Every finding on record at Granada Post Acute

Based on observation, interview, and record review, facility failed to ensure the low-temperature dishwashing machine reached the required sanitizing water temperature of 120 degrees Fahrenheit (F, unit of temperature) prior to washing soiled dishes, and ensure dietary staff adhered to proper food safety practices when a cook was observed performing meal preparation without a beard net. These failures had the potential to result in improperly sanitized dishware and food contamination, which could increase the risk of foodborne illness, cross-contamination, and the transmission of infectious organisms potentially affecting all residents receiving meals and food services from the facility. Findings: 1. During a concurrent observation and interview on 6/15/2026 at 8:24 a.m., with the Dietary Assistant Supervisor (DAS), the low-temperature dishwashing machine was observed in operation and actively washing dishware. The machine's temperature gauge was observed with a buildup of dried water residue on the thermometer, obstructing the visibility of the temperature reading. Once the residue was removed, the thermometer registered a water temperature of 108 degrees Fahrenheit ( F, unit of temperature) during the active wash cycle. The DAS stated that the machine should be allowed to run through two or three cycles prior to washing dishware to ensure the water temperature reached the facility's required operating range of 120 to 140 F . The DAS stated that staff were responsible for verifying the machine achieved the appropriate temperature before loading and washing dishes. The DAS stated that a wash temperature of 108 F was below the acceptable operating range and stated that dishware washed at this temperature may not be adequately cleaned and sanitized. The DAS stated that failure to achieve the required water temperature could result in food-contact surfaces not being properly disinfected, increasing the risk of bacterial contamination and the potential transmission of foodborne pathogens to residents. The DAS stated that dishware should not be washed until the machine reached the required temperature and agreed that the machine was being utilized before achieving the appropriate operating temperature.2. During a concurrent observation and interview on 6/15/2026 at 11:50 a.m., in the kitchen, with [NAME] (CK) 1, CK 1 was observed actively preparing and serving resident meals. CK 1 was not wearing a beard net. CK 1 had visible facial hair extending beyond the chin area while handling food and meal trays intended for resident consumption. CK 1 stated that dietary staff were expected to wear appropriate hair restraints while preparing and serving food. CK 1 stated that beard nets should be worn by staff with facial hair to prevent hair from falling into food and to maintain sanitary food handling practices in the kitchen. CK 1 stated that the purpose of a beard net was to minimize the risk of contaminating food with hair or other particles from facial hair. CK 1 stated that failure to wear the required beard restraint could compromise food sanitation.During an interview on 6/15/2026 at 12:15 p.m., with the Dietary Supervisor (DS), the DS stated that the low-temperature dishwashing machine had been observed operating with a wash-cycle temperature of 108 F , which was below the facility's expected operating range of 120 to 140 F . The DS stated that dietary staff were responsible for ensuring the dishwashing machine reached the appropriate temperature before washing dishware and that the machine should run through three or more cycles prior to use to achieve the required temperature. The DS stated that staff should routinely monitor and verify dishwasher temperatures to ensure proper cleaning and sanitization of dishes, utensils, and food-contact surfaces. The DS stated that utilizing the machine before it reached the appropriate temperature could result in dishware not being adequately sanitized and could increase the risk of contamination. The DS stated that the thermometer should remain clean and readily readable at all times to allow staff to accurately monitor dishwasher temperatures during operation. The DS stated that the facility's personal hygiene and food safety practices require dietary staff with facial hair to wear beard nets while preparing, handling, or serving food. The DS stated that beard restraints were intended to prevent hair from contaminating food and to maintain sanitary food handling conditions. The DS stated that dietary staff have received training regarding the dishwashing settings and regarding the use of hair and beard nets. The DS stated that both the failure to ensure proper dishwasher temperatures and the failure to wear required beard restraints were not consistent with facility policies designed to protect residents' health and safety. During s review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control - Dishwashing Procedures Dishmachine) dated 2011, the P&P indicated Chemical low temperature dishmachines must maintain a water temperature of 120 F - 140 F. Dishmachine Temperature Logs must be documented prior to the start of washing at each meal to ensure proper sanitation of all dishware and trays.During a review of the facility's P&P titled Sanitation and Infection Control-Personal Hygiene dated 2011, the P&P indicated A hair net and/or head covering which completely covers all hair should be worn during meal preparation and service. Beards and/or mustaches should be closely cropped and neatly trimmed or must be covered during meal preparation and service.

Based on observation, interview, and record review, the facility failed to ensure repositioning and turning documentation was completed timely and accurately for five out of five sampled residents (Resident 32, Resident 7, Resident 95, Resident 4, and Resident 64). These failures resulted in documentation that could not be relied upon to verify care and services provided for Residents 32, 7, 95, 4, and 64. Cross reference F686.Findings: a. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 32's diagnoses included muscle weakness, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right lower leg, unstageable pressure ulcer (a severe wound where the true depth and tissue damage cannot be seen because it is completely obscured by dead tissue) of the sacral region (near tailbone), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 32's Minimum Data Set ([MDS], a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 32's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 32 was entirely dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 32's History and Physical (H&P), dated 3/16/2026, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's Braden Scale for Predicting Pressure Sore Risk Assessment (an evidence-based clinical assessment tool used to predict a patient's risk of developing pressure injuries [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence]), dated 4/27/2026, the assessment indicated Resident 32 was at very high risk for the development of a pressure ulcer. During a review of Resident 32's Care Plan titled, Skin Integrity Impaired, initiated 5/10/2026, the care plan indicated to turn and reposition Resident 32 at least every two hours. During a concurrent interview and record review on 6/17/2026 at 10:50 a.m. with the Director of Staff Development (DSD), Resident 32's Turning and Repositing Flow Sheet, dated 6/2026, was reviewed. The record did not indicate Resident 32 was repositioned on 6/3/2026 at 11:00 p.m., 6/4/2026 at 11:00 p.m., 6/5/2026 at 11:00 p.m., 6/9/2026 at 11:00 p.m., and 6/11/2026 from 7:00 a.m. to 1:00 p.m. The DSD stated that the Certified Nursing Assistants (CNAs) were expected to document the repositioning and turning of residents every two hours, document repositioning after care was provided, and document resident refusals when applicable. The DSD stated documentation should be completed timely to accurately reflect care provided. The DSD stated that because the repositioning was not documented as completed every two hours, there was potential for Resident 32 to develop a pressure ulcer. The DSD stated documentation was not completed timely and confirmed the medical record could not verify whether repositioning occurred during the time periods. During a concurrent interview and record review on 6/18/2026 at 9:47 a.m. with Registered Nurse (RN) 1, Resident 32's ADL Task Flow Sheet, dated 6/2026, was reviewed. The flow sheet indicated charting for the 3:00 p.m. to 11:00 p.m. shift was entered at 10:52 p.m. on 6/15/2026, and at 8:30 p.m. on 6/16/2026. RN 1 stated staff were expected to document care at the time the task was completed. RN 1 stated documentation was not completed timely and stated late entries reduced the reliability of the record. RN 1 stated the documentation did not identify the position to which Resident 32 was repositioned and confirmed the medical record could not verify whether repositioning interventions were performed during the identified time periods due to untimely documentation. b. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included muscle weakness, pressure ulcer of unspecified site, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and multiple sclerosis (MS, a chronic autoimmune disease of the central nervous system). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 7 was entirely dependent on staff for ADLs. During a review of Resident 7's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 6/14/2026, the assessment indicated Resident 7 was at high risk for the development a pressure ulcer. During a review of Resident 7's Care Plan titled, Incontinent of Bowel (undated), the care plan indicated to reposition and turn Resident 7 every two hours and as needed. During observations made on 6/16/2026 at 9:46 a.m., 12:34 p.m., and 2:01 p.m., in Resident 7's room, Resident 7 was observed on his back. During observations made on 6/17/2026 at 8:49 a.m. and 1:06 p.m., in Resident 7's room, Resident 7 was observed on his back. During a concurrent interview and record review on 6/17/2026 at 9:03 a.m. with Certified Nursing Assistant (CNA) 2, Resident 7's Turn and Repositioning Flow Sheet, dated 6/2026, was reviewed. The Flow Sheet did not indicate Resident 7 was repositioned on 6/16/2026 at 12:00 p.m. and 2:00 p.m. CNA 2 confirmed that she was Resident 7's assigned CNA on 6/16/2026. CNA 2 stated Resident 7 was not repositioned because the resident refused. CNA 2 stated her documentation should have indicated that Resident 7 refused to accurately depict the care was not provided and so that the charge nurse would be made aware of the resident's refusals. c. During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 95's diagnoses included muscle weakness, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 95's MDS, dated [DATE], the MDS indicated Resident 95's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 95 required maximal assistance (helper does more than half the effort) for toileting, showering, and lower body dressing. During a review of Resident 95's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 6/14/2026, the assessment indicated Resident 95 was at risk for the development of a pressure ulcer. During a concurrent interview and record review on 6/17/2026 at 10:50 a.m. with the DSD, Resident 95's Turning and Repositing Flow Sheet, dated 6/2026, was reviewed. The flow sheet did not indicate Resident 95 was repositioned on 6/12/2026 at 2:00 p.m. and 6/14/2026 from the hours of 12:00 a.m. to 6:00 a.m. d. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included muscle weakness, muscle wasting and atrophy (loss of muscle tissue), palliative care (compassionate care for people who are near the end of life), and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the right hip. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 4 had range of motion impairments on both lower extremities. During a review of Resident 4's Care Plan titled, ADLs, initiated 3/8/2024, the care plan indicated to turn and re-position Resident 4 at least every two hours and as often as needed. During a review of Resident 4's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 6/11/2026, the assessment indicated Resident 4 was at moderate risk for the development of a pressure ulcer. During observations made on 6/16/2026 at 12:20 p.m. and at 2:02 p.m., in Resident 4's room, Resident 4 was observed positioned on her back. During a concurrent interview and record review on 6/18/2026 at 9:47 a.m. with RN 1, Resident 4's ADL Task Flow Sheets, dated 6/2026, were reviewed. The flow sheets did not indicate a designated section for the documentation of repositioning for Resident 4. RN 1 stated the facility's practice was to reposition residents every two hours according to the facility turning schedule, and document the intervention after completion. RN 1 stated that if there was no documentation in place for Resident 4's repositioning, then the intervention could not be verified as completed. e. During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 64's diagnoses included muscle weakness, muscle wasting and atrophy, and dementia (a progressive state of decline in mental abilities).During a review of Resident 64's MDS, dated [DATE], the MDS indicated Resident 64's cognitive skills for daily decision making were intact. The MDS indicated Resident 64 required maximal assistance for toileting, showering, and putting on footwear. During a review of Resident 64's Care Plans titled, ADLs, initiated 7/25/2022, and At Risk for Pressure Sore (undated), the care plan indicated to turn and reposition Resident 64 at least every two hours and as often as needed. During a concurrent interview and record review on 6/17/2026 at 10:50 a.m. with the DSD, Resident 64's Turning and Repositing Flow Sheet, dated 6/2026, was reviewed. The flow sheet did not indicate Resident 64 was repositioned on 6/10/2026 at 4:00 a.m. and 6:00 a.m., and on 6/11/2026 at 6:00 a.m. During a review of the facility's P&P titled, Charting and Documentation, revised 7/2025, the P&P indicated the facility was to ensure documentation in the medical record would be complete, and accurate.

Based on interview and record review, the facility failed to ensure the minimum data set (MDS- a resident assessment tool) was accurately completed for one of one sampled residents (Resident 1), when Resident 1's MDS did not include his active diagnosis of dementia (a progressive state of decline in mental abilities).This failure had the potential to place Resident 1 at risk of not receiving comprehensive care that addressed his diagnosis of dementia.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included pneumonia (an infection/inflammation in the lungs), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), 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 1's History and Physical (H&P) dated 5/12/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Aet (MDS- a resident assessment tool), dated 4/24/2026, the MDS indicated Resident 1 had no cognitive impairment (ability to think and understand). The MDS indicated Resident 1 required partial assistance from staff for personal hygiene. The MDS indicated Resident 1 required substantial assistance with toileting and setup assistance for eating.During a concurrent interview and record review on 6/17/2026 at 12:05 p.m. with MDS Nurse (MDSN 1), Resident 1's MDS dated [DATE] and diagnosis list were reviewed. Resident 1's diagnosis list indicated a diagnosis of dementia. Resident 1's MDS Section I (MDS section dedicated to documenting the resident's active diagnoses) did not indicate a diagnosis of dementia. MDSN 1 stated she should have included Resident 1's diagnosis of dementia when she completed the MDS assessment. MDSN 1 stated all active diagnoses should be documented in the MDS assessment, because it drives the care plans and interventions implemented for residents. MDSN 1 stated failure to include Resident 1's diagnosis of dementia placed the resident at risk of not receiving comprehensive care that addressed dementia specific needs.During an interview on 6/18/2026 at 10:03 a.m. with the Director of Nursing (DON), the DON stated accurate MDS assessments were important to ensure the residents' plan of care were comprehensive and the resident's specific needs were addressed.During a review of the facility's policy and procedure (P&P), titled, Resident Assessments last revised 10/2023, the P&P indicated, Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.During a review of the facility's Resident Assessment/Care Plan Coordinator (MDS) Job description, indicated, Inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS).

Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS]- a resident assessment tool) for a significant change status was completed for one of two sampled residents (Resident 3) after the resident experienced a fall resulting in a fracture (a broken bone) on 1/28/2026. This failure resulted in delayed assessment and delayed transmission of Resident 3's significant change in condition to the Centers for Medicare and Medicaid Services (CMS, a federal agency within the U.S. Department of Health and Human Services (HHS) that administers major healthcare programs) and had the potential to negatively affect the resident's care planning, and delivery of necessary care and services related to the fall and fracture. Cross reference F657Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), fracture of the right fibula (broken calf bone), and muscle weakness (loss of muscle strength). During a review of Resident 3's History and Physical (H&P), dated 10/23/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS]- a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 3's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 3 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 3 required supervision or touching (helper provides verbal cues and/or contact guard assistance as resident competes activities) assistance for sitting on the side of the bed and/or standing position. During a concurrent interview and record review on 6/15/2026 at 6/15/2026 at 9:14 a.m., at Resident 3's bedside, with Resident 3, Resident 3 was observed lying in bed. Resident 3 stated she had a fall at the facility in 1/2026, which resulted in a left ankle fracture. Resident 3 stated prior to the fall, she was able to walk. Resident 3 stated currently she could not walk and/or get out of bed without staff assistance. During a concurrent interview and record review on 6/17/2026 at 9:16 a.m., with MDS Nurse (MDSN) 1, Resident 3's situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/28/2026, was reviewed. The SBAR indicated on 1/28/2026 at 2:55 p.m., Resident 3 was walking in the hallway with two staff members when she lost her balance, twisted her left ankle, and fell backward to the floor. MDSN 1 stated the SBAR indicated Resident 3 complained of left ankle pain rated at 7out of 10, on a pain scale (0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-10= severe pain). MDSN 1 stated the SBAR indicated Resident 3 was transferred to the general acute care hospital (GACH) for evaluation due to a fall and pain. During a concurrent interview and record review on 6/17/2026 at 10:00 a.m., with MDSN 1, Resident 3's records, including a progress note, dated 1/28/2026, were reviewed. The progress note indicated Resident 3 returned to the facility from the GACH on 1/28/2026. The progress note indicated Resident 3 had an acute (a sudden) fracture to the medial malleolus (bony bump on the inner side of the ankle) and distal fibula (a bony bump on the outside of the ankle). MDSN 1 stated she was responsible for completing the MDS assessments for the facility. MDSN 1 stated Resident 3's fall with fracture, hospital transfer, increased pain, and decline in ability to ambulate (walk) independently should have prompted the facility to evaluate Resident 3 for a significant change in status assessment. MDSN 1 stated the MDS assessment process was used to identify changes in a resident's condition and ensure the resident's care plan accurately reflected the resident's current needs. MDSN 1 stated when a resident had a significant change in condition, the facility was required to complete a significant change in status assessment after the significant change was identified. MDSN 1 stated there was no documented evidence that a significant change MDS assessment was completed after Resident 3's fall with fracture on 1/28/2026. MDSN 1 stated the facility should have completed the assessment to evaluate Resident 3's current needs related to mobility, fall risk, pain, ADL assistance, and care planning after the fracture. During an interview on 6/17/2026 at 1:00 p.m., with the Director of Nursing (DON), the DON stated residents who experience a fall with injury should be assessed to determine whether the resident had a significant change in condition. The DON stated a significant change in status MDS should be completed when the resident's condition declined and the change required review and revision of the resident's care and services. The DON stated the interdisciplinary team (IDT- a coordinated group of healthcare professionals who collaborate and evaluate comprehensive care for a resident) should have evaluated Resident 3's fall, left ankle fracture, and need for additional safety, care and services approaches. The DON stated failure to complete a significant change in status MDS assessment may have delayed identification of the resident's current needs, and negatively affect care planning and the delivery of necessary care and services. The DON stated this placed Resident 3 at risk for continued falls, injury, weakness, decline in ADLs, and further decline in overall condition. During a review of the facility's policy and procedure (P&P) titled Resident Assessment, revised 10/2023, the P&P indicated the facility was mandated to complete a comprehensive MDS assessment for any significant change in resident's status.

