Every finding on record at Greenfield Care Center of South Gate

Based on observation, interview and record review, the facility failed to meet professional standards of quality, for one of three residents (Resident 2), by failing to: 1). Administer the dorzolamide hydrochloride (Hcl)-timolol maleate ophthalmic solution (a prescription eye drop used to lower high eye pressure caused by open-angle glaucoma [a chronic eye disease where fluid drains too slowly from the eye, building pressure that gradually damages the optic nerve and causes permanent vision loss] or ocular hypertension [a condition where the pressure inside the eye-is higher than normal]), twice a day, as verbalized by Resident 2 and as per physician's order. 2). Ensure Resident 2's dorzolamide was stored in a way accessible for the staff to administer. 3). Ensure staff documented in Resident 2's medication administration record (MAR) after the dorzolamide eye drops were administered. 4). Clarify error in documentation when medication administration were documented by mistake by a staff. These failures placed Resident 2 at risk for severe eye complications including increased eye pressure, which can lead to permanent optic nerve (the nerve that transmits visual information from the retina [thin, light sensitive layer of tissue at the back of the eye that converts light into nerve signals for the grain] at the back of the eye to the brain) damage and gradual vision loss.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included glaucoma, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 6/2/2026, the MDS indicated Resident 2 had intact cognition (the ability to process thoughts). The MDS indicated Resident 2 had vision impairment. Resident 2 was independent with upper body dressing, eating, oral, personal and toileting hygiene. Resident 2 was independent with rolling left and right position, sitting to lying, lying to sitting on side of bed, sit to stand. During a review of Resident 2's Order Summary Report dated 4/9/2026, the order summary report indicated dorzolamide HCL-Timolol Maleate ophthalmic solution 2-0.5 per cent (%), instill one drop into the left eye twice a day, for glaucoma. During a review of Resident 2's care plan report titled, The Resident Has Impaired Visual Function Related To Eye Dryness, dated 8/25/2026, one of the interventions indicated to administer medication as ordered. During an interview on 8/28/2026 at 8:31 p.m., Resident 2 stated his physician ordered the eye drops for glaucoma (dorzolamide) twice a day but only received the eyedrops once a day. Resident 2 stated he was afraid to complain because he feared retaliation from the facility staff. During interview on 8/28/2026 at 9:55 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he could not find Resident 2's dorzolamide in the medication cart on 8/28/2026 at around 8:00 p.m. so Resident 2's dorzolamide was not administered. LVN 1 stated that he asked Registered Nurse (RN) 1 where Resident 2's dorzolamide was, but RN 1 could not locate the eyedrops. During interview on 8/28/2026 at 10:04 p.m., with RN 1, RN 1 stated Resident 2's dorzolamide eye drops was found in another medication cart (unspecified). RN 1 stated the facility received one box of dorzolamide on 8/10/2026 which contained 60 individual pouches. The dorzolamide box had an opened date of 8/15/2026. The dorzolamide box had 46 unopened pouches left. RN 1 stated based on the date the dorzolamide box was opened (8/15/2026), and the physician's prescribed dose/ order of one drop twice a day, there should have been 26 pouches used and 34 pouches left. RN 1 stated, the box contained 46 remaining dorzolamide unopened pouches, which was 12 more than was expected to be left. RN 1 stated that he should not have documented the administration of Resident 2's dorzolamide HCL-Timolol Maleate eye drops because he did not administer the medication. During a concurrent interview and record review on 8/29/2026 at 7:23 p.m., with LVN 2, Resident 2's MAR for 8/29/2026 was reviewed. LVN 2 stated Resident 2's MAR indicated that Resident 2 had received all of his medications except the insulin (medicine for diabetes [high blood sugar levels]), which Resident 2 refused. LVN 2 stated, on 8/29/2026, she did not administer Resident 2's eye drops (dorzolamide) because the eyedrops were not in the medication cart. LVN 2 stated the dorzolamide eye drops was found on a top drawer of another medication cart (unspecified which cart). LVN 2 stated she documented all medications as administered by mistake. During an interview on 8/29/2026 at 7:28 p.m., with RN 2, RN 2 stated that if a medication was not administered, the nurse should not document the medication as administered. During an interview on 8/29/2026 at 8:46 p.m., with RN 1, RN 1 stated that on 8/28/2026, approximately 4:00 p.m., he received an endorsement from LVN 3, who went home sick and informed RN 1 that Resident 2's medications had already been administered. RN 1 stated that when he observed that Resident 2's dorzolamide HCL-Timolol maleate eye drops had not been documented as administered, he entered his initials on the MAR indicating that the dorzolamide was administered, even though he did not administer the eye drops. RN 1 stated he checked the bubble-packed medications that had been administered but did not check Resident 2's eye drops. During an interview on 8/29/2026 at 8:56 p.m., LVN 2 stated it was important to administer the dorzolamide eye drops as ordered to prevent vision loss. LVN 2 stated the Director of Nurses (DON) instructed her to leave the facility before the end of her shift due to the medication omission involving Resident 2. During an interview on 8/29/206 at 9:26 p.m., with the with the DON, the DON stated Resident 2 missed multiple doses (unspecified) of the dorzolamide and could result in potential adverse effects including vision loss. The DON stated Resident 2's physician will be notified and will follow up with the ophthalmologist (specialist for eye problems and conditions). During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure in Medication Administration, dated 7/2013, the P&P indicated medications must be administered in accordance with the written orders of the attending physician, medications must be charted following the administration by the licensed nurse who administered the medication. During a review of the facility's P&P titled, P&P on Administration of Eye Drops, dated7/2012, the P&P indicated the facility must ensure that eye medications are appropriately provided based on (MD) Medical Doctor's order.

Based on observation, interview, and record review, the facility failed to ensure one of one sample residents' (Resident 1) privacy and confidentiality were protected when staff used a personal cellular device to photograph and transmit photographs of the resident without evidence that proper facility protocol had been followed and authorization had been obtained. This deficient practice had the potential to place Resident 1 at risk for unauthorized disclosure, use, or distribution of the resident's image and compromised the facility's ability to maintain the resident's privacy and confidentiality. FindingsDuring a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 diagnoses included cerebral infarction (when a blood clot or fatty plaque blocks an artery), aphasia (a disorder that makes it difficult to speak), aneurysm (a weak spot in the wall of an artery that causes it to balloon or bulge outward), muscle weakness, dysphagia (difficulty swallowing) and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/22/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (ability to think and process) was severely impaired. The MDS indicated Resident 1's speech was unclear (slurred or mumbled words). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's History and Physical (H&P), dated 11/28/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a telephone interview on 8/19/2026 at 12:59 p.m., with Resident 1's Responsible Party (RP) 1, RP 1 stated that Licensed Vocational Nurse (LVN) 1 contacted her and informed her of an incident involving Resident 1 and Certified Nursing Assistant (CNA) 1. RP 1 stated that, following the notification, she asked LVN 1 to send her photographs of Resident 1's left facial area and left shoulder so she could assess Resident 1's appearance. RP 1 stated that during the evening of 8/17/2026, LVN 1 sent her two photographs of Resident 1's face and left shoulder. RP 1 confirmed that the photographs were received directly from LVN 1. During an interview on 8/19/2026 at 1:06 p.m., with LVN 1, LVN 1 stated that he sent photographs of Resident 1, to RP 1. LVN 1 stated that the photographs were sent to RP 1 via LVN 1's personal cellular phone on 8/17/2026, during the evening shift, following the alleged incident involving Resident 1 and the CNA 1. LVN 1 was asked whether he followed a facility-approved process before taking or transmitting photographs of the resident using his personal cellular phone. LVN 1 stated that he did not know whether using a personal cellular phone to send photographs of residents to family members or responsible parties was permitted per the facility's policies and procedures. LVN 1 stated that he did not send the photographs to anyone other than RP 1. LVN 1 confirmed that photographs of Resident 1 were transmitted from a staff member's personal cellular phone to an individual identified as Resident 1's RP, without first confirming the correct process for sharing resident's personal information outside the facility. LVN 1 stated that not following the company's procedures regarding the sharing of a resident's health information could compromise the resident's privacy and confidentiality. During an interview on 8/19/2026 at 1:33 p.m., with the Director of Nursing (DON), the DON stated that staff were prohibited from taking photographs of residents using personal cell phones, as this practice did not comply with facility policies, resident privacy requirements, or established protocols. The DON stated that the facility maintained an assigned facility-owned cell phone, which was utilized by authorized staff, such as the wound care nurse and physician, to photograph wounds for clinical purposes only, and that all photographs were uploaded directly into the resident's medical record. The DON stated that if photographs were requested to be shared with a resident's responsible party, the facility must first obtain the appropriate consent forms and secure the necessary approvals prior to releasing or transmitting any images. The DON stated that the use of personal cell phones by staff during work hours was prohibited and emphasized that no staff member should ever take, store, send, or share photographs of residents using personal electronic devices under any circumstances. The DON stated that adherence to these procedures was necessary to protect resident privacy, confidentiality, and residents' rights. The DON stated that all staff upon hire were given the employee handbook where it indicated that the use of personal cell phones was not permitted during work hours. During a review of the facility's policy and procedure (P&P) titled Protected Health Information, Management and Protection dated 4/2014, the P&P indicated, It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. During a review of the facility's P&P, titled, Confidentiality of information and Personal Privacy, dated 10/2017, the P&P indicated: The facility will safeguard the personal privacy and confidentiality of all resident personal and medical data. The P&P indicated release of resident information, including video, audio, or computer stored information, will be handled in accordance with resident rights and privacy policies. During a review of the facility's P&P titled Company Employee Handbook- General Policies dated 1/2026, the P&P indicated You may not use personal communication devices such as cell phones, smart phones and pagers during work hours and in work areas, unless you are using a Company-provided device for business purposes. To protect Company security you may never use camera cell phones to take pictures on Company property without the prior written approval of the Company. Additionally, you may never use your cell phone or another device to engage in any form of audio or video recording on Company premises without the prior written approval of the Company and the written consent of the individual to be recorded.

Based on interview and record review, the facility failed to ensure residents were free from verbal and mental abuse for two of three sampled residents (Resident 2 and Resident 3).This deficient practice resulted in Resident 1 verbally and mentally abusing Residents 2 and 3.Findings:1. 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 chronic respiratory failure with hypoxia (the body or brain is not getting enough oxygen), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and difficulty walking.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 3/12/2026, the MDS indicated Resident 3's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 3 required setup assistance (helper sets up or cleans up, resident completes activity) from staff with activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 3's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions.During an interview on 3/18/2026 at 10:03 a.m., Resident 3 stated her roommate (Resident 1) was not mentally stable and frequently used profanity towards staff and visitors. Resident 3 stated it was a sad experience sharing a room with Resident 1. Resident 3 stated she was scared and mentally exhausted.2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included type 2 diabetes mellitus, peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and hypertension (high blood pressure).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact. The MDS indicated Resident 2 was independent with eating, oral hygiene, and toileting.During a review of Resident 2's H&P, dated 2/27/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions.During an interview on 3/18/2026 at 10:10 a.m., with Resident 2 (Resident 1's roommate), Resident 2 stated, Resident 1 had repeatedly called her offensive names. Resident 2 stated she felt neglected and verbally abused. Resident 2 stated Resident 1's mental condition was not a justification (a reason why something is okay) for exposing others to verbal abuse and yelling. Resident 2 stated the facility should have stepped in to help from the beginning.3. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included bipolar disorder (sometimes called manic- depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and dementia (a progressive state of decline in mental abilities) with behavioral disturbance.During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 1 required setup and clean-up assistance (helper sets up or cleans up, resident completes activity) from staff with ADLs.During a review of Resident 1's H&P, dated 11/15/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During an attempted interview on 3/18/2026 at 11:00 a.m., with Resident 1, Resident 1 became verbally aggressive and started yelling profanity. During an interview on 3/19/2026 at 9:00 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated abuse included verbal actions such as yelling and using profanity. LVN 1 stated this behavior could cause emotional harm to another resident. LVN 1 stated cognitive impairment did not excuse the impact of that behavior on others.During an interview on 3/19/2026 at 10:00 a.m., with the Administrator (ADM), the ADM stated he was the abuse coordinator and ensured the facility maintained a safe, respectful, abuse-free environment at all times. The ADM stated this included making sure staff were properly trained to recognize and report abuse and ensuring timely intervention to protect resident rights.During an interview on 3/19/2026 at 10:08 a.m., with the Director of Nursing (DON), the DON stated abuse included any behavior that caused harm, including verbal and emotional harm such as yelling, name calling, or intimidation. The DON stated regardless of a resident's cognitive status, the facility has the responsibility to protect all residents from abuse.During a review of the facility's Policy and Procedure (P&P) titled, Abuse and Neglect Prevention Management, revised 2/2018, the P&P indicated, the facility is committed to protecting residents against all forms of abuse, potential abuse, and to ensure residents safety, and neglect by staff members, other residents or any individuals.

Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered by the physician for five of five sampled residents (Resident 2, 3, 4, 5, and 6).This failure resulted in residents' delay in receiving prescribed medications, which could lead to adverse drug reactions and ineffective treatment of medical conditions.Findings:a. During a review of Resident 2's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 2/17/2026 with diagnoses including type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor would healing) and hypertension (HTN- high blood pressure).During a review of Resident 2's Medication Administration Record (MAR) dated March 2026, the MAR indicated metformin (medication that treats high blood sugar) oral (by mouth) tablet 1000 milligram (mg- unit of measurement) was scheduled for 7:30 a.m.During a concurrent observation and interview on 3/10/2026 at 9:55 a.m. with Licensed Vocational Nurse (LVN) 1 outside of Resident 2's room, LVN 1 stated she was going to administer metformin 1000 mg tab to Resident 2. LVN stated metformin was scheduled to be given at 7:30 a.m. and stated the medication was being administered late.During an observation on 3/10/2026 at 10:00 a.m. in Resident 2's room, LVN 1 handed the metformin to Resident 2. Resident 2 refused to take the metformin pill and stated that his primary care physician (PCP) instructed him to take metformin along with his last bite of breakfast. Resident 2 stated he was supposed to take the medication with his breakfast and not two hours later.b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 2/23/2026 with diagnoses including type 2 diabetes mellitus and hypertension.During a review of Resident 3's MAR dated March 2026, the MAR indicated clonidine (medication that relaxes blood vessels) 0.1 mg oral tablet scheduled for 9:00 a.m.During a concurrent observation and interview on 3/10/2026 at 10:18 a.m. with LVN 2, outside of Resident 3's room, LVN 2 stated he was preparing Resident 3's medications. LVN 2 stated he was going to administer clonidine 0.1 mg tablet to Resident 3 which was scheduled to be administered at 9:00 a.m. but he was running behind on passing medications.c. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 10/8/2025 and re-admitted the resident on 12/18/2025 with diagnoses including congestive heart failure (condition where the heart is unable to pump blood efficiently) and atrial flutter (abnormal heart rhythm).During a review of Resident 4's MAR dated March 2026, the MAR indicated, glipizide (medication that lowers high blood sugar level) 2.5 mg oral tablet was scheduled for 7:30 a.m.During an observation on 3/10/2026 at 10:40 a.m. with LVN 1 outside of Resident 4's room, LVN 1 was observed administering glipizide 2.5 mg tablet to Resident 4.d. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 1/6/2023 and re-admitted the resident on 12/28/2023 with diagnoses including hypertension and congestive heart failureDuring a review of Resident 5's MAR dated March 2026, the MAR indicated carvedilol (medication that treats heart problems and high blood pressure) 25 mg oral tablet was scheduled for 7:30 a.m. and furosemide (medication that removes excess water and salt in the body) 20 mg oral tablet was scheduled for 9:00 a.m.During a concurrent observation and interview on 3/10/2026 at 10:28 with LVN 2, outside of Resident 5's room, LVN 2 stated he was preparing Resident 5's medications. LVN 2 stated he was going to administer carvedilol 25 mg tablet which was scheduled for 7:30a.m. and furosemide 20 mg tablet which was scheduled for 9:00 a.m.e. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 10/18/2024, and re-admitted the resident on 2/24/2026 with diagnoses including end stage renal disease (condition where the kidneys stop working) and hydrocephalus (condition where to much fluid build inside the brain).During a review of Resident 6's MAR dated March 2026, the MAR indicated levetiracetam (medicine used to treat seizures) 500 mg oral tablet was scheduled at 9:00 a.m. and valproic acid (medication that helps stop seizures and treats mood swings) 250 mg oral capsule was scheduled for 9:00 a.m.During a concurrent observation and interview on 3/10/2026 at 10:45 a.m. with LVN 2, outside of Resident 6's room, LVN 2 stated he was preparing Resident 6's medications. LVN 2 stated he was going to administer levetiracetam 500 mg oral tablet and valproic acid 250 mg oral tablet to Resident 6. LVN stated levetiracetam and valproic acid were scheduled for 9:00 a.m.During an interview on 3/10/2026 at 2:36 p.m. with LVN 1, LVN 1 stated nurses administer medications one hour before or one hour after scheduled time per physician's order. LVN stated that timely pain medications prevent unnecessary discomfort and pain, diabetes medications often require food for proper absorption, late seizure medications increases seizure risk, and delayed blood pressure medications can affect blood pressure control.During an interview on 3/10/2026 at 2:57 p.m. with LVN 2, LVN 2 stated medications must be given on time, especially those administered multiple times a day, to avoid doses being given too close to each other. LVN 2 stated staff has a one hour window before and after the medication scheduled time of the physician's order, and giving blood pressure or seizure medications late can result in elevated blood pressure or increased seizure risk for residents.During an interview on 3/10/2026 at 4:36 p.m. with Assistant Director of Nursing (ADON), the ADON stated medications should be given on time for maximum effect, with a one hour window before or after the scheduled time. ADON stated that diabetic medications must be given with meals to prevent low blood sugar. ADON stated some blood pressure medications may cause stomach problems if not given with food and may not control blood pressure effectively if administered late.During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure in Medication Administration dated July 2013, the P&P indicated, Drugs must be administered in accordance with the written orders of the attending physician.Medication must not be prepared in advance and must be administered within one hour before or after administration time per M.D. [doctor] order.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 disinfected the glucometer (device to measure blood sugar) and blood pressure cuff when used between two of four sampled residents (Resident 3 and Resident 5).This failure had the potential to place the residents at risk for cross-contamination and infections, compromising residents' overall health and safety.Findings:During a review of Resident 3's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 2/23/2026 with diagnoses including Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN-high blood pressure).During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 1/6/2023 and re-admitted the resident on 12/28/2023 with diagnoses including muscle weakness and hypertension.During a concurrent observation and interview on 3/10/2026 at 10:18 a.m. with LVN 2 outside of Resident 3's room, LVN 2 was observed walking out of Resident 3's room and placed the glucometer and blood pressure cuff on top of the medication cart 1. LVN 2 stated he had just checked Resident 3's blood sugar and blood pressure. LVN 2 did not disinfect the glucometer or blood pressure cuff after use.During an observation on 3/10/2026 at 10:22 a.m. in Resident 3's room, LVN 2 administered Resident 3's medications. LVN 2 then walked out of Resident 3's room, grabbed the glucometer that was on top of medication cart 1, and placed it inside a medication cart 1 drawer without disinfecting. LVN 2 then positioned medication cart 1 outside of Resident 5's room.During a concurrent observation and interview on 3/10/2026 at 10:28 a.m. with LVN 2 outside of Resident 5's room, LVN 2 stated he was going to check Resident 5's blood pressure before medication administration. LVN 2 took the same blood pressure cuff from the medication cart 1 and proceeded to check Resident 5's blood pressure. LVN 2 did not disinfect the blood pressure cuff before or after using on Resident 5.During an interview on 3/10/2026 at 2:57 p.m. with LVN 2, LVN 2 stated he did not disinfect the glucometer after he checked Resident 3's blood sugar and before placing the glucometer back in the medication cart 1 drawer. LVN 2 stated he did not disinfect the blood pressure cuff before and after using the blood pressure cuff to check Resident 5's blood pressure. LVN 2 stated not disinfecting the glucometer and blood pressure cuff between residents could have resulted in contagious infections being passed on from one resident to another.During an interview on 3/10/2026 at 3:15 p.m. with the Infection Control Nurse (ICN), the ICN stated glucometers and blood pressure cuffs were cleaned and disinfected between residents and before and after each use. The ICN stated the importance of disinfecting the equipment was to prevent passing on infections, and failing to do so could cause infections to be spread from person to person.During an interview on 3/10/2026 at 4:36 p.m. with Assistant Director of Nursing (ADON), the ADON stated glucometers and blood pressure cuffs needed to be disinfected before and after each use and failing to do so could cause outbreaks of infections within the facility.During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2018, the P&P indicated, Reusable items are cleaned and disinfected or sterilized between residents.Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions.During a review of glucometer's Assure Manufacturer's Guide undated instructions, the instructions indicated, The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens [blood germs].

Based on interview, and record review, the facility failed to ensure one of one Certified Nursing Assistant (CNA) 3 rom registry staffing (temporary contracted staffing) received facility training on abuse prevention prior to providing care to residents.The deficient practice had the potential to place residents at risk for abuse and neglect.Findings:During an interview on 2/19/2026 at 11:46 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated, the facility did not provide abuse prevention training or in-service prior to starting her shift. During an interview on 2/19/2026 at 12:20 p.m., with the Director of Staff Development, the (DSD) stated, the facility hires some staff as registry fillers (come only as needed, maybe one or two shifts) The DSD stated these temporary staff were not provided education on the facility's abuse policy and procedures prior to them beginning their shift at the facility.During an interview on 2/19/2026 at 9:15 a.m., with the Director of Nursing (DON), the DON stated, registry staff should receive facility abuse training to ensure they have the expected level of abuse training and knowledge. The DON stated that hiring staff who do not have abuse training could potentially result in lack of abuse identification, reporting, and prevention.During a review of the facility's records, there was no documentation of mandatory abuse training provided for temporary registry staff.During a review of the facility's policy and procedure (P&P) titled, Abuse and Neglect Prevention Management dated 2/2018 indicated, All staff will be trained on the following topics during orientation, and ongoing re: issues related to abuse prevention practices: A. Facility abuse and neglect prevention protocol.

Based on interview and record review, the facility failed to notify one of three sampled residents' (Resident 1) responsible party (RP 1), regarding the resident's refusal of shower seven times. This failure resulted in Resident 1's RP 1 not being aware of the resident's refusal of shower and resident's hygiene needs not being assisted and met. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including history of schizophrenia (a mental illness that is characterized by disturbances in thought), traumatic (a result of trauma) subdural (within the skull) hemorrhage (bleeding within the skull, near the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance which can cause confusion, agitation, movement problems, and coma). The admission Record indicated Resident 1 had a responsible party (RP-designated decision maker), RP 1. During a review of Resident 1's History of Physical (H&P), dated 9/7/2025, the H&P indicated Resident 1 did not have capacity to understand and make medical decisions. During a review of Resident 1's care plan titled, Non-Compliance of Plan of Care, Treatment, Medications. dated 5/15/2025, one of the care plan interventions indicated to notify Resident 1's Medical Doctor (MD) and Responsible Party (RP) for non-compliance. During a review of Resident 1's Documentation Survey Report, for 10/2025, the report indicated no bathing was offered or provided from 10/10/2025 through 10/16/2025. During a review of Resident 1's progress notes, for 10/2025, the progress notes did not indicate RP 1 was notified about Resident 1's shower and complete bed bath refusals. During a concurrent interview and record review on 10/31/2025 at 11:10 a.m. with Registered Nurse 1 (RN 1), the facility's P&P titled Refusal of Treatment, dated 5/2013, Resident 1's Documentation Survey Report, dated 10/2025, Resident 1's progress notes, dated 10/2025, and Resident 1's care plan titled Non-Compliance of Plan of Care, Treatment, Medications. dated 5/15/2025, were reviewed. RN 1 stated Resident 1 refused seven of eight showers or complete bed baths and had only received one shower from 10/1/2025-10/30/2025 as indicated in the report. RN 1 stated the facility did not implement the refusal P&P and Resident 1's non-compliance care plan after each refusal. RN 1 stated partial and other baths were only offered as alternatives after Resident 1 refused a complete bed bath and shower. RN 1 stated the 14 other and partial baths as indicated in Resident 1's Documentation Survey Report indicated Resident 1 refused full head-to-toe bed bath and shower. RN 1 stated the P&P and care plan intervention for Resident 1's refusal of shower should have been followed, including notifying the RP time Resident 1 refused complete bed bath or shower on 10/7/2025, 10/10/2025, 10/14/2025, 10/17/2025, 10/21/2025, 10/24/2025, and 10/28/2025. RN 1 stated the P&P titled Refusal of Treatment indicated, the date and time of the shower attempts, Resident 1's response and the reason for refusal, name of the person offering the shower, education about the risk of refusal, and any adverse effects from the refusal, should have been documented in the progress notes, but were not. RN 1 stated there was no documentation in the progress notes that RP 1 was notified about Resident 1's refusals to be bathed or showered. RN 1 stated not notifying RP 1 about Resident 1's refusal of care was a violation of the RP's rights. During an interview on 10/31/2025 at 12:20 p.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated other bath indicated Resident 1 frequently refused showers and only accepted showers when RP 1 was present. CNA 3 stated other bath meant Resident 1 was cleaned from waist to toe, partial bath meant Resident 1 was cleaned from neck to toe, and completed bed bath meant Resident 1 was completely cleaned from head to toe. CNA 3 stated Resident 1's refusal should have been documented alongside the alternate interventions of other and partial bath to show that complete baths and showers were offered to Resident 1. During an interview on 11/3/2025 at 12:20 p.m. with the Director of Nursing (DON), the DON stated Resident 1's care plan was not followed when the facility did not notify RP 1of Resident 1's seven shower refusals. The DON stated the facility should have documented in Resident 1's progress notes about the refusal, how Resident 1 responded, and how Resident 1's care was provided. During a review of the facility's P&P titled Refusal of Treatment, dated 5/2013, the P&P indicated documentation pertaining to refusal of treatment should include the treatment refused, the resident's response and reason for refusal, and that the resident was informed of the purpose of treatment and consequences of not receiving the treatment.

