Every finding on record at Hollenbeck Palms

Based on interviews and record reviews, the facility failed to ensure that the resident's medical record was complete and accurately documented for one (1) of two sample residents (Resident 1) in accordance with the facility's Policy and Procedures (P&P) titled Record Content when:Resident 1's Medication Administration Record (MAR, official legal document used in healthcare settings to track all the prescription and over-the-counter medicines given to a patient) indicated that Resident 1 received Boost at 8:00 AM and 1:00 PM on 11/07/2025, while the resident was out of the facility for a medical appointment on 11/07/2025 from 8 AM to 2 PM.License Vocational Nurse (LVN) 1 documented in Resident 1's MAR Resident 1's pain was assessed at 10:49 AM, provided non-pharmacological interventions (NPI, any treatment, therapy, or lifestyle change used to prevent or manage health conditions, relieve pain, or improve well-being without using medication) by sending Resident 1 to activities and Restorative Nursing Assistant (RNA, helps patients improve and maintain physical mobility, recover from injuries, and perform daily tasks), and documented the interventions as effective while the resident was out of the facility for a medical appointment on 11/07/2025 from 8 AM to 2 PM.LVN 2 documented in Resident 1's MAR the skin/wound assessment, provided wound treatment, and assessed and measured Resident 1's wound on 11/07/2025 at 10:36 AM while Resident 1 was out for a medical appointment on 11/07/2025 from 8 AM to 2 PM. These deficient practices had the potential to result in inaccurate medical records and compromise continuity of care by preventing staff from determining whether the residents ordered care, treatments, assessments, and nutritional supplements were provided.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of heart failure (heart unable to pump blood enough to meet the body's need), dementia (a progressive brain disorder that slowly destroys memory and thinking skills) and Alzheimer's disease (a brain disorder that destroys memory and other important mental functions). During a review of Resident 1 's Minimum Data Set (MDS-a resident assessment tool), dated 9/25/2025, the MDS indicated Resident 1 had severe impairment; cognitive (the mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. It also Resident 1 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity) on eating, personal hygiene (the ability to maintain personal hygiene). During a record review of Resident 1's Order Summary Report dated ordered 10/29/2025 at 3:40 PM indicated appointment with medical doctor (MD) for 11/7/2025 at 9:50 AM. During a record review of Resident 1's Progress Notes dated 8/11/2026 at 10:57 AM was reviewed. The Progress notes indicated on 11/7/2025 at 8:16 AM Resident 1 went to MD's appointment via wheelchair alert oriented accompanied by facility staff. The Progress Notes also indicated on 11/7/2025 at 2:29 PM Resident 1 came back to the facility from MD appointment. During a concurrent interview and record review on 8/11/2026 at 2:09 PM with LVN 1, Resident 1's MAR for the month of 11/1/2025 to 11/30/2025 was reviewed. LVN 1 stated the MAR indicated, a pain assessment was conducted on 11/7/2025 on day shift (7 AM to 3 PM) and it showed Resident 1 did not have any pain. During a concurrent interview and record review on 8/11/2026 at 2:11 PM with LVN 1, Resident 1's MAR for the month of 11/1/2025 to 11/30/2025 was reviewed. LVN 1 stated the MAR indicated on 11/7/2025, during the day shift, a NPI was provided to Resident 1. LVN 1 stated according to Resident 1's MAR, Resident 1 was taken to activities and encouraged to take slow, deep breaths, and that it was effective on 11/7/2025, during the day shift. During a concurrent interview and record review on 8/11/2026 at 2:15 PM with LVN 1, Resident 1's MAR for the month of 11/1/2025 to 11/30/2025 was reviewed. LVN 1 stated that the MAR indicated that on 11/7/2025, during the day shift, NPI was performed. LVN 1 stated according to Resident 1's MAR, Resident 1 participated in the RNA program and music therapy (using music, singing, or instruments to help a person feel better, relax, communicate, or improve their physical and emotional well-being) on 11/7/2025, during the day shift. LVN 1 stated the MAR also indicated these interventions were effective. During a concurrent interview and record review on 8/11/2026 at 2:20 PM with LVN 1, Resident 1's MAR for the month of 11/1/2025 to 11/30/2025 was reviewed. LVN 1 stated that the MAR indicated that on 11/7/2025 at 8 AM and 1 PM, Resident 1 was given Boost Very High Calorie (HVC) chocolate flavor (a nutritional drink used to help gain or maintain weight). LVN 1 stated according to the resident's MAR, Resident 1 drank 100 percent (100%) of Boost on 11/7/2025 at 8 AM and 1 PM. During a concurrent interview and record review on 8/11/2026 at 2:35 PM, Resident 1's Wound Weekly Observation tool was reviewed with LVN 2. LVN 2 stated that the Wound Weekly Observation tool dated 11/7/2025 at 10:26 AM indicated that Resident 1's treatment and assessment were completed, and the resident's wound was measured. LVN 2 stated, I'm not sure what happened, but it looks like the documentation indicated that the resident was not in the facility when the wound weekly observation was done. LVN 2 also stated that the documentation in the wound weekly observation tool was not accurate since Resident 1 was not at the facility at that time. LVN 2 stated that it is supposed to be documented accurately in case of any change in condition and for continuity of care. During a concurrent interview and record review on 8/11/2026 at 2:58 PM, with Activity Director (AD), Resident 1's Individual Activity Participation Record for the month of 11/2025 was reviewed. AD stated according to the individual Activity Participation Record Resident 1 did not attend the activity on 11/7/2025. During a concurrent interview and record review on 8/11/2026 at 3:50 PM, with Restorative Nursing Assistant (RNA 1), of Resident 1's RNA documentation titled Ambulation for the month of 11/2025 was reviewed. The RNA documentation titled Ambulation indicated no records found that Resident 1 had RNA. RNA 1 stated Resident 1 did not participate in the RNA program on 11/7/2025 because Resident 1 was out for a doctor's appointment. During a concurrent interview and record review on 8/12/2025 at 10:34 AM, with Registered Nurse (RN 1), the facility's document titled Transportation and Off-Campus Escort Log for 11/2025 was reviewed. RN 1 stated according to the log, Resident 1 left the faciity on [DATE] at 8:00 AM and returned to the facility on [DATE] at 2:16 PM. During a concurrent interview and record review on 8/12/2026 at 11:03 AM, Resident 1's Medication Admin Audit Report dated 8/11/2026 at 1:14 PM with LVN 1 was reviewed. LVN 1 stated according to the audit report, Resident 1's pain scale monitoring was scheduled for 11/7/2025 at 7:00 AM. The administration time was 11/7/2025 at 10:49 AM and was documented on 11/7/2026 at 10:50 AM. LVN 1 stated that the Medication Admin Audit Report indicated that a NPI of Resident 1 being taken to activities and encouraged to take slow, deep breaths was attempted and participation in the RNA program and music therapy were performed with administration time at 10:45 AM, and it was documented on 11/7/2025 at 10:50 AM. During a concurrent interview and record review on 8/12/2026 at 11:15 AM, with LVN 1 Resident 1's Medication Admin Audit Report dated 8/11/2026 at 3:26 PM was reviewed. LVN 1 stated the Medication Admin Audit Report indicated that Boost VHC was scheduled 11/7/2025 at 8AM, the administration time was 11/7/205 8:26 AM and was documented 11/7/2025 at 8:28 AM. LVN 1 also stated that Boost VHC was scheduled 11/7/2025 at 1 PM, administration date 11/7/2025 at 1:08 PM and it was documented on 11/7/2025 at 1:08 PM. During an interview on 8/12/2026 at 11:20 AM with LVN 1, LVN 1 stated that I made a mistake (with the documentation in MAR for NPI, pain assessment, wound assessment and administration of Boost), sometimes we are busy. LVN 1 acknowledged mistake and stated, I am m sorry. During a concurrent interview and record review on 8/12/2026 at 11:30 AM with the Director of Nursing (DON), the facility's Policy and Procedures (P&P), dated 11/2017 and titled Record Content, was reviewed. The DON stated the P&P indicated all required records, or accurate reproductions, shall be maintained in such a form as to be legible and readily available. The P&P also indicated that complete entries must be accurate and timely (recorded within the time it was done). The DON also stated the facility did not follow its P&P; LVN 1 did not pay attention to the time of administration, or the treatment was provided and LVN 1 documentation in Resident 1 MAR was not accurate. The DON stated all documentation should be accurate.

Based on observation, interview, and record review, the facility failed to provide supervision (the act of overseeing, managing, or directing a person, group, or process to ensure tasks are completed correctly and safely) or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance [when a caregiver keeps one or two hands on the patient's body at all times to steady the patient's balance) as indicated in the Minimum Data Set (MDS, resident assessment tool) for one (1) of three (3) sampled residents (Resident 1), who had a prior history of falls. As a result, on 5/21/2026, when Resident 1 ambulated to the activity room with a four-wheeled walker (a mobility aid designed to roll alongside with a patient without the need to lift it) without assistance or supervision, Resident 1's four-wheeled walker caught on the metal floor transition strip (a piece of trim used to bridge the gap where two different types of flooring meet) at the entrance to the activity room. Resident 1 fell to the floor and sustained a left distal femur (thigh bone) fracture. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 5/21/2026 and subsequently to GACH 2 on 5/22/2026, where the resident underwent open reduction internal fixation (ORIF, a major surgery used to repair severe bone fractures that cannot be properly healed with a simple cast or splint) on 5/26/2026.Findings:Cross Reference F656 During a review of Resident 1's admission Record, dated 2/12/2019, the admission Record indicated the facility admitted Resident 1 on 2/12/2019 and readmitted to the facility on [DATE] with diagnoses that included ataxia (loss of muscle control), difficulty in walking, and repeated falls. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required supervision or touching assistance with toilet transfer, and walking 10, 50, and 150 feet. During a review of Resident 1's Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall) dated 4/29/2026, the Fall Risk Assessment indicated Resident 1 was a high risk for fall due to use of walker, prior falls, weak gait (steps are short, resident may shuffle) and overestimates (when residents/patients think they can perform tasks beyond the resident/patients' physical capacity, and the primary risks are falls and or injury) or forgets limits. During a review of Resident 1's GACH 2 Discharge (DC) Summary, dated 5/27/2026, the DC Summary indicated Resident 1's transfer from GACH 1 to GACH 2 on 5/22/2026 was for higher level of care for trauma orthopedic (a branch of medicine that focuses on diagnosing and treating injuries that affect the bones, joints, muscles, tendons, ligaments, and nerves) consult. The DC Summary indicated discharge diagnoses included status post (S/P) fall with left distal femur fracture S/P ORIF, and a history of left femur neck fracture S/P repair in 2022. The DC Summary further indicated an Assessment/Plan for Resident 1 which included the need for a complex operative fixation (using hardware to hold broken bones) of the severely comminuted (shattered) injury. The DC Summary also indicated Resident 1 had a computed tomography scan (CT scan, an imaging procedure that combines a series of X-ray [radiograph, a medical imaging test that create/produce images/pictures of structures inside the body] images taken from different angles) of the left lower extremities on 5/23/2026, which indicated an acute intra-articular fracture (a broken bone where the crack extends directly into a joint and damages the smooth cartilage) of the distal femur involving portions of the intramedullary rod (a strong metal rod that surgeons insert directly down the hollow, marrow-filled center of a broken bone), and moderate knee joint lipohemarthrosis (fat and blood mixing inside the joint cavity which happens when a bone breaks so deeply that it cracks into the joint, causing fatty bone marrow and blood to leak inside). During a concurrent observation of Resident 1 in Resident 1's room and interview on 6/10/2026 at 11:50 AM, Resident 1 was seated in a wheelchair visibly grimacing (wrinkled brows or a twisted mouth-used to express physical pain, disgust, or disapproval), and Resident 1 was holding Resident 1's left knee. Resident 1 stated Resident 1's left knee hurt. Resident 1 stated Resident 1 fell on 5/21/2026 when Resident 1's four-wheeled walker caught on the metal floor transition strip at the entrance to the activity room. Resident 1 stated the metal floor transition strip caused Resident 1 to lose balance, fall, and hit her left knee on the floor. During an interview on 6/10/2026 at 12:12 PM, the Activity Director (AD) stated Resident 1's fall incident occurred at approximately 1:40 PM on 5/21/2026 while the AD was assisting another resident (Resident 3) to the activity room, with Resident 1 following behind the AD. The AD stated when the AD turned around, the AD saw Resident 1 in the process of falling, with Resident 1's walker moving forward during the fall. The AD stated Resident 1 landed on the floor, and the AD immediately walked to Resident 1 and assisted Resident 1 sitting up on a chair. The AD reported that the AD was the only staff member in the activity room at the time of Resident 1's fall. During a concurrent interview and record review with the Licensed Vocational Nurse (LVN) 1 on 6/10/2026 at 1:27 PM, Resident 1's fall risk assessment, dated 4/29/2026, was reviewed. The fall risk assessment indicated Resident 1 was a high risk for fall due to use of the walker, prior falls, weak gait and the resident was overestimating or forgetting limits. LVN 1 stated Resident 1 was assessed at high risk for fall and Resident 1 had multiple fall incidents before the recent fall on 5/21/2026. LVN 1 stated Resident 1 required assistance when walking and should have been supervised and assisted by a Certified Nursing Assistant (CNA) on 5/21/2026 when Resident 1 was walking to the activity room to keep the resident safe. LVN 1 stated LVN 1 did not see any other staff in the activity room other than the AD when LVN 1 arrived in the activity room on 5/21/2026 after being notified of Resident 1's fall. LVN 1 stated, after Resident 1 fell to the floor, Resident 1 pointed to Resident 1's left knee with facial grimacing. LVN 1 stated upon assessment, Resident 1's left knee was observed swollen. During a concurrent observation in Resident 1's room and interview with Resident 1 on 6/10/20226 at 1:50 PM, Resident 1 was seen lying in bed resting. Resident 1 stated Resident 1 had surgery on the left knee and Resident 1 is not allowed to walk at this time. Resident 1 stated Resident 1 has not been allowed to use the walker after the fall (on 5/21/2026) and Resident 1 used the wheelchair to go around. During an interview on 6/10/2026 at 2:15 PM, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 required supervision and assistance while walking with the four-wheel walker due to Resident 1 was assessed as high risk for fall and had gait/balance problem. CNA 1 stated it is important to keep an eye on Resident 1 to ensure Resident 1 gets to where she was going safely. During a concurrent interview and review of Resident 1's MDS mobility assessment dated [DATE], with the Registered Nurse Supervisor (RN) on 6/10/2026 at 3:10 PM, Resident 1's MDS mobility assessment indicated Resident 1 required supervision or touching assistance while walking with the four-wheeled walker for Resident 1's safety. The RN stated Resident 1 required contact guard assistance, which included for staff to hold the resident while walking as indicated in Resident 1's MDS mobility assessment. During an interview on 6/10/2026 at 4:18 PM, CNA 2 stated Resident 1 no longer ambulated after the injury to Resident 1's left knee. CNA 2 stated Resident 1 required assistance to transfer from the bed to the wheelchair and from the wheelchair back to the bed. CNA 2 stated Resident 1's fall was avoidable. CNA 2 stated Resident fall could have been prevented if a staff had been supervising Resident 2 when the resident was walking to the activity room on 5/21/2026. During an interview on 6/10/2026 at 4:36 PM, the RN stated Resident 1 previously ambulated with a four-wheeled walker but after the fall (on 5/21/2026) Resident 1 is wheelchair-bound (a person who is unable to walk and relies on a wheelchair for mobility/moving freely), and required assistance for transfers between the bed and the wheelchair. The RN stated the metal floor transition strip at the entrance to the activity room posed an accident hazard for residents. During a concurrent observation of a metal floor transition strip on the floor across the entrance to the activity room and an interview with the Maintenance Service Supervisor (MSS) on 6/11/2026 at 1:40 PM, the metal floor transition strip was elevated from the floor. The MSS measured the threshold of the metal floor transition strip going in and out of the activity room. The MSS stated the metal floor transition strip was raised 3/8 of an inch toward the outside of the activity room and flat toward the inside of the activity room. During an interview on 6/11/2026 at 3:31 PM, the Registered Physical Therapist (RPT, healthcare professional who helps people improve movement, reduce pain, and regain physical function after an injury, illness, surgery, or disability) stated Resident 1 was able to walk around with the four-wheeled walker with supervision before the fall on 5/21/2026. During a review of the facility's Policy and Procedure (P&P) titled, Fall Prevention, revised 7/2024, the P&P indicated that the facility assesses residents risk for fall, follow -up and evaluate falls of residents in order to assess the residents condition; identify the reason for the fall to reduce the potential of future reoccurrence. During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 10/4/2022, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. P&P also indicated that the residents' safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P&P titled, Resident Safety - Hazardous Areas, Devices and Equipment, revised 8/2024, the P&P indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure residents safety and mitigate accident hazards to the extent possible.