Based on observation, interview, and record review, the facility failed to implement and follow physician orders for orthostatic blood pressure (the measurement of blood pressure changes that occur from a sitting or lying position to a standing position) monitoring and recording for one of three sampled residents (Residents 24). This failure had the potential to place Resident 24 at risk for undetected orthostatic hypotension, dizziness, syncope (fainting), falls, injury, delayed medical intervention, and adverse cardiovascular complications related to changes in blood pressure upon position changes.Findings: During a review of Resident 24's admission Record, the admission Record indicated the facility admitted Resident 24 on 2/14/2024. Resident 24's diagnoses included depressive disorder (a serious mood disorder characterized by a persistent low mood, loss of interest and low energy, lasting at least two weeks), muscle weakness, dysphagia (difficulty in swallowing), hepatic encephalopathy (a serious decline in brain function due to severe liver disease), hypotension (low blood pressure), and orthostatic hypotension (a sudden drop in blood pressure that occurs when you stand up after sitting or lying down). During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2026, the MDS indicated Resident 24's mental capacity was intact. The MDS indicated that Resident 24 was partially dependent (helper does less than half the effort) on staff to complete activities of daily living. During a review of Resident 24's History and Physical (H&P) dated 6/5/2026, the H&P indicated Resident 24 had the capacity to make medical decisions. During a review of Resident 24's physician order dated 4/10/2026, the order indicated to monitor and record Resident 24's orthostatic blood pressure. The order indicated to record the lying blood pressure, wait for 5 minutes and then have Resident 24 sit and check the sitting blood pressure in the morning every Sunday. Notify the medical doctor if the systolic blood pressure's difference is 20 millimeters of mercury (mmHg, a unit for measuring blood pressure) or if the diastolic blood pressure's difference is 10 mmHg or more, or if the resident complains of lightheadedness, dizziness, or vision changes. During a review of Resident 24's physician order dated 6/4/2026, the order indicated to monitor and record Resident 24's orthostatic blood pressure. The order indicated to record the lying blood pressure, then wait for 5 minutes, and then have the resident sit and check the sitting blood pressure, in the morning every Sunday. Notify the medical doctor if the systolic blood pressure's difference is 20 mmHg or if the diastolic blood pressure's difference is 10 mmHg or more, or the resident complains of lightheadedness, dizziness or vision changes. During a review of Resident 24's Weights and Vitals Summary record for the months of May and June 2026, the records did not indicate that on 5/3/2026, 5/10/2026, 5/17/2026, 5/24/2026, 6/7/2026 and 6/14/2026, Resident 24's orthostatic blood pressures were monitored. During a concurrent interview and record review on 6/17/2026 at 2:53 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 24's Physician Orders for May and June 2026, the Weight and Vital Summary records dated May and June 2026, were reviewed. The physician orders indicated orthostatic blood pressure monitoring. The Weight and Vital Summary records did not indicate orthostatic blood pressure readings were documented. LVN 1 stated that the absence of documented orthostatic blood pressure monitoring indicated that the ordered assessments were either not completed or not recorded. LVN 1 stated that it was important to follow the physician orders and consistently monitor orthostatic blood pressures as prescribed to assess for changes in Resident 24's cardiovascular status, identify symptoms such as dizziness or hypotension, and ensure timely intervention when abnormalities were identified. LVN 1 stated that failure to perform and document orthostatic blood pressure monitoring as ordered could place the resident at risk for undetected changes in condition, falls, injury, and delayed medical evaluation. During a concurrent interview and record review on 6/17/2026 at 3:24 p.m., with the Director of Nursing (DON), Resident 24's Physician Orders for May and June 2026 and the Weight and Vital Summary records for May and June 2026 were reviewed. The DON stated that there was a physician order for orthostatic blood pressure monitoring to be completed as prescribed, including Sundays. Upon review of the records, the DON stated that orthostatic blood pressure readings were not documented on multiple Sundays and agreed that the facility was unable to demonstrate that the ordered monitoring had been completed. The DON stated that nursing staff were expected to follow all physician orders as written and accurately document completed assessments in the medical record. The DON stated that orthostatic blood pressure monitoring was an important assessment used to identify changes in blood pressure associated with position changes, monitor for symptoms of dizziness or hypotension, and evaluate a resident's risk for falls and injury. During a review of the facility's policy and procedure (P&P) titled, Physician Orders: Orders/Receiving/transcribing dated 7/2024, the P&P indicated, Physician Orders are obtained to provide a clear direction in the care of the resident. During a review of the facility's P&P titled Blood Pressure, Measuring dated 10/2025, the P&P indicated, to measure orthostatic blood pressure, follow steps to obtain blood pressure reading while sitting or lying down and immediately after helping the resident to a standing position. Note the changes in both the systolic and diastolic measurements compared to the reading taken while the resident was in a seated position. The P&P indicated the following information should be recorded in the resident's medical record:1. The date and time the blood pressure was measured.2. The name and title of the individual(s) who measured the blood pressure.3. The blood pressure reading.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer (PU- localized damage to the skin and/or underlying tissue usually over a bony prominence) prevention interventions were implemented for two of two sampled residents (Residents 32 and 52), by failing to: 1. Ensure Resident 32 received timely repositioning. 2. Ensure Resident 52's low air mattress (LAM- a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) was set according to the resident's weight. These failures had the potential to place Residents 32 and 52 at risk for pressure ulcer development and/or worsening skin integrity. Findings: a. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 32's diagnoses included muscle weakness, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right lower leg, unstageable pressure ulcer (a severe wound where the true depth and tissue damage cannot be seen because it is completely obscured by dead tissue) of sacral region (near tailbone), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 32's Minimum Data Set ([MDS], a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 32's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 32 was entirely dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 32's History and Physical (H&P), dated 3/16/2026, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's Care Plan titled, ADLs, initiated 1/30/2025, the care plan indicated to check Resident 32 at least every two hours for wetness or soiling and as needed. During a review of Resident 32's Braden Scale for Predicting Pressure Sore Risk Assessment (an evidence-based clinical assessment tool used to predict a patient's risk of developing pressure injuries [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence]), dated 4/27/2026, the assessment indicated Resident 32 was a very high risk for the development of a pressure ulcer. During a review of Resident 32's Care Plan titled, Skin Integrity Impaired, initiated 5/10/2026, the care plan indicated to turn and reposition Resident 32 at least every two hours. During an observation on 6/16/2026 at 9:33 a.m., in Resident 32's room, observed Resident 32's Turning Schedule (undated) posted at head of the bed. The schedule directed staff to reposition Resident 32 every two hours by alternating the resident's position between the back and side-facing positions. During an observation on 6/16/2026 at 2:03 p.m., Resident 32 was observed lying on her back in bed. The turning schedule indicated Resident 32 was to be positioned facing the window. During a phone interview on 6/16/2026 at 8:10 a.m. with Family Member (FM) 1, FM 1 stated, on 6/15/2026, during the 3:00 p.m. to 11:00 p.m. shift, the certified nursing assistant (CNA) did not change and reposition Resident 32 from the hours of 2:30 p.m. and 6:30 p.m. FM 1 stated that Resident 32 was changed around 2:30 p.m. by the previous shift and Resident 32 soiled herself shortly after. FM 1 stated Resident 32 was not changed until 6:30 p.m. FM 1 stated that the CNAs were supposed to reposition Resident 32 every two hours because she had a history of pressure sores and needed to be changed timely. During a phone interview on 6/16/2026 at 12:35 p.m. with CNA 3, CNA 3 stated she was assigned to Resident 32 during the 3 p.m. to 11 p.m. shift on 6/15/2026. CNA 3 stated she recalled being unable to reposition Resident 32 at 4 p.m. because she was assisting another resident. CNA 3 stated it was crucial for Resident 32 to be cleaned and repositioned promptly given Resident 32's risk of developing a pressure ulcer. During a concurrent interview and record review on 6/17/2026 at 10:50 a.m. with the Director of Staff Development (DSD), Resident 32's Turning and Repositing Flow Sheet, dated 6/2026, was reviewed. The flow sheet did not indicate Resident 32 was repositioned on 6/3/2026 at 11:00 p.m., 6/4/2026 at 11:00 p.m., 6/5/2026 at 11:00 p.m., 6/9/2026 at 11:00 p.m., and 6/11/2026; 7:00 a.m. to 1:00 p.m. The DSD stated the CNAs were expected to document the repositioning and turning of residents every two hours, document repositioning after care, and document resident refusals when applicable. The DSD stated documentation should be completed timely to accurately reflect care provided. The DSD stated that because the repositioning was not documented as completed every two hours, there was potential for Resident 32 to develop a pressure ulcer. The DSD stated Resident 32's documentation was not completed timely. The DSD stated Resident 32's medical record could not verify whether repositioning was performed. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, revised 7/2023, the P&P indicated to choose a frequency for the residents' repositioning based on the resident's risks factors, and to reposition all residents with or at risk of pressure injuries on an individualized schedule. During a review of the facility's P&P titled, Repositioning, revised 7/2024, the P&P indicated the facility staff were to check the care plan, assignment sheet or the communication system to determine resident-specific positioning needs. During a review of the facility's P&P titled, Charting and Documentation, revised 7/2025, the P&P indicated the facility was to ensure documentation in the medical record would be complete, and accurate. b. During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and muscle weakness (loss of muscle strength). During a review of Resident 52's H&P, dated 1/15/2026, the H&P indicated Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52's cognitive skills for daily decision making was intact. The MDS indicated Resident 52 was dependent (helper does all the effort) on staff for ADLs. During a review of Resident 52's physician order, dated 4/15/2026, the physician order indicated Resident 52 was to have a low air loss mattress (LAM) with the setting adjusted to 210-pound (Lbs., a unit of measuring weight). During a review of Resident 52's care plan titled LAM, dated 1/14/2026, the care plan indicated Resident 52 required a low air mattress with the setting maintained at 210 Lbs. The care plan indicated the intervention as a part of Resident 52's pressure ulcer prevention and skin integrity management. During a review of Resident 52's record titled Weights and Vitals Summary, dated 6/1/2026, the record indicated on 6/1/2026, Resident 52's weighed 198 pounds. During an observation on 6/15/2026 at 10:43 a.m., and 6/15/2026 at 2:45 p.m., at Resident 52's bedside, Resident 52 was observed lying on a LAM. The LAM setting was observed at 280 pounds. During an interview on 6/16/2026 at 1:45 p.m., with the Director of Nursing (DON), the DON stated Resident 52's weight was 198 pounds. The DON stated the LAM should have been set according to the resident's weight and the physician order to provide appropriate pressure redistribution. The DON stated staff were expected to check the mattress setting and ensure it matched the physician order and care plan. The DON stated Resident 52's mattress was not set according to the resident's weight and ordered 210-pound setting. The DON stated this failure had the potential to reduce the effectiveness of pressure redistribution provided by the LAM and placed Resident 52 at risk for increased pressure to bony prominences, skin breakdown, pressure ulcer development, and/or worsening skin integrity. During a review of the facility's P&P titled Air Mattress, undated, the P&P indicated the purpose of using special air mattresses was to decrease pressure from the resident's weight in bed, and to promote the healing of or the prevention of pressure ulcers. The P&P further indicated to monitor the mattress to assure that it is functioning properly, and that air level assures that the resident's body does not touch the bed. During a review of the facility's record titled, Drive: Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System Operating Manual, undated, the record indicated to determine the resident's weight and set the control knob to that weight setting on the control unit.

Based on interview and record review, the facility failed to ensure behavior episodes and the number of hours of sleep were monitored for two of five sampled residents (Resident 2 and Resident 11) receiving psychotropic medication (any drug that changes brain function resulting in alteration to mood, thoughts, feelings or behavior).These failures had the potential to place Resident 2 and 11 at risk for unnecessary psychotropic medication use and unidentified and unaddressed changes in behavior.Findings:1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included chronic obstructive pulmonary disorder (COPD, a chronic lung disease causing difficulty in breathing), pneumonia (an infection/inflammation in the lungs), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 2's History and Physical (H&P) dated 6/4/2026, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 4/28/2026, the MDS indicated Resident 2 had moderate cognitive skills for daily decision making (ability to think and understand). The MDS indicated Resident 2 was dependent on staff for toileting, bathing and required setup assistance for eating.During a concurrent interview and record review on 6/16/2026 at 12:02 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 2's medical record and physician orders dated 6/2/2026 were reviewed. The physician order indicated, Quetiapine Fumarate (Seroquel, medication used to treat schizophrenia by improving thinking, mood and behavior) Oral Tablet 25 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount). Give 1 tablet by mouth every 12 hours for schizophrenia manifested by visual hallucinations of seeing people in the ceiling. The physician order also indicated, Monitoring of behavior episodes of schizophrenia manifested by sudden angry outburst as evidenced by increased agitation and aggressiveness every shift for Seroquel. The medical records did not indicate there was a physician order for the behavior monitoring of Resident 2's visual hallucinations. LVN 2 stated the behavior monitoring order for Seroquel was incorrect, and monitoring of Resident 2's visual hallucinations should have been ordered instead. LVN 2 stated monitoring Resident 2's visual hallucinations was important to ensure effectiveness of medication regimen and to determine the need of physician reassessment.During a concurrent interview and record review on 6/16/2026 at 12:27 p.m. with the Quality Assurance (QA) Nurse, Resident 2's Psychotherapeutic Drug Informed Consent Form dated 6/1/2026 and medical records were reviewed. Resident 2's Psychotherapeutic Drug Informed Consent Form for Seroquel indicated a behavioral manifestation of visual hallucination of seeing people in the ceiling. Resident 2's medical records did not indicate there was a physician order for the behavior monitoring of Resident 2's visual hallucinations. The QA Nurse stated failure to ensure the correct behavior manifestation was being monitored placed resident at risk of inadequate monitoring and unidentified and unaddressed changes in behavior.2. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and depression (mental health condition that causes deep feelings of sadness and loss of interest in activities).During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 had no cognitive impairment. The MDS indicated Resident 11 required substantial assistance from staff for toileting, bathing, and setup assistance for eating.During a concurrent interview and record review on 6/17/2026 at 10:08 a.m. with Registered Nurse (RN) 1, Resident 11's physician orders dated 5/18/2026 and medical records were reviewed. The physician orders indicated, trazadone hydrochloride (medication used to regulate mood and sleep) oral tablet 50 mg. Give 1.5 tablet by mouth at bedtime for depression manifested by verbalization of difficulty in sleeping due to current health condition. The medical records did not indicate there was a physician order for monitoring Resident 11's hours of sleep. RN 1 stated Resident 11's hours of sleep should have been monitored to ensure the medication was effective. RN 1 stated monitoring the effectiveness of medications was important to ensure resident's issues were being properly addressed and physician was notified if any changes in regimen were needed.During an interview with the Director of Nursing (DON) on 6/18/2026 at 10:03 a.m., the DON stated monitoring for the indicated behavior of psychotropic medications was important to ensure the medication was effective in treating the manifested behavior. The DON stated failure to monitor the indicated behavior placed Resident 11 at risk of improper medication management as staff would not be able to assess if the medication was treating the behavior, and therefore would not be able to notify the physician for adjustments in medication regimen.During a review of the facility's Policy and Procedure (P&P), titled, Behavioral Assessment, Intervention and Monitoring revised 3/2019, the P&P indicated, when medications were prescribed for behavioral symptoms, documentation would include specific target behaviors, expected outcomes, monitoring for efficacy and adverse consequences.

Based on interview and record review, the facility failed to ensure the consultant pharmacist's Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication, to the physician) recommendation was reviewed, addressed, and followed up with the physician for pain management therapy and non-pharmacological interventions for one of two sampled residents (Resident 3). This failure had the potential to affect Resident 3's pain management, comfort, and quality of care.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), fracture of the right fibula (calf bone), and muscle weakness (loss of muscle strength). During a review of Resident 3's History and Physical (H&P), dated 10/23/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS]- a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 3's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 3 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 3's care plan titled Pain, dated 10/21/2025, the care plan indicated to administer Oxycodone-Acetaminophen (a medication used to treat pain) as ordered by the physician. The care plan indicated to monitor non-pharmacological interventions. During a review of Resident 3's physician order, dated 3/11/2026, the physician order indicated to administer Oxycodone-Acetaminophen 10-325 milligrams (mg, a unit of dose measurement), one tablet by mouth every four hours as needed (PRN) for severe pain 7-10 (pain scale 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain). During a concurrent interview and record review on 6/16/2026 at 1:30 p.m., with the Director of Nursing (DON), Resident 3's Medication Regimen Review (MRR) dated 5/1/2026 through 5/7/2026, was reviewed. The MRR indicated the consultant pharmacist recommended pain management therapy and documentation of non-pharmacological interventions prior to administering each as needed (PRN) dose of Oxycodone- Acetaminophen to Resident 3. The MRR did not indicate the physician was notified of the pharmacist's recommendation. The DON stated there was no documentation that the physician reviewed the MRR or addressed the recommendation. The DON stated Resident 3 did not have documented non-pharmacological interventions, and the consultant pharmacist's recommendation was not communicated to Resident 3's physician. The DON stated non-pharmacological interventions were necessary for Resident 3 to help manage pain prior to administering PRN pain medication. The DON stated non-pharmacological interventions may include repositioning, offering rest periods, applying comfort measures, and encouraging relaxation techniques, based on the resident's needs. The DON stated the facility failed to ensure the consultant pharmacist's drug regimen review recommendation was communicated to Resident 3's physician. The DON stated this failure had the potential to affect Resident 3's pain management, comfort, and quality of care. During a review of the facility's policy and procedure (P&P) titled Consultant Pharmacist Reports, dated 6/2021, the P&P indicated the consultant pharmacist informs the Director of Nursing (DON) about resident-specific medication irregularities and provides recommendations. The P&P indicated the DON was responsible for acting on these recommendations and reports to the physician.

