271's left leg which included pulling the left leg while holding on to the left ankle. Resident 271's left knee remained in a bent position while PT 2 pulled Resident 271's left leg. PT 2 stated Resident 271 used to fully extend both knees. PT 2 stated Resident 271's knees currently did not fully extend and Resident 271's both hips had stiffness (inability to move easily and without pain). PT 2 stated nursing staff (in general) did not notify the rehabilitation staff (in general) regarding Resident 271's decline in ROM on both legs. During an interview on 6/9/23 at 9:18 AM with Restorative Nursing Aide 5 (RNA 5), RNA 5 stated RNA order for ROM for Resident 271 was stopped and RNA 5 did not know the reason why the order was stopped. During an observation on 6/9/23 at 9:21 AM with PT 2 of Resident 271's RNA treatment session, Resident 271 sat in a wheelchair facing a hallway railing with RNA 5 and RNA 6 positioned on either side of Resident 271's wheelchair. RNA 5 and RNA 6 assisted Resident 271 from sitting in the wheelchair to standing. Resident 271 failed to fully stand upright. During an interview on 6/9/23 at 9:21 AM with PT 2 while observing Resident 271's RNA treatment session, PT 2 stated Resident 271 used to be able to stand more upright. PT 2 stated Resident 271's limited ROM in both hips and both knees limited Resident 271's ability to stand. During a review of Resident 271's JMA, dated 6/9/23, indicated Resident 271 had left hip moderate joint mobility limitation (50-75% available ROM, 25-50% loss of motion), right hip minimal joint mobility limitation (75-100% available ROM, 0-25% loss of motion) and moderate joint mobility limitations on both knees. During an interview on 6/9/23 at 11:59 AM with the Director of Medical Records (DMR), the DMR stated Resident 271's clinical record did not include Resident 271's RNA Flow Sheet for 3/2023. The DMR stated the RNA services were not provided to Resident 271 if the clinical record did not include the RNA Flow Sheet. During a follow-up interview on 6/9/23 at 1:59 PM with the DMR, the DMR stated Resident 271's entire clinical record did not include RNA Flow Sheet for 3/2023. During a concurrent interview and a review of Resident 271's PT evaluations, dated 12/8/22, on 6/9/23 at 2:53 PM with the DON, Resident 271's clinical record was reviewed. The DON stated Resident 271 did not have any limitation with walking until Resident 271 was readmitted to the facility on [DATE] from a General Acute Care Hospital after undergoing left hip surgery. The DON reviewed Resident 271's PT Evaluation, dated 12/8/22, and stated Resident 271 had WFL ROM in both legs. The DON reviewed Resident 271's PT Discharge Summary, dated 2/21/23 and stated the PT Discharge Summary recommended ROM to Resident 271's both legs. The DON reviewed Resident 271's physician's order, dated 2/27/23, which indicated for the RNA to provide ambulation to Resident 271 with HHA of 2 persons. The DON reviewed Resident 271's RNA Flow Sheet for 2/2023 and the DON stated RNA (in general) provided AAROM to Resident 271's both legs. The DON stated Resident 271's physician's order, dated 2/27/23, for ambulation with HHA of 2 persons was not implemented. The DON reviewed Resident 271's physician's order, dated 3/2/23, for ambulation using the FWW. The DON stated there was no documented evidence Resident 271 received RNA for AAROM to both legs and ambulation using the FWW since the RNA Flow Sheet for 3/2023 was not in Resident 271's clinical record. The DON stated the PT Evaluation, dated 3/7/23, indicated Resident 271 had WFL ROM in both legs. The DON reviewed Resident 271's PT Discharge Summary, dated 4/3/23, which included recommendations for transfers and ROM. The DON stated Resident 271 had physician's order, dated 4/3/23, for RNA to provide AAROM to both legs and practice sit to stand using the handrail, five times per week. The DON reviewed Resident 271's RNA Flow Sheet for 5/2023 and stated AAROM to both legs was discontinued on 5/2/23. The DON stated Resident 271 could develop contractures (chronic loss of joint motion associated with deformity and joint stiffness) if ROM was not provided. The DON reviewed Resident 271's physician's orders, nursing notes, and RNA Flow Sheet for 5/2023.The DON was unable to find any documented reason for discontinuing Resident 271's RNA for AAROM to both legs on 5/2/23. The DON reviewed Resident 271's JMA assessments from 12/8/22 (upon re-admission to the facility) and 6/9/23. The DON stated Resident 271 went from WFL ROM to both legs (upon re-admission) to developing moderate joint mobility limitations in the left hip, minimal mobility limitations in the right hip, and moderate joint mobility limitation on both knees. The DON stated Resident 271's ROM limitations to both hips and both knees would make standing difficult for Resident 271. The DON stated the RNAs (in general) should report to the licensed nurses (in general) or to the rehabilitation staff (in general) directly if there was a change in Resident 271's status, including ROM. The DON stated, the RNA staff did not report Resident 271's change in status during weekly RNA meetings. The DON stated Resident 271's ROM limitations in both hips and both knees were preventable. A review of the facility's Policy and Procedure titled, Prevention of Decline in Range of Motion, revised 2023, indicated Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. The policy further indicated residents who exhibit limitations in range of motion will be referred to the therapy department for focused assessment of range of motion. A review of the facility's Policy and Procedure titled, Restorative Nursing Programs, revised 2023, indicated the facility provides maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. A review of the facility's undated job description for Restorative Nursing Assistant indicated RNA skills included the ability to communicate & coordinate with other departments in facilitating and coordinating functions.

Based on interview and record review, the facility failed to provide treatment and care in accordance with the resident's care plan and the facility's policies and procedures for one of two sampled residents (Resident 1) by failing to: 1. Administer Dulcolax (medication used to treat constipation) 10 milligrams (mg, unit of measurement) by mouth every other day (on [DATE] and [DATE]) for bowel (the long tube in the body that helps digest food and carries solid waste out of the body) management as ordered by the physician. 2. Start and administer Dulcolax 5 mg by mouth daily and Docusate 250 mg by mouth daily for bowel management on [DATE] as ordered by the physician. 3. Assess and monitor Resident 1's bowel sounds (sounds made by moving food, fluid, and gases in the intestines) on [DATE], [DATE], and [DATE]. 4. Assess, monitor, and document the size or amount of Resident 1's bowel movements every shift from [DATE] to [DATE]. 5. Transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) in a timely manner (with little or no delay) on [DATE] for a medical evaluation of the resident's abdominal distension and difficulty swallowing. As a result, Resident 1 who had a history of fecal impaction [a hard, dry mass of stool becomes stuck in the colon (large intestine) or rectum (anus)], increased abdominal distension (bloating and swelling of the abdomen) that started on [DATE], decreased oral intake that started on [DATE], and difficulty swallowing that started on [DATE]. Resident 1 did not receive medical evaluation and or treatment until [DATE] (22 hours later) at GACH 1 at 11:08 am. Resident 1's computerized tomography (CT) scan [a test that produces images of areas inside the body) of the abdomen and pelvis (large bone near the base of the spine) result dated [DATE], indicated massive free intraperitoneal (the area that contains the abdominal organs) air with likely perforated viscus [a life-threatening condition that occurs when the wall of the gastrointestinal (relating to the stomach and intestines) tract ruptures] and fecal residue throughout the colon and into the rectum. On [DATE], at 4 pm, Resident 1 became less responsive with declining oxygen saturation (measures the amount of oxygen being carried by red blood cells) and was transferred to GACH 2 for higher level of care. On [DATE], at 10:18 am, Resident 1 expired at GACH 2 due to septic shock (a life-threatening condition caused by widespread infection) from bowel perforation (a hole in the wall of the small intestine or the colon). Findings: A review of Resident 1's Face Sheet indicated the facility initially admitted the resident on [DATE], and readmitted the resident on [DATE], with diagnoses including encounter for orthopedic (branch of medicine concerned with the correction of deformities of bones or muscles) aftercare following surgical amputation (removal of a body part), other acute osteomyelitis (bone infection) of the left ankle and foot, acquired absence of the left great toe, and metabolic encephalopathy (a condition in which brain function is disturbed due to different diseases or toxins in the body). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated Resident 1 was able to make his needs known and had moderately impaired cognition (ability to make decisions). The MDS indicated Resident 1 required extensive assistance with most activities of daily living (ADLs). The MDS indicated Resident 1 was incontinent of bowel and bladder. A review of Resident 1's Admission Notes dated [DATE], indicated the resident was awake, alert, and oriented to name, date and time. The notes indicated the resident's abdomen was soft and distended with active bowel sounds in all four quadrants (regions that divide the abdomen). A review of Resident 1's History and Physical (H & P) dated [DATE], indicated Resident 1 had the capacity to understand and make decisions and was self-responsible. A review of Resident 1's Admission Orders dated [DATE], indicated for the resident to receive Bisacodyl (medication to increase activity of the intestines to cause a bowel movement), 10 mg by mouth every other day for bowel management. A review of Resident 1's untitled Care Plan dated [DATE], indicated the resident had alteration in bowel elimination related to decreased mobility and history of constipation and fecal impaction. The interventions were to administer medications as ordered and observe and report signs and symptoms of constipation such as abdominal cramping, distension or mass, decreased bowel sounds, nausea, vomiting, and hard and dry stool. A review of Resident 1's Licensed Progress Notes dated [DATE], timed at 12:21 pm, indicated Nurse Practitioner 2 (NP 2) was notified of Resident 1's increased abdominal distension and complaint of discomfort (location not specified) rated as 5 out of 10 (0 means no pain and 10 means having the worst pain). The notes indicated NP 2 ordered an abdominal, kidney, ureter, and bladder (KUB) X-ray (a test that produces images of the body structures). A review of Resident 1's Licensed Progress Notes from [DATE] to [DATE], there was no documentation indicated Resident 1's bowel sound were monitored as indicated in the resident's care plan. A review of Resident 1's X-ray of the abdomen results dated [DATE], indicated moderate colonic ileus (a temporary lack of the normal muscle contractions of the intestines) and marked amount of stool in the colon and rectum. A review of NP 1's Telehealth (use of digital information and communication technologies to access health care services remotely) Progress Note dated [DATE], untimed, indicated NP 1 was aware of Resident 1's moderate colonic ileus. The note indicated Resident 1 refused to speak with NP 1 per nurse. The note indicated Resident 1 was currently asymptomatic and denied nausea, vomiting, shortness of breath, or chest pain. The note indicated Resident 1 had chronic pain and Norco (drug used to treat moderate to severe pain) dose was previously decreased. The note indicated the resident's last bowel movement was on [DATE] with loose stool. The note indicated to increase dose of Dulcolax, repeat KUB X-ray in a week, and continue to monitor the resident. A review of Resident 1's Licensed Progress Notes dated [DATE], timed at 7:20 pm, indicated NP 1 was notified of the X-ray results and gave new orders. A review of Resident 1's Physician Orders dated [DATE], untimed, indicated the following orders: 1. KUB X-ray on [DATE] 2. Discontinue previous Dulcolax order. 3. Start Dulcolax 5 mg one tablet by mouth daily for five days for bowel management and hold for loose stool. 4. Start Docusate 250 mg by mouth daily for bowel management. A review of Resident 1's untitled Care Plan, dated [DATE], indicated the resident had bowel management problem and the interventions included to monitor the resident's bowel movement every shift, monitor for abdominal distension, bowel sounds, nausea, vomiting, loose (watery) stools and diarrhea (three or more loose stool per day), administer Dulcolax and Docusate as ordered, and notify the physician as needed. A review of Resident 1's Medication Administration Record (MAR) for [DATE], there was no documentation that Resident 1 received Dulcolax 10 mg by mouth every other day on [DATE] and [DATE] as ordered by the physician. The MAR indicated Resident 1 received the new order of Dulcolax 5 mg by mouth on [DATE] at 9 am, instead of [DATE] as ordered. A review of Resident 1's Licensed Progress Notes dated [DATE], timed at 1 pm, indicated the resident was noted with episodes of poor oral intake. The notes indicated Resident 1 refused his breakfast and lunch meal. The notes indicated the staff offered food substitutions, but the resident stated, I don't want anything. I don't feel like eating. A review of Resident 1's Licensed Progress Notes dated [DATE], timed at 12:30 pm, indicated Resident 1 had difficulty swallowing medication during medication pass, but was able to drink and swallow thin liquids. The notes indicated Resident 1 refused his breakfast and lunch meal and stated he was unable to keep anything down. The notes indicated Resident 1 was noted with mild discomfort (location was not specified). A review of Resident 1's Licensed Progress Notes dated [DATE], timed at 1 pm, indicated NP 1 was notified regarding the resident's change in condition. The notes indicated NP 1 ordered to transfer the resident to GACH 1 for further evaluation secondary to difficulty swallowing and abdominal distension. A review of Resident 1's Licensed Progress Notes dated [DATE], timed at 1:30 pm, indicated Licensed Vocational Nurse 1 (LVN 1) attempted and called multiple transportation companies to arrange transportation with no availability or answer. The notes indicated for the staff to follow-up with transportation. A review of Resident 1's Licensed Progress Notes dated [DATE], timed at 2:25 pm, indicated LVN 1 received a call from GACH 1 intake department staff and informed LVN 1 that GACH 1 was unable to accommodate the resident until [DATE] by 7 am due to no laboratory technician (a professional who is involved in every aspect of laboratory work, from recording data to maintaining equipment) available. The notes indicated per GACH 1 staff, they needed to do laboratory tests on Resident 1 and there were no laboratory services until [DATE]. A review of Resident 1's Licensed Progress Notes dated [DATE], timed at 6:35 pm, indicated LVN 2 arranged transportation with Ambulance 1 for the resident's transfer to GACH 1 on [DATE] between 8 am to 9 am. The notes indicated the resident and the resident's family were informed of the resident's scheduled transfer to GACH 1 on [DATE]. A review of Resident 1's Licensed Progress Notes dated [DATE], timed at 9:25 am, indicated the resident was awake, alert and verbally responsive and was transferred to GACH 1 by Ambulance 1. A review of Resident 1's Physician Note from GACH 1 dated [DATE], timed at 11:08 am, indicated the resident was brought in by ambulance from Skilled Nursing Facility 