Based on observation, interview, and record review, the facility failed to develop a resident centered fall care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of three (3) sampled residents (Resident 1), who had a prior history of falls. This deficient practice resulted to Resident 1 falling on the floor and transfer to General Acute Care Hospital (GACH) on 5/21/2026 and undergoing a left knee open reduction internal fixation (ORIF, a major surgery used to repair severe bone fractures that cannot be properly healed with a simple cast or splint) on 5/26/2026. Findings: During a review of Resident 1's admission Record, dated 2/12/2019, the admission Record indicated the facility admitted Resident 1 on 2/12/2019 and readmitted to the facility on [DATE] with diagnoses that included ataxia (loss of muscle control), difficulty in walking, and repeated falls. During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 3/3/2026, the MDS indicated Resident 1 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required supervision or touching assistance with toilet transfer, and walking 10, 50, and 150 feet. During a review of Resident 1's Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall) dated 4/29/2026, the Fall Risk Assessment indicated Resident 1 was a high risk for fall due to use of walker, prior falls, weak gait (steps are short, resident may shuffle) and overestimates (when residents/patients think they can perform tasks beyond the resident/patients' physical capacity, and the primary risks are falls and or injury) or forgets limits. During a review of Resident 1's GACH 2 Discharge (DC) Summary, dated 5/27/2026, the DC Summary indicated discharge diagnoses included status post (S/P) fall with left distal femur fracture S/P ORIF, and a history of left femur neck fracture S/P repair in 2022. During a concurrent observation of Resident 1 in Resident 1's room and interview on 6/10/2026 at 11:50 AM, Resident 1 was seated in a wheelchair visibly grimacing (wrinkled brows or a twisted mouth-used to express physical pain, disgust, or disapproval), and Resident 1 was holding Resident 1's left knee. Resident 1 stated Resident 1's left knee hurt. Resident 1 stated Resident 1 fell on 5/21/2026 when Resident 1's four-wheeled walker caught on the metal floor transition strip at the entrance to the activity room. Resident 1 stated the metal floor transition strip caused Resident 1 to lose balance, fall, and hit her left knee on the floorDuring an interview on 6/10/2026 at 12:12 PM, the Activity Director (AD) stated Resident 1's fall incident occurred at approximately 1:40 PM on 5/21/2026 while the AD was assisting another resident (Resident 3) to the activity room, with Resident 1 following behind the AD. The AD stated when the AD turned around, the AD saw Resident 1 in the process of falling, with Resident 1's walker moving forward during the fall. The AD stated Resident 1 landed on the floor, and the AD immediately walked to Resident 1 and assisted Resident 1 sitting up on a chair. The AD reported that the AD was the only staff member in the activity room at the time of Resident 1's fall. During a concurrent interview and record review with the Licensed Vocational Nurse (LVN) 1 on 6/10/2026 at 1:27 PM, Resident 1's fall risk assessment, dated 4/29/2026, was reviewed. The fall risk assessment indicated Resident 1 was a high risk. LVN 1 stated Resident 1 had multiple fall incidents before the recent fall on 5/21/2026. LVN 1 stated Resident 1 required assistance when walking and should have been supervised and assisted by a Certified Nursing Assistant (CNA) on 5/21/2026 when Resident 1 was walking to the activity room to keep the resident safe. LVN 1 stated LVN 1 did not see any other staff in the activity room other than the AD on 5/21/2026. LVN 1 stated Resident 1's left knee was observed swollen after the fall. During an interview on 6/10/2026 at 2:15 PM, CNA 1 stated Resident 1 required supervision and assistance while walking with the four-wheel walker due to Resident 1 was assessed as high risk for fall and had gait/balance problem. CNA 1 stated it is important to keep an eye on Resident 1 to ensure Resident 1 gets to where she was going safely. During a concurrent interview and review of Resident 1's MDS mobility assessment dated [DATE], with the Registered Nurse Supervisor (RN) 1 on 6/10/2026 at 3:10 PM, Resident 1's MDS mobility assessment indicated Resident 1 required supervision or touching assistance while walking with the four-wheeled walker for Resident 1's safety. RN 1 stated Resident 1 required contact guard assistance, which included for staff to hold the resident while walking as indicated in Resident 1's MDS mobility assessment. During an interview on 6/10/2026 at 4:18 PM, CNA 2 stated Resident 1's fall could have been prevented if a staff had been supervising the resident when the resident was walking to the activity room on 5/21/2026. During an interview on 6/11/2026 at 1:32 PM, LVN 1 stated Resident 1's care plan should have included supervision and assistance during ambulation to ensure the resident was safe and to prevent another fall. During a concurrent interview and review of Resident 1's care plan, with the Registered Nurse Supervisor (RN) 1 on 6/11/2026 at 2:26 PM, RN 1 stated Resident 1's care plan should have been more resident centered to include supervision and contact guard assistance to ensure she does not fall from unsteady gait while the resident is ambulating with her 4 wheeled walker. During a concurrent interview and review of Resident 1's care plan, with the Minimum Data Set (MDS) coordinator on 6/11/2026 at 2:30 PM, the MDS coordinator stated Resident 1's care plan should be specific to include supervision to prevent another fall incident. During a review of the facility's P&P titled, Care Plan - Comprehensive, revised 3/2025, the P&P indicated the Inter Disciplinary Team (IDT, comprised of team members from different disciplines working together, with a common purpose, to set goals, make decisions, and share resources and responsibilities) shall develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment within seven (7) days after completion of the comprehensive assessment and after each MDS assessment, except discharge assessment.

Based on interview and record review, the facility failed to notify the physician that a medication was not given as ordered for one (1) of two (2) sampled residents (Resident 1) as indicated in the facility's Policy and Procedure (P&P), titled Medication and Treatment Administration Records, when:Registered Nurse 1 (RN 1) did not notify the physician when bisoprolol fumarate (medication used to treat hypertension [high blood pressure -BP]) was not given on 10/18/2025 at 8 PM.RN 1 did not notify the physician of Resident 1's low blood pressure and heart rate (HR) readings on 10/18/2025 at 7:03 PM. This deficient practice had the potential to result in delays in the necessary care and treatment of Resident 1, which could affect the resident's overall wellbeing.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 8/24/2023 and readmitted on [DATE] with diagnoses that included but not limited to chronic congestive heart failure (CHF-a serious condition in which the heart does not pump blood as efficiently as it should, causing blood to back up and fluid to build up in the lungs, legs, and body), hypertension, and atrial fibrillation (common heart condition causing an irregular, often rapid heart rate). During a review of Resident 1's Care Plan for cardiovascular problems dated 9/22/2025, the care plan indicated to monitor the resident's vital signs as needed and to notify the doctor of significant abnormalities. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 9/25/2025, the MDS indicated Resident 1 had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet (ft-unit of measure for height, distance and short lengths). The MDS also indicated Resident 1 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for resident to complete the activity) with eating, shower/bathing self, upper and lower body dressing, putting on/taking off footwear, and oral/toileting/personal hygiene. During a review of Resident 1's Weights and Vitals Summary Record dated 10/18/2025 and timed at 7:03 PM, BP was 72/51 millimeters of mercury (mmHg-standard unit of pressure for blood pressure (low blood pressure if 90/60 mmHg or lower). During a review of Resident 1's Progress Notes dated 10/18/2025 at 9:52 PM, the progress notes indicated vital signs were BP 72/51, HR or pulse 57 beats per minute (normal HR for adults is 60 to 100 beats per minute). The progress notes did not indicate if the physician was notified. During a review of the Order Summary dated 10/31/2025, the Order summary indicated an order on 9/19/2025 for Bisoprolol Fumarate oral tablet 10 milligrams (mg-a metric unit of mass equal to one-thousandth of a gram, primarily used to measure medical dosages or nutritional supplements), give one tablet every 12 hours for hypertension and hold for systolic (top number in a blood pressure reading, measuring the maximum force of your blood pushing against artery walls when the heart contracts and beats) BP less than 110 and HR less than 60. During a phone interview on 2/24/2026 at 3:23 PM with RN 1, RN 1 stated bisoprolol was not given on 10/18/2025 for the evening dose because the resident's BP and HR were low. RN 1 stated the physician was not notified and should have been notified that bisoprolol was not given to Resident 1 and that Resident 1's BP and HR were on 10/18/2025 at 7:03 PM. RN 1 stated she did not recheck Resident 1 BP and HR after getting the low BP of 72/51 and HR of 57 beats per minute and it placed Resident 1 at risk for change in condition and delay in care or treatment that could have led to the resident's hospitalization and/ or death. During a concurrent interview and record review on 2/24/2026 at 3:35 PM with Assistant Director of Nursing (ADON), the progress note dated 10/18/2025 and timed at 9:52 PM was reviewed. ADON stated the progress notes indicated Resident 1's BP and HR were low on 10/18/2025 (specific time not indicated). ADON stated the progress notes did not indicate that RN 1 notified the physician that bisoprolol was not given and that Resident 1's BP and HR were low. ADON also stated the progress notes did not indicate that RN 1 rechecked the BP and HR. During a concurrent interview and record review on 2/24/2026 at 4 PM with the ADON, the P&P titled Medication and Treatment Administration Records, revised 1/2026, was reviewed. The P&P indicated medications and treatments shall be administered as prescribed by the physician and shall be recorded by the responsible licensed nurse as the medication and/or treatment is provided. The attending physician shall be notified in the event an order cannot be administered as prescribed. ADON stated the P&P indicated the attending physician shall be notified in the event that an order cannot be administered as prescribed and when a resident's routine medication was withheld, the explanation is to be recorded in the nurses' notes/comments. ADON stated the physician should have been notified that the bisoprolol was not given due to Resident 1's low BP and HR by RN 1. The ADON also stated RN 1 should have also documented in the resident's progress notes the reason why the bisoprolol was not given. ADON stated RN 1 did not follow the facility's P&P of notifying the doctor of Resident's low BP and HR and that Resident 1 did not receive the Bisoprolol. ADON stated this placed the resident at risk for delayed care, a change in condition that could result in paramedics (persons trained to give emergency medical care to injured or ill people outside of a hospital setting) being called, hospitalization, and even death.