Based on interview and record review, the facility failed to revise the care plan for one of two sampled residents (Resident 3) after the resident experienced a fall on 1/28/2026, which resulted in a fracture (a broken bone). This failure had the potential to result in ineffective care, treatment, and services for Resident 3, and placed the resident at increased risk for additional falls, injury, and unmet care needs. Cross reference F637Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), fracture of the right fibula (calf bone), and muscle weakness (loss of muscle strength). During a review of Resident 3's History and Physical (H&P), dated 10/23/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS]- a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 3's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 3 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).The MDS indicated Resident 3 required supervision or touching (helper provides verbal cues and/or contact guard assistance as resident competes activities) assistance from staff for sitting on the side of the bed and/or standing position. During a concurrent interview and record review on 6/15/2026 at 9:14 a.m., at Resident 3's bedside, with Resident 3, Resident 3 was observed lying in bed. Resident 3 stated she had a fall at the facility in 1/2026, which resulted in a left ankle fracture. Resident 3 stated prior to the fall, she was able to walk. Resident 3 stated currently she could not walk and/or get out of bed without staff assistance. During a concurrent interview and record review on 6/17/2026 at 9:16 a.m., with MDS Nurse (MDSN) 1, Resident 3's situation, background, assessment, recommendation ([SBAR]- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/28/2026, was reviewed. The SBAR indicated on 1/28/2026 at 2:55 p.m., Resident 3 was walking in the hallway with two staff members when she lost her balance, twisted her left ankle, and fell backward to the floor. MDSN 1 stated the SBAR indicated Resident 3 complained of left ankle pain rated at 7out of 10, on a pain scale (0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-10= severe pain). MDSN 1 stated the SBAR indicated Resident 3 was transferred to the general acute care hospital (GACH) for evaluation due to a fall and pain. During a concurrent interview and record review on 6/17/2026 at 10:00 a.m., with MDSN 1, Resident 3's records, including a progress note, dated 1/28/2026, were reviewed. The progress note indicated Resident 3 returned to the facility from the GACH on 1/28/2026. The progress note indicated Resident 3 had an acute (a sudden) fracture to the medial malleolus (bony bump on the inner side of the ankle) and distal fibula (calf bone). MDSN 1 stated Resident 3's care plan should have been revised with updated and individualized nutritional interventions to address the significant change of a fall with injury. MDSN 1 stated new updated interventions were necessary to help prevent falls, injury, and ADL decline. During a concurrent interview and record review on 6/17/2026 at 10:15 a.m., with MDSN 1, Resident 3's care plan titled Risk for falls, dated 10/21/2025, was reviewed. The care plan did not indicate additional or revised interventions after Resident 3's fall and left ankle fracture were identified. MDSN 1 stated Resident 3 had a care plan that addressed the resident's risk for fall; however, the care plan was not revised with additional individualized interventions after Resident 3's fall on 1/28/2026 which resulted in a left ankle fracture. During an interview on 6/17/2026 at 1:00 p.m., with the Director of Nursing (DON), the DON stated residents who experience falls and injuries should have their comprehensive care plans reviewed and revised to include updated interventions based on the resident's current condition and needs. The DON stated licensed staff should have evaluated Resident 3's fall and left ankle injury and updated the care plan with resident centered interventions to address the resident's risk for falls and injury. The DON stated these updated interventions would guide staff in providing consistent care for Resident 3 and help ensure staff were aware of the resident's current fall risks and care needs. The DON stated failure to revise the care plan after a fall with injury placed Resident 3 at risk for inadequate care and services, further falls, injury, and decline in ADLs. During a review of the facility's policy and procedure (P&P) titled Care Plan- Comprehensive Person- Centered, dated 1/2025, the care plan indicated a comprehensive care plan was developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. The P&P indicated the care plans were revised as needed on changes in resident's conditions.

Based on observation, interview, and record review, the facility failed to ensure two of four staff-dependent sampled residents' (Resident 25 and Resident 39) fingernails were trimmed and maintained in a clean manner. This failure had the potential to result in a negative impact on Resident 25 and Resident 39's quality of life and self-esteem and had the potential to result in sustaining an injury from scratching and developing an infection.Findings: a. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 25's diagnoses included hypertension (HTN- high blood pressure), anxiety (a feeling of fear), and muscle weakness (loss of muscle strength). During a review of Resident 25's History and Physical (H&P), dated 2/16/2026, the H&P indicated Resident 25 had fluctuating capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 4/30/2026, the MDS indicated Resident 25's cognitive skills for daily decision making (the ability to think and process information) was intact. The MDS indicated Resident 25 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During a review of Resident 25's care plan titled ADLs, dated 7/25/2025, the care plan indicated the staff would keep Resident 25's fingernails clean and short. During an observation on 6/15/2026 at 9:14 a.m., at Resident 25's bedside, Resident 25's fingernails were observed long and untrimmed with dark brown debris underneath the nail bed. During a concurrent observation and interview on 6/17/2026 at 1:35 p.m., in Resident 25's room, with Certified Nursing Assistant (CNA) 1, Resident 25's fingernails were observed. Resident 25's fingernails were long and untrimmed. CNA 1 stated Resident 25's fingernails were sharp, long and required trimming. CNA 1 stated nail care was one of the responsibilities of the CNA which included trimming and cleaning the resident's fingernails when they became long and dirty. CNA 1 stated residents' nails should be checked daily to ensure the nails remained clean and neat. CNA 1 stated residents sometimes scratched their skin, and if they scratched hard enough, they could break the skin and create an open wound. CNA 1 stated if a resident had dirty fingernails and scratched themselves, this increased the risk of infection. b. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), HTN, and muscle weakness. During a review of Resident 39's H&P, dated 5/7/2026, the H&P indicated Resident 39 had fluctuating capacity to understand and make decisions. During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39's cognitive skills for daily decision making was intact. The MDS indicated Resident 39 was dependent (helper does all the effort) on staff for ADLs. During a review of Resident 39's care plan titled ADLs, dated 5/6/2026, the care plan indicated staff would keep the resident's fingernails clean and short. During a concurrent observation and interview on 6/15/2026 at 10:28 a.m., at Resident 39's bedside, with Resident 39, Resident 39 was observed with long fingernails. Resident 39's fingernails were untrimmed with visible black debris underneath the fingernails. Resident 39 stated staff had not assisted with trimming or cleaning the nails. During an interview on 6/17/2026 at 1:45 p.m., with CNA 1, CNA 1 stated Resident 39 required staff assistance with personal hygiene and ADL care, including nail care. CNA 1 stated Resident 39's nails should be checked daily to ensure the nails remained clean and neat. During an interview on 6/17/2026 at 1:58 p.m., with the Director of Nursing (DON), the DON stated staff were expected to provide assistance with ADL care and keep residents' fingerprints clean and short. The DON stated nail care should be assessed daily. The DON stated residents who required assistance with cleaning or trimming their nails should be assisted by the CNA's or licensed nurses. The DON stated fingernails were a source of bacteria, and dirty or untrimmed nails could contribute to the spread of infection, especially among residents who may not be able to maintain their own hygiene. The DON stated routine nail care was an essential part of both personal hygiene and infection control. The DON stated the facility failed to ensure residents' fingernails were kept clean and trimmed. The DON stated this placed Residents 25 and 39 at risk for poor hygiene, discomfort, skin breakdown, and infection. During a review of the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care of, revised 2/2018, the P&P indicated residents' nails will be kept clean and trimmed to prevent infection, scratches, and injuries.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- a federal assessment requirement to help ensure individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care and referred to special services as needed) Level 2 evaluation was completed for one of one sampled residents (Resident 1).This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included pneumonia (an infection/inflammation in the lungs), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P) dated 5/12/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/24/2026, the MDS indicated Resident 1 had no cognitive impairment (ability to think and understand). The MDS indicated Resident 1 required partial assistance from staff for personal hygiene. The MDS indicated Resident 1 required substantial assistance with toileting and setup assistance for eating.During a review of Resident 1's Preadmission Screening and Resident Review (PASARR) level 1 screening dated 1/26/2024, the PASARR indicated the need for a Level 2 PASARR evaluation.During a concurrent interview and record review on 6/17/2026 at 12:19 p.m. with the Social Services Director (SSD), Resident 1's PASARR Level 2 Determination Letter dated 1/26/2024 and medical records were reviewed. Resident 1's medical records indicated a PASARR Level 2 evaluation had not been completed. The PASARR Level 2 Determination Letter indicated Resident 1 required a level 2 PASARR evaluation, but it was not completed because the individual was unable to participate in the evaluation. The SSD stated, Resident 1 either refused to participate or was not in the facility when the PASARR Level 2 evaluation was attempted. The SSD stated staff should have submitted another PASARR Level 1 screening to prompt another PASARR level 2 evaluation. The SSD stated PASARR evaluations were important to ensure residents were appropriately screened for mental illnesses, ensure resident placement was accurate, and referrals were made to appropriate programs and services.During an interview with the Director of Nursing (DON) on 6/18/2026 at 10:03 a.m., the DON stated PASARR evaluations were important to ensure resident placement was appropriate and resources such as programs and services were coordinated depending on resident needs.During a review of the facility's Policy and Procedure (P&P), titled, Preadmission Screening and Resident Review dated 4/2017, the P&P indicated, Level 2 full evaluation shall be conducted by a Department of Health Care Services (DHCS) Contractor for determination when the Level 1 screen identifies the resident having Mental Illness (MI) or Intellectual Disability (ID).

Based on interview and record review, the facility failed to ensure a Urologist (medical doctor who specializes in treating diseases of the urinary tract in both men and women, as well as the male reproductive system) was consulted in a timely manner as ordered on 1/19/2026, and upon readmission to the facility on 2/20/2026 for one of one sampled residents (Resident 5) with an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine). This failure had the potential to place Resident 5 at risk for indwelling catheter related complications such as urinary tract infections (UTI- an infection in the bladder/urinary tract) and sepsis (a life-threatening blood infection).Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included hydronephrosis (swelling of a kidney caused by a backup of urine), hypertension (HTN-high blood pressure), presence of urogenital implants (medical device surgically placed in the body to support or replace the function of the urinary and reproductive organs), and obstructive reflux uropathy (a blockage in the urinary tract and backward flow of urine from the bladder into the kidneys). During a review of Resident 5's History and Physical (H&P) dated 1/20/2026, the H&P indicated Resident 5 did not have the capacity to understand or make medical decisions. During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 5/18/2026, the MDS indicated Resident 5 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 5 required moderate assistance from staff for personal hygiene and substantial assistance for toileting and lower body dressing. The MDS indicated Resident 5 had an indwelling catheter. During a review of Resident 5's physician order dated 2/20/2026, the physician order indicated, Foley (indwelling urinary catheter) catheter diagnosis obstructive reflux uropathy. 1. During a concurrent interview and record review on 6/17/2026 at 9:41 a.m. with Case Manager (CM) 1, Resident 5's physician order dated 1/19/2026 was reviewed. The physician order indicated Urology consultation upon availability for possible suprapubic [(foley catheter) a flexible tube surgically inserted directly into the bladder through an incision in the lower abdomen] placement. CM 1 stated she called the urology office on 2/6/2026 and started the consult process by faxing Resident 5's face sheet. CM 1 stated she should have initiated the consult process sooner, within the week the urology consult order was placed. CM 1 stated typically the urology office would call within 72 hours of receiving the resident's face sheet to coordinate an appointment. CM 1 stated the urology office never called to coordinate an appointment, and then Resident 5 was hospitalized on [DATE]. CM 1 stated she should have followed up with the urology office to ensure the required documents were received and the urology consult appointment was scheduled. CM 1 stated a urologist would have been more knowledgeable about Resident 5's obstructive reflux uropathy and able to better manage his care. CM 1 stated failure to ensure the urologist was consulted for a resident with a chronic indwelling foley catheter placed the resident at risk for recurrent urinary tract infections and complications such as sepsis (a life-threatening blood infection). During an interview on 6/17/2026 at 9:58 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 5's urology consult should have been initiated and completed when the initial order was placed on 1/19/2026. RN 1 stated the urologist consult was important because of Resident 5's chronic indwelling catheter. 2. During a concurrent interview and record review on 6/17/2026 at 10:17 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 5's physician order dated 6/3/2026 was reviewed. The physician order indicated, Urology consult when available, pending insurance authorization. LVN 3 stated Family Member (FM) 2 requested a urology consult for Resident 5. LVN 3 stated when she spoke with Resident 5's physician, he agreed with the necessity of the consult and ordered a urology consult. During an interview on 6/17/2026 at 9:41 a.m. with CM 1, CM 1 stated when Resident 5 was readmitted to the facility on [DATE], the urology consult order should have been placed. CM 1 stated Resident 5's physician wanted all of his previous orders reinstated, and the urology consult was never reordered. CM 1 stated she should have followed up on Resident 5's urology consult when the resident was readmitted to the facility. During an interview on 6/17/2026 at 9:58 a.m. with Registered Nurse (RN) 1, RN 1 stated although Resident 5 was hospitalized , the urology consult should still have been followed up on upon readmission to the facility. RN 1 stated the urologist consult was important because of Resident 5's history of having a chronic indwelling catheter, recurrent UTI's, and hospitalizations. RN 1 stated Resident 5's care would have been better managed if a urologist was overseeing his care. RN 1 stated failure to ensure the urologist was consulted placed Resident 5 at further risk for UTI's and sepsis. During an interview on 6/18/2026 at 10:03 a.m. with the Director of Nursing (DON), the DON stated the case manager should have followed up on the Urologist consult in a timely manner. The DON stated it was the facility's policy to facilitate and help coordinate resident access to medical specialists. During a review of the facility's Policy and Procedure (P&P) titled, Referral to Medical Specialist dated 1/2024, the P&P indicated, Purpose: to ensure timely, appropriate, and coordinated referral of residents to medical specialists when indicated by clinical condition, physician recommendation, or resident/family request.

Based on observation, interview, and record review, the facility failed to follow the menu and standardized recipes for one of four sampled residents (Resident 31).This failure had the potential for affecting Resident 31's meal satisfaction. FindingsDuring a review of Resident 31's admission Record, the admission Record indicated the facility admitted the resident on 3/13/2026 with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (loss of muscles strength), and hypertension (HTN-high blood pressure).During a review of Resident 31's History of Physical (H&P), dated 3/16/2026, the H&P indicated Resident 31 could make needs known but cannot make medical decisions.During a review of Resident 31's Minimum Data Set (MDS- a resident assessment tool), dated 4/6/2026, the MDS indicated Resident 31's cognition (the ability to understand and process information) was intact. The MDS indicated Resident 31 was dependent (helper does all the effort) on staff for activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 31's physician diet order, dated 4/2/2026, the physician's order indicated Resident 31 was to receive a regular texture consistent carbohydrate diet, with no salt added.During a concurrent observation and interview on 6/15/2026, at 12:34 p.m. at Resident 31's bedside, Resident 31's lunch tray was observed to contain a sandwich with meat and cheese. Resident 31 stated he did not request cheese with the sandwich.During an interview and record review on 6/17/2026 at 10:16 a.m. with the Dietary Supervisor (DS), the lunch menu recipe titled French Dip Sandwich for 6/15/2026 was reviewed. The DS stated the recipe included roast beef, salt, pepper, and a soft French roll. The DS stated the recipe did not include cheese. The DS stated the importance of following recipes consistently to avoid placing Resident 31 at risk for receiving food items that could cause food allergies, or items the resident dislikes.During a concurrent interview on 6/17/2026 at 3:13 p.m., with [NAME] 1, [NAME] 1 stated the facility was responsible for following the facility's established recipes. [NAME] 1 stated when residents request any addition to their meals, such as adding cheese, this should be indicated on the resident's meal ticket. [NAME] 1 stated the facility did not follow the French dip sandwich recipe on 6/15/2026 because Resident 1 did not request cheese. [NAME] 1 stated this had the potential to place Resident 31 at risk for may not liking his meal.During a review of the facility's policy and procedure (P&P) titled [NAME] Job Description undated, the P&P indicated [NAME] responsibilities were to review menus prior to preparation of food.prepare meals in accordance with planned menus.prepare food in accordance with standardized recipes.