1 (SNF 1) for abdominal distention for 2 days and difficulty swallowing. The note indicated the resident had an abdominal X-ray done at SNF 1 on [DATE] which showed moderate colonic ileus. A review of Resident 1's CT scan of the abdomen and pelvis result from GACH 1 dated [DATE], timed at 3:11 pm, indicated massive free intraperitoneal air with likely perforated viscus and considerable fecal residue throughout the colon and into the rectum. A review of Resident 1's Physician Note from GACH 1 dated [DATE], at 3:45 pm, indicated the resident's CT scan of the abdomen and pelvis result showed massive colonic dilatation (state of being open or widened) with impacted (hardened and stuck together) stool. The note indicated GACH 1 Physician performed digital fecal disimpaction (the use of fingers to manually remove stool from the rectum). The note indicated, at 4 pm, the resident suddenly appeared less responsive with declining oxygen saturation, elevated heart rate, and no blood pressure registering. The note indicated the resident was placed on oxygen at 15 liters per minute (L/min) via non-rebreather mask (device used to deliver oxygen) with the resident becoming more alert. The note indicated suspect colonic perforation (hole in the large intestine that can cause stool to leak in the abdomen) leading to events of septic shock. The note indicated, at 4:12 pm, paramedics (medical professional who specializes in emergency treatment) arrived and transferred the resident out for higher level of care. A review of Resident 1's Emergency Department (ED) Record from GACH 2 dated [DATE], timed at 4:32 pm, indicated the resident was from SNF 1 and sent to GACH 1 for abdominal distension and difficulty tolerating oral intake. While at GACH 1, the resident was noted to become less responsive and eventually went into respiratory distress. The ER record indicated upon Emergency Medical Services (EMS, a system that provides emergency medical care) arrival, the resident had agonal breathing (abnormal and inadequate pattern of breathing), was bagged (adding air into the lungs by using a hand-held device during an emergency) and transported to GACH 2 ED. The ED record indicated in ED, the resident was hypoxic (having too little oxygen), hypotensive (low blood pressure), intubated (insertion of a tube either through the mouth or nose and into the airway to aid with breathing), and started on pressors (medications that raise the blood pressure and increase cardiac output). A review of Resident 1's Discharge Summary from GACH 2 dated [DATE], indicated the resident presented with four weeks of increasing abdominal girth and one week of increasing abdominal pain. The resident presented from outside hospital for abdominal pain and radiographs demonstrating pneumoperitoneum (the presence of air or gas in the abdominal cavity). The resident decompensated and required intubation and maximal pressor support. Upon arrival to GACH 2 ED, the resident had massive amount of pneumoperitoneum on CT scan with very large rectosigmoid (the lower portion of the sigmoid colon and the upper portion of the rectum) dilation and small bowel thickening. The discharge summary indicated the resident was extremely unstable and had extensive discussion with the resident's family over the phone regarding the resident's poor prognosis and other options. The resident's family wanted to proceed with surgery. The discharge summary indicated upon transport to the operating table, the patient became pulseless. Advanced cardiac life support (ACLS, a group of procedures and techniques that treat immediately life-threatening conditions) was initiated on [DATE] at 10:10 am. The discharge summary indicated the time of death was called on [DATE] at 10:18 am. A review of Resident 1's death certificate, dated [DATE], indicated the immediate cause of death was septic shock and the other significant condition contributing to death was non traumatic (not caused by trauma) bowel perforation. During an interview on [DATE], at 11:50 am., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was alert, oriented, and totally dependent on the staff for ADLs. CNA 1 stated Resident 1 had a big stomach since his admission to the facility and the nurses were aware of it. CNA 1 stated she remembered that on [DATE], she helped Resident 1 eat his breakfast, but the resident only drank apple juice and nutrition shake. CNA 1 stated Resident 1 stated he did not feel good. CNA 1 stated she reported it to the charge nurse. CNA 1 stated the resident already had a physician order to go to the hospital. CNA 1 stated Resident 1 used to eat 80% of his meals but started to refuse and say no to food lately (unable to state how may days). CNA 1 stated she notified LVN 1 about Resident 1's refusal of his breakfast on [DATE] and LVN 1 was aware. During an interview on [DATE], at 12:06 pm, Licensed Vocational Nurse 3 (LVN 3) stated Resident 1 was alert, oriented, and was compliant with his medications. LVN 3 stated Resident 1 used to eat 80% to 100% of his meals. LVN 3 stated she was aware that the resident's abdomen got bigger. LVN 3 stated that on the day of the transfer ([DATE]), the resident refused his breakfast. LVN 3 stated the resident was sent out to the hospital via regular ambulance because of abdominal distension and poor oral intake. During an interview on [DATE], at 12:25 pm, Registered Nurse 2 (RN 2) stated Resident 1 was able to verbalize his needs. RN 2 stated Resident 1 had history of fecal impaction (date unknown). RN 2 stated Resident 1 had KUB done and had an order for a repeat KUB in a week, but the resident was transferred to the hospital. RN 2 stated for a resident (in general) with complaints of constipation, the nurse needed to assess for bloating, check the last bowel movement and quantity and consistency of the bowel movement and continue to monitor the bowel movement and notify the physician as needed. During an interview on [DATE], at 2:11 pm, LVN 1 stated when Resident 1 was readmitted to the facility on [DATE], the resident had some abdominal distension but unsure when it started. LVN 1 stated NP 1 was aware and ordered a KUB X-ray. LVN 1 stated the resident was being monitored for abdominal pain, nausea, vomiting, frequency of bowel movements, and size of the abdomen. LVN 1 was unable to provide documentation that Resident 1's abdomen size was monitored. LVN 1 stated on [DATE], Resident 1 refused breakfast and lunch. Resident 1's family visited and brought something for the resident, but he only ate a little bit of the food. LVN 1 stated the resident did not complaint of anything on [DATE]. LVN 1 stated the day after (on [DATE]), Resident 1 reported some abdominal discomfort and stated he wanted to be sent out to the hospital. LVN 1 stated she notified NP 1 and NP 1 ordered to transfer the resident to GACH 1. During an interview on [DATE], at 2:37 pm, CNA 2 stated the resident was able to verbalize his needs, was incontinent and wore adult incontinent brief. CNA 2 stated on [DATE], the resident's bowel movement was hard and looked like three pieces shaped like pebbles. CNA 2 stated he documented that the resident had a bowel movement but did not document the consistency or amount/size of the stool. CNA 2 stated he did not report it to the charge nurse. CNA 2 stated the resident's abdomen was big and the nurses were aware of it. During an interview on [DATE], at 3:58 pm, LVN 2 stated Resident 1 was a big guy and had a big abdomen. LVN 2 stated a few days after the readmission on [DATE], the resident had abdominal distension. LVN 2 stated NP 1 was notified and ordered a KUB. During an interview on [DATE], at 10:54 am, CNA 3 stated on [DATE], the resident did not want to eat his lunch and spat out the food. CNA 3 stated the resident said that his stomach did not want to take the food and he had a stomach pain. CNA 3 stated the resident only drank his juice. CNA 3 stated she reported it to LVN 1. CNA 3 stated the resident had a bowel movement that day and the resident's stool was soft. CNA 3 stated she documented the number of times the resident had a bowel movement and the consistency of the stool, if the stool was hard, normal, or diarrhea. A concurrent review of Resident 1's Nurse Assistant Notes - A.M. Shift dated [DATE], indicated CNA 3 documented that the resident had a normal bowel movement twice during her shift. CNA 3 stated the documentation did not ask for the amount or the size of the stool. During an interview on [DATE], at 1:40 pm, CNA 4 stated Resident 1 had a big abdomen. CNA 4 stated the resident's stool was soft, dark, and smelled bad. CNA 4 stated she documented how many times the resident pooped on the ADL book. CNA 4 stated she documented if the resident's stool was normal, hard, or diarrhea. CNA 4 stated the ADL documentation did not include the size or amount of the stool. During an interview on [DATE], at 4:35 pm, NP 1 stated when Resident 1 was admitted to the facility on [DATE], NP 1 tried to do a telehealth with the resident, but the resident refused. NP 1 stated she obtained the report from the nurse. NP 1 stated on [DATE], the KUB X-ray results showed moderate ileus. NP 1 stated the resident was asymptomatic and the resident was still having bowel movements. NP 1 stated she tried to speak with the resident (on [DATE]) via telehealth but the resident refused again because the resident was not happy that NP 1 decreased the resident's Norco (pain medication) dose. NP 1 stated on [DATE], she ordered to send Resident 1 to GACH 1 for evaluation of ileus and to rule out small bowel obstruction. NP 1 stated Resident 1 continued to be alert and oriented, able to make demands and verbalize his needs. NP 1 stated the nurse did not report any other changes in the resident's status. NP 1 stated she was completely unaware that Resident 1 did not go to the hospital on [DATE] as she ordered. NP 1 stated the facility staff did not notify her of any issues about transportation and GACH 1 accommodation on [DATE]. NP 1 stated if she knew about GACH 1's inability to accommodate Resident 1, NP 1 would have ordered to send the resident to any available GACH. NP 1 stated at that point, Resident 1 just needed to be seen and evaluated at any hospital. During a follow-up interview and concurrent review of Resident 1's Licensed Progress Notes, dated [DATE], on [DATE], at 9:57 am, LVN 1 stated there was an issue with getting transportation because it was a weekend and GACH 1 could not accommodate the resident on [DATE]. LVN 1 stated she endorsed the transfer to LVN 2 and RN 1 when she left the facility. During a follow-up interview and concurrent review of Resident 1's Licensed Progress Notes, dated [DATE], on [DATE], at 3:15 pm, LVN 2 stated LVN 1 reported to her about the resident's difficulty swallowing and abdominal distension on [DATE]. LVN 2 stated the resident only ate 20% of his dinner and just drank water. LVN 2 stated at 8 pm, the resident complained of abdominal pain and generalized pain, so she gave the resident Norco. LVN 2 stated she arranged transportation with Ambulance 1 to transfer Resident 1 to GACH 1 on [DATE] between 8 am to 9 am. LVN 2 stated she updated NP 1 that the resident would be transferred to GACH 1 in the morning of [DATE]. LVN 2 stated NP 1 stated it was ok for the resident to go to GACH 1 the following day. LVN 2 was unable to find documentation that she notified NP 1 of the delay in the resident's transfer. During a concurrent interview and review of Resident 1's MAR for the month of [DATE], on [DATE], at 3:58 pm, the Director of Nursing (DON) stated there was no documentation on the resident's MAR indicated Resident 1 received Dulcolax 10 mg every other day as ordered on [DATE] and [DATE]. The DON stated on [DATE], the Dulcolax 10 mg order was discontinued and changed to Dulcolax 5 mg daily for 5 days and Docusate 250 mg daily was added. The DON stated Dulcolax 5 mg and Docusate 250 mg was started on [DATE] instead of [DATE] because the order did not specify to give the medications now. The DON stated the resident was noted with abdominal distension on admission. The DON stated for a resident with abdominal distension, staff needed to monitor for bowel movement, bowel sounds, and oral intake every shift. The DON stated she was unable to find documentation that Resident 1's bowel sound were monitored on [DATE], [DATE], and [DATE] as indicated on the resident's care plan. The DON stated if there was any issue with transportation or the receiving facility, the staff needed to update the ordering physician or nurse practitioner to see what he or she wanted to do from there. Staff needed to check with the physician or nurse practitioner if he or she would want to transfer the resident somewhere else and carry out the order. During an interview on [DATE], at 4:35 pm, RN 1 stated on [DATE], LVN 1 reported to her that Resident 1 was not eating and there was an order to transfer the resident to GACH 1. RN 1 stated she assessed the resident, and the resident was alert and verbally responsive. RN 1 stated the resident had abdominal distension but denied pain, had active bowel sounds, passed gas, and had a small, soft, and brown bowel movement during repositioning. During an interview on [DATE], at 2:07 pm, the DON stated the CNAs documented in the ADL sheet if the resident was continent or incontinent of bowel and documented the number of times the resident had a bowel movement. The DON stated the CNAs documented the consistency of the stool, if the stool was hard, normal or diarrhea but did not document the size or the amount of the resident's stool (from [DATE] to [DATE]). During an interview on [DATE], at 2:54 pm, the DON stated the facility did not have a policy and procedure on monitoring of bowel habits or documenting the size or amount of the stool. A review of the facility's policies and procedures titled Resident Assessment, revised in 2011, indicated the purpose of this procedure was to examine and assess the resident for any abnormalities in health status, which provided a basis for the care plan. The steps in the procedures included for the nurse to examine and note the following: Gastrointestinal (1) abdominal distension and hardness; (2) rebound or guarding; (3) bowel sounds in all four quadrants hypoactive, normal, or hyperactive; (4) stool consistency; (5) diarrhea or constipation; (6) hemorrhoids; and (7) fecal impaction. The policy indicated for the nurse to notify the physician of any abnormalities such as, but not limited to: distended, hard abdomen or absence of bowel sounds. A review of the facility's policies and procedures titled Administering Medications, revised in ,d+[DATE], indicated medications shall be administered in a safe and timely manner, and as prescribed. The policy indicated medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). A review of the facility's policies and procedures titled Bowel Management, revised in 2022, indicated as part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. In addition, the nurse shall assess and document/report the following: presence of fecal impaction, abdominal assessment, digital rectal examination, onset, duration, frequency, severity of signs and symptoms, all current medications, all active diagnoses, and recent labs. The policy indicated check for diffuse or localized tenderness and listen for bowel sounds in area of suspected ileus or obstruction. The policy indicated the physician will help identify individuals who may need hospitalization to manage a gastrointestinal disorder; for example, when intestinal infarction (a condition in which there is inadequate blood flow to the small intestine), peritonitis (inflammation of the membrane lining the abdominal wall), or mechanical obstruction was suspected. The policy indicated the staff and physician will monitor the individual's response to interventions and overall progress; for example, overall degree of discomfort or distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc.