Based on interview and record review, the facility failed to ensure non consensual sexual contact (any sexual touching or contact that occurs without the explicit [clear] and voluntary agreement with individuals involved) did not recur for two of three sampled residents (Resident 1 and Resident 2), by failing to:1). Ensure Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting was conducted and plan of care with interventions created after the incident on 6/13/2025 when Resident 2 kissed Resident 1 in Resident 1's room and attempted to climb into Resident 1's bed.This failure resulted in the second nonconsensual sexual contact on 11/8/2025 when Certified Nursing Assistant 3 (CNA 3) witnessed Resident 1 placing his hand on Resident 2's upper thigh while in the family room (a room where residents gather), unsupervised by facility staff.Cross Refer to F609 and F610.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1, a male resident, was admitted to the facility on [DATE], with diagnoses including history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) and aphasia (a disorder that makes it difficult to speak). The admission Record indicated Resident 1 had a responsible party, Family Member 1 (FM 1). During a review of Resident 1's History and Physical (H&P), dated 4/27/2025, 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 5/7/2025, the MDS indicated Resident 1 had unclear speech, impaired vision, and severe cognitive impairment. The MDS indicated Resident 1 did not exhibit physical behavioral symptoms toward others such as abusing others sexually or engaging in public sexual acts. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort) on staff for personal hygiene (ability to maintain personal hygiene such as combing hair or shaving), rolling left and right (the ability to roll from lying on back to left and right side), and transferrin g from sitting to lying and from lying to sitting on the side of the bed. During a review of Resident 1's progress notes, dated 6/14/2025 at 1:32 a.m., the progress notes indicated on 6/13/2025 at 7:30 p.m., a CNA (unidentified) notified Licensed Vocational Nurse (LVN) 5 Resident 2 was observed kissing Resident 1 in Resident 1's room. The progress notes indicated upon LVN 5's arrival in Room A, LVN 5 observed Resident 2 kissing Resident 1 and was attempting to climb up the bed of Resident 1 from her wheelchair. The progress notes indicated both residents (Residents 1 and 2) were separated. The progress notes indicated Residents 1 and 2 were notified that male and female residents cannot be alone in each other's room, nor can be intimate in any way while under the facility's care. The progress notes indicated Resident 1 indicated that Resident 2 kissed him and accepted it. The progress notes indicated will continue with plan of care (POC). During a review of Resident 1's clinical records since admission [DATE]), Resident 1's clinical records did not indicate notes or consent provided for a consensual relationship with other residents in the facility. During a review of Resident 1's Care Plans, dated 6/2025, the care plans did not indicate a plan of care regarding the kissing incident on 6/13/2025 was created or interventions to address unconsented kissing incidents and prevention of potential sexual abuse. During a review of Resident 1's Weekly Nursing Summary, dated 6/16/2025, the weekly summary indicated Resident 1 was verbal, alert, and confused. During a review of Resident 1's Progress Notes, dated 11/8/2025 at 2:26 p.m., the progress notes indicated a Charge Nurse (CN- unidentified) reported to Registered Nurse (RN) 4 that a CNA (unidentified) saw Resident 1 put his hands in between Resident 2's thighs while the CNA (unidentified) was passing by the family room. The progress notes indicated the (unidentified) CNA told two (2) Restorative Nursing Assistants (RNA- unidentified) who were in the hallway at the time. The progress notes indicated one RNA removed Resident 2 from the family room. During a review of Resident 1's care plan titled At risk for emotional distress related to allegation of sexual abuse against resident, dated 11/8/2025, the interventions indicated to allow resident time to answer questions and to verbalize feelings, perceptions and fears, assessment of resident, place call light within reach at all times, identify resident's coping mechanisms, monitor every shift for any signs and symptoms (S/S) of emotional distress for 3 days, monitor/document Resident 1's feelings and notify the physician (MD) and resident representative for any S/S of change of condition (COC). 2). During a review of the Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including history of hydrocephalus (increased pressure in the brain, can cause cognitive problems), bacterial diseases (illnesses caused by bacteria that can multiply and cause harm within the human body), amnestic disorder (a condition with partial or total memory loss), and mild cognitive impairment (decline in thinking, remembering, or reasoning). The admission Record indicated Resident 2 had a power-of-attorney for care (an agent who makes decisions on behalf of the resident). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and could independently wheel 150 feet in a manual wheelchair. The MDS indicated Resident 2 required setup assistance (helper assists only prior to or following the activity, resident completes the activity) to transfer between a wheelchair and bed and walk ten feet. During a review of Resident 2's progress notes, dated 6/14/2025 at 1:32 a.m. (late entry), the progress notes indicated at 7:30 p.m., date not indicated, a CNA (unidentified) notified LVN 5 regarding a resident (unspecified) from Room A (Resident 1). The progress notes indicated upon LVN 5's arrival in Room A, Resident 2 was observed kissing Resident 1. The progress notes indicated Resident 2, who was in her wheelchair, was attempting to climb to the top of Resident 1's bed. The progress notes indicated both residents (Residents 1 and 2) were separated and were notified that male and female residents cannot be alone in each other's room, nor can be intimate in any way while under the facility's care. The progress notes indicated Resident 2 stated she went to Resident 1's room to greet him with a happy father's day and offered him a kiss. During a review of Resident 2's clinical records since admission [DATE]), Resident 2's clinical records did not indicate notes or consent provided for a consensual relationship with other residents in the facility. During a review of Resident 2's Care Plans, dated 6/2025, the care plans did not indicate a plan of care regarding the kissing incident on 6/14/2025 was created or interventions to address unconsented kissing incidents and prevention of potential sexual abuse. During a review of Resident 2's H&P dated 10/28/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's progress notes, dated 11/8/2025 at 2 p.m., the progress notes indicated a CN (unidentified) reported to RN 4 that a CNA (unidentified) saw Resident 1 put his hands in between Resident 2's thighs while the CNA (unidentified) was passing by the family room. The progress notes indicated the (unidentified) CNA told 2 RNAs (unidentified) who were in the hallway at the time. The progress notes indicated the 2 RNAs went to Residents 1 and 2right away and observed Resident 1 was in the patio. The progress notes indicated one RNA removed Resident 2 from the family room. During a review of Resident 2's care plan titled At risk for emotional distress related to allegation of sexual abuse,, dated 11/8/2025 the interventions indicated to allow the resident time to answer questions and to verbalize feelings, perceptions and fears, assessment of resident, place call light within reach at all times, identify resident's coping mechanisms, monitor every shift for any S/S of emotional distress for 3 days, monitor/document resident's feelings and notify MD and resident representative for any S/S of COC. During an interview on 11/10/2025 at 1:25 p.m. with RN 4, RN 4 stated on 11/8/2025 she investigated the alleged sexual abuse (any act of sexual contact including unwanted sexual touching, forced sexual acts and rape that occur without consent) between Resident 1 and Resident 2, when CNA 3 passed by the family room on 11/8/2025, witnessed Resident 1's hands were placed between Resident 2's thighs and suspected sexual abuse. RN 4 stated neither Residents 1 nor 2 had the capacity to consent for any form of sexual contact due to both residents' severe cognitive impairment. RN 4 stated Resident 1 placing his hands between Resident 2's thighs could have been sexually motivated (refers to the impulse to gratify sexual needs and encompasses the human desire and interest in participating in sexual activities, activated by both internal and external signals). RN 4 stated CNA 3 should have immediately intervened, separated the Residents 1 and 2, and remained with the residents instead of walking away and telling RNA 1. RN 4 stated the inappropriate, nonconsensual contact (any sexual touching or contact that occurs without the explicit [clear] and voluntary agreement with individuals involved) between Residents 1 and 2 was allowed to continue due to CNA 3's lack of intervention. During an interview on 11/12/2025 at 9:07 a.m. with CNA 3, CNA 3 stated on 11/8/2025 at 11:30 a.m., while passing by the family room, CNA 3 stated she observed Resident 1 and Resident 2 sitting in the family room and Resident 1's hand was on Resident 2's upper thigh. CNA 3 stated the family room had no staff present or any supervision. CNA 3 stated the contact may have been sexually motivated. CNA 3 stated she walked down the hallway (approximately 20 feet down the hallway) and informed RNA 1 about Resident 1's hand was on Resident 2's thigh. During an interview on 11/12/2025 at 11:30 a.m. with RNA 1, RNA 1 stated on 11/8/2025, CNA 3 notified her (RNA 1) that Resident 1 was touching Resident 2's inner upper thigh, while in the family room, unsupervised, but did not stop to intervene because she was at lunch. RNA 1 stated she ran 20 feet down the hallway to intervene and separated Residents 1 and 2 who were in the family room. RNA 1 stated she physically removed Resident 2 from the family room to prevent continued abuse. RNA 1 stated CNA 3 should have immediately intervened and removed Resident 2 and should not have left the family room after witnessing a potential sexual abuse between Residents 1 and 2. RNA 1 stated CNA 3 delayed staff response and allowed the witnessed sexual abuse to continue. During a concurrent interview and record review on 11/12/2025 at 12:02 p.m. with LVN 3, Residents 1 and 2's progress notes and care plans for 6/2025, were reviewed. LVN 3 stated both residents' progress notes dated 6/13/2025 indicated Resident 1 and Resident 2 had a previous incident of nonconsensual sexual contact when Resident 2 kissed Resident 1 and when Resident 2 attempted to climb into Resident 1's bed. LVN 3 stated neither Resident 1 nor Resident 2 had the capacity to provide consent for any sexual activity, thus the incident was sexual abuse. LVN 3 stated the facility did not create a care plan for Resident 1 and Resident 2 to address the sexual abuse on 6/13/2025, including emotional, physical and location monitoring. LVN 3 stated not creating care plan interventions on the history of sexual abuse on 6/13/2025 put Resident 1 and Resident 2 at high risk of repeated sexual abuse. LVN 3 stated Resident 1's hand on Resident 2's inner thigh was sexual in nature and could have been prevented if interventions were implemented to prevent repeated sexual abuse. LVN 3 stated Residents 1 and 2's locations should have been monitored, and interactions should have been supervised. During an interview on 11/12/2025 at 12:21 p.m. with RN 1, RN 1 stated Resident 1 and Resident 2 care plans were not updated after the sexual abuse on 6/13/2025. RN 1 stated Resident 1's and Resident 2's locations were not monitored to maintain separation. RN 1 stated an IDT meeting should have been conducted after the sexual abuse incident on 6/13/2025, including both residents' representatives, the Social Services department, Nursing department, and Activities department, to ensure adequate care and services were provided. During a concurrent interview and record review on 11/12/2025 at 2:48 p.m. with the DON, the facility's P&P titled Abuse and Neglect Prevention Management, dated 1/2018, Resident 1's progress notes, dated 6/2025, Resident 1's MDS, dated [DATE], Resident 2's Progress Notes, dated 6/13/2025, Resident 2's MDS, dated [DATE], and Resident 1's Progress Notes, dated 11/8/2025 were reviewed. The DON stated on 6/13/2025 during the evening (time not specified), LVN 5 notified her (DON) that in the evening 6/13/2025 (time not specified), Resident 2 kissed Resident 1 and Resident 2 climbed on top of Resident 1's bed. The DON stated she should have informed the nursing staff to immediately assess, monitor, and update the care plans for Resident 1 and Resident 2 but did not. The DON stated the P&P titled Abuse and Neglect Prevention Management indicated nonconsensual sexual contact of any type is sexual abuse. The DON stated that both residents' progress notes indicated Resident 2 kissed Resident 1 and kissing was considered sexual contact. The DON stated Resident 1's MDS indicated Resident 1 had severe cognitive impairment. The DON stated Resident 2's MDS indicated Resident 2 had severe cognitive impairment. The DON stated neither resident had the capacity to consent to sexual contact, therefore the nonconsensual kissing was sexual abuse. The DON stated the P&P should have been followed to respond to the sexual abuse on 6/13/2025 but was not. The DON stated Resident 1's and Resident 2's IDT team meetings should have occurred, care plans should have been updated, and the residents should have been assessed, monitored for emotional and physical changes, and residents' locations monitored to ensure they maintain separation. The DON stated those steps could have prevented sexual abuse in the future. The DON stated Resident 1 and Resident 2 were not evaluated by a psychologist to rule out negative effects of sexual abuse and plan the residents' care. The DON stated Resident 1 and Resident 2 may not receive appropriate services because Resident 1 and Resident 2 were not assessed after the sexual abuse on 6/13/2025The DON stated CNA 3 should not have walked away after witnessing potential sexual abuse on 11/8/2025. The DON stated this delay allowed potential sexual abuse to continue and risk Resident 2's safety. The DON stated CNA 3 should have immediately intervened and removed Resident 2 from the family room.During an interview on 11/13/2025 at 3:05 p.m. with Family Member (FM) 2, FM 2 stated FM 2 stated she was notified about the sexual abuse on 6/13/2025 and 11/8/2025. FM 2 stated as Resident 2's primary decision maker, she did not consent to Resident 2 to have any sexual contact with other residents and did not want Resident 1 and Resident 2 unsupervised together. FM 2 stated the facility did not provide a plan of care or outline interventions to prevent sexual abuse from recurring. FM 2 stated she would have felt violated if another resident touched her upper thigh, consensually. FM 2 stated the facility has not informed her about any changes in Resident 2's plan of care and how the facility plans to prevent recurrence. During an interview on 11/13/2025 at 4:13 p.m. with FM 1, FM 1 stated she was notified about the sexual abuse on 6/13/2025 and 11/8/2025. FM 1 stated she was Resident 1's primary decision maker and did not consent to Resident 1 having any sexual contact with other residents and did not want unsupervised visits between Resident 1 and Resident 2, especially after Resident 2 climbed into Resident 1's bed and kissed him on 6/13/2025. FM 1 stated she would have felt scared if another resident kissed her and climbed into her bed. During a concurrent interview and record review on 11/14/2025 at 3:15 p.m. with the Director of Staff Development (DSD), the facility's In-Service Binder, for 2025, was reviewed. The DSD stated following the sexual abuse in June 2025, in-services and trainings were not provided to the facility staff because she was not notified of the incident. The DSD stated staff should have been in-serviced and trained to prevent repeated sexual abuse, especially between two residents. During a review of the facility's P&P titled Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is a non-consensual sexual contact of any type with a resident. The P&P indicated staff should manage the allegations by removing and protecting the residents and assessing the residents for injury and notifying the Admin. The P&P indicated after the resident has been cared for, the licensed nurse should document the resident's condition each shift for 72 hours, update the care plan with identified actions that took place, updates the 24-hour report to alert following shifts to the allegations as well as the care plan updates and communicated specific care plan updates to direct care staff.

Based on interview and record review, the facility failed to report an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) to the California Department of Public Health (CDPH), for one of three sampled residents (Resident 1), when Resident 2 kissed Resident 1, who did not have the capacity to understand and make decisions (consent) and was found lying in Resident 1's bed. This failure resulted in a delay in the investigation by the CDPH and placed Resident 1 at risk for further abuse by Resident 2. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) and aphasia (a disorder that makes it difficult to speak).During a review of Resident 1's History and Physical (H&P), dated 4/27/2025, 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 5/7/2025, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment and did not exhibit physical behavioral symptoms toward others such as abusing others sexually or engaging in public sexual acts. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort) on staff for personal hygiene (ability to maintain personal hygiene such as combing hair or shaving), rolling left and right (the ability to roll from lying on back to left and right side), and transferring from sitting to lying and from lying to sitting on the side of the bed.During a review of Resident 1's Weekly Nursing Summary, dated 6/9/2025, the summary indicated Resident 1 was verbal, alert, and confused. During a review of Resident 1's Progress Notes, dated 6/14/2025, the progress notes indicated another resident (Resident 2) kissed Resident 1 and attempted to climb into Resident 1's bed. The progress notes did not indicate the incident was reported to the Administrator (Admin) or the CDPH.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hydrocephalus (increased pressure in the brain which could cause problems with cognition [ability to think and reason] problems) and amnestic disorder (a condition with partial or total memory loss).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and could independently (resident completes the activity by themselves with no assistance) wheel 150 feet in a manual wheelchair. The MDS indicated Resident 2 required setup assistance (helper assists only prior to or following the activity, resident completes the activity) to transfer between a wheelchair and bed.During a review of Resident 2's Progress Notes, dated 6/13/2025, the Progress Notes indicated Certified Nurse Assistant (unnamed) reported Resident 2 kissed Resident 1 and attempted to climb into Resident 1's bed. The Progress Notes did not indicate the incident was reported to the Administrator (Admin) or the CDPH. During an interview on 11/12/2025 at 12:21 p.m. with Registered Nurse (RN) 1, RN 1 stated she was assigned to Resident 1 and Resident 2 on 6/14/2025, the day after the alleged sexual abuse between the residents and had not reported the incident to the Administrator (ADM) nor the CDPH. RN 1 stated Residents 1 and Resident 2 had cognitive impairment, and neither could consent. RN 1 also stated, Resident 2 kissing Resident 1 and the incident (on 6/14/2025) licensed nurses should have followed the abuse policy to report the allegation of sexual abuse. During a concurrent interview and record review on 11/12/2025 at 2:48 p.m. with the Director of Nursing (DON), the facility's P&P titled, Abuse and Neglect Prevention Management dated 2/2018, Resident 1's Progress Notes dated 6/2025, Resident 1's MDS, dated [DATE], and Resident 2's Progress Notes, dated 6/13/2025, were reviewed. The DON stated on 6/13/2025, Licensed Vocational Nurse (LVN) 5 notified her that Resident 2 was found kissing Resident 1 and had climbed on top of him (Resident 1) in his bed. The DON stated she did not instruct LVN 5 to report the incident to the CDPH. The DON stated nonconsensual sexual contact of any type was considered sexual abuse. The DON stated Resident 2 kissing Resident 1 was considered sexual contact and sexual abuse because Resident 1 and Resident 2 had severe cognitive impairment and neither resident could consent to sexual contact. The DON stated the incident between Resident 1 and Resident 2 should have been reported to the CDPH. The DON also stated the incident on 6/13/2025 was not reported to the CDPH in part because Resident 2 had forgotten the incident and there were no complaints from the residents or the resident representatives. The DON stated it was important to ensure allegations of sexual abuse were reported to the CDPH for resident safety. During a concurrent interview and record review on 11/12/2025 at 3:43 p.m. with the Admin, Resident 2's Progress Note, dated 6/13/2025, was reviewed. The Admin stated he was the facility's Abuse Coordinator and licensed nurses should have informed him and the CDPH of the incident (alleged sexual abuse) between Resident 1 and Resident 2 on 6/13/2025, however was not done. During an interview on 11/13/2025 at 9:20 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she saw Resident 2 kissing Resident 1's lips and laying in Resident 1's bed, on top of Resident 1, on 6/13/2025. CNA 2 stated she was a mandated reporter and should have reported the sexual abuse to the Admin and CDPH.During a review of the facility's P&P titled, Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is non-consensual sexual contact of any type with a resident. The P&P indicated all facility employees are required to report any known or suspected abuse immediately upon identifying a concern. The P&P indicated all allegations of abuse will be reported to the Admin and the state survey and certification agency no later than two hours after the allegation is made.

Based on interview and record review, the facility failed to investigate an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1), when Resident 2 kissed Resident 1, who did not have the capacity to understand and make decisions (consent), and was found lying in Resident 1's bed.This failure resulted in a sexual abuse not being addressed, resulting in the potential for repeated sexual abuse.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1, a male resident, was admitted to the facility on [DATE], with diagnoses including history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) and aphasia (a disorder that makes it difficult to speak). The admission Record indicated Resident 1 had a responsible party, Family Member 1 (FM 1). During a review of Resident 1's History and Physical (H&P), dated 4/27/2025, 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 5/7/2025, the MDS indicated Resident 1 had severe cognitive impairment and did not exhibit physical behavioral symptoms toward others such as abusing others sexually or engaging in public sexual acts. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort) on staff for personal hygiene (ability to maintain personal hygiene such as combing hair or shaving), rolling left and right (the ability to roll from lying on back to left and right side), and transferring from sitting to lying and from lying to sitting on the side of the bed.During a review of Resident 1's Weekly Nursing Summary, dated 6/9/2025, the summary indicated Resident 1 was verbal, alert, and confused. During a review of Resident 1's Progress Notes, dated 6/14/2025, the progress notes indicated another resident, Resident 2, kissed Resident 1 and attempted to climb into Resident 1's bed. The progress notes did not indicate whether Resident 1, Resident 2, or any potential witnesses were interviewed.2. During a review of the Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including history of hydrocephalus (increased pressure in the brain, can cause cognitive problems), bacterial diseases (illnesses caused by bacteria that can multiply and cause harm within the human body), amnestic disorder (a condition with partial or total memory loss), and mild cognitive impairment (decline in thinking, remembering, or reasoning). The admission Record indicated Resident 2 had a power-of-attorney for care (an agent who makes decisions on behalf of the resident). During a review of Resident 2's History and Physical (H&P), dated 10/28/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and could independently (resident completes the activity by themselves with no assistance) wheel 150 feet in a manual wheelchair. The MDS indicated Resident 2 required setup assistance (helper assists only prior to or following the activity, resident completes the activity) to transfer between a wheelchair and bed.During a review of Resident 2's Progress Notes, dated 6/13/2025, the progress notes indicated another resident, Resident 2, kissed Resident 1 and attempted to climb into Resident 1's bed. The progress notes did not indicate whether Resident 1, Resident 2, or any potential witnesses were interviewed.During an interview on 11/12/2025 at 12:21 p.m. with Registered Nurse 2 (RN 2), RN 2 stated she was the RN assigned to Resident 1 and Resident 2 on 6/14/2025, the day after the sexual abuse. RN 2 stated there was no investigation into the incident.During a concurrent interview and record review on 11/12/2025 at 2:48 p.m. with the Director of Nursing (DON), the facility's P&P titled Abuse and Neglect Prevention Management, dated 2/2018, Resident 1's Progress Notes, dated 6/2025, Resident 1's MDS, dated [DATE], and Resident 2's Progress Notes, dated 6/13/2025, were reviewed. The DON stated the P&P indicated nonconsensual sexual contact of any type was sexual abuse. The DON stated that both residents' progress notes indicated Resident 2 kissed Resident 1 and kissing was considered sexual contact. The DON stated Resident 1's MDS indicated Resident 1 had severe cognitive impairment. The DON stated Resident 2's MDS indicated Resident 2 had severe cognitive impairment. The DON stated neither resident could consent to sexual contact and thus the nonconsensual kissing was sexual abuse and should have been investigated according to the P&P. The DON stated Licensed Vocational Nurse 5 (LVN 5) notified her that Resident 2 kissed Resident 1 and climbed on top of him in his bed in the evening 6/13/2025. The DON stated she did not instruct LVN 5 to investigate the incident. The DON stated the incident on 6/13/2025 was not investigated because Resident 2 had forgotten the incident and there were no complaints from the residents or the resident representatives. The DON stated the incident should have been investigated to prevent future sexual abuse.During a concurrent interview and record review on 11/12/2025 at 3:43 p.m. with the Administrator (Admin), Resident 2's Progress Note, dated 6/13/2025, was reviewed. The Admin stated he was the facility's abuse coordinator and investigator. The Admin stated he should have been notified about the incident described in the progress note but was not notified. The Admin stated the incident was not investigated but should have been investigated to prevent future abuse.During an interview on 11/13/2025 at 9:20 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she saw Resident 2 kissing Resident 1's lips and laying in Resident 1's bed, on top of Resident 1, on 6/13/2025. CNA 2 stated she never investigated the incident, never provided a written statement, and was never interviewed about the incident by any facility staff.During a review of the facility's P&P titled Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is non-consensual sexual contact of any type with a resident. The P&P indicated resident-to-resident altercations are investigated in an objective, timely, and complete manner. The P&P indicated all allegations of abuse will be investigated and the written findings of the investigation will be reported to the department of public health within five days of the alleged occurrence.

Based on interview and record review, the licensed nurse failed to follow physician's orders for two of three sampled residents (Resident 2 and Resident 3) when:1. Resident 2's blood pressure readings and heart rate were not recorded and documented on the Medication Administration Record (MAR), for six days in the month of August 2025 and one day in the month of September 2025.2. Resident 3's arteriovenous fistula (AV fistula, direct connection between an artery and a vein) dressing was not removed four hours after dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment on 9/10/2025 and 9/11/2025.3. Resident 3 was not administered oxygen as ordered at two liters (measurement for gas volume) per minute.4. Resident 3's oxygen saturation level (O2 sat- a measurement of how much oxygen the blood was carrying as a percentage) was not assessed on room air.These deficient practices demonstrated a lack of nursing competency in assessment, documentation, and implementation of care, which had the potential to compromise the residents' health and safety. Findings:1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), anxiety (a feeling of fear, dread, and uneasiness), and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 8/29/2025, the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 2 required setup assistance with eating, oral hygiene, toileting hygiene, and bed-to-chair transferring. The MDS indicated Resident 2 required supervision with showering/ bathing, personal hygiene, and walking. During a review of Resident 2's History and Physical (H&P), dated 8/18/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, dated 9/11/2025, the report indicated to hold lisinopril (medication to treat high blood pressure [HTN]) and metoprolol tartrate (medication to treat HTN) for systolic blood pressure (top number in a blood pressure reading) less than 110 beats per minute (BPM) or heart rate less than 60 BPM. During a review of Resident 2's Medication Administration Records (MAR), dated from 8/1/2025 to 9/11/2025, the MAR indicated Resident 2's blood pressure was below the parameter (a set value that helped control something) and did not receive lisinopril and metoprolol on 8/2, 8/14, 8/16, 8/21, 8/23, 8/27, and 9/6/2025. During a concurrent interview and record review on 9/11/2025 at 12:23 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's Vital Summary, dated from 8/1/2025- 9/11/2025 was reviewed. There were no blood pressure or heart rate readings documented on 8/2, 8/14, 8/16, 8/21, 8/23, 8/27, and 9/6/2025. LVN 1 stated that Resident 2's blood pressure or heart rate readings should be documented. LVN 1 stated the licensed nurse was responsible for taking vital signs (basic measure of how your body was working) and documenting in the residents' progress notes or MAR. LVN 1 stated the licensed nurse should have completed the documentation by the end of the shift to make sure the residents were in safe and stable condition. LVN 1 stated it was important to document the blood pressure readings and heart rate on the Vital Summary or the MAR for residents' safety. LVN 1 stated it was important to know the residents' blood pressure to prevent medication error (mistake in giving medicine). LVN 1 stated that incomplete documentation posed risks such as not knowing if Resident 2's blood pressure was too low, the next shift being unaware of prior events, difficulty tracing the resident's history, and potential delays in necessary care.During an interview on 9/12/2025 at 11:36 a.m. with the Director of Nursing (DON), the DON stated the licensed nurse should measure and document the residents' blood pressure on the MAR. The DON stated that documentation was necessary so the next shift would know the previous blood pressure reading. The DON stated it was important to document the blood pressure readings in the MAR to ensure the continuity of care. The DON stated documentation must be completed by the end of the shift to serve as a baseline for the next shift. The DON stated that documentation should be timely and accurate, and failing to document blood pressure was unacceptable. The DON stated that without documented blood pressure, administering blood pressure medication could cause hypotension (low blood pressure) leading to dizziness, weakness, or fainting. The DON stated the facility's policy required blood pressure readings to be documented in the MAR.During a review of the facility's policy and procedure (P&P) titled Vital Sign, dated 7/2012, the P&P indicated the vital signs and O2 saturations would be documented in all appropriate areas in the resident's medical record. 2a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included end stage renal disease (ESRD, irreversible kidney failure), congestive heart failure (CHF, a heart disorder which caused the heart to not pump the blood efficiently), and chronic respiratory failure (a long-term condition where the lungs could not get enough oxygen).During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognitive skills for daily decision making. The MDS indicated Resident 3 required setup assistance with eating and oral hygiene. The MDS indicated Resident 3 required supervision with personal hygiene. The MDS indicated Resident 3 was dependent (helper did all the effort) on staff for toileting hygiene, showering/ bathing, and bed-to-chair transferring. During a review of Resident 3's H&P, dated 6/17/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's care plan for ESRD, revised on 6/17/2025, the care plan goals indicated Resident 3 would remain free from complications daily. The care plan interventions indicated staff were to monitor Resident 3's left upper arm arteriovenous fistula (AV fistula, a direct connection between an artery and a vein) site for redness, swelling, local warmth, tenderness, bruit (a swishing sound over a blood vessel), thrill (a vibration over a blood vessel), and bleeding.During a review of Resident 3's nursing progress notes, dated 9/10/2025 at 7:27 p.m., the nursing progress notes indicated on 9/10/2025 at 4:10 p.m., Resident 3 returned from dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).During a concurrent observation and interview on 9/11/2025 at 10:50 a.m. with Resident 3, in Resident 3' room, observed Resident 3's left upper arm. The arm was covered with a pressurized dressing (dressing that applied firm and consistent pressure to a site) over the AV fistula site. Resident 3 stated the licensed nursing staff did not check her AV fistula site or dressing after she returned from dialysis on 9/10/2025. During a concurrent observation and interview on 9/11/2025 at 1:24 p.m. with LVN 1, in Resident 3's room, observed Resident 3's left upper arm. The arm was covered with a pressurized dressing over the AV fistula site. LVN 1 stated the pressurized dressing was from Resident 3's dialysis center and should have been removed four hours after returning. LVN 1 stated the licensed nurse should remove the dressing on the AV fistula site to prevent clogging. LVN 1 stated Resident 3 could not be dialyzed if the AV fistula was clogged. During an interview on 9/12/2025 at 10:40 a.m. with Registered Nurse (RN) 1, RN 1 stated it was not acceptable that Resident 3 still had the dressing over her AV fistula site on the morning of 9/11/2025. RN 1 stated the licensed nurse should remove the AV fistula dressing within four hours of returning from the dialysis center to ensure enough blood flow. RN 1 stated the licensed nurse would not be able to assess for signs and symptoms of infection or bleeding if the AV fistula site was covered with a dressing. RN 1 stated it was important to assess the AV fistula site. RN 1 stated it was a nursing intervention to remove the dressing after four hours and did not require a physician's order. RN 1 stated that leaving the pressure dressing on the AV fistula posed risks of fistula occlusion (something that obstructed the blood flow) and malfunction. RN 1 stated the residents could not start dialysis and might have hypovolemia (the body had too little blood or fluid), electrolytes imbalance, and even a heart attack. During an interview on 9/12/2025 at 11:36 a.m. with the DON, the DON stated it was standard of care to remove the pressurized dressing on the AV fistula in four hours of returning from dialysis. The DON stated that all the licensed nurses should know this. During a review of the facility's P&P titled Dialysis Services, dated 8/2012, the P&P indicated staff should assess the dialysis accesses site for bruit and thrill, any signs of bleeding or swelling, any sign and symptoms of infection.2b. During a review of Resident 3's Order Summary Report, dated 9/11/2025, the report indicated to administer oxygen at a rate of two liters (measurement for gas volume) per minute via nasal cannula (NC, a small plastic tube, which fit into the person's nostrils for providing supplemental oxygen) as needed for shortness of breaths (SOB), wheezing (a high-pitched sound made when breathing was restricted/obstructed in the lungs), chest pain, and oxygen saturation level (O2 sat, a measurement of how much oxygen the blood was carrying as a percentage) less than 90 percent (%) on room air. During a review of Resident 3's care plan for chronic respiratory failure, revised on 7/23/2025, the care plan interventions indicated to administer oxygen at a rate of two liters per minute via NC as needed for SOB, wheezing, chest pain, and O2 sat less than 90% on room air. During a concurrent observation and interview on 9/11/2025 at 1:24 p.m. with LVN 1 in Resident 3's room, observed Resident 3 receiving oxygen at a rate of five liters per minute via NC. LVN 1 stated Resident 3 should have received two liters of oxygen instead of five liters per minute. LVN 1 stated it was not acceptable to administer five liters oxygen per minute to Resident 3 because it was not ordered. LVN 1 stated Resident 3 could not adjust the oxygen level. LVN 1 stated the licensed nurses should ensure the oxygen was administered as ordered during rounds (regular checks by nurses to ensure resident safety and care) throughout the shift. LVN 1 stated Resident 3 was receiving too much oxygen, and it put Resident 3's health at risk. LVN 1 stated it was important to follow the physician's order. LVN 1 stated that administering oxygen at a rate of five liters per minute did not align with the care plan's intervention. LVN 1 stated staff should implement the care plan's interventions. During an interview on 9/12/2025 at 10:40 a.m. with RN 1, RN 1 stated Resident 3 should not receive more oxygen than ordered because of the diagnosis of CHF and chronic respiratory failure. RN 1 said Resident 3 could drown (lungs were overwhelmed, making it hard to breathe) from excessive oxygen, causing an imbalance in oxygenation and blood gas exchange (how oxygen entered the blood and carbon dioxide left it). RN 1 stated the licensed nurse should follow and comply with the physician's orders. During an interview on 9/12/2025 at 11:36 a.m. with the DON, the DON stated the certified nursing assistant should not adjust the oxygen level and should notify the licensed nurses. The DON stated the licensed nurse needed to ensure the oxygen was administered as ordered during the shift because it was important to follow the physician's order. The DON stated Resident 3 had a diagnosis of CHF and chronic respiratory failure and should not receive too much oxygen because it would increase cognitive confusion. 2c. During a concurrent interview and record review on 9/11/2025 at 1:46 p.m. with LVN 1, Resident 3's Weights and Vitals Summary, dated from 9/1/2025 - 9/11/2025, was reviewed. The Weights and Vitals Summary indicated Resident 3's O2 sat was obtained when the resident was receiving oxygen via NC and not on room air from 9/1/2025 - 9/11/2025. LVN 1 stated the licensed nurse should check Resident 3's O2 sat on room air to ensure an accurate assessment. During an interview on 9/12/2025 at 10:40 a.m. with RN 1, RN 1 stated the licensed nurse should check Resident 3's O2 sat on room air as ordered. RN 1 stated it was not acceptable to obtain an O2 sat when on oxygen because it was not a correct assessment. RN 1 stated the licensed nurses should assess the resident before administering the oxygen. RN 1 stated giving oxygen could unnecessarily cause more harm than good for the residents because of overcompensation (when the body tried to fix an imbalance, but the correction seemed too strong) in blood gas exchange. RN 1 stated that competent staff were essential to provide services that met residents' needs. RN 1 stated this highlighted a need for additional training to improve staff competency levels because any mistakes could compromise the health of the residents.During an interview on 9/12/2025 at 11:36 a.m. The DON stated for an accurate reading, the licensed nurse should have residents breathe room air for 30 minutes before checking the O2 sat. During a review of the facility's Charge Nurse Job Description, undated, the Job Description indicated, the charge nurse's responsibilities included following standards of nursing practices and implementing the facility's policies and procedures. The Job Description indicated the charge nurse should administer and document direct resident care, medications, and treatments per physicians' orders, and accurately record all care provided. The Job Description further indicated the charge nurse should implement an accurate comprehensive care plan based on resident's needs and assessment, and competently perform basic nursing skills. During a review of the facility's P&P titled Oxygen Therapy, dated 1/2024, the P&P indicated it was the policy of the facility that oxygen was administered as ordered by the physician.