Based on observation, interview and record review the facility (Facility 1) failed to clarify and continue the therapeutic diet (a specially prescribed meal plan that modifies normal eating to treat a medical condition, managing nutrients, calories, textures, or allergies for health improvement, often prescribed by doctors and planned by dietitians for things like diabetes, heart disease, kidney issues, or post-surgery recovery) for one (1) of four (4) sampled residents (Resident 1) upon admission to the facility on 9/19/2025. This failure resulted in Resident 1 receiving the incorrect diet for three (3) days (9/19/2025 to 9/23/2025) upon admission to the facility.During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of chronic (long-term) congestive heart failure (a condition where the heart muscles become too weak or stiff to pump blood efficiently causing fluid to back up in the lungs and body) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1'S Minimum Data Set (MDS - a resident assessment tool), dated 9/25/2025, the MDS indicated the resident was severely impaired (never/rarely made decision) with cognitive (ability to think, remember, and reason) skills for daily decision making. The MDS indicated, Resident 1 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two [2] or more helpers is required for the resident to complete the activity) with walking 50 feet, going from lying down to sitting on the side of the bed, rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear, personal hygiene and eating. It also indicated, Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with walking 10 feet, chair/bed-to-chair transfers and going from sitting to standing.During a concurrent interview and record review on 1/27/2026 at 1:25 PM with Assistant Director of Nursing (ADON), Resident 1's Order Summary Report dated 9/19/2025 was reviewed. Resident 1's Order Summary Report indicated an order from 9/19/2025 at 2:36 PM indicating the order confirmed by ADON for pureed diet (foods blended, whipped or mashed into a smooth, thick, pudding-like consistency that requires no chewing), pureed texture, thin liquids consistency (the consumption of liquids that have the same consistency as water an flow quickly requiring no thickeners to be added). ADON stated when she received report from Resident 1's previous skilled nursing facility (SNF 2), the report she received from an unknown staff member was that Resident 1 was on a pureed diet. During an interview on 1/27/2026 at 3:45 PM with SNF 2's Registered Nurse (RN), RN stated Resident 1's diet upon discharge from their facility was fortified (foods that have vitamins and minerals added to them that are not naturally present or were lost during processing and aims to improve nutritional quality, boost nutrient density), soft and bite sized texture and thin liquids.During an interview on 1/27/2026 at 4:11 PM with ADON, ADON stated on 9/19/2025 when she was receiving report from an unknown staff member from SNF 2, she was told that Resident 1 would need one on one feeding assistance and was on a pureed diet. ADON stated a speech therapy (ST) evaluation (a clinical assessment to determine if a person can eat and drink safely without choking, or inhaling food into their lungs) was then ordered on 9/22/2025 when Resident 1's family member told them Resident 1 was not on a pureed diet at SNF 2. During a review of Resident 1's ST Evaluation Note dated 9/23/2025, Resident 1's ST Evaluation Note indicated the ST screen was completed per nursing for a possible diet upgrade and a by mouth trial of ground mechanical soft (tender, chopped and ground foods designed to require minimal chewing and easier swallowing)/thin liquids consistency was given without any signs or symptoms of Resident 1 aspirating (the accidental breathing in of food, liquid, or stomach contents in the airway and lungs instead of swallowing them). The ST Evaluation Note also indicated Resident 1's diet was upgraded to ground mechanical soft texture. During a review of Resident 1's SNF 2 Order Summary Report dated 9/19/2025, Resident 1's SNF 2 Order Summary Report indicated Resident 1's diet for fortified diet, soft and bite sized texture, thin consistency and liberalized diet (a nutrition approach that relaxes strict dietary restrictions to allow for more freedom, flavor and enjoyment of food). During an interview on 1/28/2026 at 12:36 PM with ADON, ADON stated when a resident is transferred from another facility, the resident's diet is checked against the verbal report from SNF 2's staff they are given along with a copy of the physician orders that came with the resident. ADON stated when Resident 1 was transferred, only the resident's facesheet (admission record) and medication list were received and did not contain Resident 1's order summary report indicating any diet order and the only information she had received regarding Resident 1's diet was through verbal report. ADON further stated a last set of orders should have been sent when Resident 1 was transferred and since it wasn't received, she should have requested the documentation from SNF 2 to ensure all physician's/ discharge orders were reconciled (the structured, formal process of comparing a patient's current, comprehensive medication list [including home meds, OTCs, and supplements] with new orders at every transition of care [admission, transfer, discharge]. It aims to prevent errors like omissions, duplications, or interactions, ensuring safe, accurate, and continued care) for continuity of care for Resident 1. During a concurrent interview and record review on 1/28/2026 at 2:10 PM with ADON, the facility's policy and procedure (P&P) titled, Transfer Record/Transfer or Discharge Documentation, revised 4/2025 was reviewed. The P&P indicated admission of resident from another health care facility the transfer record: content should at least include the nursing; dietary and social information should be received with the resident. ADON stated because they did not receive all the records for Resident 1 when the resident was admitted from SNF 2 on 9/19/2025, the missing records should have been requested by the licensed nurse from SNF 2. During a review of the facility's P&P titled, Transfer Record/Transfer or Discharge Documentation, revised 4/2025, the P&P indicated, A transfer Record that is complete and accurate with resident information in sufficient detail to provide for continuity of care shall be transferred with the resident at the time of the transfer to another health care facility. The P&P further indicated, If the specified records are not received, the health information staff is to contact the facility's Discharge Planner or health information department to request these copies STAT (as soon as possible).

Based on observation, interview, and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) was set at the correct setting for two (2) of four (4) sampled residents (Residents 9 and 28) under pressure ulcer care area. This failure had the potential to result in the deterioration of Resident 9's pressure ulcer and development of Resident 28's pressure ulcer. Findings: 1. During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 8/31/2025. Resident 9's diagnoses included muscle weakness, dementia (progressive brain disorder that slowly destroys memory and thinking skills), abnormal posture, and full incontinence of feces. During a review of Resident 9's Minimum Data Set (MDS, standardized care and screening tool), dated 11/17/2025, the MDS indicated the resident was severely impaired (never/rarely made decision) with cognitive (ability to think, remember, and reason) skills for daily decision making. MDS indicated Resident 9 was dependent (helper does all the effort) on toileting and needed substantial /maximal assistance (helper does more than half of the effort) for personal hygiene. The MDS also indicated Resident 9 was at risk for developing pressure ulcer/ injuries. The MDS also indicated Resident 9's skin and ulcer/ injury treatment included pressure reducing device for bed and application of ointments/medications. The MDS also indicated Resident 9 had 1 Stage 3 pressure ulcer (full-thickness skin wound where fat may be visible, but bone, tendon, or muscle are not exposed). During a review of Resident 9's Order Summary Report, dated 12/10/2025, the Order Summary Report indicated a physician's order dated 9/10/2025 for a low air loss mattress for wound management. During a review of Resident 9's Care Plan, revised date 9/1/2025, the Care Plan indicated Resident 9 was diagnosed with full incontinence of feces, mixed incontinence, dementia. The care plan also indicated LAL mattress for wound management. During a review of Resident 9's Weights and Vitals, dated 12/12/2025, the Weights and Vitals indicated on 1/7/2025 at 11:20 AM, Resident 9's weight was 111.6 pounds (lbs. to measure weight or mass). During a review of Resident 9's Braden Scale (an assessment tool used for predicting the risk for developing pressure sores), dated 12/1/2025, the Braden Scale indicated a score of 15, meaning resident was at risk for developing pressure injury. During an observation on 12/9/2025 at 10:05 AM in Resident 9's room, observed resident lying in bed with LAL mattress set at 400 lbs. During an observation on 12/9/2025 at 10:58 AM at Resident 9's room observed resident on bed with LAL mattress was set on 400 lbs. setting. During an interview on 12/10/2025 at 1:15 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 9's LAL mattress should not be set at 400 lbs. LVN 2 stated Resident 9's weight was 111.6 lbs so the LAL mattress should be set at 100 lbs. LVN 2 stated setting the LAL incorrectly can possibly worsen Resident 9's stage 3's pressure ulcer. During an interview on 12/12/2025 at 7:49 AM with the Assistant Director of Nursing (ADON), the ADON stated the LAL mattress should always be on proper setting based on residents' weight to evenly distribute the weight and promote optimal healing. During an interview on 12/12/2025 at 7:56 AM with the Treatment Nurse (TN), TN stated setting Resident 9's LAL mattress at 400 lbs was not acceptable. TN stated it was too firm for Resident 9 which could possibly worsen the resident's Stage 3 pressure ulcer. 2. During a review of Resident 28's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of cerebral ischemia (when blood flow to the brain is reduced, cutting off oxygen and nutrients, which can damage or kill brain cells) and dementia with anxiety (a normal feeling of unease, worry or fear often a reaction to stress). During a review of Resident 28's MDS, dated [DATE], the MDS indicated the resident was severely impaired (never/rarely made decision) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 28 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with chair/bed-to-chair transfers, rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear, personal hygiene and eating.During a review of Resident 28's Order Summary Report, dated 12/12/2025, Resident 28's Order Summary Report indicated an order initiated on 6/27/2025 for Resident 28 to have a LAL, with the setting to be at the resident's current weight to maintain skin integrity (overall condition of the skin).During a review of Resident 28's Care Plan, dated 5/23/2025, Resident 28's Care Plan indicated Resident 23 was at risk for pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) and indicated an intervention for Resident 28 to have a LAL with the setting to be at the resident's current weight to maintain skin integrity. During an observation on 12/9/2025 at 9:20 AM inside Resident 28's room, Resident 28 was observed asleep in bed with her LAL setting observed to be set to around 320 lbs. During an interview on 12/11/2025 at 2:42 PM with Treatment Nurse (TN), TN stated both she and the License Vocational Nurses (LVNs) are in charge of ensuring the resident's LAL was in the correct setting. TN added the settings correlate with the resident's weight. During a concurrent interview and record review on 12/11/2025 at 2:45 PM with TN, Resident 28's electronic medical record (EMR; a digital version of a resident's paper chart containing health history, diagnoses, medications, allergies and treatment plans all stored on a computer) dated 12/17/2023 to 12/11/2025 was reviewed. Resident 28's EMR indicated Resident 28's current weight was 86.3 lbs. TN stated Resident 28's LAL being on the setting of 320 lbs on 12/9/2025 was not correct and defeats the purpose of the LAL which is to evenly distribute the resident's weight on the mattress. TN further stated if the LAL setting is not correct, it can put more pressure on the resident's bony prominences (where the bone is more noticeable or sticks out that can be felt easily and is at higher risk for pressure sores) which can lead to skin breakdown (damage to the skin and underlying tissue, ranging from minor scrapes to severe pressure ulcers caused by factors including prolonged pressure, friction, and moisture). During an interview on 12/12/2025 at 9:39 AM with the ADON, ADON stated the purpose of a LAL was to provide optimal healing for skin breakdown and even distribution around the weight of the resident. The ADON stated Resident 28's LAL being set to 300 lbs or more poses a risk of the mattress being too firm and can cause the skin breakdown over the resident's bony prominences. During a review of the facility's policy and procedure (P&P) titled, Low Air Loss Mattress, dated 6/30/2022, the P&P indicated the Low Air Loss system is a high quality and affordable air support surface suitable for very high-risk pressure ulcer prevention and treatment. It has been specifically designed for prevention of incidence of pressure ulcers and treatment of existing pressure ulcers and offers an optimal solution for pressure redistribution. The P&P also indicated under it's procedure to, Turn the Pressure Adjust Knob to set a comfortable pressure level using the weight scale as a guide.During a review of the LAL User Manual (undated), the LAL User Manual indicated under product features that, This analog (physical) control unit includes and 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 proper food handling and the food service area was maintained in a clean and sanitary manner in accordance with the facility's policy and procedure (P&P) by failing to ensure:1. One dented saltshaker was free of food residue and was not crusted.2. One pepper shaker did not contain red food residue and had a dirty label.3. 3 burgundy plate covers were not peeling, chipped, and scratched. 4. 27 black food trays were not peeling and chipped. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.Findings: During an observation in the kitchen at 8:07 AM, the saltshaker was observed to be dented and dirty with crusted food residue. During an observation in Dining room [ROOM NUMBER] at 12/11/2025 at 8:01 AM, 3 burgundy plate covers were observed to be peeling, chipped, and scratched. During an observation in Dining room [ROOM NUMBER] at 12/11/2025 at 11:49 AM, 27 black serving trays were observed to be peeling and chipped. During a concurrent observation and interview on 12/12/2025 at 10:06 AM with the Assistant Director of Nursing (ADON), the ADON stated that the saltshaker appeared rusted, dented, and crusted with dry left-over food residue. The ADON added the saltshaker's lid area was dirty with brown colored food residue. During a concurrent observation and interview on 12/12/2025 at 10:07 AM with the ADON, the ADON stated the pepper shaker was cracked and contained green colored food residue. ADON also stated this was unsanitary (dirty or unhealthy and therefore likely to cause disease). During a concurrent observation and interview on 12/12/2025 at 10:10 AM with the ADON, ADON stated the burgundy plate covers showed wear and tear (deterioration or damage of objects), with multiple areas of rubber peeling from the lid and rough edges. The ADON stated this was not acceptable. During a concurrent observation and interview on 12/12/2025 at 10:12 AM with the ADON, the ADON stated the black food trays had uneven edges, appears melted and chipped with exposed brown -color metal. ADON stated these were not acceptable, as they can possibly harbor bacteria. ADON also stated the plastic peel can possibly fall in the food. ADON also stated the residents can possibly have plastic ingestion (eating plastic) that can cause sickness or harm to residents. During a concurrent observation and interview on 12/12/2025 at 10:38 AM with the Registered Dietitian (RD) and the Director of Dining (DD), the RD stated metal saltshaker was dirty, crusted with brown colored food residue, and dented. The DD stated pepper shaker contained red food residue and had a dirty label. The DD confirmed the burgundy plate covers were observed to be peeling, chipped, and scratched and the black serving trays in Dining room [ROOM NUMBER] were observed to be peeling and chipped. The RD stated this condition was 100 percent unacceptable. RD stated this increased the risk for potential cuts to the residents and staff and could cause material contamination (foreign or unsafe materials get into the food or onto contact surfaces, making the food unsafe to eat). RD also stated that plastic peel could be ingested by residents and that damaged surface could harbor bacteria. During a concurrent interview and record review on 12/12/2025 at 10:50 AM with the RD, the facility's P&P titled, Sanitation and Infection Control Receiving and Storage, revised 5/2023 was reviewed. The RD stated that the P&P indicated all items are to be checked to detect unacceptable items, example dented, swollen or rusted can. During a concurrent interview and record review on 12/12/2025 at 10:52 AM with the RD, the facility's P&P titled, Damage Dishware, revised 5/2023 was reviewed. The RD stated the P&P indicated any plates, cups, dishes or other dishware including meal trays that are cracked, chipped, or in any way has its surface disrupted, shall be disposed of in proper manner. The P&P also indicated it is the responsibility of all persons who handle dishware to inspect for chipped or cracks on the surface. Any piece of dishware that is chipped, cracked, or had any other interruptions of the glazed surface should be immediately removed from service. The P&P also indicated meal service trays used for the resident meal should be inspected for broken or cracked corners which can be injurious to residents. These trays should be removed from service.