Based on interview and record review, the facility failed to ensure proper hydration (process of replacing water in the body. This can be done through drinking water and eating food with high water content. Every cell, tissue, and organ needs water to properly function) for one of two sampled residents (Resident 1), who needed assistance with eating, decreased eating and drinking and at times refused to eat or drink, including: 1. Failure to provide Resident 1 with daily estimated fluid required (1091 - 1274 milliliters (ml), a unit of measurement) as assessed by Registered Dietitian 1 (RD 1) on 11/16/18. 2. Failure to measure the amount of fluids Resident 1 was consuming daily. 3. Failure to promptly notify Resident 1's attending physician (Physician 1) and RD 1 when Resident 1's decreased her oral intake. 4. Failure to implement Resident 1's plan of care for dehydration risk by not monitoring signs and symptoms of dehydration such as decreased urine output, darkened urine, constipation, poor skin turgor, dry mouth, and expression of thirst, encouraging Resident 1 to drink fluids with meals and with medication pass, and referring Resident 1 to Physician 1 and RD 1 for review of hydration needs. 5. Failure to revise Resident 1's plan of care for dehydration risk to develop and implement new interventions to improve fluid intake. 6. Failure to implement the facility's policy on Resident Hydration and Prevention of Dehydration by not having the dietitian (RD 1) re-assess Resident 1 for hydration adequacy when Resident 1's intake diminished and by not documenting amount of fluid intake and the urine output to determine imbalance. As a result, on 12/10/18, Resident 1 experienced altered level of consciousness, increased weakness, and lethargy (a state of tiredness, fatigue, or lack of energy) requiring transfer to General Acute Care Hospital 1 (GACH 1), where Resident 1 was admitted and treated for [REDACTED]. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills), and [MEDICAL CONDITION] (chronic and severe mental disorder that affects how a person thinks, feels, and behaves). A review of Resident1's Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 9/27/18, indicated Resident 1 was usually able to communicate, had severe impairment in cognition (mental process involved in knowing, learning, and understanding things), required limited assistance with eating, extensive assistance with bed mobility, dressing, personal hygiene and bathing, and total assistance with transfers and toilet use. Resident 1 was on a mechanically altered diet and had no symptoms of poor appetite, fever, vomiting, dehydration and/or swallowing problem. Resident 1 was 63 inches tall and weighed 79 pounds (lbs.) with no weight loss or weight gain of 5% or more in the last month. A review of Resident 1's laboratory results dated [DATE], indicated the sodium level was 140 milliequivalent per liter (mEq/L, a unit of measurement and normal range 136 to 145); the potassium level was 4.9 mEq/L (normal range 3.5 to 5.1), the chloride level was 106 mEq/L (normal range 98 to 107), the blood urea nitrogen (a waste product of the digestion of protein) was 54 milligram per deciliter (mg/dL, a unit of measurement, normal range 7 to 18), and the creatinine (a test that measures kidney function) was 1.2 mg/dL (normal range 0.6 to 1.3). Sodium, potassium and chlorine are electrolytes from food and fluids. A review of Resident 1's Care Plan for Dehydration dated 11/12/18, indicated Resident 1 was at risk for dehydration related to poor or fluctuating oral food/fluid intake secondary to diagnoses. The goal was for Resident 1 to have minimal signs and symptoms of dehydration and to receive and consume fluids daily. The approaches included observing Resident 1's fluid intake with meals, observing signs of poor fluid intake, encouraging Resident 1 to drink fluids with meals and with medication pass, referring Resident 1 to the physician and the RD 1 for review of hydration needs, providing Resident 1 with fluids between meals, and observe for signs of dehydration such as decreased urine output, darkened urine, constipation, poor skin turgor, dry mouth, and expression of thirst. A review of the Nutrition Screening and Assessment by RD 1 dated 11/16/18, indicated Resident 1 weighed 80 lbs. and had a body mass index (BMI - a screening tool that can indicate whether a person is underweight, have a healthy weight, excess weight, or obesity) of 14.1 (BMI below 18.5 is underweight). Resident 1's estimated fluid requirement ranged from 1091 milliliters (ml) to 1274 ml per day. Resident 1's drank an average of 60% of the needed fluids. The nutritional goal included promoting adequate hydration. A review of the physician's orders [REDACTED]. Physician 1 also ordered fortified mechanical soft, ground texture, no added salt diet, and thin liquids with all meals. A review of the Nursing Assistant Notes - A.M. (7 a.m. to 3 p.m.) Shift for 11/2018, indicated Resident 1 consumed 50 to 100% of breakfast and lunch from 11/13 through 11/30/18. The Nurse Assistant Notes - P.M. (3 p.m. to 11 p.m.) Shift, indicated Resident 1 consumed 60 to 100% of the dinner from 11/13 through 11/21/18, on 11/27/18 and on 11/29/18. Resident 1 refused dinner from 11/22/18 through 11/25/18 and on 11/30/18. Resident 1 consumed 25% of the dinner on 11/26/18 and 11/28/18. A review of the Nurse Assistant Notes - A.M. and P.M. Shift for 12/2018, indicated Resident 1 refused breakfast on 12/1/18, lunch on 12/2/18 and 12/5/18, and dinner from 12/1 through 12/5/18, on 12/8/18, and on 12/9/18. Resident 1 consumed 20 to 30% of breakfast and lunch from 12/7/18 through 12/10/18. A review of the Licensed Personnel Progress Notes had no documentation Resident 1's fluid intake was closely monitored and Resident 1 was monitored for signs and symptoms of dehydration when Resident 1's intake decreased starting on 12/1/18. A review of the Licensed Personnel Progress Notes dated 12/9/18 timed at 2:20 p.m., indicated Resident 1 was noted with poor appetite during lunch. Resident 1 was encouraged to consume food three times but refused and encouraged to drink fluids. Resident 1 drank juice and milk (the amount was not specified). At 9:15 p.m., the note indicated Resident 1 refused dinner and was monitored for poor appetite. A review of the Licensed Personnel Progress Notes dated 12/10/18 timed at 5 a.m. and 10 a.m., indicated Resident 1 was on monitoring for poor appetite. Resident 1 was encouraged to eat snacks. There was no documentation Resident 1 was offered and drank enough fluids. There was no documentation Physician 1 and RD 1 were notified of Resident 1's poor eating and drinking and refusal to eat and drink. A review of the Licensed Personnel Progress Notes dated 12/10/18 timed at 2:50 p.m., indicated Resident 1 was in bed noticeably weak and lethargic. Resident 1's oxygen saturation (a measurement of oxygen level in the body's red blood cells) was 85% on room air (with no supplemental oxygen), the blood pressure was 93/63 millimeters of mercury (mmHg - normal range 90/60 -120/80), and the respiratory rate was 22 breaths per minute (normal range 12 to 20). The licensed nurse notified Physician 1, who ordered to transfer Resident 1 to GACH 1 via 911 (emergency transport) due to altered level of consciousness and lethargy. A review of the Licensed Personnel Progress Notes dated 12/10/18 timed at 3:15 p.m., indicated emergency transport arrived and took over Resident 1's care. Resident 1 was on 5 liters per minute (L/min, a unit of measurement) of oxygen via a non-rebreather mask (a method for delivering high concentrations of oxygen. It consists of a facemask with an attached oxygen reservoir bag and a one-way valve, which prevents the victim's exhaled air from mixing with the oxygen in the reservoir bag) with oxygen saturation of 100%. Resident 1 was arousable and responsive and left the facility via gurney. A review of GACH 1 Emergency Department (ED) History & Physical exam dated 12/10/18 timed at 3:51 p.m., indicated Resident 1 presented with altered mental status, [MEDICAL CONDITION] (condition of the body in which the tissues are starved of oxygen), and [MEDICAL CONDITION] (low blood pressure). Resident 1 was nonverbal with cold and cyanotic (marked by bluish or purplish discoloration due to deficient oxygenation of the blood) extremities. The primary clinical impression indicated severe dehydration. A review of the laboratory results dated [DATE] timed at 4:30 p.m., indicated the sodium was 175 mEq/L (high), the potassium was 6.7 mEq/L (high), the chloride of 147 mEq/L (high), the blood urea nitrogen (BUN) was 153 mg/dL (high), and the creatinine of 3.26 mg/dL (high). A review of GACH 1 Discharge Summary dated 1/4/19, indicated Resident 1 was admitted for dehydration and [MEDICAL CONDITION]. Resident 1 was given aggressive hydration and dietary requirements were completed by constant and round-the clock help in feeding. During an interview on 12/20/18, at 2:48 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 used to eat most of her food and drink a lot of milk, but had episodes of refusing her meals. CNA 1 stated Resident 1 stopped eating and refused to drink anything a week before she was transferred to the hospital. CNA 1 stated she tried to feed Resident 1 and give water via spoon, but Resident 1 would close up her mouth, spit out the food, and the water would drip out of her mouth. CNA 1 stated she reported the issue to Licensed Vocational Nurse 1 (LVN 1). CNA 1 stated she offered Ensure (nutrition drink supplement), but Resident 1 would not take it. During an interview on 12/20/18 at 3:23 p.m., LVN 1 stated Resident 1 used to eat most of her meals and loved to drink milk. LVN 1 stated Resident 1 refused to eat or drink anything two to three days before she was hospitalized . LVN 1 stated she offered Ensure with a straw, but Resident 1 refused to take it. LVN 1 stated she tried notifying the physician (unable to specify date), but did not receive a call back and endorsed it to LVN 2. During an interview on 1/25/19 at 1:44 p.m., RD 1 stated she saw Resident 1 on 11/16/18 for the initial assessment. RD 1 stated she did not receive any report from the facility staff regarding a decrease in Resident 1's oral intake or refusal to eat or drink. RD 1 stated notifying her would have been beneficial for Resident 1 because she would have reevaluated the resident's diet and recommended weekly weights, laboratory tests, and nutrition drink supplements. During an interview on 1/25/19 at 2:42 p.m., LVN 2 stated Resident 1 used to eat 80 to 90% of her meals, but refused to eat or drink the week of the transfer. LVN 2 stated she monitored Resident 1 for signs and symptoms of dehydration and encouraged snacks and fluids. LVN 2 stated she told CNA 1 to give Ensure, but Resident 1 refused it. LVN 2 stated she called and left a message for the attending physician, but could not remember if the physician called back. During an interview on 1/25/19 at 3:02 p.m., the Director of Nursing (DON) stated when a resident had poor oral intake, the licensed nurse should closely monitor the resident's meal and fluid intake and output, notify the physician, the registered dietitian and the responsible party, and offer alternative interventions to address the poor oral intake. The DON reviewed the clinical record and was unable to find documented evidence Resident 1's fluid intake and hydration status was monitored or that Physician 1 and RD 1 were promptly notified of Resident 1's poor fluid intake. The DON stated the plan of care was not revised and there were no alternative interventions provided to Resident 1 to ensure proper hydration. A review of the facility's undated policy and procedures titled, Resident Hydration and Prevention of Dehydration, indicated the facility will endeavor to provide adequate hydration and to prevent and treat dehydration. The dietitian will assess all residents for hydration adequacy at least quarterly and more often as necessary per resident's need. Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standards of practice. Nursing will assess for signs and symptoms of dehydration during daily care. Nurses' Aides will provide and encourage intake of bedside snack and meal fluids on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. Physician will be informed. The dietitian, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration. Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. Interdisciplinary Team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved.