Based on interview and record review, the facility failed to protect one of three resident's (Resident 1) right to be free from physical abuse by another resident (Resident 2). This deficient practice resulted in Resident 1 being slapped on the right side of the face by Resident 2.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/16/2025, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 required supervision with eating and using a wheelchair. The MDS indicated Resident 1 required partial assistance (helper did less than half the effort) with oral hygiene and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper did more than half the effort) with toileting hygiene and showering/ bathing. The MDS indicated Resident 1 was dependent (helper did all the effort) on staff for bed-to-chair transferring. During a review of Resident 1's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's care plan titled Resident at risk for recurrent fall/injury, revised on 7/23/2025, the care plan indicated staff were to observe Resident 1 frequently and to place Resident 1 in a supervised area when out of bed.During a review of Resident 1's nursing progress notes, dated 9/10/2025 at 9:33 a.m., the nursing progress notes indicated on 9/10/2025 at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 reported to Registered Nurse (RN) 1 that Resident 2 slapped Resident 1. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), anxiety (a feeling of fear, dread, and uneasiness), and major depressive disorder. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 required setup assistance with eating, oral hygiene, toileting hygiene, and bed-to-chair transferring. The MDS indicated Resident 2 required supervision with showering/ bathing, personal hygiene, and walking. During a review of Resident 2's H&P, dated 8/18/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's care plan titled Chronic confusion related to dementia as evidenced by altered interpretation (a changed understanding or explanation of something) or response to stimuli (anything that caused a physical or behavioral change), revised on 8/29/2025, the care plan indicated staff were to maintain a pleasant and quiet environment.During a review of Resident 2's nursing progress notes, dated 9/10/2025 at 9:41 a.m., the nursing progress notes indicated on 9/10/2025 at 9:05 a.m., LVN 1 reported to RN 1 that Resident 2 slapped Resident 1. During an interview on 9/11/2025 at 11:14 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 9/10/2025 around 8:50 a.m., he informed Resident 1 that it was time to shower, and Resident 1 replied No. CNA 1 stated Resident 2 was upset because Resident 1 yelled No when getting ready for the shower. CNA 1 stated that Resident 2 was looking at Resident 1 with furrowed eyebrows before she (CNA 1) stepped out of the room to get the Hoyer lift (a device that helped move people with limited mobility safely between surfaces). CNA 1 stated she left Resident 1 in the wheelchair by her bed. CNA 1 stated she went to get the Hoyer lift to transfer Resident 1 from wheelchair to shower chair. CNA 1 stated within four seconds of leaving the room, she heard Resident 2 cursing (using rude, offensive, or swear words) at Resident 1. CNA 1 stated Resident 1 was sitting in the wheelchair next to Resident 2's left side of the bed. CNA 1 stated Resident 1 asked Resident 2 Why are you cussing at me? I never did anything to you. CNA 1 stated Resident 2 got out of the bed, cursed at Resident 1, slapped Resident 1's right side of her face and punched Resident 1's stomach. CNA 1 stated she stopped Resident 2 and separated the residents. CNA 1 stated that she would not have left Resident 1 alone in the room with Resident 2, if she had known that Resident 1 could unlock the wheelchair and wheel to Resident 2's bedside. CNA 1 stated Resident 2 was ambulatory (able to walk) and capable of being physically aggressive (ready to fight or forceful) toward other residents. CNA 1 stated she should have taken Resident 1 with her when she left the room to get the Hoyer lift to prevent Resident 2 from physically attacking Resident 1. During an interview on 9/11/2025 at 12:23 p.m. with LVN 1, LVN 1 stated on 9/10/2025 at 9 a.m., she was passing medication outside room [ROOM NUMBER]. LVN 1 stated CNA 1 power-walked to her from room [ROOM NUMBER] and informed her that Resident 2 slapped Resident 1 on the right side of her face. LVN 1 stated CNA 1 did not bring Resident 1 with her. LVN 1 stated Resident 1 was sitting in the wheelchair at her bedside and Resident 2 was sleeping in bed. LVN 1 stated she separated the residents and placed Resident 1 in another room. LVN 1 stated neither Residents 1 nor 2 were able to provide any details about what happened. LVN 1 stated it was not acceptable to leave Resident 1 with an upset roommate because it might escalate to verbal, physical, or emotional abuse. LVN 1 stated staff should take precautions to separate the residents for safety, remove the upset resident, and de-escalate the situation. LVN 1 stated the incident would have been prevented if CNA 1 had removed Resident 1 from the room when Resident 2 became upset. During an interview on 9/12/2025 at 10:41 a.m. with RN 1, RN 1 stated on 9/10/2025 around 9 a.m., LVN 1 informed her that Resident 2 slapped Resident 1 on the right side of the face. RN 1 stated CNA 1 was wheeling Resident 1 out of her (Resident 1's) room when she (RN 1) arrived. RN 1 stated Resident 2 was resting in bed. RN 1 stated leaving Resident 1 with Resident 2, who was upset with Resident 1, might further escalate the situation. RN 1 stated Resident 1 could self-propel in the wheelchair and go to Resident 2's side of the room. RN 1 stated it was not acceptable to leave Resident 1 in the room with Resident 2 after Resident 2 slapped Resident 1. RN 1 stated CNA 1 should have removed Resident 1 away from Resident 2 immediately when Resident 2 became verbally aggressive toward Resident 1. RN 1 stated Resident 1 was not protected. RN 1 stated CNA 1 should have taken Resident 1 with her to report the incident to LVN 1. RN 1 stated the incident was preventable. RN 1 stated all staff should protect the residents. During an interview on 9/12/2025 at 12:25 p.m. with the Administrator in Training (AIT), the AIT stated staff should have immediately separated the residents after Resident 2 slapped Resident 1. The AIT stated the facility should provide as safe of an environment as possible. The AIT stated it was not acceptable to leave Resident 1 in the same room as Resident 2 after the incident. The AIT stated Resident 1 was not protected. The AIT stated Resident 2 slapping Resident 1 was preventable. The AIT stated CNA 1 should have left Resident 1 in bed or asked someone to bring the Hoyer lift to the room. During a review of the facility's Policy and Procedure (P&P) titled Abuse Policy, dated 10/2024, the P&P indicated residents would be protected from abuse and harm while residing at the facility. The P&P indicated no abuse or harm of any type would be tolerated, and residents would be monitored for protection. The P&P indicated all staff should monitor residents and identify potential signs and symptoms of abuse. The P&P indicated residents would be protected from the alleged offenders. The P&P further indicated that staff witnessing abuse would immediately intervene to protect the resident.

Based on observation, interview, and record review, the facility failed to ensure infection control measures were maintained and/or implemented for eight of 19 sampled residents (Residents 71, 70, 74, 1, 18, 52, 5, and 20) when: 1. Signage for enhanced barrier precautions (EBP, infection control measures used to reduce the spread of multidrug-resistant organisms [MDROs], requiring staff to wear a protective gown and gloves during high-contact activity) was not placed outside of Rooms A, B, and C.2. Certified Nursing Assistant (CNA) 2 and CNA 3 did not don the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) before entering Room D.3. CNA 1 did not don the required PPE before entering Resident 5's room.4. Failed to ensure Resident 20's suprapubic catheter (a tube inserted through the abdomen into the bladder that allows urine to drain from the bladder into a bag) drainage bag was not touching the floor.5. Licensed nursing staff failed to ensure the safe disposal of sharps (devices with sharp points or edges that can puncture or cut skin) containers (containers used to dispose of contaminated sharps) that were overfilled with sharps beyond the manufacturer's fill line for two of three sharps containers attached to medication carts 2 and medication cart 3. These deficient practices placed all facility residents at risk due to transmission of Coronavirus 2019 (COVID-19, a contagious respiratory virus) and/or MDROs from one resident to another, and to other staff. These deficient practices also placed Resident 20 at risk of infection.1.a. During a review of Resident 71’s admission Record, the admission Record indicated the facility originally admitted Resident 71 on 12/23/2024, and most recently re-admitted Resident 71 on 6/16/2025. Resident 71’s admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood) and obstructive sleep apnea (a sleep disorder characterized by repeated pauses in breathing during sleep due to a blockage in the upper airway). During a review of Resident 71’s MDS, dated [DATE], the MDS indicated Resident 71 was independent with cognitive skills (the mental abilities used in thinking, learning, remembering, and problem-solving) for daily decision making. The MDS indicated Resident 71 was dependent on staff for all mobility while in and out of bed. During a review of Resident 71’s physician order, dated 7/4/2025, the order indicated staff were to implement EBP due to Resident 71’s multiple open wounds. During a review of Resident 71’s care plan titled “Resident is on Enhanced Barrier Precautions…,” revised 7/4/2025, the care plan indicated staff were to post clear signage outside of Resident 71’s room (Room A) to indicate the type of precaution in place and the required PPE. During an observation on 7/16/2025 at 9:34 a.m., outside of Room A, no EBP signage was observed on the wall or door. Signage for droplet precautions (measures taken to prevent the spread of infection transmitted through respiratory droplets, requiring staff to wear a surgical mask) was observed posted on the wall. During an observation on 7/16/2025 at 2:45 p.m., outside of Room A, no EBP signage was observed on the wall or door. Signage for droplet precautions was observed posted on the wall. During an observation on 7/17/2025 at 8:25 a.m., outside of Room A, no EBP signage was observed on the wall or door. Signage for droplet precautions was observed posted on the wall. b. During a review of Resident 70’s admission Record, the admission Record indicated the facility admitted Resident 70 on 1/9/2024. Resident 70’s admitting diagnoses included generalized muscle weakness and presence of a gastrostomy tube (a surgically placed tube that provides a way to deliver nutrition, fluids, and medications directly into the stomach). During a review of Resident 70’s MDS, dated [DATE], the MDS indicated Resident 70 had severe cognitive impairment (a significant decline in mental abilities), and was dependent on staff for toileting hygiene and for showering/bathing. During a review of Resident 70’s physician order, dated 3/21/2025, the order indicated staff were to implement EBP due to Resident 70’s colonization (the presence of microorganisms [i.e., bacteria, viruses, or fungi] within a person, without any apparent symptoms or disease) with an MDRO. During a review of Resident 70’s care plan titled “Resident is on Enhanced Barrier Precautions,” dated 3/21/2025, the care plan indicated staff were to post clear signage outside of Resident 70’s room (Room B) to indicate the type of precaution in place and the required PPE. During an observation on 7/16/2025 at 2:40 p.m., outside of Room B, no EBP signage was observed on the wall or door. Signage for droplet precautions was observed posted on the wall. During an observation on 7/17/2025 at 8:25 a.m., outside of Room B, no EBP signage was observed on the wall or door. Signage for droplet precautions was observed posted on the wall. c. During a review of Resident 74’s admission Record, the admission Record indicated the facility originally admitted Resident 74 on 3/13/2024, and most recently re-admitted him on 1/17/2025. Resident 74’s admitting diagnoses included perforation of intestine (a serious medical condition where a hole or tear develops in the wall of the gastrointestinal tract) and generalized muscle weakness. During a review of Resident 74’s MDS, dated [DATE], the MDS indicated Resident 74 had moderate cognitive impairment (a decline in mental abilities, such as memory, thinking, and problem-solving) and required partial or moderate assistance from staff for toileting hygiene and for showering/bathing. During a review of Resident 74’s physician order, dated 3/27/2025, the order indicated staff were to implement EBP due to Resident 74’s colonization with an MDRO. During a review of Resident 74’s care plan titled “Resident is on Enhanced Barrier Precautions,” dated 3/27/2025, the care plan indicated staff were to post clear signage outside of Resident 74’s room (Room C) to indicate the type of precaution in place and the required PPE. During a review of Resident 1’s admission Record, the admission Record indicated the facility admitted Resident 1 on 5/15/2025. Resident 1’s admitting diagnoses included pleural effusion (a collection of fluid around your lungs) and pneumonia (lung inflammation caused by infection). During a review of Resident 1’s MDS, dated [DATE], the MDS indicated Resident 1 did not have cognitive impairments, and was dependent on staff for showering, and required substantial to maximal assistance from staff for mobility while in and out of bed. During a review of Resident 1’s physician order, dated 7/4/2025, the order indicated staff were to implement EBP due to the presence of Resident 1’s indwelling PleurX catheter (a thin, flexible tube placed in the chest to drain fluid), Resident 1’s colonization with an MDRO, and the presence of an open wound. During a review of Resident 1’s care plan titled “Resident is on Enhanced Barrier Precautions,” dated 7/4/2025, the care plan indicated staff were to post clear signage outside of Resident 1’s room (Room C) to indicate the type of precaution in place and the required PPE. During a review of Resident 18’s admission Record, the admission Record indicated the facility admitted Resident 18 on 8/14/2024 and most recently re-admitted him on 8/18/2024. Resident 18’s admitting diagnoses included reduced mobility, paraplegia (inability to move the legs and lower body), and a pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) of the right buttock. During a review of Resident 18’s MDS, dated MDS 5/25/2025, the MDS indicated Resident 18 had moderate cognitive impairment and was dependent on staff for toileting, showering, and mobility while in and out of bed. During a review of Resident 18’s physician order, dated 3/27/2025, the order indicated staff were to implement EBP due to Resident 18’s colonization with an MDRO. During a review of Resident 18’s care plan titled “Resident is on Enhanced Barrier Precautions,” dated 3/27/2025, the care plan indicated staff were to post clear signage outside of Resident 18’s room (Room C) to indicate the type of precaution in place and the required PPE. During an observation on 7/16/2025 at 9:37 a.m., outside of Room C, no EBP signage was observed on the wall or door. Signage for droplet precautions was observed posted on the wall. During an observation on 07/16/2025 2:34 p.m., outside of Room C, no EBP signage was observed on the wall or door. Signage for droplet precautions was observed posted on the wall. During an observation on 7/17/2025 at 8:26 a.m., outside of Room C, no EBP signage was observed on the wall or door. Signage for droplet precautions was observed posted on the wall. During an interview on 7/17/2025 at 11:10 a.m., with Infection Preventionist Nurse (IPN), the IPN stated EBP required staff to wear a protective gown, and droplet precautions only required a surgical mask. During an interview on 7/17/2025 at 11:19 a.m., with the IPN, the IPN stated it was important to ensure signage for any required precautions was posted for infection control and to prevent transmission of infection. The IPN stated that without clear signage there was potential for the spread of infection. 2. During a review of Resident 52’s admission Record, the admission Record indicated Resident 52 was admitted on [DATE]. Resident 52’s admitting diagnoses included high blood pressure. During a review of Resident 52’s MDS, dated [DATE], the MDS indicated Resident 52 did not have cognitive impairments and required substantial to maximal assistance from staff for toileting, showering, and mobility while in bed. During a review of Resident 52’s progress note, dated 7/11/2025, the progress note indicated Resident 52 tested positive for Covid-19. During a review of Resident 52’s physician order, dated 7/12/2025, the order indicated staff were to implement novel respiratory precautions (an infection control measure requiring staff to put on a disposable gown, eye protection [goggles or face shield], a fit-tested respirator [a mask that protects the wearer from hazardous airborne substances], and gloves) prior to entering Resident 52’s room. During a review of Resident 52’s care plan titled “…On Novel Respiratory Precautions,” dated 7/11/2025, the care plan indicated staff were to use the required PPE when providing care. During an observation on 7/15/2025 at 3:33 p.m., at Resident 52’s bedside, CNA 2 entered Resident 52’s room and was not wearing a respirator-type face mask, face shield/goggles, or a gown. During an observation on 7/15/2025 at 3:41 p.m., at Resident 52’s bedside, CNA 3 entered Resident 52’s room and was not wearing a respirator-type face mask, face shield/goggles, or a gown. During an interview on 7/15/2025 at 3:52 p.m., outside of Resident 52’s room, with CNA 2, CNA 2 stated he did not see the signage indicating novel respiratory precautions before entering Resident 52’s room. CNA 2 stated he should have put on the required PPE prior to entering Resident 52’s room. CNA 2 stated the importance of putting on the required PPE was to prevent the transmission of Covid-19. During an interview on 7/15/2025 at 3:56 p.m., with CNA 3, CNA 3 stated he did not see the signage indicating novel respiratory precautions before entering Resident 52’s room. CNA 3 stated the failure to use the required PPE created the risk for the spread of Covid-19. During an review of the facility P&P titled Infection Prevention and Control Program dated 2001, the P&P indicated that important facets of infection prevention included instituting measures to avoid complications or dissemination. It also indicated outbreak management procedures included preventing the spread of infection to other residents. 3. During an observation on 7/16/2025 at 8:04 a.m., inside Resident 5’s room, CNA 1 was at Resident 5’s bedside assisting with Resident 5 with her breakfast meal set up. CNA 1 was not wearing a disposable gown nor gloves. CNA 1 peeled Resident 5’s orange with her bare hands. A “Droplet Precaution” sign and a PPE donning and doffing signs were posted to the right of Resident 5’s door. During a review of Resident 5’s admission Record (Face Sheet), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 5’s MDS, dated [DATE], the MDS indicated Resident 5’s cognition (process of thinking) was severely impaired. The MDS indicated Resident 5 required setup assisting with eating and was dependent on staff’s assistance with toileting, bathing, and dressing. During a review of Resident 5’s History and Physical (H&P), dated 12/14/2024, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions. During a review of Resident 5’s Progress Notes, dated 7/11/2025, the Progress Notes indicated Resident 5 was exposed to COVID-19 and was placed on droplet isolation precaution. During a review of Resident 5’s Order Summary Report, order dated 7/11/2025, the Order Summary Report indicated to place Resident 5 on droplet isolation precautions for ten days. During a review of Resident 5’s Care Plan, titled “Isolation Precaution related to COVID-19 Exposure”, dated 7/11/2025, the Care Plan interventions indicated to place Resident 5 on droplet isolation precautions as ordered and to use isolation barriers, such as PPE, as indicated. During an interview on 7/16/2025 at 8:06 a.m., with CNA 1, CNA 1 stated she brought Resident 5’s breakfast tray into the room and assisted Resident 5 with uncovering her drinks and peeling her orange. CNA 1 stated she did not realize Resident 5 was on droplet isolation. CNA 1 stated because Resident 5 had the droplet isolation sign and the donning and doffing of PPE signs next to her door, she was required to wear a gown and gloves before entering her room. CNA 1 stated Resident 5 was exposed to COVID-19 and wearing the appropriate PPE was necessary to protect herself from contracting COVID-19 and from spreading to other residents and staff. During an interview on 7/17/2025 at 9:42 a.m., with the Director of Staff Development (DSD), the DSD stated prior to entering a resident’s room, the staff were responsible for being attentive to any isolation signs next to the resident’s door. The DSD stated for a droplet isolation, prior to entering the room, the staff had to don a disposable gown, gloves, and a mask. The DSD stated when assisting a resident with meals, which is near the resident, any droplet in the air could land on the skin or contaminate clothing. During a concurrent observation and interview on 7/17/2025, with the Infection Preventionist Nurse (IPN), outside of Resident 5’s room, the IPN was observed donning a disposable gown and gloves. The IPN stated she was going into Resident 5’s room to retest Resident 5 for COVID-19 because she was exposed by a staff member. The IPN stated the facility currently had a COVID-19 outbreak and donning the proper PPE prior to entering Resident 5’s room was necessary to prevent the further spread of COVID-19 to other staff and residents. During a review of the facility’s P&P titled, “Droplet Precautions Policy”, revised 1/2025, the P&P indicated, “Anyone entering the resident [droplet isolation] room should perform hand hygiene and don a face mask. If there is substantial risk of exposure to mucous membranes or spraying of respiratory secretions, if the pathogen/clinical syndrome indicates, in addition to face mask, PPE should also include a gown, gloves, and face shield or goggles.” 4. During a review of Resident 20’s admission Record, the admission Record indicated the facility originally admitted Resident 20 on 4/29/2022 and readmitted on [DATE]. Resident 20’s admitting diagnoses included urinary tract infection, urogenital implant (catheter), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 20’s admission Nursing Assessment, dated 7/10/2025, the admission Nursing Assessment indicated Resident 20’s cognition was moderately impaired. The admission Nursing Assessment indicated Resident 20 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 20’s Order Summary Report, dated 7/10/2025, the Order Summary Report indicated Resident 20 would have suprapubic catheter, and the facility would provide care every shift. During an observation on 7/15/2025 at 10:27 a.m., and 12:35 p.m., in Resident 20’s room, Resident 20 was observed lying in bed with suprapubic catheter. The catheter drainage bag was observed on the right side of Resident 20's bed, touching the floor during both observations. During an interview on 7/15/2025 at 1:34 p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated the catheter bag should be hanging from the side of the resident bed, not on the floor. CNA 4 stated Resident 20’s catheter bag on the floor was not sanitary and could cause infection. During an interview on 7/16/2025 at 4:15 p.m., with the Director of Nursing (DON), the DON stated catheter drainage bag must be secured to the resident’s bed and should never be touching the floor under any circumstances. The DON stated that when the catheter bag touches the floor increases the risk of bacterial contamination, which could potentially place Resident 20 at risk of catheter associated urinary tract infections. During a review of the facility’ policy and procedure (P&P) titled “Catheter Care, Urinary”, undated the facility would maintain the catheter tubing and drainage bag clean and would ensure the catheter tubing and drainage bag were kept off the floor. 5. During an observation on 7/17/2025 at 11:05 a.m., a sharps container was attached to medication cart 2 filled with used needles, lancets and other sharps. The container was observed to be overfilled with sharps that passed the manufacturer’s fill line. During an interview on 7/17/2025 at 11:05 a.m., with Licensed Vocational Nurse, LVN 1 stated, This container is full and does pose an infection control risk to residents. During an observation on 7/17/2025 at 11:19 a.m., a sharps container was attached to medication cart 3 containing needles, lancets and other sharps. The container was observed to be filled beyond the manufacturer’s fill line. During an interview on 7/19/2025 at 12:40 p.m., with Registered Nurse (RN), RN 3 stated, It is an infection control risk having the sharps container filled beyond the fill line. During a review of the facility’s policy and procedure (P&P) titled, “Sharps Disposal”, undated, the P&P indicated, “During use, containers for contaminated sharps will be handled as follows: Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or accidents while attempting to push sharps into the container.”