Based on observation, interview, and record review, the facility failed to timely develop a comprehensive care plan for one out of three sampled residents (Resident 1), who refused to wear a hearing aid (a small electronic device worn in or behind the ear to amplify [increase] sounds, designed to help people with hearing loss).This failure had the potential for miscommunication and Resident 1's needs not being met. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included systolic (congestive) heart failure ([CHF], a heart disorder that causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 1's care plan titled, Resident has difficulty hearing staff, dated 11/9/2022, the care plan indicated Resident 1 received hearing aids. The care plan goal indicated for Resident 1 to be able to hear effectively during conversation. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 6/2/2025, the MDS indicated Resident 1 had moderate cognitive (ability to think, remember and solve problems) impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for Activities of Daily Living (ADLs) such as showering/bathing self and putting on/taking off footwear. The MDS indicated Resident 1 had minimal difficulty in hearing (in some environments such as when a person speaks softly or setting is noisy).During a concurrent observation and interview on 8/11/2025 at 10:20 a.m. with Resident 1 in Resident 1's room, Resident 1 stated, she could not hear and was observed not wearing hearing aids. During a concurrent observation and interview on 8/11/2025 at 10:36 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, CNA 1 was observed speaking directly into the resident's ear. CNA 1 stated, Resident 1 refused to wear her hearing aids. During an interview on 8/11/2025 at 2:46 p.m. with the Social Services Director (SSD), the SSD stated she offered Resident 1 hearing aids in the past and the resident refused to wear them. During a concurrent interview and record review on 8/12/2025 at 11:03 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's care plan titled, Resident has difficulty hearing staff, dated, 11/9/2022 was reviewed. LVN 2 stated that Resident 1 often refused to wear their hearing aid and communicated with Resident 1 by speaking closer to Resident 1's ear. LVN 2 stated that hearing aids were part of Resident 1's care and her refusal should have been care-planned when constant refusal was identified, however was not done.During an interview on 8/12/2025 at 2:41 p.m. with the Director of Nursing (DON), the DON stated, staff should have initiated a care plan to address Resident 1's refusal to wear her hearing aid when the problem was first identified. During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P also indicated, The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2), received proper treatment and assistive devices to maintain hearing abilities by failing to:Assist Resident 1 when the resident reported her hearing aids did not work properlyAssist Resident 2 when the resident reported he had concerns with hearing and ensure Resident 2 was assessed by the Otolaryngologist ([ENT doctor] specializing in the care for ear, nose and throat conditions) routinely.These failures had the potential for Residents 1 and 2 not being able to hear adequately during conversations with staff and other residents and could lead to misunderstanding or miscommunication between the residents and staff. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included systolic (congestive) heart failure ([CHF], a heart disorder that causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 1's care plan titled, Resident has difficulty hearing staff, dated 11/9/2022, the care plan indicated Resident 1 received hearing aids. The care plan goal indicated for Resident 1 to be able to hear effectively during conversation. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 6/2/2025, the MDS indicated Resident 1 had moderate cognitive (ability to think, remember and solve problems) impairment. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for Activities of Daily Living (ADLs) such as showering/bathing self and putting on/taking off footwear. The MDS indicated Resident 1 had minimal difficulty in hearing (in some environments such as when a person speaks softly or setting is noisy).During a concurrent observation and interview on 8/11/2025 at 10:20 a.m. with Resident 1 in Resident 1's room, Resident 1 stated, she could not hear and was observed not wearing hearing aids. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 2's diagnoses included metabolic encephalopathy (a change in the brain's function due to an underlying cause).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident did not have cognitive impairment. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance) for ADLs such as bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on the bed), and transfers. The MDS indicated Resident 2 had minimal difficulty in hearing and did not use a hearing aid or hearing appliance. During a concurrent observation and interview on 8/11/2025 at 11:49 a.m., with Resident 2 in Resident 2's room, Resident 2 stated, he couldn't hear as well as he used to and believed he needed hearing aids. Resident 2 stated he had informed the Social Services Director (SSD) (date/time not specified) of his concern regarding his hearing but had not received any follow-up. During a concurrent interview and record review on 8/12/2025 at 9:52 a.m., with Medical Records (MR), Resident 2's ENT Doctor exams were reviewed. MR stated Resident 2's most recent ENT exam was on 9/24/2024.During an interview on 8/12/2025 at 10:29 a.m. with Certified Nurse Assistant (CAN) 1, CNA 1 stated Resident 1 notified her that her hearing aids did not work and had informed Licensed Vocational Nurse (LVN) 2 and the SSD (date not specified). During an interview on 8/12/2025 at 11:03 a.m. with LVN 2, LVN 2 stated he was not aware of Resident 1's report that the resident's hearing aids did not work. LVN 2 stated Resident 1 was hard-of-hearing and had seen Resident 1 without her hearing aids and had to communicate with the resident by coming in closer while speaking with her.During a concurrent interview and record review on 8/12/2025 at 12:12 p.m., with the SSD, Resident 1's hearing exam, dated 5/18/2025, Resident 2's hearing exam, dated 9/25/2024, and Social Service Progress Notes for Resident 2 were reviewed. SSD stated all residents should be seen routinely by the ENT doctor every six months or at least twice a year. The SSD stated Resident 2 should have been seen by the ENT doctor on 05/2025 however the resident was not. The SSD also stated there was no documentation to indicate why Resident 2 was not seen by the ENT in 05/2025. The SSD stated there should have been documentation from Social Services to ensure Resident 2's hearing needs were assessed routinely.During an interview on 8/12/2025 at 2:24 p.m., with the Director of Nursing (DON), the DON stated CNAs should report and document any concerns with resident hearing devices as soon as they're identified so the resident's devices could be fixed as needed. During a review of facility's undated Job Description for, Director of Social Services, the job description indicated, General Duties and Responsibilities included: Coordinate social service activities with other departments as necessary and assure that the social service progress notes are informative and descriptive of the services provided and of the resident's response to the service.During a review of facility's undated policy and procedure (P&P) titled, Hearing Aid, Care of, the P&P indicated, The purpose of this procedure is to maintain the resident's hearing at the highest attainable level. The P&P indicated to, Assess the resident's knowledge of operating the hearing aid and to report complaints to the nurse supervisor.

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one of three sampled residents (Resident 1) who had a diagnosis of osteopenia (a decrease in bone mineral density and causes bones to get weaker). This deficient practice had the potential for staff not to properly care for Resident 1 and placed the resident at risk for further injuries and fractures (broken bone). Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included fracture, contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused the joints to shorten and become very stiff) and other specified disorders of bone density and structure of the right shoulder. During a review of Resident 1's History and Physical (H&P), dated 1/14/2025, 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 11/22/2024, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 was totally dependent on staff for activities of daily living (ADLs) such as eating, oral hygiene, toileting hygiene, showering, upper body dressing, bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on the bed) and transfers. During a review of Resident 1's X-ray (image of the structures inside of the body, its organs and other internal structures for diagnostic purposes) Report dated 4/24/2021, the Report indicated Resident 1 had diffused osteopenia. During a review of Resident 1's care plan titled, Diffuse Osteopenia, Risk for: Joint deformities, pain, spontaneous fracture, decline Range of Motion (ROM), dated 3/15/2025, the care plan interventions included to handle resident gently during care especially when moving, turning and repositioning the resident and to observe for joint bone pain and stiffness and notify doctor accordingly. During an interview with the Director of Nursing (DON) on 5/5/2025 at 11:08 a.m., the DON stated the care plan for osteopenia did not have the location of the osteopenia. The DON stated the purpose of the care plan was to guide the care of the residents and the care plan should have been more specific for the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure interventions to prevent the development or worsening of pressure ulcers (PU, localized damage to the skin and/or underlying tissue usually over a bony prominence) were implemented for four of seven sampled residents (Residents 288, 74, 23, and 191) when: 1. Low-air-loss-mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) settings were incorrect for Residents 288, 74, and 191. 2. Resident 23 was not provided with a LALM as ordered by the resident's physician. 3. Resident 191's LALM was labeled with the wrong resident's name and weight settings. These deficient practices placed Residents 288, 74, 23, and 191 at risk for the development or worsening condition of existing pressure ulcers. Findings: 1. During an interview on 3/26/2025 at 9:15 a.m., with the Treatment Nurse (TN), the TN stated LALMs created air flow to stabilize pressure within the mattress, and relieved pressure placed on the resident's skin. The TN stated the LALM settings were based on the residents' weight, and stated the higher the weight setting, the more firm the mattress. The TN stated she, or any licensed nurse, could adjust the settings on the LALM to ensure that the settings were accurate to the resident's weight. The TN stated that if the LALM settings were not correct, there was the potential for a new PU to develop or for existing PUs to worsen. a. During a review of Resident 288's Admission Record, the Admission Record indicated Resident 288 was admitted to the facility on [DATE]. Resident 288's admitting diagnoses included generalized muscle weakness and other symptoms and signs involving the musculoskeletal system. During a review of Resident 288's Minimum Data Set (MDS, a resident assessment tool), dated 3/8/2025, the MDS indicated Resident 288 had severe cognitive impairment (a significant decline in cognitive abilities that interferes with daily functioning and daily living). The MDS indicated Resident 288 had impairments to her lower extremities (legs) on both sides of her body and was dependent for staff for mobility while in and out of bed. The MDS indicated Resident 288 was at risk for developing PUs. During a review of Resident 288's active physician order, dated 3/6/2025, the order indicated Resident 288 was to have a low air loss mattress (LALM) for wound management, at the 150-pound (lb., a unit of measuring weight) setting. During a review of Resident 288's weekly weight record, dated 3/25/2025, the record indicated Resident 288 weighed 154 lbs. on 3/25/2025. During an observation on 3/24/2025 at 2:18 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed on a LALM. The mattress settings were set at the 350-lb. setting. During an observation on 3/25/2025 at 12:45 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed on a LALM. The mattress settings were set at the 350-lb. setting. During an observation on 3/26/2025 at 8:40 a.m., at Resident 288's bedside, Resident 288 was observed lying in bed on a LALM. The mattress settings were set for the 350-lb. setting. During a concurrent interview and record review, on 3/26/2025 at 9:19 a.m., with the TN, Resident 288's LALM physician order dated 3/6/2025, and weight measurement record dated 3/25/2025, were reviewed. The TN stated the physician order indicated Resident 288's LALM was to be set at the 150-lb. setting, and stated Resident 288's most recent weight was 154 lbs. During a concurrent observation and interview, on 3/26/2025 at 9:20 a.m., at Resident 288's bedside, with the TN, the TN stated Resident 288's LALM was set for the 350-lb. setting, and stated this was not the correct setting. b. During a review of Resident 74's Admission Record, the Admission Record indicated Resident 74 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 74's admitting diagnoses included generalized muscle weakness, Stage 3 PU (full-thickness loss of skin, dead and black tissue may be visible) to the tailbone region, and Stage 4 PU (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) to the left hip, and Stage 2 PU (partial-thickness loss of skin, presenting as a shallow open sore or wound) to an unspecified buttock. During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74 did not have any cognitive impairments. The MDS indicated Resident 74 required substantial to maximal assistance from staff to roll left and right while in bed. The MDS indicated Resident 74 had unhealed PUs and was at risk for developing additional PUs. During a review of Resident 74's active physician order, dated 1/24/2025, the order indicated Resident 74 was to have a LALM for wound management. During a review of Resident 74's monthly weight record, dated 3/3/2025, the record indicated Resident 74 weighed 140 lbs. on 3/3/2025. During an observation on 3/25/2025 at 8:56 a.m., at Resident 74's bedside, observed Resident 74's LALM set for the 280-lb. setting. During a concurrent observation and interview on 3/25/2025 at 10:31 a.m., with Resident 74, at Resident 74's bedside, observed Resident 74's LALM set for the 280-lb. setting. Resident 74 stated the LALM was for his wounds, and stated that he would like for the mattress to be softer. Resident 74 stated the mattress was very firm, that when he woke up every morning his back hurt. Resident 74 stated the LALM was supposed to be set for his weight, and asked if the mattress could be softer. During an observation on 3/26/2025 at 8:47 a.m., at Resident 74's bedside, observed Resident 74's LALM set for the 250-lb. setting. During a concurrent interview and record review, on 3/26/2025 at 9:24 a.m., with the TN, Resident 74's LALM physician order dated 1/24/2025, and weight measurement record dated 3/3/2025, were reviewed. The TN stated Resident 74 had orders for a LALM, and stated Resident 74's most recent weight was 140 lbs. The TN stated Resident 74's LALM settings should be set according to Resident 74's weight. During a concurrent observation and interview on 3/26/2025 at 9:25 a.m., at Resident 74's bedside, with the TN, observed Resident 74's LALM set for the 250-lb. setting. The TN stated this was not the correct setting for the resident and stated it should be set for the 150-lb. setting. 2. During a review of Resident 23's Admission Record, the Admission Record indicated Resident 23 was admitted to the facility on [DATE]. Resident 23's admitting diagnoses included symptoms and signs involving the musculoskeletal system and osteonecrosis (a condition where bone tissue dies due to a loss of blood supply) to his left arm. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 had mild cognitive impairment. The MDs indicated Resident 23 required substantial to maximal assistance from staff to roll from left to right while in bed. The MDS indicated Resident 23 was at risk for developing PUs. During a review of Resident 23's active physician order, dated 2/28/2025, the order indicated Resident 23 was to have a LALM for wound management. During an observation on 3/25/2025 at 9:12 a.m., at Resident 23's bedside, Resident 23 was observed lying in bed. Resident 23 did not have an LALM mattress in place. During an observation on 3/25/2025 at 12:50 p.m., at Resident 23's bedside, Resident 23 was observed lying in bed. Resident 23 did not have an LALM mattress in place. During an observation on 3/26/2025 at 8:44 a.m., at Resident 23's bedside, Resident 23 was observed lying in bed. Resident 23 did not have an LALM mattress in place. During a concurrent interview and record review, on 3/26/2025 at 9:27 a.m., with the TN, Resident 23's active physician orders were reviewed. The TN stated Resident 23 had orders for a LALM. During a concurrent observation and interview on 3/26/2025 at 9:27 a.m., at Resident 23's bedside, with the TN, the TN stated Resident 23 did not have a LALM mattress as ordered by the physician. The TN stated she could not state why Resident 23 did not have a LALM mattress. 48131 3. During an observation on 3/24/2025 at 10:05 a.m., Resident 191's room, observed Resident 191 lying in bed on a LALM. The LALM control indicated the bed was set at 130 lbs. The LALM control was labeled with another resident's name and indicated the LALM should be set to 80 lbs. During a review of Resident 191's Admission Record, the admission record indicated Resident 191 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 191's diagnoses iincluded Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the right and left lower legs, congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), sepsis (a life-threatening blood infection), and chronic kidney disease (damaged kidneys that cannot filter blood properly over a long period). During a review of Resident 191's History and Physical (H&P), dated 2/5/2025, the H&P indicated Resident 191 did not have the capacity to understand and make decisions. During a review of Resident 191's MDS, dated [DATE], the MDS indicated Resident 191's cognition was severely impaired. The MDS indicated Resident 191 was dependent (helper does all the effort) on staff for oral hygiene, toileting and bathing. During a review of Resident 191's Order Summary Report dated 3/26/2025, the order summary report indicated Resident 191 was ordered a LALM every shift for wound management on 3/14/2025. During a review of Resident 191's Order Summary Report dated 3/26/2025, the order summary report indicated Resident 191 was ordered a LALM set to 120 lbs. per the resident's weight of 115 lbs. every shift for wound management on 3/26/2025. During a review of Resident 191's care plan titled, Alteration in Skin Integrity: Actual Pressure Sore, undated, the care plan indicated Resident 191 had an unstageable (a type of full-thickness skin and tissue loss where the wound bed is covered by dead tissue making it impossible to determine the true depth or stage) PU to the coccyx (tailbone). The care plan goal indicated Resident 191's PU would decrease in size in the next 30 days and the risk for further skin breakdown would be reduced every day for three months. The care plan interventions indicated to use a LALM as ordered. During a review of Resident 191's care plan titled, Resident is incontinent (the inability to control the bladder [the organ that stores urine] or bowels [the organ responsible for digesting food and eliminating waste]) of Bowel and Bladder, undated, the care plan indicated Resident 191 was at risk for skin impairment and pressure sores. The care plan goal indicated Resident 191 would minimize the risks for skin impairments related to incontinence in the next three months. The care plan interventions indicated to use a pressure reducing mattress if necessary. During a review of Resident 191's Weight and Vitals Summary record, dated 3/26/2025, the Weights and Vitals Summary record indicated Resident 191 weighed 115 lbs. on 3/18/2025 and 3/25/2025. During a review of Resident 191's Braden Scale (measures the risk for development of a pressure sore) dated 3/21/2025, the Braden Scale indicated Resident 191 was chairfast (cannot walk safely and confined to a chair or wheelchair), had very limited (unable to make frequent or significant changes in position independently) mobility and was at high risk of developing PUs. During a concurrent observation and interview on 3/24/2025 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 191's LALM controls were observed. LVN 2 stated the LALM was for the wrong resident. LVN 2 stated the name and setting on the label was for a different resident and should not have been placed on Resident 191's LALM. LVN 2 stated having the wrong label on Resident 191's LALM could lead to confusion and an inaccurate weight setting. LVN 2 stated an inaccurate weight setting on Resident 191's LALM would cause the bed to not be therapeutic and cause skin issues if not set to the correct setting of 130 lbs. but labeled for at 80 lbs. LVN 2 stated the LALM was for the wrong patient and was not the right label or setting for Resident 191. LVN 2 stated having the wrong label and wrong LALM may have an inaccurate weight and could cause confusion. LVN 2 stated instead of being therapeutic for the resident it can cause more skin issues if it was not at set at the correct setting. During a concurrent interview and record review on 3/26/2025 at 10:29 a.m. with the TN and the Quality Assurance Nurse (QAN), Resident 191's weight was reviewed. The QAN stated Resident 191's weight was 115 lbs. and the LALM for the resident should have been set according to the resident's weight. The TN stated the LALM was administered to the wrong resident and the LALM was not set to the correct setting for Resident 191. The TN stated if Resident 191's LALM was not set according to the resident's weight, the resident's PU could worsen. The QAN stated the licensed nurse assigned to Resident 191 was responsible for ensuring the LALM was set according to the resident's weight and that the bed was labeled correctly. The QAN stated the licensed nurse did not double check to make sure Resident 191 was in the right bed. During an interview on 3/27/2025 at 10:08 a.m. with the Director of Nursing (DON), the DON stated the LALM was used to distribute airflow based on the resident's weight to prevent skin break down. The DON stated the licensed nurses should have made rounds to ensure Resident 191's LALM was set according to her weight. During a review of the facility's policy and procedure (P&P) titled Air Mattress, undated, the P&P indicated the purpose of using special air mattresses was to decrease pressure from the resident's weight in bed, and to promote the healing of or the prevention of pressure ulcers. The P&P further indicated to monitor the mattress to assure that it is functioning properly, and that air level assures that the resident's body does not touch the bed. During a review of the facility document titled Treatment Nurse Job Description, undated, the document indicated the treatment nurse was required to administer treatments as prescribed and implement interventions as indicated and as ordered by the physician. During a review of the facility's document titled, Drive: Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System Operating Manual, undated, the document indicated to determine the resident's weight and set the control knob to that weight setting on the control unit.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for three of 19 sampled residents (Residents 23, 19, and 24) were completed and documented accurately. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Residents 23, 19, and 24's health status. This deficient practice also created the potential for Residents 23, 19, and 24 to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being. Findings: 1. During a review of Resident 23's Admission Record, the Admission Record indicated Resident 23 was admitted to the facility on [DATE]. Resident 23's admitting diagnoses included oropharyngeal phase dysphagia (swallowing problems occurring in the mouth and/or the throat). During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 3/6/2025, the MDS indicated Resident 23 had mild cognitive impairment (a condition where memory and thinking problems are noticeable but not severe enough to interfere with daily activities). The MDS indicated Resident 23 required substantial to maximal assistance from staff to roll from left to right while in bed. The MDS did not indicate Resident 23 had any dental concerns, including broken natural teeth or fragments of teeth. During an observation on 3/25/2025 at 9:43 a.m., Resident 23 was observed with foul mouth odor and poor/missing dentition. The teeth present were black in color and appeared broken and/or fragmented. During an interview on 3/26/2025 at 10:48 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated one of the purposes of the MDS assessment was to assist with care planning and to ensure residents received the care they needed. The MDSN stated that the MDS identifies the care areas that need to be addressed. During a concurrent interview and record review, on 3/26/2025 at 10:54 a.m., with the MDSN, Resident 23's MDS Section L, dated 3/6/2025, was reviewed. The MDSN stated she completed Resident 23's MDS dated [DATE], and stated the MDS did not indicate Resident 23 had any dental concerns. The MDSN stated Resident 23's current dental status met the MDS criteria for obvious or likely broken teeth and stated Resident 23's MDS was not accurate. The MDSN stated the MDS assessment should be accurate and stated an inaccurate MDS assessment could lead to Resident 23 not receiving necessary dental care. 51684 2. During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), dementia (progressive state of decline of mental abilities), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently) and muscle weakness. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24's cognitive skills was intact. The MDS indicated Resident 24 required maximum assistance from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves.) During concurrent observation and interview on 3/24/2025 at 11:13 a.m., in Resident 24's room, Resident 24 was observed sitting up in bed with no upper and lower teeth. Resident 24 stated she did not have any natural teeth and oft or puree foods. During a concurrent interview and record review on 3/25/2025 at 3:05 p.m., with the MDSN, Resident 24's MDS, dated [DATE] was reviewed. The MDSN stated Resident 24's MDS oral/dental assessment was coded incorrectly and did not reflect the resident's actual oral and/or dental status. The MDSN stated because Resident 24 did not have natural teeth, and the MDS should have been coded correctly. The MDSN stated inaccuracy of the MDS assessment had the potential to result in not meeting the resident's care needs and services. 3. During a review of Resident 19's Admission Record, the facility admitted Resident 19 on 9/28/2023 and readmitted Resident 19 on 1/14/2025 with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (loss of muscle strength), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and anxiety (feeling of fear). During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 19 required maximum (helper does more than half the effort) assistance from staff for ADL's. During a telephone interview on 3/24/2025 at 2:59 p.m., with Resident 19's responsible party (RP 1), RP 1 stated Resident 19 did not have any natural teeth and was on a pureed diet (foods that have been blended or mashed into a smooth, pudding-like consistency). During an observation on 3/26/2025 at 9:40 a.m., in the facility's dining room, Resident 19 was observed sitting up in wheelchair eating pureed food with no upper and lower teeth. During a concurrent interview and record review on 3/26/2025 at 9:46 a.m., with the MDSN, Resident 19's MDS, dated [DATE] was reviewed. The MDSN stated she was aware of Resident 19 not having any natural teeth. The MDSN stated Resident 19's MDS oral/dental status assessment was coded incorrectly and did not reflect the resident's actual oral and/or dental status. The MDSN stated because Resident 19 did not have natural teeth, the MDS should have been coded correctly. The MDSN stated inaccuracy of the MDS assessment had the potential to result in not meeting the resident's care needs and services. During a review of the facility's policy and procedure (P&P) titled Certified Accuracy of the Resident Assessments, revised on 11/2019, the P&P indicated any person completing a portion of the Minimum Data Set must sign and certify the accuracy of that portion of the assessment. The P&P also indicated the information captured on the resident assessment should reflect the status of the resident.