Based on observation, interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Residents 65 and 6) under the environment care area, had their call light within reach in accordance with the care plan. This failure had the potential to put Residents 65 and 6 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident.1. During a review of Resident 65's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of obstructive hypertrophic cardiomyopathy (when the heart muscle thickens abnormally making it hard for it to pump blood out to the body, essentially blocking the outflow) and generalized muscle weakness (a widespread lack of strength affecting many muscles throughout the body).During a review of Resident 65'S Minimum Data Set (MDS - a resident assessment tool), dated 12/11/2025, the MDS indicated the resident had intact (ability to think, remember, and reason) cognitive skills for daily decision making. Resident 65 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with personal hygiene. Resident 65 needed partial/moderate assistance (helper does less than half the effort) with walking 10 and 50 feet, chair/bed-to-chair transfers, going from lying down to sitting on the side of the bed, and upper and lower body dressing (the ability to dress and undress above and below the waist). Resident 65 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with rolling left and right in bed and needed setup or clean-up assistance (helper sets up and cleans up; resident completes activity) with eating. During a review of Resident 65's Care Plan, dated 12/6/2025, Resident 65's Care Plan indicated Resident 65 was at high risk for falls related to gait/balance problems and vision/hearing problems. The care plan interventions included were to ensure the resident's call light to be within reach and encourage the resident to use it for assistance as needed. The care plan indicated Resident 65 needs prompt response to all requests for assistance.During a concurrent observation in Resident 65 's room and interview on 12/9/2025 at 8:53 AM, Resident 65 was observed in bed. Resident 65's call light was observed wrapped around and hanging off the left siderail (adjustable metal or rigid plastic bars that attach to the bed) of the resident's bed and touching the floor. Resident 65 stated she could not reach the call light and that she has a hard time reaching for things.During a concurrent observation and interview on 12/9/2025 at 9:06 AM with Licensed Vocational Nurse 1 (LVN 1) inside Resident 65's room, Resident 65's call light was observed wrapped around and hanging off the left siderail of Resident 65's bed and touching the floor. LVN 1 stated Resident 65's call light was hanging off the left side of Resident 65's bed and was not within reach. During an interview on 12/10/2025 at 1:19 PM with LVN 1, LVN 1 stated the purpose of a call light is for the residents to be able to call for help and get assistance if needed and if a resident's call light is out of reach, it poses a risk for the resident to get up out of bed without assistance and fall. During an interview on 12/12/2025 at 9:32 AM with Assistant Director of Nursing (ADON), ADON stated the purpose of a call light is by being the priority safety lifeline of the resident to reach the staff in case of an emergency and if it is not within reach, then the resident cannot be heard and could potentially sustain a fall or change of condition. 2. During a review of Resident 6's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of muscle weakness, Acute kidney failure (when the kidneys suddenly become unable to filter waste products from the body), edema (swelling caused by too much fluid trapped in the body's tissues).During a review of Resident 6's MDS, dated [DATE], the MDS indicated the resident had intact cognitive skills for daily decision making. Resident 6 was dependent on oral hygiene, toileting hygiene, and personal hygiene. The MDS also indicated Resident 6 was dependent on toilet transfer (the ability to get on and off the toilet or commode), and from sit to lying (the ability to move from sitting on side of bed to lying flat on the bed). During a review of Resident 6's Care Plan, dated 9/13/2025, the Care Plan indicated Resident 6 was diagnosed with generalized muscle weakness. The care plan interventions included were to ensure the resident's call light to be within reach and encourage the resident to use it for assistance.During an observation on 12/09/2025 at 10 AM in Resident 6's room, Resident 6 was observed lying on bed and the resident's call light was observed on the floor.During an observation on 12/9/2025 at 10:57 AM in Resident 6's room, Resident 6 was observed lying on bed and the resident's call light was observed on the floor.During a concurrent observation and interview on 12/9/2025 at 11:20 AM with LVN 2 in Resident 6's room, Resident 6's call light was observed on the floor. LVN 2 stated Resident 6's call light should be within residents' reach all the time.During an interview on 12/12/2025 at 12:43 PM with LVN 2, LVN 2 stated call lights are supposed to be within resident's reach at all times and not on the floor. LVN 2 added the call light was the primary means of communication to alert staff when residents need assistance. LVN 2 stated unreachable call light could possibly lead to fall, unattended emergencies or trust issues, causing residents to feel neglected or helpless. During a record review of the facility's policy and procedures (P&P) titled, Use of Call light, revised 1/2019, the P&P indicated purpose was to respond to resident's call for assistance. The P&P also indicated to ensure all call lights/ hand bells are placed on the bed at all times, never on the floor or bedside stand. During a record review of the facility's P&P titled, Baseline Care Plans, revised 7/13/2022, the P&P indicated that the interdisciplinary team shall develop and implement a baseline care plan for each resident that includes the instruction needed to provide effective and person-centered care of the resident.

Based on observation, interview, and record review the facility failed to promote respect and dignity for one (1) of 1 sampled resident (Residents 19) under the dignity care area by failing to ensure that Resident 19 was free from visible food stains on her clothing and dry, crusted discharge on her left eye. This deficient practice had the potential to negatively impact Resident 19's self-esteem and psychosocial well-being (state of mental, emotional, and social health of an individual). Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was initially admitted to the facility on [DATE]. Resident 19's diagnoses included depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), difficulty in walking, and osteoarthritis (the cartilage within a joint begins to break down and the underlying bone begins to change causing reduced function and disability). During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 11/15/2025, the MDS indicated Resident 19's cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions). The MDS also indicated Resident 19 was dependent on personal hygiene (ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing /drying face and hands). During a review of Resident 19's Care Plan, revised 12/2/2025, the Care Plan indicated Resident 19's Activities of Daily Living (ADL) selfcare deficit and dependence on staff for personal hygiene. The care plan included interventions for the staff to work around her to accommodate her needs, respect her dignity and residents' rights. Other interventions were to assist out of bed and help with personal hygiene, dressing, ask resident her preference, give a choice, provide grooming, and assist with clean clothes daily as needed. During a concurrent observation and interview on 12/9/2025 at 1:50 PM at the hallway with the Activity Director (AD), Resident 19 was observed sitting in the wheelchair. Resident 19's left eye was observed with dry, yellowish colored crusted eye discharge and visible cranberry stains on her white shirt. AD stated Resident 19 should be wearing a shirt without stains and her eyes should have been cleaned and free from discharge. During an interview on 12/10/2025 at 1:38 PM with the licensed vocational nurse 2 (LVN 2), LVN 2 stated the residents should not have any food stains on their clothes. LVN 2 stated, Residents are supposed to be well kept for dignity. It is important for the residents to be properly groomed. During a concurrent interview and record review on 12/12/2025 at 8:21 AM with the Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled, Grooming and Personal Hygiene, revised 1/2010 was reviewed. The ADON stated the P&P indicated, all nursing and other skilled nursing staff have a responsibility to monitor and contribute to residents' grooming and hygiene. During a concurrent interview and record review on 12/12/2025 at 8:25 AM with the ADON, the facility's P&P titled, Baseline Care Plans revised 7/13/2022 was reviewed. The ADON stated the P&P indicated the interdisciplinary team shall develop and implement a baseline care plan for each resident that includes the instruction needed to provide effective and person-centered care of the resident. During a concurrent interview and record review on 12/12/2025 at 8:26 with the ADON, the facility's P&P title Quality of life -Dignity revised 3/2025 was reviewed. The ADON stated the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The P&P also indicated residents shall be treated with dignity and respect at all times. The Residents shall be groomed as they wish to be groomed. During an interview on 12/12/2025 at 8:32 AM with the ADON, the ADON stated lunch was served at 12 PM and the residents should be clean and well-groomed all the time. The ADON stated there should not be any food stain on the residents' clothing, and yellow, crusted, dry discharge on the residents' eyes for the purpose of maintaining the resident's dignity.

Based on observation, interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 17) under unnecessary medication care area was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 17's hours of sleep was monitored for the use of Trazodone (a medicine used to improve mood, energy, and focus), in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to place Resident 17 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the resident's mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnosis included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a natural human emotion characterized by feelings of worry, nervousness, or unease). During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 10/9/2025, the MDS indicated Resident 17's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervisions required). The MDS indicated Resident 17 required setup or clean up assistance (helper set up or cleans up) with eating. The MDS indicated Resident 17 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/off footwear and personal hygiene. Resident 17 did not have any mood symptoms. The MDS indicated Resident 17 was taking antidepressant During a review of Resident 17 's Order Summary Report dated 12/11/2025, the Order Summary Report indicated the following: Trazadone 50 milligrams (mg, unit of measurement) tablet, give 1 tablet by mouth at bedtime, for depression manifested by insomnia (inability to sleep), with order date of 11/14/2025. Trazodone 25 mg, by mouth one time a day for depression manifested by insomnia, with order date of 12/9/2025. During a concurrent record review of Resident 17 's Medication Regimen Review (MRR), dated 12/8/2025 for the month of December 2025, and interview with the Pharmacist Consultant (PC) on 12/12/2025 at 8:39 AM, the PC stated to check the effectiveness of Trazodone, Resident 17 should have had a physician's order to monitor sleep. During a concurrent record review of Resident 17's physician's orders, and interview with the Assistant Director of Nursing (ADON) on 12/12/2025 at 11:10 AM, the ADON stated Trazadone was ordered for Resident 17's inability to sleep because resident has insomnia. The ADON stated the licensed nurses should have monitored Resident 17's number of hours of sleep to monitor the effectiveness of Trazodone and the need for medication adjustment if necessary. The ADON stated Resident 17 was not and should have been monitored for hours of sleep for resident's use of Trazodone since 11/14/2025. During a review of facility's P&P, revised on 4/2025, the P&P indicated unnecessary drug is any drug used without adequate monitoring and without indications for its use. During a review of the facility's P&P titled, Psychotropic Drugs, revised on 4/2024, the P&P indicated Residents have the right to be free from chemical restraints (the use of medications such as psychotropic medications imposed for purposes of discipline or staff convenience and not required to treat the resident's medical symptoms). Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.

Based on observation, interview, and record review, the facility failed to revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one (1) of 1 sampled resident (Resident 17) under care planning care area to manage the resident's behavioral problems with manifestations of striking at staff and others, crying, and danger to self and others.This deficient practice had the potential to prevent Resident 17 from receiving care that addressed the resident's specific needs, which could negatively affect the residents' overall wellbeing.Findings:During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnosis included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a natural human emotion characterized by feelings of worry, nervousness, or unease). During a review of Resident 17's Care Plan focusing on behavior problems manifested by crying, striking at staff and others, been danger to self and others like kicking, initiated on 10/3/2025, the Care Plan indicated the following interventions: Behavior monitoring Psychiatric evaluation and follow up treatment as indicated. Will anticipate and meet needs Will encourage to attend group activities that is of interest Will explain purpose of procedure before starting During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 10/9/2025, the MDS indicated Resident 17's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervisions required). The MDS indicated Resident 17 required setup or clean up assistance (helper set up or cleans up) with eating. The MDS indicated Resident 17 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/off footwear and personal hygiene. During a review of Resident 17 's Interdisciplinary Team meeting (IDT, is a collaborative session in healthcare) notes, dated 10/9/2025, the IDT notes indicated currently has a companion who attends to her needs. During a concurrent observation and interview with Resident 17 on 12/9/2025 at 8:30 AM, Resident 17 was observed sitting in the wheelchair, and moving up and down the hallway. Resident 17 was observed alone. Resident 17 stated, I do not know their plans for me here. During a concurrent record review and interview with MDS nurse (MDSN) on 12/12/2025 at 9:16 AM, Resident 17's care plans and IDT notes, dated 10/9/2025, were reviewed. MDSN stated the IDT meeting notes indicated that Resident 17 had a companion, which was an intervention to address the resident's behavior. MDSN stated having a companion was not and should have been documented in Resident 17's care plan to manage behavior problems of crying, striking staff and others, and danger to self and others like kicking. During a concurrent record review and interview with the Assistant Director of Nursing (ADON) on 12/12/2025 at 11:26 AM, Resident 17's Care Plan was reviewed. The ADON stated all licensed nurses can initiate and revise care plans. The ADON stated Resident 17's care plan interventions to address resident's behavioral problems of striking at staff and others, crying, and danger to self and others like kicking should have included the presence of a companion with the resident at all times or during designated times as agreed upon with the Resident's representative. The ADON emphasized that updating or revising care plans is important to ensure staff members caring for Resident 17 have the necessary knowledge to provide appropriate care During a review of the facility's Policy and Procedure titled, Resident Assessment Instrument: Minimum Data Set and Comprehensive Care Plan, revised 7/13/2022, the P&P indicated comprehensive care plan is developed and revised by the IDT, with the participation of the resident and/or resident's representative, and include measurable objectives and time frames to meet the resident's needs. It also indicated care plans are updated as the resident conditions change and as revision is needed, and after each assessment, including the comprehensive and quarterly review assessment.