Based on interview and record review, the facility failed to provide its residents care and services in accordance with professional standards of practice and the comprehensive care plan to manage pain for one of three sampled resident (Resident 1) by failing to: 1. Failure to address Resident 1's complaint of leg pain identified and documented on 2/9/17 by the psychiatric (medical professional trained in mental illness) Physician's Assistant 1 (PA 1) to ensure prompt medical evaluation and interventions. 2. Failure to accurately assess Resident 1's left leg pain from 2/9/17 to 2/11/17. 3. Failure to implement the Care Plan for pain by not monitoring and assessing Resident1's complaints of pain, not evaluating causes of the pain and effectiveness of interventions, and by not notifying the physician of Resident 1's left leg pain. 4. Failure to implement the facility's policy and procedures on Pain Assessment and Management by not alleviating Resident 1's pain, not assessing and effectively recognizing the presence of pain, not identifying the characteristics and underlying causes of pain and not monitoring for the effectiveness of interventions. As a result, Resident 1 suffered unnecessary severe pain to the left hip/leg from 2/9/17 to 2/11/17, when Resident 1 was transferred to a General Acute Care Hospital (GACH) and was diagnosed with [REDACTED]. Findings: A review of Resident 1's admission Face Sheet indicated, Resident 1 was admitted to the facility, on 9/23/13, and readmitted on [DATE] with [DIAGNOSES REDACTED]. to think, feel, and behave clearly). A review of the Minimum Data Set (MDS - standardized assessment and care planning tool), dated 12/4/16, indicated Resident 1's cognitive skills (memory and thinking skills) were severely impaired, required extensive assistance with one-person physical assist for bed mobility and dressing, and was totally dependent with two-person physical assist with transferring in and out of bed or wheelchair. The MDS indicated Resident 1 did not have any pain. A review of the Care Plan, dated 9/11/16, developed for Resident 1's alteration in comfort manifested by complaints of pain related to diagnoses, included in the interventions observing verbal or non-verbal complaints of pain; assessing cause, site, location, frequency, and duration of pain; determining what alleviated pain and address as needed; determining what made the pain worse; administering pain medications as ordered, monitoring for side effects; and notifying the physician as needed. A review of Resident 1's physician's order, dated 9/1/15 indicated the resident had a routine order for [MEDICATION NAME] ([MEDICATION NAME] - a narcotic-like pain reliever used for moderate to severe pain), 50 milligrams (mg), by mouth twice a day for pain management. The physician's order did not indicated the type and location of Resident 1's pain. A review of Resident 1's physician's order, dated 9/1/15, indicated the resident had a PRN (as needed) order for Tylenol, 325mg, two tablets, by mouth, very four hours, as needed for pain (not to exceed 3 gram in 24 hours). A review of Resident 1's Pain Monitoring Record, dated from 2/1/17 to 2/12/17, indicated the nursing staff assessed Resident 1's pain level at 0 (based on the pain rating scale level from zero to 10: zero indicating no pain, and 10 the worst pain possible). A review of the Psychiatric Progress Note by PA 1 dated 2/9/17, indicated Resident 1 seemed quite sad and almost tearful, stated was very depressed because her (did the PA document if right or left) leg hurt and wanting to go to the hospital. PA 1 documented Resident 1 had a, Positive sad affect. A review of the Pain Monitoring Record documented by the licensed nurses indicated Resident 1 had no pain from 2/9/17 to 2/11/17 during all shifts (7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m.). The pain monitoring documented on 2/9/17 contradicted PA 1's documentation on the same day. A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of Resident 1's Licensed Personnel Progress Notes, from 2/9/17, timed at 5 p.m. to 2/11/17 timed at 7:15 a.m., indicated Resident 1 had no pain. The licensed personnel did not address the pain documented by PA 1. There was no documented evidence the licensed nurses evaluated Resident 1's leg pain, and her ability to move the lower extremities. A review of Resident 1's the Licensed Personnel Progress Notes, date 2/11/17, timed at 9:15 a.m., indicated Resident 1 had left hip swelling with pain level 10/10. A review of Resident 1's physician's order, dated 2/11/17, timed at 9:30 a.m., indicated to transfer the resident to GACH 1 for evaluation of left hip pain/swelling. A review of Resident 1's Licensed Personnel Progress Notes, dated 2/11/17 indicated, timed at 2 p.m., indicated Resident 1 was transferred to a GACH. A review of Resident 1's Resident Transfer Record form dated 2/11/17 indicated Resident 1 was transferred to GACH 1 for evaluation related to left hip swelling, severe pain, and left hip deformity. A review of Resident 1's History and Physical from GACH 1, dated 2/11/17, indicated the x-rays (diagnostic examination of bone structures) showed acute spiral [MEDICAL CONDITION] proximal femoral (thigh bone) shaft and [MEDICAL CONDITION] superior lateral acetabulum (left [MEDICAL CONDITION]). On 10/11/17 at 11:08 a.m., during an interview with Licensed Vocational Nurse (LVN 1) and a concurrent review of Resident 1's record, LVN 1 stated a Certified Nursing Assistant (CNA 1) reported to him that Something Abnormal. LVN 1 stated he checked Resident 1's left leg and the left leg looked, Abnormal, not straight. LVN 1 stated Resident 1 would yell if her leg was touched. LVN 1stated Resident 1 looked different and he told CNA 1 not to touch the Resident. LVN 1 stated he called the Registered Nurse Supervisor (RN 1) and RN 1 notified the resident's physician. LVN 1 stated Resident 1's physician gave an order for [REDACTED]. On 10/12/17 at 12:57 p.m., during an interview with the Director of Nursing (DON) with concurrent record review of PA 1's Progress Note dated 2/9/17, the DON stated the licensed nurse on duty reviews the physician's progress and checks new orders. The DON stated the licensed nurses were to assess pain level when a resident had pain, give pain medication for complaints of pain, and notify the physician to control the pain. The DON stated Resident 1's pain status should have been monitored and the physician should have been notified of the lack of pain control. On 11/9/17 at 9:15 a.m., during an interview, LVN 2 stated she did not review the PA's notes after the PA's visits. LVN 2 stated the PA did not mention about Resident 1's pain to her so she did not aware of it. LVN 2 stated Resident 1, Always complains of pain, cries, and uses bad words. Resident 1's pain was assessed on 2/9/17 and Resident 1 stated, Pain is everywhere, and Don't touch me. A review of the facility's policy and procedure titled, Pain-Clinical Protocol, with a revision date of 4/2007, indicated staff would identify individuals who have pain or who are at risk for having pain. Pain assessments should occur on admission to the facility, at each quarterly review, whenever there is a significant change in condition, and at any time pain is suspected. A review of the facility's policy and procedure titled, Pain Assessment and Management, with a revision date of 10/2010, indicated that pain management as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain. g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. Further record review of the licensed nursing notes and interdisciplinary notes indicated no documentation Resident 1's pain to the left leg, mobility of the hip joint, cause of pain, location, frequency, duration of pain, and what alleviated or worsened the pain.

Based on observation, interview and record review the facility failed to adequately monitor residents with special needs to prevent serious medical conditions by failing to: 1.Ensure supervision to five of 30 sampled residents (Resident 6, 8, 11, 21 and 22), 50 of 55 Randomly Selected Residents (RSR 32-36 and 38-82). Of the 55, 31 residents (RSR 35, 36, 38, 41- 50, 52-61, 70, 74 and 78-81) were from the the secured (locked) unit during an all-day outing to the park two miles away from the facility. As a result, one resident (RSR 69) was kicking the wheelchair of another resident (RSR 62), chasing and arguing with staff, stating he will the emergency response system (911); Resident 34 was smoking without a smoking apron over dry grass under a tarp (waterproof cloth or plastic used as a cover) and two residents were wandering (walk or move away) from the park without staff awareness. 2. Ensure five of 30 sampled residents (Residents 6, 8, 11, 22) and 50 Randomly Selected Residents (RSR 32, 34-36, 38-43, 46-60, 62, 65, 66, 70, 71, 76-78 and 80) were offered sunscreen or sunblock which resulted in skin redness, pain and discomfort. The outside air temperature was hot (90 degrees Fahrenheit. An Immediate Jeopardy was called on July 7, 2016, at 4:20 p.m., with the administrator and director of nursing (DON) for failure to monitor and supervise residents with special needs to prevent and intervene for serious medical conditions and injuries. A Plan of Correction (POC) was submitted on July 8, 2016, at 6:08 p.m., as follows: 1. On July 7, 2016, all residents returned to the facility from outing safely. Residents went to the park outing on July 7, 2016, from 8 am-10 am until 3pm - 5pm. Upon return, residents were assessed by the charge nurses for any sign of adverse reactions related to his/her off site event participation. Resident 6, 8, 11, 22, 32, 34-36, 38-43, 46-60, 62, 65, 66, 70, 71, 76-78 and 80- Body assessment was done, redness was observed on body, aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged. Resident 21 - Body assessment done, redness on face and bilateral forearms, aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged, CMP panel was done due to complaints of nausea, vomiting and diarrhea, on 7/8/16. Resident 33 - Body assessment done, redness on cheek, aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged. Resident complained of diarrhea while on outing on July 7, 2016, and was placed on 72-hour monitoring and no further episodes since returning from outing. CMP panel was done due to complaints of diarrhea, on 7/8/16. Resident 64 - Body assessment done, redness on face and bilateral forearms, aloe vera applied, no complaint of pain/ discomfort, fluids encouraged, CMP panel was done routinely monthly on 7/8/16. Resident 44, 45, 61, 63, 67-69, 72-75, 79, 80 and 81 - Body assessment done, no unusual observations noted, no complaint of pain/discomfort, fluids encouraged. 2. Nursing department and the activity staff will jointly review/assess any residents scheduled for an outing by the activity department and determine who should participate. In-service was given to staff on July 7, 2016, regarding: Offsite Activity Policy & Procedure. 3. The nursing department and the activity staff will jointly assess and determine those residents that should participate in facility outings. 4. The residents will have to consent to attend the outing. 5. The nursing department will ensure that the residents ' medical, physical, mental and psychosocial needs are not compromised while off site. To ensure there is sufficient staff accompanying the resident, the nursing department will assign a minimum ratio of 1 licensed nurse for every 15 residents and 1 CNA for every 5-6 residents. 6. The residents will be monitored for any significant change in their condition, during the outing. Please see enclosed Policy & Procedures. During the outing, staff will bring a facility outing supply kit, that will include items such first aid kit, aloe vera, sunscreen, blood pressure cup, alcohol pads, thermometers, etc. Facility will include any medication, medication administration record and dietary orders, along with resident outing log (roster). Licensed staff will be in-serviced on dispensing medications to residents when residents are off site. Scheduled and essential PRN medications will only be given the amounts and dosages needed for the length of the anticipated absence. Medication will be prepared by licensed nurse whom will place in individual pouches with specific times and signed. During the outing, licensed nurse will administer medication and verify with the copies of medication administration record. 7. The facility will keep an open line of communication between the accompanying licensed staff and the nursing supervisor in the facility (on site). 6. Upon return to the facility, the residents will be assessed by the charge nurse for any sign of adverse reaction(s) related to his/her offsite event participation. 7. Any significant findings will be attended to and reported immediately to the attending physician and his/her responsible party. 8. Weather will be monitored during outings. For hot weather, the following measures to keep residents and clients comfortable can be used: keep residents well hydrated with particular attention to dependent residents, minimize physical activities during the hottest parts of the day, avoid hot foods and heavy meals, encourage frozen treats such as popsicles between meals. Residents will be encouraged to hydrate to prevent dehydration. Facility will provide hydration by supplying appropriate amount of fluids, which include bottled water. In-service will be given on hot weather advisory and resident hydration. 9. To prevent possible elopement, routine resident checks shall be made at least every 2 hours or as needed to ensure the safety and well-being of the resident. Head counts will be conducted at the minimum, beginning of the outing and at the end of the outing. 