Based on observation, interview, and record review, the facility failed to ensure care plans were developed and interventions implemented for three of 19 sampled residents (Residents 71, 37, and 67). This deficient practice placed Residents 71, 37, and 67 at risk for not receiving the necessary interventions for the services and/or treatments they were receiving.Findings: 1. During a review of Resident 71’s admission Record, the admission Record indicated the facility originally admitted Resident 71 on 12/23/2024, and most recently re-admitted Resident 71 on 6/16/2025. Resident 71’s admitting diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and obstructive sleep apnea (a sleep disorder characterized by repeated pauses in breathing during sleep due to a blockage in the upper airway). During a review of Resident 71’s Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2025, the MDS indicated Resident 71 was independent with cognitive skills (the mental abilities used in thinking, learning, remembering, and problem-solving) for daily decision making. The MDS indicated Resident 71 was dependent on staff for all mobility while in and out of bed. During a review of Resident 71’s physician order, dated 6/16/2025, the order indicated Resident 71 was to receive oxygen therapy (a medical treatment that involves administering supplemental oxygen to individuals with breathing difficulties or low blood oxygen levels) at two (2) liters per minute (L/min, a unit for measuring oxygen delivery rate) as needed. During an observation on 7/15/2025 at 11:33 a.m., at Resident 71’s bedside, Resident 71 was observed receiving oxygen therapy via nasal cannula (a small plastic tube, which fits into the person’s nostrils for providing supplemental oxygen). During an observation on 7/16/2025 at 8:54 a.m., at Resident 71’s bedside, Resident 71 was observed receiving oxygen therapy via nasal cannula. During an interview on 7/16/2025 2:27 p.m., with the DON, the DON stated there should be a care plan oxygen administration for residents on oxygen therapy. The DON stated it would include interventions such as keeping the resident’s head elevated for ease of breathing and monitoring the resident’s oxygen levels. During a concurrent interview and record review, on 7/16/2025 2:28 p.m., with the DON, Resident 71’s current care plans were reviewed. The DON stated Resident 71 did not have a current care plan for oxygen therapy and stated there should be one. The DON stated that if the MDS were accurate, it would have prompted staff to create a care plan for Resident 71’s oxygen therapy. 2. During an observation on 7/15/2025 at 9:54 a.m., 7/15/2025 at 1:16 p.m., and 7/16/2025 at 9:45 a.m., in Resident 37’s room, Resident 37 was lying in bed, and one floor mat was observed folded up and set against a wheelchair.During a review of Resident 37’s admission Record (Face Sheet), the Face Sheet indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (decrease in muscle mass that can cause a decline in muscle strength and function), bipolar disease (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 37’s MDS, dated [DATE], the MDS indicated Resident 37’s cognition (process of thinking) was severely impaired. The MDS indicated Resident 37 used mobility devices such as a walker and wheelchair. The MDS indicated Resident 37 required maximal assistance (helper does more than half the effort) with bathing, dressing, and personal hygiene. The MDS indicated Resident 37 had a fall with no injury since her admission to the facility. The MDS indicated Resident 37 took anticonvulsant medication (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions) in the facility. During a review of Resident 37’s History and Physical (H&P) dated 8/15/2024, the H&P indicated Resident 37 did not have the capacity to understand and make decisions. During a review of Resident 37’s Fall Risk Assessment, dated 6/14/2025, the Fall Risk Assessment indicated Resident 37 was at a high risk for falls. During a review of Resident 37’s Order Summary Report, order dated 7/8/2025, the Order Summary Report indicated to place a floor mat (cushioned floor pad designed to help prevent injury should a person fall) on the right side of Resident 37’s bed. During a concurrent observation and interview on 7/17/2025 at 8:57 a.m., with Certified Nursing Assistant (CNA) 5 in Resident 37’s room, Resident 5 was observed lying in bed, and one floor mat was folded up against the wall. CNA 5 stated she was aware Resident 5 was a fall risk and assisted Resident 5 to the restroom. CNA 5 stated after she assisted Resident 5 back to bed, she did not place the floor mat on the right side of Resident 37’s bed. CNA 5 stated due to Resident 37’s risk for falls, placing the floor mat was necessary to prevent injuries.During a concurrent interview and record review on 7/17/2025 at 9:55 a.m., with Registered Nurse (RN) 1, Resident 37’s Care Plan titled, “At Risk for Falls”, revised 6/16/2025, was reviewed. The Care Plan interventions indicated to place a floor mat to the right side of the bed. RN 1 stated all care plan interventions were created as a guide to provide the best care to Resident 37. RN 1 stated when Resident 37 was in bed, the floor mat was supposed to be placed on the right side of the bed. RN 1 stated when a staff member assisted Resident 37 back to bed, they were responsible for placing the floor mat. RN 1 stated the purpose of the floor mat was to decrease the risk of injury if Resident 37 were to fall from her bed. RN 1 stated without the floor mat in place, Resident 37 was at risk of sustaining an injury from a fall such as a bruise, a skin tear, or a fracture.During an interview on 7/18/2025 at 8:54 a.m., with the DON, the DON stated Resident 37 had recurrent falls and the care plan was revised to include interventions to decrease the risk of falls and injuries. The DON stated the floor mat was to be placed on Resident 37’s right side any time Resident 37 was in bed. The DON stated without the floor mat placement, if Resident 37 fell out of bed, Resident 37 could sustain an injury.During a review of the facility’s P&P titled, “Safety and Supervision of Residents”, revised 4/2025, the P&P indicated, “Implementing interventions to reduce accident risks and hazards shall include the following:a. Communicating specific interventions to all relevant staff;b. Assigning responsibility for carrying out interventions;c. Provide training, as necessary; d. Ensuring that interventions are implemented; ande. Documenting interventions.”3. During a review of Resident 37’s Order Summary Report, order date 8/12/2024, the Order Summary Report indicated to give Depakote (an anticonvulsant) 250 milligrams (mg, a unit of measurement), by mouth two times a day for bipolar disorder manifested by Resident 37 being calm to yelling. During a concurrent interview and record review on 7/17/2025 at 8:12 a.m., with RN 1, Resident 37’s Care Plans, dated 8/12/2024 through 7/17/2025, were reviewed. The Care Plans did not address the use of Depakote to treat Resident 37’s bipolar disorder as manifested as being calm to yelling. RN 1 stated a care plan to address Resident 37’s use of Depakote and the behavioral manifestations of Resident 37’s bipolar disorder should have been developed. RN 1 stated the care plan would address the use of Depakote, non-pharmacological interventions (interventions to treat a health problem without using medication), and monitoring for side effects and the frequency of behavior. RN 1 stated the care plan would include interventions to inform Resident 37’s physician of any change of condition. During an interview on 7/18/2025 at 8:52 a.m., with the DON, the DON stated care plans were developed to guide the care for each resident. The DON stated Resident 37 should have had a care plan developed to address the use of Depakote to ensure Resident 37 was properly monitored for side effects and frequency of behaviors. The DON stated without a care plan, Resident 37 was at risk of not receiving the necessary care and services related to her use of Depakote which could result in undetected side effects or worsening behavior.4. During a review of Resident 67’s admission Record (Face Sheet), the Face Sheet indicated Resident 67 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD- irreversible kidney failure), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic polyneuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 67’s MDS, dated [DATE], the MDS indicated Resident 67’s cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 67 was dependent on staff’s assistance with toileting, bathing, and dressing. The MDS indicated Resident 67 took antidepressant medication (medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and chronic pain). During a review of Resident 67’s Order Summary Report, order dated 6/15/2025, the Order Summary Report indicated to give Cymbalta (an antidepressant medication), by mouth in the morning related to type 2 diabetes mellitus with diabetic polyneuropathy.During a concurrent interview and record review on 7/17/2025 at 8:24 a.m., with RN 1, Resident 67’s Care Plans, dated 6/15/2025 through 7/17/2025, were reviewed. The Care Plans did not address Resident 67’s use of Cymbalta for polyneuropathy. RN 1 stated Resident 67 should have had a care plan developed to address the use of Cymbalta, monitoring for any side effects, and non-pharmacological interventions. RN 1 stated without a care plan with resident-specific interventions, Resident 67 was at risk of suffering undetected side effects from Cymbalta such as dry mouth, nausea and vomiting, and diarrhea. During an interview on 7/18/2025 at 8:33 a.m., with the DON, the DON stated Resident 67 should have had a care plan developed to address Resident 67’s use of Cymbalta to ensure Resident 67 was properly monitored for side effects and efficacy of pain management. The DON stated without a care plan, Resident 67 was at risk of not receiving the necessary care related to her use of Cymbalta which could result in undetected side effects and mismanaged pain.During a review of the facility’s P&P titled “Care Plans, Comprehensive Person-Centered” revised 4/2025, the P&P indicated a comprehensive care plan was to be developed for each resident. The P&P indicated the care plan was to describe the services provided.

Based on interview and record review, the facility failed to clarify hold parameters (specific instructions that accompany a medication order for safe and effective drug administration) for amlodipine (medication to lower blood pressure) and lisinopril (medication to lower blood pressure) for one of seven sampled residents (Resident 19).This deficient practice had the potential to result in Resident 19 experiencing bradycardia (heart rate less than 60 beats per minute [bpm], a normal heart rate is between 60 to 100 bpm) with symptoms of dizziness, fatigue, chest pain, and/or fainting.Findings:During a review of Resident 19's admission Record (Face Sheet), the Face Sheet indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (elevated blood pressure). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 7/1/2025, the MDS indicated Resident 19's cognition (process of thinking) was intact. The MDS indicated Resident 19 was independent in eating, oral hygiene, toileting, and personal hygiene.During a review of Resident 19's Order Summary Report, order date 3/18/2025, the Order Summary Report indicated to:1. Give amlodipine 5 milligrams (mg, unit of measurement) by mouth, once a day for hypertension. Hold medication if systolic blood pressure (SBP- pressure in the arteries when the heart beats) less than 110 millimeters of mercury (mmHg, unit of blood pressure measurement).2. Give lisinopril 5 mg by mouth, once a day for hypertension. Hold if SBP less than 110 mmHg.During a concurrent interview and record review on 7/17/2025 at 11:06 a.m., with Registered Nurse (RN) 3, Resident 19's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/1/2025 through 7/31/2025, was reviewed. The MAR indicated Resident 19 had the following pulse rates less than 60 bpm:- 7/1/2025, 54 bpm, amlodipine and lisinopril administered- 7/2/2025, 58 bpm, amlodipine and lisinopril administered- 7/3/2025 58 bpm, amlodipine and lisinopril administered- 7/4/2025, 58 bpm, amlodipine and lisinopril refused by Resident 19- 7/6/2025, 54 bpm, amlodipine and lisinopril administered- 7/7/2025, 54 bpm, amlodipine and lisinopril administered- 7/8/2025, 54 bpm, amlodipine and lisinopril administered- 7/10/2025, 56 bpm, amlodipine and lisinopril held due to pulse less than 60 bpm- 7/12/2025, 54 bpm, amlodipine and lisinopril administered- 7/14/2025, 54 bpm, amlodipine and lisinopril administered- 7/16/2025, 56 bpm, amlodipine and lisinopril held due to pulse less than 60 bpm- 7/17/2025, 56 bpm, amlodipine and lisinopril held due to pulse less than 60 bpmRN 3 stated their electronic MAR (eMAR) prompted the licensed nurse to check Resident 19's blood pressure and pulse rate prior to administering amlodipine and lisinopril. RN 3 stated it was standard practice to hold these medications when the pulse rate was less than 60 bpm. RN 3 stated she held Resident 19's amlodipine and lisinopril on 7/10/2025, 7/16/2025, and 7/17/2025 because Resident 19's pulse rate was less than 60 bpm. RN 3 stated Resident 19's orders did not specify hold parameters for pulse rate. RN 3 stated the licensed nurses, including herself, who administered Resident 19 his amlodipine and lisinopril, should have informed Resident 19's physician of Resident 19's pulse rate below 60 bpm. RN 3 stated informing the physician would result in clarification of the orders or change in medication. RN 3 stated continuing to administer Resident 19 amlodipine and lisinopril with his pulse rate below 60 bpm placed him at risk of bradycardia which could cause dizziness, chest pain, fainting, and/or fatigue. During an interview on 7/18/2025 at 9:01 a.m. with the Director of Nursing (DON), the DON stated Resident 19's order for amlodipine and lisinopril to reflect parameters to hold the medications if Resident 19's pulse rate was below 60 bpm. The DON stated amlodipine and lisinopril had the potential to lower Resident 19's even more and clarifying the orders was important to ensure those medications were held appropriately. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 1/2025, the P&P indicated, Medications are administered in a safe and timely manner.During a review of the facility's P&P titled, Medication and Treatment Orders, revised 1/2025, the P&P indicated, Orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on observation, interview and record review, the facility did not accommodate the preference to use a urinal for one of 19 sampled residents (Resident 1). This deficient practice resulted in Resident 1 wearing and voiding into an incontinence brief despite being continent, removing his ability to void in a dignified manner. Cross-reference: F-tags F657, F690Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/15/2025. Resident 1's admitting diagnoses included pleural effusion (a collection of fluid around your lungs) and pneumonia (lung inflammation caused by infection). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 did not have cognitive impairments, and was dependent on staff for showering, and required substantial to maximal assistance from staff for mobility while in and out of bed. During a review of Resident 1's admission Nursing Assessment, dated 5/15/2025, the assessment indicated Resident 1 was incontinent bladder. The assessment was documented by Registered Nurse (RN) 2. During a review of Resident 1's care plan titled The resident has bladder incontinence., dated 5/29/2025, indicated Resident 1 preferred to use a urinal. During an interview on 7/15/2025 at 12:58 p.m. with Resident 1, Resident 1 stated staff kept him in an incontinence brief. Resident 1 stated he was not incontinent and stated the incontinence brief prevented him from being able to use a urinal because he had difficulty removing the brief on his own. Resident 1 stated he would prefer to use a urinal and would feel better if he did not need to void into an incontinence brief. During an interview on 7/17/2025 at 1:15 p.m., with RN 2, RN stated Resident 1's admission Nursing Assessment, dated 5/15/2025, was not accurate, and Resident 1 was not incontinent. RN 2 stated use of an incontinence brief, while continent, was a dignity concern. During an observation on 7/17/2025 at 1:32 p.m., at Resident 1's bedside, no urinal was observed at Resident 1's bedside. During an interview on 7/17/2025 at 1:37 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she assumed Resident 1 was incontinent. CNA 1 stated she did not ask Resident 1 if he could use a urinal or if he wanted to use a urinal. CNA 1 stated it was important to provide a urinal to continent residents, if that was their preference, to help them to maintain their independence and ensure their dignity was maintained. During a concurrent observation and interview on 7/17/2025 at 1:42 p.m., at Resident 1's bedside, with CNA 1, CNA 1 stated Resident 1 did not have a urinal at his bedside. During a review of the facility's policy and procedure (P&P) titled Dignity, revised 1/2025, the P&P indicated staff were to ensure each resident was cared for in a manner that promoted or enhanced their sense of well-being and feelings of self-worth and self-esteem. The P&P indicated individual preferences were to be identified during the assessment process and facility culture was to support dignity and respect for residents by honoring their choices and preferences.

Based on observation, interview, and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the Responsible Party (RP) 2 prior to administering Depakote (an anticonvulsant medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions) and placing the bed against the wall for one of five sampled residents (Resident 37).This deficient practice resulted in the facility obtaining informed consent from Resident 37, who did not have the capacity to understand and make decisions, and resulted in Resident 37 making uninformed decisions regarding her care and unable to understand the risks and benefits of her treatment.Findings:a. During a review of Resident 37's admission Record (Face Sheet), the Face Sheet indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (decrease in muscle mass that can cause a decline in muscle strength and function), bipolar disease (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). The Face Sheet indicated RP 2 listed as Resident 37's emergency contact.During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 5/18/2025, the MDS indicated Resident 37's cognition (process of thinking) was severely impaired. The MDS indicated Resident 37 used mobility devices such as a walker and wheelchair. The MDS indicated Resident 37 required maximal assistance (helper does more than half the effort) with bathing, dressing, and personal hygiene. The MDS indicated Resident 37 took anticonvulsant medication in the facility.During a review of Resident 37's Order Summary Report, order date 8/12/2024, the Order Summary Report indicated to give Depakote 250 milligrams (mg, a unit of measurement), by mouth two times a day for bipolar disorder manifested by Resident 37 being calm to yelling.During an interview on 7/17/2025 at 8 a.m., with Registered Nurse (RN) 1, RN 1 stated informed consent should only be obtained from the resident if the resident had the mental capacity to understand and make medical decisions. RN 1 stated if the resident did not have the mental capacity to understand and make medical decisions, informed consent would be obtained from the RP. RN 1 stated Resident 37 was on Depakote to treat behavioral symptoms manifested by her bipolar disorder. RN 1 stated prior to administering Depakote, Resident 37's physician was responsible for explaining the use of the medication, the side effects, and the risks and benefits to ensure an informed decision could be made.During a concurrent interview and record review on 7/17/2025 at 8:05 a.m., with RN 1, Resident 37's Informed Consent, dated 8/13/2024, was reviewed. The Informed Consent indicated informed consent for the use of Depakote 250 mg was obtained from Resident 37. RN 1 stated, on 8/13/2024, she verified informed consent was obtained from Resident 37. During a concurrent interview and record review on 7/17/2025 at 8:07 a.m., with RN 1, Resident 37's History and Physical (H&P), dated 7/10/2024, was reviewed. The H&P indicated Resident 37 could make needs known but could not make medical decisions. RN 1 stated when Resident 37 was admitted to the facility, Resident 37's medical documents from her previous facility were faxed on 7/31/2024. RN 1 stated Resident 37 did not have the capacity to make medical decisions, therefore could not fully understand the use of Depakote, the side effects, and the risk and benefits. RN 1 stated informed consent should have been obtained from RP 2 to ensure an informed decision was made. During an interview on 7/18/2025 at 8:45 a.m., with the Director of Nursing (DON), the DON stated informed consent for the use of Depakote should have been obtained from RP 2 instead of Resident 37. The DON stated allowing RP 2 to make an informed decision would ensure RP 2 was aware of all treatments administered to Resident 37 and to make any necessary decisions thereafter.b. During an observation on 7/15/2025 at 9:54 a.m., in Resident 37's room, Resident 37 was lying in bed, and the left side of the bed was against the wall. During a review of Resident 37's Order Summary Report, order date 8/12/2024, the Order Summary Report indicated Resident 37 could have the bed against the wall, per Resident 37's request. During a review of Resident 37's Care Plan titled, At risk for Self-Injury Related to the Bed Against the Wall, dated 6/11/2025, the Care Plan's interventions indicated to allow Resident 37 to make an informed choice by explaining the risks, benefits, and alternatives. During a concurrent interview and record review on 7/17/2025 at 8:16 a.m., with RN 1, Resident 37's Informed Consent, dated 6/11/2025, was reviewed. The Informed Consent indicated informed consent for the bed against the wall was obtained from Resident 37. RN 1 stated, on 6/11/2025, she verified informed consent was obtained from Resident 37. RN 1 stated informed consent should not have been obtained from Resident 37 due to not having the capacity to understand the risks and benefits of having her bed against the wall and unable to make an informed decision.During a review on 7/18/2025 at 8:42 a.m., with the DON, the DON stated although Resident 37 requested to have her bed against the wall, Resident 37 was not able to fully understand the risks of her request. The DON stated the risks and benefits should have been explained to RP 2 to ensure RP 2 made an informed decision for Resident 37's safety. During a review of the facility's Policy and Procedure (P&P) titled, Informed Consent of Physical and Chemical Restraints, revised 1/2025, the P&P indicated, It is the policy of this facility to have an informed consent prior to initiation of Chemical/Physical treatment or procedure.

Based on observation, interview, and record review, the facility failed to ensure the call light (a device that residents use to request assistance from staff) was within reach for one of six sampled residents (Resident 82). This deficient practice had the potential to result in delay or an inability for Resident 82 to obtain necessary care and services as needed. Findings:During concurrent observation and interview on 7/15/2025 at 11:14 a.m., in Resident 82's room, with Resident 82, observed Resident 82 lying in bed. Resident 82's call light was observed on the left side of the resident's bed. Resident 82's call light was not within reach. Resident 82 stated she needed assistance with personal care and was not able to reach the call light to call for assistance. During a review of Resident 82's admission Record, the admission Record indicated the facility admitted Resident 82 on 7/14/2025 with diagnoses including seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and acute respiratory failure (a critical condition where the lungs cannot adequately oxygenate the blood). During a review of Resident 82's History and Physical (H&P), dated 6/5/2025, the H&P indicated Resident 82's cognition (ability to think, remember, and reason) was intact. During a review of Resident 82's admission Nursing Assessment, dated 7/14/2025, the admission Nursing Assessment indicated Resident 82 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 82's care plan titled Resident at risk for falling, date initiated 7/15/2025 indicated the facility would keep call light within the resident's reach. During a concurrent observation and interview on 7/15/2025 at 11:24 a.m., in Resident 82's room, with Registered Nurse (RN) 1, Resident 82 was observed lying in bed. RN 1stated Resident 82's call l light was hanging on the left side of the resident bed not within reach. RN 1 stated Resident 82's call light should have been within reach for the resident to be able to call for assistance when needed. RN 1 stated the call light not within reach was a resident's safety issue, and placed Resident 82 at risk for fall and injury. During a review of the facility's policy and procedure (P&P) titled Call light/Bell, undated, the P&P indicated the facility would provide the resident with the call light and would be placed within reach when resident in bed.

Based on interview and record review, the facility failed to timely notify one of three sampled residents' (Resident 81) physician of significant weight loss on 3/17/2025 and 6/3/2025.This deficient practice resulted in a delay in care and services and had the potential to result in further weight loss. Cross Reference F692.Findings:During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple myeloma (a type of blood cancer that affects white blood cells), cauda equina syndrome (a rare but serious condition where the nerve roots at the bottom of the spinal cord, called the cauda equina, are compressed), and chronic kidney disease (a type of blood cancer that affects).During a review of Resident 81's Minimum Data Set (MDS- a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 81's cognition (process of thinking) was severely impaired. The MDS indicated Resident 81 was dependent on staff's assistance with eating, oral hygiene, toileting, bathing, and lower body dressing. During a review of Resident 81's History and Physical (H&P), dated 6/14/2025, the H&P indicated Resident 81 had fluctuating capacity to understand and make decisions.During an interview on 7/17/2025 at 11:27 a.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 stated the RNAs were responsible for weighing the residents based on the physician's order. RNA 1 stated residents were weighed upon their admission to the facility then weekly for a total of four weeks. RNA 1 stated unless the resident's physician orders for more frequent weights, the residents would then be weighed once a month. RNA 1 stated any fluctuations in a resident's weight had to be reported timely to the licensed nurse. During a concurrent interview and record review on 7/17/2025 at 11:36 a.m., with RNA 1, Resident 81's Weights, dated 3/21/2025 through 6/20/2025, were reviewed. The Weights indicated on 03/21/2025, Resident 81 weighed 166 lbs. and on 03/27/2025, Resident 81 weighed 139 lbs. which was a 16.27 percent (%) weight loss. The Weights indicated on 05/03/2025, Resident 81 weighed 147 lbs. and on 06/03/2025, Resident 81 weighed 136 lbs. which was a 7.48% weight loss. RNA 1 stated Resident 81 had weight loss indicated on 3/27/2025 and 6/3/2025 and should have been reported to the licensed nurse on duty. During an interview on 7/17/2025 at 12:10 p.m., with Registered Nurse (RN) 1, RN 1 stated the RNAs were responsible for weighing the residents per the physician's order and report any weight changes to the Director of Nursing (DON) and licensed nurses. RN 1 stated reporting the weight changes were essential for timely physician notification and implementation of interventions to prevent further weight loss. During a concurrent interview and record review on 7/17/2025 at 12:13 p.m., with RN 1, Resident 81's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/27/2025 through 6/26/2025, were reviewed. The SBARs did not indicate Resident 81's physician was notified of his weight loss on 3/27/2025 and 6/3/2025. The SBAR, dated 3/31/2025, indicated Resident 81 had poor oral intake (not eating and/or drinking enough food and liquids to meet the body's needs) but did not indicate Resident 81's weight loss. RN 1 stated once there was knowledge of a resident's weight loss, the resident's physician had to be notified as soon as possible to obtain new orders to prevent further weight loss. During an interview on 7/18/2025 at 9:11 a.m., with the DON, the DON stated when a resident had unplanned weight loss, the RNAs and licensed nurses were responsible for informing her. The DON stated she would collaborate with the licensed nurse to inform the resident's physician and obtain new orders such as a change in diet, nourishment snacks, and/or new medications. The DON stated timely physician notification was necessary to treat the resident right away and not delay care. During a concurrent interview and record review on 7/18/2025 at 9:15 a.m., with the DON, Resident 81's Weight Management Review, dated 4/8/2025 and 6/23/2025, were reviewed. The Weight Management Review, dated 4/8/2025, indicated Resident 81's physician was notified of significant weight loss due to recent hospitalizations and poor oral intake and new orders were given. The Weight Management Review, dated 6/23/2025, indicated Resident 81's physician was notified of Resident 81's fluctuating weight gain and weight loss and new order was given to administer Megace (medication to increase appetite). The DON stated she was not made aware of Resident 81's weight loss on 3/27/2025 and 6/3/2025, thus Resident 81's weight loss was not addressed until Resident 81's monthly Weight Management Review on 4/8/2025 and 6/23/2025. The DON stated the delay in physician notification resulted in the delay of implementing orders and additional interventions to prevent further weight loss. During a review of the facility's Policy and Procedure (P&P) titled, Weight Assessment and Intervention, revised 9/2016, the P&P indicated, Any weight change of five pounds or 5% or greater within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician and an interdisciplinary team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents), then meeting with weight variance will be started. The attending physician of the subject resident will be notified for the significant weight loss or gain.

Based on interview and record review, the facility failed to provide a written notice of financial liability (Skilled Nursing Facility Advance Beneficiary Notice- SNF ABN) to two out of three sampled residents (Resident 13 and Resident 23) when Medicare Part A coverage ended and the residents chose to continue receiving skilled nursing services. This failure had the potential to result in unexpected pay charges for Resident 13 and Resident 23.Findings: a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure ( a condition in which the heart cannot pump enough blood to meet the body's needs), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 13's Minimum Data Set ([MDS], a resident assessment tool), dated 7/11/2025, the MDS indicated Resident 13's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 13 required substantial assistance (helper does more than half of the effort) when toileting and lower body dressing. During a review of Resident 13's History and Physical (H&P), dated 3/21/2025, the H&P indicated Resident 13 had the capacity to understand and make decisions. During a review of the facility's Beneficiary Notice List of Resident discharged Within the Last Six Months Worksheet, dated 7/16/2025, the Worksheet indicated Resident 13's Medicare Part A coverage ended on 4/9/2025 and remained in the facility. During a review of Resident 13's SNF Beneficiary Notification Review form, dated 7/16/2025, the form indicated the facility or provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. b. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), chronic pain syndrome, and lack of coordination. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23's cognitive skills were moderately impaired. The MDS indicated Resident 23 was entirely dependent on staff for toileting hygiene, bathing, lower body dressing, and taking off footwear. During a review of the facility's Beneficiary Notice List of Resident discharged Within the Last Six Months Worksheet, dated 7/16/2025, the Worksheet indicated Resident 23's Medicare Part A coverage ended on 7/4/2025 and remained in the facility. During a review of Resident 23's SNF Beneficiary Notification Review form, dated 7/16/2025, the form indicated the facility or provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. During an interview on 7/17/2025 at 12:22 p.m. with the Business Office Manager (BOM), the BOM stated the SNF ABN form was normally provided to Medicare Part A residents that had benefit days remaining and chose to stay in the facility. The BOM stated Resident 13 and 23 should have received the SNF ABN form. The BOM stated she did not provide the SNF ABN form to Resident 13 and Resident 23 because she mistakenly believed the SNF ABN form was replaced by the Detailed Explanation of Non-Coverage (DENC- explains the specific reasons for the end of covered services) form based on an email sent by corporate. The BOM stated she misread the email and did not provide the form to residents since 1/2025. The BOM stated failing to provide the SNF ABN form to Resident 13 and Resident 23 violated resident rights to be made aware of services not covered by Medicare. During a review of the facility's Policy and Procedure (P&P), titled, Medicare Advanced Beneficiary Notice (undated), the P&P indicated the facility was to ensure residents are informed in advance when changes will occur to their bills. The P&P indicated if the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) was notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). The P&P indicated the facility issued the Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers, but may not pay for because the care was considered not medically reasonable and necessary, or custodial. The P&P indicated the resident (or representative) may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility.

