Every finding on record at Guardian Rehabilitation Hospital

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 did not violate the resident's rights to be treated with respect and dignity for one of four sampled residents (Resident 1) by failing to ensure:1. CNA 1 did not record a video of Resident 1 without Resident 1 and/or Resident 1 Responsible Party 1's (RP 1) consent in multiple occassions.2. CNA 1 did not post a video of Resident 1 on social media3. CNA 1 did not take videos and use personal cellphone inside the facility and inside residents' room during working hours.These deficient practices violated Resident 1's right to be treated with respect and dignity and the potential to subject Resident 1 and other residents to humiliation (the act of being made to feel ashamed, embarrassed, or worthless, often publicly).Findings:During a review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and heart failure (a condition in which the heart does not pump blood as well as it should).During a review of Resident 1's History and Physical (H&P) dated 3/7/2026, the H&P indicated that, Resident (1) does not have the capacity to understand or make decisions.During a review of the Minimum Data Set (MDS - resident assessment tool) dated 3/14/2026, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 was total dependent 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 1's Care Plan (CP) indicated the following:dated 3/9/2026, the CP indicated that Resident 1 has cognitive loss manifested by short term memory impairment, long term memory impairment and poor recall ability. The CP indicated interventions including providing pleasant interaction that is reassuring when residents are confused.Dated 3/9/2026, the CP indicated that Resident 1 has psychosocial impairment related to psychosis (heart failure (a condition in which the heart does not pump blood as well as it should), infection. The CP indicated interventions including to, staff will always approach resident in a calm and unhurriedly manner and to provide emotional support.During a review of a complaint submitted to District Office, received on 3/3/2026 at 2:50 p.m., a complaint received regarding CNA 1 who posted a video of Resident 1 on social media with two videos attached to the complaint intake.During an interview with Resident 1 on 3/17/2026 at 2:02 p.m., Resident 1 stated, there was an incident where a staff member took a video of himself while he was in the background and it was posted on social media (TikTok). Resident 1 stated, he was told about it just recently and he did not sign consent, and he did not give permission for him to be posted on social media.During an interview with Certified Nursing Assistant 1 (CNA 1) on 3/17/2026 at 2:10 p.m., CNA 1 stated, he had been taking videos and posting on his social media (TikTok) since November 2025. CNA 1 stated, he is aware that he is not allowed to use personal cellphone during work hours and staff are not allowed to take videos or photos inside residents' rooms.During a concurrent record review and follow-up interview with CNA 1 on 3/17/2026 at 2:37 p.m., CNA 1 reviewed his TikTok account with surveyor and stated, his TikTok video was dated 12/13/2025 and another video was posted on 12/15/2025 and both videos were taken inside Resident 1's room and Resident 1 was seen laying on the bed in the background. CNA 1 stated his videos with Resident 1 on the background are still posted on his social media account. CNA 1 further stated, there are also videos on his social media account where he took his videos inside Activity Room/Dining Room, and some were taken in the facility hallways. CNA 1 stated, when he took the videos and posted it online, he did not ask for permission and consent from Resident 1.During a concurrent interview and record review with Director of Staff and Development (DSD) on 3/17/2026 at 2:48 p.m., DSD stated, staff are not allowed to use their personal cellphone during working hours, and staff are not allowed to take photos and videos inside residents' room. DSD stated, if photos or videos of residents are to be taken, they need to ask for permission and a consent needs to be signed. DSD stated, photos and/or videos of residents are to be used for medical purposes only. DSD reviewed CNA 1's TikTok account with surveyor and stated, the videos posted on CNA 1's TikTok account were dated 12/13/2025 and 12/15/2025 where the videos were taken inside Resident 1's room and Resident 1 was seen in the background. DSD stated, there are also videos posted on CNA 1's TikTok account where it was taken inside Activity Room/Dining Room and also in the hallway of the facility.During an interview with Director of Nursing (DON) on 3/17/2026 at 3:26 p.m., DON stated, she was aware of the incident where CNA 1 posted a video on his TikTok account where Resident 1 can be seen on the background while laying on his bed inside Resident 1's room. DON stated staff are not allowed to use personal cellphones during working hours unless it's emergency. DON further stated, staff are also not allowed to take photos and videos of residents without consent. DON stated, it is a type of abuse when staff takes videos and photos of residents without authorization and consent. DON further stated, there are no written consents on file when CNA 1 took videos of Resident 1 inside Resident 1's room and posted it on his TikTok account. During a review of facility's policy and procedure (P&P), titled, Abuse Reporting and Prevention reviewed on 1/26/2026, the P&P indicated that, Facility will monitor areas that have the potential to lead to abusive situations, areas include:. Taking photographs or records of a resident and/or his/her private space without the resident's or resident's responsible party's written consent is a violation of the resident's right to privacy and confidentiality.During a review of the facility's P&P titled, Uses and Disclosures of Protected Health Information: Verbal Agreement, reviewed on 1/26/2026, the P&P indicated that, the facility shall give a resident the opportunity to either verbally agree or object to the use or disclosure of protected health information (PHI) in a facility directory, to a clergyman, or to person(s) involved in the resident's care. Disclose resident's PHI that is directly relevant to the person's involvement with the resident's care, in the exercise of a professional judgment the disclosure is in the best interest of the resident.During a review of the facility's P&P titled, Cellular Phone Policy, reviewed on 1/26/2026, the P&P indicated that, It is the policy of this facility that cellular phone use is not permitted in resident care areas. Direct caregivers shall turn off or place their cellular phones on vibrate upon arrival to the facility.During a review of the facility's Job Description (JD) titled, Certified Nursing Assistant Job Description, reviewed on 1/26/2026, the JD indicated that, General Duties and Responsibilities: Do not disclose resident's protected health information and promptly report suspected or known violations of such disclosure to your supervisor.

Based on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 3/2/2026 by failing to: 1.Ensure 13 residents (unidentified) on pureed diet (foods that do not require chewing and are easily swallowed, all food should be smooth and pureed to the consistency of pudding) received bread texture in form that meet their needs and in accordance with international Dysphagia Diet Initiative (IDDSI- a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed bread was lumpy and liquid seeping out, not smooth and had small pieces of bread crust present requiring chewing before swallowing. 2.Ensure minced and moist texture bread was prepared according to the IDDSI- Level Five minced and moist foods- (all foods prepared for this diet must be soft, moist with all excess fluid drained, and minced to size no larger than 4mm fits through the gaps of fork prongs) when 16 residents (unidentified) received hamburger Bun/bread that was not small (minced) did not fit though the fork prongs and it was dry not moist. 3.Follow the food production recipe for 16 Residents (unidentified) on the soft and bite size diet (food particle are soft and chopped into 1/2 inch pieces) who received minced hamburger mixed with cheese instead of hamburger chopped into 1/2 inch pieces. These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake and increased choking risk for the 13 residents who received the pureed bread.Findings:1.During an observation of the tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch on 3/2/2026 at 11:50AM, the pureed bread looked lumpy, and milk floating on top while in a pan on the steam table. During the same observation and interview with Cook1 (Cook1) on 3/2/2026 at 11:55AM, Cook1 stated the pureed bread was bread mixed with milk and blended a little, it was like bread soaked in milk. During a concurrent interview and taste test of the pureed bread with Dietary Supervisor (DS), Cook1 and Cook2, on 3/2/2026 at 12:45PM, the pureed bread had a lumpy texture. There were small pieces of bread and residue stayed in the mouth requiring chewing. Cook1 stated Cook1 made a mistake and prepared bread soaked in milk instead of pureed bread. Cook2 stated it would need to be blended longer to make a smooth product. [NAME] 1 stated this can affect the swallowing of the bread and result in choking in residents on puree diet. During a concurrent interview on 3/2/2026 at 12:45PM with the Dietary Supervisor (DS), the DS stated the consistency of the pureed bead was not smooth and some bread stays in the mouth. The DS stated they would blend the bread mixture until it was soft and smooth and not sticky. During a review of the facility recipe titled Pureed (IDDSI Level 4)Breads, cakes, cookies, pancakes and other bread products (dated 2025) the recipe indicated, puree bread on low speed adding milk gradually.the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. 2. During an observation in the kitchen on 3/2/2026 at 11:40AM, Cook1 blended the hamburger buns until they were minced into uneven sizes some bread particles larger than others. During a concurrent observation and interview on 3/2/2026 at 11:40AM, cook 1 stated the blended bread is for a minced moist bread. Cook1 stated there is nothing on the bread, no broth, water or any moisture. During an observation of the tray line (tray line- a system of food preparation, in which trays move along an assembly line) service for lunch on 3/2/2026 at 11:50AM, the minced and moist bread looked dry, not cohesive and crumbly, there were some larger pieces of bread. While serving the minced and moist bread observed the crumbly bread fell from the scoop spread out and was all over the plate. During a concurrent interview and taste test of the pureed bread with Dietary Supervisor (DS), Cook1 and Cook2, on 3/2/2026 at 12:45PM, Cook1 stated the bread was minced in the food processor and no moisture was added to it. Cook1 tested the texture of the bread using a fork and stated it was not moist and fell apart on the plate. [NAME] 1 stated some bread pieces were large and did not fit the gaps of the fork prongs per minced and moist size chart. Cook1 stated should have added moisture to the minced bread to make the bread moist and not crumbly. The DS stated not following the menu could cause not preparing the correct texture and potential for some residents to have difficulty swallowing and not liking the food. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 5 Minced and Moist is usually eaten with spoon or fork, for people who cannot bite off pieces of food safely but have some basic chewing ability. It is important that food is not sticky. You should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork. Size of the food is 4mm, which is about the gap between the prongs of a standard dinner fork. Food testing method: Spoon tilt test and Fork drip test. 3. During an observation in the kitchen on 3/2/2026 at 11:50AM, Cook1 served minced hamburger meat mixed with melted cheese over a crumbly bread to residents who were on soft and bite size diet (food particle are soft and chopped into 1/2 inch pieces). During a concurrent observation and interview with Cook1 and Cook2 on 3/2/2026 at 12:45PM Cook1 stated [NAME] 1 did not follow the recipe to prepare the soft and bite size hamburger. Cook1 stated instead of serving hamburger cut into 1/2 inch size [NAME] 1 stated [NAME] 1 made a minced hamburger meat and mixed with cheese to make a minced and moist and served over the minced bread. Cook2 stated some residents may not like minced and not eat the food. During an interview with the DS on 3/2/2026 at 12:45PM, the DS stated cooks (in general) should always follow the menu and recipe to make sure correct texture and recipe were served. The DS stated not following the menu could make some residents not happy with the food and decrease intake. During a review of the facility's recipe titled Bacon Cheeseburger on a bun (dated 2026) the recipe indicated, Soft and Bite size IDDSI level 6: Tender meat, chop into pieces =1.5 cm by 1.5 cm in size serve with minced and moist bun, shaped/molded into a circle, meat on top, top with minced an moist bun. During a review of facility policy and procedures (p & p) titled, Menu Planning (dated 2023), the p & p indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines.Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. During a review of the facility's cook's job description (dated 2019), the job description indicated, General duties and responsibilities: Review menus prior to preparation of food, prepare meals in accordance with planned menus, and prepare food for therapeutic diets in accordance with planned menus.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1.The dishware was not sanitized with adequate amount of sanitizer. Sanitizers and disinfectants were used on food contact surfaces such as dishes to prevent food borne illness (food poisoning). 2. The kitchen towel used to wipe food contact surfaces was not stored in the sanitizer solution bucket. 3. One medium container of sliced ham with use by date 2/25/2026 and one medium container of previously prepared tuna salad with use by date of 2/26/26 exceeding storage period for deli meat and tuna salad were stored in the walk-in refrigerator. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 75 out of 79 residents (unidentified) who received food from the facility.Findings:During an observation in the dishwashing area on 3/2/2026 at 9:30AM, Dishwasher (DW1) was rinsing the dirty dishes and loading them inside the dish machine and Dietary Aide (DA1) was removing the washed dishes and storing them on shelves. During the same observation and interview with DW and DA1 on 3/2/2026 at 9:30AM, the DW stated chlorine sanitizer was used to sanitize the dishes. DA1 was asked to demonstrate dish machine operation and sanitizer effectiveness. DA1 immersed the test strip on the dish surface and compared it to a color chart on the test strip bottle that showed sanitizer was not in range. The recommended concentration level for chlorine sanitizer is between 50-100 parts per million (PPM). The test strip compared to color chart indicated 0 no sanitizer. During the same observation and interview on 3/2/2026 at 9:30AM with DS and DA1, DA1 stated the machine was working the morning of 3/20/2026 and the sanitizer test was effective. During a concurrent review of the dishwashing sanitizer log record dated 3/2/2026, indicated the sanitizer was in normal range at 50 PPM.During a concurrent interview on 3/2/2026 at 9:30AM with the Dietary Supervisor (DS), the DS started the dishwasher and retested the sanitizer solution three times. The DS stated and verified that the sanitizer was 0 PPM and was not effective in sanitizing the dishes. The DS instructed the kitchen staff (unidentified) to remove all washed dishes from storage and contacted the repair company. The DS stated facility would use disposable plates and utensils. The DS stated dishes have not been sanitized and could result in cross contamination of dishes and make residents sick. During a review of facility Dish Machine Temperature Log dated March 2026, the log indicated Chlorine should be 50-100 PPM, Alert dietary supervisor if temperature and /or chlorine are not correct level. 2. During an observation in the kitchen on 3/2/2026 at 10:45 AM, [NAME] (Cook 1) used a kitchen towel stored on top of the counter to wipe food preparation counters. Then after finishing wiping the counter, [NAME] 1 left the towel on the counter. During a concurrent observation and interview with cook1 on 3/2/2026 at 10:50AM, Cook1 stated the kitchen towel should be stored in a sanitizer solution when not in use. Cook1 stated the kitchen towel was disposable and was going to discard it but forgot and left it on the counter. [NAME] 1 stated the towel did not have sanitizer on it. Cook1 stated it was important to clean the counters with kitchen cloth and sanitizer because it sanitized counters so there is no contamination.During a review of the 2022 U.S. Food and Drug Administration Food Code, Code 3-304.14 Wiping Cloths, use Limitation, indicated, (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be:(1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; 3.During an observation in the kitchen on 3/2/2026 at 11AM there was one medium container of sliced ham with a date of 2/25/2026 and one container of previously prepared tuna salad with date 2/26/2026 stored in the walk-in refrigerator. During a concurrent observation and interview on 3/2/2026 at 11AM with [NAME] 1 and the DS, Cook1 stated the date on the label was when the tuna salad was prepared. Cook1 stated the ham was thawed in the refrigerator and then the package was opened and dated. Cook1 stated the kitchen staff (in general) would keep the tuna salad and ham for three days. Cook1 stated if the tuna salad stayed too long then it could go bad and make the residents sick. The DS removed the ham and the tuna salad and stated the tuna salad and ham were expired and would discard.During a review of facility policy and procedures (P&P) titled, labeling and Dating of Foods (dated 2023) the P&P indicated, newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines. During a review of facility P&P titled, Procedure for Refrigerated Storage (dated 2023) the P&P indicated, All refrigerated foods are to be kept the amount of time per the Refrigerated Storage Guidelines . During a review of the facility Refrigerated Storage Guide, the maximum refrigeration time for tuna salad is 3 days; and the maximum refrigeration time once meat has thawed for luncheon meats, ham, bacon, and frankfurters is 5 days. During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.17 titled Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking indicated, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 4) was free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) by failing to: -Ensure nursing staff (in general) released Resident 4's lap tray (is considered a physical restraint in a nursing home when it is attached to a wheelchair or chair in a manner that restricts a resident's freedom of movement, prevents them from rising, and cannot be easily removed by the resident) every two hours and reposition as indicated in Resident 4's Physical Restraint Care Plan and the facility's Physical Restraint policy and procedure (P&P). This failure restricted Resident 4's freedom of movement (the right of a person to change their position, stand up, walk around, or move their limbs as they wish). This failure also had the potential for Resident 4 to experience a decline in physical functioning, psychosocial harm (damage to a person's mental health, emotions, or social well-being), impaired circulation, and physical harm from entrapment (occurs when a person using a wheelchair becomes caught, wedged, or tangled in a restraint).Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4 on 1/9/2022 and readmitted Resident 4 on 10/27/2025 with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of falling, dementia (a progressive state of decline in mental abilities), and adult failure to thrive (poor appetite, weight loss, fatigue, and overall progressive decline in a person's ability to carry out everyday activities). During a review of Resident 4's History and Physical (H&P) dated 10/28/2025, the H&P indicated Resident 4 could make some needs known but could not make medical decisions. During a review of Resident 4's informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) titled Proposed Treatment Physical Restraint: Lap Tray, dated 12/12/2025, the informed consent indicated Resident 5's responsible party, Family Member 1 (FAM 1) signed the consent for restraints. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 12/15/2025, the MDS indicated Resident 4 could sometimes make herself understood and rarely had the ability to understand others. The MDS indicated Resident 4's vision was impaired (sees large print but not regular print in newspapers/books). The MDS indicated Resident 4 had restraints that prevented Resident 4 from rising from a chair. During a review of Resident 4's Physical Restraint Care Plan dated 12/22/2025, the Care Plan indicated Resident 4 needed a physical restraint: lap tray to maintain proper body posture while in wheelchair and the nursing interventions were to release the lap tray at least every two hours and to reposition Resident 4. During a review of Resident 4's Restraint Review dated 12/22/2025, the Restraint Review indicated the facility started the use of a lap tray on 12/12/2025 for Resident 4 while Resident 4 was up in a wheelchair. During a review of Resident 4's Order Summary Report dated 2/28/2026, the Order Summary Report indicated a physician order to apply a lap tray while on wheelchair for proper trunk (chest area) control. During an observation on 3/2/2026 at 10:05 AM, Resident 4 was observed in the activity room sitting on her (Resident 4) wheelchair with a lap tray. During a concurrent interview and record review on 3/2/2026 at 9:27 AM with Registered Nurse 3 (RN 3), Resident 4's MDS dated [DATE] was reviewed. RN3 stated the MDS indicated Resident 4 had a chair restraint that prevented Resident 4 from rising. RN 3 stated she could not explain why Resident 4's MDS indicated Resident 4 had a restraint. During an interview on 3/4/2026 at 9:52 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the facility placed a lap tray on Resident 4 only when she (Resident 4) was on a wheelchair for trunk support and to prevent her (Resident 4) from falling out of the wheelchair. During an interview on 3/4/2026 at 9:55 AM with LVN 2 and LVN 5, LVN 2 stated the facility staff (unidentified) needed to remove Resident 4's restraints for 15 minutes every two hours. LVN 2 and LVN 5 could not provide an answer if the facility released Resident 4's restraints for 15 minutes every two hours. During an observation on 3/4/2025 at 10:35 AM, a demonstration of the lap tray application to a wheelchair was observed. The lap tray was observed to be strapped to both wheelchair's arms and had a strap that locked into place behind the back rest of the wheelchair. The lap tray was observed to be restrictive and could not be removed when the straps were applied. During a concurrent interview and record review on 3/4/2026 at 10:43 AM with the Director of Nursing (DON), the facility's P&P titled, Lap Trays, dated 1/26/2026 was reviewed. The DON stated the P&P indicated the lap tray was to provide a safe and alternative to more restrictive physical restraints. The DON stated the P&P indicated the lap tray would assist in preventing residents (in general) from standing and falling while in a wheelchair. The DON was asked if the lap tray would restrict a resident's (in general) freedom of movement and if the lap could be considered a restraint, the DON answered yes. During a concurrent interview and record review on 3/4/2026 at 10:43 AM with the Director of Nursing (DON), the facility's P&P titled, Physical Restraints, dated 1/26/2026 was reviewed. The DON stated the P&P indicated if restraints were utilized, the opportunity for motion and exercise should be provided for a period of not less than ten (10) minutes during each two (2) hour period in which the restraints were utilized. The DON stated the facility did not have any documentation regarding restraint monitoring for and removal of restraints (in general). The DON stated the facility should have documented if the facility released Resident 4's restraints per the facility's policy. During a concurrent interview and record review on 3/4/2026 at 11:28 AM, with the DON and the facility's Administrator (ADM), Resident 4's Restraint Assessment, dated 12/12/2025 was reviewed. The Restraint Assessment indicated Resident 4 was confused, disoriented, had poor safety awareness, had poor trunk control when up in wheelchair, and had episodes of slouching and leaning forward. The Restrain Assessment indicated that an interdisciplinary team (IDT - a group of experts from different fields like doctors, nurses, and social workers who work closely together, sharing information to create a single, coordinated plan for a resident) recommended that Resident 4 would benefit from the use of a lap tray while on a wheelchair. The DON and ADM stated the lap tray was a restraint because it (lap tray) prevented Resident 4's freedom of movement.