10. Appropriate attire will be provided to residents on an outing. If a resident insists on wearing other clothing, it will be care planned and IDT regarding the risks and benefits of not wearing appropriate clothing/attire. Extra clothes will be provided by Social Services department to ensure if a resident needed a change of clothing while on outing it would be available. Extra clothes will be part of the facility outing supply kit. 11. A continuous quality improvement program was implemented, under the supervision of the director of nursing, to ensure that residents are appropriate for outings. The activity and nursing department will perform the following systemic changes: prior to residents participating they will be assessed to ensure the residents medical, physical, mental and psychosocial needs are not compromised while off site, residents will be monitored for any significant change, open lines of communication will be maintained between licensed staff and the nursing supervisor in the facility, monthly report of any findings will be given to the administrator. Any deficiencies will be corrected immediately, and the findings will be documented and submitted at the quarterly continuous quality improvement committee meeting for further review or corrective action. On July 8, 2016 at 6:08 p.m. (afterhours), the facility submitted an acceptable plan of correction. On July 11, 2016, at 8:03 a.m., the Administrator and DON were verbally informed the IJ was abated. Findings: During an observation on July 7, 2016 at 8:05 a.m., the facility staffs were gathering residents for an outing. Thirteen residents were observed sitting in a large van getting ready for an outing at the park. In a concurrent interview, Activity 1 was asked for the names of the residents in the van but was unable to name them. During an interview on July 7, 2016 at 10:00 a.m., Activity 1 stated the park outing was a change from the activity schedule due to concerns (residents complained there were not enough outings) brought up at a group meeting on July 6, 2016. Activity 1 stated she met with the LVN supervisor to arrange medications, the dietary supervisor to arrange meals, the director of nursing, and the administrator on July 6, 2016 at 4 p.m., to coordinate the park outing for July 7, 2016. (a). During an observation on July 7, 2016, at 3:15 p.m., there were a total of 55 residents with 9 facility staff at an outing in a community park two miles away from the facility. At the time of arrival, a Randomly Selected Resident (RSR) 69 was kicking RSR 62's wheelchair. Staff 1 prompted RSR 69 not to kick the wheelchair. RSR 69 began chasing Staff 1 around the park with his wheelchair and stated he was going to call the law enforcement. A review of the Face Sheet for RSR 69 indicated the resident was recently readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 69's Medication Administration Record (MAR), dated July 2016, indicated a physician's order [REDACTED]. During an interview with licensed vocational nurse (LVN 14), on July 7, 2016, at 3:20 p.m., he stated he was one of the two charge nurses who accompanied the residents. LVN 14 was asked how he would account for these 55 residents and stated he was taking a head count of each residents. LVN 14 showed a hand written roster of residents who attended the outing. A review of the roster did not contain the timing of the head counts or the frequency and staffing ratio to residents, to ensure the residents were monitored or supervised of their whereabouts and safety. A review of the of the roster for the residents who attended the park outing, revealed there were 31 residents (11, 22, RSRs 35, 36, 38, 41-50,RSRs 52-61, RSR 70, RSR 74, and RSRs 78-81) from the secured unit who required close supervision due to wandering behavior and psychotic disorders (dysregulation of thought processes). Review of the residents' medical records revealed the following: A review of the Face Sheets and Medication Administration Record (MAR) for 31 residents indicated all 31 residents had mental health [DIAGNOSES REDACTED]. Thirteen of 31 residents [DIAGNOSES REDACTED]. 1. Resident 11 was recently readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 11's Medication Administration Record (MAR), dated July 2016, indicated a physician's order [REDACTED]. 2. Resident 22 was recently readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 22's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 3. RSR 35 was recently readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 35's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 4. RSR 36 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 36's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 5. RSR 38 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 38's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 6. RSR 41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 41's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 7. RSR 42 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 42's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 8. RSR 43 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 43's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 9. RSR 44 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 44's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 10. RSR 45 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 45's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 11. RSR 46 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 46's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 12 SR 47 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 47's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. 13. RSR 48 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RSR 48's Medication Administration Record (MAR), dated July 2016, indicated a physician order [REDACTED]. On July 7, 2016 at 3:15 p.m., 55 Randomly Selected Residents (RSR) were observed sitting in their wheelchairs or walking around the park. There were three tarps providing shade to residents and staff - one next to a walkway to the parking lot and two directly side-by-side close to the walkway toward the restroom. RSR 69 was observed sitting in his wheelchair, propelling himself along the walkway close to the parking lot. RSR 62 was sitting in his wheelchair, blocking the pathway. RSR 69 yelled at RSR 62 to move. When RSR 62 did not move his wheelchair out of the pathway, RSR 69 kicked the left wheel of RSR 62's wheelchair multiple times. Staff 1 verbally asked RSR 69 to stop kicking RSR 62's wheelchair. RSR 69 then proceeded to chase and yell at Staff 1, stating he will call law enforcement. During a concurrent observation on July 7, 2016 at 3:20 p.m., RSR 34 was sitting in his wheelchair under the side-by-side tarps, which were shading multiple residents and staff. RSR 34 was also observed smoking a cigarette over a dry grass area. According to the National Fire Protection Association's study entitled Brush, Grass, and Forest Fires published in November 2013, smoking materials were the heat source in almost half (47%) of the brush or brush and grass mixture fires during the years of 2007-2011. During an interview on July 7, 2016 at 4:28 p.m., the administrator stated the facility staffs, including the director of nursing (DON), the administrator, and activity staff, had put together the outing the day before. According to the administrator all residents were offered the opportunity to attend outings. During an interview with Resident 22 on July 7, 2016 at 5:25 p.m. regarding the activities at the park, he stated he slept most of the time and ate popsicles at the park. During an interview with RSR 69 on July 7, 2016 at 5:40 p.m., he stated he watched other people and residents in the park. In an interview with Resident 8 on July 7, 2016 at 5:56 p.m., he stated, I didn't do much. I walked around a lot .I was smoking in the park. During an interview with the Medical Director, on July 8, 2016, at 2:36 p.m., he stated residents must have an order prior to attending an outing because the residents needed to be assessed, the time of the event, functional status of the residents, especially for Dementia (disconnection of reality) due to risk of getting lost, and their medications. During an interview with the DON, on July 13, 2016, at 1:30 p.m., she stated of the 55 residents who attended the park outing; only seven (7) had orders from their physicians to attend the outing. There were 48 residents who attended the activity without physician ' s approval. Review of Off-Premise Activities revised August 2006, indicated off-premise activities are monitored for safety. Residents are considered appropriate for off-premise activities based on physician ' s approval and resident ' s request to participate in the outing. An appropriately qualified and authorized individual will accompany the activity director/coordinator on field trips to help oversee the residents and tend to any medical or behavioral problems that might arise. (b) Residents went to the park outing on July 7, 2016, from 8 am-10 am until 3pm - 5pm. At 5:30 p.m., the 55 were assessed by the charge nurses for signs and symptoms of adverse (harmful) reactions related to the off-site event participation. A total of 41 residents (Resident 6, 8, 11, 22 and RSR 32, 34-36, 38-43, 46-60, 62, 65, 66, 70, 71, 76-78 and 80) had acquired skin redness or sunburn, pain, and discomfort to these areas. 1. An admission face sheet indicated Randomly Selected Resident (RSR 56) was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. RSR 56 did not have a physician's orders [REDACTED]. During an observation on July 7, 2016 at 4:40 p.m. following the outing RSR 56 was observed in the dining room of the center building. The residents face and scalp were a bright red color. During an interview on July 7, 2016 at 4:40 p.m., RSR 56 stated he had attended the outing. RSR 56 stated it was Too Hot. The resident stated his nose and scalp were hurting. When asked if he had been offered sunblock he said no. The resident was also asked how he spent the day . His response was I smoked cigarettes. When asked if he had enough water to drink on the outing he stated he mostly drank soda. 2. An admission face sheet indicated RSR 38 was admitted to the facility on [DATE] and readmitted [DATE]. The resident's [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Trazadone (antidepressant) 100 mg by mouth every day at hour of sleep for depression manifested by trying to hurt herself. Haldol (antipsychotic medication) 10 mg twice a day for schizophrenia manifested by verbally abusive behavior. RSR 38 did not have a physician's orders [REDACTED]. During an observation on July 7, 2016 at 4:50 p.m., RSR 38 was observed in the dining room of the center building. The resident's cheeks were bright red. An attempt to interview was made however the resident did not respond. 3. An admission face sheet indicated RSR 77 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. RSR 77 did not have a physician's orders [REDACTED]. On July 7, 2016 at 5 pm, RSR 77 was observed sitting in a wheelchair in his room. The resident was wearing pants and a long sleeve shirt. During an interview at the same time RSR 77 was asked if he had enjoyed the outing at the park. The resident stated, It was a little too hot. When asked if he had been wearing the same clothes he stated Ya. Residents 6, 8, 11, 22, 32, 34-36, 39-43, 46-55, 55-60, 62, 65, 66, 70, 71, 76-78 and 80- Body assessments were done, redness was observed on body, Aloe Vera applied, fluids encouraged. Resident 21 - Body assessment done, redness on face and bilateral forearms, aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged, CMP panel was done due to complaints of nausea, vomiting and diarrhea, on 7/8/16 Resident 33 - Body assessment done, redness on cheek, aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged. Resident complained of diarrhea while on outing on July 7, 2016, and was placed on 72-hour monitoring and no further episodes since returning from outing. CMP panel was done due to complaints of diarrhea, on 7/8/16. Resident 64 - Body assessment done, redness on face and bilateral forearms, aloe vera applied, no complaint of pain/ discomfort, fluids encouraged, CMP panel was done routinely monthly on 7/8/16. Resident 44, 45, 61, 63, 67-69, 72-75, 79, 80 and 81 - Body assessment done, no unusual observations noted, no complaint of pain/discomfort, fluids encouraged. According to the All Facilities Letter from the California Department Of Public Health (<http://www.cdph.ca.gov/certlic/facilities/Documents/LNC-AFL-16-06.pdf>), dated June 7, 2016, indicated facilities to implement recommended precautionary measures to keep individuals safe and comfortable during extremely hot weather because elderly and other health-compromised individuals are more susceptible to extremes in temperature and possible dehydration. The L&C Program recommends facilities review Fast Facts: Preventing Summer Heat Injuries and implement the following measures to keep residents and clients comfortable during extremely hot weather: Dress in lightweight, loose-fitting clothing ·Keep residents well hydrated with particular attention to dependent residents ·Minimize physical activities during the hottest parts of the day ·Stay indoors and out of the sun during the hottest parts of the day ·Avoid hot foods and heavy meals ·Keep a hydration station readily available to residents, family, and staff ·Be alert to adverse changes in patient and resident conditions that may be heat related ·Develop and implement a system to monitor hydration status and be prepared to take appropriate interventions ·Pay special attention to patients with medications that make the patient susceptible to high Temperatures, e.g., psychotropic medications .