Based on observation, interview, and record review, the facility failed to provide grooming services for one (1) of seven (7) sampled residents (Resident 48) under activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) care area, in accordance with the facility's policy and procedures (P&P) titled Grooming and Personal Hygiene . This deficient practice resulted in Resident 48's unkempt and dirty fingernails potentially leading to skin injury, infection, and scarring.Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] with diagnosis which dementia (progressive brain disorder that slowly destroys memory and thinking skills), muscle weakness, depression (severe feelings of sadness and hopelessness). During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool), dated 11/1/2025, the MDS indicated Resident 48's cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions). The MDS also indicated Resident 48 was dependent on personal hygiene (he ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing /drying face and hands.) During a review of Resident 48's care plan initiated on 3/8/2023, date revised 11/11/2025, the care plan indicated Resident 48's ADL selfcare deficit staff to work around the resident to accommodate the resident's needs and respect her dignity and residents' rights. The care plan also indicated Resident 48 was dependent on staff for personal hygiene and intervention includes: to help with personal hygiene, provide grooming and to check nails daily and report to licensed charge nurse for any brittleness, cracked or splitting or hang nails. The care plan indicated will provide grooming and assist with clean clothes daily and as needed. During a concurrent observation of Resident 48 and interview on 12/10/2025 at 9:57 AM in the activity room with the Activity Director (AD), observed Resident 48's fingernails were jagged, and with yellowish and brownish discoloration and jagged. AD stated Resident 48's fingernails were dirty, yellowish and brownish in color. During a concurrent observation of Resident 4 and interview on 12/10/2025 at 1:42 PM with the License Vocational Nurse (LVN) 2, observed Resident 48's fingernails were jagged, with yellowish and brownish discoloration. LVN 2 stated Resident 48's nails were dirty, with brownish yellowish color substance on the nail, and the resident's fingernails were jagged. LVN 2 also stated Resident 48's fingernails need to be trimmed. LVN 2 stated this can possibly cause skin injury, and the fingernails can harbor bacteria. LVN 2 also stated Resident 48 was dependent on personal hygiene and it should have been provided by the facility staff. During a concurrent interview and record review on 12/12/2025 at 8:21 AM with the Assistant Director of Nursing (ADON), the facility's policy and procedures (P&P) titled Grooming and Personal Hygiene revised date 1/2010 was reviewed. ADON stated the P&P indicated, all nursing and other skilled nursing staff have a responsibility to monitor and contribute to residents' grooming and hygiene. ADON also stated the P&P also indicated observed nails for signs of brittleness, cracked or splitting, or hang nails; report to licensed charge nurse for follow up. The P&P also indicated check nails on daily basis and refer to the grooming nurse.

Based on observation, interview and record review, the facility failed to measure the external catheter length (insertion site to hub) for Peripherally Inserted Central Catheter (PICC, a thin, flexible tube inserted into a small arm vein and guided to a large central vein near the heart) line for one of 28 sampled residents (Resident 24), in accordance with Facility's policy and procedure (P&P) titled PICC Dressing Change. This failure had the potential to put Resident 28 at risk for PICC line dislodgement (the act of being forced or moved from a secure, fixed) and developing complications like thrombosis (the formation of a blood clot [clump of blood] inside a blood vessel [vein or artery] that blocks or slows blood flow), and infection (when harmful germs invade the body).Findings: During a review of Resident 24's admission Record, it indicated the resident was admitted to the facility on [DATE], admitting diagnoses of malnutrition, weight loss and encounter for adjustment and management of vascular access device (a thin, flexible tube placed into a blood vessel to provide long-term or repeated access for giving medications, fluids and nutrition). During a review of Resident 24's Minimum Data Set (MDS - a resident assessment tool) dated 12/1/2025, the MDS indicated Resident 24's cognitive skills for daily decision making was modified independence (some difficulty in new situations only). The MDS indicated Resident 24 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/off footwear and personal hygiene. During a review of Resident 24's Order Summary Report. dated 11/28/2025, indicated the following orders:- order of PICC line insertion with double lumen right upper arm, ordered on 11/26/2025.- Total Parenteral Nutrition (TPN, a way to give a person complete liquid nutrition directly into a vein via a catheter) feeding, infusion rate of 64 milliliters (ml, unit of measurement) per hour for 24 hours, total volume of 1536 ml per day, ordered on 11/26/2025. During a review of Resident 24's Care Plan titled TPN, dated 11/26/2025, indicated an approach to measure the external catheter length for PICC upon admission and with each dressing change. During a review of TPN/ Peripheral Parenteral Nutrition (PPN, short-term intravenous [a medical method to deliver fluids, meds, nutrients] feeding) medication record (same as intravenous therapy medication record), indicated an order for central line dressing, securement device, cap change and measure external catheter length every seven days, with order date of 12/5/2025. During a review of Resident 24's intravenous therapy medication record, for the month of December 2025, it indicated Resident 24 has a right upper arm PICC line that was inserted on 11/26/2025, with two lumens (port), and external catheter length of 39 centimeters. It also indicated the PICC line dressing, secure device, cap change and measure external catheter length every 7 days and as needed was signed on 12/9/2025 by Registered Nurse 1 (RN 1). The record did not indicate a PICC line's external catheter measurement for 12/9/2025. During an observation on 12/9/2025 at 2:02 PM, Resident 24 was in bed, with ongoing IV therapy connected to the resident's PICC line. During an observation on 12/10/2025 at 11 AM, Resident 24's PICC line in right upper arm was observed. PICC line dressing was dated 12/9/2025. During a concurrent record review of Resident 24's TPN/PPN medication record (same as intravenous therapy medication record) for the month of December 2025, and an interview with MDS nurse (MDSN) on 12/12/2025 at 10:30 AM, MDSN verified there is no measurement of Resident 24's external catheter documented on 12/9/2025. MDSN stated it is important to measure the external catheter length every after dressing changed to ensure that the PICC line was not dislodged during dressing change. During a concurrent record review of Resident 24's medical records dated 12/9/2025 to 12/12/2025, and an interview with the Assistant Director of Nursing (ADON) on 12/12/2025 at 10:43 AM, the ADON stated there is no documented evidence that Resident 24's external catheter length was measured after dressing changed on 12/9/2025. ADON stated RN 1 documented in Resident 24's progress notes on 12/9/2025 at 11:25 PM that PICC line dressing was changed, site clean, dry, and intact, no redness, swelling or pain noted. The ADON stated RN 1 did not and should have documented the length of the external catheter on that note. The ADON stated it was important to measure the external catheter length and compare it to the baseline measurement on 11/26/2026 that was 39 cm, to ensure the length is the same, and that there was no accidental pulling of the catheter during dressing change procedure. During a review of Facility's P&P titled PICC Dressing Change, dated March 2023, indicated length of external catheter is obtained upon admission and during dressing changes. The P&P also indicated to document in the medical records the date and time, site assessment and length of external catheter.

Based on observation, interview, and record review, the facility failed to ensure facility staff donned (put on) proper personal protective equipment (PPE; clothing and equipment that is worn or used to protect against hazardous substances and/or environments) prior to entering a contact isolation (a transmission based precaution used to stop germs from spreading through direct touch with a resident or indirect touch with contaminated objects in their environment) room for two (2) of nine (9) sampled residents (Residents 28 and 45) in accordance with the facility's policy and procedure (P&P) This failure had the potential to result in the spread of infection to other residents in the facility.Findings:1. During a review of Resident 28's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of cerebral ischemia (when blood flow to the brain is reduced, cutting off oxygen and nutrients, which can damage or kill brain cells) and dementia (a progressive state of decline in mental abilities) with anxiety (a normal feeling of unease, worry or fear often a reaction to stress).During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool), dated 11/23/2025, the MDS indicated the resident was severely impaired (never/rarely made decision) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 28 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with chair/bed-to-chair transfers, rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear, personal hygiene and eating. 2. During a review of Resident 45's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of atherosclerotic (the buildup of fats and cholesterol in the artery [blood vessel] walls) heart disease (problems with the heart or blood vessels) of native (original) coronary artery (one of the heart's blood vessels that wraps around it's surface, branching off the aorta [the body's largest artery] to deliver vital oxygen-rich blood to the heart muscle itself) without angina pectoris (chest pain or discomfort) and dementia. During a review of Resident 45's MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 45 needed supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) with walking 10 and 50 feet and with putting on/taking off footwear. Resident 45 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with upper and lower body dressing and eating and was independent with chair/bed-to-chair transfers, going from sitting to standing, personal hygiene and eating. During a review of Resident 45's Order Summary Report, dated 12/12/2025, Resident 45's Order Summary Report indicated an order initiated 12/5/2025 to place Resident 45 on contact isolation due to Herpes Zoster (Shingles; a painful, blistering rash caused by the reactivation of the chickenpox virus [Varicella-Zoster Virus; a highly contagious disease marked by an itchy, blister-like rash] that lies dormant in your nerves after one has had the chickenpox, appearing as a stripe or patch on only one side of the body)During a review of Resident 45's Care Plan, dated 12/5/2025, Resident 45's Care Plan indicated Resident 45 was on contact isolation due to Herpes Zoster and included an intervention to wear proper PPE. During an observation on 12/9/2025 at 8:18 AM in the hallway outside of Residents 28 and 45's room, a contact precautions sign was observed outside the room and indicated to clean hands on room entry, wear a gown on room entry, wear gloves on room entry and to clean hands when exiting. During an observation on 12/9/2025 at 9:16 AM in the hallway right outside the doorway to Residents 28 and 45's room, Certified Nurse's Aide 1 (CNA 1) was observed inside the room not wearing a gown and cleaning up around Resident 45's bed and bedside and removing and changing the linen of Resident 45's bed. During an interview on 12/9/2025 at 9:20 AM with CNA 1, CNA 1 stated he was not wearing a gown while in Residents 28 and 45's room while cleaning up around the bedside and changing the linen for Resident 45. CNA 1 stated he thought he only had to wear a gown while providing the residents with direct care. During an interview on 12/10/2025 at 3:13 PM with Infection Preventionist (IP), IP stated Resident 45 was on contact isolation for having shingles and before entering the room, staff are expected to don full PPE including a gown and gloves regardless of what they are doing inside the room. IP stated if staff do not properly don PPE prior to entering the room, it poses a risk for that staff member, especially if they are not vaccinated for chickenpox to contact the chickenpox virus themselves as well as spreading it to another resident, their co-workers or at home. During a concurrent observation and interview on 12/11/2025 at 10:40 AM outside the doorway of Residents 28 and 45's room, Licensed Vocational Nurse 1 (LVN 1) was observed inside the room not wearing a gown picking up something off the ground next to Resident 28's bedside and throwing it away in the trash can. LVN 1 stated she was not wearing a gown and should have been.During an interview on 12/11/2025 at 11:10 AM with LVN 1, LVN 1 stated that she should have been wearing a gown prior to entering Residents 28 and 45's room earlier that day since the room is under contact isolation and her not wearing a gown poses a risk for spreading infection. During an interview on 12/12/2025 at 9:34 AM with the Assistant Director of Nursing (ADON), ADON stated the expectation of staff before entering a contact isolation room is to don full PPE (gown and gloves), regardless of what they plan to do inside the room to create a barrier for infection so that they do not take whatever the resident may have outside of the room to the other residents and staff. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control - Transmission Based Precautions, revised 10/2022, the P&P indicated:A. Contact - The purpose of contact precautions is to prevent transmission of infections that are spread by direct (e.g. [for example] person-to-person) or indirect contact with the resident or environment. Contact precautions require the use of appropriate Personal Protective Equipment (PPE), including a gown and gloves upon entering the room or making contact with the resident or the resident environment.B. Gownsa. [NAME] gown upon entry into the room or cubicle.b. Gowns should also be worn when body contact with the environmental surfaces and items in the room that may be contaminated is anticipated.