Based on interview and record review, the facility failed to provide care in accordance with professional standards for one of one sampled resident (Resident 33) by failing to rotate (a method to ensure repeated injections are not administered in the same area) the injection sites for subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration. This failure had the potential for Resident 33 to experience complications such as hardening of the skin, pain, redness, itching, swelling, and inflammation at the skin injection sites.Findings:During a review of Resident 33's admission Record, the admission Record indicated the facility originally admitted Resident 33 on 10/6/2023 and readmitted Resident 4 on 6/7/2024 with diagnoses that included type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), adult failure to thrive (a syndrome is characterized by unexplained weight loss, malnutrition and disability), and peritoneal adhesions (bands of scar tissue that form between abdominal tissues and organs). During a review of Resident 33's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2025, the MDS indicated Resident 33 rarely/never could make herself (Resident 4) understood and rarely/never had the ability to understand others. During a review of Resident 33's History and Physical (H&P), dated 2/20/2026, the HP indicated Resident 33 did not have the capacity (ability) to understand and make decisions. During a review of Resident 33's Order Summary Report dated 2/28/2026, the Order Summary Report indicated a physician order for Insulin Glargine (a long-acting insulin injected once daily to manage blood sugar for 24 hours) subcutaneous with instructions to rotate injection sites. During a concurrent interview and record review on 3/4/2026 at 2:47 PM with Licensed Vocational Nurse 6 (LVN 6) and Registered Nurse 3 (RN 3), Resident 33's Location of Administration Report for Insulin Glargine dated 3/3/2026 was reviewed. The Location of Administration Report indicated the facility licensed nurses (unidentified) did not rotate insulin injection sites on the following dates, times, and skin locations:-2/1/26 at 9:18 PM subcutaneously Abdomen - RLQ (right lower quadrant - the bottom-right quarter of your abdomen, spanning from your belly button down to the right hip bone).-2/2/26 at 9:23 PM subcutaneously Abdomen - RLQ-2/22/26 at 10:17 PM subcutaneously Abdomen - RLQ-2/23/26 9:47 PM subcutaneously Abdomen - RLQ During a concurrent interview on 3/4/2026 at 2:47 PM with LVN 6 and with RN3, LVN6 stated Resident 4's insulin injection sites were not rotated. RN 3 stated the licensed nursing staff (unidentified) should rotate the insulin injection sites to prevent hardening of the skin. RN 3 stated licensed nursing staff (in general) who administered insulin should be able to see in the electronic medical record where the previous insulin injection was given for staff (licensed nursing staff) to be able to rotate the injection sites. During a concurrent interview and record review on 3/4/2026 at 2:53 PM with the Director of Nursing (DON), Resident 33's Location of Administration Report for Insulin Glargine dated 3/3/2026 was reviewed. The Location of Administration indicated the facility's licensed nurses (unidentified) did not rotate insulin injection sites on the following dates, times and locations:-2/1/26 at 9:18 PM subcutaneously Abdomen - RLQ-2/2/26 at 9:23 PM subcutaneously Abdomen - RLQ-2/22/26 at 10:17 PM subcutaneously Abdomen - RLQ-2/23/26 9:47 PM subcutaneously Abdomen - RLQDuring a concurrent interview on 3/4/2026 at 2:53 PM with the DON, the DON stated the facility's licensed nurses (unidentified) should have rotated the insulin injection sites to prevent skin hardening at the injection sites. During a concurrent interview and record review on 3/4/2026 at 2:55 PM with the DON, the facility's policy and procedure (P&P) titled, Insulin Administration, dated 1/26/2026 was reviewed. The DON stated the P&P indicated Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). The DON stated the facility licensed nursing staff should have rotated insulin injection sites according to the facility's policy.

Based on observation, interview, and record review the facility failed to provide proper care and treatment to help improve the communication abilities for one of one sampled resident (Resident 75) by failing to: -Ensure to provide Resident 75 with a communication board (is a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) and with interpreter services. This failure had the potential for Resident 75 not to be able to communicate her (Resident 75) needs with the facility's staff (in general) and had the potential to delay care/treatment. Findings:During a review of Resident 75's admission Record, the admission Record indicated the facility admitted the resident on 3/8/2024 with diagnoses that included primary open angle glaucoma (a chronic eye disease where fluid buildup slowly increases pressure, damaging the nerve connecting the eye to the brain causing gradual permanent side-vision loss), left eye, indeterminate (cannot accurately classify how severe the damage is) stage, unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance (acting out, agitated, aggressive or mood/personality changes). During a review of Resident 75's History and Physical (H&P) dated 3/9/2025, the H&P indicated Resident 75 did not have the capacity (ability) to understand and make decisions. During a review of Resident 75's Resident Care Plan titled Communication Deficit dated 5/20/2025, the Resident Care Plan indicated Resident 75 had a communication deficit and had difficulty making needs known. The Resident Care Plan indicated Resident 75 had difficulty understanding others and had a language barrier. The Resident Care Plan indicated the goals for Resident 75 included having activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) needs met every shift and would communicate with others daily. The Resident Care Plan indicated an intervention that staff would anticipate Resident 75's needs and use a communication device. The Resident Care Plan indicated an intervention which included translation by the same language speaking staff and family. During a review of Resident 75's Minimum Data Set (MDS, a resident assessment tool) dated 2/7/2026, the MDS indicated Resident 75 needed an interpreter to communicate with a doctor and health care staff. The MDS indicated Resident 75 had severe cognitive (ability to think, understand, and reason) impairment. The MDS indicated Resident 75 required partial/moderate assistance (helper does less than half the effort) for toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear. During a concurrent observation and interview on 3/2/2026 at 12:09 PM with Resident 75 in Resident 75's room, Resident 75 stated, My English not good enough to understand, sorry. Resident 75 began to speak in another language (not English). There was no communication device, translator availability information, and communication board observed in Resident 75's room. The weekly menu and activity calendar posted in Resident 75's room was observed in English. During a concurrent observation and interview on 3/2/2026 at 12:16 PM with Resident 75 and Certified Nurse Assistant 1 (CNA1), in Resident 75's room, CNA 1 stated Resident 75 spoke a different language and could not respond in English. CNA 1 stated he (CNA1) would speak to Resident 75 in English, but Resident 75 would respond in another language. CNA 1 stated sometimes Resident 75 did not understand and CNA 1 would demonstrate using signals. CNA 1 stated Resident 75's family member (unidentified) would speak the same language and when Resident 75's family member (unidentified) visited, the facility would use Resident 75's family member (unidentified) as a translator, otherwise the facility would not know what Resident 75 would need. During a concurrent observation and interview on 3/2/2026 at 12:46 PM in Resident 75's room with Registered Nurse1 (RN1), RN 1 stated the facility did not have a method of contacting a translator for a resident (in general) who did not speak English. RN 1 stated the staff (in general) would use nonverbal cues to communicate with Resident 75. RN 1 stated if something was wrong with Resident 75, the staff would not be able to understand Resident 75, and the resident may not have been able to understand the staff without a translator. RN 1 stated she (RN1) would use her (RN1) phone and would use google translate (an artificial intelligence tool that acts as a digital interpreter) to understand what Resident 75 tried to communicate (in general). RN1 stated she (RN1) should not be using her (RN1) own phone. RN 1 stated Resident 75 spoke a different language and there were no signs posted in Resident 75's language inside Resident 75's room. RN 1 stated a Resident 75 would feel more comfortable to express her (Resident 1) needs in her (Resident 75) own language. During a concurrent observation and interview on 3/2/2026 at 1:02 PM in Resident 75's room with the Director of Nursing (DON), the DON stated the facility did not have a formal translation system and should have one in place. The DON stated if a resident (in general) needed anything, the facility's staff (in general) would not be able to communicate. The DON stated anything complex such as a nursing assessment (step of care that checks a resident's physical and emotional health to identify needs) and no formal translation system, the staff would not be able to communicate with Resident 75 because she (Resident 75) would not understand. The DON stated the facility would call the family but if the family did not pick up the phone or if it was in the middle of the night the facility needed to have a formal translating system in place. The DON stated the facility should not rely on Resident 75's family. The DON stated Resident 75's message board with menus and activities posted were all in English. The DON stated Resident 75 would not be able to understand what activities or menu were in place. During a review of the facility's policy and procedure (P&P) titled Translation or Interpretation Services, dated 1/26/2026, the P&P indicated The facility provides assistance to residents with limited English proficiency.through translation and interpretation services. The P&P indicated When encountering Limited English Proficiency (LEP) individuals, staff members will conduct an initial language assessment and notify the Social Services Department of the resident's need for translation or interpreter services. The P&P indicated The facility provides competent oral translation of vital information that is not available in written translation, and non-vital information in a timely manner and at no cost to the resident through one or more of the following means;.contracted interpreter services, voluntary community interpreters who are trained and competent in the skill of interpreting, telephone interpretation service. The P&P indicated Providing meaningful access to services provided by the facility requires that the limited English proficient resident's needs and questions are accurately communicated to the facility staff. During a review of the facility's policy and procedure (P&P) titled Residents Who Present with Communication Barriers, dated 1/26/2026, the P&P indicated It is the policy of this facility to meet the needs of residents who present with communication barriers. Ref. S483.lO(a) Resident Rights. S483.l0(c)(l), (4), (5) rights to be informed. The P&P indicated Communication supports psychosocial well-being by enabling residents to participate in their care and interact with others. The P&P indicated Communication boards will be provided at no charge to the resident so that non-English speakers. can use pictograms to communicate needs and desires. During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 1/26/2026, the P&P indicated To reside and receive services with reasonable accommodation of resident needs and preferences.

Based on observation, interview, and record review, the facility failed to set the appropriate setting for a Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of four sampled residents (Resident 8) reviewed for pressure ulcers/injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) This failure had the potential to cause harm to Resident 8 by increasing the risk of skin breakdown and development of pressure ulcers/injuries.Findings:During a review of Resident 8's admission Record, the admission Record indicated the facility initially admitted the resident on 10/20/2025, with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities),unspecified protein-calorie malnutrition (a state of nutritional deficiency where inadequate intake of protein and calories leads to body composition changes), diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Order Summary Report dated 10/20/2025, the Order Summary Report indicated Resident 8 was incapable of participating in her treatment plan. During a review of Resident 8's Physician Progress Note dated 10/21/2025, the Physician Progress Note indicated Resident 8 was on hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 1/26/2026, the MDS indicated the resident had severe cognitive impairment (impaired ability to think, understand, and reason) for daily decision making. The MDS indicated Resident 8 was dependent on the staff (helper does all of the effort) for sitting to stand, chair/bed to chair transfer, and tub/shower transfer. The MDS indicated Resident 8 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 8 utilized a pressure reducing device for bed.During a review of Resident 8's Weights and Vitals Summary, the Weights and Vitals Summary indicated the resident weighed 104 pounds (lbs., a unit of weight) on 2/4/2026. During a review of Resident 8's Order Summary Report dated 2/24/2026, the Order Summary Report indicated may apply LALM for skin integrity without any documented specific parameters for settings. During a review of Resident 8's Risk for Skin Breakdown/Pressure Ulcer Care Plan dated 2/25/2026, the Risk for Skin Breakdown/Pressure Ulcer Care Plan indicated Resident 8 was at risk for the development of pressure ulcers related to fragile skin. The Risk for Skin Breakdown/Pressure Ulcer Care Plan indicated the intervention was a LAM. During a concurrent observation, interview, and record review on 3/2/2026 at 3:38 PM, with Licensed Vocational Nurse4 (LVN 4), in Resident 8's room, Resident 8 was observed on a Drive LALM with settings set between 0 and 80 lbs. LVN 4 stated Resident 8's LALM settings were set at 0 to 80 lbs. LVN 4 stated the LALM settings were based on a resident's weight (in general). LVN 4 verified Resident 8's weight in the medical record and stated Resident 8's weight was currently 104 lbs. LVN4 stated the resident could have developed redness, skin problems and a pressure ulcer because the mattress was at the wrong setting. During a concurrent observation and interview on 3/2/2026 at 3:45 PM, with Registered Nurse 1 (RN 1) in Resident 8's room, RN 1 stated Resident 8's LALM was set between 0-80lbs. RN 1 stated an incorrect setting would have defeated the purpose of the LALM and Resident 8 could have developed problems with skin integrity. RN 1 stated a wrong setting would not have managed what the LALM was supposed to do. During a concurrent observation and interview on 3/2/2026 at 3:49 PM, with the Director of Nursing (DON), in Resident 8's room, the DON stated LALMs were set according to the residents' weight and stated Resident 8's LALM was set between 0-80lbs. The DON stated Resident 8's LALM was not at the correct setting, and if the LALM was not at the correct pressure the resident could have developed a pressure ulcer if the LALM was too soft.During a review of the facility's policy and procedure (P&P) titled, Low Air Loss Mattress dated 1/26/2026, the P&P indicated It is the policy of the facility to provide for the proper placement and management of a low air loss mattress when utilized by a resident. During a review of the user manual titled Med-Aire Assure 8 Alternating Pressure Mattress Replacement System with Low Air Loss undated, the user manual indicated This manual should be used for the initial set up of the system and for future reference. The user manual indicated Support surfaces or specialized mattress systems are used as part of an overall, multi-disciplinary, multi-dimensional care plan intended to prevent and treat pressure injuries. The user manual indicated This analog control unit includes an easy-to-use pressure dial that is adjustable to the patient's weight and comfort.

Based on observation, interview, and record review, the facility failed to ensure to administer one of six medications correctly to one of three sampled residents (Resident 79) as prescribed in the morning of 3/3/2026. This failure had the potential of medication errors that might cause adverse reactions (a harmful, unintended result caused by taking medication).Findings:During an observation on 3/3/2026 at 9:26 AM, the Licensed Vocational Nurse 2(LVN 2) prepared six medications for Resident 79. One of those six medications was one tablet of cetirizine (generic for Zyrtec, an antihistamine used to relieve symptoms of allergies) 10 milligrams (mg, unit to measure mass), administered orally (by mouth).During a review of Resident 79's medication orders, the order, dated 2/7/2026 at 6:52 PM, indicated to give cetirizine 5 mg one tablet by mouth two times a day for allergy.During an interview and an observation on 3/3/2026 at 12:52 PM with LVN 2 at the medication cart 1, the surveyor asked to see the cetirizine bottle for Resident 79. LVN 2 pulled out a bottle of cetirizine 10 mg and stated that it was the bottle. When asked to see Resident 79's medication order, LVN 2 reviewed the electronic health record system and stated Resident 79's medication order indicated cetirizine 5 mg. LVN 2 stated she (LVN2) made a mistake, and the medication error reporting process included to alert the supervisor and the resident's (Resident 79) physician.During an interview on 3/3/2026 at 3:55 PM, the Director of Nursing (DON) stated the adverse reactions for cetirizine included dizziness and the facility would be monitoring the resident (Resident 79). During a review of the facility's policy and procedures (P&P) dated October 2017, the P&P indicated Medications are administered as prescribed. Prior to administration, . the physician's orders are checked for the correct dosage schedule.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled kitchen staff (Dietary Aide 2 [DA2]) was routinely trained and evaluated for competency related to their kitchen duties when: -DA2 did not know the proper sanitizer test strip to use for the manual dishwashing sanitizer solution. On 3/2/2026 at 10AM, DA2 tested the sanitizer solution using the wrong test strip and procedure. These deficient practices had the potential to result in unsafe and unsanitary food production that could place 75 out of 79 residents in the facility who received food at risk for food borne illness (food poising). Findings: During an observation in the kitchen on 3/2/2026, at 10AM Dietary Aide (DA2) was sanitizing dishes in the sanitizer solution made with QUAT sanitizer (quaternary ammonium-QUAT, a type of sanitizing solution used to sanitize food contact surfaces). During a concurrent observation and interview on 3/2/2026, at 10AM with DA2, DA2 was asked to check the sanitizer solution concentration. DA2 attempted to use the dish machine sanitizer (chlorine sanitizer) test strip to test the sanitizer concentration for the manual dish washing sanitizer solution. DA2 stated the test strip was not working, he (DA2) said the normal range is 100 PPM and color change should be blue. During the same observation and interview on 3/2/2026 at 10AM, the Dishwasher staff (DW) gave the correct sanitizer test strip to DA2. DA2 immersed the test strip in the sanitizer solution and counted for 20 seconds to read the results. DA2 then stated the dishes must be submerged in the sanitizer solution for five to ten minutes before the dishes were removed to air dry. During an interview on 3/2/2026 at 10:30AM with the Dietary Supervisor (DS), the DS stated DA2 was using the wrong test strip to test the sanitizer solution concentration. The DS stated staff (kitchen staff in general) needed to know how to check solutions. The DS stated if the kitchen staff (in general) did not check the sanitizer correctly, the dishes could potentially be contaminated and not sanitized. During an interview on 3/2/2026 at 10:55AM with the DS, the DS stated that he (DS) had provided in-services to staff (unidentified) on sanitizer solutions and how to check for concentration. The DS stated he (DS) did not know if the annual competency review included the sanitizer solution testing. During a review of Dietary Aide's job description not dated, the job description indicated, General Duties and Responsibilities: wash and clean utensils as directed. During a review of facility's Annual Dietary Competency evaluation for dietary Aide manual dishwashing and checking sanitizer concentration was not listed for review. During a review of manufacturer procedure titled manual pot and pan washing procedure, the manufacturer procedure indicated, submerge in sanitizer sink for one minute or as specified by product label. During a review of the Manufacturer recommendation for the sanitation range testing posted on the sanitizer dispensing area, indicated, 1.Testing solution should be at room temperature 65-75 degrees Fahrenheit, 2.Withdraw and tear off approximately 2 inches of the paper from dispenser, dip test paper for 10 seconds in the test solution, 3.compare colors immediately with colors on the test paper package to determine PPM (ALWAYS COMPARE AGAINST PACKAGE SCALE), 4.testing solution should be between 150-400PPM parts per million.