Based on observation, interview, and record review, the facility failed to provide adequate intervention and care for six of 71 Randomly Selected Residents (RSR 34, 83, 84, 85, 55 and 68) who had skin rashes with itching. RSR 34, RSR 83, RSR 84, RSR 85, RSR 55 and RSR 68 had skin rashes with itching and received multiple treatments for skin rashes with no relief by failing to: a. Identify the clinical signs and symptoms of the skin condition, such as itching and scratching, and raised red itchy papules (pimple-like) all over the resident ' s body, as suspicious for scabies. b. To provide appropriate treatment to the skin rashes after the multiple treatments had failed. c. Develop policies and procedures to include investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and [MEDICATION NAME] (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the outbreak of scabies. These failures resulted to inadequate intervention and care , RSR 34, 55, 68, 83, 84 and 85, experienced discomfort and skin injuries such as skin tears, scabs (crust that forms over a cut or wound during healing) caused by intense itching and scratching of the skin. On July 11, 2016, at 4 p.m., an immediate jeopardy (IJ) was called due to the failure of the facility to protect the residents from a contagious skin infestation (parasites on the skin) acquired at the facility without appropriate intervention and care. The administrator and director of nursing (DON) were verbally notified of the findings. On July 13, 2016, at 1:20 p.m., the facility submitted an acceptable plan of correction and the IJ was abated for the following reasons: The administrator and director of nursing (DON) were notified of the findings. 1. The Public Health Nurse was notified of the skin rash outbreak and recommendations from the Public Health Nurse were followed to prevent the spread of the skin rash. 2. All residents were re- assessed. Six residents identified with a long history of skin rashes with itching and their roommates were seen by the dermatologist and treated with Eli mite cream (a medication applied to the skin and used to treat scabies, a contagious skin infestation, caused by tiny mites that burrow into your skin, causing a very itchy skin). 3. An infection control program was developed to include investigation of skin rashes, reporting outbreaks of skin rashes to the public health department, preventing the transmission of skin rashes, controlling a possible skin infestation (overrun by pests or parasite) by administering treatments and [MEDICATION NAME] treatments to residents, roommates and the facility staff and surveillance and tracking of skin rashes. 4. In-services and training were provided to the staff for identification of and preventing the spread of skin rashes that could be scabies. 5. The facility had a plan in place to provide [MEDICATION NAME] treatment of [REDACTED]. 6. Surveillance logs of residents, direct care givers and a separate listing of their contacts to identify individual infections in residents and staff and to identify clusters of infection were provided to the department daily. Findings: A review of the facility ' s Non- Pressure Sore Skin Problem Report, dated March 18, 2016, indicated Resident 34 had generalized skin rashes, described as red raised rashes with evidence of itching. The preventive measures indicated to keep the area clean, dry, and to apply [MEDICATION NAME] 0.1 percent (%) cream (to treat variety of skin condition) to generalize body rashes every day for 21 days. Resident 34 ' sweekly progress report dated April 2, 2016; indicated skin rashes were noted on Resident 34 ' s upper back. The nurse ' s notes dated April 9, 2016, indicated red and pink rashes were noted on the right upper back and shoulders, with pink scattered areas to lower back. On April 10, 2016, the Dermatologist (medical expert that deals with skin problems) saw Resident 34 at the facility and diagnosed the skin condition as [MEDICAL CONDITION] (inflammation of the skin) and psoriasis (a persistent, long [MEDICATION NAME] disease that causes the skin cells to build up rapidly on the surface of the skin. The extra skin cells are thick, silvery and itchy, dry and red patches). The treatment order was to apply [MEDICATION NAME] (anti-fungal cream) every day for one month to the arms and [MEDICATION NAME] 0.1 % every day for two weeks. The weekly nurses notes dated April 15, 2016, to April 22, 2016, indicated, Resident 34 was still noted with red rashes to side of body with itching. [MEDICATION NAME] cream was continued to be applied for the skin rashes. On June 10, 2016, the nurse ' s notes indicated Resident 34 ' s body rashes were still noted as pink elevated rashes with scratching, old scars present from rashes. On June 10, 2016, the Dermatologist ordered to mix 10 milliliter (ml) of Tea Tree Oil to 100 ml of water and apply to body rashes every day for two weeks. According to Nursing 2011 Drug Handbook , Tea tree oil is 100 % pure essential oil, used as lotion for dermatoses (non-[MEDICAL CONDITION] disorder of the skin). Caution not to apply oil to wounds or to skin that ' s dry or cracked. On June 18, 2016, Resident 34 ' s body assessment indicated there were scattered body rashes/patches. The nurse ' s notes identified right and left arm abrasions (scraped area) with treatment of [REDACTED]. On June 21, 2016, the physician ordered [MEDICATION NAME] (used to prevent and treat minor skin irritations) ointment to perineum (space between the anus genital areas) for 14 days. A review of the Non-pressure Skin Problem Report from July 2, 2016 to July 9, 2016, indicated presence of rashes with scabs to legs, redness to perineum area, self-inflicted scratches to left side of face and redness to face. Resident 34 was receiving triple antibiotic for the abrasion on the face, [MEDICATION NAME] ointment to the perineal area and [MEDICATION NAME] 0.1 % to rashes on both legs. On July 7, 2016, at 3:30 p.m., the Treatment Nurse (TN 1) performed Resident 34 ' s skin/body assessment after a sun exposure while out on a group facility activities at the park. During this time, Resident 34 was observed to have both arms with reddish dots and skin rashes to the front upper body parts, between the fingers of the right hand, right armpit and both legs. The right arm had open [MEDICAL CONDITION] (skin tears or wound) and dry scabs (crusts that form over a cut or wound during healing). On July 7 2016, a 3:40 p.m., during an interview with Resident 34, with an interpreter, he stated, I scratch all the time, day and night. Current treatment was not helping, the cream they apply don't work. I'm tired of it. At 3:45 p.m., TN 1 stated Resident 34 was already being seen regularly by a Dermatologist for skin condition. A review of the clinical record on July 7, 2016, indicated Resident 34 was originally admitted on [DATE]. The [DIAGNOSES REDACTED]. Resident 34 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool) dated June 7, 2016, indicated Resident 34 had the ability to understand others, make self-understood, and required extensive assistance with one person assistance with most of activities of daily living (ADLs) that included bed mobility, dressing toilet use and personal hygiene. On July 8, 2016, at 10 a.m., during an observation with Certified Nurse Assistant (CNA) 1, Resident 34 ' s upper back, trunk, and legs were covered with raised red papules (pimple-like rash). At 10:15 a.m., during an interview, CNA 1 stated she had observed Resident 34 with skin rashes all the time. CNA 1, stated she applied A and D ointment (skin protectant) to dry areas of the skin. On July 8, 2016, at 10:30 a.m., during an interview with License Vocational Nurse (LVN) 3, she stated Resident 34 had been receiving Tea tree oil prescribed by the Dermatologist for the skin rashes. On July 11, 2016, during an interview with the DON at 9 a.m., she stated the Dermatologist was at the facility and ordered for Resident 34 to be transferred to the general acute hospital (GACH) due to increased redness of the skin. Resident 34 was transferred back to the skilled nursing facility (SNF) the same day. The GACH record indicated Resident 34 was diagnosed with [REDACTED]. On July 12, 2016, the District Public Health Nurse (PHN) was onsite. At 2:16 p.m., during an interview with the PHN, she stated as per direction by the District Medical Director of Public Health, the two stations affected by RSRs 34, 83, 84, 85, 55, and 68 with clinical presentation of Scabies will be closed for admission effective July 12, 2016. The District PHN stated staff and residents for the two stations and the residents from the other stations were to receive the required treatment of [REDACTED].<http://www.cdc.gov/parasites/scabies/health_professionals/meds.html>: Brand name product: [MEDICATION NAME]-[MEDICATION NAME] is safe and effective when used as directed and is the drug of choice for the treatment of [REDACTED]. The facility would be on surveillance for six weeks due to a Scabies outbreak in the facility. On July 12, 2016, Resident 34 was treated with [MEDICATION NAME] cream. On July 13, 2016, at 10 a.m., during an interview with Resident 34, he stated the itching and redness of the skin rashes had decreased after the [MEDICATION NAME] treatment. b. Resident 83 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a standardized assessment and care screening tool) dated April 5, 2016; indicated Resident 83 usually understood others, able to make self-understood and required extensive assistance with one person during transfers, dressing, toilet use and personal hygiene. A review of the facility ' s Non- Pressure Sore Skin Problem Report dated January 1, 2016; indicated Resident 83 had generalized skin rashes on the body. The skin rashes were described as red and brown scabs with itching and treated with [MEDICATION NAME] (for [MEDICAL CONDITION]=condition of the skin which it becomes red and swollen) 0.05 % cream. On February 24, 2016, the Dermatologist ordered for Tea Tree Oil 10 ml. mixed with 100 ml of water to be applied to the generalize body rashes every day for two weeks. On March 10, 2016, the Dermatologist ordered Tea Tree Oil 10 ml mixed with 100 ml of water, apply to generalized body rash. On March 31, 2016, an order was obtained for [MEDICATION NAME] 50 mg by mouth every 6 hours for itching for 30 days. On April 1, 2016, a physician ' s order of [MEDICATION NAME] (treat variety of skin condition) cream was obtained to be applied to the generalized skin rashes to the body times 14 days. On April 2, 2016, it was indicated in the nurse ' s notes Resident 83 was given [MEDICATION NAME] 50 milligrams for complaints of body itching. It was indicated there were multiple skin scratches on arms, legs and back. On April 18, 2016, an order was obtained to apply [MEDICATION NAME] 1 % cream to generalized body and extremities scattered body skin rashes every day for 30 days. On May 1, 2016, an order was obtained to discontinue the previous order for [MEDICATION NAME] cream and start treatment with Tea Tree Oil 10 ml with 100 ml water to be applied to the generalized body rash every day for 14 days. On May 15, 2016, physician ' s consultation follow-up notes indicated Resident 83 was evaluated for the progress of the skin rashes which were not responding to the multiple therapies. Tea tree oil was ordered daily for one month for the skin rashes. On May 17, 2016, an order to apply Amalactin cream (treatment applied to mild to severe forms of dry, scaly skin). On June 30, 2016, an order to apply [MEDICATION NAME] 1 % cream twice daily for 21 days for scattered body rash and [MEDICATION NAME] 25 mg by mouth every 6 hours as needed for itching for 21 days. On July 11, 2016, at 1 p.m. during an observation with Certified Nurse Assistant (CNA) 1 it was observed Resident 83 ' s front and back, upper trunk, legs and neck were covered with multiple scattered raised red skin rashes. Resident 83 informed CNA 1 (in Spanish) his left ear was very itchy. During an interview at 1:05 p.m., CNA 1 stated Resident 83 had been having skin rashes all over his body for over a year. During an interview with the DON on July 11, 2016, at 2 p.m., DON stated Resident 83 ' s skin condition had gone to multiple unsuccessful skin treatments. The DON also stated there were no skin outbreaks among the residents and facility personnel and there had been no report of scabies infestation in the facility. On July 11, 2016, at 3:30 pm., the director of staff developer (DSD), who was also the Infection Control Nurse was asked for a list of residents with skin rashes and the facility policy and procedure regarding surveillance and tracking of skin rash, recognition and management of skin rash when rash does not improve after multiple treatment attempts. The DSD stated that skin rash was not included in the surveillance of infection. On July 12, 2016, Resident 83 was treated with [MEDICATION NAME] cream. c.RSR 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a standardized assessment and care screening tool) dated April 10, 2016, indicated RSR 84 usually understood others, usually is able to make self-understood and required limited assistance with transfers, dressing and toilet use. On February 4, 2016, Resident 84 ' s physician ordered to apply [MEDICATION NAME] 0.1% cream twice a day for 21 days to the skin rashes; daily showers with [MEDICATION NAME] (skin cleanser) every day for 7 days. On February 23, 2016, the physician ordered to apply Tea tree oil to the generalized skin rashes every day for 10 days. On March 7, 2016, the physician ordered to apply Tea tree oil to the generalized rash every day for 30 days. On March 19, 2016, the physician ordered to apply warm compresses to rashes on the face and arms for 5 minutes every four hours for 7 days. On April 21, 2016, the physician re-ordered to apply Tea tree oil to the generalized rash every day for two weeks. On April 24, 2016, the physician ordered for apply a warm compress to side of the head and ear for 5 minutes every four hours for 7 days. On June 2, 2016, the physician re-ordered [MEDICATION NAME] 0.1 % cream to body once a day for 2 weeks and Tea tree oil to the body rashes every day for two weeks. The body assessment dated [DATE], indicated RSR 84 had scattered body rashes with no physician order for [REDACTED].>On July 11, 2016, at 11:00 a.m., during an observation with the TN 1, it was observed RSR 84's hands and feet had multiple scattered rashes, raised red papules. RSR 84 stated during that time he was itchy. During an interview with the DON on July 11, 2016, at 2 p.m., she stated Resident 84 had a skin condition and was treated with multiple unsuccessful treatments. The DON also denied that there had been any skin outbreaks among the residents and facility personnel and there had been no report of scabies infestation in the facility. On July 12, 2016, Resident 84 was treated with [MEDICATION NAME] cream. d. RSR 85 was originally admitted to the facility on [DATE], and readmitted on [DATE], and January 1, 2016 with the [DIAGNOSES REDACTED]. The body assessment dated [DATE], indicated RSR 85 had generalized body skin rashes and itching. The physician ordered to mix 10 ml of Tea Tree oil with 100 ml of water and apply to generalized body skin rashes daily x 21 days and re-assess. Consequent body assessments on 1/29/2016, 2/6/2016, 2/13/2016, 2/21/2016, 2/28/2016, 3/5/2016, 3/11/2016, 3/19/2016, 3/25/2016, 4/3/2016, 4/10/2016/4/16/2016, and 4/23/2016, indicated RSR 85 had scattered body rashes with raised papules, and dry skin. The interdisciplinary notes dated 3/2/16 and 5/25/16 indicated Resident 85 ' s skin integrity was monitored for effectiveness of treatment with Tea tree oil. The Minimum Data Set (MDS- A standardized assessment and care screening tool) dated February May 27, 2016 indicated RSR 85 able to repeat three words after first attempt during Brief Interview for Mental Status (BIMS), speaks clearly, usually makes self-understood, and usually understands others. RSR 85 requires extensive assistance with transfer, dressing, and toilet use, and has never exhibited behavior of rejection of care. On April 28, 2016, RSR 85 ' s physician ordered to mix 10 ml of Tea tree oil to 100 ml of water and apply to body rashes daily x 2 weeks for [MEDICAL CONDITION] as needed (PRN). On May 14, 2016, physician re-ordered to mix Tea tree oil 10ml to 100ml of water and apply to body rashes daily 7 days. On May 20, 2016, physician ordered, Mix tea tree oil 10 ml with 100 ml of water, apply to body rashes daily x 7 days. On May 28, 2016, the physician re-ordered, Mix 10ml of tea tree oil with 100ml of waters to generalized body rashes daily x 14 days. On June 13, 2016, the physician re-ordered, Mix 10 ml of tea tree oil with 100ml of water (H20), apply to body rashes on the trunk of body daily x 21 days. The body assessment dated [DATE], and July 9, 2016 indicated RSR 85 had scattered rashes, few scabs visible on bilateral upper arms, pink and faded on chest and abdomen. On July 11, 2016, at 11:07 a.m., during an observation with TN 2 in station 2, it was observed RSR 85 ' s hands, feet, back, and stomach had multiple scattered raised red papules. TN 2 confirmed Resident 85 still had skin rashes. During an interview at 11:10 a.m., RSR 85 stated, I feel itchy, and it feels like bugs living in my arms . During an interview with the Director of Nursing (DON) on July 11, 2016 at 2:00pm, she stated that staff members had not notified her of Residents 85's skin condition and the multiple ineffective treatments. On July 12, 2016, Resident 85 was treated with [MEDICATION NAME] cream. e. An admission face sheet indicated RSR 55 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of