Based on observation, interview, and record review, the facility failed to provide Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]), Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function), and Speech Therapy ([ST or SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) to one of four sampled residents (Resident 53), who had range of motion (ROM, full movement potential of a joint [where two bones meet]) mobility (ability to move) and swallowing problems. The facility failed to: 1. Provide Resident 53 with PT and OT evaluations upon admission to the facility in accordance with physician orders, dated 12/21/2022. 2. Provide Resident 53 with PT and OT evaluations upon admission to the facility in accordance admission notes, dated 12/22/2022. 3. Provide Resident 53, who received gastrostomy (G-tube- tube placed directly into the stomach for feeding and medication administration) feedings with a SLP evaluation in accordance with the physician orders, dated 12/27/2022. 4. Provide PT, OT, and SLP services consistent with the facility's job descriptions and the facility's policy and procedure (P&P) titled, Skilled Nursing Rehabilitation Services. 5. Provide Resident 3 PT and OT evaluations in accordance with the physician orders, dated 9/5/2022 and 10/23/2023, the facility's job descriptions for PT and OT, and the facility's P&P titled, Skilled Nursing Rehabilitation Services. These deficient practices resulted in Resident 53 not receiving any interventions to improve speech, cognition (ability to think, understand, learn, and remember), the ability to eat by mouth, mobility, and activities of daily living (ADLs), resulting in Resident 53's dependence on staff for mobility and ADLs and a decline in the resident's physical and psychosocial well-being. These failures also had the potential to prevent Resident 3 from improving mobility, ADLs, and overall physical and psychosocial well-being. Cross reference F677, F684, and F688. Findings: a. A review of Resident 53's GACH Neurology (branch of medicine concerned with the a. study and treatment of disorders involving the brain, spinal cord, and nerves) Progress Note, dated 12/18/2022, indicated Resident 53's overall mental status appeared to be improving. The Neurology Progress Note indicated Resident 53 was fully awake, alert, followed simple commands, and held the arms and legs against gravity (active movement). A review of Resident 53's Admission Record, indicated Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Admission Record indicated Resident 53's diagnoses included psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorders (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning), seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness), starvation (suffering caused by hunger), and attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding). A review of Resident 53's physician orders, dated 12/21/2022 timed at 11:41 p.m., indicated to provide PT and OT evaluation/consult as needed. A review of Resident 53's Admission Progress Note, dated 12/22/2022 timed at 1:02 a.m., indicated Resident 53 was admitted to the facility on [DATE] at 11:25 p.m. under skilled level of care, for PT and OT evaluation. The Admission Progress Note indicated Resident 53 was alert with episodes of confusion, able to make needs known, was striking out at staff, resisted care while cleaning and changing, and kept moving the arm (unspecified). A review of Resident 53's Progress Note, dated 12/22/2022 timed at 3:00 p.m., indicated Resident 53 was found in the middle of the bed with both legs dangling outside of the bed. The Progress Note indicated Resident 53 was assisted back to bed and repositioned. The Progress Note indicated Resident 53's physician was informed, and a physician order was carried out to place the bed in the lowest position and floor mats. A review of Resident 53's physician orders, dated 12/27/2022 timed at 2:20 p.m., indicated to provide a SLP evaluation and treatment as indicated. A review of Resident 53's physician orders, dated 12/29/2022 timed at 4:32 p.m., indicated PT and OT evaluation/consult as needed was discontinued. A review of Resident 53's physician orders, dated 2/22/2023 timed at 4:44 p.m., indicated discontinue speech therapy evaluation and treatment as indicated. A review of Resident 53's physician orders, dated 3/25/2024, indicated for Restorative Nursing Aide ([RNA] Certified Nursing Aide program that helps residents to maintain their function and joint mobility) to provide passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) on both arms and both legs, followed by the application of both elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four to six hours, three to five times per week. A review of Resident 53's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 4/2/2024, indicated Resident 53 had severely impaired cognition. The MDS indicated Resident 53 did not have any ROM impairments to both arms and legs. The MDS indicated Resident 53 was dependent (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) for rolling to either side, transferring from sit to lying, chair/bed-to-chair transfers, oral hygiene (cleaning teeth), showering/bathing, and dressing. During an interview on 5/28/2024 at 10:48 a.m. with the Director of Rehabilitation (DOR), the DOR stated therapy services helped residents regain ability and function. During an observation on 5/29/2024 at 8:13 a.m., in Resident 53's room, Resident 53 was observed lying in bed, awake, with the head-of-bed (HOB) elevated and a bed sheet covered Resident 53's legs. Resident 53 smiled but did not speak and was receiving feeding through a G-tube. Resident 53 did not actively move either arms or legs upon request. Resident 53's body twitched (short, jerky sudden movements) intermittently (did not happen continuously) and both elbows were in a bent position. Resident 53's hips and knees were visibly rotated away from the body with the knees bent, resembling a frog-like leg position, despite the presence of the bed sheet over both legs. Resident 53's ankles and feet were not visible. During an observation on 5/29/2024 at 9:09 a.m., in Resident 53's room, Resident 53 was observed lying in bed, alert, with the HOB elevated. Resident 53's elbows were in a bent position. Restorative Nursing Aide (RNA) 3 performed ROM exercises on Resident 53's left arm and then applied an elbow extension splint (splint that prevents bending at the elbow) on the left arm. RNA 3 performed ROM exercises on Resident 53's right arm and then applied an elbow extension splint on the right arm. Resident 53's legs were rotated away from the body, both knees were bent, and both ankles were positioned in plantarflexion (ankles bent with toes pointing away from the body). RNA 3 performed ROM exercises on both of Resident 53's legs. During an interview on 5/29/2024 at 9:37 a.m. with RNA 3, RNA 3 stated she performed PROM on both of Resident 53's arms and legs and applied elbow extension splints on the resident's elbows. During a concurrent interview and record review on 5/29/2024 at 4:06 p.m. with the DOR in the presence of the Assistant Director of Nursing (ADON) and the MDS Coordinator (MDS 1), the DOR reviewed the facility's Rehabilitation electronic documentation system (clinical therapy records) and stated Resident 53 never received any PT, OT, or SLP services while residing in the facility. During a telephone interview on 5/30/2024 at 9:36 a.m. with Resident 53's family member (FM) 1, FM 1 stated Resident 53 used to walk, dress, and do everything without assistance but had mental health problems. FM 1 stated Resident 53 had gotten worse while residing at the facility since Resident 53 could no longer move and talk. During an interview on 5/30/2024 at 11:32 a.m. with Speech Therapist (SLP) 1, SLP 1 stated a resident with a G-tube did not mean the resident could not chew or swallow. SLP 1 stated a Speech Therapist was the best person to determine whether a resident could swallow. SLP 1 stated the purpose of Speech Therapy included interventions for speech, swallowing, language, and cognition. During a concurrent interview and record review on 5/30/2024 at 11:56 a.m. with the DOR, Resident 53's physician orders for PT and OT evaluation, dated 12/21/2022, Admission Progress Note, dated 12/22/2022, and physician orders for SLP evaluation, dated 12/27/2022, were reviewed. The DOR stated Resident 53's Admission Progress Note, dated 12/22/2022, indicated Resident 53 was admitted for skilled level of care, including PT and OT evaluations. The DOR stated the physician orders for PT and OT evaluation were not completed and were discontinued on 12/29/2022 for an unknown reason. The DOR reviewed Resident 53's physician orders, dated 12/27/2022, for a SLP evaluation and treatment. The DOR stated the SLP evaluation was not completed and the SLP evaluation was discontinued on 2/22/2023. The DOR stated the resident's payor source (person, organization, or entity that pays for the care services administered by a health provider) had to be verified prior to evaluating a resident for therapy. The DOR stated the facility did not complete the PT, OT, and SLP evaluations on Resident 53 in accordance with the physician orders. During an interview on 5/30/2024 at 3:44 p.m., the DOR stated the purpose of PT, OT, and SLP were to improve the resident's strength and attempt to return the resident to his/her prior level of function (ability prior to admission to the facility). The DOR stated PT interventions were for the resident's legs, mobility, standing, transfers, and ambulation (the act of walking). The DOR stated OT interventions included interventions to the resident's arms, self-care, and ADLs. During a concurrent interview and record review on 5/31/2024 at 9:49 a.m. with the Assistant Director of Nursing (ADON) and MDS Coordinator (MDS 1), Resident 53's physician orders for PT and OT, dated 12/21/2022, Admission Progress Notes dated, 12/22/2022, physician's orders for SLP, dated 12/27/2022, and job descriptions for PT, OT, and SLP were reviewed. The MDS 1 stated, the admission Progress Note indicated Resident 53 was admitted to the facility for skilled services, including PT and OT. MDS 1 stated Resident 53's physician orders, dated 12/21/2022, for PT and OT evaluation was discontinued on 12/29/2022. The ADON stated the standard of practice for discontinuing physician orders included contacting the physician for an order to discontinue treatment and then the designated staff would carry out the order. MDS 1 reviewed Resident 53's Progress Notes dated 12/2022 and stated there were no nursing notes indicating Resident 53's physician was contacted to discontinue the PT and OT evaluation order. MDS 1 reviewed Resident 53's physician orders, dated 12/27/2022, for SLP evaluation and stated the order was discontinued on 2/22/2023. MDS 1 stated, there were no nursing notes indicating Resident 53's physician was contacted to discontinue the SLP evaluation order. The ADON and MDS 1 stated they did not know the reason Resident 53 did not receive any therapy. The ADON stated Resident 53 should have received PT, OT, and SLP evaluations. The ADON stated the purpose of therapy was for mobility and to regain strength. The ADON and MDS 1 stated facility did not attempt to maintain Resident 53's ability since Resident 53 did not receive any therapy services. The ADON stated she did not know whether Resident 53's mobility, ADLs, speech, and swallow could have improved since Resident 53's physician orders for PT, OT, and SLP were never carried out. The ADON stated according to the facility's job descriptions for PT, OT, and SLP, the facility did not provide therapy to Resident 53 in accordance with the job descriptions. During an interview on 5/31/2024 at 12:45 p.m. with the Acting Administrator (AADM), the AADM stated the facility was responsible for a resident's care, including following the treatment plan and physician orders, upon accepting the resident's admission to the facility. A review of the facility's undated job description titled, Speech Pathologist, indicated the purpose for this position was to evaluate, treat, document and/or facilitate care for residents with impaired ability to swallow or communicate due to disease process. The SLP job description indicated the SLP was authorized to Evaluate resident's functional needs when referred by the resident's attending physician and Follow physician's orders, facility policies and procedures to evaluate and treat residents. A review of the facility's policy and procedure titled, Skilled Nursing Rehabilitation Services, indicated each resident with physician orders for therapy services will receive an assessment. b., A review of Resident 3's Admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included type 2 diabetes mellitus (high blood sugar), myocardial infarction (heart attack), hemiplegia or hemiparesis (weakness or inability to move one side of the body) following cerebral infarction (stroke, brain damage due to a loss of oxygen to the area) affecting the right dominant (used most often) side, dysphagia (difficulty swallowing), acquired absence of the left toes, and acquired absence of the right leg below the knee. A review of Resident 3's physician orders, dated 9/5/2022 timed at 4:57 p.m., indicated PT/OT evaluation as needed. A review of Resident 3's physician orders, dated 9/6/2022 timed at 4:53 p.m., indicated the physician orders for PT/OT evaluation as needed, dated 9/5/2022, was discontinued. A review of Resident 3's physician orders, dated 10/23/2023 timed at 8:33 p.m., indicated PT/OT evaluation as needed. A review of Resident 3's physician orders, dated 10/24/2023 timed at 12:43 p.m., indicated the physician orders for PT/OT evaluation as needed, dated 10/23/2023, was discontinued. A review of Resident 3's physician orders, dated 11/27/2023, indicated for the RNA to provide PROM on both arms and both legs, 3-5x/week with one person assist as tolerated. A review of Resident 3 MDS, dated [DATE], indicated Resident 3 had severely impaired cognition, had ROM impairments to one arm and one leg, and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for rolling to either side, transferring from sit to lying, chair/bed-to-chair transfers, oral hygiene (cleaning teeth), showering/bathing, and dressing. During an interview on 5/28/2024 at 10:48 a.m. with the DOR, the DOR stated therapy services helped residents regain ability and function. During an observation on 5/28/2024 at 11:30 a.m., in Resident 3's room, Resident 3 was observed asleep while lying in bed with HOB elevated and receiving liquid feeding through the gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding). Resident 3 woke up easily to sound but did not speak. Resident 3 attempted to move the left hand to reach forward but no other active movement was observed in both arms and both legs. During an observation on 5/29/2024 at 8:47 a.m., in Resident 3's room, Resident 3 was observed lying in bed with the HOB elevated and receiving liquid feeding through the G-tube. During an observation on 5/29/2024 at 8:53 a.m., in Resident 3's room, the ADON came into Resident 3's room to disconnect the G-tube from the liquid feeding machine. RNA 2 stood on the left side of Resident 3's bed and performed exercises on Resident 3's left shoulder. RNA 2 walked to the right side of Resident 3's bed and performed exercises on Resident 3's right shoulder. RNA 2 removed the bed sheet over Resident 3's legs. Resident 3 was observed to have the absence of the right lower leg below the knee and the absence of toes on the left foot. RNA 2 performed exercises to the right hip and then performed exercises to the left hip. During an interview on 5/29/2024 at 9:04 a.m. with RNA 2, RNA 2 stated she performed PROM exercises to both arms and both legs since Resident 3 did not assist with the exercises. During an interview on 5/29/2024 at 11:36 a.m. with PT 1, PT 1 stated she had never seen Resident 3 for PT services. During a concurrent interview and record review on 5/29/2024 at 11:50 a.m. with the DOR, Resident 3's therapy documentation and physician orders were reviewed. The DOR stated Resident 3 received a PT evaluation on 4/14/2021 and had not received any PT services since 4/14/2021. The DOR stated Resident 3 had never received any OT services. The DOR reviewed Resident 3's physician orders, dated 9/5/2022, for PT/OT evaluation as needed which was discontinued on 9/6/2022. The DOR stated Resident 3 never received PT and OT evaluations in accordance with the physician orders, dated 9/5/2022. The DOR reviewed Resident 3's physician orders, dated 10/23/2023, for PT/OT evaluation as needed which was discontinued on 10/24/2024. The DOR stated never received the PT and OT evaluations in accordance with the physician orders, dated 10/23/2023, but received RNA services to continue to help Resident 3. The DOR stated the facility discontinued the physician orders for PT and OT without completing the evaluation if the PT and OT evaluation was not necessary. During an interview on 5/29/2024 at 3:18 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 3 used to have a leg prosthesis (device designed to replace a missing part of the body or to make a part of the body work better) and stood up with assistance to transfer to the chair despite weakness to one-side of the body. CNA 7 stated Resident 3's abilities changed about two to three years ago but did not know the reason for Resident 3's decline. CNA 7 stated Resident 3 currently had stiffness in both arms and required complete care. During an interview on 5/30/2024 at 11:56 a.m. with the DOR, the DOR stated the resident's payor source (person, organization, or entity that pays for the care services administered by a health provider) had to be verified prior to evaluating a resident for therapy. During an interview on 5/30/2024 at 8:46 a.m. with CNA 4, CNA 4 stated Resident 3's function has been the same for the past two years. CNA 4 stated Resident 3 did not speak, had leg amputations (loss or surgical removal of a body part), required G-tube feeding, and required two people for dressing due to difficulty lifting both arms. During an interview on 5/30/2024 at 9:02 a.m. with the MDS 1, MDS 1 stated Resident 3 used to sit up in a wheelchair, had conversational language, and would eat. MDS 1 stated Resident 3 went to the hospital (unknown date) for an unknown reason and returned to the facility (unknown date) requiring total dependence for ADLs and mobility. During an interview on 5/30/2024 at 3:44 p.m. with the DOR, the DOR stated the purpose of OT included intervention to a resident's arms, self-care, and ADLs. The DOR stated the purpose of PT included intervention to a resident's legs, mobility, standing, transfers, and ambulation (the act of walking). The DOR stated the purpose of therapy was to improve a resident's strength and attempt to return the resident to their prior level of function (ability prior to admission to the facility). During an interview on 5/31/2024 at 12:45 p.m. with the AADM, the AADM stated the facility was responsible for a resident's care, including following the treatment plan and physician orders, upon accepting the resident's admission to the facility. During an interview and record review on 5/31/2024 at 4:18 p.m. with Registered Nurse (RN) 1, Resident 3's nursing Progress Notes were reviewed. RN 1 stated the process of discontinuing a physician's order included calling the physician who will decide whether to discontinue the order. RN 1 reviewed Resident 3's nursing Progress Notes for the months of 9/2022 and 10/2023. RN 1 stated there were no nursing progress notes indicating the physician was called to discontinue PT and OT evaluations during the months of 9/2022 and 10/2023. A review of the facility's undated job description titled, Physical Therapist, indicated the purpose of this position was to evaluate, treat, document and/or facilitate care for residents with impaired ability to function at an independent level due to disease process. The PT job description indicated the PT was authorized to evaluate resident's functional needs when referred by the resident's attending physician and follow physician's orders, facility policies and procedures to evaluate and treat residents. A review of the facility's undated job description titled, Occupational Therapist, indicated the purpose of this position was to evaluate, treat, document and/or facilitate care for residents with impaired ability to perform activities of daily living at an independent level due to disease process. The OT job description indicated the OT was authorized to evaluate resident's functional needs when referred by the resident's attending physician and follow physician's orders, facility policies and procedures to evaluate and treat residents. A review of the facility's policy and procedure (P&P) titled, Skilled Nursing Rehabilitation Services, indicated each resident with physician orders for therapy services will receive an assessment.

Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for one of four sampled residents (Resident 53) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility by failing to: 1. Monitor Resident 53's ROM in each joint of both arms and legs upon admission, quarterly, and annually in accordance with the facility's policies and procedures (P&P) titled, Resident Mobility and Range of Motion, which indicated the resident's comprehensive assessment will identify a resident's current range of motion of his or her joints. 2. Provide Resident 53 with active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises from 12/23/2022 (admission assessment) to 5/1/2023 (more than four months) in accordance Resident 53's admission Rehab Screening Form (brief assessment of a resident's abilities) recommendations, dated 12/23/2022. 3. Provide Resident 53 with passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) of the ankles in accordance with physician orders, dated 3/25/2024. 4. Assess and monitor Resident 3, 56, and 61's ROM in each joint of both arms and both legs upon admission, quarterly, and annually in accordance with the facility's policies and procedures (P&P) titled, Resident Mobility and Range of Motion. 5. Provide Resident 3 with PROM of both elbows, wrists, hands, knees, and the left ankle in accordance with physician orders, dated 11/27/2023. 6. Provide Resident 56 with active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) of the right wrist and hand in accordance with physician orders, dated 4/7/2023. These deficient practices resulted in Resident 53 requiring full physical assistance to perform exercises of both arms and legs and Resident 53's development of both ankle contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). These deficient practices also had the potential for Resident 3, 56, and 61 to experience an undetected decline in ROM and the development of contractures. Cross reference F580, F656, F677, F726, and F825 Findings: a. A review of Resident 53's general acute care hospital (GACH) Neurology (branch of medicine concerned with the study and treatment of disorders involving the brain, spinal cord, and nerves) Progress Note, dated 12/18/2022, indicated Resident 53 was fully awake, alert, and followed simple commands. The Neurology Progress Note also included a physical examination, which indicated Resident 53 held the arms and legs against gravity (active movement). A review of Resident 53's Admission Record indicated Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Admission Record indicated Resident 53's diagnoses included psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorders (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness), starvation (suffering caused by hunger), and attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding). A review of Resident 53's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 4/2/2024, indicated Resident 53 had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 53 did not have any ROM impairments to both arms and legs. The MDS indicated Resident 53 was dependent (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) for rolling to either side, transferring from sit to lying, chair/bed-to-chair transfers, oral hygiene (cleaning teeth), showering/bathing, and dressing. A review of Resident 53's Progress Note, dated 12/22/2022 timed at 3:00 p.m., indicated Resident 53 was found in the middle of the bed with both legs dangling outside of the bed. The Progress Note indicated Resident 53 was assisted back to bed and repositioned. The Progress Note indicated Resident 53's physician was informed, and a physician order was carried out to place the bed in the lowest position and floor mat. A review of Resident 53's admission Rehab Screening Form, dated 12/23/2022, indicated Resident 53 did not have any contractures or ROM impairments in both arms, but had a ROM impairment in one leg. The Rehabilitation Screening Form indicated Resident 53's left leg was within functional limits ([WFL] sufficient movement without significant limitation) and the right leg (hip) had tightness into flexion (bending the leg at the hip joint toward the body) and abduction (moving the leg away from the body). The Rehab Screening Form indicated to provide Resident 53 with Restorative Nursing Aide ([RNA] Certified Nursing Aide program that help residents to maintain their function and joint mobility) for AAROM exercises on both arms and legs, three to five times per week (3-5x/week) as tolerated. A review of Resident 53's Restorative Flow Sheets (record of RNA sessions) for 12/2022, 1/2023, 2/2023, 3/2023, and 4/2023 indicated AAROM exercises on both arms and legs were not included. A review of Resident 53's quarterly Rehab Screening Form, dated 4/9/2023, indicated Resident 53 did not have any contractures or ROM impairments in both arms. The Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Form indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. A review of Resident 53's physician orders, dated 5/1/2023, indicated for the RNA to provide Resident 53 with PROM on both arms and legs, 3-5x/week with one person assist as tolerated. A review of Resident 53's quarterly Rehab Screening Forms, dated 7/9/2023 and 10/10/2023, indicated Resident 53 did not have any contractures or ROM impairments in both arms. The Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Forms indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. A review of Resident 53's annual Rehab Screening Form, dated 1/9/2024, indicated Resident 53 did not have any contractures and did not have any ROM impairments in both arms. The Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Form indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. A review of Resident 53's physician orders, dated 3/25/2024, indicated for RNA to provide PROM on both arms and legs, followed by the application of both elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four to six hours (4-6 hours), 3-5x/week. A review of Resident 53's quarterly Rehab Screening Form, dated 4/9/2024, indicated Resident 53 did not have any contractures or ROM impairments in both arms. The Rehab Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Form indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. During a concurrent interview and record review on 5/28/2024 at 10:48 a.m. with the Director of Rehabilitation (DOR), the facility's Rehab Screening Form was reviewed. The DOR stated the Rehab Screening Form was completed upon a resident's admission, quarterly, change of condition, and annually. The DOR stated ROM was assessed as either having no impairment, impairment on one side, or impairment on both sides. The DOR stated the Rehab Screening Form did not include a ROM assessment for limitations in each joint of the arms (shoulders, elbows, wrists, and hands) and the legs (hips, knees, ankles). The DOR stated RNA services helped residents maintain their ROM and function. During an observation on 5/29/2024 at 8:13 a.m., in Resident 53's room, Resident 53 was lying awake in bed with the head-of-bed (HOB) elevated and a bed sheet covering Resident 53's legs. Resident 53 smiled but did not speak. Resident 53's body twitched (short, jerky sudden movements) intermittently (did not happen continuously) and both elbows were in a bent position. Resident 53's hips and knees were visibly rotated away from the body with the knees bent, resembling a frog-like leg position, despite the presence of the bed sheet over both legs. Resident 53's ankles and feet were not visible. Resident 53 was not wearing any splints on both arms and legs. During an observation on 5/29/2024 at 9:09 a.m., in Resident 53's room, Resident 53 was observed lying awake in bed with the HOB elevated. Resident 53's elbows were in a bent position. Restorative Nursing Aide (RNA) 3 performed ROM exercises on Resident 53's left arm, including shoulder abduction (lifting the arm away from the body) and adduction (returning the arm toward the body), shoulder rotation (circular motion) in clockwise and counterclockwise directions, shoulder flexion (lifting the arm upward) and extension (returning the arm downward), elbow flexion (bending) and extension (straightening), and then applied an elbow extension splint (splint that prevents the resident from bending at the elbow) on the left arm. RNA 3 performed ROM exercises on Resident 53's right arm, including shoulder abduction and adduction, shoulder rotation in clockwise and counterclockwise directions, shoulder flexion and extension, elbow flexion and extension, and then applied an elbow extension splint on the right arm. Resident 53's legs were rotated away from the body, both knees were bent, and both ankles were positioned in plantarflexion (ankles bent with toes pointing away from the body). RNA 3 performed ROM exercises on Resident 53's right leg, including hip abduction (moving the leg away from the body) and adduction (returning the leg toward the body), hip rotation clockwise and counterclockwise while the knee was extended, hip flexion (bending the leg at the hip joint toward the body) with knee flexion (bending the knee), and ankle rotation. RNA 3 did not move Resident 53's right ankle into dorsiflexion (ankle bent with toes pointing toward the body). RNA 3 performed ROM exercises on Resident 53's left leg, including hip abduction, hip rotation clockwise and counterclockwise with the knee extended, hip flexion with knee flexion, and ankle rotation. RNA 3 did not move Resident 53's left ankle into dorsiflexion. RNA 3 then performed exercises to the left-hand fingers into flexion and extension, left wrist rotation, left wrist flexion and extension, right-hand fingers into flexion and extension, right wrist rotation, and right wrist flexion and extension. During an interview on 5/29/2024 at 9:37 a.m. with RNA 3, RNA 3 stated she performed PROM on both of Resident 53's arms and legs and applied both elbow extension splints. During an interview on 5/29/2024 at 11:36 a.m. with Physical Therapist (PT, professional trained in the restoration, maintenance, and promotion of optimal physical function) 1, PT 1 stated the ROM exercises that the RNAs were expected to perform for each resident's legs included hip flexion and extension, hip abduction and adduction, knee flexion and extension, and ankle dorsiflexion and plantarflexion to prevent contractures. During a concurrent interview and record review on 5/29/2024 at 4:06 p.m. with the DOR, in the presence of the Assistant Director of Nursing (ADON) and the MDS Coordinator (MDS 1), the facility's Rehabilitation electronic documentation (clinical therapy records) for PT, Occupational Therapy [(OT) profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)], and Speech Therapy ([ST or SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) was reviewed. The DOR stated Resident 53 never received any PT, OT, or SLP services while residing in the facility. During a concurrent interview and record review on 5/29/2024 at 4:23 p.m. with the DOR, Resident 53's Rehab Screening Form, dated 12/23/2022, was reviewed. The DOR stated Resident 53 had ROM impairments in the right leg due to tightness in the hip. The DOR stated Resident 53 did not have any contractures in both legs upon admission to the facility. During a concurrent observation and interview on 5/29/2024 at 4:38 p.m., with Resident 53, in the presence of the DOR, ADON, and MDS 1, in Resident 53's room, Resident 53 was observed lying in bed with a bed sheet covering both legs. The DOR lifted the bed sheet to view both legs. Resident 53 did not have any splints on both legs. Resident 53's ankles were positioned in plantarflexion. The DOR attempted to provide ROM to Resident 53's ankles into dorsiflexion, but Resident 53's ankles remained in plantarflexion. During an interview on 5/29/2024 at 4:43 p.m. with the DOR, ADON, and MDS 1, the DOR, ADON, and MDS 1 stated Resident 53 had plantarflexion contractures of both ankles. MDS 1 stated the ROM assessment in a resident's MDS indicated whether a resident had any ROM limitations but did not indicate which joint had a ROM limitation. The DOR stated the Rehab Screening Form did not include any assessment of a resident's ROM at each joint and the facility was not monitoring each resident's ROM. The ADON stated ROM exercises, movement, proper positioning, and splints assisted in preventing contractures. The ADON stated Resident 53 did not have any splints on both legs. The ADON and MDS 1 stated the facility did not know Resident 53 had both ankle plantarflexion contractures, and therefore, did not know when Resident 53's contractures developed. The ADON stated contractures increased a resident's risk of developing skin breakdown (tissue damage caused by friction, shear, moisture, or pressure) and fractures (break in the bone). The ADON and MDS 1 stated Resident 53's plantarflexion contractures in both ankles were preventable. During an interview on 5/30/2024 at 11:11 a.m. with PT 1, PT 1 stated contractures were a fixed positioning of a joint. PT 1 stated contractures were not reversible but could be surgically released. PT 1 stated contractures could be delayed with ROM exercises, proper positioning, and the application of splints. During a concurrent interview and record review on 5/30/2024 at 11:46 a.m. with the DOR, Resident 53's Rehab Screening Forms, dated 12/23/2022 and 4/9/2023, and physician orders dated, 5/1/2023, for RNA were reviewed. The DOR stated the Rehab Screening Form, dated 12/23/2022, included a recommendation for RNA to perform AAROM exercises to both arms and legs. The DOR stated Resident 53 did not receive RNA until the physician orders, dated 5/1/2023, which indicated for the RNA to perform PROM to both arms and legs. The DOR stated Resident 53 did not receive RNA for AAROM exercises from 12/23/2022 to 5/1/2023. The DOR stated the Rehab Screening Form, dated 4/9/2023, indicated to continue the RNA ROM exercise program but the DOR did not verify if Resident 53 was received RNA services. The DOR stated the facility's Rehab Screening Form did not monitor Resident 53's ROM. During an interview on 5/30/2024 at 3:44 p.m. with the DOR, the DOR stated AAROM meant a resident moved as much as possible but required additional help from another person. The DOR stated PROM meant the resident required full physical assistance. During a concurrent interview and record review on 5/31/2024 at 10:28 a.m. with the ADON and MDS 1, Resident 53's Rehab Screening Form, dated 12/23/2022, the Restorative Flow Sheets, and physician orders dated, 5/1/2023, for RNA were reviewed. The ADON stated the Rehab Screening Form, dated 12/23/2022, indicated a recommendation for RNA to provide AAROM exercises to both arms and legs. The ADON stated Resident 53 had some movement in both arms and both legs if the recommendation was for AAROM. The ADON and MDS 1 reviewed the Restorative Flow Sheets from 12/2022 to 4/2022 and stated Resident 53 did not receive RNA for AAROM exercises for four months. MDS 1 stated Resident 53 started receiving RNA for PROM exercises to both arms and legs in accordance with the physician order, dated 5/1/2023. MDS 1 stated the physician orders changed from AAROM to PROM which indicated Resident 53 could have declined in the ability to move. The ADON stated the Rehab Screening Form should have indicated Resident 53 was monitored for ROM (at each joint) since the RNAs were not trained to observe ROM. The ADON stated Resident 53's ROM limitations were preventable. b. A review of Resident 3's Admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included type 2 diabetes mellitus (high blood sugar), myocardial infarction (heart attack), hemiplegia or hemiparesis (weakness or inability to move one side of the body) following cerebral infarction (stroke, brain damage due to a loss of oxygen to the area) affecting the right dominant (used most often) side, dysphagia (difficulty swallowing), acquired absence of the left toes, and acquired absence of the right leg below the knee. A review of Resident 3's annual Rehab Screening Form, dated 11/6/2023, indicated Resident 3 had a ROM impairment in one arm and a ROM impairment in one leg. The Rehab Screening Form did not indicate which arm and which leg had ROM impairments. The Rehab Screening Form indicated Resident 3 had the same level of function without decline and to continue the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) program. A review of Resident 3's physician orders, dated 11/27/2023, indicated for the RNA to provide PROM on both upper extremities and both lower extremities, 3-5x/week with one person assist as tolerated. A review of Resident 3's quarterly Rehab Screening Form, dated 2/6/2024, indicated Resident 3 had a ROM impairment in one arm and a ROM impairment in one leg. The Rehab Screening Form did not indicate which arm and which leg had ROM impairments. The Rehab Screening Form indicated Resident 3 had the same level of function without decline and to continue the RNA program. A review of Resident 3 MDS, dated [DATE], indicated Resident 3 had severely impaired cognition, had ROM impairments to one arm and one leg, and was dependent for rolling to either side, transferring from sit to lying, chair/bed-to-chair transfers, oral hygiene, showering/bathing, and dressing. A review of Resident 3's quarterly Rehab Screening Form, dated 5/7/2024, indicated Resident 3 had a ROM impairment in one arm and a ROM impairment in one leg. The Rehab Screening Form did not indicate which arm and which leg had ROM impairments. The Rehab Screening Form indicated Resident 3 had the same level of function without decline and to continue the RNA program. During a concurrent interview and record review on 5/28/2024 at 10:48 a.m. with the DOR, the facility's Rehab Screening Form was reviewed. The DOR stated the Rehab Screening Form was completed upon a resident's admission, quarterly, change of condition, and annually. The DOR stated ROM was assessed as either having no impairment, impairment on one side, or impairment on both sides. The DOR stated the Rehab Screening Form did not include a ROM assessment for limitations in each joint of the arms (shoulders, elbows, wrists, and hands) and the legs (hips, knees, ankles). The DOR stated RNA services helped residents (in general) maintain their ROM and function. During an observation on 5/28/2024 at 11:30 a.m., in Resident 3's room, Resident 3 was observed asleep while lying in bed with the HOB elevated and receiving liquid feeding through the G-tube. Resident 3 woke up easily to sound but did not speak. Resident 3 attempted to move the left hand to reach forward but no other active movement was observed in both arms and both legs. During an observation on 5/29/2024 at 8:47 a.m., in Resident 3's room, Resident 3 was observed lying in bed with the HOB elevated receiving liquid feeding through the G-tube. During an observation on 5/29/2024 at 8:53 a.m., in Resident 3's room, the ADON came into Resident 3's room to disconnect the G-tube from the liquid feeding machine. RNA 2 stood on the left side of Resident 3's bed and performed exercises on Resident 3's left arm, including shoulder flexion (lifting the arm upward) and extension (returning the arm downward), shoulder horizontal abduction (lifting the arm from shoulder level in front of the body toward the side and away from the body) and horizontal adduction (lifting the arm from shoulder level on side of the body toward the front of the body), and shoulder rotation (circular motion). RNA 2 did not perform any exercises on the left elbow, wrist, or fingers. RNA 2 walked to the right side of Resident 3's bed and performed exercises on Resident 3's right arm including, shoulder flexion and extension, shoulder horizontal abduction and adduction, and shoulder rotation. RNA 2 did not perform any exercises to Resident 3's right elbow, wrist, and hand. RNA 2 removed the bed sheet over Resident 3's legs. Resident 3 was observed to have the absence of the right lower leg below the knee and a cushioned boot underneath the left foot. RNA 2 performed exercises to the right leg, including hip flexion (bending the leg at the hip joint toward the body) and extension (returning the leg down away from the body), hip abduction (moving the leg away from the body) and adduction (returning the leg toward the body), and hip rotation. RNA did not perform any exercises to the right knee. RNA 2 removed the cushioned boot from the left foot, and Resident 3 was observed with the absence of toes. RNA 2 performed exercises to the left leg, including hip flexion and extension, hip abduction and adduction, and hip rotation. RNA 2 did not perform any PROM to the left knee and left ankle. During an interview on 5/29/2024 at 9:04 a.m. with RNA 2, RNA 2 stated she performed PROM exercises to both arms and both legs. RNA 2 described and demonstrated the ROM exercises performed to Resident 3's arms and legs. RNA 2 stated she moved both of Resident 3's arms at the shoulder joint upward and downward (shoulder flexion and extension), side to side (shoulder horizonal abduction and horizonal adduction), and circles (shoulder rotation). RNA 2 stated she moved both of Resident 3's legs at the hip joint upward and downward (hip flexion and extension), side to side (hip abduction and adduction), and circles (hip rotation). During an interview on 5/29/2024 at 11:24 a.m. with the DOR, the DOR stated the ROM exercises that the RNAs were expected to perform for each resident's arms included shoulder flexion and extension, shoulder abduction (lifting the arm up and away from the body) and adduction (returning the arm downward to the side of the body), elbow flexion (bending the elbow) and extension (straightening the elbow), wrist flexion (bending the wrist downward) and extension (bending the wrist upward), and finger flexion (bending the fingers toward the palm) and extension (straightening out the fingers). The DOR stated it was important to perform ROM exercises to each joint to improve circulation and prevent stiffness. During an interview on 5/29/2024 at 11:36 a.m. with PT 1, PT 1 stated the ROM exercises that the RNAs were expected to perform for each resident's legs included hip flexion and extension, hip abduction and adduction, knee flexion (bending the knee) and extension (straightening out the knee), and ankle dorsiflexion (bending the ankle toward the body) and plantarflexion (bending the ankle away from the body) to prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). During a concurrent interview and record review on 5/29/2024 at 12:36 p.m. with the DOR, Resident 3's Rehab Screening Forms were reviewed. The DOR stated Resident 3's Rehab Screening Forms, dated 11/6/2023, 2/6/2024, and 5/7/2024, indicated Resident 3 had a ROM impairment in one arm and ROM impairment in one leg due to Resident 3's hemiplegia affecting the right side of the body. During an interview on 5/29/2024 at 2:36 p.m. with RNA 2, RNA 2 stated she did not perform ROM exercises to both of Resident 3's elbows, wrists, and hands because the physician orders indicated to perform exercises to Resident 3's upper extremity. During an interview on 5/29/2024 at 4:43 p.m. with the DOR, ADON, and MDS 1, MDS 1 stated the ROM assessment in a resident's MDS indicated whether a resident had any ROM limitations but did not indicate which joint had a ROM limitation. The DOR stated the Rehab Screening Form did not include any assessment of a resident's ROM at each joint and stated the facility was not monitoring each resident's ROM. During an interview on 5/31/2024 at 10:28 a.m., with the ADON, the ADON stated the Rehab Screening Form should have monitored a resident's ROM since the RNAs were not trained to observe ROM. c. A review of Resident 56's Admission Record, indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (high blood sugar), hemiplegia or hemiparesis following a cerebrovascular disease affecting the left dominant side, aphasia (loss of ability to understand or express speech as a result of brain damage), and dysphagia (difficulty swallowing). A review of Resident 56's physician orders, dated 4/7/2023, indicated for the RNA to provide AROM on the right arm and right leg and PROM on the left leg, three to five times per week, with one person assist. A review of Resident 56's RNA Referral, dated 4/7/2023, indicated Resident 56 had increased stiffness on the left side of the body and refused to have the left arm touched. A review of Resident 56's quarterly Rehab Screening Forms, dated 6/22/2023, 9/24/2023, and 12/24/2023, indicated Resident 56 had ROM impairments in both arms and both legs. The Rehab Screening Form indicated Resident 56 had the same level of function without decline and to continue the RNA program. A review of Resident 56's MDS, dated [DATE], indicated Resident 56 had moderately impaired cognition and had ROM impairments to one arm and one leg. The MDS also indicated Resident 56 required substantial/maximal assistance (helper does more than half the effort) for rolling to either side, oral hygiene, showering/bathing, and upper body dressing, and was dependent for chair/bed-to-chair transfers and lower body dressing. A review of Resident 56's annual Rehab Screening Form, dated 3/24/2024, indicated Resident 56 had ROM impairments in both arms and both legs. The Rehab Screening Form indicated Resident 56 had the same level of function without decline and to continue the RNA program. During a concurrent observation and interview on 5/28/2024 at 10:05 a.m., with Resident 56, in Resident 56's room, Resident 56 was observed awake while lying in bed. Resident 56 moved the right arm and right leg without any physical assistance. Resident 56's left arm was positioned with the left shoulder rotated toward the body, the elbow was bent and touching Resident 56's chest, the wrist was bent downward, and the knuckles of each finger were bent toward the palm. Resident 56's left leg was resting on the bed. Resident 56 stated he was unable to move the left side of the body and stated someone (unknown) performed exercises with Resident 56 at least once per day. During a concurrent interview and record review on 5/28/2024 at 10:48 a.m. with the DOR, the facility's Rehab Screening Form was reviewed. The DOR stated the Rehab Screening Form was completed upon a resident's admission, quarterly, change of condition, and annually. The DOR stated ROM was assessed as either having no impairment, impairment on one side, or impairment on both sides. The DOR stated the Rehab Screening Form did not include a ROM assessment for limitations in each joint of the arms (shoulders, elbows, wrists, and hands) and the legs (hips, knees, ankles). The DOR stated RNA services helped residents maintain their ROM and function. During an observation on 5/29/2024 at 10:02 a.m., in Resident 56's room, Resident 56 was observed awake while lying in bed and performed exercises with RNA 1. Resident 56 performed AROM at the shoulder joint to lift the right arm upward (shoulder flexion) to shoulder level and downward (shoulder extension) without any physical assistance. Resident 56 required some physical assistance to perform right shoulder rotation (circular motion) and right elbow flexion (bending) and extension (straightening). Resident 56 did not perform any ROM exercises of the wrist and the hand. Resident 56 required some physical assistance to perform right hip and knee exercises. Resident 56 did not perform any right ankle exercises. RNA 1 performed PROM exercises to Resident 56's left leg, including hip flexion (bending the leg at the hip joint toward the body) and extension (returning the leg down away from the body). RNA did not perform PROM of the left knee and ankle. RNA 1 stated Resident 56 did not have physician orders to perform ROM exercises to the left arm because Resident 56 did not want anyone to touch it. During an interview on 5/29/2024 at 10:10 a.m. with RNA 1, RNA 1 described and demonstrated the ROM exercises performed with Resident 56. RNA 1 stated Resident 56 performed ROM exercises on the right arm, including moving the shoulder joint upward and downward (shoulder flexion and extension) and rotation. RNA 1 stated Resident 56 required some physical assistance to perform some right arm and right leg exercises and could only tolerate left hip flexion exercises due to pain. During an interview on 5/29/2024 at 11:24 a.m. with the DOR, the DOR stated the ROM exercises that the RNAs were expected to perform for each resident's arms included shoulder flexion and extension, shoulder abduction and adduction, elbow flexion and extension, wrist flexion (bending the wrist downward) and extension (bending the wrist upward), and finger flexion (bending the fingers toward the palm) and extension (straightening out the fingers). The DOR stated it was important to perform ROM exercises to each joint to improve circulation and prevent stiffness. During an interview on 5/29/2024 at 2:32 p.m. with RNA 1, RNA 1 stated Resident 56 did not perform any ROM exercises on the right wrist and hand because Resident 56 already used the right hand constantly to eat and reposition the body. RNA 1 stated Resident 56 did not perform any ROM exercises to the right ankle because Resident 56 was starting to have pain in the right leg. During an interview on 5/29/2024 at 4:43 p.m. with the DOR, ADON, and MDS 1, MDS 1 stated the ROM assessment in a resident's MDS indicated whether a resident had any ROM limitations but did not indicate which joint had a ROM limitation. The DOR stated the Rehab Screening Form did not include any assessment of a resident's ROM at each joint and stated the facility was not monitoring each resident's ROM. During a concurrent interview and record review on 5/30/2024 at 1:15 p.m. with the DOR, Resident 56's Rehab Screening Forms, dated 4/7/2023, 6/22/2023, 9/24/2023, 12/24/2024, and 3/24/2024, were reviewed. The DOR stated Resident 56's Rehab Screening Forms did not include any assessment

Based on interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 provided care and services to prevent an injury for one of three sampled residents (Resident 1) by failing to: 1. Ensure CNA 1 provided two-person physical assistance (help from two person) when using a Hoyer Lift (mechanical lift, a device used by staff to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from Resident 1 ' s bed to the wheelchair. 2. Ensure CNA 1 used the Hoyer lift according to the manufacturer ' s instructions, indicating to use a two-person assistance for transferring a person to a wheelchair with one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle or sides of the sling to seat the patient well into the back of the chair. As a result, CNA 1 transferred Resident 1 to the wheelchair on her own, without assistance, and the Hoyer lift hit Resident 1 in the left eye. Resident 1 was transferred to the general acute care hospital (GACH) due to the injury sustained to the left eye and was diagnosed with a corneal abrasion (a superficial scratch on the clear, protective window at the front of the eye [cornea]). Findings: During a review of Resident 1 ' s Admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including glaucoma (a group of eye conditions that can cause blindness. The nerve connecting the eye to the brain is damaged, usually due to high eye pressure), type 2 diabetes mellitus (a long-term condition that impairs the way the body regulates and uses sugar as a fuel), difficulty in walking, and muscle weakness. During a review of Resident 1 ' s History and Physical (H&P), dated 10/29/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 2/3/2023, the MDS indicated Resident 1 had the capacity understand and be understood. The MDS indicated Resident 1 had total dependence for transfers out of bed and required two-person physical assistance. During a review of Resident 1 ' s Progress Note, dated 3/18/2023, at 10:12 a.m., the note indicated at 9:45 a.m., the Charge Nurse reported Resident 1 was hit by the Hoyer lift and the resident was bleeding in the left eye. The note indicated Resident 1 was assessed and noted with a bloodshot left eye, with bloody tears coming out from it. The note indicated the facility's Medical Director was notified and ordered to transfer the resident to the hospital. During a review of CNA 1 ' s written statement, dated 3/18/2023, the statement indicated CNA 1 transferred Resident 1 to the wheelchair using the mechanical lift without the assistance of another staff member. During a review of CNA 1 ' s Disciplinary Action Notice, dated 3/18/2023, the notice indicated, During patient transfer, an injury occurred. Resident was supposed to be 2-person assist; however, the resident was transferred by the CNA alone/without assistance from another CNA. The disciplinary action notice was signed by CNA 1 on 3/18/2023. During a review of Resident 1 ' s Resident Transfer and Referral Record, dated 3/18/2023, the record indicated Resident 1 was transferred via ambulance to a general acute care hospital (GACH) on 3/18/2023 for an injury to the left eye. During a review of Resident 1 ' s GACH After Visits Summary, dated 3/18/2023, the summary indicated Resident 1 was diagnosed with a corneal abrasion and decreased vision. During a review of Resident 1 ' s Follow-Up Investigation Report, dated 3/20/2023, the report indicated on 3/18/2023, an eye patch was applied to Resident 1 ' s left eye. The report indicated Resident 1 arrived from the GACH with a diagnosis of corneal abrasion related to injury. The report indicated the following physician ' s orders: 1. Erythromycin Ophthalmic Ointment (used to treat bacterial infections of the eye) 5 milligrams per gram (mg/g, unit of measurement) instill 1 application in the left eye every 6 hours for 7 days. 2. Fluorometholone Ophthalmic Suspension 0.1% (used to treat eye conditions caused by inflammation [swelling]) instill 1 drop in the left eye every 4 hours for 10 days. 3. Follow-up appointment with ophthalmologist (eye doctor) on 3/21/2023 at 11 a.m. During an interview on 3/31/2023, at 11:51 a.m., with Registered Nurse (RN) 1, RN 1 stated she was the supervisor on 3/18/2023, day shift. RN 1 stated Licensed Vocational Nurse (LVN) 1 reported CNA 1 used the Hoyer lift to transfer Resident 1 to the wheelchair and when CNA 1 moved the Hoyer lift away from the resident, Resident 1 leaned forward, and the cradle part of the lift hit the resident in the left eye. RN 1 stated Resident 1 ' s left eye sclera (the white outer layer of the eyeball) was blood red and had blood-tinged tears. RN 1 stated 911 (emergency services) was called and Resident 1 was transferred to the GACH via ambulance. During an interview on 3/31/2023, at 12:02 p.m., with LVN 1, LVN 1 stated on 3/18/2023, the Hoyer lift hit Resident 1 in the left eye, when CNA 1 transferred Resident 1 to the wheelchair. LVN 1 stated it was required to have two-staff assistance when transferring a resident with the Hoyer lift. LVN 1 stated CNA 1 had not mentioned she had asked another staff for assistance when she transferred Resident 1 to the wheelchair. During an interview on 3/31/2023, at 12:44 p.m., with CNA 2, CNA 2 stated she was caring for Resident 1 today, 3/31/2023. CNA 2 stated when she transferred Resident 1 from the bed to the wheelchair, she requested two to three staff for assistance to transfer the resident using the Hoyer lift for safety. During an interview on 3/31/2023, at 1:22 p.m., with CNA 3, CNA 3 stated CNA 1 had not asked her for assistance to transfer Resident 1 to the wheelchair on 3/18/2023. CNA 3 stated when using the Hoyer lift, there should be at least two staff assisting for the safety of the resident and the staff. During an interview on 3/31/2023, at 1:40 p.m., with CNA 5, CNA 5 stated CNA 1 had not asked her for help to transfer Resident 1 to the wheelchair on 3/18/2023. CNA 5 stated a minimum of two staff must be used when using the Hoyer lift and three staff should assist if the resident was heavier. During an interview on 3/31/2023, at 2:07 p.m., with the Director of Staff Development (DSD), the DSD stated the Hoyer lift must be used with a minimum of two staff. The DSD stated one staff controlled the mechanical lift and the other staff was to guide the lift and ensure the resident was safe. The DSD stated she had interviewed CNA 1 over the telephone and stated the first thing CNA 1 said was that she knew she was supposed to have another staff assist her when she transferred Resident 1 using the Hoyer lift. The DSD stated CNA 1 had not mentioned that she had asked anyone for help when she transferred Resident 1 to the wheelchair. The DSD stated Resident 1 ' s accident was preventable because CNA 1 should have had another staff assist her when she transferred Resident 1 to the wheelchair using the Hoyer lift. During an interview on 3/31/2023, at 3 p.m., with Resident 1 in the hallway, Resident 1 stated CNA 1 had transferred her from the bed to the wheelchair using the Hoyer lift by herself. Resident 1 stated other staff had used the Hoyer lift and transferred her to the wheelchair by themselves, but this was the first time she got hurt. Resident 1 stated the Hoyer lift was not raised high enough and it moved and hit her in the left eye. Resident 1 stated it was very bad when the accident happened because the resident's eye was a very delicate area. Resident 1 stated she was very scared because her eye was all bloody and she was afraid she could lose her eye. During a telephone interview on 4/10/2023, at 12:10 p.m., with CNA 1, CNA 1 stated on 3/18/2023, she transferred Resident 1 to the wheelchair using the Hoyer lift by herself. CNA 1 stated when she was retracting the Hoyer lift, Resident 1 leaned forward while she adjusted her blouse, and the metal bar of the Hoyer lift grazed (slightly hit) the resident ' s left eye. CNA 1 stated Resident 1 ' s left eye was bleeding a little bit and she went to get the Charge Nurse and the Supervisor to assess the resident. CNA 1 stated she was trained to use the Hoyer lift and was instructed to always have two-person assistance when transferring a resident, but she had transferred Resident 1 on her own. CNA 1 stated she did not remember if she had asked someone for assistance, but at the end of the day it was her fault because she should have had another staff member assist her. CNA 1 stated she was not thinking when she transferred Resident 1 on her own. CNA 1 stated it was a mistake that would not happen again. During a review of the facility ' s assistive devices lesson plan, dated 3/20/2023, the plan indicated the sling lift/Hoyer lift must be used with two staff members. During a review of the manufacturer instructions for the battery powered patient lift user manual, dated 10/18/2018, the manual indicated manufacturer recommended two assistants be used for all lifting and transfers. The manual indicated for transferring to a wheelchair one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle or sides of the sling to seat the patient well into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward. During a review of the facility ' s policy and procedure (P&P) titled, Mechanical Lift Use, undated, the P&P indicated, The mechanical lift shall be used according to the manufacturer ' s instruction booklet. During a review of the facility ' s P&P titled, Mechanical Lift (Hoyer Brand), dated 7/2012, the P&P indicated, It is the policy of this facility to move a resident who is totally dependent in transfer by a mechanical means for resident ' s safety. The P&P indicated the procedure must be performed by nursing assistants or licensed nurses who have been in-serviced on use of the device. The P&P indicated, as one person (First person) operates and maneuvers the lift, Move lift slowly away from bed. (Second person should guide the sling.) .First person to lower the patient down SLOWLY, and the second person guides the resident into the chair.