Based on observation, interview, and record review, the facility failed to ensure two of 32 sampled residents' rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) met the minimum space requirements of 80 square feet for each resident. This failure had the potential to result in inadequate space to provide safe nursing care and privacy for the residents in room [ROOM NUMBER] and room [ROOM NUMBER]. Findings:During an initial observation tour of the facility on 3/4/2026 from 10:10 AM to 11:30 AM, the facility staff (unidentified) were observed with enough space to provide care and services to the residents in each of the facility's rooms. During a review of the facility's room waiver request letter dated 3/6/2026, the room waiver request letter indicated the facility requested a room waiver for room [ROOM NUMBER] and room [ROOM NUMBER]. The room waiver request letter indicated there was enough space to provide for each resident's care dignity and privacy. The room waiver request letter indicated the rooms were in accordance with the special needs of the residents and would not have an adverse effect (undesirable effect) on residents' health and safety or impede the ability of any resident in the rooms to attain his or her highest practicable well-being. The room waiver request letter indicated the following measurements:Room Number of Beds Square Feet102 2 158.35 (13'5.04 X 11 '9.6)114 4 287 (20' X 14'4.2) During an interview on 3/4/2026 at 2:05 PM with the Director Rehabilitation Services (DRB), the DRB stated most of the therapy provided by the facility was done in the residents' rooms. The DRB stated there was enough room for therapy in all of the rooms at the facility. During an interview on 3/4/2026 at 2:26 PM with Resident 89, Resident 89 stated she (Resident 89) did not have any issues with the size of room [ROOM NUMBER]. The Department is recommending continuation of the room waiver request.

Based on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of four sampled residents (Resident 1) when Resident 1 was admitted with a medical device called a Leaf Sensor (uses a wearable sensor and display monitor for turn status and alert that provides point-of-care turn reminders and measures turn quality).This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received. During a review of the admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), actinic keratosis (AK - is a rough, scaly patch on your skin caused by too much sun or UV exposure), and rosacea (a common skin condition that causes flushing or long-term redness on your face). The admission Record also indicated Resident 1 was discharged on11/11/2025.During a review of the Minimum Data Set (MDS - resident assessment tool) dated 11/11/2025, the MDS indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required moderate to moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Braden Scale Assessment (a tool used to evaluate a patient's risk of developing pressure ulcers [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence]), dated 10/7/2025, the Braden Scale Assessment indicated a score of 18 (mild risk for developing pressure ulcer).During a review of Resident 1's Licensed Personnel Progress Notes (LPPN), dated 10/7/2025, the LPPN indicated that Resident 1 was admitted with a Leaf Sensor on the mid-chest.During a review of Resident 1's Order Summary Report, dated 10/7/2025, the Order Summary Report indicated that the physician ordered, Reinforce leaf sensor with Tegaderm (a clear, thin, sticky film dressing that over the skin) if dislodge or falls off.During a review of Resident 1's Care Plan (CP) for risk of skin breakdown, initiated on 10/8/2025, the CP indicated that Resident 1 had a left chest leaf sensor and was at risk for potential infection and skin breakdown. The CP indicated a goal of Resident 1, will not have any signs and symptoms of infection, and will not have any skin breakdown left chest leaf sensor site. The same CP included interventions such as:i. Provide good skin care during showers and when giving bed baths,ii. Assess skin integrity when giving careiii. Assess for presence of pain and provide appropriate intervention as needed,iv. Reinforce leaf sensor with Tegaderm if dislodge or fall off.During an interview with Certified Nursing Assistant 1 (CNA 1) on 12/9/2025 at 12:49 p.m., CNA 1 stated, Resident 1 had a leaf sensor patch on his chest. CNA 1 stated, they had given showers to Resident 1 with his leaf sensor patch on. CNA 1 stated, she was told that it (the sensor) can get wet, but she was not informed how to care for the patch or what it was for.During an interview with Treatment Nurse 1 (TXN 1) on 12/9/2025 at 1:01 p.m., TXN 1 stated, Resident 1 had a leaf sensor patch on his chest area upon admission which monitors Resident 1's positioning. TXN 1 stated, he had not taken care of a resident with a leaf sensor device and there were no in-services or education done for residents on this type of device. TXN 1 stated, they are to reinforce the Tegaderm if leaf sensor device gets dislodged or falls off, but he never had to reinforce the Tegaderm. TXN 1 stated he never fully assessed Resident 1's skin underneath the device. TXN 1 further stated, he does not know how it monitors Resident 1's positioning as the leaf sensor monitoring device that the antenna was connected to was not in the facility throughout Resident 1's admission.During a follow-up interview and concurrent record review of Resident 1's CP with TXN 1 on 12/9/2025 at 1:22 p.m., TXN 1 reviewed Resident 1's CP for the leaf sensor device and stated, there was no assessment for Resident 1's pain, no assessment was done for Resident 1's skin integrity and they did not reinforce the leaf sensor because the Tegaderm did not fall off or dislodged throughout Resident 1's stay. TXN 1 stated, he did not assess Resident 1's skin integrity underneath the leaf sensor and was unable to evaluate any signs of skin infection such as skin tears, skin damage and any allergic reaction. TXN 1 further stated, if the skin was not assessed and evaluated according to Resident 1's CP, it was a neglect on their part as this could lead to skin redness, infection and possibly sepsis (a life-threatening blood infection).During an interview with Director of Nursing (DON) on 12/9/2025 at 1:38 p.m., DON stated, Resident 1 was admitted with a leaf sensor patch on his (Resident 1's) chest. DON stated, I googled search (a web browser to search for explanation of a complex or technical subject using simple, plain language that an average person, who is not an expert in that specific field, can easily understand) what the leaf sensor is for, and it was identified that it's a monitoring device on repositioning resident while on bed and there's a machine at home that the family can monitor. DON stated, they do not have a specific policy and procedure on the leaf sensor device, but they follow the manufacturer's guidelines on medical devices that residents may be admitted with. DON stated, Resident 1's leaf sensor patch was never removed throughout his (Resident 1) stay in the facility and the order was to reinforce the Tegaderm if the leaf sensor device gets dislodged or falls off. DON stated, there was no documentation if the leaf sensor device was actually reinforced and there was no documentation if Resident 1's skin integrity was assessed underneath the leaf sensor device, and/or if there's any pain assessment was done.During an interview with Administrator (ADM) on 12/9/2025 at 2:17 p.m., ADM stated, they had an order to reinforce Resident 1's leaf sensor device if the Tegaderm gets dislodged or falls off and they have a CP on that device as well. ADM stated there was no documentation that Resident 1's skin integrity was assessed and if the interventions of the CP were followed for the leaf sensor device.During a review of the facility's P&P titled, Comprehensive Care Planning, reviewed on 1/14/2025, the P&P indicated that, It is the policy of this facility that a comprehensive care plan be developed for each resident. The plan of care must include measurable objectives and time frames and describe the services that are to be furnished to attain or maintain the resident's highest practicable level of well-being. During a review of the manufacturer's guidelines, titled, Leaf Patient Monitoring System, revised on 8/23/2017, the guidelines indicated the following information:A. The Leaf Patient Monitoring System monitors the orientation and activity of patients susceptible to pressure ulcers.B. General warnings:i. Do not apply the Leaf Patient Sensor to broken, irritated, or infected areas of skin. Applying the Leaf Patient Sensor to broken or irritated areas of skin can potentially lead to infection or tissue damage. Inspect the condition of the skin around the sensor application area periodically, or as indicated by clinical judgment, to look for signs of skin irritation or signs of infection.ii. Though the adhesive material used in the Leaf Patient Sensor is commonly used in other healthcare products and has a well-established safety profile, an allergic reaction to the adhesive is possible. If a patient experiences a rash, skin redness, itching, or swelling in the area where the Leaf Patient Sensor was applied, this may be a sign of an allergic reaction and should be evaluated immediately by the patient's doctor or other member of their care team.C. Risks: A patient may experience skin irritation, redness, or itching where the Leaf Patient Sensor has been applied.D. Life of the Device: The Leaf Patient Sensor is designed to work until the battery is depleted or the adhesive is worn out, which is typically 7-16 days. The device is designed for one-time use (on a single patient).

Based on interview, and record review, the facility failed to follow professional standards of practice by failing to manage, assess and monitor resident and implement the facility policy and procedure (P&P) titled, Licensed Nurses - Assessments and Notes, for one of four sampled residents (Resident 1), when resident was admitted with a medical device called a Leaf Sensor (uses a wearable sensor and display monitor for turn status and alert that provides point-of-care turn reminders and measures turn quality).This deficient practice placed Resident 1 at risk of developing skin-related risks such as skin irritation or damage, allergic reactions, skin tears, bruising and infection.Cross Reference F656During a review of the admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), actinic keratosis (AK - is a rough, scaly patch on your skin caused by too much sun or UV exposure), and rosacea (a common skin condition that causes flushing or long-term redness on your face). The admission Record also indicated Resident 1 was discharged on11/11/2025.During a review of the Minimum Data Set (MDS - resident assessment tool) dated 11/11/2025, the MDS indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required moderate to moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Braden Scale Assessment (a tool used to evaluate a patient's risk of developing pressure ulcers [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence]), dated 10/7/2025, the Braden Scale Assessment indicated a score of 18 (mild risk for developing pressure ulcer).During a review of Resident 1's Licensed Personnel Progress Notes (LPPN), dated 10/7/2025, the LPPN indicated that Resident 1 was admitted with a Leaf Sensor on the mid-chest.During a review of Resident 1's Order Summary Report, dated 10/7/2025, the Order Summary Report indicated that the physician ordered, Reinforce leaf sensor with Tegaderm (a clear, thin, sticky film dressing that over the skin) if dislodge or falls off.During a review of Resident 1's Care Plan (CP) for risk of skin breakdown, initiated on 10/8/2025, the CP indicated that Resident 1 had a left chest leaf sensor and was at risk for potential infection and skin breakdown. The CP indicated a goal of Resident 1, will not have any signs and symptoms of infection, and will not have any skin breakdown left chest leaf sensor site. The same CP included interventions such as:i. Provide good skin care during showers and when giving bed baths,ii. Assess skin integrity when giving careiii. Assess for presence of pain and provide appropriate intervention as needed,iv. Reinforce leaf sensor with Tegaderm if dislodge or fall off.During an interview with Certified Nursing Assistant 1 (CNA 1) on 12/9/2025 at 12:49 p.m., CNA 1 stated, Resident 1 had a leaf sensor patch on his chest. CNA 1 stated, they had given showers to Resident 1 with his leaf sensor patch on. CNA 1 stated, she was told that it (the sensor) can get wet, but she was not informed how to care for the patch or what it was for.During an interview with Treatment Nurse 1 (TXN 1) on 12/9/2025 at 1:01 p.m., TXN 1 stated, Resident 1 had a leaf sensor patch on his chest area upon admission which monitors Resident 1's positioning. TXN 1 stated, he had not taken care of a resident with a leaf sensor device and there were no in-services or education done for residents on this type of device. TXN 1 stated, they are to reinforce the Tegaderm if leaf sensor device gets dislodged or falls off, but he never had to reinforce the Tegaderm. TXN 1 stated he never fully assessed Resident 1's skin underneath the device. TXN 1 further stated, he does not know how it monitors Resident 1's positioning as the leaf sensor monitoring device that the antenna was connected to was not in the facility throughout Resident 1's admission.During a follow-up interview and concurrent record review of Resident 1's CP with TXN 1 on 12/9/2025 at 1:22 p.m., TXN 1 reviewed Resident 1's CP for the leaf sensor device and stated, there was no assessment for Resident 1's pain, no assessment was done for Resident 1's skin integrity and they did not reinforce the leaf sensor because the Tegaderm did not fall off or dislodged throughout Resident 1's stay. TXN 1 stated, he did not assess Resident 1's skin integrity underneath the leaf sensor and was unable to evaluate any signs of skin infection such as skin tears, skin damage and any allergic reaction. TXN 1 further stated, if the skin was not assessed and evaluated according to Resident 1's CP, it was a neglect on their part as this could lead to skin redness, infection and possibly sepsis (a life-threatening blood infection).During an interview with Director of Nursing (DON) on 12/9/2025 at 1:38 p.m., DON stated, Resident 1 was admitted with a leaf sensor patch on his (Resident 1's) chest. DON stated, I googled search (a web browser to search for explanation of a complex or technical subject using simple, plain language that an average person, who is not an expert in that specific field, can easily understand) what the leaf sensor is for, and it was identified that it's a monitoring device on repositioning resident while on bed and there's a machine at home that the family can monitor. DON stated, they do not have a specific policy and procedure on the leaf sensor device, but they follow the manufacturer's guidelines on medical devices that residents may be admitted with. DON stated, Resident 1's leaf sensor patch was never removed throughout his (Resident 1) stay in the facility and the order was to reinforce the Tegaderm if the leaf sensor device gets dislodged or falls off. DON stated, there was no documentation if the leaf sensor device was actually reinforced and there was no documentation if Resident 1's skin integrity was assessed underneath the leaf sensor device, and/or if there's any pain assessment was done.During an interview with Administrator (ADM) on 12/9/2025 at 2:17 p.m., ADM stated, they had an order to reinforce Resident 1's leaf sensor device if the Tegaderm gets dislodged or falls off and they have a CP on that device as well. ADM stated there was no documentation that Resident 1's skin integrity was assessed and if the interventions of the CP were followed for the leaf sensor device.During a review of the facility's P&P titled, Licensed Nurses - Assessments and Notes, reviewed on 1/14/2024, the P&P indicated that, Meaningful and informative notes shall be written by a licensed nurse to reflect the care and treatment, observations and assessments and other appropriate entries. A license nurse shall complete the following assessments on admission, with the MDS assessment updates, and as often as resident condition warrants: Braden/skin, Pain. When a licensed nurse is writing a weekly summary, the following records are to be reviewed to ensure that the information entered coordinated with the other discipline's documentation: Care Plan; Treatment Records; Other specialty records.During a review of the facility's P&P titled, Facility Assessment, reviewed with QAA/QAPI committee on 8/26/2025, the P&P indicated that, Indications for residents accepted to facility and their diseases and common conditions. That may develop, the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. Category: Integumentary System: Pressure injury, Vascular, Diabetic, Ulcers and Surgical wounds sites . In the event our residents have conditions not listed above, staff will be provided with education and training on how to meet the needs, care and service.During a review of the facility's P&P titled, Comprehensive Care Planning, reviewed on 1/14/2025, the P&P indicated that, It is the policy of this facility that a comprehensive care plan be developed for each resident. The plan of care must include measurable objectives and time frames and describe the services that are to be furnished to attain or maintain the resident's highest practicable level of well-being. During a review of the manufacturer's guidelines, titled, Leaf Patient Monitoring System, revised on 8/23/2017, the guidelines indicated the following information:A. The Leaf Patient Monitoring System monitors the orientation and activity of patients susceptible to pressure ulcers.B. General warnings:i. Do not apply the Leaf Patient Sensor to broken, irritated, or infected areas of skin. Applying the Leaf Patient Sensor to broken or irritated areas of skin can potentially lead to infection or tissue damage. Inspect the condition of the skin around the sensor application area periodically, or as indicated by clinical judgment, to look for signs of skin irritation or signs of infection.ii. Though the adhesive material used in the Leaf Patient Sensor is commonly used in other healthcare products and has a well-established safety profile, an allergic reaction to the adhesive is possible. If a patient experiences a rash, skin redness, itching, or swelling in the area where the Leaf Patient Sensor was applied, this may be a sign of an allergic reaction and should be evaluated immediately by the patient's doctor or other member of their care team.C. Risks: A patient may experience skin irritation, redness, or itching where the Leaf Patient Sensor has been applied.D. Life of the Device: The Leaf Patient Sensor is designed to work until the battery is depleted or the adhesive is worn out, which is typically 7-16 days. The device is designed for one-time use (on a single patient).