Based on observation, interview, and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility failed to: 1. Ensure staff wear Personal Protective Equipment (PPE, protective clothing such as gown, gloves, goggles, mask) before administering medication to Resident 35 via gastrostomy tube (G-tube, a surgically inserted tube that provides a way to deliver nutrition, fluids, and medications directly to the stomach) on 10/24/2024. This deficient practice had the potential to result in Resident 35 developing an infection and spread of infection among staff and residents. 2. Ensure the Legionella (a type of bacteria spread through small droplets of water that can cause legionellosis [Legionnaires' Disease, a serious and potentially deadly lung infection]) Water Management Program policy and procedure was implemented when Facility lost water supply due to water main break outside the facility on 10/23/2024. This deficient practice had the potential to result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and spread of waterborne illness in the facility. 3. Ensure infection control prevention was maintained when Minimum Data Set Nurse (MDSN), Certified Nurse Assistant (CNA 5), and Restorative Nurse Assistant (RNA 1) did not perform hand hygiene (washing hands with soap and water for at least 20 seconds [time measurement] or using an alcohol-based hand sanitizer [substance used to make something clean and hygienic]) while assisting Resident 8 and Resident 24, Resident 40 and Resident 46, and Resident 10 and Resident 11 respectively with feeding. This deficient practice had the potential to result in spread of infection between residents that could compromise the health of the residents, visitors, and staff. Findings: 1. During a review of Resident 35's Admission Record, the Admission Record indicated Resident 35 was originally admitted to the facility on [DATE]. Resident 35's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a medical condition that causes weakness or an inability to move on one side of the body) affecting left side, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems). During a review of Resident 35's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/17/2024, the MDS indicated Resident 35's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 35 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear and personal hygiene. It also indicated a nutritional approach of feeding tube while in the facility. During a review of Resident 35's order summary report, dated 10/24/2024, indicated the following: Gastrostomy tube, ordered on 10/03/2024. Restorative Nurse Assistant (RNA) to apply left hand splint in the morning, ordered on 9/30/2021. During a concurrent observation on 10/23/2024 at 9:18 AM, in Resident 35's room, and interview with RNA 2, Resident 35 was sitting in wheelchair while RNA 2 was applying splint to Resident 35's left hand. RNA 2 stated she only need to wear gloves during splint application and did not need to wear gown. RNA 2 stated Resident 35's left hand need to be held while placing the splint. During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 10/24/2024 at 9:21 AM, LVN 1 was not wearing gown while obtaining Resident 35's blood pressure and prior to medication administration via Resident 35's G-tube. LVN 1 stated she had to held Resident 35's arm to place the blood pressure cuff when obtaining blood pressure. LVN 1 stated Resident 35 receives all medication through his G-tube. LVN 1 was stopped by surveyor before LVN 1 attempts to access Resident 35's G-tube. LVN 1 stated there was no signage outside Resident 35's room to alert staff and visitors regarding Resident 35's isolation precaution. During a concurrent observation and interview with Infection Preventionist (IP) on 10/24/2024 at 10:20 AM, IP stated Resident 35 has a G-tube and enhanced barrier precaution (EBP, an infection control practice that involves wearing gowns and gloves during high-contact activities with residents in nursing homes) should be applied during high contact activities such as splint application and medication administration. IP nurse verified there was no EBP signage outside Resident 35's room to alert staff and visitors to wear appropriate PPE while rendering close contact care to Resident 35. During a follow up interview on 10/24/2024 at 10:34 AM with LVN 1 and concurrent record review of Resident 35's active orders, LVN 1 verified that Resident 35 has no order for EBP. LVN 1 stated that Resident 35 has G-tube for a while now. During an interview on 10/25/2024 at 10:57 AM with Assistant Director of Nursing (ADON), she stated the facility does adhere EBP, wherein PPE, such as wearing gown, gloves, and mask, is needed during physical contact care to residents with G-tube. ADON stated Resident 35 has a G-tube and PPE should have been used when RNA applied left hand splint because it required a physical contact with Resident 35. ADON stated LVN 1 should have worn a gown when obtaining blood pressure and administering medication because the activity required close contact with Resident 35. ADON verified Resident 35 did not have an order for EBP. ADON stated EBP is important for Resident 35, so he won't catch a virus and infection because he have an external device which is the G-tube that is a quick portal entry of bacteria and virus. During a review of Facility's Policy and Procedure titled Enhanced Barrier Precautions, revised on March 2024, indicated EBP involve gown and glove use during high-contact resident care activities to those increased risk of multidrug-resistant organism (MDRO, a bacteria that does not respond to antibiotics) acquisition (example, resident with wounds or indwelling medical devices [a medical device that is left inside the body]). It indicated a physician order is obtained for EBP for residents with indwelling medical devices even if the resident is not known to be infected or colonized with EBP. It also indicated EBP should be followed when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. High-contact resident activities included the following: Dressing Providing hygiene Device care or use of feeding tube 2. During an interview on 10/23/2024 at 6:30 AM with Director of Nursing, she stated there was a main water line repair affecting water supply to the entire facility. DON stated there will be no water in faucets and toilets. During an interview on 10/25/2024 at 8:54 AM with Engineer Assistant (EA), he stated that on 10/23/2024 around 5AM, facility did not have water supply running to the facility pipes because of a main water line break outside the facility. EA stated that during that time, there was water stagnation in facility's water pipes, and there was a water pressure and temperature change when water supply came back on 10/23/2024 at 10:46 AM. EA stated that facility uses a third-party company for their water management. EA stated facility had an annual check for legionella last October 2023. EA stated the main water line incident on 10/23/2024, where in the facility did not have a running water for few hours (almost 6 hours) was a major issue and third-party company should have been called to check facility's water lines and supply to make sure it was not contaminated and for safety. During an interview on 10/25/2024 at 9:14 AM with IP, she stated Facility did not have water supply for few hours due to water main break outside the facility on 10/23/2024. She stated water should have been tested when water supply came back on 10/23/2024 to make sure there is no presence of legionella in the water that is supplying the facility and residents. IP stated water stagnation and change in water temperature is an indicative to check water for legionella. IP stated presence of legionella in the water is harmful to the residents. IP stated residents might get sick, develop pneumonia, fever, cough or get hospitalized if they consumed anything that is contaminated with legionella. During an interview on 10/25/2024 at 11:50 AM with Director of Nursing (DON), she stated that Facility has a water management team that consist of different department heads and IP. DON stated that anyone of them should have thought and called the third company in accordance with the water management program policy when Facility had a water incident on 10/23/2024. During a review of Facility's Policy and Procedure (P&P) titled, Water Management Program, revised 1/2023, the P&P indicated the identification of situations that can lead to Legionella growth, such as construction water main breaks water temperature flactuations water pressure changes water stagnation The water management program will be reviewed at least once a year or sooner if any of the following occur: There is a major maintenance or water service change. 49537 3a. During a review of Resident 24's Admission Record, the Admission Record indicated the facility admitted Resident 24 on 11/16/2023 with diagnoses that included dementia (a progressive state of decline in mental abilities), protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), hypokalemia (electrolyte imbalance that occurs when potassium [a mineral that the body needs to work properly] levels in the blood are lower than normal), and hypo-osmolality (condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (a condition where the plasma sodium [essential mineral the body needs in small amounts to maintain fluid balance] concentration is lower than normal). During a review of Resident 24's History and Physical (H&P-formal document that physicians produce through resident interview, physical exam and the summary of the testing either obtained or pending) dated 10/7/2024, the H&P indicated Resident 24 did not have the capacity to understand and make decisions. During a review of Resident 24's MDS dated [DATE], the MDS indicated Resident 24 had severe cognitive impairment. The MDS also indicated Resident 24 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating. During a review of Resident 24's Care Plan focused on ADL (Activities of Daily Living-a measure of a person's ability to care for themselves without assistance) related to advanced age, multiple health comorbidities, required assistance with ADL, initiated on 8/23/2024, indicated interventions for Eating: set up assist if resident is in the mood, if falling asleep and not feeding herself: Total feeder. During a review of Resident 8's Admission Record, the Admission Record indicated the facility admitted Resident 8 on 2/5/2020 with diagnoses that included dementia, muscle weakness (loss of muscle strength due to aging and underlying health conditions), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred causing difficulty in breathing). During a review of Resident 8's H&P dated 4/15/2023, the H&P indicated Resident 8's aspiration (accidentally inhaling food, liquid, or other material into the lungs) risk was high and had severe altered mental status (AMS-change in mental function that stems from illnesses, disorders and injuries affecting the brain). During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 had severe cognitive impairment and was dependent with eating. During an observation on 10/23/2024 at 7:48 AM at the [NAME] Dining Room, MDSN was observed assisting Resident 24 and Resident 8 with eating breakfast. MDSN was holding a glass of juice to Resident 24's mouth and held Resident's 24's utensils to feed resident. MDSN used both of her hands feeding Resident 24. MDSN then helped Resident 8, holding a cup of juice to Resident 8's mouth and held Resident 8's utensil to feed resident. MDSN did not perform hand hygiene in between helping both Resident 24 and Resident 8. 3b. During a review of Resident 46's Admission Record, the Admission Record indicated the facility admitted Resident 46 on 5/19/2023 with diagnoses that included cerebral infarction (a serious medical condition that occurs when the brain's blood supply is disrupted), dysphagia (difficulty swallowing), severe protein calorie malnutrition, adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function), and alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 46's MDS dated [DATE], the MDS indicated Resident 46 had severe cognitive impairment and was dependent with eating. During a review of Resident 40's Admission Record, the Admission Record indicated the facility admitted Resident 40 on 1/13/2020 with diagnoses that included alzheimer's disease, dementia, muscle weakness, and major depressive disorder (a mental health condition that can impact how a person feels, thinks, and behaves). During a review of Resident 40's H&P dated 4/9/2024, the H&P indicated Resident 40 did not have the capacity to understand ad make decisions. During a review of Resident 40's MDS dated [DATE], the MDS indicated Resident 40 had severely impaired cognitive skills for daily decision making and was dependent with eating. During an observation on 10/23/2024 at 7:52 AM at the [NAME] Dining Room, CNA 5 was observed assisting Resident 40 and Resident 46 with eating breakfast. CNA 5 held Resident 46's glass to assist Resident 40 to drink from the glass and held Resident 46's utensils with both hands to assist resident with feeding. CNA 5 then turned to assist Resident 40 with the resident's breakfast without performing hand hygiene. 3c. During a review of Resident 10's Admission Record, the Admission Record indicated the facility admitted Resident 10 on 3/8/2023 with diagnoses that included alzheimer's disease, dementia, dysphagia, anorexia (an eating disorder that causes people to weigh less that is considered healthy for their age and height, usually by excessive weight loss), and abnormal weight loss (losing weight without trying or unintentionally). During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 has moderately impaired cognitive skills for daily decision making and was dependent with eating. During a review of Resident 11's Admission Record, the Admission Record indicated the facility admitted Resident 11 on 12/26/2023 with diagnoses that included dementia, dysphagia, cerebral infarction, and hemiplegia and hemiparesis of the left non dominant side. During a review of Resident 11's H&P dated 12/29/2023, the H&P indicated Resident 11 did not have the capacity to understand or make decisions. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 had severe cognitive impairment and required set up or clean up assistance with eating. During an observation on 10/24/2024 at 7:43 AM in the RNA Room, RNA 1 was observed feeding Resident 10, touching, and holding Resident 10's utensils, cup, plate, and glass consecutively using both of her hands. RNA 1 then moved her chair closer to Resident 11 and started feeding resident, touching utensils, cup, plate, and glass. RNA 1 did not perform hand hygiene before assisting Resident 11. At 7:45 AM, RNA 1 moved her chair closer to Resident 10 and resumed feeding Resident 11, without performing hand hygiene. During an observation on 10/24/24 at 7:49 AM, RNA 1 left the RNA room to get Resident 11 a cup of coffee at the main dining room. RNA 1 was not observed performing hand hygiene before leaving the room. RNA 1 came back and opened a drawer in the counter, got sugar and spoon to mix in the coffee, and gave it to Resident 11. RNA 1 was further observed going to Resident 10's table, mixed the resident's food, touched Resident 10's hair and face and RNA 1 did not perform hand hygiene in between the tasks. During a concurrent observation and interview on 10/24/2024 at 7:52 AM, RNA 1 moved her chair closer to Resident 11's table, held Resident 11's water glass and utensils, RNA 1 moved her chair back closer to Resident 10's table, touched resident's wheelchair, and resumed feeding Resident 10, without performing hand hygiene before moving from Resident 11 to Resident 10. When RNA 1 was asked what step was missed when she was helping Resident 10 and Resident 11 with feeding, RNA 1 stated she did not perform hand hygiene. During an interview on 10/25/2024 at 9:10 AM with RNA 1, RNA 1 stated, if helping two (2) residents with feeding, setting up of trays were done one at time, perform hand hygiene before and after setting up Tray 1, then set up Tray 2. RNA 1 confirmed she did not perform hand hygiene after helping Resident 10 and before helping Resident 11 and every time she moved from helping both residents during breakfast on 10/24/2024. RNA 1 stated germs (microscopic bacteria, viruses, fungi that can cause disease) can be spread from one resident to another if hand hygiene was not performed and residents could get sick. During a concurrent interview and record review on 10/25/2024 at 9:25 AM with the DON, the facility's P&P titled Feeding the Resident, dated 1/2020 was reviewed. The DON stated according to their policy, staff can be assigned to help two (2) or more residents who need feeding assistance simultaneously but cannot cross meaning if staff's left hand was used to help feed Resident A on staff's left-hand side, left hand cannot be used to help Resident B who was on staff's right-hand side. If both hands were used to help Resident A, hand hygiene must be performed before helping Resident B, alcohol rub is acceptable but if hands got soiled with food, hand washing needed to be done. During the same interview on 10/25/2024 at 9:25 AM, the DON stated it was important to follow the facility's hand hygiene policy to mitigate the spread of pathogens (bacteria, virus, or other microorganism that can cause disease) from resident to resident. During a review of the facility's P&P titled Feeding the Resident revised 1/2020, the P&P indicated one (1) staff may be assigned to two (2) or more residents who need feeding assistance. The P&P also indicated to observe universal precautions (a set of hygienic practices that healthcare workers use to prevent the spread of infectious diseases and originally developed for patients with known bloodborne diseases), wash hands before assisting resident. During a review of the facility's P&P titled Standard Precautions, revised 12/2023, the P&P indicated standard precautions (a set of infection control practices that healthcare providers use to prevent the spread of diseases, are used in all healthcare settings and apply to all patients) will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. The P&P also indicated standard precautions included hand hygiene which referred to handwashing with soap (anti-microbial or non-antimicrobial) or using alcohol-based hand rubs (gels, foams, rinses) that do not require access to water.