Based on observation, interview, and record review, the facility failed to ensure care plans (a document that outlines a resident's care needs, diagnosis, and treatment goals) were developed and/or implemented for two of 19 sampled residents (Residents 288 and 191) when: 1. Resident 288 did not have padding on her siderails. 2. Resident 191, who was receiving oxygen, did not have an oxygen sign posted outside her doorway. These deficient practices placed Resident 288 at risk for physical harm and injury and had the potential to delay necessary monitoring and safety interventions (actions nurses take to help residents achieve their care plan goals) related to Resident 191's oxygen administration. Findings: 1. During a review of Resident 288's Admission Record, the admission record indicated Resident 288 was admitted to the facility on [DATE]. Resident 288's admitting diagnoses included epilepsy (a neurological condition characterized by recurrent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]). During a review of Resident 288's Minimum Data Set (MDS, a resident assessment tool), dated 3/8/2025, the MDS indicated Resident 288 had severe cognitive impairment (a significant decline in cognitive abilities that interferes with daily functioning and daily living). The MDS indicated Resident 288 had impairments to her lower extremities (legs) on both sides of her body and was dependent for staff for mobility while in and out of bed. During a review of Resident 288's care plan titled High risk for trauma/injuries related to: Seizure Disorder, dated 3/6/2025, the care plan indicated staff were to apply padding to both siderails while the resident was in bed. During an observation on 3/24/2025 at 2:29 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed with metal siderails to both sides of her bed. No padding was applied to either siderail. During an observation on 3/25/2025 at 1:38 p.m., at Resident 288's bedside, Resident 288 was observed lying in bed with metal siderails to both sides of her bed. No padding was applied to either siderail. During an interview on 3/26/2025 at 2:52 p.m., with Registered Nurse Supervisor (RN) 1, RN 1 stated that when a resident has a diagnosis of seizure disorder, staff were to apply padding to the siderails of the bed. During a concurrent interview and record review on 3/26/2025 at 2:54 p.m., with RN 1, Resident 288's care plan titled High risk for trauma/injuries related to: Seizure Disorder, dated 3/6/2025, was reviewed. RN 1 stated the care plan indicated Resident 288 had a diagnosed seizure disorder and the care plan interventions indicated Resident 288 was to have padding on both of her siderails. RN 1 stated the purpose of padding the siderails was to prevent injury if Resident 288 were to have a seizure while in bed. During a concurrent observation and interview, 3/26/2025 at 2:56 PM, at Resident 288's bedside, with RN 1, Resident 288 was observed lying in bed with her head leaning against the siderail on the right side of her bed. RN 1 stated there was no padding to either of Resident 288's siderails. RN 1 stated Resident 288 was at risk for injury and could hurt herself if she were to have a seizure. 48131 2. During an observation on 3/24/2025 at 10:05 a.m., in Resident 191's room, observed Resident 191 lying in bed receiving supplemental oxygen via a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at three liters per minute. Observed Resident 191's room did not have an oxygen sign posted outside of the room's doorway. During a review of Resident 191's Admission Record, the admission record indicated Resident 191 was initially admitted on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), dependence on supplemental oxygen, pneumonia (an infection/inflammation in the lungs), congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 191's History and Physical (H&P), dated 2/5/2025, the H&P indicated Resident 191 did not have the capacity to understand and make decisions. During a review of Resident 191's MDS, dated [DATE], the MDS indicated Resident 191's cognition was severely impaired. The MDS indicated Resident 191 was dependent (helper does all the effort) on staff for oral hygiene, toileting and bathing. During a review of Resident 191's Order Summary Report dated 3/26/2025, the order summary report indicated an order for oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 2 liters per minute (LPM) every shift for hypoxia. During a review of Resident 191's care plan titled, Congestive Heart Failure, undated, the care plan indicated Resident 191 had potential shortness of breath (difficulty breathing), chest pains, irregular pulse (heart rate), and elevated blood pressure (the force of your blood pushing against the walls of your blood vessels (like the tubes that carry blood) as your heart pumps) related to compromised cardiac (heart) function. The care plan interventions indicated to administer continuous oxygen at 2 LPM. During a concurrent interview and record review on 3/26/2025 at 12:40 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 191's care plans were reviewed. LVN 3 stated she could not find a care plan regarding Resident 191's oxygen administration. LVN 3 stated an oxygen care plan was important because it would have oxygen parameters, when to call the doctor and how to use the oxygen safely. LVN 3 stated the MDS Nurse (MDSN) usually initiates a care plan upon admission, or any licensed nurse can initiate the oxygen care plan. LVN 3 stated if Resident 191's oxygen was started after admission, a change of condition should have been initiated along with an oxygen care plan. During an interview on 3/26/2025 at 12:48 p.m. with the MDSN, the MDSN stated the use of oxygen should be care planned. The MDSN stated the admitting nurse should have updated the care plans. The MDSN stated Resident 191's oxygen care plan should have been restarted when she was readmitted to the facility. The MDSN stated without a care plan there are no interventions (the actions a nurse takes to help residents achieve their health goals) on how to monitor Resident 191's oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) and when to call the doctor. The MDSN stated without an oxygen care plan, Resident 191's oxygen therapy was not being monitored and there were no goals or outcomes of when to discontinue the resident's oxygen. During an interview on 3/27/2025 at 10:03 AM with the Director of Nursing (DON), the DON stated there should be a care plan for oxygen therapy. The DON stated moving forward, the facility would ensure an oxygen care plan was done for all residents receiving oxygen so that the nursing staff would know the parameters, when to call the doctor, when to change the tubing and apply the oxygen signage. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the care plan described the services staff were to provide to allow the resident to achieve their highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P&P titled Bed Safety and Bed Rails, revised 8/2022, the P&P indicated additional safety measures were to be implemented for residents identified as having a higher than usual risk for injury. During a review of the facility's P&P titled, Resident Assessment: Care Planning - Interdisciplinary Team, undated, the P&P indicated the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized care plan for each resident and the care plan is based on the resident's comprehensive assessment.

Based on interview and record review, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR, a screening tool that helps identify possible serious mental illness [SMI], and if the resident requires specialized services) was submitted for one of four sampled residents (Resident 74). This deficient practice placed Resident 74 at risk of not receiving recommended or required treatments for diagnosed SMIs, or appropriate placement in a facility to meet Resident 74's needs. Findings: During a review of Resident 74's Admission Record, the Admission Record indicated Resident 74 was admitted on [DATE] and was most recently readmitted on [DATE]. Resident 74's admitting diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and anxiety disorder (a group of mental health conditions characterized by excessive and persistent fear or worry, often interfering with daily life). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment tool), dated 2/5/2025, the MDS indicated Resident 74 did not have any cognitive impairments (difficulties with thinking, learning, remembering, and making decisions). The MDS indicated Resident 74 required substantial to maximal assistance from staff for bed mobility. During a review of Resident 74's Level I PASRR assessment, dated 1/15/2025, the Level I PASRR assessment indicated the individual completing the assessment was to indicate whether the resident had a diagnosed SMI. Resident 74's Level I PASRR did not reflect his SMI diagnoses of psychosis, depression, or anxiety disorder. During a review of Resident 74's PASRR determination letter, dated 1/15/2025, the determination letter indicated Resident 74 did not require a Level II PASRR Mental Health Evaluation because the Level I PASRR indicated Resident 74 did not have any SMIs. During an interview on 3/26/2025 at 1:22 p.m., with the Social Services Director (SSD), the SSD stated that the Level I PASRR was completed by the hospital, prior to the resident's admission to the facility. The SSD stated she reviewed the Level I PASRR's upon the resident's admission to the facility. The SSD stated that if the Level I PASRR was not completed accurately by the hospital staff, she completed a new Level I PASRR for submission to the required agencies. During a concurrent interview and record review, on 3/26/2025 at 1:26 p.m., with the SSD, Resident 74's Level I PASRR, dated 1/15/2025, was reviewed. The SSD stated the Level I PASRR did not reflect Resident 74's SMIs of psychosis, depression, and anxiety disorder. The SSD stated a new and accurate Level I PASRR should have been completed and submitted but was not. The SSD stated the purpose of the PASRR assessment was to ensure residents received mental health services and recommendations, and an inaccurate assessment prevented the resident from receiving those services. During a review of the facility's policy and procedure (P&P) titled Preadmission Screening and Resident Review, dated 4/2017, the P&P indicated all residents admitted to the facility were to have a Level I PASRR completed to identify residents with serious mental illness (SMI) and ensure those residents received the services they required for their SMI, and in the appropriate setting.