RSR 55's medical record revealed the resident was being treated for [REDACTED]. Physician ' s orders dated November 30, 2014 and December 21, 2014, indicated to apply [MEDICATION NAME] (used to treat itching, redness, dryness, crusting, scaling, inflammation) 0.1% cream for scattered body skin rashes. Review of the Non-Pressure Sore Skin Problem Report dated November 8, 15, 22, 29, 2014, indicated the resident had a scattered red generalized body rashes. On December 6, 13, 20, 21, 27, 2014, the Non Pressure Skin Problem Report indicated skin rashes had a slow response to treatment, and to continue treatment. In addition on January 3, 10, 17, 2015, the same treatment for [REDACTED]. Review of a Non-Pressure Sore Skin Problem Report, dated June through August 2015 indicated RSR 55 had scattered body rashes. A physician's order dated July 25, 2015, indicated to apply [MEDICATION NAME] Cream (used for itching and inflammation of certain skin conditions) 0.05% ointment to scattered body rash daily. The skin rashes resolved in August 2015, then returned May 2016. A physician's order on May 3, 2016, indicated to mix 10 milliliters (ml) of tree oil with 100 ml of water and apply to generalized body rashes daily. Another physician's order on July 11, 2016, indicated to apply [MEDICATION NAME] 0.1 % cream to generalized body skin rashes. Review of a Non-Pressure Sore Skin Problem Report dated July 11, 2016, indicated RSR 55 had a scattered pin point rashes. The resident was treated with [MEDICATION NAME] (used for the treatment of [REDACTED]. During an interview on July 12, 2016 at p.m., the Director of Nursing (DON), stated Residents 55's skin condition was provided with multiple treatments which were ineffective treatments. The DON stated there had not been any scabies outbreaks among the residents or staff. On July 12, 2016, Resident 55 was treated with [MEDICATION NAME] cream. f. Resident 68 was originally admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a standardized assessment and care screening tool) dated June 4, 2016, indicated Resident 68 able to make self-understood, have episodes of confusion and required extensive assistance with transfers, dressing, toilet use and personal hygiene. A review of Resident 68 ' s clinical record indicated a physician ' s order on April 29, 2016, to apply [MEDICATION NAME] 1% cream to generalized body rashes every day for 14 days. On June 2, 2016, Dermatology Consult notes indicated Resident 68 ' s skin rashes had been unresponsive to multiple therapies. The plan of treatment was to continue [MEDICATION NAME] 0.05% cream and to start treatment for [REDACTED]. On June 23, 2016, an order to continue to apply [MEDICATION NAME] 0.05% cream every day to the scattered body rash for 30 days On July 11, 2016, at 12:00p.m., it was observed in the presence of TN 1 Resident 68 ' s arms and back was covered with multiple scattered raised red papules. During an interview at this time with Resident 68 stated she was itchy and had bugs in her skin. At this time TN 1 stated the resident had history of scabies. During an interview with the DON on July 11, 2016, at 2p.m. she stated staff members had not notified her of Resident 68 ' s skin condition and the multiple unsuccessful treatments. During an interview with the DON on July13, 2016, at 1p.m., she stated that she did not know if Resident 68 had skin scraping, a test to check for scabies, due to resident past [DIAGNOSES REDACTED]. On July 12, 2016, Resident 68 was treated with [MEDICATION NAME] cream. According to the facility ' s undated policy and procedure, Scabies Prevention and Control Programs, indicated it is recommended that Health Care Facility (HCF) incorporate a scabies prevention program that involves all levels of the health care team. Essential elements of a successful scabies prevention program include: 2. Healthcare workers who are trained to be suspicious of scabies in themselves or their patients if unexplained rash or pruritus occurs in them or their patients, and to report such occurrences to their supervisors. In addition, the Summary of Action Steps indicated, Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic patients or employees. According to CDC (Centers for Disease Control): Human scabies is caused by an infestation of the skin by the human itch mite. The adult female scabies mites burrow into the upper layer of the skin where they live and deposit their eggs.) The microscopic scabies mite almost always is passed by direct, prolonged, skin to skin contact with a person who is already infected. Institutions such as nursing homes and extended care facilities are often sites of scabies outbreaks. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. The mites in crusted scabies are much more numerous (up to 2 million per patient). Because they are infested with such large numbers of mites, persons with crusted scabies are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for [REDACTED]. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash.

Based on observation, interview and record review, the facility staff failed the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection by failing to: Identify the clinical signs and symptoms of the skin condition for six of 71 Randomly Selected Residents (RSR 34, 83, 84, 85, 55 and 68) such as itching and scratching, and raised red itchy papules (pimple-like) all over the residents body as suspicious for scabies. Develop policies and procedures to include investigation of skin rashes, reporting skin outbreaks to the public health department, preventing the transmission of skin rashes, administering treatments and [MEDICATION NAME] (preventive treatment) to residents, roommates and the facility staff, conduct surveillance and tracking of scabies (program for early detection of infested patients and staff) to contain the skin rashes outbreak associated with which caused severe itching and discomfort. Refer to F 309. Findings: a. On July 7, 2016, at 3 p.m., during a skin/body assessment of Resident 34 with the Treatment Nurse and an interpreter, Resident 34 was observed to have both arms with reddish dots and skin rashes to the front upper body parts, between fingers of right hand, right armpit and both legs. The right arm had open lesions (wound) and dry scabs. During a concurrent interview, Resident 34 stated, I scratch all the time, day and night. The medication was not helping, the cream they apply don't work. I'm tired of it. According to the treatment nurse, Resident 34 was already being seen regularly by a dermatologist (skin specialist). A review of the medical record on July 7, 2016, at 3:30 p.m., indicated Resident 34 had received multiple treatments for the rash with itching from March 2, 2015, to present time. However, the rash continues without relief. On July 11, 2016, at Resident 34 was transferred to an acute hospital for evaluation of the skin rash. However, the facility did not request to test for scabies. On July 12, 2016, Resident 34 was treated with [MEDICATION NAME] (medication that treats scabies) cream on the advice of the Public Health Nurse. In an interview on July 13, 2016, at 10 a.m., Resident 34 stated that the itching and redness had decreased. b. Resident 83 was observed with scratching his left ear and left arm during observation on July 11, 2016, at 1 p.m. Further observation, with CNA 1, Resident 83 ' s front and back upper trunk, legs and neck were covered with multiple scattered raised red papules. Resident 83 stated to CNA 1 (in Spanish) that his left ear was itchy. During an interview, Resident 83 stated that his, Whole body was itching all the time. Upon closer observation, resident ' s left ear was red. A review of the medical records indicated Resident 83 had received multiple treatments for the skin rash since admission on August 10, 201,2 and readmitted on [DATE], unsuccessfully. There was no record that a skin scraping was considered to determine if the skin rash was scabies. During an interview with the DON on July 11, 2016, at 3:30 p.m., she stated that the current dermatologist used Tea Tree oil because of its less side effects to residents. According to the California Department of Public health, Prevention and Control of Scabies in California Long-Term Care Facilities dated March 2008, indicated, A scabies control program should be developed and approved by the infection control committee. The program should designate a physician such as the medical director who will act as program coordinator. This physician should be given the authority to notify attending physicians, perform diagnostic procedures such as skin scraping and to order [MEDICATION NAME] and therapeutic scabicide treatments on exposed residents. The health care workers should be educated about the epidemiology of scabies and how to identify and report any unusual pruritus, rashes or skin lesions. During an interview with the DON on July 11, 2016, at 3:45 p.m., she stated that she was unaware if an investigation had been completed to identify the cause of the resident's rashes. She also stated that there was no surveillance and tracking the skin rash outbreak. c. On July 11, 2016, at 11:00 a.m., Treatment Nurse was asked to accompany the Surveyor to RSR 84's room. The Surveyor observed RSR 84's hands and feet with multiple scattered raised red papules. RSR 84 stated he was itchy. A review of RSR 84's body assessment dated [DATE], indicated RSR 84 had a rash to the scalp. The physician ordered to: clean area with normal saline and leave open to air for seven days. On February 4, 2016, the physician ordered to apply [MEDICATION NAME] 0.1% cream twice a day for 21 days and then to reassess. Added ordered on the same date were: daily showers with [MEDICATION NAME] every day for 7 days. On February 23, 2016, the physician ordered to apply Tea tree oil to the generalized rash every day for 10 days. On March 7, 2016, the physician ordered to apply Tea tree oil to the generalized rash every day for 30 days. On March 19, 2016, an order for [REDACTED]. On April 21, 2016, the physician ordered to apply Tea tree oil to the generalized rash every day for two weeks. On April 24, 2016, an order for [REDACTED]. On June 2, 2016, an order was received for [MEDICATION NAME] 0.1 % cream to body once a day for 2 weeks. Added order on the same day was for Tea tree oil to the body rash every day for two weeks. The body assessment dated [DATE], indicated RSR 84 had scattered body rash with no physician order for [REDACTED]. During an interview with the DON on July 11, 2016, at 2 p.m. she stated that staff members had not notified her of Resident 84's skin condition and the multiple unsuccessful treatments. The DON also denied that there had been any skin outbreaks among the residents and facility personnel and there had been no report of scabies infestation in the facility. On July 12, 2016, Resident 84 was treated with [MEDICATION NAME] cream on the advice of the Public Health Nurse. In an interview on July 13, 2016, at 10:30 a.m., Resident 84 stated that the itching and redness had decreased. d. An admission face sheet indicated RSR 55 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of RSR 55's medical record revealed the resident was being treated for [REDACTED]. Physician ' s orders dated November 30, 2014 and December 21, 2014, indicated to apply [MEDICATION NAME] (used to treat itching, redness, dryness, crusting, scaling, inflammation) 0.1% cream for scattered body skin rashes. Review of the Non-Pressure Sore Skin Problem Report dated November 8, 15, 22, 29, 2014, indicated the resident had a scattered red generalized body rashes. On December 6, 13, 20, 21, 27, 2014, the Non Pressure Skin Problem Report indicated skin rashes had a slow response to treatment, and to continue treatment. In addition on January 3, 10, 17, 2015, the same treatment for [REDACTED]. Review of a Non-Pressure Sore Skin Problem Report, dated June through August 2015 indicated RSR 55 had scattered body rashes. A physician's order dated July 25, 2015, indicated to apply [MEDICATION NAME] Cream (used for itching and inflammation of certain skin conditions) 0.05% ointment to scattered body rash daily. The skin rashes resolved in August 2015, then returned May 2016. A physician's order on May 3, 2016, indicated to mix 10 milliliters (ml) of tree oil with 100 ml of water and apply to generalized body rashes daily. Another physician's order on July 11, 2016, indicated to apply [MEDICATION NAME] 0.1 % cream to generalized body skin rashes. Review of a Non-Pressure Sore Skin Problem Report dated July 11, 2016, indicated RSR 55 had a scattered pin point rashes. The resident was treated with [MEDICATION NAME] (used for the treatment of [REDACTED]. During an interview on July 12, 2016 at p.m., the Director of Nursing (DON), stated Residents 55's skin condition was provided with multiple treatments which were ineffective treatments. The DON stated there had not been any scabies outbreaks among the residents or staff. On July 12, 2016, Resident 55 was treated with [MEDICATION NAME] cream. e. Resident 85 was observed on July 11, 2016 at 11:07am scratching her upper arm, and fingers in the presence of the treatment male nurse in station 2. Further observation of resident 85 with the treatment male nurse indicated that resident 85 has rash on the bilateral upper arm, feet, fingers, back, and stomach area with multiple scattered raised red papules. Resident 85 states, I feel itchy, and it feels like bugs living in my arms . A review of resident 85 ' s medical records indicated that resident had received multiple treatments for skin rash since initial admission in September 12, 2016, and re-admission in February 27, 2015, and January 1, 2016 respectively were unsuccessful. There was no record that a skin scraping was done or considered to determine if the skin rash was scabies. During an interview with the Director of Nursing (DON) on July 11, 2016 at 2:00pm, she stated that staff members had not notified her of Residents 85 ' s skin condition and the multiple ineffective treatments. The DON also denies that there had been any skin outbreaks among the residents and facility personnel and there had been no report of scabies infestation in the facility. She also states, there is no surveillance and tracking of skin rash outbreak by the facility . On July 12, 2016, Resident 85 was treated with [MEDICATION NAME] cream. On July 13, 2016 at 10:00am, Resident 85 states, I feel clean and they have been applying some kind of cream to my body too, it feels better and I don ' t itch like I used to, they apply some cream all over my body and it feels better too . e. On July 11, 2016, at 12:00p.m., Treatment Nurse was asked to accompany the Surveyor to Resident 68 ' s room. The Surveyor observed Resident 68 ' s arms and back covered with multiple scattered raised red papules. Resident 68 stated she was itchy and has bugs on her skin. At this time the Treatment Nurse stated the resident has a history of scabies. A review of the medical records indicated Resident 68 had received multiple treatments for the skin rash since admission April 15, 2014 and readmitted on [DATE]. However the rash continues without relief. There was no record that a skin scraping was considered to determine if the skin rash was scabies. During an interview with the DON on July 11, 2016, at 2p.m. she stated that staff members had not notified her of Resident 68 ' s skin condition and the multiple unsuccessful treatments. The DON also denied that there had been any skin outbreaks among the residents and facility personnel and there had been no report of scabies infestation in the facility. On July 11, 2016, Resident 68 was transferred to an acute hospital for evaluation of the skin rash. However, the facility did not request to test for scabies. On July 12, 2016, Resident 68 was treated with [MEDICATION NAME] cream on the advice of the Public Health Nurse. In an interview on July 13, 2016, at 10:30a.m., Resident 68 stated that there is no more itching and she was feeling better. f. Resident 68 was originally admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a standardized assessment and care screening tool) dated June 4, 2016, indicated Resident 68 able to make self-understood, have episodes of confusion and required extensive assistance with transfers, dressing, toilet use and personal hygiene. A review of Resident 68 ' s clinical record indicated a physician ' s order on April 29, 2016, to apply [MEDICATION NAME] 1% cream to generalized body rashes every day for 14 days. On June 2, 2016, Dermatology Consult notes indicated Resident 68 ' s skin rashes had been unresponsive to multiple therapies. The plan of treatment was to continue [MEDICATION NAME] 0.05% cream and to start treatment for [REDACTED]. On June 23, 2016, an order to continue to apply [MEDICATION NAME] 0.05% cream every day to the scattered body rash for 30 days On July 11, 2016, at 12:00p.m., it was observed in the presence of TN 1 Resident 68 ' s arms and back was covered with multiple scattered raised red papules. During an interview at this time with Resident 68 stated she was itchy and had bugs in her skin. At this time TN 1 stated the resident had history of scabies. During an interview with the DON on July 11, 2016, at 2p.m. she stated staff members had not notified her of Resident 68 ' s skin condition and the multiple unsuccessful treatments. During an interview with the DON on July13, 2016, at 1p.m., she stated that she did not know if Resident 68 had skin scraping, a test to check for scabies, due to resident past [DIAGNOSES REDACTED]. On July 12, 2016, Resident 68 was treated with [MEDICATION NAME] cream.