Based on observation, interview and record review, the facility did not ensure three of six sampled resident's (Resident 37, 6, and 10) environment was free from accidental hazards (a source of danger that has the potential to cause harm) when hot water temperatures inside the resident's bathrooms were measured to be above 120 degrees Fahrenheit (F- unit of measurement for temperature). This deficient practice placed Residents 37, 6 and 10 at risk for scalding (very hot) and burns (injury related to exposure to heat or flame) related to hot water temperatures. Findings: 1. During a review of Resident 37's admission record, the admission record indicated the resident was initially admitted to the facility on [DATE] and re admitted on [DATE] with a diagnosis of aphasia (language disorder that makes it difficult to communicate with others) following cerebral infarction (a serious condition that occurs when an area of the brain tissue dies due to a lack of blood flow), difficulty in walking, hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (one-sided muscle weakness) following unspecified cerebrovascular disease (a condition that can damage brain tissue) affecting right dominant side (the side of the brain or body that is more active or used more than the other side), low back pain and anxiety disorder (condition in which a person has excessive worry and feelings of fear). During a review of Resident 37's History and Physical (H&P), dated 11/29/2023, H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 37'S Minimum Data Set (MDS - a federally mandated resident assessment care screening tool), dated 9/05/2024, the MDS indicated the resident needed partial/moderate assistance (helper does less than half the effort) with bed mobility, transfers (how resident moves to and from bed, chair, wheelchair, standing position), toilet use, personal and oral hygiene. During a review of Resident 37's Care Plan initiated on 11/27/2023 and revised on 10/23/2024 indicated, Resident 37 was at risk for communication problem. Interventions indicated, will ensure to provide a safe environment. 2. During a review of Resident 6's admission record, the admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of cerebral infarction, epilepsy (a sudden, abnormal burst of electrical activity in the brain that causes temporary changes in behavior, movement, or awareness), personal history of malignant neoplasm of breast (abnormal growth of tissue), muscle weakness and difficulty walking. During a review of Resident 6's (H&P), dated 2/29/2024, H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated the resident needed partial/moderate assistance with bed mobility, transfers, toilet use, and substantial assistance (helper does more than half the effort) for personal hygiene. 3. During a review of Resident 10's admission record, the admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height), muscle weakness, difficulty in walking, dysphagia (swallowing difficulties), constipation (a condition in which a person has uncomfortable or infrequent bowel movements), other Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and hearing loss. During a review of Resident 10'S MDS, dated [DATE], the MDS indicated the resident was dependent (helper does all of the effort) for oral, personal and toileting hygiene, showers, and transfers. During an observation in Resident 37's bathroom (shared bathroom with Resident 6) on 10/22/2024 at 8:08 AM, Resident 37 was inside bathroom using the sink washing her hands sitting on her wheelchair. Observed Resident 37 continue to try to wash hands but would quickly remove hands from running water. Resident 37 exited bathroom without fully washing her hands. During an interview with Certified Nurse Assistant (CNA2) on 10/22/2024 at 8:30 AM, CNA2 stated Residents 37, Resident 6 and Resident 10 would sometimes use their wheelchairs to wheel themselves to the bathroom to wash their hands without asking for assistance. During a concurrent observation and interview with Engineer Assistant on 10/22/2024 at 8:51 AM, Engineer Assistant using a thermometer (an instrument for measuring and indicating temperature) tested water coming out from the faucet/ sink in Resident 37 and Resident 6's bathroom. Observed Engineer Assistant test water for 3 seconds and stated, the water temperature should be below 120 Fahrenheit, right now, the thermometer is reading at 128.6 Fahrenheit. Water is hot for the residents; it would be scalding hot to touch and they can suffer a burn. During a concurrent observation and interview with Engineer Assistant on 10/22/2024 at 8:55 AM, Engineer Assistant used a thermometer and tested the water coming out from the faucet/ sink in Resident 10's bathroom and stated, the water temperature in here is 127.7 Fahrenheit. This too can place the resident at risk for a burn. During a concurrent interview with Engineer Assistant on 10/25/2024 at 3:50 PM, Engineer Assistant stated, We do not check the resident rooms water temperature, we only check the boiler temperature in the building. What happens is, that sometimes someone will complain about the water temperature, so we just adjust the boiler. I think that is how it (water from Reisdent 37, 6 and 10's bathroom sink) got so hot. Engineer Assistant also stated, they do not measure weekly and document the water temperatures in designated areas to ensure the water temperatures are within the acceptable range for resident's use. A review of the facilities Policies & Procedures (P&P) titled, Monitoring Water Temperatures-Protocol revised 4/2023 indicated, the facility recognizes potential risk for scalding and burns related to water temperatures. The Chief Engineer monitors water temperatures to minimize risk for injuries for residents, visitors, and employees. The P&P also indicated, the Chief Engineer directs weekly measurements and documentation of water temperatures in designated areas using thermometers in accordance with manufacturer guidelines. The findings will be included in the preventive maintenance program logs. The P&P indicated, scalding, and burning injuries present potential risk for residents and patients. The P&P also indicated the table below: Water Temperature Time to Receive Third Degree Burn (This type of burn destroys the outer layer of skin [epidermis] and the entire layer beneath) 100 F Safe Temperatures for Bathing* 127 F 1 minute 133 F 15 seconds 140 F 5 seconds 148 F 2 seconds 155 F 1 second In addition, the P&P indicated, burns can occur even at water temperatures below those identified in the table depending on an individual's condition and the length of exposure and based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn. A review of the facility's policy and procedure titled, Safe Environment-Resident Rights revised 10/2024, indicated, The resident has a right to a safe, clean, and comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Cross reference: F755 Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Nine (9) medication errors out of 27 total opportunities for error, to yield an overall medication error rate of 33.3 % for one (1) of five (5) residents observed for medication administration (Residents 35). Licensed Vocational Nurse 1 (LVN 1) failed to administer Resident 35's medications within 60 minutes of scheduled time of 8 AM on 10/24/2024. This deficient practice had the potential to result in Resident 35 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Resident 35'ss health and well-being to be negatively impacted. Findings: During a review of Resident 35's Admission Record, the Admission Record indicated Resident 35 was originally admitted to the facility on [DATE]. Resident 35's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a medical condition that causes weakness or an inability to move on one side of the body) affecting left side, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems). During a review of Resident 35's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/17/2024, the MDS indicated Resident 35's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 35 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 35's Physician's Order, dated 10/24/2024, the Physician's Order indicated the following: 1. Amlodipine (a medication used to treat high blood pressure) tablet 10 milligram (mg, unit of measurement), give 1 tablet via gastrostomy tube (G-tube, is a small, flexible tube that's surgically inserted into the stomach through the abdomen to provide nutrition, fluids, and medicine) one time a day for hypertension (HTN-high blood pressure). Ordered on 3/30/2023. 2. Aspirin (a medication that reduces pain, fever, inflammation, and blood clotting) chewable 81 mg, give 1 tablet via G-tube one time a day for angina (chest pain or discomfort). Ordered on 2/6/2020. 3. Carvedilol (a medication that slows down the heart rate making it easier for the heart to pump blood around the body) 25 mg, 1 tablet via G-tube two times a day, for HTN, hold if systolic blood pressure (SBP, the first and higher number in a blood pressure reading) lower than 100 and heart rate lower than 60. Ordered on 3/30/2023. 4. Isosorbide (a medication used for management of angina) tablet 30 mg, give 1 tablet via G-tube one time a day for angina. Ordered on 10/24/2024. 5. Losartan (a medication used to treat high blood pressure) 100 mg, give 1 tablet via G-tube one time a day for HTN, hold in SBP lower than 100 and heart rate lower than 60. Ordered on 3/30/2023. 6. Multivitamins with minerals liquid, give 5 milliliters (ml, unit of measurement) via G-tube one time a day for supplement. Ordered on 2/06/2020. 7. Potassium (mineral that is important for many body functions) liquid 20 milliequivalent (unit of measurement)/15 ml, give 15 ml via G-tube one time a day for supplement. Ordered on 4/17/2023. 8. Fluticasone (used to treat sneezing, itchy or runny nose) nasal (used to describe things relating to the nose) spray, 2 spray in both nostrils (one of the two holes in your nose), one time a day for allergy (overreaction to a substance that is typically harmless to most people). Ordered on 2/06/2020. 9. Artificial tears (eye drops that help relieve dry eyes), instill 2 drops in both eyes one time a day for dry eyes. Ordered on 2/06/2020. During a concurrent medication administration observation for Resident 35 and interview with LVN 1 on 10/24/2024, at 10:22 AM, LVN 1 was observed administering Resident 35's medications. LVN 1 stated that the following medications were Resident 35's scheduled medications for 8 AM: Amlodipine tablet 10 mg, 1 tablet. Aspirin chewable 81 mg, 1 tablet. Carvedilol 25 mg, 1 tablet. Isosorbide tablet 30 mg, 1 tablet. Losartan 100 mg, 1 tablet. Multivitamins with minerals liquid, 5 ml. Potassium liquid 20 MEQ/15 ml, 15 ml. Fluticasone nasal spray, 2 spray in both nostrils. Artificial tears 2 drops in both eyes. During an interview with LVN 1 at 10/24/2024 at 10:35 AM, LVN 1 verified that she administered Resident 35's 8 AM medication late because she gave them after 9 AM. She stated that medications can be administered one hour before or after the scheduled time. LVN 1 stated, If medications were not administered on time, for example blood pressure medications, it can affect the blood pressure of the residents which can cause a change in the residents' condition. During an interview on 10/24/2024 at 4:42 PM, the Assistant Director of Nursing (ADON) stated that it was important to administer medication as ordered to get the full benefit of the medication and to prevent complications of inconsistent timing of medication administration. The ADON stated their medication administration time in the morning is scheduled at 8 AM, and medications can be administered one hour before or after 8 AM. During a review of Facility's Policy and Procedure (P&P) titled, Medication and Treatment Administration Records, revised on 11/2023, the P&P indicated medications and treatments shall be administered as prescribed by the physician, times adjusted to 8:00 am, 1:00 pm, 5:00 pm and 9:00 pm. During a review of Facility's P&P titled, Administering Medications, revised on 11/14/2019, the P&P indicated medications must be administered within one (1) hour of their prescribed time.