Based on observation, interview, and record review, the facility failed to implement their system of infection prevention and control program for six of 6 sampled residents (49, 239, 4, 45, 289, 63) when: a. Certified Nursing Assistant (CNA) 5 did not wear personal protective equipment ((PPE) equipment designed to protect the wearer's body from infection that includes gowns, gloves, mask or goggles) upon entering an contact isolation (a form of isolation in which anyone entering the patient's room and having direct contact with the resident or environment wears PPE) rooms shared by Resident 49, 239, and 4. In addition to, CNA 5 did not perform hand washing after providing assistance to Resident 49. b. Resident 45's urinary drainage bag was observed touching the floor after CNA 5 provided activities of daily living (ADL-daily activities that a resident perform such as feeding, bathing, dressing, grooming) care. c. Licensed Vocational Nurse (LVN) 3 was observed not wearing PPE while inside the contact isolation room shared by Residents 289 and 63. d. Housekeeping Staff (HK) 2 did not wear PPE upon entering the contact isolation room shared by Residents 49, 239 and 4. e. Resident 4 was fixing Resident 239's bed,who is on contact isolation, without wearing proper PPE. f. CNA 7 did not perform hand washing and did not wear PPE upon entering a contact isolation room shared by Residents 49, 239 and 4. g. Physical Therapy Assistant (PTA) 1 did not wear PPE upon entering the isolation room of Resident 45 and did not perform hand washing prior to providing therapy to the resident. h. The facility did not follow its policy and procedure by placing residents with known infection, which includes cohorting (grouping residents with common infection) residents and assessing possible roommates of residents on contact isolation, who have low risk of acquiring infections. These deficient practices had the potential to result in the spread of infections to other residents, staff, and visitors in the facility. Due to these deficient practices, the Administrator (ADM), Director of Nursing and Infection Preventionist (a person who is an expert on practical methods of preventing and controlling the spread of infectious diseases) were verbally notified of an Immediate Jeopardy (IJ) situation, on (MONTH) 25, 2019, at 6:26 p.m. This was determined due to the potential spread of infections to other residents, staff or visitors when contact isolation precautions and cohorting of isolated residents were not implemented by the facility. The written removal plan was accepted on (MONTH) 25, 2019, at 7:38 p.m. The IJ was removed in the presence of the ADM and the DON at the facility on (MONTH) 26, 2019, at 7:57 p.m., after the facility's plan of action was verified to have been implemented. Findings: a. A review of Resident 49's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. functioning). A review of Resident 49's History and Physical dated 7/9/19 indicated the resident does not have the capacity to understand and make decisions. On 8/24/19, at 5:43 a.m., during the initial tour of the facility, Certified Nursing Assistant (CNA) 5 entered the room shared by Residents 49, 239 and 4 without wearing PPE. CNA 5 entered the bathroom and gave a paper towel to Resident 49. CNA 5 was observed touching the environmental surfaces in the shared room including the bathroom door knob, the privacy curtain, and Resident 49's bedside table. CNA 5 left the room after giving the paper towel without washing her hands. Resident 49 called for help a second time and CNA 5 entered the room again without wearing PPE. CNA 5 picked up a roll of toilet paper that fell under the bed and gave it to Resident 49. The resident was coughing and used the roll of toilet paper to cover her mouth while coughing. CNA 5 did not perform hand washing before leaving the room. On 8/24/19, at 5:46 a.m., during an interview, CNA 5 stated Resident 49 asked for paper towels and toilet paper. CNA 5 stated the shared room of Residents 49, 239 and 4 has a sign posted by the door indicating, Contact isolation. CNA 5 stated the isolation is for Resident 239, but did not know what type of isolation. CNA 5 further stated she only wears PPE in the room if she is taking care of the Resident 239 who is on isolation. CNA 5 further stated she did not perform hand washing before leaving the isolation room. On 8/24/19, at 6:52 a.m., during an interview, Registered Nurse (RN) 3 stated Resident 239 was admitted to the facility on [DATE]. RN 3 stated he did the admission assessment. RN 3 further stated Resident 239 is in contact isolation for [MEDICAL CONDITION] (MRSA-drug resistant organism that can cause wound infections and infections of invasive devices such as catheters) of the nares and is receiving antibiotic (medicine used to treat infections) treatment for [REDACTED]. b. A review of Resident 45's Admission Record indicated the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. functioning) and neuromuscular dysfunction of the bladder (causes difficulty or full inability to pass urine without use of tube to drain urine). A review of Resident 49's History and Physical dated 8/21/19 indicated the resident has fluctuating capacity to understand and make decisions. A review of Resident 49's Order Summary Report dated 8/21/19 indicated the following orders: - Connect Foley catheter (an indwelling flexible tube inserted into the urinary tract to drain urine) 18FR (French - size of catheter) to bedside drainage bag (a device that collects the drained urine). - Foley catheter care daily and as needed every shift. A review of Resident 45's Progress Notes dated 8/23/19 indicated the resident is on isolation precautions and is on Meropenem (antibiotic) every 8 hours for ESBL (Extended Spectrum Beta Lactamase-a protein produced by a strain of bacteria that causes medications to be ineffective) of the urine. On 8/24/19, at 6:21 a.m., Resident 45's indwelling catheter drainage bag was observed touching the floor. Resident 45's bed was in a low position. On 8/24/19, at 6:27 a.m., during an interview, CNA 5 stated she placed Resident 45's bed to the lowest position after changing the resident's adult briefs. CNA 5 verified and stated Resident 45's indwelling catheter drainage bag was touching the floor. CNA 5 further stated the catheter drainage bag should not touch the floor to prevent contamination (the presence of undesirable organisms that may cause infection). On 8/24/19, at 12:54 p.m., during an interview, the Quality Assurance (QA) Nurse stated the indwelling catheter drainage bag should not touch the floor to prevent contamination. A review of the facility's policy and procedure titled, Indwelling Catheter, dated 5/14, indicated, .Urinary catheters are cared for by all licensed nursing personnel .Caution should be taken not to allow the ends of the spout to touch anything that will contaminate it . c. A review of Resident 289's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 289's Minimum Data Set (MDS - a comprehensive assessment and care planning tool) dated 8/16/19 indicated the resident's brief interview of mental status (BIMS- screens for cognitive impairment) score was 15 (a score of 13-15 indicates intact (cognition-process of acquiring knowledge and understanding through thought, experience, and the senses)), required extensive assistance with one-person physical assist with bed mobility, transfer, toilet use, personal hygiene and bathing. A review of Resident 289's Physician order [REDACTED]. - Contact precautions for Extended Spectrum Beta Lactamase (ESBL, a protein produced by a strain of bacteria that causes drug resistance) in the urine until further orders. - [MEDICATION NAME] (antibiotic) 500 milligrams (mg) intravenously (IV, in the vein) one time a day for urinary tract infection until 8/26/19. On 8/24/19, at 7:10 a.m., during an observation, LVN 3 was inside Resident 289's room while talking to the resident. LVN 3 was holding onto the privacy curtain with her right hand without any PPE (gowns and gloves). Resident 289's room was observed with a contact isolation sign (measures intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment) placed on top of an isolation cart (set of drawers containing PPE). Resident 289's roommate, Resident 63, was observed in his bed. A review of Resident 63's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 63's physician progress notes [REDACTED]. On 8/24/19, at 12:04 p.m., during an interview, the Director of Staff Development (DSD) stated, To prevent the spread of infection of ESBL, we do the contact precautions, we do (wear) gloves and wash hands. I am supposed to check that it is being followed. The DSD further stated, You wear your PPE before you enter an isolation room. You are supposed to wear gloves when you hold the curtain. The policy is before we enter an isolation room and when your body is inside, you are supposed to wear your PPE to prevent the spread of infections. On 8/25/19, at 7:04 a.m., during an interview, Registered Nurse (RN) 2 stated, We wear PPE when we do patient care. We wear PPE before we go inside. It is not okay not to wear PPE even if you just say hi to the resident. On 8/25/19, at 9:24 a.m., during an interview, Certified Nursing Assistant (CNA) 3 stated, When going to the isolation room, wear gown, gloves and all the PPE needed depending on what kind of isolation there is. When you leave the room, remove your PPE first and then you wash your hands. It is not okay to go inside the isolation room even if you don't touch the patient because it is an infected room. On 8/25/19, at 4:56 p.m., during an interview, Resident 289 stated staff sometimes do not wear the yellow gown when they come into the room to provide care. On 8/26/19, at 3:20 p.m., during an interview, the Assistant Director of Nursing (ADON) stated, The Admission coordinator is responsible for room assignments for new admissions. They also make the bed availability and they decide where to put the residents. I am not sure if they are aware of the cohorting. On 8/26/19, at 3:46 p.m., during a concurrent interview and record review, the ADON stated Resident 63 is vulnerable for development of infections due to his compromised condition. The ADON also stated Resident 63 is exposed to Resident 289's ESBL infection because they share a room. d. On 8/24/19, at 10:57 a.m., during an observation, Housekeeping Staff (HK) 2 was observed entering the room shared by Residents 49, 239 and 4. HK 2 did not wear PPE prior to entering the contact isolation room. On 8/24/19, at 11:56 a.m., during an interview, Licensed Vocational Nurse (LVN) 5 stated if a shared room is on contact isolation, all staff must wear PPE before entering the room. e-f. A review of Resident 239's admission record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 239's Order Summary Report dated 8/24/19, indicated an order for [REDACTED]. A review of Resident 4's Admission record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's History and Physical dated 6/18/19 indicated the resident had a history of [REDACTED]. On 8/24/19, at 11:25 [NAME]M., during an interview, Resident 239 stated she had a knee surgery a couple of days ago. Resident 239 stated she is not sure why she is on contact isolation. Resident 239 stated the hospital staff told her, I have a bug or something. Resident 239 further stated she is currently getting treatment for [REDACTED]. A review of Resident 239's Progress Notes dated 8/25/19, at 6:30 a.m., indicated, .Resident is a new admit. Resident is s/p (status [REDACTED]. On 8/25/19, at 9:04 a.m., during a concurrent observation and interview with RN 1, Resident 4 was observed fixing the bed of Resident 239. Resident 4 was not wearing any PPE while fixing the linen and blanket of Resident 239's bed. CNA 7 entered the shared isolation room of Residents 49, 239 and 4 without wearing any PPE. CNA 7 touched Resident 239 on the right shoulder and wheeled Resident 239 out of the room. CNA 7 did not perform hand washing before entering and after leaving the room. RN 1 stated every time anybody enters an isolation room, they have to wash hands and wear the appropriate PPE. RN 1 stated Resident 239 [MEDICAL CONDITION] of the nares and is currently receiving antibiotic treatment for [REDACTED]. g. On 8/25/19, at 3:05 p.m., during a concurrent observation and interview, Physical Therapy Assistant (PTA) 1 entered Resident 45's room without wearing PPE. PTA 1 did not perform hand washing, touched the privacy curtains in Resident 45's room. PTA 1 stated he did not see the isolation sign posted by the door when he entered Resident 45's room. A sign indicating, Stop was observed by the door of Resident 45's room and a sign indicating, Contact Isolation was observed on top of the isolation cart located outside the room by the door. On 8/25/19, at 3:15 p.m., during an interview, RN 1 stated he provided in-services only to the nursing department on 8/24/19 when staff have been observed to enter isolation rooms without wearing PPE. h. On 8/25/19, at 4:44 p.m., during an interview, the Director of Staff Development (DSD) stated she is also the Infection Control Nurse. The DSD also stated she is not the one responsible for room placement of residents being admitted with isolation precautions. The DSD was unable to give an answer when asked how residents are placed in the room together if they have an infection. On 8/25/19, at 4:55 p.m., during an interview, the Director of Nursing (DON) stated the facility did not follow its policy and procedure in cohorting Residents 45 and 289. The DON stated Residents 45 and 289 have the same microorganisms causing an infection. The DON also stated the facility did not follow its policy and procedure in placing Resident 239, who is on contact isolation [MEDICAL CONDITION], in a room with residents who are at low risk for acquisition (chances of getting the infection). The DON also stated Residents 49 and 4 have high risk of acquiring [MEDICAL CONDITION] because all of the residents use the same toilet. On 8/26/19, at 5:48 p.m., during an interview, the Admissions Coordinator (AC) stated she coordinates with a registered nurse on duty for room placement. The AC further stated it was RN 3 who determined the placement for Resident 239. A review of the facility's policy and procedure titled, Infection Control, dated 5/2018, indicated, .The facility maintains written standards, policies and procedures for the infection control program, which includes .When and how isolation should be used for a resident, including the type and duration of the isolation, depending upon the infectious agent or organism involved .The facility has designated the Director of Staff Development as the Infection Preventionist (IP) to oversee the infection control program .The IP utilizes the facility policies to address standard and transmission-based precautions . A review of the facility's policy and procedure titled, Infection Control-Enhanced Standard Precautions, dated 3/2017, indicated, .When single resident rooms are not available, residents with the same MDRO (multi-drug resistant organism (an organism that is hard to treat with antibiotics))will be cohorted in the same room .When cohorting residents is not possible, MDRO residents will be placed in rooms with residents who are at low risk for acquisition .Use contact precautions for specified patients known or suspected to be infected or colonized with epidemiologically (dealing with incidence, distribution and control of a disease) important microorganisms that can be transmitted by direct with the patient .Wash hands before and after utilizing gloves or coming in direct contact with resident/environment for 15-30 seconds .Gowns are worn to prevent the transfer of infectious agents from the resident's skin, clothing, bedding and environmental surfaces to the HCP (health care personnel) bare skin and clothing . c. A review of the admission record, indicated Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated Resident 43 had moderate cognitive impairment. During medication administration observation on 08/24/19 at 5:43 a.m., licensed vocational nurse (LVN 3) was observed wash hands, wear clean gloves and used the same gloves to close Resident 43's privacy curtains. LVN 3 was observed touch Resident 43's finger, stuck and obtain a blood sample to check the resident's blood sugar. However, LVN 3 did not change her gloves or perform hand hygiene. d. A review of the admission record, indicated Resident 84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated Resident 84 had no cognitive impairment. A review of a history and physical (H&P) dated 7/15/19, indicated Resident 84 had the capacity to understand and make decisions. During medication administration on 8/24/19 at 8:09 a.m., LVN 4 was observed wash hands,wear clean gloves, closed privacy curtains, and checked Resident 84's blood pressure wearing the same gloves. LVN 4 did not change gloves or perform hand hygiene. During an interview on 8/25/19 at 11:58 a.m., LVN 4 stated l should not touch potentially contaminated surfaces with clean gloves (bedside table, privacy curtains) then provide care to residents because of spread of infection. I should have removed my gloves and washed my hands. A review of the facility's policy titled Infection Control-Enhanced Standard Precautions dated 3/16, indicated to change gloves during the care of a resident to prevent cross contamination

Based on observation, interview, and record review, the facility failed to ensure care was provided to three out of ten sampled residents (Resident 1, 2 and 3) in a timely manner that enhanced their individual and dignity to prevent accidents. 1) Resident 1 who sustained a fracture to the distal left femoral (is the larger and stronger of the two bones in the leg below the knee) about knee stated, Nurses take a long time to respond to the call light. 2) Resident 2 stated who prefer to remain anonymous, Nurses take 40 minutes to answer call light and sometimes I just have to pee on my bed. 3) Resident 3 stated who prefer to remain anonymous, The 3-11 night shift takes up to 40 minutes to answer the call light and sometimes I need to request pain medication, but have to wait. These deficient practices resulted in injury and had the potential for the residents experiencing embarrassment, feeling humiliated and disrespected. (Cross refer to F246) On 7/25/17 at 2:29 p.m., an Immediate Jeopardy (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 declared for F241 and F246 and the facility's administrator (ADM, a person responsible for managing an organization) and the director of nursing (DON, a person who provides direction to the nursing staff and coordinate health services) were notified of the serious findings that threatened the health and safety of the residents. The IJ was lifted on 7/26/17 at 2:17 p.m. in the presence of the ADM and the DON after the facility provided an acceptable written plan of correction (P(NAME)). Findings: On 7/24/17 at 12:50 p.m., during an interview Resident 1 indicated sustaining a left knee fracture due to a fall when picking up a pillow while in the wheelchair. Resident 1 stated not calling the nurse because of the delay of response from the nurses to answer the call lights. On 7/24/17 at 12:59 p.m., during an observation, the light above room [ROOM NUMBER] was lighting up, but not audible to the facility staff. On 7/24/17 at 1:05 p.m., during an interview Certified Nurse Assistant (CNA 1) stated that call lights are only audible in the panel located at the nurses' station. On 7/24/17 at 3:30 p.m. during an observation of the nursing station, License Vocational Nurse (LVN 1) was observed on scrolling on her cell phone while the call light panel was wringing. During the concurrent interview LVN 1 stated she failed to answer the call light because she though other staffs were rounding. On 7/24/17 at 3:34 p.m., during an interview Resident 2 stated, The 3-11 night staff takes between 30-40 min to answer the call light; sometimes, someone will come in turn off the call light and say someone will come back. During the concurrent interview, Resident 2 stated peeing in the bed due to nurses not responding to the call light promptly. On 7/25/17 at 7:35 a.m., during an interview Resident 3 stated that staff from 3-11 night shift takes 40 minutes to answer the call lights. Resident 3 stated that this concern was discussed with Activity Assistant (AA) on the month of 6/17 council meeting. A review of the Resident's Council Meeting minutes for the months of 5/17 through 7/17 did not indicated any problems with the call lights for those months. On 7/25/17 at 9:05 a.m., during an interview and record review of the council minutes AA stated, One resident complained about the call lights and the roommates not been changed, but she did not documented the complaint on the council minutes because it wasn't something of concern. On 7/26/17 2:02 p.m., during a telephone interview Family member (F1) stated that nurses take between 10-20 minutes to answer call lights. F1 stated that Resident 1 sometimes calls her to asker to call the facility so that nurses can answer the call light and bring Resident 1's pain medication. On 7/25/17 at 1:51 p.m., during an interview and record review of a policy Director of Nursing (DON) stated that nurses should not be on their phone, and every facility staff is responsible to answer the call lights as soon as possible. A review of the facility's duties and responsibilities of the CNA included providing personal nursing care functions, which included answering resident's calls' as promptly as feasible, and assure that residents who are unable to call are checked regularly. A review of the undated facility's policy titled, Answering Call Light indicated all staff is responsible to answer call lights as soon as possible and if the staff responding to the call light is unable to assist resident, he/she will report the president's request/needs to licensed nurse or staff who can respond to the request.

Based on observation, interview and record review, the facility failed to ensure all residents' call lights were audible upon activation and that the facility's staff answered residents' call lights promptly for three of 10 alert residents. These failures resulted in residents not being accommodated and needs not being met, thus resulting in adverse resident outcomes. On 7/25/17 at 2:29 p.m., an Immediate Jeopardy (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 declared for F241 and F246 and the facility's administrator (ADM, a person responsible for managing an organization) and the director of nursing (DON, a person who provides direction to the nursing staff and coordinate health services) were notified of the serious findings that threatened the health and safety of the residents. The IJ was lifted on 7/26/17 at 2:17 p.m. in the presence of the ADM and the DON after the facility provided an acceptable written plan of correction (P(NAME)). Findings: On 7/24/17 at 12:50 p.m., during an interview Resident 1 indicated sustaining a left knee fracture due to a fall when picking up a pillow while in the wheelchair. Resident 1 stated not calling the nurse because of the delay of response from the nurses to answer the call lights. A review of the Admissions Record Face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. below the knee and fracture of lower end of left femoral (is the larger and stronger of the two bones in the leg below the knee). A review of Resident 1's Minimum Data Set (MDS, Resident Assessment and Care Screening) dated 6/23/17, indicated that Resident 1 was intact of cognitive skills for daily decision-making. MDS indicated Resident 1 required of one person physical assist for locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor) and required of a wheelchair as a mobility device. A review of the Fall Risk Assessment form dated 6/28/17 indicated Resident 1 was at high risk for fall. A review of the document facility's radiology report tittled, Patient Report, dated 7/15/17 indicated distal femoral fracture about left knee. A review of Resident 1's care plan titled, Risk for fall and related injuries, re-evaluated 6/17, indicated under approach plan (1) call light to be within reach, (2) frequent visual checks to ensure safety, and (3) encourage resident to wait for staff to assist with transfers. On 7/24/17 at 12:59 p.m., during an observation, the light above room [ROOM NUMBER] was lighting up, but not audible to the facility staff. On 7/24/17 at 1:05 p.m., during an interview Certified Nurse Assistant (CNA 1) stated that call lights are only audible in the panel located at the nurses' station. On 7/24/17 at 3:30 p.m. during an observation of the nursing station, License Vocational Nurse (LVN 1) was observed on scrolling on her cell phone while the call light panel was wringing. During the concurrent interview LVN 1 stated she failed to answer the call light because she though other staffs were rounding. On 7/24/17 at 3:34 p.m., during an interview Resident 2 stated, The 3-11 night staff takes between 30-40 min to answer the call light; sometimes, someone will come in turn off the call light and say someone will come back. During the concurrent interview, Resident 2 stated peeing in the bed due to nurses not responding to the call light promptly. On 7/25/17 at 7:35 a.m., during an interview Resident 3 stated that staff from 3-11 night shift takes 40 minutes to answer the call lights. Resident 3 stated that this concern was discussed with Activity Assistant (AA) on the month of 6/17 council meeting. A review of the Resident's Council Meeting minutes for the months of 5/17 through 7/17 did not indicated any problems with the call lights for those months. On 7/25/17 at 9:05 a.m., during an interview and record review of the council minutes AA stated, One resident complained about the call lights and the roommates not been changed, but she did not documented the complaint on the council minutes because it wasn't something of concern. On 7/26/17 2:02 p.m., during a telephone interview Family member (F1) stated that nurses take between 10-20 minutes to answer call lights. F1 stated that Resident 1 sometimes calls her to asker to call the facility so that nurses can answer the call light and bring Resident 1's pain medication. On 7/25/17 at 1:51 p.m., during an interview and record review of a policy Director of Nursing (DON) stated that nurses should not be on their phone, and every facility staff is responsible to answer the call lights as soon as possible. On 7/25/17 at 2:05 p.m., during an interview and observation of the call lights of the hall ways by rooms [ROOM NUMBERS] DON stated, You cannot hear the call lights from here, only at the nurse station. A review of the facility's duties and responsibilities of the CNA included providing personal nursing care functions, which included answering resident's calls' as promptly as feasible, and assure that residents who are unable to call are checked regularly. A review of the undated facility's policy titled, Answering Call Light indicated all staff is responsible to answer call lights as soon as possible and if the staff responding to the call light is unable to assist resident, he/she will report the president's request/needs to licensed nurse or staff who can respond to the request.

Based on observation, interview, and record review, the facility failed to ensure care was provided to three out of ten sampled residents (Resident 1, 2 and 3) in a timely manner that enhanced their individual and dignity to prevent accidents. 1) Resident 1 who sustained a fracture to the distal left femoral (is the larger and stronger of the two bones in the leg below the knee) about knee stated, Nurses take a long time to respond to the call light. 2) Resident 2 stated who prefer to remain anonymous, Nurses take 40 minutes to answer call light and sometimes I just have to pee on my bed. 3) Resident 3 stated who prefer to remain anonymous, The 3-11 night shift takes up to 40 minutes to answer the call light and sometimes I need to request pain medication, but have to wait. These deficient practices resulted in injury and had the potential for the residents experiencing embarrassment, feeling humiliated and disrespected. (Cross refer to F246) On 7/25/17 at 2:29 p.m., an Immediate Jeopardy (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 declared for F241 and F246 and the facility's administrator (ADM, a person responsible for managing an organization) and the director of nursing (DON, a person who provides direction to the nursing staff and coordinate health services) were notified of the serious findings that threatened the health and safety of the residents. The IJ was lifted on 7/26/17 at 2:17 p.m. in the presence of the ADM and the DON after the facility provided an acceptable written plan of correction (P(NAME)). Findings: On 7/24/17 at 12:50 p.m., during an interview Resident 1 indicated sustaining a left knee fracture due to a fall when picking up a pillow while in the wheelchair. Resident 1 stated not calling the nurse because of the delay of response from the nurses to answer the call lights. On 7/24/17 at 12:59 p.m., during an observation, the light above room [ROOM NUMBER] was lighting up, but not audible to the facility staff. On 7/24/17 at 1:05 p.m., during an interview Certified Nurse Assistant (CNA 1) stated that call lights are only audible in the panel located at the nurses' station. On 7/24/17 at 3:30 p.m. during an observation of the nursing station, License Vocational Nurse (LVN 1) was observed on scrolling on her cell phone while the call light panel was wringing. During the concurrent interview LVN 1 stated she failed to answer the call light because she though other staffs were rounding. On 7/24/17 at 3:34 p.m., during an interview Resident 2 stated, The 3-11 night staff takes between 30-40 min to answer the call light; sometimes, someone will come in turn off the call light and say someone will come back. During the concurrent interview, Resident 2 stated peeing in the bed due to nurses not responding to the call light promptly. On 7/25/17 at 7:35 a.m., during an interview Resident 3 stated that staff from 3-11 night shift takes 40 minutes to answer the call lights. Resident 3 stated that this concern was discussed with Activity Assistant (AA) on the month of 6/17 council meeting. A review of the Resident's Council Meeting minutes for the months of 5/17 through 7/17 did not indicated any problems with the call lights for those months. On 7/25/17 at 9:05 a.m., during an interview and record review of the council minutes AA stated, One resident complained about the call lights and the roommates not been changed, but she did not documented the complaint on the council minutes because it wasn't something of concern. On 7/26/17 2:02 p.m., during a telephone interview Family member (F1) stated that nurses take between 10-20 minutes to answer call lights. F1 stated that Resident 1 sometimes calls her to asker to call the facility so that nurses can answer the call light and bring Resident 1's pain medication. On 7/25/17 at 1:51 p.m., during an interview and record review of a policy Director of Nursing (DON) stated that nurses should not be on their phone, and every facility staff is responsible to answer the call lights as soon as possible. A review of the facility's duties and responsibilities of the CNA included providing personal nursing care functions, which included answering resident's calls' as promptly as feasible, and assure that residents who are unable to call are checked regularly. A review of the undated facility's policy titled, Answering Call Light indicated all staff is responsible to answer call lights as soon as possible and if the staff responding to the call light is unable to assist resident, he/she will report the president's request/needs to licensed nurse or staff who can respond to the request.