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnosis of dementia (condition of a person losing the ability to think, remember and reason) and history of fall, received care and services to prevent fall by failing to: 1. Implement Resident 1's Dementia Care Plan and At Risk for Fall Care Plan to ensure: Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1 explained procedure, remind not to have position change, remind for safety, reassure resident safety, and avoid environmental hazard (using multiple ramps) to Resident 1 before transporting Resident 1 in a wheelchair. 2. Identify and develop an appropriate care plan to addressed how to safely transport Resident 1 using wheelchair when resident have episodes of forgetfulness, confusion and poor safety awareness to maximize resident safety. 3. Ensure Resident 1 who had dementia, episodes of confusion, forgetfulness, poor safety awareness was safe when pushed in a wheelchair up and down the ramp (a slope or incline that connects two different surfaces) and did not have an accident. 4. Ensure to use an alternative safer route of transport for resident with dementia that have poor safety awareness and did not use a route (with multiple ramps) closer to the street parking for staff convenience. These failures resulted in Resident 1, who made a sudden movement while being wheeled in a wheelchair, to fall and sustain a right clavicle (a long bone that connects the shoulder blade and the breastbone, allowing free movement of the arm) fracture (broken bone) and experience severe pain. Resident 1 was transferred to General Acute care Hospital (GACH) for treatment and evaluation. Findings: During a concurrent observation and interview on 2/12/2025 at 10:15 am with Resident 1 in her room, Resident 1 was observed with blue sling (a device that holds a broken arm or shoulder while it heals) on her right arm and guarding (the body's ways of protecting an injury) her right arm. Resident 1 stated her right shoulder hurts. Resident 1 stated her pain level was four on a scale of 0 to 10 on a numeric pain scale (zero meaning no pain and 10 meaning the worst pain imaginable. A pain level of four meant mild pain). Resident 1 stated her pain level was eight (severe pain) when touched. Resident 1 stated the pain was from the right side of her neck down to her right shoulder. Resident 1 stated she was told (unable to recall who informed her) she got fractured from a fall (did not specify exact location) but does not remember the fall incident. During an interview on 2/12/2025 at 10:38 am., CNA 2 stated on 1/29/2025, LVN 1 was pushing Resident 1 in a wheelchair and asked her (CNA 2) to wheel Resident 1 from the basement to the front of facility to meet Resident 1's Family Member (FM 1) for dental appointment. CNA 2 stated LVN 1 instructed her to take the route that uses multiple ramps closer to the street parking lot to transport Resident 1 but did not provide safety precaution instructions. CNA 2 stated she had taken care of Resident 1 before at least more than ten times. CNA 2 stated Resident 1 usually ambulated (walked) with a walker and did not use a wheelchair on daily basis. CNA 2 stated that day (on 1/29/2025) was the first time she transported Resident 1 in a wheelchair. CNA 2 stated she did not give any instructions to Resident 1 before and during the transport or before approaching the ramp because Resident 1 was calm during transport. CNA 2 stated she did not see a reason to explain the procedure (the transport) to Resident 1, remind the resident to avoid any sudden movements or provide reassurance regarding safety, as the resident was calm prior to transport. During a concurrent observation and interview on 2/12/2025 at 10:58 am, at the facility basement, CNA 2 demonstrated how she transported Resident 1 on 1/29/2025. CNA 2 stated, when she received the resident in the basement from LVN 1, she transported Resident 1 alone using the wheelchair. CNA 2 demonstrated how she maneuvered the resident backward down Ramp 1 (ramp by the basement). CNA 2 stated and demonstrated that she then used her back to push the doubles door open (leading to Ramp 2 in the basement) CNA 2 stated she wheeled Resident 1 facing forward while going up the Ramp 2. During the concurrent observation and interview on 2/12/2025 at 10:58 am, CNA 2 stated Resident 1 all of a sudden appeared nervous, made a sudden movement halfway up the incline of Ramp 2, and caused the wheelchair to tilt to the right side. CNA 2 stated she released the wheelchair and attempted to catch Resident 1 from behind, grabbing the resident by both shoulders, but was unable to support her (Resident 1), resulting in Resident 1 falling. CNA 2 stated Resident 1 landed on her buttocks, with her back and head leaning against the seat of the wheelchair. CNA 2 stated Resident 1's head did not hit the floor. CNA 2 stated the fall was an accident, and she (CNA 2) did not expect Resident 1 would make a sudden movement. CNA 2 stated Resident 1 was not used to being transported in a wheelchair. CNA 2 stated that the accident could have been prevented if she had requested assistance from another staff member to transport Resident 1 who could have assisted her (CNA 2) from ensuring Resident 1 will not make sudden movements and prevent Resident 1 from falling. During a concurrent observation and interview on 2/12/2025 at 11:30 am with Maintenance Supervisor (MS) 1, MS 1 stated on 1/29/2025, he heard someone called for help from Ramp 2. MS 1 stated he saw Resident 1 sitting on the floor while CNA 2 was on the right side of the wheelchair, holding the wheelchair and Resident 1. MS 1 stated he went to the nurses' station to report that Resident 1 fell . MS 1 stated the ramps were usually used for ambulance transport. MS 1 stated there are several ramps, Ramp 1 inside the facility basement, Ramp 2 outside the double doors, followed by two more ramps (Ramp 3 and Ramp 4) after the facility gate. MS 1 stated there was another way to exit the facility that did not need to pass through ramps. MS 1 showed the exit path going to the garage and it was a flat surface. MS 1 stated using the garage is a safer way to transport the resident. During a concurrent observation and interview on 2/12/2025 at 11:58 am, at the basement of the facility, MS 1 measured the steepness of the ramps and stated Ramp 1 at the basement of the facility had a length of 200 inches and rise of 15 inches. Ramp 2 outside the basement double doors had a length of 160 inches and a rise of 10 inches, Ramp 3 had length of 64 inches and rise of 7 inches, and Ramp 4 had a length of 230 inches and rise of 12 inches. MS 1 stated They were steep ramps for wheelchair transport. MS 1 stated the basement ramps (Ramp 1, Ramp 2, and Ramp 4) were steep, and it was a safer route to transport the wheelchair thru the garage. MS 1 stated the ambulance transporters usually used two persons to transport the resident when using the ramps. During an interview on 2/12/2025 at 12:05 pm., CNA 2 stated she did not know why she chose to go through the ramps instead of going through the garage. CNA 2 stated the ramps were closer to where FM 1 parked. During an interview on 2/12/2025 at 12:17 pm with LVN 1, LVN 1 stated Resident 1 has dementia and on high fall risk precaution. LVN 1 stated although Resident 1 had dementia, she (the resident) could follow directions. LVN 1 stated he picked up Resident 1 from Resident 1's room from bed to wheelchair and told Resident 1 she (the resident) was going to her dental appointment. LVN 1 stated he did not assess if Resident 1 was comfortable with the use of wheelchair, did not explain to Resident 1 that she will be using wheelchair, did not instruct Resident 1 not to make sudden position change, and that she would be transported using the ramps. LVN 1 stated at the basement elevator, he approached CNA 2 to bring Resident 1 at the facility entrance to meet FM 1 for a dental appointment. LVN 1 stated he asked CNA 2 to take the path (with multiple ramps) closer to the street parking but did not provide any instructions to CNA 2 to ensure Resident 1 was informed about safe transport procedure. LVN 1 stated they should have explained the procedure to Resident 1 and reassured Resident 1 of safe transport. During a concurrent interview and record review on 2/12/2025 at 12:20 pm, Resident 1's Fall Risk Care Plan dated 10/28/2024 was reviewed. LVN 1 stated Resident 1 had dementia and was on high fall risk precautions. Resident 1's care plan for fall indicated Resident 1 had episodes of confusion and forgetfulness, had poor safety awareness and history of falls, had episodes of trying to be independent beyond physical capability and did not use assistive device or call light for assistance, required assistance with mobility and transfers, and have balance problems during transfers. LVN 1 stated the care plan goal was to ensure to minimize risk for falls and minimize injury secondary to falls. LVN 1 stated the staff should have followed the care plan and instructed Resident 1 not to have sudden position changes, provide adequate assistance during transport, and ensure to do frequent reminders regarding safety to prevent accident. LVN 1 stated Resident 1 did not have a care plan to addressed Resident 1 being transported in the wheelchair because Resident 1 was ambulatory and do not use wheelchair. LVN 1 stated the care plan for fall and dementia did not address what to do in the event Resident 1 had episode of confusion or forgetfulness while being transported in a wheelchair because Resident 1 was not using a wheelchair independently and was being assisted by one staff during transport. LVN 1 stated because of the incident (fall) they should add two person assist when transporting Resident 1 in a wheelchair to prevent future accidents. During a concurrent interview and record review on 2/12/2025 at 12:25 pm, Resident 1's Alzheimer's (a brain disorder that gradually destroys memory and thinking skills) and Dementia Care Plan dated 10/28/2024 was reviewed. LVN 1 stated the care plan indicated Resident 1 had episodes of confusion and forgetfulness, at risk for further decline in cognition and decision making. LVN 1 stated the dementia care plan interventions indicated the staff should have explained all procedures prior to assisting with care, gave simple directions one at a time using short words and simple sentences, provided reassurance as needed with frequent verbal reminders as necessary, and monitored and anticipated resident needs. LVN 1 stated they (LVN 1 and CNA 2) should had followed the care plan and explained the procedure to Resident 1 and reassured Resident 1 of safe transport to prevent the accident. During an interview on 2/12/2025 at 1:40 pm, Registered Nurse Supervisor (RN) 1 stated she rushed to the reported location (Ramp 2) and saw Resident 1 on the floor leaning on the wheelchair with CNA 1 at the right side of Resident 1. RN 1 stated Resident 1 was transported back to the room for assessment. RN 1 stated Resident 1 complained of right arm pain. RN 1 stated she assessed Resident 1 and noted the resident had a bruise on the right side of the head and had limited right arm range of motion (the extent or degree of movement that a joint can achieve). RN 1 stated Resident 1 have dementia, have episodes of forgetfulness but she (Resident 1) could follow instructions but just need constant reminders. RN 1 stated LVN 1 and CNA 2 should have reminded Resident 1 not to do a sudden movement during wheelchair transport and assessed environmental factors to ensure the prevention of accidents. During an interview on 2/12/2025 at 3 pm, the Director of Rehabilitation (DOR) stated Resident 1 does not use wheelchair and able to ambulate with a walker for short distances. The DOR stated Resident 1 could have benefited with instructions on using ramps with a wheelchair to reassure Resident 1 of safe transport. The DOR stated the best practice was to use the correct type of wheelchair, have two staff members during transport, and provide the resident with instructions prior to transport (using the ramps). During a concurrent interview and record review on 2/12/2025 at 3:55 pm with the Director of Nursing (DON), Resident 1's fall risk care plan dated 10/28/2024 and Resident 1's Alzheimer's and Dementia Care Plan dated 10/28/2024 were reviewed. The DON stated Resident 1 was a high risk for fall, with dementia, and needed safety awareness and constant reminder. The DON stated Resident 1's fall risk care plan included to instruct Resident 1 not to make sudden movements. The DON stated Resident 1's Dementia care plan included explaining all procedures prior to assisting care. The DON stated the staff should have followed Resident 1's care plan to ensure Resident safety and avoid accidents. The DON stated the care plan did not have an intervention to addressed Resident 1 being transported in the wheelchair and what to do in the event Resident 1 had episode of confusion or forgetfulness. The DON stated they will add two person assist when transporting Resident 1 in a wheelchair to ensure resident safety. The DON stated there was an alternative route that staff could use that did not require using ramps. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted on [DATE], with diagnoses including dementia, metabolic encephalopathy (a brain disorder when chemical imbalance in the blood affects the brain function), hypertension (high blood pressure), intervertebral disc degeneration (refers to symptoms of back or neck pain caused by wear-and-tear), unspecified fall, and weakness. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Notes, dated 7/25/2024, the SBAR notes indicated Resident 1 had an unwitnessed fall in the room. The SBAR notes indicated Resident 1 was found sitting on the floor inside her room, Resident 1 stated she was trying to pick up something on the floor and tried to get up but unable to and decided to sit on the floor. During a review of Resident 1's At Risk for Falls and Injuries Care Plan dated 10/28/2024, the care plan indicated Resident 1 had episodes of confusion and forgetfulness, had poor safety awareness and history of falls, Resident 1 had episodes of trying to be independent beyond physical capability and did not use assistive device or call light for assistance, required assistance with mobility and transfers and have balance problems during transfers. The care plan goal was to ensure to minimize risk for falls and minimize injury secondary to fall. The interventions indicated to instruct Resident 1 not to have sudden position changes and provide adequate assistance during transfers and ensure to do frequent reminders regarding safety. During a review of Resident 1's Alzheimer's and Dementia Care Plan dated 10/28/2024, the care plan indicated Resident 1 had episodes of confusion and forgetfulness, at risk for further decline in cognition and decision making. The care plan goal indicated Resident 1 will be oriented to time, place and person. The interventions indicated to explain all procedures prior to assisting care and provide reassurance as needed with frequent verbal reminders, give simple directions one at a time using short words and simple sentences, provide reassurance as needed with frequent verbal reminders as necessary, and monitor and anticipate needs. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and caring-screening tool), dated 1/24/2025, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired. The MDS indicated Resident 1 could express ideas and wants and able to understand others. The MDS indicated Resident 1 required partial to moderate assistance (helper lifts or holds trunk or limbs and provides less than half the effort) with walking at fifty and one hundred fifty feet distance. The MDS indicated Resident 1 used a walker and did not use wheelchair. During a review of Resident 1's Fall Risk Evaluation dated 1/28/2025, the fall risk evaluation indicated Resident 1 had intermittent confusion, ambulatory, incontinent, balance problem with standing and walking, have gait problems, jerking, unstable when making turns, unsteady gait, shuffling gait, required use of assistive devices, took medications that cause lethargy (a state of feeling tired, sluggish, and lacking energy) or confusion, and had three or more predisposing diseases. The fall risk evaluation indicated Resident 1 scored 18. The fall risk evaluation indicated if a total score of 10 or greater, the resident should be considered a high risk for potential falls, a fall prevention protocol should be initiated immediately, and documented on the resident's care plan. During a review of Resident 1's Licensed Personnel Progress Notes, dated 1/29/2025 at 10:20 am, the progress notes indicated MS 1 called RN 1's attention at the nurses' station to inform Resident 1 was on the floor by the ramp (Ramp 2) outside the building. The progress notes indicated RN 1 immediately went to the site (location of Ramp 2), found Resident 1 sitting on the floor along the ramp, her back and head leaning against the seat of the wheelchair, had no change on level of consciousness, and had no bleeding. The progress notes indicated FM 1 and CNA 2 was at the site of incident (location of Ramp 2) and immediately called for help and assistance from another staff (RN 1). During a review of Resident 1's SBAR Communication Notes, dated 1/29/2025, the SBAR notes indicated Resident 1 had a witnessed fall on 1/29/2025. The SBAR notes indicated, Resident 1 had right lateral side of head purplish discoloration, abrasion on right elbow measuring approximately five centimeter (cm, unit of measurement) in length with minimal bleeding. The SBAR notes indicated the nurses applied ice packs to Resident 1's right side of the head and right shoulder, gave Tylenol (a pain reliever used to treat mild and moderate pain) 1 gram (unit of measurement) as ordered, and cleansed the resident's right elbow abrasion with normal saline and treated with hydrogel (medication for wound healing). The Change of Condition (COC) on the SBAR indicated Resident 1 complained of pain at level eight to nine and unable to move her right arm. The COC indicated the physical therapist came and applied an immobilizer (essential medical devices that are used to restrict the movement of the arm, providing support, stability, and protection during the healing process). The SBAR notes indicated Resident 1's attending physician (MD) was notified and the MD ordered to transfer Resident 1 to GACH for further evaluation. During a review of Resident 1's physician's orders dated 1/29/25, the order indicated to transfer Resident 1 to GACH for further evaluation and treatment. During a review of the GACH Records titled, Emergency Department to Hospital Admission Note (EDN), dated 1/29/2025, the EDN indicated Resident 1 had a closed displaced fracture of the clavicle. The EDN indicated Resident 1 had right shoulder pain, right forearm pain, and sustained hematoma (bruise) to the right forehead after a fall from wheelchair while going up a ramp. The EDN indicated Resident 1 was oriented to self and place and able to follow commands. The EDN provided wound care to Resident 1's right forearm wound. The EDN notes indicated a right arm sling was applied. During a review of Resident 1's right shoulder Xray (a procedure that uses radiation to create images of inside of the body) report dated 1/29/2025, the report indicated nondisplaced fracture (a broken bone where pieces remained in place and aligned) of distal (away from the center) clavicle. During a review of Resident 1's Medication Administration Record (MAR), for the month of January 2025, the MAR indicated pain rating of 0 = (equals) no pain, 1 to 4= mild pain, 5 to 7=moderate pain, 8 to 10=severe pain. The MAR indicated Resident 1 had pain level of 8 (severe pain) on 1/29/2025 at 10:31 am and received two tablets of acetaminophen (medication to treat pain and reduces fever) 500 milligrams (mg, a unit of measurement) for severe pain. During a review of Resident's History and Physical (H & P) dated 2/4/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of the IDT (Inter Disciplinary Team, a team of professionals from various fields who work together toward the goals of the resident Care Plan Summary notes) notes, dated 2/11/2025, the IDT notes indicated Resident 1 was readmitted on [DATE] from GACH and had right clavicle fracture from a fall at the facility on 1/29/2025. Resident 1's FM 2 wanted Resident 1 to be encouraged to ambulate using assistive device especially during appointment. The IDT notes indicated Resident 1 will use wheelchair with two person assist. The IDT notes indicated the facility will implement preventive measures of siderails, grab bars and visual checks. During a review of facility's policy and procedure (P&P) titled, Dementia Care assessment dated reviewed 1/2017, the P&P indicated people with dementia have significantly impaired intellectual functioning that interferes with normal activities and lose the ability to maintain control, and may experience behavioral problems such as agitation, delusions and hallucinations. The P&P indicated it is the policy of the facility to identify and assess residents with dementia and to provide the highest quality care by providing the necessary care without compromising the resident's rights. The P&P indicated, the IDT will develop a plan of care to maximize the resident's remaining functional level, individual approaches that focus on a resident's individual needs and attempts to understand behavior as a form of communication to reduce behavioral expression of distress. During a review of facility's P&P on Falling Star Program, reviewed 7/2018, the P&P indicated the facility will identify residents who are at high risk for falls and attempt to increase supervision for residents on high fall risk. The P&P indicated if the resident has a fall after being placed on the program, the IDT will develop additional approaches to reduce additional falls. During a review of facility's P&P, titled Fall Risk and Prevention of Injury reviewed 3/2019, the P&P indicated it was the policy of the facility to identify residents that were risk for falls and to implement a plan of care in an attempt to prevent fall. The policy indicated the approaches to prevent falls and or fractures included orienting the resident their room and surroundings as appropriate and to keep the resident's environment free of unnecessary obstacles.