Based on observation, interview and record review the facility failed to ensure Certified Nurse Assistants (CNA 1), CNA 2, and CNA 3, did not use a frayed, worn-out sling (accessory attached to a mechanical lift [mechanical device used to transfer a resident between surfaces while supporting the resident's weight and providing stability]) to transfer the resident from a wheelchair to bed for one of one resident (Resident 1). The facility failed to: 1. Ensure laundry workers checked lift ' s slings daily after wash and air dry to identify bleached stains, tears, or any signs of sling ' s fragility and wear and tear in accordance with the facility ' s policy titled, ' Mechanical Lift Policy. ' 2. Ensure the director of staff development (DSD) and maintenance supervisor (MS) removed slings from circulation immediately if any signs of deterioration or excessive wear and tear were identified in accordance with the facility ' s policy titled, ' Mechanical Lift Policy ' . 3. Ensure CNAs examined sling for absence of durability deterioration signs prior to its use to transfer Resident 1 via mechanical lift, in accordance with the facility ' s policy titled, ' Mechanical Lift Policy. ' These deficient practices resulted in Resident 1 ' s fall from the ripped sling during transfer from a wheelchair to bed. Resident 1 subsequently was transferred to a general acute care hospital (GACH) for pain management and pain treatment that consisted of 37 doses of intravenous ([IV] into a vein) and oral analgesics (medication to relieve pain administered by mouth) including [MEDICATION(S)] (narcotic pain medication used for severe pain), [MEDICATION(S)] (narcotic pain medication five to ten times more potent [strong, powerful] than [MEDICATION(S)] used for severe pain), [MEDICATION(S)] Acetaminophen (combination of an opioid [a group of pain-relieving drugs that work by interacting with specific cells in the body] and non-opioid pain reliever for moderate to severe pain), and [MEDICATION(S)] (medication for nerve pain). Resident 1 was placed at risk to have potential side effects from receiving narcotics opioids including severe constipation, dizziness, [CONDITION(S)], blurred vision, drowsiness, and confusion. These deficient practices also resulted in Resident 1 ' s experiencing emotional distress and extreme fear every time she is being transferred with a mechanical lift due to vivid recollection of the sound of the tearing apart sling, which resulted in her fall. Findings: During a record review of Resident 1's admission record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses including [CONDITION(S)] (excessive body fat and more than 100 pounds overweight), muscle weakness, difficulty in walking, pain in right hip, fusion of spine (surgical procedure [NAME] two or more small bones in the back together so no movement occurs between them), unilateral primary [CONDITION(S)] (a condition in which there is a breakdown of the joint cartilage [rubbery material that eases friction in joints]) of the right hip, major depressive disorder (mental health disorder characterized by persistent sadness and loss of interest in activities causing significant life impairment) and anxiety disorder (mental health problem characterized by constant worry). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/15/2022, the MDS indicated Resident 1 had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making and required supervision with eating, extensive (resident involved in activity, staff provide weight bearing support) two or more persons physical assistance with bed mobility, and dressing, and was totally dependent on staff for transfers between surfaces and toilet use. During a record review of Resident 1's licensed nurses progress notes dated 4/13/2022 and timed at 4:10 p.m., the note indicated; while CNA 1, CNA 2 and CNA 3 were transferring Resident 1 by mechanical lift from a wheelchair to bed. During this transfer the sling from the lift, which held the resident, ripped on the right bottom part and Resident 1 slowly fell on the floor. The note indicated Resident 1 first hit the floor with the right side of the leg, then right buttock, then left heel, left buttock and then the back. During a review of Resident 1 ' s licensed nurses progress notes (NPN), dated 4/13/2022 at timed 4:20 p.m., the NPN indicated Resident 1 complained of pain throughout the whole body and rated it as ten out of ten on a Pain Scale from one to ten where ten is the worst pain. The note indicated Resident 1 stated, I am in pain, I cannot move, because if I move, it hurts a lot, my whole body is throbbing, I do not want to be touched. The note indicated on 4/13/2022 at 5:30 p.m., Resident 1 was transferred to the GACH via emergency medical transport for evaluation due to fall. During a review of Resident 1's Discharge Summary (DS) from the GACH dated 4/15/2022 at 3:31 p.m., the DS indicated Resident 1 was admitted to the GACH medical floor on 4/14/2022 with back pain, right knee pain, and complaints of total body pain due to a fall. The DS indicated Resident 1 was treated for pain with IV and oral analgesics from 4/13/2022 until 4/18/2022, at the GACH. During a record review of Resident 1's Flowsheets from the GACH dated 4/13/2022 to 4/18/2022, the Flowsheets indicated Resident 1 ' s pain score ranged from five to ten, while hospitalized . The flowsheet indicated Resident 1 experienced pain in various body areas: including neck, back, right hip, and generalized body pain. The Flowsheets indicated Resident 1 ' s pain onset was described as ongoing, with intermittent frequency and awakened her from her sleep. The Flowsheets indicated Resident 1 ' s pain description ranged from aching, spasm, radiating, sharp, and shooting. During a record review of Resident 1's Medication Administration Records (MAR) from the GACH dated 4/13/2022 to 4/18/2022, the MAR indicated Resident 1 received 37 doses of various potent (medication with a very strong effect) pain medication as follows: 1.Two doses of [MEDICATION(S)] [MEDICATION(S)] 4.0 milligrams ([mg] a unit of measurement) as one time in the emergency department. 2. One dose of [MEDICATION(S)] 0.5 mg via IV every six hours as needed for pain. 3. Fourteen doses of [MEDICATION(S)] 4.0 mg via IV every six hours as needed for pain. 4. Seven doses of [MEDICATION(S)] Acetaminophen ([MEDICATION(S)]) 7.5 mg of [MEDICATION(S)]/325 mg of Acetaminophen one tablet every six hours as needed. 5. Thirteen doses of [MEDICATION(S)] 800 mg three times a day. During a record review of article titled Understanding opioid (narcotic) pain medications, dated 6/7/2021 from www.drugs.com (nationally recognized an independent medicine information website), side effects of narcotics and opioids are including severe constipation, dizziness, [CONDITION(S)], blurred vision, and confusion. During an interview with Resident 1 on 6/7/2022 at 11:30 a.m., the resident stated on 4/13/2022 at around 4:15 p.m., the facility staff were transferring her from the wheelchair to bed by using a mechanical lift when the sling ripped, and she fell on the floor. Resident 1 stated, it was the sling's fault, the facility was at fault. The facility was at fault because they were using the same raggedy sling and the edges were frayed. The facility was not supposed to use a worn-out sling. On 6/7/2022 at 1:11 p.m., during an interview and record review of the Sling Check Logbook, the maintenance supervisor (MS) confirmed there was no documented evidence of action taken and disposition of broken, torn, or worn-out slings prior to Resident 1 ' s fall incident. The MS stated, after Resident 1 ' s fall incident on 4/13/2022 the facility started to document actions taken when the laundry staff identified torn or worn-out slings. On 6/7/2022 at 1:33 p.m., during an interview with the administrator (ADM) and review of a photograph taken 4/13/2022 of the sling after it ripped the ADM stated Resident 1 fell because the worn-out sling ripped. The ADM stated the slings were frayed on the edges and the top part was unstitched. ADM stated if a sling was frayed it should not be used because accidents can happen. During an interview with the infection preventionist (IP) on 6/17/2022 at 10:05 a.m., IP stated on 4/13/2022 after Resident 1 fell , she saw the sling that was used to mechanically lift Resident 1. IP confirmed it was a full body sling. IP stated, she attended the safety meeting after Resident 1 ' s fall incident, and confirmed they looked at all the slings in the facility for wear and tear condition. IP stated they disposed of eight slings because either the color was faded, it had frayed edges, small holes (from cigarette ash), or they had stitching that was coming apart. During an interview with the director of staff development (DSD) on 6/17/2022 at 11:41 a.m., DSD confirmed that after the safety meeting to address Resident 1 ' s fall incident, the facility decided to pull eight slings out of service so the staff would not use them. DSD stated, she used some of the worn-out slings they identified from the inventory to demonstrate to staff what the slings should not look like. DSD stated, one had a hole from smoking. DSD stated, the eight slings they removed should not have been available for use in the utility room in the first place. The eight slings identified by the committee should not have been in circulation for use by the staff. During a concurrent observation and interview with Resident 1 on 6/17/2022 at 11:57 p.m., Resident 1 stated the fall incident made her feel very panicky and traumatized especially whenever she was being transferred from the wheelchair to her bed with the mechanical lift. Resident 1 stated every time she is being transferred in a sling by mechanical lift she freaks out and she gets transferred by mechanical lift twice a day. Resident 1 stated she vividly recalls the tearing sound every time she is being transferred. Resident 1 stated, I will never forget the sound of it, and I say a prayer every time I get on the sling. Resident 1 stated, the facility ' s equipment is old and since the fall incident, my back pain and right hip pain got worse. Resident expressed her concern about the quality of the sling because it was supposed to hold 450 pounds and she was 427 pounds, and it still tore. Resident 1 was observed tearing up and wiping her tears with her sheets while narrating her story. On 6/17/22 at 12:11 p.m. during an interview with ADM and concurrent review of the Safety Meeting minutes dated, 4/15/2022, the ADM stated after Resident 1 fell the Safety Committee met to discuss the incident and do a root cause analysis (process for identifying the root cause of the problem) of the cause of Resident 1 ' s fall. The committee inspected the facility lift sling inventory. The slings were checked for rips, holes, wear, and tear. The ADM stated the sling that was used to lift Resident 1 looked worn and faded. The facility also identified eight of 31 slings that had questionable durability and could be potentially problematic. The ADM confirmed the committee identified the root cause of Resident 1 ' s fall as the lack of staff awareness for sling wear and tear. The ADM stated Resident 1's fall was avoidable. During a record review of facility policy titled ' Mechanical Lift Policy ' revised 7/2012, the policy indicated the following: 1.Laundry will check slings daily after wash and air dry with careful observance to any bleached stains, tears, or any signs of fragility to slings. 2. DSD and MS will remove slings immediately if any signs of deterioration or excessive wear and tear are found. 3. CNAs will examine all slings prior to use ensuring there are no tears, for resident ' s safety. During a record review of facility's owner ' s Operations and Maintenance manual (2008) for slings, policy indicated after each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. During a review of facility's user manual titled ' Battery Powered Patient lift, ' dated 2018, the manual indicated a Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. The manual indicated a warning that after each laundering to inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. During a review of the facility ' s policy ' Falls Management ' dated 12/2014, the policy indicated the facility will provide a consistent process for evaluating, managing, and reducing falls to minimize risks and improve quality of life, for residents who are at risk for falls. During a review of the Facility Assessment Tool (a tool the facility uses to evaluate its resident population and identify the resources needed to provide the necessary person-center care and services the residents require) updated 4/1/2022, the tool indicated the facility was committed to have the necessary supplies and equipment to protect and promote the health and safety of the residents, Equipment including bed scales, mechanical lifts and lift slings. According to the Assessment Tool the facility will ensure adequate supply, appropriate maintenance, and replacement of items.

Based on observation, interview, and record review, the facility failed to follow a resident's plan of care and ensure the physician's orders were implemented to notify the physician when a resident's blood sugars (Normal Reference Range [NRR] 70/99 milligrams/deciliters ([mg/dl] units of measurement) was elevated at 448 mg/dl for one of 11 sampled residents (Resident 1). Resident 1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's physician was not informed of Resident 1's Change of Condition (COC) with elevated blood sugars (BS) over 400 mg/dl within 30 minutes after receiving insulin. These failures resulted in Resident 1 having a delay in care and treatment, experiencing a COC of a high blood glucose level requiring a transfer to a general acute care hospital (GACH) on 10/22/2020. This had the potential for the other 10 diabetic residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) not to receive their ordered amount of insulin to manage their blood glucose as indicated in their sliding scale. On 11/20/2020 at 8:26 a.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared under F 684. The facility's administrator (ADM) was notified of the immediacy and seriousness of the residents' health and safety being threatened due to the facility's Licensed Vocational Nurses 1 and 2 (LVNs 1 and 2) not monitoring Resident 1's [CONDITION(S)] (elevated blood sugar) and LVN 3 not documenting blood sugars and insulin administration for Residents 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. On 11/21/2020 at 3 p.m., the facility submitted an acceptable POA for the correction of the IJ that included the following: 1. Resident 1 was readmitted back from the GACH on 10/27/2020 related to the 911 (emergency services) discharge on 10/22/2020 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. LVN 1 and LVN 2 were trained by the Director of Nursing (DON) on the facility's diabetes management/blood glucose/insulin policies and procedures, documentation of results, monitoring and documentation of monitoring, when to notify the physician or alternate physician or Medical Director (MD) when a change in condition is noted, new orders received and when to transfer the patient out via 911. They were also in-serviced on the proper documentation of blood sugars and insulin administration in the resident's health record at the time the blood sugar and/or insulin is administered. 3. On 11/20/2020, Licensed Vocational Nurse 3 (LVN 3) was counseled and given a one on one in-service by the Director of Nursing (DON) on the facility's diabetes management/blood glucose/insulin policies and procedures, documentation of results, monitoring and documentation of monitoring, when to notify the physician or alternate physician or Medical Director (MD) when a change in condition is noted, new orders received and when to transfer the patient out via 911. LVN 3 was also in-serviced on the proper documentation of blood sugars and insulin administration in the resident's health record at the time the blood sugar and/or insulin are administered. 4. LVN 3 was trained and demonstrated competency by the pharmacy nurse consultant on 11/21/2020. 5. On 11/20/20, the RN rechecked the blood sugars for the diabetic residents. 6. Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 blood sugars were rechecked on 11/20/2020. 7. On 11/20/2020 by 8 p.m., the pharmacist nurse consultant shall conduct an in-service education with 3-11 shift licensed nurses regarding blood glucose checks, sliding scale implementation, documentation of results, monitoring and documentation of monitoring, when to notify the physician or alternate physician or Medical Director when a change in condition is noted, new orders received and when to transfer the patient out via 911. On 11/21/2020 by 8:00 a.m., the pharmacist nurse consultant shall conduct an in-service education with the 11-7 and 7-3 shift licensed nurses regarding the above. 8. Any nurse who is on medical leave, extended absence, or who hasn't been scheduled recently, shall not be allowed to return to the nursing floor until receiving the training noted above. 9. The DON/Designee shall do random checks three times/week for the next two weeks, then one time a week for the next 3 months. The physician's orders for blood glucose monitoring and insulin administration shall be compared to the actual Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/21/2020 at 3:20 p.m., the ADM, Director of Nurses (DON), and the Infection Preventionist (IP) were notified the IJ was lifted after an on-site validation of the Plan of Action (POA) via observations, interviews and record review was verified. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's admission Minimum Data Set (MDS), a resident assessment and care screening tool, dated 7/7/2020 indicated Resident 1 was severely impaired in cognitive skills (thought process) for daily decision-making and was unable to be understood and understand others. According to the MDS, Resident 1 was assessed as requiring limited assistance with bed mobility, and was totally dependent with transferring, locomotion on and off the unit, and required a one-person physical assistance with eating and personal hygiene. According to the MDS, Resident 1 received seven days of insulin injections since last admission to the facility. A review of Physician 1's orders indicated for Resident 1 to receive [MEDICATION(S)] KwikPen (insulin replacement that acts longer than regular insulin, providing a low, steady level of insulin) solution Pen-injector 100 units/milliliters ([ml] units of measurement) 25 units subcutaneously (under the skin) every 12 hours and hold medication if blood sugars (BS) are less than 150 milligrams (mg)/deciliters (dl) related to Type 2 diabetes. Also, [MEDICATION(S)] (fast-acting insulin) solutions 100 unit/ml inject as per sliding scale if: 70-150= 0 units, BS less than 70 mg/dl to give [MEDICATION(S)] 150-200= 2 units 201-351= 4 units 251-300= 6 units 301-350= 8 units 351-400= 10 units, BS more than 400 mg/dl give 12 units and call physician A review of Resident 1's care plan titled, At Risk for Recurrent [CONDITION(S)] Related to Diabetes Mellitus, revised on 2/9/2020 with a target date of 1/5/2021, Resident 1 would have less or no episodes of [CONDITION(S)] (elevated blood sugars). The staff's interventions included to monitor signs of [CONDITION(S)] (blood glucose above 400 mg/dl) increase thirst, increased urination, appetite, nausea and vomiting, administered medication, evaluate, record and report effectiveness/adverse, and notify physician if any COC. A review of a Situation, Background, Assessment and Recommendation ([SBAR] an internal communication form), dated 10/22/2020 and timed at 6:33 a.m., written by Registered Nurse 1 (RN 1) indicated a COC for Resident 1, who had an elevated BS of 448 mg/dl on 10/22/2020 at 6 a.m. [MEDICATION(S)] administered as ordered and primary physician called with no success. The SBAR indicated 30 minutes after Resident 1's BS was rechecked it remained elevated at 407 mg/dl. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's progress note, dated 10/22/2020 and timed at 6:19 a.m., written by RN 1 indicated 12 units of [MEDICATION(S)] were given to Resident 1 for a BS of 448 mg/dl as per sliding scale. A review of Resident 1's medical chart indicated there was no documented evidence of Resident 1's blood glucose levels (blood glucose [sugar that the bloodstream carries to all the cells in the body to supply energy]) were being monitored on 10/22/2020 for over four (4) hours from 6:30 a.m., to 11:15 a.m., when Resident 1 was found unresponsive. A review of Resident 1's progress note, dated 10/22/2020 and timed at 1:58 p.m., written by Licensed Vocational Nurse 2 (LVN 2) indicated on 10/22/2020 at approximately 11:10 a.m., Certified Nurse Assistant 1 (CNA 1) reported Resident 1 did not looked well. The Progress note indicated LVNs 1 and 2 observed Resident 1 non-responsive to verbal and tactile (touch) stimuli (something that incites to action or exertion or quickens action, feeling, and thought), and not responsive to sternum rub (application of painful stimuli with the knuckles of closed fist to the center chest of a resident who is not alert and does not respond to verbal stimuli). The progress notes indicated Resident 1's blood pressure was 108/57 (Normal Reference Range [NRR] 110/70- 120-80), heart rate 87 (NRR 60-100 per minute), respirations 19 (NRR 12-20 per minute), oxygen saturation was 98% (NRR 95-100%) at three (3) litters of oxygen via nasal cannula (lightweight tube which on one end splits into two prongs which are placed in the nostrils to deliver supplemental oxygen to a resident in need of respiratory help). The progress note indicated paramedics were called at 11:15 a.m., after receiving an order from Resident 1's primary physician for a 911 transfer to the GACH. A review of Resident 1's physician telephone orders, dated 10/22/2020 and timed at 1:31 p.m., indicated to transfer Resident 1 to a GACH via 911 due to non-responsiveness to verbal, tactile stimuli, and sternum rub, eye pupils non-reactive to light. A review of Resident 1's Paramedic Run Sheet, dated 10/22/2020 indicated the paramedics were called at 11:16 a.m., and arrived at Resident 1 at 11:24 a.m. The paramedic documentation indicated, Resident 1's BS was 437 mg/dl, BP of 105/59, and pulse of 83 bpm. The Paramedics left with Resident 1 at 12:12 p.m. A review of Resident 1's GACHs Emergency Department (ED) note indicated Resident 1 was admitted to the GACH on 10/22/2020 at 12:23 p.m. from the nursing home. The ED note indicated Resident 1 presented from nursing home less responsive and with a fever 99.9 Fahrenheit ([F] NRR 97.9 to 98.6). Resident 1 was administered antibiotics (medicines that fight bacterial infections) and liquids for [CONDITION(S)] treatment and readmitted to the nursing home five days later on 10/27/2020. According to the American Diabetes Association (ADA), high blood sugar happens when the body has too little insulin or when the body cannot use insulin properly. [CONDITION(S)] can be a serious problem if not treat, it is important to treat as soon as detect it. If fail to treat [CONDITION(S)], a condition called ketoacidosis (diabetic coma) could occur. Ketoacidosis develops when the body does not have enough insulin. Without insulin, the body cannot use glucose for fuel, so the body breaks down fats to use for energy. Ketoacidosis is life-threatening and needs immediate treatment. https://www.diabetes.org/diabetes/medication-management/blood-glucose-testing-and-control/[CONDITION(S)] On 10/26/2020 at 5:31 p.m., during an interview, Resident 1's family member 1 (FM 1) stated it was not the first time Resident 1 was found unresponsive because of the neglect of the facility's staff to manage his BS. On 10/23/2020 at 3:52 p.m., during an interview, LVN 1 stated on 10/22/2020 at approximately 7-7:30 a.m. he received a report from RN 1 during shift report of Resident 1's BS being above 400 mg/dl. LVN 1 stated at 9:10 a.m., the same day CNA 1 reported to him Resident 1 was unresponsive. LVN 1 stated upon assessment, Resident 1 was noted not responding to verbal and tactile stimuli and he initiated a sternum rub. LVN 1 stated after the insulin administration by RN 1 at 7:30 a.m., he did not follow-up with an assessment of Resident 1's BS. LVN 1 stated Resident 1 was transferred to the GACH 20 minutes after Resident 1 was found unresponsive [sic]. LVN 1 stated he waited 20 minutes to transfer Resident 1 to the GACH because he was waiting for the primary physician to call back with orders. On 10/23/2020 at 5:30 p.m., during a telephone interview, CNA 1 stated on 10/22/2020 at 9 a.m. she notified LVN 1 Resident 1 was not responding to tactile and verbal stimuli when she was attempting to wake him up. CNA 1 stated not remembering at what time LVN 1 went to the room to check on Resident 1 but remembered Resident 1 was transferred before lunch time. On 10/26/2020 at 11:26 a.m., during a telephone interview, LVN 2 stated on 10/22/2020 at 11 a.m., she and LVN 1 went to check on Resident 1 after receiving a report from CNA 1 Resident 1 was found unresponsive. LVN 2 stated she did not recheck Resident 1's BS after RN 1 reported during the change of shift of Resident 1's elevated BS because she had other residents to care for and the assigned nurse was LVN 1. On 10/29/2020 at 4:57 a.m., during a telephone interview, RN 1 stated on 10/22/2020 of administering Resident 1 12 units of insulin after the blood sugar check indicated a BS of 448mg/dl at 6 a.m. RN 1 stated giving a report to LVNs 1 and 2 regarding Resident 1's blood sugar levels and waiting for Resident 1's physician to return phone call for further instructions. On 11/2/2020 at 2:44 p.m., during an interview, RN 2 stated the policy of the facility was to recheck residents blood sugar levels every 15-30 minutes when elevated. RN 2 stated on 10/22/2020 she did not received report from the night shift RN 1 regarding Resident 1's elevated blood sugar levels. On 11/3/2020 at 10:05 a.m., during an interview, CNA 2 stated on 10/22/2020 at 9 a.m., she assisted CNA 1 with Resident 1 when they both noted the resident was unresponsive. CNA 2 stated LVN 1 was notified immediately but Resident 1 was not transferred to the GACH until 11:30 a.m., [sic] because she was one of the staff that assisted to push Resident 1' bed to the front of the facility before the arrival of the paramedics. On 11/3/2020 at 11:24 a.m., during a concurrent interview and review of Resident 1's MARs, COC and progress notes, RN 2 indicated there was no documentation Resident 1 received the insulin ordered as per sliding scale. RN 2 stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 2 stated LVN 1 documented an assessment of Resident 1 at 8:35 a.m. but there was no documentation the BS was rechecked. RN 2 stated no documentation was found of physician notification for Resident 1's COC at 9 a.m., when found unresponsive. RN 2 stated [CONDITION(S)] was a life-threatening situation requiring 911 transfer and staff do not need to wait for a physician's order. A review of the facility's policy and procedures (P/P) titled, [CONDITION(S)], revised 11/2020 indicated it was the facility's policy to prevent complications to the insulin controlled diabetic residents. The P/P indicated the staff would take vital signs, record, do finger sticks blood sugars and continue to monitor every 30 minutes until further orders from the physicians are received. Continue to monitor resident's for change of [CONDITION(S)] and notify physician. On 11/20/2020 at 6:05 a.m., during a concurrent observation, interview and record review of the MAR, LVN 3 was observed documenting BS on residents MARs and that insulin was given. LVN 3 stated he did not enter in the MARs the BS checks and the administered insulin. LVN 3 was later observed writing random room numbers and BS on a white piece of paper. LVN 3 stated he checked 11 resident's (Residents 1-11) BS but was unable to provide information utilizing a glucometer (medical device for determining the approximate concentration of glucose in the blood) or documentation written for the 11 residents. LVN 3 stated he administered insulin to several residents but did not remembered who because he did not document the information of the BS check and the insulin. LVN 3 stated no documentation was done regarding the BS for the 11 residents. LVN 3 stated he was aware BS are documented upon being checked to ensure residents received the therapeutic dose of insulin per the physician's orders. On 11/20/2020 at 6:35 a.m., during an interview, RN 1 stated BS are documented upon check and insulin is administered as indicated in resident's orders. RN 1 stated not administering the appropriate amount of insulin can be harmful to the resident and life threatening. On 11/21/2020 at 2 p.m., during a concurrent interview and record review of Resident 1's MARs, progress notes, and COC, the DON stated LVNs 1 and 2 were aware of the policy for COC and Resident 1 requiring a transfer to the GACH when BS were elevated in the morning of 10/22/2020. The DON stated no assessment or monitoring found on Resident 1's chart. The DON stated LVN 3 fail to document the BS and insulins of Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. A review of the facility's P/P titled, Change of Condition, revised 7/2012 indicated Licensed Nurses would initiate proper first aid measures until emergency response personnel (911) arrives to the facility. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior would be communicated to the physician with a request for physician visit immediately.