Based on observation, interview and record review, the facility failed to ensure all residents' call lights were audible upon activation and that the facility's staff answered residents' call lights promptly for three of 10 alert residents. These failures resulted in residents not being accommodated and needs not being met, thus resulting in adverse resident outcomes. On 7/25/17 at 2:29 p.m., an Immediate Jeopardy (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 declared for F241 and F246 and the facility's administrator (ADM, a person responsible for managing an organization) and the director of nursing (DON, a person who provides direction to the nursing staff and coordinate health services) were notified of the serious findings that threatened the health and safety of the residents. The IJ was lifted on 7/26/17 at 2:17 p.m. in the presence of the ADM and the DON after the facility provided an acceptable written plan of correction (P(NAME)). Findings: On 7/24/17 at 12:50 p.m., during an interview Resident 1 indicated sustaining a left knee fracture due to a fall when picking up a pillow while in the wheelchair. Resident 1 stated not calling the nurse because of the delay of response from the nurses to answer the call lights. A review of the Admissions Record Face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. below the knee and fracture of lower end of left femoral (is the larger and stronger of the two bones in the leg below the knee). A review of Resident 1's Minimum Data Set (MDS, Resident Assessment and Care Screening) dated 6/23/17, indicated that Resident 1 was intact of cognitive skills for daily decision-making. MDS indicated Resident 1 required of one person physical assist for locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor) and required of a wheelchair as a mobility device. A review of the Fall Risk Assessment form dated 6/28/17 indicated Resident 1 was at high risk for fall. A review of the document facility's radiology report tittled, Patient Report, dated 7/15/17 indicated distal femoral fracture about left knee. A review of Resident 1's care plan titled, Risk for fall and related injuries, re-evaluated 6/17, indicated under approach plan (1) call light to be within reach, (2) frequent visual checks to ensure safety, and (3) encourage resident to wait for staff to assist with transfers. On 7/24/17 at 12:59 p.m., during an observation, the light above room [ROOM NUMBER] was lighting up, but not audible to the facility staff. On 7/24/17 at 1:05 p.m., during an interview Certified Nurse Assistant (CNA 1) stated that call lights are only audible in the panel located at the nurses' station. On 7/24/17 at 3:30 p.m. during an observation of the nursing station, License Vocational Nurse (LVN 1) was observed on scrolling on her cell phone while the call light panel was wringing. During the concurrent interview LVN 1 stated she failed to answer the call light because she though other staffs were rounding. On 7/24/17 at 3:34 p.m., during an interview Resident 2 stated, The 3-11 night staff takes between 30-40 min to answer the call light; sometimes, someone will come in turn off the call light and say someone will come back. During the concurrent interview, Resident 2 stated peeing in the bed due to nurses not responding to the call light promptly. On 7/25/17 at 7:35 a.m., during an interview Resident 3 stated that staff from 3-11 night shift takes 40 minutes to answer the call lights. Resident 3 stated that this concern was discussed with Activity Assistant (AA) on the month of 6/17 council meeting. A review of the Resident's Council Meeting minutes for the months of 5/17 through 7/17 did not indicated any problems with the call lights for those months. On 7/25/17 at 9:05 a.m., during an interview and record review of the council minutes AA stated, One resident complained about the call lights and the roommates not been changed, but she did not documented the complaint on the council minutes because it wasn't something of concern. On 7/26/17 2:02 p.m., during a telephone interview Family member (F1) stated that nurses take between 10-20 minutes to answer call lights. F1 stated that Resident 1 sometimes calls her to asker to call the facility so that nurses can answer the call light and bring Resident 1's pain medication. On 7/25/17 at 1:51 p.m., during an interview and record review of a policy Director of Nursing (DON) stated that nurses should not be on their phone, and every facility staff is responsible to answer the call lights as soon as possible. On 7/25/17 at 2:05 p.m., during an interview and observation of the call lights of the hall ways by rooms [ROOM NUMBERS] DON stated, You cannot hear the call lights from here, only at the nurse station. A review of the facility's duties and responsibilities of the CNA included providing personal nursing care functions, which included answering resident's calls' as promptly as feasible, and assure that residents who are unable to call are checked regularly. A review of the undated facility's policy titled, Answering Call Light indicated all staff is responsible to answer call lights as soon as possible and if the staff responding to the call light is unable to assist resident, he/she will report the president's request/needs to licensed nurse or staff who can respond to the request.

Based on interview and record review, the facility failed to provide the necessary care for one of three sampled residents (Resident 1) by failing to: 1. Conduct an interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) care conference to address change in resident's behaviors, 2. Determine the type and frequency of resident supervision and provide the needed supervision based on the assessed resident's needs, 3. Monitor effectiveness of interventions, and 4. Review and revise the care plan. These deficient practices made it possible for Resident 1 to wander into the female residents' room and exposed himself. The exposure resulted in emotional stress to Residents 2 and 3. As a result of Resident 1's exposure, Resident 2 cried for a couple of hours, had bad dreams, became scared and stated that she did not feel safe in the facility. Resident 3 stated that she felt angry. Findings: A review of Resident 1's Admission Record indicated that Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/15/16, indicated Resident 1 usually understood others and was able to make self-understood. The MDS indicated that Resident 1 required supervision to limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) from staff with activities of daily living. A plan of care for [MEDICAL CONDITION] manifested by hearing voices, wandering, and physically aggressive was developed for Resident 1 on 3/8/16. The staff interventions indicated to approach the resident calmly, speak in a calm voice, explain all procedures before the task, encourage to perform independent activities of daily living, attempt to refocus behavior to something positive when exhibiting inappropriate behavior, encourage resident to discuss interest and concerns, give medications as ordered, monitor behavior every shift, remove resident from stimuli that increase agitation or untoward behavior, psychiatric consult as needed, SSD (social service director) visits as scheduled, and encourage activity attendance of resident's choice and preference. A review of Resident 1's Change of Condition SBAR -Behavior Change, (SBAR, Situation-Background-Assessment-Recommendation, provides a framework for communication between members of the health care team), dated 4/5/16, at 9:30 pm, indicated that Resident 1 wandered into Room X. The Behavioral Change (Episodic) Care Plan of the SBAR indicated that Resident 1 was to be engaged in an activity, utilize a calm approach, redirection or diversion, modify environment as needed, monitor behavior and observe effectiveness of interventions. The Progress Note Updates of the SBAR indicated to provide frequent visual checks. A review of Resident 1's Change of Condition SBAR-Behavior Change, dated 4/18/16 at 6:15 pm, indicated Resident 1 was seen wandering into residents' rooms and trying to open locked doors. Resident 1 was difficult to redirect and follow commands. The Behavioral Change (Episodic) Care Plan of the SBAR indicated to engage Resident 1 in an activity, utilize a calm approach, redirection or diversion, modify environment as needed, monitor behavior and observe effectiveness of interventions. The Progress Note Updates of the SBAR indicated the physician was notified and an order was received to transfer Resident 1 to the acute hospital for psychological evaluation but no bed was available at the time. There was no documented evidence that the facility assessed and determined the type and frequency of resident monitoring/supervision based on Resident 1's behavior. There was no indication that Resident 1's care plans were reviewed for effectiveness. A review of Resident 1's Change of Condition SBAR-Mental Status Change, dated 4/20/16, at 3:05 pm, indicated Resident 1's increased irritability, agitation, paranoia (baseless suspicion of the motives to others), hallucinations (something the resident see, hear, feel, smell or taste that does not exist in reality), and restlessness. The Progress Note Updates of the SBAR indicated Resident 1 was transferred to the hospital for evaluation. During an interview on 5/6/16 at 8:42 a.m., Resident 3 (roommate of Resident 2) stated there were two incidents when Resident 1 came into their room (Room X). The first incident was around 10 p.m. (could not remember the date) and Resident 1 was standing against the wall by Room X Bed A. Resident 2 just came out of the restroom and told Resident 1 to get out of the room. Resident 1 closed the door instead but failed to leave the room. Resident 3 stated she went outside to get help by going through the adjoining restroom. Resident 3 stated the second incident happened a few days later after the first incident Resident 1 came into Room X. Resident 2 was in bed and told Resident 1 to go away. Resident 3 heard the conversation and pulled the curtain back and saw Resident 1 standing against the closet inside Room X. Resident 3 stated the 3 p.m. to 11 p.m. shift nurse came and took Resident 1 out of the room. Resident 2 went outside because she was so scared. On 5/6/16 at 8:50 a.m., during an interview, Resident 2 stated there were two incidents when Resident 1 came into their room (Room X). Resident 2 stated on the first incident when Resident 1 came into Room X, Resident 2 was coming out of the restroom approximately 10 p.m. (could not recall what day), Resident 1 was standing by the door inside Room X and then closed the door. Resident 1 dropped his pants and Resident 3 went out to get help. During that time, while Resident 3 was out to get help, Resident 2 was alone with Resident 1. Resident 2 stated she got scared. Resident 2 stated that the second incident occurred around evening time when Resident 1 came into Room X again and stood against the closet wall. Resident 2 stated she was screaming and telling Resident 1 to go away. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was able to make self-understood and understood others. Resident 2 required extensive (weight-bearing support) assistance with activities of daily living. A review of Resident 3's Admission Record indicated Resident 3 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was able to make self-understood and understand others. Resident 3 required limited assistance with activities of daily living. During an interview on 5/6/16 at 9:08, social worker (SW 1) stated Resident 1 had a behavioral problem of exposing his private part to females. On the second day (3/2/16) of Resident 1's first admission to the facility, he went into a residential front door and it took four people to get Resident 1 back to the facility. SW 1 stated Resident 1 hit her and knocked two of her teeth that became loose. Resident 1 was sent to the hospital for psychological evaluation. Resident 1 returned to the facility on [DATE] and was having behavior of exposing his private part. He exposed himself to the dietary supervisor (DS) and other females on several occasions during the 3 p.m.-11 p.m. and 11p.m.-7 a.m. shift. On 5/6/16 at 9:30 a.m., during an interview, the DS stated on 4/8/16, Resident 1 opened his jeans and exposed his private part to her as she walked towards Resident 1 in the hallway. The DS reported the incident to the director of staff development (DSD), SW 1, and business office staff. The staffs told the DS that there had been incidents like these before, so just document the incident. On 5/6/16, at 12:20 p.m., during an interview and concurrent review of Resident 1's clinical record, the director of nursing (DON) stated that, Frequent visual check is constant monitoring of the resident especially those with behavior problem. We do care plan upon significant change of condition. During the same interview and concurrent review of Resident 1's record, the DON stated, We only have 72 hours monitoring after the incidents and we document in the nursing notes every shift. The DON stated they documented when there was a behavioral episode that occurred, using tally marks to determine Resident 1's frequency of behavior such as when nurses caught Resident 1 going into other residents' rooms. The DON stated there was not really any change in Resident 1's behavioral care plans. The DON stated Resident 1's care plans did not indicate any intervention regarding the type and frequency of supervision. On 5/6/16 at 1:30 p.m., during a follow up interview, Resident 2 stated she did not feel safe in the facility and stated she had been having bad dreams. During an interview on 5/6/16 at 1:51 p.m. and concurrent review of Resident 1's record, the Minimum Data Set nurse (MDS 1) stated Resident 1's daughter never showed up for IDT care conference. MDS 1 stated if the resident's family does not come and the resident could not participate in IDT care conference, they still do IDT care conference. MDS 1 was unable to find documented evidence of Resident 1's IDT care conference. During an interview on 5/6/16 at 2:15 p.m., and concurrent review of Resident 1's record, the DON stated there was no IDT care conference conducted for Resident 1 for behavioral incidents. Resident 1 should have had an IDT care conference conducted with or without Resident 1's family because of his inappropriate sexual behaviors. On 5/6/16 at 3:19 p.m., during a follow up interview, Resident 3 stated Resident 2 got scared and cried. Resident 2 remained and stayed in her room and did not want to go out because she was afraid of seeing Resident 1. During an interview on 5/6/16 at 3:30 p.m., the registered nurse (RN 1) stated Resident 2 was more shaken and scared; very upset and cried for a couple of hours during the incident of 4/18/16 incident. During an interview on 5/6/16 at 4:17 p.m., and review of resident 1's record, the DON stated that Resident 1 was monitored hourly for 72 hours between 4/5/16 to 4/7/16 (after 4/5/16 incident) and 4/18/16 to 4/19/16 (after 4/18/16 incident). The DON stated there was no documentation indicating supervision or monitoring was done between 4/8/16 to 4/17/16 to address Resident 1's sexual behavioral history. A review of the Hourly Checklist (72 hour monitoring record) of Resident 1's whereabouts indicated the following: 1. From 4/5/16, starting at 7 p.m. to 4/7/16, at 6 am, a total of 35 hours out of 72 hours. 2. From 4/18/16, starting at 6 p.m. to 4/19/16, at 3 am, a total of 22 hours out of 72 hours. 3. There was no monitoring conducted for Resident 1 in skilled Nursing facility while he was waiting for a bed in the acute hospital for psychological evaluation until the resident was transferred on 4/20/16 at 4 pm. A review of the facility policy and procedure titled, Safety and Supervision of Residents revised December 2007 indicated: 1. Resident-oriented approach to safety: 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. 3. Implementing interventions to reduce accident risks for 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 4. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed and d. Evaluating the effectiveness of new or revised interventions 5. Systems approach to safety: 6. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 7. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in resident's condition. A review of the facility policy and procedure titled, Behavior Assessment and Monitoring, revised April 2007 indicated monitoring: if the resident is being treated for [REDACTED]. A review of an undated facility' s policy and procedure titled, Care Plans indicated the following: 1. Assess the resident upon admission and initiate a plan of care for the key problems or possible problems identified. 2. All goals will be measureable 3. Add changes to the resident's status as they occur.