Based on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Residents 49 and 54) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: -For Resident 49, put on a left knee splint correctly during the 1/28/25 Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment session as ordered by a physician. -For Resident 49, provide an appropriate RNA order for wearing both knee splints for no more than three hours as determined by physical therapy. -For Resident 54, provide resident with active range of motion (AROM, movement at a given joint when the person moves voluntarily) exercises to both upper extremities and both lower extremities during the 1/28/25 RNA treatment session as ordered by a physician. These deficient practices had the potential for injury and worsening of contractures (a stiffening / shortening at any joint, that reduces the joint's range of motion) in Resident 49 and a decline in strength and functioning in Resident 54. CROSS REFERENCE TO F726 Findings: a. A review of Resident 49's Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening blood infection) with septic shock (life-threatening drop in blood pressure), muscle wasting and atrophy (gradual decline), and generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). A review of Resident 49's History and Physical (H&P) dated 11/14/24 indicated the resident lacked the capacity to make medical decisions. A review of Resident 49's Contractures Care Plan revised 11/21/24, indicated the resident was at risk for contractures related to limited mobility with impaired ROM of BUE and BLE. The care plan interventions indicated to report any abnormality to physician, RNA program as ordered, and physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) and occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation and treatment. A review of the Physician's Order Summary Report dated 12/13/24 indicated for RNAs to perform donning (put on) and doffing (take off) of bilateral (both sides) knee splints four to six hours as tolerated for Resident 49, to prevent further tightness / contracture once a day seven days a week. A review of Resident 49's Minimum Data Set (MDS - a resident assessment tool) dated 10/29/25, indicated the resident had severe cognitive impairments (difficulty with or unable to make decisions, learn, remembering things), had functional limitations in ROM on both sides of the lower extremities (LE, hip, knee, ankle, foot) and did not have any functional limitations in ROM on the upper extremities (UE, shoulder, elbow, wrist, hand). The MDS indicated Resident 49 required dependent assistance from staff with toileting hygiene, showering, lower body dressing, sit to lying, sit to stand, and bed-to-chair transfers. During an observation on 1/28/25 at 10:38 a.m., in Resident 49's room, Resident 49 was sitting up in a wheelchair. RNA 1 took two splints from the closet and put the knee splints on Resident 49's left and right knees. RNA 1 put the left knee splint low on the Resident 49's leg and the knee portion of the splint was on the lower part of the leg and not over the left knee. RNA 1 put the right knee splint over the right knee. RNA 1 then indicated the RNA treatment was complete and left the room. During an observation and concurrent interview on 1/28/25 at 11:07 a.m., in Resident 49's room, Physical Therapist (PT) 1 observed the left knee splint on Resident 49's left leg and stated the left knee splint was too low and should be put on higher. PT 1 proceeded to take off the left knee splint and placed it higher on Resident 49's leg and the knee portion of the splint was over the left knee. PT 1 stated splints should be put on correctly because otherwise the splints were not serving its purpose, and the contracture could get worse. During an interview on 1/29/25 at 2:22 p.m., the Director of Nursing (DON) stated RNAs need to place splints on residents correctly so that residents did not develop contractures and have limitations in ROM. A review of the facility's policy and procedure (P&P) titled, Splint Application, revised 5/17 indicated, Splints must be applied correctly to maintain the resident's range of motion and prevent contractures and further loss of range of motion. b. A review of Resident 49's Physical Therapy Evaluation and Plan for Treatment dated 11/14/24, indicated the resident had impairments in ROM in both knees in extension (cannot fully straighten both knees). The PT Evaluation indicated a long-term goal for Resident 49 to safely wear a knee extension splint on left knee and right knee for up to four hours with minimal signs and symptoms of redness, swelling, discomfort or pain. A review of Resident 49's PT Treatment Encounter Notes dated 11/19/24, indicated the resident tolerated both knee splints for 30 minutes. The PT Treatment Encounter Notes indicated on : -11/26/24, Resident 49 tolerated both knee splints for 45 minutes. -11/27/24, Resident 49 tolerated both knee splints for 45 minutes. -12/2/24, Resident 49 tolerated both knee splints for 45 minutes. -12/3/24, Resident 49 tolerated both knee splints for one hour -12/4/24, Resident 49 tolerated both knee splints for one hour. -12/5/24, Resident 49 tolerated both knee splints for two hours. -12/6/24, Resident 49 tolerated both knee splints for two and a half hours. -12/9/24, Resident 49 tolerated both knee splints for three hours without signs of skin breakdown or redness. -12/10/24, Resident 49 tolerated both knee splints for three hours without adverse skin effects. -12/11/24, Resident 49 tolerated both knee splints for three hours. A review of the PT Discharge Summary dated 12/11/24, indicated Resident 49's maximum tolerance for the goal of wearing a knee extension splint on left and right knee with minimal signs and symptoms of redness, swelling, discomfort or pain was three hours. During a concurrent interview and record review on 1/29/25 at 9:19 a.m. with PT 1, Resident 49's Physical Therapy records were reviewed. PT 1 stated PT established the maximum time Resident 49 could tolerate both knee splints without the splints bothering her was three hours. PT 1 stated three hours was the safe wearing time for Resident 49 without the splints causing skin irritation or breakdown or pain. PT 1 stated Resident 49's current RNA order was to wear both knee splints for four to six hours as tolerated. PT 1 stated the RNA order should not be to wear both knee splints for four to six hours, it should be to wear both knee splints for three hours maximum. PT 1 stated because Resident 49 was tolerating the knee splints for three hours with PT, Resident 49 should not wear the knee splint for more than three hours, because Resident 49 could have skin irritation, pain, skin breakdown, and soreness. A review of the facility's P&P titled, Splint Application, revised 5/17, indicated splints be applied correctly to maintain the resident's range of motion and prevent contractures and further loss of range of motion. c. A review of Resident 54's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side and bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee. A review of Resident 54's MDS dated [DATE], indicated the resident had no cognitive impairment, had functional limitation in ROM impairment on one side of the upper extremity, and did not have any functional limitation in ROM on the lower extremities. The MDS indicated Resident 54 required setup or clean-up assistance with eating and oral hygiene, moderate assistance with bed mobility, sit to stand, bed-to-chair transfers, and walking, and dependent assistance with toileting hygiene and lower body dressing. The MDS also indicated Resident 54 received six days of RNA for active ROM and six days of RNA for walking. A review of the Physician's Order Summary Report dated 1/28/25, indicated the following orders for Resident 54: -RNAs to perform ambulation using front-wheeled walker (FWW, type of mobility aid with wide base of support and two wheels in the front) once a day, six times a week as tolerated dated 7/2/24. -RNAs to perform AROM to BLE every day six times a week as tolerated dated 7/2/24. -RNAs to perform AROM to BUE every day six times a week as tolerated dated 7/2/24. -RNAs to supervise resident using stationary bike (personal bike) for 10 minutes every day six times a week as tolerated dated 12/9/24. A review of Resident 54's Musculoskeletal Care Plan revised 12/12/24, indicated the resident was at risk for impaired mobility and function related to limited mobility, impaired ROM of RUE, and left sided hemiplegia. The care plan goal indicated to maintain current level of function without any signs and symptoms of complications daily for 90 days. The care plan interventions included RNA program as ordered. A review of Resident 54's Contractures Care Plan, revised 12/12/24, indicated the resident was at risk for impaired contractures related to limited mobility and impaired ROM of RUE. The goal indicated to minimize incidence of contractures daily for 90 days and the care plan interventions included RNA program as ordered and encourage participation to exercise and activity program. During an observation and concurrent interview on 1/28/25 at 8:50 a.m., Resident 54 was sitting up in a wheelchair in Resident 54's room. Resident 54 stated she walked with RNA, would like to keep doing exercises for her arms and legs, and now only walked. Resident 54 stated walking did not help with the arms and legs. Resident 54 was able to move both arms a little past shoulder level, and was able to straighten and bend both elbows, wrist and fingers. During an observation of Resident 54's RNA treatment session and interview on 1/28/25 at 9:51 a.m., Resident 54 was sitting in a WC in the hallway. RNA 1 and RNA 2 assisted Resident 54 to stand up. RNA 1 walked with Resident 54 with FWW while RNA 2 followed behind with the wheelchair. Resident 54 ambulated down two and a half hallways and sat down to rest for about four minutes. Resident 54 proceeded to walk with the FWW down half a hallway back into Resident 54's room. RNA 1 assisted Resident 54 in setting up the personal leg exercise stepper and Resident 54 completed the exercise for 10 minutes. RNA 1 left Resident 54's room and went to another resident's room to complete the RNA treatment for a different resident. Resident 54 did not perform any AROM exercises with RNA. During an interview and record review on 1/28/25 at 10:28 a.m., RNA 1 reviewed Resident 54's RNA orders and stated Resident 54 had RNA orders for AROM for BUE and BLE six times a week. RNA 1 stated RNA 1 did not complete the AROM exercises yet for BUE and BLE and would go back to Resident 54 to complete those exercises. During an observation and concurrent interview on 1/28/25 at 10:38 a.m., Resident 54 was sitting up in a wheelchair in Resident 54's room. RNA 1 put his hand on Resident 54's elbow and wrists and performed passive range of motion (PROM, movement at a given joint with full assistance from another person) to Resident 54's right shoulder, right elbow, right wrist, right fingers followed by PROM to Resident 54's left shoulder, left elbow, left wrist, and left fingers. RNA 1 then left Resident 54's room. RNA 1 did not complete any AROM exercises for Resident 54's BUE or BLE. RNA 1 stated Resident 54 had orders for AROM for BUE and BLE. On 1/28/25 at 10:51 a.m., during an interview, PT 1 stated residents were discharged after therapy to an RNA program depending on each resident's capacity. PT 1 stated if residents had the cognition and strength to complete AROM exercises, then residents would be put on an RNA program for AROM exercises. During an interview on 1/28/25 at 11:07 a.m., PT 1 stated RNAs should be following the AROM exercise RNA orders as written in order for the residents to use their muscles and maintain their strength. PT 1 stated residents who could perform AROM exercises should not do passive ROM exercises, because the residents could get weaker or develop contractures. During an interview on 1/29/25 at 10:07 a.m., the Director of Staff Development (DSD) stated Resident 54 had an order for RNA for AROM for BUE and BLE. The DSD stated that RNAs should perform AROM exercises for BUE and BLE for Resident 54 because that was the physician's order and that was the specific program that the rehabilitation department determined was appropriate for Resident 54. The DSD stated it was important for Resident 54 to perform the BUE and BLE AROM exercises herself because otherwise Resident 54 would rely on equipment or others to move their joints. During an interview on 1/29/25 at 2:22 p.m., the Director of Nursing (DON) stated the RNA program was to help residents maintain their strength, endurance, and abilities so that the residents did not decline in ambulation and function. The DON stated the RNA program was established by rehabilitation department for each resident. The DON stated it was important for RNAs to follow the RNA program and RNA orders. The DON stated it was important for RNAs to communicate if they were not completing AROM exercises for the resident. A review of the facility's P&P titled, Limitations in Range of Motion and Mobility and Referrals for Therapy, revised 10/17, indicated a resident who enters the facility without limited range of motion did not experience a reduction in range of motion. A resident with limited range of motion would be provided appropriate treatment and services.

Based on observation, interview, and record review, the facility failed to ensure annual competencies were completed for six of six sampled Restorative Nursing Aides, who perform RNA program tasks including putting on and taking off splints and braces. This deficient practice had the potential to result in injury, worsening contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), and skin breakdown for residents who require splints and braces for physical therapy. CROSS REFERENCE TO F688 Findings: A review of Restorative Nursing Aide (RNA) 2's RNA Competency Evaluation dated 8/23/24 indicated there was no skills performance check on how to put on and take off splints and braces. A review of RNA 1's RNA Competency Evaluation dated 11/18/24 indicated there was no skills performance check on how to put on and take off splints and braces. A review of RNA 3's RNA Competency Evaluation dated 11/29/24 indicated there was no skills performance check on how to put on and take off splints and braces. Further review of RNA 4, 5 and 6's competency evaluations indicated there was no skills performance check on how to put on and take off splints and braces. During an observation on 1/28/25 at 10:38 a.m., in Resident 49's room, Resident 49 was sitting up in a wheelchair. Restorative Nursing Aide (RNA) 1 took two knee splints from the closet and placed knee splints on Resident 49's left and right knees. RNA 1 put the left knee splint low on the Resident 49's leg and the knee portion of the splint was on the lower part of the leg and not over the left knee. RNA 1 put the right knee splint over the right knee. RNA 1 indicated the RNA treatment was complete and left the room. During an observation and interview on 1/28/25 at 11:07 a.m. in Resident 49's room, Physical Therapist (PT) 1 observed the left knee splint on Resident 49's left leg and stated the left knee splint was too low and should be placed higher on the left leg. PT 1 proceeded to take off the left knee splint and placed it higher on Resident 49's leg where the knee portion of the splint was over the left knee. PT 1 stated splints should be put on correctly because otherwise the splints were not serving its purpose and Resident 49's contracture could get worse. During an interview and record review on 1/29/25 at 10:07 a.m., the Director of Staff Development (DSD) stated she was the supervisor for the RNAs and the RNA competencies were completed annually with the therapy department. The DSD reviewed RNA 1 and RNA 2's annual competency dated 11/18/24 and 8/23/24 and stated there was no competency check for how to put on and take off splints and braces. The DSD stated there should be a competency check for how to put on and take off splints and braces, because the facility needed to make sure the RNAs were putting the splints and braces on properly and in the correct place, to ensure it did not cause any injury to the residents. The DSD stated the RNA annual competency checklist did not include splints or braces. During an interview and record review on 1/29/25 at 2:48 p.m., the DSD reviewed annual competencies for RNA 3 4, 5 and 6 and confirmed the RNAs did not receive an annual competency for putting on and taking off splints and braces. During an interview and record review on 1/30/25 at 8:12 a.m., PT 1 reviewed the annual RNA competency checklist and confirmed PT 1 did not review and evaluate RNAs on splinting and brace skills. A review of the facility's policy and procedure titled, Policy for Staff Competencies, revised 1/2017, indicated, performance evaluations are to ensure that staff has the appropriate competencies and skills to assure resident safety and to provide care which includes assessing, evaluating, planning and implementing resident care plans and responding to resident needs, performance evaluations of staff will be completed annually. A review of the facility's policy and procedure titled, Splint Application, revised 5/2017, indicated, it is the policy of the facility that splints be applied correctly to maintain the resident's range of motion and prevent contractures and further loss of range of motion.

Based on observation, interview, and record review, the facility failed to maintain six of six electrical rehabilitation therapy (given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for resident use. This deficient practice had the potential for injury to residents using the therapy equipment during therapy treatment. Findings: A review of the upper and lower extremity bicycle - Therapy Equipment (TE) 1 and TE 2's User Manual (UM) revised 12/8/2020, indicated a Certificate of Conformance Inspection, consisting of an electrical safety check, was recommended to be performed at least biannually (every two years). Users should follow and complete the following recommendations on an ongoing basis: routinely check for power cord fraying or any other damages to the power cord. Check to ensure that the cycle ergometer was operating smoothly. Always check that the power cord, cardia pickup and display control cables were properly routed and were not in danger or being snagged/pulled by the lower or upper cycle operation. Always keep the system clean and keep any debris, such as paper, string, cloth, or clothing away from the cycle moving parts. A review of the automatic parallel bars (TE 4's) undated Operation and Service Guide (OSG) indicated, under Preventative Maintenance, to frequently inspect the power cord and plug for frayed wires and/or damaged insulation. Gears should be checked every six months for adequate grease. During an observation on 1/28/25 at 11:07 am, in the facility's Occupational Therapy (OT) gym, a resident was observed using an upper and lower extremity bicycle, (TE 1). During a concurrent interview, Physical Therapist (PT) 1 stated the facility's rehabilitation department had six different electrical equipment items for residents to use during therapy treatment sessions. PT 1 stated in the OT gym, there was a TE 1 and an adjustable work table (TE 3). PT 1 proceeded to walk to the gym on the other side and stated there was another upper and lower extremity bicycle (TE 2), automatic parallel bars (TE 4), an exercise leg stepper (TE 5), and an adjustable therapy mat (TE 6). PT 1 stated the rehabilitation department did not calibrate or check any of the six electrical therapy equipment items. During an interview on 1/28/25 at 3:15 pm, in the PT and OT gym, the facility's Maintenance Director (MTD) stated the staff did not have any logs or documentation of any preventive or general maintenance performed on the six therapy equipment items. The MTD stated he had not performed any maintenance checks on TE 3, TE 6, or TE 4 and had checked TE 1, TE 2, and TE 5 as needed, if the therapists reported any issues. During an interview on 1/29/25 at 8:40 am, the Administrator (ADM) stated the facility did not have any policy regarding maintenance of electrical equipment for the rehabilitation department. The ADM stated the facility's policy was to follow the manufacturer's manual for each equipment item. During an interview and record review on 1/29/25 at 10:25 am, the ADM stated it was important to perform maintenance on electrical rehabilitation equipment because residents could be injured by the equipment. The ADM stated the facility did not have a manufacturer's user manual for TE 3 (the adjustable work table). On 1/29/25 at 2:22 pm, during an interview, the Director of Nursing (DON) stated it was important to maintain the rehabilitation equipment, because many of the residents use the equipment during therapy to regain their strength and endurance to return to the community. The DON stated the rehabilitation equipment needed to be safe for the residents to use. A review of TE 5's undated UM indicated do not attempt any servicing or adjustments other than those described in this manual. All else must be left to trained serviced personnel familiar with electro-mechanical equipment and authorized under the laws of the country in question to carry out maintenance and repair work. TE 5's UM indicated under Maintenance to check the pedal to make sure they are tight (monthly), all bolts that were installed during assembly need to be tightened as much as possible. A review of TE 6's Operating and Technical Manual (OTM) revised 1/2016, indicated under Quality Assurance, It is recommended that a program of regular and appropriate quality assurance including electrical safety inspections be utilized for this equipment. A qualified service personnel or third party service organization should be capable of performing the necessary testing and documentation.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent accident risks and hazards for one of five sampled residents (Resident 77. Resident 77 was not provided supervision and assistance with transfers. This deficient practice resulted in Resident 77 sustaining a fall on 1/27/2025, which had the potential for the resident to develop an injury. Findings: A review of Resident 77's Admission Record indicated the facility admitted the resident on 1/9/2025 with diagnoses including hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body), difficulty in walking, lack of coordination (a condition that affects the body's ability to control and execute smooth, precise movements), cerebral infarction (stroke, injury to part of the brain that can affect the use of the body and the ability to speak and walk), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), and unspecified mood affective disorder (a group of mental health conditions characterized by significant and persistent disturbances in mood). A review of Resident 77's Minimum Data Set (MDS, a resident assessment tool) dated 1/16/2025, indicated the resident had severe cognitive impairment (ability to think, understand, and reason) and normally used a walker and a wheelchair. The MDS indicated Resident 77 required substantial / maximal assistance (helper does more than half the effort) with toileting hygiene, required partial / moderate assistance (helper does less than half the effort) with walking 10 feet, with sitting to standing, and with transferring to and from a bed to a chair or wheelchair. The MDS further indicated Resident 77 did not have any fall history on admission to the facility. A review of Resident 77's Fall Risk Evaluation dated 1/23/2025, indicated the resident was considered a high risk for potential falls. A review of Resident 77's care plan revised 1/23/2025, indicated the resident had an actual fall on 1/22/2025 and an unwitnessed fall on 1/23/2025. The care plan indicated the goal for Resident 77 was to be free from future falls and complications. The care plan interventions included frequent visual monitoring, placing the call light within easy reach, encouraging the resident not to get up without assistance, keeping the resident's surroundings free from clutter, and applying a bed alarm. During a concurrent observation and interview on 1/27/2025 at 12:38 AM, in Resident 77's room, the resident was observed sitting on floor, a wheelchair was observed near the resident, and the resident's call light was lying on the bed. Resident 77 stated he did not know how he got on the floor. There were no injuries observed on Resident 77's head or body. Resident 77 stated he was not in pain. Further observation indicated there were no facility staff present in Resident 77's room. During an interview on 1/27/2025 at 1 PM, Registered Nurse Supervisor (RNS) 1 stated Resident 77 fell from his wheelchair. RNS 1 stated Resident 77 was brought into his room by wheelchair from the dining room prior to the fall. RNS 1 stated that she assessed Resident 77, and the resident did not have any visible physical injuries. RNS 1 stated Resident 77 was not in pain but could not recall what happened. RNS 1 stated Resident 77's Nurse Practitioner (NP) was at bedside assessing the resident and provided orders to transfer the resident to the General Acute Care Hospital (GACH). RNS 1 stated there were no staff that saw Resident 77 fall. RNS 1 stated Resident 77 was a high risk for falls and normally needed assistance with transferring from the wheelchair, the bed, and with ambulation to the bathroom. RNS 1 stated if Resident 77 had assistance with transferring the resident would not have attempted to get out of the wheelchair by themselves and would not have fallen. RNS 1 stated there was a potential Resident 77 could have injured himself because of the fall. A review of Resident 77's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 1/27/2025, indicated the resident had a fall, was awake, verbally responsive, and had no shortness of breath. The form indicated Resident 77 was found sitting on the floor, was assessed and denied any pain or discomfort. The form indicated Resident 77 was able to move both upper and lower extremities without difficulty and had no new skin breakdown. The form indicated Resident 77 answered incoherently and the Nurse Practitioner was notified. A review of the Physician's Order dated 1/27/2025 at 1:46 PM, indicated Resident 77 was transferred to GACH 1 for further evaluation status post fall. A review of Resident 77's GACH After Visit Summary dated 1/27/2025, indicated the resident was seen in the emergency department when he was found fallen out of his wheelchair. The summary indicated Resident 77 had a Computed Tomography (CT - diagnostic imaging procedure that uses a computer linked x-ray machine to create detailed images of the inside of the body) scan of the brain and neck which did not show any internal bleeding or injuries. The summary indicated Resident 77's blood work did not show any acute abnormal findings. The summary further indicated it was safe for Resident 77 to return to the facility. During an interview on 1/30/2025 at 2:45 PM, the Director of Nursing (DON) stated Resident 77 was a high risk for potential falls and had fallen before at the facility. The DON stated Resident 77 needed assistance transferring and was not safe to ambulate on their own. The DON stated Resident 77 needed frequent visual monitoring and supervision to prevent falls. The DON stated there was a potential for Resident 77 to fall again and develop an injury if the resident would not be adequately monitored and supervised. A review of the facility's policy and procedure titled, Fall Risk & Prevention of Injury to Include Pathological Fractures, reviewed 1/14/2025 indicated, It is the policy of the facility to identify residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. This include minimizing risk for pathological fractures .If the Fall Risk Assessment score is ten (10) or above, the resident is at risk for falls and a plan of care will be developed with approaches in an attempt to prevent falls, including falls with serious injury .Approaches to prevent falls and/or fracture may include: . Encouraging the resident to ask for assistance .scheduled toileting programs .assisting residents with ambulation as appropriate.