Based on observation, interview, and record review the facility failed to ensure residents were free from neglect for 41 (Residents 6, 8, 11, 22 and RSR 32, 34-36, 38-43, 46-60, 62, 65, 66, 70, 71, 76-78 and 80) of 55 residents who attended a whole day unsheduled outing at the park two miles away from the facility. The outside air temperature was hot (90 degrees Farenheit), residents were not applied sunblocks which resulted to skin redness or sunburn, pain, and discomfort to these areas. Findings: A body assessment was done to the 55 residents upon their return to the facility on [DATE] at 5p.m., A total of 41 residents (Resident 6, 8, 11, 22 and RSR 32, 34-36, 38-43, 46-60, 62, 65, 66, 70, 71, 76-78 and 80) had acquired skin redness or sunburn to after an off premise outing. On July 7, 2016, all residents returned to the facility from outing safely. Residents went to the park outing on July 7, 2016, from 8 am-10 am until 3pm - 5pm. Upon return, residents were assessed by the charge nurses for any sign of adverse reactions related to his/her off site event participation. a. An admission face sheet indicated Randomly Selected Resident (RSR 56) was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of physician's orders dated April 7, 2016, included: [MEDICATION NAME] (antipsychotic) 5 milligrams (mg) three times a day for [MEDICAL CONDITION] manifested by auditory hallucinations, [MEDICATION NAME] (antipsychotic) 600 mg by mouth at hour of sleep for [MEDICAL CONDITION] manifested by hypersexual activity, [MEDICATION NAME] (mood stabilizer) 500 mg by mouth three times a day for [MEDICAL CONDITION] manifested by yelling for no apparent reason. RSR 56 did not have a physician's order to go out on pass. During an observation on July 7, 2016 at 4:40 p.m. following the outing RSR 56 was observed in the dining room of the center building. The residents face and scalp were a bright red color. During an interview on July 7, 2016 at 4:40 p.m., RSR 56 stated he had attended the outing. RSR 56 stated it was Too Hot. The resident stated his nose and scalp was hurting. When asked if he had been offered sunblock he said no. The resident was also asked how he spent the day his response was I smoked cigarettes. When asked if he had enough water to drink on the outing he stated he mostly drank soda. b. An admission face sheet indicated RSR 38 was admitted to the facility on [DATE] and readmitted [DATE]. The resident's [DIAGNOSES REDACTED]. Review of physician's orders dated June 29, 2016, included [MEDICATION NAME] (for manic-[MEDICAL CONDITION]) 300 milligrams (mg) twice a day for [MEDICAL CONDITION]. Trazadone (antidepressant) 100 mg by mouth every day at hour of sleep for depression manifested by trying to hurt herself. [MEDICATION NAME] (antipsychotic medication) 10 mg twice a day for [MEDICAL CONDITION] manifested by verbally abusive behavior. RSR 38 did not have a physician's order to go out on outings. During an observation on July 7, 2016 at 4:50 p.m., RSR 38 was observed in the dining room of the center building. The resident's cheeks were bright red. An attempt to interview was made however the resident did not respond. c. An admission face sheet indicated RSR 77 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Physician's orders dated May 9, 2016 included [MEDICATION NAME] (antipathetic medication) 10 mg by mouth daily and at hour of sleep for [MEDICAL CONDITION] manifested by striking out at others. RSR 77 did not have a physician's order to go on outings. On July 7, 2016 at 5 pm, RSR 77 was observed sitting in a wheelchair in his room. The resident was wearing pants and a long sleeve shirt. During an interview at the same time RSR 77 was asked if he had enjoyed the outing at the park. The resident stated, It was a little too hot. When asked if he had been wearing the same clothes he stated Ya. Resident 6, 8, 11, 22, 32, 34-36, 39-43, 46-55, 55-60, 62, 65, 66, 70, 71, 76-78 and 80- Body assessment was done, redness was observed on body, aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged. Resident 21 - Body assessment done, redness on face and bilateral forearms, aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged, CMP panel was done due to complaints of nausea, vomiting and diarrhea, on 7/8/16, see attached results. Resident 33 - Body assessment done, redness on cheek, aloe Vera applied, no complaint of pain/ discomfort, fluids encouraged. Resident complained of diarrhea while on outing on July 7, 2016, and was placed on 72-hour monitoring and no further episodes since returning from outing. CMP panel was done due to complaints of diarrhea, on 7/8/16, see attached results. Resident 64 - Body assessment done, redness on face and bilateral forearms, aloe vera applied, no complaint of pain/ discomfort, fluids encouraged, CMP panel was done routinely monthly on 7/8/16, see attached results. Resident 44, 45, 61, 63, 67-69, 72-75, 79, 80 and 81 - Body assessment done, no unusual observations noted, no complaint of pain/discomfort, fluids encouraged. According to the All Facilities Letter, dated June 7, 2016, indicated facilities to: Implement recommended precautionary measures to keep individuals safe and comfortable during extremely hot weather because elderly and other health-compromised individuals are more susceptible to extremes in temperature and possible dehydration. The L&C Program recommends facilities review Fast Facts: Preventing Summer Heat Injuries and implement the following measures to keep residents and clients comfortable during extremely hot weather: <http://www.cdph.ca.gov/certlic/facilities/Documents/LNC-AFL-16-06.pdf> During an interview with the DON, on July 13, 2016, at 1:30 p.m., she stated of the 55 residents who attended the park outing; only 7 residents had orders from their physician to attend the outing. A review of the facility policy titled Off-Premise Activities dated August 2006, indicated residents are considered appropriate for off-premise activities based on the physician approval and the physician's order allowing the resident to attend the activity outings should be verified by the Activity Director/Coordinator. Refer to F323

Based on interview and record review, the facility failed to ensure that one of one sampled resident (Resident 1), who had difficulty in swallowing and history of choking incidents, received adequate supervision during meals as indicated in the plan of care to prevent a repeat of the choking incident. This failed practice resulted in Resident 1 choking on some food particles and subsequently expired. Findings: During a review of the clinical record for Resident 1, the admission record (face sheet) indicated she was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. cells), bipolar disorder (serious shifts in mood, energy, thinking, and behavior), and schizophrenia (a serious mental illness in which someone cannot think or behave normally and often experiences delusions). A review of the comprehensive Minimum Data Set (MDS), a standardized assessment and care planning tool, dated [DATE], indicated Resident 1 had the ability to make herself understood and understand others. According to the MDS, Resident 1 required supervision from staff for most of her activities of daily living including eating. The MDS indicated she was receiving mechanically altered diet (diet containing ground or pureed foods that are easy to chew, often eaten by people who have dental problems or are edentulous). A review of Resident 1's medical record, with RN 1, indicated Resident 1 has had history of choking from food materials. An entry in the Nurse's Notes , dated [DATE], at 2:20 PM, indicated that at around 1:20 PM, that day on [DATE], resident Resident 1 was found lying in bed, mouth full of food, and with harsh breath sounds. Resident 1 was noted with cyanotic (bluish discoloration of the skin and mucous membranes due to not having enough oxygen in the blood) lips and fingertips. The nurse ' s notes further indicated that Heimlich maneuver (an emergency technique for preventing suffocation when a person's airway or windpipe becomes blocked by a piece of food or other object) was initiated, and suctioning was done which improved the resident's condition. Resident 1 was then transferred to an acute hospital for further evaluation and came back to this facility on [DATE]. A review of an entry in the Dysphagia (difficulty in swallowing) documentation report, with RN 1, indicated that on [DATE], Resident 1 had a speech/swallow evaluation by a therapist who recommended resident to undergo swallow/diet management and safety training. The evaluation report indicated Resident 1 appears to be tolerating mechanically soft (MS) diet, with poor safety and risk for choking. A review of an entry in the dysphagia documentation report, with RN 1, dated [DATE], indicated Resident 1 was on maximum assist with meals for safety, due to being easily distracted, and with risk for choking. A review of an entry in the dysphagia documentation report, with RN 1, dated [DATE], indicated Resident 1 was discharge from speech/swallow rehabilitation therapy but will still be on maximum assistance for safety compliance because of poor safety awareness and increased risk for choking. A review of an entry in the Nurses Notes, with RN 1, dated [DATE], at 1:30 PM, indicated Resident 1 had another episode of choking. The entry indicated that at around 1 PM, on [DATE], Resident 1 was noted by staff standing in front of her closet door and then she fell down on her back. Resident 1 appeared to be cyanotic and unable to respond to tactile (touch) or verbal stimuli. Heimlich maneuver was performed immediately and some liquid and soft food came out from her mouth. After a few minutes resident responded well and was refusing care. A care plan developed in [DATE], and re-evaluated in [DATE], indicated Resident 1 was at risk for further choking and/or aspiration (breathing in foreign materials) secondary to actual episodes of choking, history of choking, taking large bites of food, refusing staff to assist with feeding, taking other resident's food that are on different therapeutic diet, and taking and grabbing food from trays/carts. Among the approach plan to be implemented included monitoring resident during meals and observing for any difficulty in swallowing, supervising trays/carts during meals, and monitoring access to solid foods. The recapitulation of physician orders [REDACTED]. A review of an entry in the nurse's notes by Licensed Vocational Nurse 1 (LVN 1), dated [DATE], at 3 PM, indicated that at around described what happened to Resident 1 that day: 12:22 PM, on [DATE], Resident 1 was found by her Certified Nurse Assistant 1 (CNA 1) in her room, on the floor, and gasping for air. Knowing that Resident 1 is a choke hazard, CNA 1 yelled for help and initiated the Heimlich maneuver. LVN 1 immediately arrived and continued the Heimlich maneuver. Resident was noted regurgitating puree food during the Heimlich maneuver. Emergency 911 was called and after two minutes of the Heimlich maneuver, resident was still unresponsive. Cardiopulmonary resuscitation (CPR, an emergency procedure using rescue breathing and chest compressions to help a person whose breathing and heartbeat have stopped) was initiated and continued until emergency personnel arrived. Fire department arrived and Resident 1 was attended to by three Emergency medical technicians, (EMT) for another 10 ten minutes. Resident 1 was unresponsive to CPR. At around 12:56 PM, Resident 1 was still without a pulse, and was pronounced deceased by the EMT. During an interview with Registered Nurse 1 (RN 1), on [DATE], at 2 PM, she stated that on [DATE], during lunch time, Resident 1 choked on a hot dog she took from her roommate's tray. She said Resident 1 was found in her room, on the floor, unresponsive, by CNA 1 assigned to her. RN 1 said that they tried the Heimlich maneuver on the resident, while waiting for the paramedics, but was unsuccessful. She further stated that Resident 1 and her roommate usually eat in their room and Resident 1 needs supervision during meals because she had difficulty in swallowing and history of choking. RN 1 stated that she does not know why Resident 1 was not supervised at that time. During an interview with CNA 1, on [DATE], at 2:45 PM, he stated that after he delivered the food tray for Resident 1 and her roommate, she opened a carton of milk for her and left the room to deliver a food tray for a resident in another room. CNA 1 stated that he left Resident 1s room only for a short time. CNA 1 stated that when he came back to Resident 1's room she was already on the floor and unresponsive. He stated that he knows that Resident 1 needs supervision while eating because she is at risk for choking. He further stated that Resident 1s food tray should have been delivered last so that he can be supervised while eating. The department of coroner autopsy report, dated [DATE], indicated that Resident 1's cause of death was choking due to obstructive food bolus.