Based on observation, interview, and record review, the facility staff failed to ensure three of 17 sampled residents (Resident 7, 9, and 10) were provided with appropriate treatment and services to prevent decline in range of motion and prevent development of contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; this can lead to permanent disability) by failing to: 1. Assess Resident 9's joint mobility accurately, monitor resident response to treatment exercises and provide range of motion exercises as ordered by the physician. This resulted in unidentified development of contracture to resident's right wrist, right hand fingers, right knee and right toes. 2. Assess Resident 7's joint mobility accurately, monitor resident response to treatment exercises and report to the rehabilitation department for reassessment and further intervention. This resulted in delayed identification of contractures to resident's left shoulder, left middle/ring/pinky (small) fingers, and left ankle. 3. Assess Resident 10's joint mobility status upon admission as indicated in the facility's policy and procedures. This resulted in resident not receiving necessary exercises to prevent development of contractures to resident's right shoulder, bilateral ankles, and moderate joint mobility limitation on bilateral hip and knees. Findings: 1. On September 14, 2016, at 3:10 p.m., during the initial tour of the facility accompanied by licensed vocational nurse 3 (LVN 3), Resident 9 was observed in bed. The resident was alert, verbally responsive, and was observed with contractures on the right wrist and fingers. LVN 3 stated the resident was on the RNA (restorative nursing assistant, a nursing aid specifically trained by the therapist to help residents maintain (range of motion/ambulation) any progress the resident made during therapy treatments, enabling them to function at a high capacity) program. According to the Admission Record, Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated March 17, 2016, and June 13, 2016, indicated Resident 9's cognitive skills for daily decision-making were moderately impaired. The resident required limited assistance from the staff with bed mobility, dressing, and extensive assistance with transfer, personal hygiene, and bathing. The MDS indicated the resident had no functional limitation in range of motion and was on the restorative nursing program five days a week. A review of Resident 9's care plan dated September 23, 2015, indicated the resident was on the RNA program for passive range of motion (PROM, performed by the RNA) exercises due [MEDICAL CONDITION] right [MEDICAL CONDITION]. The approach plan indicated the following: - RNA was to provide PROM exercises to the right upper and lower extremities five (5) times a week as tolerated. - Observe the resident for pain and discomfort, and notify the physician immediately. - Medicate the resident for pain as needed - Observe the resident for PROM exercises tolerance and notify the physician if not able to tolerate the exercises. A review of September 2016, Resident 9's summary physician's orders [REDACTED]. A Joint Mobility assessment dated [DATE] documented by the PT (physical therapist) indicated Resident 9 had no joint mobility limitations. A review of the Nursing Weekly Summary dated July 3, 2016, July 16, 2016, July 17, 2016, July 24, 2016, July 31, 2016, August 7, 2016, August 14, 2016, August 21, 2016, and September 4, 2016 indicated Resident 9 was on the RNA program for ROM, and indicated that the resident had no contractures. A review of Resident 9's RNA Treatment Record, dated August 1, 2016, through September 18, 2016, indicated the PROM exercises were provided and the resident tolerated the exercises. There was no documentation that the resident had developed contractures on the right wrist, right hand fingers, and right knee. During an interview on September 19, 2016, at 11:40 a.m., Resident 9 stated he had a stroke. The resident stated he could not remember when his right wrist and fingers started getting stiff and contracted. On September 19, 2016, at 12:05 p.m., during range of motion exercises observation, RNA 1 did not provide ROM exercises on Resident 9's contracted right wrist, right hand fingers and right toes. During an interview on September 19, 2016, at 12:15 p.m., RNA 1 was informed that ROM exercises on Resident 9's right wrist, right hand fingers, and right foot toes were not observed. RNA 1 stated sometimes there is an order not to exercise the resident's fingers. However, there was no documented physician order [REDACTED]. RNA 1 offered no further explanation why the exercises were not provided to the right wrist, right hand fingers, and right toes as ordered. During an interview on September 19, 2016, at 3 p.m., the assistant director of nursing (ADON) stated she was unable to find documentation about the Resident 9's contracted right wrist and right hand fingers. ADON stated she will make an appointment for PT to come and assess the resident's joint mobility status. On September 20, 2016, at 11:30 a.m., the PT came to assess Resident 9's joint mobility status. The PT notes indicated that the resident had moderate joint mobility limitations on the right upper extremity and left lower extremity. The PT notes indicated a recommendation for splint application to the right hand. During an interview on September 20, 2016, at 1:55 p.m., RNA 1 stated she was not sure when the resident's right hand contractures developed. During an interview on September 22, 2016, at 10:20 am, PT stated there was a problem about the joint mobility assessment form currently being used by the facility. There was no accurate description of Resident 9's right wrist extension contracture and the right knee extension contracture. He also stated he could not say when those contractures started, because these were not reported to him by the nursing staff. 2. On September 15, 2016, at 4 p.m., Resident 7 was observed in bed, lying on his right side. The resident was alert, oriented and verbally responsive. He stated he had weakness on his left side of the body, and received exercises from the RNA. On September 20, 2016, at 3:35 p.m., Resident 7 was observed in the room, he stated his left arms and leg needed help to move, and he was unable to open his left fingers fully. He stated he needed a ball to keep his left fingers open, and occasionally when he opened his left fingers, he experienced pain that radiated to his left upper arm. According to the Admission Record, Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, (MDS, a standardized assessment and care screening tool), dated April 22, 2016, and June 19, 2016, indicated Resident 7's cognitive skills for daily decision-making were intact. The MDS indicated the resident required limited assistance from the staff with bed mobility, dressing, and extensive assistance with transfer, hygiene, and bathing. The MDS indicated the resident had no functional limitation in range of motion and received restorative nursing program five (5) days a week. A Joint Mobility assessment dated [DATE] documented by the PT (physical therapist) indicated Resident 7 had no joint mobility limitations. A review of Resident 7's physician's orders [REDACTED]. 1. RNA to perform AAROM (active assistive range of motion) exercises to resident's left upper extremity daily five times a week. 2. RNA to perform AROM (active range of motion) exercises on the right upper extremity as tolerated daily five times a week. A physician's orders [REDACTED]. 1. RNA to perform ambulation using the parallel bars every day as tolerated five times a week. 2. RNA to perform sit to stand exercises, using the parallel bars as tolerated every day five times a week. A review of Resident 7's care plan dated August 15, 2014, for AROM/AAROM exercises secondary to spinal cord injury and left sided [MEDICAL CONDITION] indicated the resident was on the RNA program. The approach plan included for the RNA to perform the exercises, monitor for pain and discomfort, medicate for pain as needed, monitor for tolerance of the exercises and notify the physician if unable to tolerate, and the rehabilitation department to assess at all times for possible decline. Another care plan with the same date indicated the resident was on RNA program for ambulation exercises secondary to left side [MEDICAL CONDITION] and spinal cord injury. The approach plan included for the RNA to ambulate as tolerated daily five times a week, and the rehabilitation department to assess for possible decline at all times. A review of Resident 7's Nursing Weekly Summaries from August 3, 2016, August 10, 2016, August 17, 2016, August 24, 2016, one undated entry, September 7, 2016, and September 14, 2016, indicated the resident had no contractures or joint mobility limitations, and on the RNA program five times a week. A review of Resident 7's RNA Treatment Sheet, from August 1, 2016, through September 20, 2016, indicated the resident received the range of motion exercises as ordered by the physician. There was no documentation that the resident had problem opening his left hand fingers. On September 22, 2016, at 10 am, the PT came to assess Resident 7's joint mobility status. The PT indicated in his report that the resident had moderate joint mobility limitations on the left shoulder, left middle/ring/pinky (small) fingers, and left ankle. The PT recommended a left hand splint to prevent any further decline in the ROM. During an interview on September 22, 2016, at 10:20 a.m., PT stated he had not received report of any changes in the resident's joint mobility status from the nursing staff. 3. During the treatment observation on September 15, 2016, at 11:20 a.m., Resident 10 was in bed. The resident was alert and rarely responded to verbal inquiry. Resident 10's legs remained flexed during the whole treatment. On September 16, 2016, at 1:00 p.m., the resident's family member visited and encouraged the resident to extend both knees/legs, but the resident did not move. The resident's family member asked the resident why he did not want to extend the knees/legs, and the resident stated it was painful. According to the Admission Record, Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated July 25, 2016, indicated Resident 10's cognitive skills for daily decision making were severely impaired. The resident required supervision with eating, extensive assistance from the staff with bed mobility, locomotion in the room, dressing, and was totally dependent for transfer, locomotion off the unit, toilet use, personal hygiene, and bathing. The MDS indicated the resident had no functional limitation in range of motion. A review of Resident 10's recapped physician's orders [REDACTED]. A review of Resident 10's care plan dated July 25, 2016 for self-care deficit related to the multiple diagnoses. The approach plans indicated that the rehabilitation department evaluate and assess the resident for treatment as indicated, and notify the physician for any changes. A review of Resident 10's Nursing Weekly Summaries dated July 22, 2016, July 29, 2016, August 12, 2016, August 19, 2016, August 27, 2016, and September 10, 2016, indicated the resident had no contractures or joint mobility limitations. During an interview, and review of Resident 7's medical record on September 16, 2016, at 12:05 p.m., with the assistant director of nursing (ADON), she stated she was unable to find documentation that PT (physical therapist) had assessed Resident 10's joint mobility status. She stated she will refer the resident to PT for the joint mobility assessment. During an interview on September 16, 2016, at 4:25 p.m., LVN 4 stated Resident 10 was able to straighten his legs before. LVN 4 stated that resident's family member used to exercise the resident's legs when she came to visit the resident. On September 19, 2016, at 12 p.m., the PT came to assess Resident 10's joint mobility status. The PT indicated in his report that the resident had minimal joint mobility limitation on the right shoulder, bilateral ankles, and moderate joint mobility limitation on bilateral hip and knees. PT recommended that the resident will be on the RNA program for AAROM on both upper extremities, and PROM on both lower extremities five times a week as tolerated. During an interview on September 19, 2016, at 12:50 am, PT stated the nursing staff did not inform him about Resident 10's admission (July 25, 2016). The PT stated that the resident did not have an initial joint mobility assessment status and recommendation for treatment exercises. During an interview on September 22, 2016, at 12:20 p.m., the MDS nurse stated PT does the initial joint mobility assessment, but the nursing staff had to inform PT for newly admitted residents. A review of the facility's undated General Restorative and Supportive Nursing Care policy and procedures indicated the following: - Each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities; - Provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning. - Provide range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited ROM. According to the facility's undated policy and procedures for Joint Mobility Assessment indicated, that all residents will be assessed for joint mobility limitations upon admission.

Based on observation, interview, and record review, the facility failed to ensure that residents received and consumed foods in the appropriate form (nectar thickened liquid-a mechanically altered liquid that is as thick as a milkshake that pours in a continuous stream without breaking into drops. Common natural nectar thick liquids include nectar, tomato juice, and buttermilk) as in therapeutic diet (mechanically altered food as part of the treatment for [REDACTED]. The facility also failed to ensure two of the three dietary aides, Dietary Aide 1 and 3, who prepared the liquids with thickened consistencies, received training on correct measurement of the thickener and preparation of thickened liquids for seven of seven residents with difficulty swallowing and requiring thickened liquids (Resident 2, 3, 4, 5, 6, 7, and 8). Resident 2, who had dysphagia (difficulty swallowing) and who had a sign at the head of the bed, which indicated Thickened Liquids Only, was provided with a pitcher containing regular (unthickened) water at the bedside. The physician's orders [REDACTED]. Resident 3, who had dementia (loss of brain function that occurs with certain diseases and affects memory, thinking, language, judgment, and behavior), had a sign at the head of the resident's bed, which indicated Thickened Liquids Only. The resident was provided with a glass of milk that was not thickened, but rather with a regular consistency for lunch. The physician's orders [REDACTED]. Two of the three dietary aides, Dietary Aide 1 and 3, who were assigned to prepare the nectar thickened liquids, did not understand the written instruction on how much thickener to add to liquids, such as water, milk, and juice. The facility was not able to provide documented evidence of training provided to the dietary aides. The certified nursing assistant (CNA 1) did not check the consistency of water before providing the pitcher of water at Resident 2's bedside. The certified nursing assistant (CNA 2) and the licensed nurse (LVN 1) did not check the consistency of milk before providing Resident 3 with a glass of milk on the lunch tray. These deficient practices had a potential to result in choking and aspiration pneumonia (an inflammation/infection of the lungs that occurs when foreign matter is inhaled into the lungs), which could lead to difficulty breathing, hospitalization , administration of antibiotics, [MEDICAL CONDITION] (a life threatening complication of an infection) for seven of the seven residents with swallowing difficulties, requiring them to have liquids with thickened consistency. On August 28, 2015 at 3:53 p.m., an immediate jeopardy (IJ) was declared and the director of nursing (DON) and the dietary service supervisor (DSS) were informed of residents that were at risk of choking and aspiration pneumonia because they were not being provided with liquids at the proper consistency. On August 28, 2015 at 6:03 p.m., the IJ was abated and the DON was notified after verifying on-site, that the facility had implemented an acceptable plan of correction. The facility's plan of correction was implemented by: 1. The DON providing in-service to direct nursing care staff regarding monitoring of residents, who required nectar-thickened or honey-thickened liquids (liquids that stick to the sides of a cup like honey and pour very slowly. Liquids include honey and cream soups) and proper consistencies of nectar thickened, honey thickened and pudding thickened (will hold its shape when scooped with a spoon) liquids. 2. The DON providing in-service to licensed nurses regarding the checking each meal tray to ensure residents received the correct therapeutic diet, which included the ordered liquid consistency. 3. The DSS providing an in-service to the dietary staff and direct nursing care staff regarding the proper preparation of different liquid consistencies, such as nectar, honey, and pudding. 4. Providing residents, who had orders for nectar thickened liquids, with ready to drink Nutri-juice Lemon-Flavored Thickened Water. 5. Ensuring that the registered nurse (RN) supervisor checked dinner trays, dietary tray cards, and the consistencies of the liquids prior to having the food products provided to the residents. Findings: On August 28, 2015, at 8:45 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. On August 28, 2015 at 10 a.m., during the tour of the facility, Resident 2 was observed lying on a low bed and reaching his arms toward the side of the bed. A sign above the head of the bed indicated Thickened Liquids Only. The certified nursing assistant (CNA 1) who was present at the time, removed the lid from the resident's pitcher. The pitcher contained regular (unthickened) water. CNA 1 stated during a concurrent interview that the water pitcher contained regular water. CNA 1 stated the water in the pitcher was supposed to be thickened and that she had forgotten to check the water prior to placing the pitcher at the resident's bedside. The CNA removed the pitcher containing unthickened water at the resident's bedside and obtained and provided the resident with a pitcher of nectar-thickened water. On August 28, 2015 at 1 p.m., during an observation, Resident 3 was lying in bed while being fed lunch by a family member. A sign, which indicated Thickened Liquids Only, was placed at the head of the resident's bed. A four-ounce glass of milk was on the meal tray. The glass of milk was covered with plastic wrap with a letter N (for nectar thickened consistency) written on the wrap. The milk had regular (unthickened) liquid consistency. CNA 2 inspected the resident's glass of milk and stated, It's too thin. It should be thick. He has a problem swallowing. It should be thick so he doesn't choke. The licensed vocational nurse (LVN 1) also inspected the resident's glass of milk and stated the milk's consistency was too thin, and that the resident's glass of (unthickened) milk would be replaced right away with a glass of nectar-thickened milk. On August 28, 2015 at 1:05 p.m., Dietary Aide 1 and the dietary service supervisor (DSS) were interviewed. Dietary Aide 1 stated she prepared glasses of milk for the meal trays, which included the glass of milk served to Resident 3. Dietary Aide 1 stated she assisted in setting up the trays. When asked how much thickener was added to the four-ounce glasses of milk for nectar-thick consistency, Dietary Aide 1 replied she added one teaspoon of thickener to each glass. Dietary Aide 1 stated if more than one teaspoon was added, the milk became too thick, and that would be difficult for the residents to swallow. When Dietary Aide 1 was asked what nectar- thick meant, she replied, It means it's supposed to be thicker. During a concurrent interview, the DSS stated the kitchen staff followed a chart which indicated how much thickener was to be add to water, juice, or milk. The DSS stated that sometimes a thickened drink needed to be shaken, due to settling nature of the thickener at the bottom of the glass. The DSS stated the glass of milk which was given to Resident 3 needed more thickener. During the interview, the DSS showed a chart titled, Resource Thicken Up, Instant Food and Drink Thickener, which indicated how much thickener was to be added to four fluid ounces of liquid for nectar, honey, and pudding consistencies. The column on the chart titled, Nectar, indicated 1T + 1 tsp (one tablespoon plus one teaspoon) for skim/1 percent (%) milk, and whole/2% milk. On August 28, 2015 at 1:10 p.m., when Dietary Aide 1 was asked what the measurement 1T + 1 tsp meant, she pointed to the section which indicated 1 tsp and stated, and I just look at that part. Dietary Aide 1 was asked what she used to measure the thickener. Dietary Aide 1 obtained a set of measuring spoons and stated, I use this one, pointing to the teaspoon. During a concurrent interview, the DSS stated Dietary Aide 1 was hired three to four months ago. The DSS stated she had given an in-service (education) in the past to the kitchen staff about thickened liquids. When asked if the dietary staff personnel files contained documentation of the training the staff received, the DSS stated No. When asked if she oversaw the food preparation, the DSS stated, Sometimes, yes. On August 28, 2015 at 2:55 p.m., during an interview, Dietary Aide 3 stated she worked at the facility for five years. When questioned how much thickener she added to four ounces of milk, Dietary Aide 3 obtained the set of measuring spoons, then pointed to the teaspoon and stated, I use one of these for four ounces. On August 28, 2015 at 3 p.m., the DSS was asked to provide documented evidence of in-services provided to the staff about thickened liquids. The DSS showed the surveyor a copy of an in-service, dated August 28, 2015, no time indicated, regarding how to use thickener according to consistency, and the difference between a tablespoon and teaspoon. The in-service was signed by Dietary Aide 1, Dietary Aide 2, Dietary Aide 3, and the evening cook. There was no documented evidence to indicate that the DSS provided in-services to the staff members regarding thickened liquids in the last one year over the past year. The DSS also failed to show that an in-service about thickened liquids was provided to the staff members. A review of the facility's policy, titled, Nutrition Care, dated 2012, indicated Thickened foods and liquids are provided to residents/patients with swallowing disorders to ensure a safe consistency for adequate nutrition and hydration, and to decrease the probability of aspiration. The appropriate consistency should be determined by the speech language pathologist, and ordered by the physician .The facility will determine whether nursing and/or dietary will thicken the liquids, of if pre-thickened products will be used. Manufacturer's instructions will be followed when using thickening agents, to provide the ordered consistency of liquids. A review of Resident 2's clinical record, indicated the resident was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. nerve and gets worse over time, and it's often associated with a buildup of pressure inside the eye) and [MEDICAL CONDITION]. The annual Minimum Data Set (MDS), a standardized assessment and care planning tool, dated May 20, 2015, indicated Resident 2 was severely impaired in his cognitive abilities, was unable to walk or talk, and was totally dependent on staff for all activities of daily living needs. A review of the Physician Orders, dated February 1, 2014, indicated to provide Resident 2 with a pureed, nectar consistency diet. The care plan for Resident 2, titled, Resident at Risk for Nutritional Problems Due to Dysphagia, dated May 15, 2015, indicated one of the approach plan included to provide pureed diet with no added salt (NAS) and nectar-thick liquid as ordered by the physician. A review of Resident 3's clinical record indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly review assessment MDS, dated [DATE], indicated Resident 3 was confused, with short and long term memory problems, was unable to walk, and was totally dependent on staff for all daily living needs. A review of the Physician Orders, dated June 4, 2015, indicated to provide Resident 3 with NAS diet, mechanical soft texture, with nectar-thick liquids. A review of Resident 4's clinical record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MDS, dated [DATE], indicated the resident was cognitively impaired, totally dependent on staff for activities of daily living, and received mechanically altered diet (diet that requires change in texture of food and liquid, such as pureed food, thickened liquids). A review of Resident 5's clinical record indicated the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MDS, dated [DATE], indicated the resident severely impaired in cognitive skills, was able to eat independently, and received mechanically altered (thickened) liquids. A review of Resident 6's clinical record indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MDS, dated [DATE], indicated the resident was cognitively impaired, totally dependent on staff for activities of daily living, and received mechanically altered (thickened) liquids. A review of the Resident 7's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated the resident was moderately impaired in cognitive skills, required supervision when eating, and received mechanically altered (thickened) liquid. A review of Resident 8's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].