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident 230) receiving oxygen therapy had properly labeled nasal cannula (tubing that provides additional oxygen through the nose), pre-filled humidifier (a medical device that adds water vapor to oxygen to help prevent dry air from irritating the sinuses and lungs), and a physician's order to administer the oxygen therapy. This deficient practice caused an increased risk in Resident 230 having skin breakdown and exacerbation of symptoms. Findings: A review of Resident 230's admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), cerebral infarction (a medical condition where blood flow to the brain is interrupted, causing brain tissue to die), and nicotine dependence. A review of Resident 230's Minimum Data Set (MDS - a resident assessment tool), dated 1/31/25, indicated no acute change in mental status, resident was alert and oriented, and had no indicators for psychosis. During a concurrent observation and interview on 1/27/25 at 9:35 am with Licensed Vocational Nurse (LVN) 2 in Resident 230's room, Resident 230 was lying in bed on her cell phone with the call light was within reach. During the observation, Resident 230 received oxygen at two liters via nasal cannula with a pre-filled humidifier. LVN 2 confirmed and stated Resident 230's nasal cannula and humidifier were not labeled, and both should be labeled. During concurrent interview and record review on 1/28/25 at 9:48 am with the Director of Staff Development (DSD), Resident 230's physician's orders were reviewed. The physician's orders indicated Resident 230 did not have an order for oxygen. The DSD stated she did not see the order for oxygen for Resident 230. The DSD stated there must be a physician's order for oxygen for residents diagnosed with COPD. The DSD stated the risk to Resident 230 was the special parameters for residents with COPD on oxygen may be missed. A review of the Physician's Order dated 1/28/25 timed at 10:07 am, indicated Resident 230 to receive oxygen via nasal cannula on continuous flow to maintain the oxygen saturation (measure of how well the body is oxygenating the blood) above 94% for diagnosis of COPD. During an interview on 1/29/25 at 9:07 am, the Director of Nursing (DON) stated both the nasal cannula and humidifier should be labeled with date and initials of the nurse who prepped the oxygen. The DON stated the risk to Resident 230 without labeling the nasal cannula and humidifier would be skin breakdown and the humidifier could run out which caused Resident 230 to have an exacerbation of symptoms such as shortness of breath. The DON stated when there was a respiratory diagnosis, there was a standard as needed oxygen order that was used, unless the nurse practitioner or physician had other oxygen orders. The DON stated for Resident 230, the standing order should have been initiated but it was missed upon the resident's admission. The DON stated the risk to Resident 230 without a physician's order would be the nurses could not administer the required oxygen. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 3/2017, indicated to verify there was a physician's order for oxygen administration. A review of the facility's P&P titled, Oxygen Concentrators, dated 6/2017, indicated pre-filled humidifiers should be dated and replaced weekly or as needed.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate documentation for one of six sampled residents (Resident 49), when Resident 49's tolerance of both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) were not documented with the accurate time. This deficient practice had the potential for inaccurate medical documentation and reporting of RNA treatments, which can minimize the facility's ability to recognize a change of condition and reassess Resident 49's tolerance for knee splints. Findings: A review of Resident 49's Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening blood infection) with septic shock (life-threatening drop in blood pressure), muscle wasting and atrophy (gradual decline), generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). A review of Resident 49's History and Physical (H&P) dated 11/14/24 indicated the resident lacked the capacity to make medical decisions. According to a review of Resident 49's Care Plan for Contractures revised 11/21/24, the resident was at risk for contractures related to limited mobility with impaired ROM of BUE and BLE. The care plan goal indicated Resident 49 would minimize the incidence of contractures daily for 90 days. The interventions indicated to report any abnormality to physician, RNA program as ordered, and physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) and occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation and treatment. A review of Resident 49's Minimum Data Set (MDS - a resident assessment tool) dated 10/29/25, indicated the resident had severe cognitive impairments (difficulty with or unable to make decisions, learn, remembering things), had functional limitations in range of motion (ROM) on both sides of the lower extremities (hip, knee, ankle, foot), and did not have any functional limitations in ROM on the upper extremities (UE, shoulder, elbow, wrist, hand). The MDS also indicated Resident 49 required dependent assistance from staff with toileting hygiene, showering, lower body dressing, sit to lying, sit to stand, and bed-to-chair transfers. A review of the Physician's Order Summary Report dated 1/28/25, indicated on 12/13/24 for RNAs to perform donning (put on) and doffing (take off) of bilateral (both sides) knee splints four to six hours as tolerated to prevent further tightness / contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) once a day seven days a week. A review of Resident 49's January 2025 RNA flowsheet, there was no indication of how many hours Resident 49 wore both knee splints from 1/1 to 1/27/25, for the RNA task to perform donning/doffing of bilateral knee splints 4 to 6 hours as tolerated to prevent further tightness/contracture once a day, seven times a week. During an observation and interview on 1/28/25 at 10:17 a.m., in Resident 49's room, Resident 49 was sitting up in a wheelchair next to the bed. Restorative Nursing Aide (RNA) 1 performed ROM exercises to Resident 49's BUE and BLE. RNA 1 stated he could not find the knee splints and did not put on the knee splints for the resident. At the conclusion of the RNA treatment, RNA 1 reviewed Resident 49's January 2025 RNA flowsheet documentation and stated, yesterday on 1/27/25, Resident 49 tolerated both knee splints for two hours only. RNA 1 did not document the splint wearing time on the RNA flowsheet. RNA 1 reviewed the front and back of the RNA flowsheet and confirmed it was not documented. RNA 1 stated Resident 49 sometimes could tolerate the splints for four hours, but sometimes she could only tolerate two hours. RNA 1 stated it should be documented how long Resident 49 was wearing the knee splints each day. RNA 1 stated there were other days Resident 49 could only tolerate two hours, but he could not remember which days because he did not document it. RNA 1 could remember that yesterday, 1/27/25, Resident 49 could tolerate wearing both knee splints for two hours. During an interview and record review on 1/28/25 at 10:51 a.m., the Physical Therapist (PT)1 stated if an RNA order indicated to put on the splints for 4 to 6 hours, it meant that the RNAs should put on the splints for 4 to 6 hours. PT 1 stated if the resident could not tolerate the splints for 4 or 6 hours, it should be documented and it should be reported to the therapy department, because it could mean that the resident may need to have therapy again to assess and adjust the splints. During a concurrent interview and record review on 1/29/25 at 9:51 a.m. with the Director of Staff Development (DSD), Resident 49's January 2025 RNA flowsheet was reviewed. The DSD stated RNA 1 did not document Resident 49 tolerated wearing both knee splints for two hours on 1/27/25. The DSD stated the RNA order for Resident 49 was to wear both knee splints for four to six hours and RNAs should document how long Resident 49 tolerated the splints each day. The DSD stated the RNA documentation should be accurate and include how long Resident 49 could tolerate the splints, because documentation should reflect what happened to the resident during RNA treatment. During an interview on 1/29/25 at 2:22 p.m., the Director of Nursing (DON) stated the RNA program was established by therapy and the program helped the residents to maintain their strength and function. The DON stated it was important for the RNAs to follow the RNA orders. The DON stated RNAs needed to document accurately to reflect what was happening during RNA treatment including how long a resident was wearing a splint. A review of the facility's policy and procedure (P&P) titled, Documentation Principles, dated 11/17, indicated resident's health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident. Entries must be accurate .specific - definite .descriptive - adequately explained.

Based on observation, interview and record review, the facility failed to ensure two of 32 sampled resident rooms (room [ROOM NUMBER] and 125) met the minimum space requirements of 80 square feet for each resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents in rooms [ROOM NUMBERS]. Findings: During an initial tour observation of the facility on 1/27/2025 from 9 AM to 11:20 AM, nursing staff were observed with enough space to provide care to the residents in each facility room. A review of a facility letter submitted to the Department, dated 1/27/2025, by the Administrator (ADM), indicated the facility requested a room variance for two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). The letter indicated that upon measurement, the rooms were slightly smaller than required, but the rooms had adequate space for the residents. The letter indicated the rooms were in accordance with the special needs of residents and would not have an adverse effect on the residents' health and safety or impede the ability of any resident in the room to attain his/her highest practicable well-being, The minimum square footage for a two (2) bedroom was 160 square feet. The minimum square footage for a three (3) bedroom was 240 square feet. The room waiver indicated rooms [ROOM NUMBERS] measurements were as follows: Room number Room size Number of Beds 102 158.35 square feet 2 125 229.54 square feet 3 During an interview on 1/30/2025 at 7:50 AM, Licensed Vocational Nurse (LVN) 1 stated he was taking care of the residents in room [ROOM NUMBER]. LVN 1 stated the room was a bit smaller when compared to other rooms but that the space was not an issue. LVN 1 stated the space in room [ROOM NUMBER] did not interfere with his ability to care for the residents in the room. During an interview on 1/30/2025 at 1:28 PM, Certified Nursing Assistant (CNA) 1 stated he was taking care of the residents in room [ROOM NUMBER]. CNA 1 stated he did not have any concerns about the amount of space in room [ROOM NUMBER] and that he felt the room was a good size. During a concurrent observation and interview on 1/30/2025 at 1:41 PM, in room [ROOM NUMBER], Resident 25 was observed being assisted by CNA 2 to her wheelchair. A dresser and bedside table were observed next to Resident 25's bed. Resident 25 stated she had no complaints about the space in her room and that she felt she had a good amount of space for her belongings. CNA 2 stated she was able to move Resident 25 in and out of her wheelchair without problems. CNA 2 stated she was fine with the amount of space in room [ROOM NUMBER]. During a concurrent observation and interview on 1/30/2025 at 2:10 PM, in room [ROOM NUMBER], Resident 27 was observed sitting on the side of his bed. A dresser and bedside table were observed next to Resident 27's bed. A wheelchair was observed on the wall across from Resident 27's bed. Resident 27 stated he had no problems with his room or the space in his room. Resident 27 stated the nursing staff was able to move him around in his wheelchair in the room.