Based on observation, interviews, record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, and develop a system to identify, report, investigate and control unsafe food practices in the dietary department. 1. The facility failed to monitor the cooling of turkey, refried beans, beef broth and custard which were Time and Temperature controlled for safety ((TCS) foods that are capable of supporting bacterial growth that can result in food borne illness unless stored, prepared and served safely) to ensure the foods were safe for consumption for 90 of 92 resident census. On (MONTH) 19, (YEAR) at 2:30 PM the temperature of the turkey was at 105 degrees Fahrenheit (F), refried beans was 125 degrees F, beef broth was at 110 degrees F, and custard was 53 degrees F approximately 15 hours after it was placed in refrigerator. The methods for safe cooling were not being utilized, and cool down logs did not indicate other food items such as refried beans and custard were monitored for cool down to ensure those foods were safe for consumption by the residents. The facility failed to ensure meat and poultry were cooked or reheated to a safe temperature sufficient to kill harmful microorganism (bacteria, virus or fungus too small for the unaided human eye to see). The three cooks, Cook 1, Cook 2, and Cook 3, were not able to accurately verbalize and demonstrate safe final cooking temperatures for poultry before it was served to the residents. This had the potential to put all 90 of total 92 resident census, who received food from the kitchen, at risk for food borne illness. 2. The facility failed to store food in a safe manner to prevent cross contamination and transmission of foodborne pathogens (are substances such as parasites or bacteria in food that cause illness or food poisoning, and in severe cases, death) for 90 of 92 resident census. The packaged and frozen ready to eat cold cuts and raw meats was left to thaw together in the same container. The raw meat had blood dripping over the ready to eat cold cuts. This had the potential to put all 90 of total 92 resident census, who received food from the kitchen, at risk for food borne illness. 3. The facility failed to maintain ice machine in a sanitary manner by not following the proper sanitation practices to prevent the growth of microorganism resembling mold. This had the potential to put all 90 residents who received ice at risk for food borne illness. Due to the deficient practices, an Immediate Jeopardy (IJ) was called on (MONTH) 20, (YEAR) at 11:15 AM. The facility's Administrator, Director of Nursing, Registered Dietitian (RD), and Dietary Services Supervisor were notified of the IJ situation. The facility staff were informed about the lack of an effective cool down method, and monitoring of the potentially hazardous foods. The facility was also informed about lack of knowledge of the cooks about final cooking temperatures and cooling down to safe temperatures for roast beef, turkey and custard. The facility was informed these deficient practices had the potential to put 90 of total 92 resident census at risk for food borne illness when (TCS) foods were not monitored. A plan of action (POA) submitted on (MONTH) 20, (YEAR) at 3:45 pm, indicated replacement of Dietary Supervisor (DSS 1) with an interim DSS 2. RD and DSS 2 were closely supervise the day-to-day operations while training, quizzing and checking dietary staff competencies on proper cooling methods, and final cooking temperatures. RD and DSS 2 were to monitor daily for accuracy of cooling temperatures and procedures until deficient practice had been resolved. RD contract hours was to be reviewed and increased until facility employed a new DSS. The potentially hazardous foods from the refrigerator was discarded. An addendum to POA provided on (MONTH) 24, (YEAR) at 8:50 am, included increased RD consultant hours to more than 35 hours a week, and job postings to hire a qualified DSS, who met the state and federal requirements. The immediate jeopardy was abated (removed) on (MONTH) 24, (YEAR) at 10:34 am, when the facility was able to demonstrate knowledge on proper cooling procedures including correct final cooking temperature of foods. Findings: 1. On 7/19/18, between 2:30 and 2:45 pm, during the tour of the kitchen three pans of (multiple) previously cooked TCS foods were were observed in the walk-in refrigerator. There was cubed turkey meat that was made on 7/18/18, in an approximately 6 inches deep pan covered with foil, a pan labeled beef juice which was made on 7/19/18 registered at 110 degrees F, and refried beans dated 7/19/18 registered at 125 degrees F. The temperature of the turkey taken with surveyors' thermometer registered 105 degrees (F). During an observation of meal preparation for dinner on 7/19/18 at 2:50 PM, Cook 1 was preparing enchiladas using the turkey from the refrigerator. During a concurrent observation and interview, Cook 1 stated the turkey was cooked a day before. Cook 1 stated she pulled the turkey out of the refrigerator the same day at around 1:00 pm, warmed it, cut it into small cubes, and returned it to the refrigerator until it was time for food preparation. Cook 1 stated she took out the pan of turkey approximately around 2:30 PM to begin her preparation of the enchilada. During an interview on the same day at 3:00 pm, Cook 1 stated Cook 3 cooked the same turkey meat, a day before on 7/18/18. Cook 1 stated she cooked the refried beans and the beef juice on the same day on 7/19/18 at 10:00 AM. Cook 1 stated refried beans were to be used for the next 3 days to make bean burritos, one of a substitute menu item. During a concurrent interview and review of the cooling log dated 6/17/18 through 7/18/18 failed to show beef juice and refried beans cooling down temperatures at 2 hours and total of 6 hours intervals. The items on the log were either beef roast, pork or turkey meat. The log did not indicate final cooling down temperatures for turkey placed in the refrigerator on 7/18/18. Cook 1 stated she forgot to record the 4 hour cooling down temperature monitoring for the turkey. Cook 1 did not know what time the turkey was placed in refrigerator on 7/18/18, and did not know what the temperature was when removed on 7/19/18 at 1:30 pm. During the interview, Cook 1 stated she reheated the turkey, but did not know the temperature of the turkey before cutting, and placing it back in to the refrigerator for later use. When asked how to determine when a turkey was safely cooked, Cook 1 stated you insert a fork inside the meat was juices run clear or sometimes the turkey had a pop up timer indicated the meat was cooked. When asked at what temperature a turkey is safely cooked, Cook 1 stated between 150 to 160 degrees F. During a record review and according to the Federal agency under Food and Drug Administration (FDA) Food Code (YEAR) (a guideline for safeguarding public health, ensuring food represents FDA's best advice for a uniform system of provisions that address the safety and protection of food offered in food service), indicated TCS foods shall be cooled within two hours from 135 degrees F to 70 degrees F. The FDA Food Code (YEAR) also indicated within a total of six hours, TCS foods had be cooled from 135 degrees F to 41 degrees F. The FDA Food Code indicated if TCS foods were not cooled accordingly, harmful bacteria could grow to sufficient numbers, causing food borne illness. The FDA Food Code identified the initial two hour cooling of TCS foods was the most critical element of the cooling down process of foods. The FDA Food Code (YEAR) indicated time and temperature control for safety food included an animal food that is raw or heat-treated. The foods prepared in large volumes or in advance for next day service, usually follow an extended process flow. These foods pass through the temperature danger zone more than one time thus the potential for the growth of spore forming or toxigenic bacteria is greater in this process. Due to its considerably higher anticipated microbial load, internal cooking temperature for poultry should read at 165 degrees F within less than 1 second or instantaneously. 2. On 7/19/18 at 3:30 PM, during an observation of the food preparation for dinner and concurrent interview, Cook 2 poured freshly cooked custard into a large deep pan and set it on food preparation area to cool down, then covered it tightly with a plastic wrap and foil. During the same day observation at 3:47 PM, the temperature of the custard (using surveyors' thermometer) registered 170 degrees F. During a concurrent interview with Cook 2 stated the custard was a dessert for tomorrows' (7/20/18) dinner. Cook 2 stated to prepare a custard, the milk had to be added to a powdered custard base before cooking it. Cook 2 stated the custard had to be cool down, before placing it in the refrigerator. Cook 2 did not indicate taking the temperature of the custard, placing it in the refrigerator, and within 2 hours retaking the temperature again to ensure safe cool down method had been utilized. During an observation of the tray line (resident meal tray assembly) service for dinner on 7/19/18 at 5:25 PM, the temperature taken by the Surveyors' thermometer of a refrigerated large deep pan of custard, tightly covered with foil registered at 138 degrees F. During a follow up visit to the kitchen 7/20/18 at 8:16 AM, the temperature of the custard was checked with Surveyors' thermometer and it registered at 53.4 degrees F. The Surveyors' thermometer was recalibrated, and temperature of the custard was rechecked, which registered at 53 degrees F. During an interview with Dietary Services Specialist (DSS 1) on 7/20/18 at 9:10 am DSS 1 stated when you cool down meats it should be cut into small pieces and monitored until it cools down to a certain temperature. DSS 1 stated she did not know the proper cooling down temperatures but The cooks know best. DSS 1 stated once the meat had cooled on the counter, it was then placed in the refrigerator. DSS 1 also stated, I expect that all the cooking, cooling and storage temperatures are good in this kitchen. DSS 1 stated meats and foods containing eggs such as custard, had to be properly monitored to ensure an appropriate safe cool down temperature was achieved. DSS 1 stated fried beans was not be monitored as a TCS food to cool down because there were no meats in it. During a concurrent interview and review of the cooling log, dated 6/17/18 through 7/18/18 did not show custard was one of the items monitored for cool down. DSS 1 stated custard contained eggs and should had been monitored for cool down. A review of the facility's policy and procedures titled Food Storage, indicated, the perishable foods, cold foods will be maintained at temperatures of 40 degrees F or below. 3. During a follow up visit to the kitchen 7/20/18 at 8:30 AM, Cook 3 was cooking roast beef in the oven. During a concurrent interview, Cook 3 stated the beef was to be used for the substitute menu, and was cooking in the oven at 400 degrees F for three and half hours. During an interview with Cook 3 and dietary staff (DS1) as translator on 7/20/18 at 8:40 AM, Cook 3 stated she had prepared the turkey on 7/18/18, for use as turkey enchilada the next day on 7/19/18. Cook 3 stated she started cooking the turkey 7/18/19 at 6:30 AM and finished cooking it at 10:00 AM. Cook 3 stated she knew the turkey had cooked by inserting a fork into the meat and the juices run clear. Cook 3 stated she left it on the counter to cool before placing it inside the refrigerator. Cook 3 stated she could not remember the time but the temperature of the turkey was about 80 degrees F when she placed it in the refrigerator. During a concurrent interview and review of the cooling logs, dated 6/17/2018 through 7/18/18 indicated that at 2 hours the temperature of the turkey was 70 degrees (F) and no further temperatures were recorded. Cook 3 did not remember when turkey was placed in the refrigerator. During a subsequent tour of the kitchen on 7/20/18 at 12:30 PM, the roast beef observed cut into four pieces and placed in the walk-in refrigerator. The temperature of the roast beef piece checked with Surveyors' thermometer, one large piece registered at 124 degrees F and another large piece registered at 120 degrees F. During an interview with Cook 2 on 7/20/18 at 1:40 PM, Cook 2 stated the roast beef did not reach 70 degrees F within the required 2 hour cool down time, was put back in the oven for it to be reheated, and to start the cooling down process again. Cook 2 also stated the custard cooked on 7/19/18 was discarded, but the newly prepared custard made was cooling on ice, while placed on the kitchen counter. During an observation in the kitchen on 7/20/18 at 2:10 pm, the following observations revealed: 7/20/18 at 2:10 p.m., the roast beef was out of the oven. 7/20/18 at 2:40 pm, the roast beef was in the refrigerator. 7/20/18 at 4:20 pm, the temperature of the roast beef checked using Surveyors' thermometer registered at 93.6 degrees F. During a follow up visit in the kitchen on 7/20/18 at 5:07 pm, the roast beef was covered with ice directly on the meat. During a concurrent interview with DSS 1 stated, The roast wasn't getting cooled down so I covered the meat directly with ice to cool it down. I should have place the meat in bags then pour ice around it but I was in a rush. During a concurrent interview with Registered Dietician (RD), stated the roast beef and the newly made custard did not cool down in time, so both foods were discarded. 4. During a tour of the kitchen on 7/19/18 at 2:10 pm, the following observations revealed: a. Multiple types of packaged raw meats and one package of ready to eat deli meat (roast beef) was thawing on the lower shelf in the walk-in refrigerator. b. Two large plastic container full of several logs of ground beef, several trays of chicken pieces, large pieces of what appeared to be beef, pork and turkey were mixed, and piled together. Some of the meats had no label making them hard to identify. Some of the meats were frozen solid, and others were well thawed. There was condensation (occurs when warm, moisture-laden air cools is inside refrigerator coming usually from an outside source) in the refrigerator. The blood was dripping on packages, in the container and on the floor of the refrigerator. During a concurrent observation and interview with DSS 1 stated the meat was shipped yesterday (7/18/18), and it was thawing for use for the next 3 days. DSS 1 stated foods were only labeled when packages was opened. DSS 1 stated cooked deli meat should not be thawing in the same container as the raw meats. DSS 1 acknowledged meat should be separated, and stored by the different types of meat. According to the FDA Food Code (YEAR), raw animal foods separated by type, cooking temperatures such that foods requiring a higher cooking temperature, like chicken, should be stored below or away from foods requiring a lower temperature, like pork and beef. The raw animal foods should be spaced or placed in separate container. A review of the facility's policy and procedures titled Policy for Safe Thawing of Foods indicated meat will be thawed on the bottom shelf of the refrigerator. Cured and precooked meats will be thawed separately from raw meats. Hamburger, chicken and pork will be thawed separately from each other and separately from any other foods. 5. During a tour of the kitchen on 7/19/18 at 3:55 pm, the ice machine in the kitchen was inspected. A clean paper towel swipe of the ice storage bin ceiling and sides produced a significant amount of black substance. The Maintenance staff (MS 1) removed the front, and the insulation panel of the ice machine to reveal the water tubing and internal ice machine system. There was black substances and spots inside tubes and valves. There was significant amount of rust on the internal parts and motors of the ice machine. During a concurrent interview with MS 1 stated the black substance in the tubing and inside the ice bin looked like mold. MS 1 stated ice machine was old and due to condensation, there was a lot of rust build up on the internal systems of the machine. MS 1 stated he cleaned the ice machine once a month, by removing the ice and draining the machine. MS 1 stated he pours the green solution inside the filter of the ice machine, and then lets the machine cycle twice to produce ice. MS 1 stated he used baking soda to scrub, hose the ice bin and drain the water. MS 1 could not remember the name of the solution used to clean the ice machine. During a follow up visit in the kitchen on 7/19/2018 at 5:30 pm, in a concurrent interview with MS 1, produced two bottles of solution and stated he used Lime-A-Way, and Pure Bright Germicidal ultra-bleach 6 percent (%) solution to clean the ice machine. MS 1 stated he measured 16 ounces (Oz) of the Lime-A-Way solution, pours it into the filter system, lets it run and allow the machine to make ice two times. MS 1 stated when ice was discarded, 10 Oz of the bleach was poured in the filter system, and the ice machine was run twice as well. MS 1 stated he finished by cleaning the inside of the ice bin with baking soda, before it was rinsed. According to the FDA Food Code (YEAR), because of the high moisture environment, mold and algae may form on the surface of the ice bins and any tubing or equipment stored in the bins. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. The equipment contacting food that is not time/temperature control for safety food: such as enclosed components of ice makers, shall be cleaned at a frequency specified by manufacturer or if manufacturer specifications are absent then at a frequency necessary to preclude accumulation of mold. A review of the facility provided ice machine manufacturer specification for cleaning of ice machine indicated cleaning procedure was: 16 oz. of Lime-A-Way solution should be diluted with 3 gallons of water and poured into the water tank and start the washing process for 30 minutes, rinse process and drain the water tank. The specification indicated for sanitizing procedure - following cleaning procedure: Dilute 1.5 oz. of 5.25% sodium Hypochlorite solution with 3 gallons of water. Pour the sanitizing solution into the water tank. Place the control switch to wash and begin sanitizing process for 15 minutes followed with rinse process and drain the water tank and clean the storage bin with water.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from rough handling and abuse. Certified Nurse Assistant 1 (CNA 1) held Resident 1's arms down while trying to force her to eat. This deficient practice resulted in injuries to Resident 1's bilateral (both sides) forearms; right forearm skin tear measured 14 centimeters (cm) by (x) 3 cm, and the left forearm measuring 11cm x 3cm. Findings: A review of the facility's Final Investigation Report, dated 9/15/17, indicated the facility reported an allegation of physical abuse that occurred on 9/6/17 to the Department of Public Health (DPH) on 9/11/17. The report indicated that while feeding Resident 1, CNA 1 held Resident 1's hands down to prevent Resident 1 from striking out at CNA 1. According to the report, Resident 1 did not want to eat, but was being forced by CNA 1. A review of the Resident 1's Admission Record (face sheet) indicated resident was admitted 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 10/13/17 indicated a brief interview for mental status (BIMS) score of 4 (0-7 severe impairment), indicated Resident 1 was severely impaired of cognition. The MDS indicated Resident 1 required extensive assistance from one person assistance for eating and all activities of daily living (ADL's), and was dependent on a wheelchair for locomotion. A review of Resident 1's care plan titled, At risk for further ADL's decline, dated 6/11/16, indicated that the goal was for Resident 1 to have no decline in ADL's through 10/13/17. The staff interventions included to encourage participation in performing ADLs within resident's capability including washing face, combing hair, feeding self, and dressing. On 10/5/17 at 2:42 p.m., during an interview, Resident 1's roommate (Resident 2) stated that CNA 1 hit Resident 1 hard on the resident's bad hand. Resident 2 stated that Resident 1 just wheeled herself out of the room bleeding and dripping blood over the floor. Resident 2 stated that CNA 1 walked out of the room when she asked why she had hit Resident 1. Resident 2 stated that Resident 1 was yelling and complaining that it hurt her. A review of the Resident 2's Admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated the resident had a BIMS score of 14 (13-15 cognition intact) and did not have any memory problems. On 10/5/17 at 2:54 p.m., during an observation and a concurrent interview, Resident 1 was noted with bilateral forearms bandages. Resident 1 stated, What happened to my arms was bad, and proceeded to wheel herself away. On 10/5/17 at 4 p.m., during an interview, Licensed Vocational Nurse (LVN 1) stated that on 9/6/17, during lunchtime (approximately 12-12:30 p.m.), CNA 1 called her into Resident 1's room. Upon entering the room, LVN 1 stated that Resident 1 was bleeding from her bilateral forearms. LVN 1 stated that CNA 1 was not able to state why the resident was bleeding. LVN 1 stated there was no documentation in the Nurses Progress Notes regarding Resident 1's injuries. During the review of the Licensed Progress Note, dated 9/6/17, indicated there were no documentation regarding Resident 1's injuries. A review of a Licensed Progress Note, dated 9/11/17, and timed at 11 a.m., indicated that on 9/6/17 at approximately noontime, CNA 1 called LVN 1 into Resident 1's room. The Progress Note indicated that Resident 1 had sustained bilateral forearm skin tears. The Director of Nurses (DON) and Supervisor were notified regarding the left skin tear measuring 11cm x 3cm and the right skin tear measured 14cm by 3cm. A review of the facility undated CNA 1's written declaration indicated, on 9/6/17 at lunchtime, CNA 1 was getting Resident 1 ready to eat when resident hit CNA 1. The declaration indicated that CNA 1 held Residents 1's hands down when resident attempted to hit her a second time. CNA 1 stated she was trying to prevent harm to herself and walked out the room. CNA 1 then returned to the room to attempt to feed Resident 1 when she observed the resident bleeding from her arms. A review of a second undated written declaration by CNA 3, indicated that CNA 3 was told by CNA 1 on 9/9/17 that she held Resident 1's hand down to prevent her from hitting her. On 10/5/17 at 4:22 p.m., during an interview, the Director of Nursing (DON) stated she reported to the administrator (ADM) on 9/6/17 regarding Resident 1's skin tears. The DON stated that physical abuse needed to be reported to DPH within 24 hours of the alleged abuse. The DON stated that during the facility's investigation, CNA 1 stated that she held Resident 1's hands down to protect herself from being hit by the resident. On 10/5/17 at 4:52 p.m., during an interview, the ADM stated that she was made aware of the incident the night of 9/6/17. The ADM stated she failed to report to DPH timely because she thought there was a possibility that the injuries were caused by Resident 1 not wearing her Geri sleeves while in the wheelchair. On 1/10/18 at 9:45 a.m., during a telephone interview, CNA 2 stated that, on 9/6/17 during lunchtime, she was feeding a resident when CNA 1 came to the nurses' station stating that Resident 1 was bleeding from her arms. CNA 2 stated that CNA 1 told her that she was trying to feed Resident 1 because she was refusing, when Resident 1 attempt to hit her. CNA 1 proceeded to hold Resident 1's arms down and accidentally tore the residents' skin from both arms. CNA 2 stated when a resident refused to eat, the staff was supposed to leave the resident and notify the charge nurse or supervisor immediately. A review of the facility's Interdisciplinary ((IDT) group of disciplines that work toward a common goal for a resident) Team Meeting Note, dated 9/13/17, indicated that the facility initiated the investigation on 9/6/17 by asking CNA 1 what had happened. The IDT note did not indicate that the facility's staff interviewed the roommates on 9/6/17 and per Resident 1's family member, Resident 2 witnessed CNA 1 cause the injuries to the resident's arm. A review of the facility's policy and procedure titled, Preventing Resident Abuse, revised 7/2012, indicated to enforce and maintain an abuse free environment for all residents. A review of the facility's policy and procedure titled, Abuse Investigation, revised 12/2014 indicated that all reports of Resident abuse, neglect and injuries of unknown source shall be immediately and thoroughly investigated by the facility and interview the resident's roommates, family members, staff and visitors.

Based on interview and record review, the facility failed to provide two-person assistance with transfers for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling on the floor, while transferred by Certified Nursing Assistant (CNA 1) alone. Resident 1 sustained a subdural hematoma (a collection of blood on the brain due to injury or trauma), lacerations (skin cut) to the left eye, elbow, and forehead which required wound closure; in addition to developing arrhythmias (an irregular heartbeat). Resident 1 was transferred to a general acute care hospital (GACH) diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record indicated the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Fall assessment dated [DATE] and 6/9/17, indicated had a high risk for falls with a score of 11(a computer generated score that determines if a resident is at risk for falls and scores the risk factors as low, medium or high). A review of Resident 1's revised plan of care, dated 3/13/17, and titled, Resident at Risk for Falls related to Impaired Mobility, indicated the staff should keep the resident's bed in a low position. A review of Resident 1's Quarterly Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 6/9/17, indicated the resident's cognition (thought process) was moderately impaired, required extensive assistance with two person physical assist during transferring. The MDS further indicated Resident 1's balance was not steady and was only able to stabilize balance with assistance and used a wheelchair as a mobility device. A review of Resident 1's History and Physical (H &P) dated 7/10/17, indicated Resident 1 did not have the capacity to understand and make decisions. A review of the nurses' note dated 8/21/17 and timed at 3:35 p.m., indicated CNA 1 was standing in front of Resident 1's wheelchair while pulling up the resident by his pants and turning the resident onto the bed. Resident 1's leg locked and CNA 1 fell backwards to the floor and Resident 1 fell on top of CNA 1. Resident 1's head landed on CNA 1's shoulder initially, then the resident's head hit the floor. Resident 1 was observed lying on his left side on the floor next to the bed, bleeding from the forehead, had a skin tear on his left hand and elbow. The resident was turned onto his back and a 4.5 centimeter (cm) laceration was seen on the left forehead. The nurses' note indicated Resident 1's blood pressure was low at 84/55 (normal reference range (NRR) is 120/80) and a heart rate of 112 beats per minute (NRR is less than 100 beats per minute (bpm)). The note indicated 911 was called and the resident was transported to the GACH. A review of the GACHs Trauma Physician's H & P, dated 8/21/17, indicated Resident 1 was brought to the emergency department by the paramedics who fell out of bed onto the floor and sustained head trauma. The Computerized Tomography (CT-detailed pictures of parts of your body and the structures inside your body) of the head showed an acute midline (in the middle) 4 millimeter (mm) subdural hematoma. The Trauma Physician's plan indicated to admit Resident 1 to ICU and to be followed by a neurosurgeon (a doctor who specializes in the nerves, brain, and the spinal cord). A review of the GACH's Neurosurgeon's H & P, dated 8/22/17, indicated Resident 1 required 24 to 48 hour observation in ICU with serial head CT scans. A review of the GACH's Cardiologist H & P, dated 8/25/17, indicated Resident 1 required a nifedipine drip (a slow infusion through the vein of a medication used to treat chest pains and high blood pressure) due to cardiac arrhythmias and hypertension. During an interview on 8/25/17 at 10 p.m., the Director of Nursing (DON) stated Resident 1 required a two-person assist and CNA 1 assisted the resident alone. Resident 1 was transferred to the hospital with a head laceration and according to the resident's family member, Resident 1 was admitted to ICU for [REDACTED]. On 11/16/17 at 11:59 a.m., during a telephone interview, CNA 1 stated that she was not able to discuss details of Resident 1's fall incident per her attorney. During a telephone interview on 11/16/17 at 12:25 p.m., CNA 2 stated on 8/21/17, the day of the incident, she was charting outside of Room 15 when she heard a noise and went into Resident 1's room. CNA 2 stated she observed Resident 1 and CNA on the floor. Resident 1, who was bleeding from his forehead, was on top of CNA 1. CNA 2 stated she and CNA 1 assisted the resident back to bed and then the charge nurse and other staff came to the resident's aid. CNA 2 stated Resident 1 required a two-person assistance, because the left side of the body was contracted and/or paralyzed. CNA 1 was alone in the room when Resident 1 was found on the floor. A review of the facility's policy titled, Accidents/Fall Risk/Injury Assessment and Prevention, dated 7/2012, indicated any resident identified as high risk will have a prevention protocol initiated and documented on the care plan, check and assess the resident's safety awareness since poor judgement, confusion and inability to comprehend could result in a fall.

Based on observation, interviews, and record review, the facility failed to ensure that Resident 1 who had a history of [REDACTED]. 1. Assess and monitor Resident 1's progressive complaints of lack of appetite, abdominal pain, nausea and vomiting, and lack of relief with the interventions provided. 2. Notify the physician and analyze the abnormal blood chemistry test results (Tests that are routinely ordered to determine a person's general health status), in a timely manner. The above failures resulted in Resident 1 calling 911 (Emergency number) without the staff's knowledge on July 14, 2015, at 12:20 a.m., and was transferred to the general acute care hospital (GACH), where Resident 1 was found to have abnormal blood chemistry levels, and a severe low blood count. The resident underwent [REDACTED]. Findings: On July 28, 2015, at 1:30 p.m., an unannounced visit was made to the facility to investigate an allegation that the facility failed to act upon Resident 1's complaints of abdominal pain, vomiting, and lack of appetite for approximately two weeks. A review of the closed record indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS, a standardized resident assessment tool), dated May 6, 2015, indicated Resident 1 was alert and able to make her needs known, and was independent in her activities of daily living (bed mobility, transfer, toileting, personal hygiene and eating). Resident 1 had the following physician's orders [REDACTED].>1. April 24, 2015, [MEDICATION NAME] 75 micrograms (mcg) by mouth (orally), once a day. 2. June 21, 2015, [MEDICATION NAME] tablet 30 mg orally once a day. 3. July 8, 2015, [MEDICATION NAME] tablet was increase to 60 mg orally once a day. A review of the physician's orders [REDACTED]. A review of Resident 1's blood chemistry laboratory test results, dated May 18, 2015, indicated the following: Sodium level (Helps maintain the water and electrolyte balance of the body, and is also important in how nerves and muscles work) was 137 milli-equivalents per milliliter (mEq/ml) (Normal range: 136-145 mEq/ml.) A repeat level was obtained on July 6, 2015 which indicated that the sodium level had dropped to 132 mEq/ml. Calcium level (A mineral that helps to make and keep bones and teeth strong, plays an important part in functioning of muscles and blood vessels, secretes hormones and enzymes, and sends messages through the nervous system) was 7.0 milligrams per deciliter (mg/dL) (Normal range: 8.6-10.3 mg/dL). A repeat level was obtained on July 6, 2015 which indicated that the Calcium level had dropped to 6.4 mg/dL. [MEDICATION NAME] level (is the body's major plasma (The colorless liquid part of blood) protein) measured 2.8 grams per deciliter (gm/dL) (Normal range: 3.5-5.7gm/dL). A repeat result was obtained on July 6, 2015 which indicated that the [MEDICATION NAME] level had dropped to 1.8 gm/dL. [MEDICAL CONDITION] Stimulating Hormone (TSH, a high levels of TSH in the blood stream indicate the [MEDICAL CONDITION] is underperforming, and is a common indication of [MEDICAL CONDITION] (the [MEDICAL CONDITION] does not produce enough of certain important hormones)) was measured at7.27 uIU per milliliter (ml) (Normal range: 0.34-5.60 uIU/ml). A repeat result was obtained on July 6, 2015 which indicated that the, [MEDICAL CONDITION] Stimulating Hormone level had increased to 15.71 uIU/ml T4, Total dL (The main hormone produced by the [MEDICAL CONDITION] that plays a role in several body functions, including growth and metabolism) dated July 6, 2015 indicated 1.8 micrograms per deciliter (mcg/dL) (Normal range: 6.0-12.0 mcg/dL). A review of the physician progress notes [REDACTED]. The May 21, 2015, physician ' s progress note did not indicate /note the results of the May 18, 2015 laboratory results. A review of the physician progress notes [REDACTED]. The progress note indicated to repeat [MEDICAL CONDITION] levels in three weeks, and to reassign the resident's care to the medical director. A review of the Vitals Report document indicated that for the period between July 9, 2015 and July 13, 2015, Resident 1's meal intake percentage indicated the following: July 9, 2015: breakfast 0-25%, lunch 0%, dinner 51-75% July 10, 2015: 51-75% breakfast & lunch, dinner 26-50% July 11, 2015: breakfast & lunch 76-100%, dinner 26-50% July 12, 2015: breakfast and lunch 1-25%, dinner76-100% July 13, 2015: breakfast and lunch 0%, dinner 76-100% A review the Nursing Resident Progress Notes, dated July 12, 2015, at 11:02 a.m., indicated Resident 1 had an episode of vomiting. The resident verbalized to the licensed nurse that she felt nauseous and bloated, and had not had a bowel movement for three days. An assessment by the licensed nurse indicated that bowel sounds were present, and there was no abdominal tenderness. An entry dated July 12, 2015 at 2:13 p.m., indicated the resident had a bowel movement after an enema (An enema is procedure used for clearing the bowel and colon of fecal matter) was administered. The Nursing Resident Progress Notes dated July 13, 2015, indicated the following entry: At 9 a.m., the Nursing Progress Note indicated Resident 1 complained of nausea, refused her breakfast tray, and verbalized that she wanted to be transferred to the hospital due to lack of appetite. The notes further indicated that the physician was notified, and ordered not to transfer the resident, and to monitor for nausea and lack of appetite. At 9:30 a.m., the Nursing Progress Note indicated that Resident 1 had vomited a moderate amount of yellowish-gray fluid. The nurse informed Resident 1 that she would notify the physician, and encouraged the resident to eat. The resident refused to eat. At 12:30 p.m., the Nursing Progress Note indicated the resident refused her lunch tray, and informed the director of nursing (DON) that she was going to call the paramedics. The DON explained to the resident that they were unable to transfer her because they did not have a physician order, and that they would continue to monitor her for lack of appetite and vomiting. The note further indicated that the resident was upset. At 4:06 p.m., the Nursing Progress Note indicated the resident complained of upper abdominal pain, on the pain scale of seven out of 10 (Ten being a worst pain a person can experience), that the resident's vital signs were within normal limits, and had active bowel sounds in all four abdominal quadrants. The notes further indicated that at approximately 4:05 p.m., the physician was updated with the resident's condition with no new orders received, and to continue to monitor. At 11:30 p.m., the Nursing Progress Note indicated that the resident complained of abdominal pain, five out of 10 pain level, and had informed the night shift licensed nurse that she received pain medication at 11 p.m. The Nursing Resident Progress Notes, dated July 14, 2015, at 12:20 a.m., indicated the resident had called 911 (Emergency number) without the staff's knowledge, and that at 12:27 a.m., the resident was transferred by paramedics to the GACH. A review of the GACH emergency department (ED) MD History and Physical (H&P), dated July 14, 2015, at 3:20 a.m., indicated Resident 1's primary [DIAGNOSES REDACTED]. The resident was presented with several weeks of decreased appetite, vomiting, and severe and constant non-radiating pain in the upper epigastric (upper abdomen) area that became worse with eating and moving. The resident reported two episodes of vomiting for that day. The second episode was described as black in color. The current symptoms were severe. The H&P also indicated the resident had been evaluated for this complaint in the past. A physician note, dated July 14, 2015, and timed at 9:30 a.m., indicated a rectal exam that revealed occult positive (presence of blood in stool that cannot be seen). A review of the GACH emergency department (ED) nursing assessment note, dated July 14, 2015, at 3:26 a.m., indicated Resident 1 complained of weakness, lack of appetite, and episodes of vomiting. The resident also complained of abdominal pain of 10, on a one to 10 pain scale. A review of the laboratory results obtained in the Emergency Department (ED) indicated that the resident tested positive for blood in the stool. Resident 1's hemoglobin level (a protein in the blood that carries oxygen from the lungs to the rest of the body) was 6.4 grams per deciliter (gm/dL) (Normal range: 12.0-16.0 gm/dL), and hematocrit level (the percentage of red blood cells in the body was 20.4% (Normal range: 37.0-47.0%). The resident was also diagnosed with [REDACTED]. The resident was transferred to the Intensive Care Unit (ICU), and then to the Operating Room (OR). A review of the Operative Note, dated July 15, 2015, indicated Resident 1 underwent exploratory laparotomy (a surgical operation where the abdomen is opened and the abdominal organs examined for injury or disease) with extensive lysis of adhesions (fibrous bands that form between tissues and organs- the tissues and organs are stuck together, and commonly develop as a result of previous surgeries in the same area). The note indicated there were multiple adhesions throughout the entire bowel, and that the surgery lasted a total of six hours. The record also indicated the resident required a total of eight blood [MEDICAL CONDITION] during her hospital stay. A review of the GACH Discharge Summary, dated August 11, 2015, (29 day stay in the GACH) indicated that postoperatively, Resident 1 [MEDICAL CONDITION] and [MEDICAL CONDITION], (when too little oxygen passes from your lungs to your blood), and required a breathing tube and ventilator (breathing machine). The summary also indicated the resident's discharge [DIAGNOSES REDACTED]. On August 25, 2015, at 10:20 a.m., a telephone interview was conducted with Resident 1, who stated she was still in the hospital. The resident indicated that when she was at the facility prior to being transferred to the hospital, she had been having a problem with her appetite, and was having episodes of vomiting and diarrhea. Resident 1 informed the nurses, who notified the physician, but the physician would only tell the nurses to observe the resident. The resident further stated that after several weeks had passed, she requested to be transferred to the hospital, but the physician refused. When she was transferred to the hospital, her blood count was very low, and she required emergency surgery for [REDACTED]. On July 28, 2015, at 1:45 p.m., during an interview, LVN 1 stated that on July 14, 2015, Resident 1 had complained of lack of appetite, did not eat anything, and had one episode of vomiting. LVN 1 also stated the resident requested to be transferred to the hospital and when she notified the physician, the physician ordered to monitor the resident. LVN 1 denied being aware that the resident had requested to be transferred to the hospital, prior to July 14, 2015. On July 28, 2015, at 2:10 p.m., during an interview with LVN 2, she stated that as far as she was aware, the resident did not have a history of vomiting, and had not complained to LVN 2 that she was nauseated. LVN 2 further stated Resident 1 routinely asked for pain medication for complaints of generalized pain.