Based on interview and record review, the facility failed to ensure for one of four sampled residents (Resident 1) who had a change in condition (CIC- is a sudden significant deviation from a patient's baseline in physical, cognitive mental ability to make decisions), manifested by chest congestion (abnormal or excessive accumulation of a body fluid), and productive cough, was assessed without a delay in treatment by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) immediately checked Resident 1's vital signs (blood pressure [BP], heart rate [HR], respirations [RR], oxygen saturation [O2 Sat - amount of oxygen in the blood] and temperature [Temp]) when Certified Nursing Assistant 2 (CNA 2) informed LVN 3 that Resident 1 had a change in condition on [DATE] at around 7:30 AM. 2. Ensure LVN 3 immediately informed a Registered Nurse 1 (RN) on duty when Resident 1 had a CIC and Resident 1's chest was congested and had a productive cough (a cough that produces mucus) on [DATE] at around 7:30 AM. 3. Ensure RN 1 immediately checked and assessed Resident 1's BP, HR, RR, O2 Sat, and Temp, and performed chest auscultation (listening to the sounds of the lungs and heart) in accordance with the resident's care plan (CP- a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient), after LVN 3 informed RN 1 that Resident 1 had a productive cough on [DATE] at 10 AM. 4. Ensure RN 1 immediately notified a medical doctor (MD) or the nurse practitioner (NP- a nurse with advanced clinical education and training) and provided an accurate assessment report that Resident 1 had a CIC with productive cough and chest congestion on [DATE] at around 7:30 AM. These deficient practices resulted in 7 hours 10 minutes delay of necessary medical services for Resident 1. On [DATE] at 2:30 PM, Resident 1 was found unresponsive (when a person does not react or able to react in a normal way when touched, spoken to) in the facility. On [DATE] at 2:40 PM, Resident 1 was transferred to a general acute care hospital (GACH) via 911. The GACH diagnosed Resident 1 with septic shock (a life-threatening condition in which a widespread infection caused organ failure and dangerously low blood pressure), severe dehydration (a life-threatening emergency that happens when the body's response to an infection damages vital organs and, often, causes death). Resident 1 died on [DATE] at 3:23 PM, two days following transfer to the GACH. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including heart transplant (the patient's own heart is either removed and replaced with the donor heart), immunodeficiency (decreased ability of the body to fight infections and other diseases) due to drugs, essential hypertension (high blood pressure), chronic kidney disease stage 4 (longstanding disease of the kidneys leading to renal failure), and quadriplegia (complete or partial loss of muscle strength that affects all four limbs and body from the neck down). A review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST - is a medical order that tells emergency health care professionals what to do during a medical crisis where the patient cannot speak for him or herself) dated [DATE], indicated, Resident 1 selected Do Not Attempt Resuscitation/DNR (allow natural death). The POLST Interventions included Selective Treatment - Goal of treating medical conditions while avoiding burdensome measures . Use medical treatment, intravenous (IV - into a vein [blood vessel] antibiotics (medication to prevent or treat infection), and IV fluids as indicated . A review of Resident 1's Physician Order Summary Report dated [DATE], indicated, Resident 1 was able to consent and/or participate in treatment plan. A review of Resident 1's Minimum Data Set (MDS - a required standardized assessment and care planning tool) dated [DATE], indicated, Resident 1 was cognitively intact (mental ability to make decisions on activities of daily living), and was dependent on staff for activities of daily living, and used wheelchair for mobility. A review of Resident 1's Nursing Notes dated [DATE] at 10 AM indicated, LVN 3 documented that Resident 1's O2 Sat was 95% (normal between 95% and 100%) on room air. However, the progress notes did not indicate LVN 3, or RN 1 also checked Resident 1's BP, HR, RR, and or assessed the resident's breath sounds (Respiratory sounds, are specific sounds generated by the movement of air through the respiratory system [lungs etc]. Lungs that are functioning normally create a smooth, soft sound, and clear sounds). A review of Resident 1's Nursing Notes on the Change of Condition (COC - is a clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains that, without intervention, may result in complications or death) dated [DATE] at 10 AM, indicated, the licensed nurses did not describe Resident 1's productive cough such as presence of phlegm (thick substance secreted from the lungs and respiratory passages) and frequency that can be indicative of a respiratory problem. The progress notes indicated LVN 3 informed Family Member for Resident 1 (FMR1) that Resident 1 had a productive cough. A review of Resident 1's Nursing Notes on the COC dated [DATE] at 10 AM, indicated, LVN 3 did not document the character, color, and amount of Resident 1's productive cough in accordance with the resident's CP. The progress notes indicated there were no additional orders to identify the root cause of the resident's symptoms of cough and chest congestion. The progress notes indicated LVN 3 informed Family Member for Resident 1 (FMR1) that Resident 1 had a productive cough. A review of Nurse Practitioner 1 (NP 1) order dated [DATE] at 10:38 AM, indicated RN 1 documented to give Resident 1 Geri-Tussin (medication for cough) 5 milliliters (mL - a unit of measure in fluid volume) by mouth every six hours as needed for cough. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - a technique that provides a framework for communication between members of the health care team and used as a tool to foster patient safety) Communication form dated [DATE] at 2:30 PM, indicated, LVN 3 documented that Resident 1 had CIC with congestion, cough, SOB, tachycardia (HR over 100 beats per minute [bpm]; normal heart rate ,d+[DATE] bpm), and difficult to arouse (lack of awareness, alertness, and wakefulness). The SBAR form indicated, Resident 1 had a productive cough (consistency and color not indicated). The SBAR indicated Resident 1's BP was ,d+[DATE] millimeters of mercury (mmHg - normal ,d+[DATE]mmHg), HR was 150 bpm (normal ,d+[DATE] bpm), RR was 30 breaths per minute (normal ,d+[DATE] breaths per minute) and Temp was 100.3 degrees Fahrenheit (F - unit of measurement: Average normal body temperature 98.6 degrees F). However, there was no SBAR dated [DATE] from 7:30 AM after CNA 3 informed LVN 3 that the resident had a CIC. A review of Resident 1's Care Plan (CP- a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) titled Alteration in respiratory function, dated [DATE] with a re-evaluation date of [DATE], indicated, Resident 1 had an alteration in respiratory function as evidence by productive cough with SOB and congestion. The CP interventions included to notify the MD to obtain Lab orders, assess Resident 1's productive cough and the character and amount, color, and odor of the sputum, and the resident's breath sounds and RR. A review of MD 1 order documented by RN 1 on [DATE] at 2:50 PM, indicated MD 1 gave an order to transfer Resident 1 to GACH for SOB, lethargy (an unusual decrease in consciousness), desaturation (low oxygen level in the blood) via 911 (the telephone number used to reach emergency medical, fire, and police services). A review of Resident 1's GACH recurring laboratory (Lab) results indicated that on [DATE] at 4:58 PM, Resident 1's blood was drawn for white blood count (WBC - cells responsible for fighting infection). The same Lab results indicated Resident 1's WBC was 11.5 thousand/microliter (thous/mcL-unit of measurement: Normal range is between 4XXX,d+[DATE].5 thousand per mcL). A review of Resident 1's CP titled Periods of lethargy at risk for fall/injury dated [DATE] with a re-evaluation date of [DATE], indicated, Resident 1 had periods of lethargy at risk for fall/injury. The CP interventions included to notify the MD if Resident 1 continued to have change in level of consciousness (a state in one's awareness and alertness). A review of Resident 1's CP titled elevated temperature dated [DATE] with a re-evaluation date of [DATE], indicated, Resident 1 had an elevated temperature. The CP interventions included to administer prescribed medication, provide cooling measures (unspecified) for comfort, Lab orders, monitor vital signs, and report changes to MD. A review of Resident 1's Nursing Notes dated [DATE] at 2:30 PM, indicated that on [DATE] at 2:30 PM, LVN 3 informed FMR1 via telephone, that Resident 1's condition was deteriorating (worsening/declining), and that resident was unresponsive, was desaturation, was receiving supplemental (extra) oxygen, the resident's HR was 150 bpm, and that the resident was transferred to a GACH emergency room (ER) via 911 on [DATE] at 2:30 PM. A review of Resident 1's GACH ER records dated [DATE] at 3:15 PM, indicated, Resident 1 arrived to the GACH from the facility on [DATE] (time not specified) The Resident had altered mental status (AMS - a change in mental function) showing symptoms of with lethargy and confusion with a Glasgow Coma Scale (GCS - describes the extent of impaired consciousness; GCS score range from 3 to 15; 15 means fully awake, score of 8 or less means person is in a coma (prolonged unconsciousness brought on by illness or injury) of 7. The ER records further indicated the resident required a Bilevel ( a pressure-controlled, time-triggered, time-cycled mode of ventilation that allows unrestricted, spontaneous breathing with or without pressure support) Positive Airway Pressure (BIPAP - a small breathing device that helps a person breathe more easily) machine to assist Resident 1 with breathing. A review of Resident 1's GACH ER Laboratory result dated [DATE], indicated, Resident 1 tested positive for COVID-19 (a highly contagious respiratory disease caused by a respiratory virus). A review of Resident 1's GACH ER Lab records dated [DATE] ordered at 3:16 PM, indicated, Resident 1 was positive for Escherichia coli (E. Coli - a bacterial infection in the intestines that causes damage to the kidneys) in the blood, positive for COVID-19 through a nasal swab, and positive for Pseudomonas Aeruginosa (a bacterial infection that can cause pneumonia, and bloodstream infections) in the urine resulting in urinary tract infection (UTI - infection in the urinary system). A review of Resident 1's GACH ER Lab records dated [DATE] at 3:17 PM, indicated, Resident 1's arterial blood gas (ABG - a test that measures the balance of oxygen and carbon dioxide in the body to see how well the lungs are working) was metabolic acidosis (too much acid in the blood interfering), WBC was 10.68 thous/mcL, and lactic acid (a chemical in the body that ais produced when cells break down carbohydrates for energy) was 4.2 millimoles per Liter (mmol/L - unit of measurement; normal is between 0.5 and 2.2). A review of Resident 1's GACH ER records dated [DATE] at 3:27 PM, indicated, Resident 1 had an electrocardiogram (ECG or EKG - a quick test to check the heart rhythm), with results of sinus tachycardia (Heartbeat greater than 100 bpm; normal 60 to 100 bpm) at 135 bpm. A review of Resident 1's GACH ER diagnostic records dated [DATE] at 3:40 PM, indicated, Resident 1's chest Xray (CXR) indicated Resident 1 had pulmonary vascular congestion/edema (enlargement of the blood vessels in the lungs), and infection, plus minus atelectatic (collapse of the lungs) changes. A review of Resident 1's GACH ER diagnostic records dated [DATE] at 5:41 PM, indicated, Resident 1's computed tomography (CT - an imaging test that helps detect diseases and injuries in the body) scan of the brain, indicated the resident had bilateral (both sides) mastoid (large bone behind the ear) effusions (accumulation of fluid in response to negative pressure or inflammation). A review of Resident 1's GACH ER diagnostic records dated [DATE] at 5:43 PM, indicated, Resident 1's CT scan of the chest, abdomen, and pelvis indicated the resident had bilateral pneumonia, and volume overload which small ascites (accumulation of fluid in the abdomen) and diffused anasarca (extreme swelling throughout the entire body). A review of Resident 1's GACH ER records dated [DATE] at 6:24 PM, indicated, Resident 1's FMR1, changed Resident 1's code status from DNR to a trial of intubation and aggressive treatment but no chest compressions, shock, or dialysis. The GACH ER records indicated Resident 1 was intubated (tube insertion through mouth or nose down into the windpipe to open the airway so oxygen can get through) due to hypoxemia (low levels of oxygen in the blood), received intravenous (IV- inside a vein) fluid resuscitation of 2,000 milliliter [mL - there is 1,000 mL in one liter] of Lactated Ringer's solution (LR - fluid used to correct metabolic acidosis [buildup of acids in the body]) used during resuscitation to improve and restore intravascular volume [volume of blood in a person's cells in the body]), antimicrobial therapy for presumed sepsis (high likelihood of body responding improperly to an infection) were ordered, serial laboratory and diagnostic tests were performed. A review of Resident 1's GACH records dated [DATE] at 6:53 PM, indicated, Resident 1 . was started on remdesivir (an antiviral medication for COVID-19), dexamethasone (aid in reducing swelling in the body), vancomycin (antimicrobial antibiotic; treatment for septic shock), cefepime (antibiotic treatment of UTI) and azithromycin (treatment for COVID-19). Resident 1 was seen by heart transplant team, infection control (prevents or stops the spread of infection) team, and nephrology (kidney) team from [DATE] until [DATE]. A review of Resident 1's GACH ER's History and Physical (H&P) dated [DATE] at 11:48 PM indicated GACH diagnosed Resident 1 with acute (sudden onset) urinary tract infection (UTI - an infection of the any part of the urinary system), septic shock, COVID-19, acute encephalopathy (severe and sudden onset of brain damage), and severe dehydration (excessive loss of body fluid). A review of GACH ER records dated [DATE] at 11:53 PM, indicated, a central line (used for multiple vasoactive medications (raises the BP), and large amounts of fluids or medicines) insertion was successfully placed to Resident 1's right femoral vein (large blood vessel in the right thigh). Resident 1 was started on vasopressors (medicines that treat severely low blood pressure) after successful insertion of the central line. Resident 1's BP was ,d+[DATE] mmHg. A review of Resident 1's GACH ER diagnostic records dated [DATE] at 11:59 PM, indicated, Resident 1 underwent a heart ultrasound of the inferior vena cava (IVC - largest vein the in the body) showed IVC diameter collapsed greater than 50% (normal 0 to 5 mmHg). A review of Resident 1's GACH ER result dated [DATE] at 3:10 AM, indicated, Resident 1's cytomegalovirus DNA (CMV DNA - a test used as an aid in the management of solid organ transplant patients and to detect whether a CMV virus exists in the body) result was detected at less than 500 International Units per milliliter (IU/mL - a unit of measurement commonly used for biological activity of substances; normal range 200 to 100,000,000 IU/ mL). A review of Resident 1's GACH Coronary Care Unit (CCU - hospital unit that specializes in the care of patients with heart problems) records dated [DATE] at 7:30 AM, indicated, Resident 1's transthoracic echocardiogram (TTE - uses sound waves to create images of the heart to see how the heart beats and for any heart issues) final result was a left ventricular ejection fraction (left side of the heart showed how much oxygen-rich blood was pumped out throughout the body) was severely depressed at 20% to 25% (normal 50% to 70%), bilateral (both sides) pleural effusions (buildup of excess fluid between the layers of the lungs) are seen, and pulmonary artery systolic pressure plus right atrial pressure (right side of the heart collects venous blood from the body) was at 36 mmHg (normal 20 mmHg or less). A review of Resident 1's GACH Death Pronouncement (to make a formal declaration of the death) Note dated [DATE] at 3:24 PM, indicated, On my physician exam, the patient [Resident 1] was found to be without pulses, heart sounds (HR) or breath sounds. Pupils fixed (not reacting to light) and dilated. Patient [Resident 1] was pronounced dead on [DATE] at 3:23 PM . A review of Resident 1's GACH CCU records dated [DATE] at 4:23 PM, indicated, Resident 1 continued to decline even with aggressive medical management. FMR1 decided to transition Resident 1 to comfort care measures (provide physical, emotional, social, and spiritual support to patient and family) and end of life care (control pain and provide comfort). Resident 1 was pronounced dead on [DATE] at 3:23 PM. During a telephone interview on [DATE] at 10:36 AM with FMR1, FMR1 stated that on [DATE] left at around 5:30 pm or so, RN 1 left a voicemail message for FMR1 stating that Resident 1, was not doing well, we (facility) called 911 and [Resident 1] was taken to the hospital. FMR1 stated, no one called me about his change of conditions. FMR1 stated FMR1 returned the telephone call and a nurse (unable to remember) told FMR1 that Resident 1 was found not very responsive and that Resident 1 , seemed to be very, very weak and that was the reason the facility transferred Resident 1 to the GACH. During an interview on [DATE] at 11:11 AM with Resident 2, Resident 2 stated Resident 2 was sharing a room with Resident 1. Resident 2 stated Resident 1 sometimes would cough a lot and then it would be done in a day or two. I think it (cough) started around end of May or early [DATE]. Resident 2 stated he was not in his room when Resident 1 was sent to the GACH on [DATE] at 2:40 PM. During an interview on [DATE] at 2:21 PM with CNA 2, CNA 2 stated that on [DATE] at around 7:30 AM, CNA 2 verbally notified LVN 3 that Resident 1 was already looking off, [Resident 1] wasn't alert as usual, pale, overly tired. CNA 2 stated that on the same day, CNA 2 was feeding lunch around 12 PM and 12:30 PM to Resident 1, but Resident 1 only had a small piece of the food and didn't want any more. CNA 2 stated, I told [LVN 3] that [Resident 1] was quiet and didn't each much of anything at all. CNA 2 stated on the same day between 2:30 PM and 2:40 PM, I observed [Resident 1] to be worse compared to morning. [Resident 1's] breathing was shallow, he looked very tired, his eyes were closed, he responded only after I tried to wake him up so many times, he just gruntled (mumbled-difficult to hear/understand) and spoke softly. It was hard for him to respond. CNA 2 stated, I got the charge nurse [LVN 3] right away. During an interview on [DATE] at 3:01 PM with LVN 2, LVN 2 stated that on [DATE] at 3:01 PM, LVN 2 went to Resident 1's room to assist LVN 3 and took Resident 1's vital signs. LVN 2 stated Resident 1 had elevated temp 100.3 F. [Resident 1] was hot to touch, the breathing was abnormal, was unable to record/get the BP, HR was 150 bpm, and O2 Sat was 80%. LVN 2 stated Resident 1 was started on 15 liters of supplemental (extra) oxygen. During a record review on [DATE] at 8:30 AM of Resident 1's entire medical paper chart, there were no Labs or CXR orders received/documented from NP 1 for [DATE] for Resident 1 when the resident's CIC was reported to NP1. During a telephone interview on [DATE] at 12:18 PM with RN 1, RN 1 stated charge nurses (LVNs) are responsible for taking initial and follow up vital signs. RN 1 stated LVNs only chart if there are any change of condition to a resident, if everything is normal, nothing to chart. RN 1 stated LVN 3 notified RN 1 that Resident 1 was coughing on [DATE] around 10 AM or 11 AM . RN 1 stated that on the same day at around 2:30 PM, LVN 3 informed RN 1 that Resident 1 was experiencing SOB, and RN 1 then informed NP 1 that Resident 1 was experiencing SOB. RN 1 stated RN 1 assessed Resident 1 in the morning and at 2:30 PM. However, RN 1 was not able to provide any documentation to support Resident 1's assessment by RN 1. During a telephone interview on [DATE] at 12:59 PM with LVN 3, LVN 3 stated, if CNAs notice anything on a resident then I will document that in the resident's chart. LVN 3 stated if a resident's vital signs are abnormal or there's a change of condition (COC - a significant decline in a resident's mental, psychosocial, or physical condition). LVN 3 stated that on [DATE] at 10 AM, LVN 3 administered Geri-Tussin as per NP 1's order to Resident 1. LVN 3 stated Resident 1's cough was productive with not too thick yellow phlegm/sputum. LVN 3 stated LVN 3 did not document Resident 1's productive on the resident's nursing notes. During a telephone interview on [DATE] at 1:44 PM with LVN 3, LVN 3 confirmed and stated that CNA 2 notified LVN 3 on [DATE] at around 10 AM and 10:30 AM, that Resident 1 was coughing but did not remember if CNA 2 mentioned that Resident 1 had a change in condition. LVN 3 stated that on [DATE] at 2:30 PM, Resident 1's BP was ,d+[DATE] mmHg which LVN 3 documented on the resident's SBAR. LVN 3 stated that on [DATE] at 2:30 PM, it was very difficult to get [Resident 1's] BP, the resident had SOB and was desaturating (low oxygen levels in the blood). LVN 3 stated after listening to Resident 1's lungs, LVN 3 notified either the RN 1 or NP 1 but was not sure who I spoke to. LVN 3 stated LVN 3 did not document Resident 1's productive on the resident's nursing notes. During a telephone interview on [DATE] at 1:44 PM with LVN 3, LVN 3 stated LVN 3 only checked Resident 1's O2 Sat on [DATE] between 10 AM and 10:30 AM. LVN 3 stated LVN 3 checked Resident 1's lung sounds, it was clear. [Resident 1] coughed out yellowish phlegm not too thick sputum. LVN 3 stated if he documented all his assessments, it would have been written in the SBAR. When asked why it was important to notify RN 1, MD, or NP 1 about Resident 1's productive cough, LVN 3 stated, it could lead to more serious problems if not treated right away. When asked what could happen to Resident 1 if RN 1, MD, or NP 1 were not notified of Resident 1's COC and productive cough, LVN 3 stated, [Resident 1] could have declined (to deteriorate) further and develop lung problems which could lead to SOB, desaturation, and worsening of the cough. During a telephone interview on [DATE] at 1:44 PM with LVN 3, LVN 3 stated when Resident 1 had a fever of 99.4 F (normal Temp range 97 F to 99 F) on [DATE] at 11 AM, LVN 3 did not notify anyone (RN, MD, or NP 1). LVN 3 stated LVN 3 stated LVN 3 applied cold towel on Resident 1's forehead and ice packs under each the resident's armpit. When asked why he did not notify RNS 1 or NP 1 about the low-grade fever, LVN 3 stated, because the temperature was not over 100 F. Upon reassessment after I gave the cooling measures, Resident 1's temperature went down to about 98 F. When asked what would have happened to Resident 1 when his low-grade fever was not treated, LVN 3 stated Resident 1 may experience chills, headaches, seizures, changes in his level of consciousness. During a telephone interview on [DATE] at 1:44 PM with LVN 3, LVN 3 stated that on [DATE] at 2:30 PM, Resident 1 was difficult to arouse ,I was calling his name with a loud voice, I touched him and shook his shoulders, he did not open his eyes, he did not verbally respond to me and immediately notified RN 1 of Resident 1's CIC condition. LVN 3 stated other nurses came into Resident 1's room to assist. LVN 3 stated he used the sphygmomanometer (manual blood pressure) to check on Resident 1's BP but was not able to get any readings. LVN 3 stated he asked other nurses to check on Resident 1's BP but the nurses was not able to get any BP readings on Resident 1. LVN 3 stated that on the same day at 2:30 PM, Resident 1's HR was 150 bpm, RR 30 per minute, O2 Sat was 82%, Temp was 100.3 F. LVN 3 stated the resident's blood glucose was checked but LVN 3 could not remember the reading. LVN 3 stated Resident 1 was administered supplemental oxygen of 15 liters using the non-rebreather mask (medical device that delivers high concentration of oxygen). LVN 3 stated CPR was not performed because Resident 1 was a do not resuscitate (DNR - no resuscitation attempt when the heart or breathing stops). During an interview on [DATE] at 2:56 PM with RN 1, RN 1 stated LVN 3 did not notify RN 1 that Resident 1 had a productive cough, [LVN 3] told me [Resident 1] is coughing. RN 1 did not ask LVN 3 the description of Resident 1's productive cough. RN 1 stated, if [LVN 3] told me the resident's cough was productive, right away I will request for a chest x-ray (CXR) order, check the lung sounds, do blood draws and .to check on the resident's oxygen saturation. RN 1 stated RN 1 visually assessed Resident 1 for SOB and none was noted. RN 1 stated, I saw [Resident 1's] chest rising and normal breathing. I listened to [Resident 1's] lung sounds and was normal. RN 1 stated RN 1 checked on Resident 1 two times before lunch, there was nothing abnormal . RN 1 stated LVN 3 did not notify RN 1 that Resident 1's Temp was 99.4 degrees F on [DATE] at 11 AM. RN 1 stated a temp of 99.4 degrees F means a possible infection is coming or already here. RN 1 stated she would have requested MD or NP for CXR order to see if Resident 1 had lung infection and blood work to check if his white blood count (white blood cells fight infection) was high. RN 1 stated RN 1 would have checked if Resident 1 was dehydrated (losing more fluid than taking in) when urine output was low, decreased food intake, high HR, and the low BP. During a concurrent observation of the facility's iPad (small computer) and interview on [DATE] at 2:56 PM with RN 1, RN 1 stated nurses use an iPad just for texting doctors or NPs .nothing else. RN 1 searched on the iPad for messages between the nurses and NP 1 on [DATE] for 15 minutes and re-started the iPad three times. When asked RN 1 to show evidence for the conversation between nurses and NP 1, RN 1 stated the text messages, were erased; only messages from [DATE] and after, are available. The other text messages to MDs and NPs messages are all here, just NP 1 messages are gone. RN 1 was not able to show SA any communications made on [DATE] between nurses and NP 1. During a return telephone call on [DATE] at 10:37 AM from NP 1, NP 1 stated the facility's nurses contact NP 1 via text message. When asked if any of the facility nurses reported Resident 1 was having a productive cough with yellowish phlegm (sputum), NP 1 stated that on [DATE] sometime in the morning (unable to state exact time), the text communication stated only that he was congested. When NP 1 was asked if any of the nurses had informed NP 1 that Resident 1 had a fever of 99.4 F, NP 1 stated, I don't recall them (nurses) mentioning it (fever). I don't see any report about a fever for this patient. NP 1 stated that the initial communication was that the patient [Resident 1] had a cough and not a fever. Then in the afternoon, the patient was still coughing and congested, but no fever was mentioned. Labs and CXR were ordered by phone. A review of the facility's undated RN Supervisor job description (a written explanation that outlines the essential responsibilities and requirements for a specific position) indicated, RN supervisor's general duties and responsibilities included performed resident assessment, initiate emergency measures, communicates with the physician the status of the resident condition and carry out any orders. However, CXR was not performed while the resident was in the facility. A review of the facility's P&P titled Emergency Care dated ,d+[DATE] indicated, all resident change of conditions (COC). If the resident's condition has changed, the attending physician should be called and the changes that have been observed should be reported. Emergency care is to be provided as necessary . Resident's family should be notified of a change in the resident's condition . Observation of the resident at regular intervals. A review of the facility's P&P titled Physician Services and Orders dated ,d+[DATE] indicated, verbal orders must be recorded immediately in the resident's clinical record by the person receiving the order and must include the date and time of order. A review of the facility's P&P titled Certified Nursing Assistant (CNA) Notes dated ,d+[DATE], indicated, CNA shall record entries in the resident's health record after .observation of how the resident looks, feels, eats, drinks, reacts, interacts . CNAs must document their observation in the resident's chart and to report all change of conditions to the charge nurse and to document in the daily notes. A review of the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Licensed Nurses - Assessments and Notes dated ,d+[DATE] indicated, changes in the resident's condition that require a call to the physician shall be recorded by the nurse reporting; the physician shall be notified promptly and the resident representative of any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a resident. Acute conditions in the resident shall have adequate follow-up notes concerning the progress and resolution of the condition.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was identified as a high risk for falls and with a prior history of a fall, was provided with a landing mat. This deficient practice resulted in Resident 1 acquiring a laceration on her arm, breaking her pelvis bone and sacrum (base of vertebrae connected to the pelvis) on 10/3/2022 when she fell from her bed, landing on the floor. Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation. Findings: A review of Resident 1's Face sheet (admission record), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including difficulty walking and muscle weakness. A review of Resident 1's risk for fall/injury care plan initiated 7/30/2022 indicated Resident 1 was a high risk for falls and injury related to an unsteady gait, cognitive impairment (unable to make decisions), weakness, the need for assistance with walking and had a history of fall. The care plan interventions included having a front wheel walker during rehabilitation therapy and for the bed to be in the lowest position with a landing mat. A review of Resident 1's History and Physical (H&P), dated 8/1/2022, indicated Resident 1 had a history of weakness and fall without head strike, a fall with right sided hip strike, and the resident was at the facility for rehabilitation. A review of the Minimum Data Set (MDS - a comprehensive, standardized assessment and care screening tool), dated 8/5/2022, indicated Resident 1 had impaired vision, cognition was moderately impaired (decisions poor; cues/supervision required), and required extensive assistance with one-person physical assist with bed mobility, transferring, walking in room, walking in corridor, dressing, toileting, and personal hygiene. According to a review of the Admission Interdisciplinary Team note (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) dated 8/5/2022, before Resident 1's admission to the facility, the resident previously had a fall in the kitchen at home. A review of Resident 1's Fall Risk Assessment, dated 8/8/2022, indicated Resident 1 scored an 18, as a score of ten or greater indicated the resident was a high risk for falls. The fall risk assessment further indicated Resident 1 had a fall in the past three months, was chair bound, had poor vision, and required assistive devices (i.e., canes, wheelchairs, walkers, furniture). A review of the Activities of Daily Living care plan initiated 8/8/2022, indicated Resident 1 required the use of a wheelchair or front wheeled walker for ambulation (walking) and had a balance problem when moving from a seated to a standing position, walking, turning around, and moving on and off the toilet. The care plan goal indicated Resident 1 would have no incident of falls, or skin breakdown for 90 days. The care plan interventions indicated to monitor and anticipate the resident's needs, provide assistance with personal hygiene and toilet needs, maintain a safe and clutter free environment. A review of Resident 1's potential for spontaneous fractures care plan initiated 8/8/2022 indicated the resident was at risk for fractures due to a history of fractures and the aging process. The care plan interventions indicated to handle Resident 1 gently on transfer. According to a review of the Physician's Order Report dated 10/1 - 10/31/2022, on 7/30/2022, the physician ordered for Resident 1's bed to be in the lowest position with a landing mat, to minimize potential injury from spontaneous / involuntary movement from bed to landing mat. A review of the Situation, Background, Assessment, Recommendation form (SBAR - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 10/3/2022, indicated Resident 1 fell from the bed to the floor and sustained a 4 centimeters (cm) x 4 cm laceration on the arm. A review of Resident 1's nursing progress notes, dated 10/3/2022, indicated Resident 1 was found on the floor at 6:50 AM by a restorative nurse assistant. The nursing progress notes indicated Resident 1 was noted to have a skin tear on her left forearm that measured 4 x 4 cm, and the resident complained of severe pain to her left hip and left leg. A review of Resident 1's Status Post Fall assessment dated [DATE], indicated the rehab professional was unable to assess the resident due to the pain and it took five people to transfer Resident 1 back to bed. A review of the Medication Administration Record (MAR) dated 10/3/2022, indicated Resident 1 was administered Tylenol 650 milligrams (mg) by mouth at 7 AM for a pain level rated at eight out of ten (using the scale of zero to ten, ten being the most severe pain). Pain rated at an eight indicated intense pain, physical activity was severely limited, and conversing required great effort. A review of the Physician's Order dated 10/3/2022 at 7:15 AM, indicated Resident 1 was to receive steri-strips one time now applied to the forearm skin tear and to monitor for any changes for 14 days. The physician's order indicated to transfer Resident 1 to the GACH for further evaluation. According to a review of the GACH emergency department (ED) note dated 10/3/2022, Resident 1 was brought in by ambulance for an unwitnessed fall. Resident 1 stated she fell to the floor on her left side and was complaining of pain all over but especially the left side. A review of the GACH H&P dated 10/3/2022 indicated Resident 1 had an unwitnessed fall and was found to have a left pelvic fracture. A review of the GACH Imaging (X-ray) results dated 10/3/20222 indicated Resident 1 had a minimally displaced superior pelvic fracture (broken bone that shifted at the top), a nondisplaced inferior pelvic fracture (broken bone on the bottom) and a sacral fracture; broken in three different areas on the left side. A review of the facility's fracture care plan initiated 10/3/2022 (after the fall) indicated Resident 1 sustained sacral and pelvic fractures. A review of the GACH Physical Therapy (PT) Initial Evaluation dated 10/5/2022 indicated Resident 1 had three documented falls in the past noted in her chart and the PT diagnoses included a decline in function and a decline in functional tolerance, and Resident 1 had left hip pain when moved or touched. A review of the GACH discharge summary dated 10/8/2022 indicated Resident 1 was found to have a left pelvic fracture that was treated without surgery and a urinary tract infection. The resident was treated with Zosyn and Vancomycin (antibiotics) and had significant pain with movement. During an observation on 10/19/2022 at 2:13 PM, Resident 1 was in bed sleeping. The landing mat was observed on both sides of the bed with bed in low position. During an interview and concurrent record review with the Director of Rehabilitation (DOR) on 10/19/2022 at 2:32 PM, Resident 1's rehabilitation notes were reviewed. The DOR stated the resident will have PT and OT five times a week, required maximum assist with bed mobility, and was total assist with transfer sit to standing. The DOR stated Resident 1 was not able to ambulate during the evaluation. During an interview with Resident 1 on 10/19/2022 at 3:19 PM, Resident 1 stated she fell , and it took two people to get her back to bed. Resident 1 stated, I cannot walk. I am in the bed. I cannot walk. They try to force me (to do therapy), but it is very hard to do it. It's amazing what could happen in one second and your life can change. I could walk before. During an interview with Licensed Vocational Nurse (LVN) 1 on 10/20/2022 at 4:14 AM, LVN 1 stated, Restorative Nurse Assistant (RNA) 1 called her around 6:50 AM in the morning and stated Resident 1 was laying on the floor next to her bed. LVN 1 stated when she entered the room, Resident 1 was on the floor holding the bed control. When asked did Resident 1 have a landing mat, LVN 1 stated, She did not have a mat. We did not have any history of falling at that time. On 10/20/2022 at 4:30 AM, during an interview regarding Resident 1's fall on 10/3/2022, RNA 1 stated, I was passing the trays and I saw the resident lying on the floor and I called the charge nurse. She was lying on her back. She did not have a landing mat on the floor. RNA 1 stated Resident 1 Was not considered a fall risk at that time because she always called for assistance. However, Resident 1's Fall Risk Assessment, dated 8/8/2022, indicated Resident 1 scored an 18, as a score of ten or greater indicated the resident was a high risk for falls. The fall risk assessment further indicated Resident 1 had a fall in the past three months, was chair bound, had poor vision, and required assistive devices. During an interview on 11/8/2022 at 11:50 AM, the Assistant Director of Nursing (ADON) stated, The resident was a fall risk and required extensive assistance with her ADLs. During her admission she was a fall risk. When asked was it important for Resident 1 to have a landing mat, the ADON stated Yes. The landing mat is to minimize injury. The ADON further stated Resident 1 had diagnoses of osteopenia (a loss of bone mineral density that weakens bones) and because the resident was high risk for fracture due to the osteopenia, the landing mat can minimize the potential for injury. During an interview on 11/10/2022 at 2 PM, the Nurse Practitioner (NP) 1 stated she was not aware the facility had not provided Resident 1 with a landing mat. NP 1 stated, I know that she has had falls in the past and with (the most recent fall, 10/3/2022) she had a significant fracture. NP 1 stated that she typically orders the landing mat for patients with a history of repeated falls and to minimize the potential for injury. A review of the facility's policy & procedure (P&P) titled, Fall Risk/Prevention, revised 7/2017, indicated it was the policy of the facility to identify residents that are at a risk for falls and to implement a plan of care to prevent falls. The P&P indicated that for a fall risk assessment score of ten or above, the resident was at risk for falls and a plan of care will be developed with approaches in an attempt to prevent falls. A review of the facility's P&P titled, Falling Star Program, revised 7/2018, indicated its purpose was to identify residents who are a high risk for falls, and the general safety precautions and interventions should be used for residents which may include maintaining the bed in the lowest position and providing floor mats at the bedside. A review of the facility's P&P titled, Falls by a Resident, revised 7/2017, indicated if the fall risk assessment score was ten or above, the resident was at risk for falls and a plan of care will be developed with approaches in an attempt to prevent falls.

Based on observation, interview, and record review, the facility's nursing staff failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for 5 of 18 residents (6, 11, 12, 15 and 16). Resident 12, was assessed continent of both bowel and bladder function (have control over), the resident had a bowel movement in his clothes three (3) times because the staff took over 20 minutes to answer the call light. Resident 6, was assessed continent of bowel function, was told by a certified nurses aide (CNA) to have a bowel movement in the diaper because the CNA was too busy to help him go to the bathroom. This deficient practice led to Resident 12 having a bowel movement in his clothes which made him feel angry and embarrassed. During an interview with Resident 6 regarding having bowel movements in the diaper, he stated I wished I had been shot in the head, lying in a diaper with stool all over him because the staff took too long (20-30 minutes) to provide assistance. Residents 11, 15 and 16 were alert, oriented and able to make their needs known, however each resident was observed wearing a diaper throughout the survey. Residents 11, 15 and 16 agreed that different staff has encouraged them to use the bathroom in their diapers. Using the bathroom in a diaper created feelings of sadness, discomfort, embarrassment and anger. Resident 11 was left feeling uncomfortable when two Certified Nursing Assistants (CNA) were speaking a non-English language while providing care for her. Speaking a non-English language in front of the resident who spoke English, created a feeling of discomfort. Findings: a. On August 25, 2011, a review of Resident 6's clinical record disclosed the resident was originally admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), an assessment tool, dated August 11, 2011, indicated Resident 6 had good short and long term memory with no impairment in cognitive skills for daily decision making. He required limited assistance with one person physical assistance for ambulation, dressing, hygiene, and toileting. This MDS also indicated the resident was had an indwelling catheter for urine and was continent of bowel. The Bowel and Bladder Assessment, dated July 23, 2011, indicated Resident 6 was continent of bowel and bladder and no further evaluation was necessary. The Care Conference Notes, dated August 4, 2011, indicated Resident 6 was admitted with an indwelling catheter for [MEDICAL CONDITION] and [MEDICAL CONDITION] and was continent of bowel. The care plan for Activity of Daily Living (ADL), dated August 1, 2011, disclosed the staff was to provide assistance with personal hygiene and toileting, monitor and anticipate the resident's needs, keep the call light within reach and encourage independence with ADLs as possible. On August 29, 2011 at 10a.m., Resident 6 was observed ambulating with the RNA with a steady gait around station I and Station II three times. The RNA stated Resident always walks around both nurses station everyday. On August 29, 2011 at 9 a.m., during an interview, Resident 6 stated, "I wear the diaper because a few times the catheter leaked on my clothes so I feel comfortable wearing the diaper. I can get around by myself but sometimes I feel a little wobbly so I call the nurse to watch me go to the bathroom because my leg would get weak and I would just fall when I was at home. I was having really bad diarrhea and I called the CNA (he could not remember who she was) and she told me she was very busy and that I should go in the diaper, I tried to hold it but I couldn't. I had stool all over my scrotal area, the catheter and the bed it was a mess, and I was very embarrassed. He further stated I was in the Armed Services for years and I wanted to be shoot in the head, lying in that mess for over 20 minutes and I will never do that again." b. On August 25, 2011, a review of Resident 12's clinical record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), an assessment tool, dated July 29, 2011, indicated Resident 12 had good short and long term memory with no impairment in cognitive skills for daily decision making, able to understand and be understood. The resident required only supervision and set up only assistance from staff for ambulation, dressing, hygiene, and toileting. This MDS also indicated the resident was always continent (has control) of urine and bowel function. The Nursing Admission Assessment, dated August 5, 2011, indicated Resident 12 is alert and orientated and continent of bowel and bladder function. The Bowel and Bladder Assessment, dated August 5, 2011, indicated Resident 12 was always continent of bowel and bladder. The Bowel and Bladder Reevaluation Document dated December 30, 2010, March 30, 2011 and June 29, 2011 all indicated the resident was continent of bowel and bladder and the staff was to continue to provide assistance with toileting. The care plan for activity of daily living, dated June 29, 2011, disclosed the staff was to monitor and anticipate the resident's needs, provide assistance with personal hygiene and toileting, keep the call light in reach and encourage independence with ADLs as possible. On August 26, 2011 at 3:35 p.m., during an interview, Resident 12 he had fallen 2 times trying to go to the bathroom and was told to use the call light but sometimes he had to wait 20-30 minutes before a nurse comes. He stated I was having diarrhea and could not wait so he had a bowel movement in his clothes he stated he was very mad, angry and embarrassed. The resident further stated it really made him feel mad when all the nurses do is watch me walk to the bathroom. Record review of the CNA notes disclosed Resident 12 was incontinent of bowel on May 12, 2011, May 27, 2011, and on June 19, 2011 all three times on the day shift. The Call Light policy dated September 1997, disclosed "the purpose was to respond promptly to the resident's call for assistance. All nursing staff must be aware of call at all times. Answer ALL call lights promptly whether or not you are assigned to the resident. Never make the resident feel you are to busy to give assistance; offer further assistance before you leave the room, this was not done." c. On August 23, 2011, at 2:15 pm, Resident 11 stated the staff tell her to use the bathroom in her diaper. Resident 11 stated she knows when she has to use the bathroom, she tells the staff when she has to go and they tell her "go in your diaper". Resident 11 stated she feels really bad and angry when she's forced to use the bathroom in her diaper. Resident 11 stated that she doesn't like going in her diaper and she just wants the staff to help her. A review of the medical record indicated Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a Psychological Assessment Form dated April 12, 2011, Resident 11 had issues with her loss of independence, fear of future physical decline and problems adjusting to her disability. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 11 was able to express her wants and was usually understood by others. Resident 11 required total assistance with her activities of daily living and was assessed as always incontinent of bowel and bladder function. A review of the Bowel and Bladder (B & B) re-evaluation dated June 16, 2011, indicated Resident 11 was incontinent. And, it was documented that Resident 11 was not a good candidate for a retraining program due to her cognitive and physical impairment. A resident care plan dated June 16, 2011, addressed Resident 11's incontinence status. The nursing interventions indicated Resident 11 would be provided with a scheduled toileting plan and a bedside commode, however, this was not observed during the survey. According to the Licensed Personnel Progress Notes dated August 20 thru August 23, 2011, Resident 11 was alert and able to make her needs known. A review of the certified nursing assistant notes for August 2011 indicated Resident 11 was incontinent of bowel and bladder function. A facility policy and procedure on "Toileting Program" dated March 2, 2001, indicated the facility would ensure each resident capable of participating either actively or passively in a toileting program would be provided consistent services based on their individual needs. d. On August 25, 2011, at approximately 10 am, Resident 16 was observed during am care, taking a shower. While in the shower, Resident 16 had a bowel movement on the floor. On August 25, 2011, at 2:45 pm Resident 16 stated she uses the bathroom in a diaper, but knows when she has to use the bathroom. Resident 16 stated the staff never take her to the bathroom and never ask if she has to use the bathroom, but she would like to use the toilet. The resident stated when she uses the diaper it gets wet and mushy, and she doesn't like that feeling. Resident 16 stated she feels bad using a diaper. A review of the medical record indicated Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Bowel and Bladder assessment dated [DATE], indicated Resident 16 was alert and able to follow commands. However, it was indicated the resident was not a candidate for a retraining program due to her cognitive and physical impairment. The Minimum Data Set assessment dated [DATE], indicated Resident 16 had clear speech and the ability to make herself understood as well as understand others. However, Resident 16 was assessed as always incontinent of bowel and bladder function. A resident care plan dated June 10, 2011, indicated Resident 16 required assistance with her activities of daily living. The nursing interventions included to monitor the resident, to anticipate her needs and to encourage the resident's independence. A resident care plan dated June 10, 2011, addressed Resident 16 being incontinent of bowel and bladder function. The nursing interventions included assisting the resident to the toilet, offering a bedpan as needed and providing a toileting schedule or training as needed. The interventions were not implemented during the survey. According to the Care Area Assessment summary on incontinence, dated June 10, 2011, the staff was to proceed with the care plan and monitor for early intervention and management, this was not done. A review of the certified nursing assistant notes for August 2011 also indicated Resident 16 was incontinent of her bowel and bladder function. A facility policy and procedure on "Toileting Program", dated March 2, 2001, indicated residents placed on a toileting program would be evaluated and receive care and services to attain the highest practicable physical and mental well being. e. On August 25 at 10:40 am, Resident 15 stated sometimes the nurses take her to the bathroom and sometimes they don't. Resident 15 stated she puts on the call light, but some nurses encourage her to go in the diaper. A review of the medical record indicated Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A resident care plan dated May 26, 2011, addressed Resident 15 requiring assistance with her activities of daily living. The nursing interventions included providing the resident assistance with her personal hygiene and toileting needs. A physicians order dated June 25, 2011, indicated Resident 15 was to receive a bowel and bladder re-training program over a two week period. A review of the medical record failed to provide documented evidence of the program being implemented. The Minimum Data Set assessment dated [DATE], indicated Resident 15 required extensive assistance with transfers and toilet use. However, the MDS indicated Resident 15 was supposed to be on a scheduled toileting program. A resident care plan dated July 2011 addressed Resident 15 being incontinent of bowel and bladder function. The nursing interventions included the implementation of a toileting plan schedule for the resident, however, this was not observed. A review of the certified nurses notes for July and August 2011, indicated Resident 15 was incontinent of bowel and bladder function and showed no evidence that a scheduled toileting program had been implemented. On August 25, 2011, at 10:50 am, Certified Nursing Assistant 3 (CNA 3) stated Resident 15 was not on a specific scheduled toileting program, but they should offer to take the resident to the bathroom every two hours. A review of the Resident Assessment Instrument manual dated July 2010 indicated an individualized resident-centered program may decrease or prevent urinary incontinence. f. On August 23, 2011, at 2:15 pm Resident 11 stated the staff speak in different languages while providing care to her and her room mates. She stated she knows they're not supposed to do it, she doesn't like it, but it seems like some of them don't care. On August 25, 2011, at 9:40 am, two Certified Nursing Assistants (CNA 4 & 5) were heard speaking a non-English language to one another while providing care for Resident 11. A facility guideline (not dated) indicated that in an effort to provide an environment of respect and comfort to the residents, all employees are to speak English while on duty. On August 25, 2011, at 2:10 pm, CNA 4 and 5 agreed that they were not supposed to speak a non- English language while providing care for the resident. They agreed that speaking a language the residents cannot understand could make them feel uncomfortable.