Based on observation, interview and record review, the facility failed to ensure food were handled, prepared, and stored in a manner that prevents foodborne illness (food poisoning) for 56 of 56 residents receiving food from the facility's kitchen, by failing to ensure: 1. Food items stored in the kitchen refrigerators and freezer (thirty-eight [38] food items), walk-in freezer (eleven [11] food items), dry storage area 1 (where breads and vegetables are stored) (three [3] food items) were labeled with open date and/or use by date (last date recommended for use of the product while at peak quality), and/or expiration date and sealed after opening. 2. Two (2) dented canned products were discarded and one (1) cracked and leaking peanut butter jar was discarded from the dry storage area 2 (where canned products, sugars and jars are stored). In addition, the facility failed to ensure the container with blue lid in the dry storage area 2 was free of dirt, dust, and dead fly. 3. Expired food products were removed and discarded. 4. Temperature logs for the kitchen refrigerators and dry room was monitored and documented daily every morning and afternoon shift. These failures 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 for 56 of 56 medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation in the facility's kitchen and interview on [DATE] at 7:42 AM with the Kitchen Manager (KM) 1, the following were observed in the three kitchen refrigerators labeled #1, #2, and #4, and one freezer (#3): In Refrigerator #1, six bowls of sliced fruits and two cups white cream in one tray, the bowls and cups were not labeled with use by or expiry date (date after which something should no longer be used). In Refrigerator #1, one jar of orange guava passion fruit juice not labeled with date opened and use by date. In addition, the jar's manufacturer expiration date was partially erased. In Refrigerator #1, there were 3 stack of food trays in the 2nd shelf. The first tray on the top, contained six cups of almond milk, labeled with preparation date on [DATE] and no label of use by date. The second tray in the middle contained 21 covered cups of juice with label of preparation date of [DATE] and no label of use by date. In Refrigerator #2, one opened box of milk, not labeled with dated opened and use by date. In Refrigerator #2, one half full grape juice, not labeled with dated opened and use by date. In Refrigerator #2, one bowl of cut fruits, labeled with preparation date that smudged off (unreadable) and was not labeled with use by date. In Refrigerator #2, one opened/used soymilk carton, not labeled with date opened and use by date. In Refrigerator #2, one bowl of tuna salad, label indicated preparation date of [DATE], and not labeled with use by date. In Refrigerator #2, three trays, stacked on top of each other: top tray with assorted dressing (35 pieces of small containers) labeled with preparation date of [DATE]; middle tray with 29 small containers of assorted dressing- not labeled with preparation date and use by date; and bottom tray with 15 small containers of assorted dressing not labeled with preparation date and use by date. In Refrigerator #2, one container of jelly, labeled with preparation date indicated [DATE], and not labeled with use by date. In Refrigerator #2, one bowl of feta cheese, labeled with preparation date of [DATE], and not labeled with use by date. In Refrigerator #2, one bowl egg salad, labeled with preparation date [DATE], and no use by date. In Refrigerator #2, one half empty jar of mayonnaise, not labeled with opened and use by date. In Refrigerator #2, one tray of Jello, labeled with preparation date of [DATE] and not labeled with use by date. In Refrigerator #2, one bowl of sliced onion, labeled with preparation date of [DATE] and not labeled with use by date. In Refrigerator #2, one bowl of sliced Jello, labeled with preparation date [DATE] and no label of use by date. In Refrigerator #2, two containers of cut fruits, labeled with preparation date [DATE], and no label of use by date. In Refrigerator #2, one tray with 18 small containers of salsa, labeled with preparation date [DATE], and no label of use by date. In Refrigerator #2, one big tray of sliced honey dew and cantaloupe, labeled pudding, preparation date of [DATE] and no label of use by date. In Refrigerator #2, one tray of pudding, labeled with preparation date of [DATE] and no label of use by date. In Refrigerator #2, one bowl of sliced cucumber, labeled with preparation date of [DATE] and no label of use by date. In Freezer #3, fifteen (15) ice cream in small bowls in the freezer, all uncovered and no label of date opened and/ or use by date. In Freezer #3, one wrapped meat, unable to read the label of item name, labeled with preparation date of [DATE] and no use by date. In Freezer #3, one wrapped meat, labeled [NAME] steaks, preparation date of [DATE] and no label of use by date. In Refrigerator #4, one deformed plastic container with yellow liquid/juice, not labeled with item name and use by date. In Refrigerator #4, one plastic container labeled Barbecue (BBQ) sauce with preparation date of [DATE], and label of use by date. In Refrigerator #4, one plastic container labeled BBQ sauce with dried brown spillage outside the lid of the container, labeled with preparation date of [DATE], and no label of use by date. In Refrigerator #4, one big Jalapeno jar, not labeled with date opened and use by date. In Refrigerator #4, tomato puree in metal container, labeled with preparation date of [DATE], and no label of use by date. In Refrigerator #4, one metal bin with meat, labeled turkey, not labeled with use by date. In Refrigerator #4, one parmesan cheese pack, plastic was open, labeled with preparation date of [DATE], and not labeled with use by date. In Refrigerator #4, one resealed parmesan cheese pack, labeled with preparation date on [DATE], no label of use by date. In Refrigerator #4, one bowl of sliced pickles, labeled with preparation date [DATE], no use by date. In Refrigerator #4, one opened sour cream, labeled with prep date [DATE], no use by date. In Refrigerator #4, One opened cottage cheese, labeled with preparation date [DATE], no use by date. The KM 1 confirmed that food items were not labeled with use by date and there was one food item labeled with use by date that was not legibly written. During a concurrent observation in the walk- in refrigerator (milk room - where milk products are stored) and dry storage area 1 located at the first floor and interview on [DATE] at 7:59 AM with KM 1, the milk room door was open. KM 1 stated there were no staff inside or outside the milk room and the milk room door should be always closed when facility staff is not inside and not restocking to maintain the desired temperature in the milk room. KM 1 stated there were 3 loaves of bread that were not labeled with expiration dates. During a concurrent observation and interview on [DATE] at 8:11 AM with KM 1 in the walk -in freezer located at the first floor, the following were observed: One pack of frozen meat and was not labeled with use by date. One pack of meatballs resealed with no label of open date or use by date. One pack of chicken nuggets, not labeled with use by date. One container of mustard, labeled with preparation date of [DATE], and no label of use by date. One block of cheese, labeled with product date of [DATE], and no label of use by date. One metal pan with frozen meat, not labeled. One Ziploc bag containing sausage, labeled with use by date ,d+[DATE]. One resealed frozen pack of unknown item, not labeled. One resealed pack resembling tater tots, not labeled. KM 1 confirmed several food items were expired, not labeled completely, and cannot be identified should be discarded. Residents and staff could become ill or sick if served with expired food. During a concurrent interview and record review on [DATE] at 10:55 AM with the Food Services Manager (FSM), the Policies and Procedures titled, Food Safety Management System- Food Safety Product Labeling and Dating Guidelines revised [DATE], indicated: Date Marking Time Control for Food Safety: ready-to-eat, time/temperature control for safety (TCS - foods that require special handling to prevent the growth of harmful bacteria. TCS foods are also known as potentially hazardous foods) food prepared in a food establishment and held longer than the subsequent meal period must be marked to indicate the date or day by which the food is to be consumed or discarded. These time/temperature parameters are intended to help control for growth of Listeria monocytogenes (species of pathogenic [disease-causing] bacteria that can be found in moist environments, soil, water and can even grow under refrigeration and other food preservation measures). Date Marking Non Time Control for Food Safety: once a product has a documented use by date, the Food and Drug Administration (FDA, responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation's food supply, cosmetics, and products that emit radiation.) Food Code and Vendor 1 Policy requires the product to be consumed or discarded` by that date. It is important to date food properly to avoid unnecessary disposal of safe food. FSM stated food items such as juice or milk, when delivered, a received date sticker should be applied on the carton, and once opened, it should be labeled with the item name, opened date and the use by date. FSM stated, labeling with preparation date was not enough and it should be discarded if there was no use by date indicated. FSM stated fresh cut fruits must also be labeled with item name, prepared date and use by date. In addition, FSM stated, ice cream scooped into small serving bowls and placed back in the freezer must be individually covered and must also be labeled with the prepared and use by dates. FSM also stated a big container of juice or juice concentrate should be labeled with date opened and use by date and once opened, manufacturer's expiration date is not followed, the use by date should be followed. FSM stated it was important to follow the opened and use by dates, if there were no labels of date opened, use by date and/or expiration date, staff would not know how old the food item was and if served to the residents and staff, they could get sick and could affect multiple residents and staff. During a review of the Facility's Policy and Procedure (P&P) for Food Safety Management System titled Food Product Shelf-Life Guidelines, revised [DATE], indicated food manufacturer/supplier code dates, use by dates, use thru dates, or expires on dates should always be considered the first level of control. 2. During a concurrent observation in the dry storage area 2 and interview on [DATE] at 8:05 AM with KM 1, the following were observed: One dented can of tomato ketchup and one dented can of corn. One peanut butter jar with visible crack on the lid, with contents seeping out, transparent tape applied around the lid with oily substance seeping out, unlabeled with date opened, and product expiration date faded and unreadable. One opened box with a thick layer of dust on top of the half-closed box, inside was granulated sugar in a plastic bag. Thick layer of dust also observed on the plastic bag of sugar and was not sealed. Patches of black round shaped material were observed under the adhesive tape sticked on top of the half- opened box. One plastic container with blue lid containing lima beans, labeled with date of [DATE], and the use by date was left blank. The blue lid was covered with thick layer of dust and 1 dead fly observed on top of the lid. KM 1 stated that dented canned goods should not be placed in the storage room and they should have been set aside to return to the company it was ordered from for disposal. KM 1 also stated the peanut butter jar that is leaking and the open plastic bag of sugar that was covered with dust should have been discarded. KM 1 added, it is not acceptable that the container of lima beans was covered with thick layer of dust and a dead fly. During an interview on [DATE] at 11:05 AM, FSM stated, staff designated for the Dry storage room was responsible for checking for any dented canned goods and set them aside to be given back to the supplier for disposal. The same staff was also responsible for maintaining cleanliness of the storage room, making sure there were no pests or insects. FSM stated dusty containers and a dead fly were not acceptable those can be source of food contamination which could cause sickness to the residents they served. During a review of the Facility's P&P titled Canned Food Safety, undated, indicated, if a can containing food has a sharp dent on the top, bottom, or side seam, it can damage the seam and allow bacteria to enter the can. Discard any can with a sharp dent on any seam. 3. During a concurrent observation in the facility's kitchen and interview on [DATE] at 7:42 AM with the KM 1, the following were observed in the Refrigerator #2 and #4, and Freezer #3: In Refrigerator #2, one chocolate syrup, preparation date of [DATE] and use by date on [DATE]. In Freezer #3, one wrapped meat labeled vegiburgers and use by date of [DATE]. In Refrigerator #4, one container of pesto sauce, labeled with use by date on [DATE]. KM 1 stated there were food items that were already past the use by dates and should have been discarded. During a concurrent observation and interview on [DATE] at 8:11 AM with KM 1 in the walk -in freezer located at the first floor, the following were observed: One pack of unknown frozen item, resealed and labeled with use by date on [DATE]. One container of basil pesto, product expiration date of [DATE]. KM 1 confirmed several food items were expired and should have been discarded, residents and staff could become ill or sick if served with the expired food. 4. During a concurrent observation in the facility's kitchen and interview on [DATE] at 7:42 AM with the KM 1, Refrigerator #4 temperature log had missing temperature readings and initials (the staff checking): [DATE], [DATE] and [DATE] were missing afternoon temperature readings and initials. [DATE], [DATE], and [DATE] were missing morning temperature readings and initials. [DATE], [DATE] and [DATE] were missing morning temperature readings and initials. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] were missing morning temperature readings and initials. KM 1 stated the refrigerator's temperature should be monitored and documented in the temperature log daily, every morning and afternoon shift and staff responsible on checking the temperature should put their initials. During a concurrent observation and interview on [DATE] at 8:05 AM with KM 1 at the dry storage area 2 the following were observed the temperature log were missing temperature readings and staff's initials for [DATE] afternoon shift, [DATE] morning and afternoon shifts, and on [DATE] morning shift. During a follow up observation on [DATE] at 9:53 AM at the Milk Room, temperature logs did not have temperature readings and staff's initials for [DATE] and [DATE] for both morning and afternoon shifts. During an interview on [DATE] at 11:05 AM with the FSM, FSM stated the cooks were responsible for checking and recording the temperatures for all the refrigerators and freezer in the kitchen and the first floor walk in freezer and refrigerators when the shift starts at 6:00 AM. FSM stated kitchen supervisor checked the logs daily. FSM also stated it was important to check and record the temperatures of the refrigerators and freezer so staff would know that food items were being stored safely. FSM also stated, FSM cannot find in their P&Ps regarding monitoring temperature readings and documenting it daily every start of morning and afternoon shift. FSM stated it should be included in their P&P that the refrigerators, milk room and dry storage area temperature readings are monitored and documented in the facility's temperature log.

Based on observation, interview, and record review, the facility failed to dispose garbage (mostly decomposable food waste or yard waste) and keep 11 of 11 garbage bin/plastic dumpster/refuse (dry material such as glass, paper, cloth, or wood that does not readily decompose) containers covered and/or not overfilled with trash as indicated on the facility policy. These deficient practices had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility. Findings: During an observation of the first-floor hallway of the kitchen on 10/22/2024 at 7:59 AM, a garbage bin without a cover was seen next to a metal cart with a plate, two used uncovered pitchers, a washcloth, roll of unused trash bags, and two open boxes of plastic aprons. There was also a rolling cart with used meal trays observed beside the uncovered garbage bin. During a concurrent observation of the dumpster area (outside the facility building) and interview on 10/22/2024 at 8:21 AM with Food Services Manager (FSM), FSM stated this area is for kitchen garbage. The area was observed to be covered with a roof and with partial walls. The following were observed: a. One rectangular plastic dumpster (large trash container designed to be emptied into a truck) overfilled with boxes with its lid open. b. One round uncovered plastic garbage bin overfilled with boxes from food deliveries. c. Five (5) round uncovered plastic garbage bins with garbage from the kitchen. d. One partially closed black garbage bin, also filled with garbage from the kitchen. FSM stated all garbage bins should have covers even if not full. FSM also stated Facilities (Maintenance department) oversaw garbage pick-up and disposal. FSM stated the Facilities were in charge of the garbage pickup schedule was twice a day every day except Sundays when garbage pickup was only once. During a concurrent observation of another dumpster area (outside the facility building behind the Assisted Living [housing for elderly or disabled people that provides nursing care, housekeeping, and prepared meals as needed] building) and interview with FSM on 10/22/2024 at 8:23 AM, two uncovered rectangular plastic dumpsters filled with garbage were observed. During an observation on 10/24/2024 at 9:50 AM at the kitchen dumpster area, the following were observed: a. One rectangular plastic dumpster overfilled with boxes. b. Three used boxes on the floor c. Two (2) overfilled and uncovered garbage bins. d. One trash bag on the floor next to the dumpster e. Three (3) trash bags were on the floor. f. One overfilled garbage bin with lid open. During an interview on 10/24/2024 at 1:40 PM with FSM, FSM stated trash bins should be covered whether full or not. FSM stated, No trash should be on the floor or ground, even if in a closed trash bag. FSM stated the trash could attract pests and wildlife that could cause problems and residents could get sick. During an interview on 10/25/2024 at 11:30 AM with Engineer Assistant (EA 1), EA 1 stated the garbage bins should be covered and trash bags should not be left on the floor/ground. EA 1 stated garbage bin and dumpster should not be overfilled. EA 1 stated this was important because it could attract vermin or animals in the area, and this can bring diseases put the residents and staff at risk. EA 1 also stated the trash were normally picked up daily in the mornings however the trash had been picked up late on 10/22/2024 that resulted to the dumpsters being overfilled. During a review of the facility's Policy and Procedure (P&P) titled, Garbage/Refuse Disposal, Sanitation & Infection Control, revised 5/2023, the P&P indicated: 1. all items shall be disposed of in appropriate dumpster, food/medical waste versus recyclable materials. 2. Dumpster lids shall be closed at all times. 3. Area around dumpsters shall be free of waste products including food, medical, paper trash and other waste to prevent harborage and feeding of pests. 4. All departments utilizing the dumpsters for waste and/or recycling purposes are responsible for maintaining the area and ensuring that the dumpster lids are closed and the area around the dumpster is free of waste.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one of one sampled resident (Resident 1) by failing to ensure facility staff did not stand above Resident 1's eye level while assisting the resident to eat. This deficient practice had the potential to affect Resident 1's self-esteem and self-worth and violates Resident 1's right to be treated with dignity. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility initially admitted the resident on 6/30/2016 and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), polyosteoarthritis (arthritis- inflammation and stiffness of the joints, affects five or more joints at the same time), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertensive heart disease with heart failure (a group of conditions that occur when chronic high blood pressure damages the heart and causes it to fail), and palliative care (a specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). During a record review of Resident 1's History and Physical (H&P), dated 5/15/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Date Set (MDS - a federally mandated resident assessment tool), dated 8/17/2024, indicated Resident 1 had severely impaired cognitive skills (the mental abilities that the brain uses to think, process information, pay attention, and remember things) for daily decision making. Resident 1 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and was dependent with oral/toileting/personal hygiene, shower/bathing self, upper and lower body dressing and putting on/taking off footwear. During a dining observation on 10/23/2024 at 7:44 AM at the [NAME] dining room, Resident 1 was sitting on a wheelchair while being assisted with eating by Certified Nurse Assistant 4 (CNA 4). CNA 4 was observed standing on the Resident 1's right side and was not within eye level of the resident. CNA 4 was instructed by the Director of Staff Development (DSD) to get a chair and sit down while helping Resident 1 with her breakfast. CNA 4 stated, I am fine standing. DSD repeated her instructions to CNA 4 but CNA 4 still refused to sit down. During an interview on 10/25/24 at 8:55 AM with DSD, DSD stated all staff assisting residents with feeding during mealtimes should be sitting down at eye level of the residents. CNA 4 should have been seated while assisting Resident 1 with her breakfast, CNA 4 did not follow the facility's policy. DSD stated that residents could feel disrespected and affect their dignity. During a review of the Policy and Procedure (P &P), titled, Feeding the Resident, revised 1/2020, the P&P indicated regardless of resident ability or eating habits, promote dignity and a pleasant environment during mealtime. During a review of the facility's P&P titled, Quality of Life - Dignity, revised 11/2023, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on interview and record review, the facility failed to prevent multiple fall (unintentional descent that results in a coming to a rest on the floor, on or against another surface, on another person, or an object) of one of two sampled residents (Resident 1) by: 1. Failing to develop and implement a fall care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for Resident 1's actual fall on 6/30/2024, 7/24/2024, and 8/2/2024 per facility policy. 2. Failing to ensure that care plan for Impaired cognition and High risk for falls dated 7/8/2024 and 7/30/2024 included interventions unique (resident specific) to Resident 1's needs. 3. Failing to ensure CNA 1 did not leave Resident 1 sitting in the wheelchair in the hallway unsupervised by facility staff on 8/2/2024 that led to the resident sliding down from the wheelchair and falling to the floor. These deficient practices resulted in Resident 1's multiple falls. On 7/24/2024 at 4:00 PM, Resident 1 slid from the wheelchair and CNA (CNA not specified) assisted resident to the floor. The resident was sent to General Acute Care Hospital (GACH) 1 and had right hip hemiarthroplasty (surgical procedure that replaces half of a joint with an artificial component, while leaving the other half intact). The resident returned to the facility on [DATE]. On 8/2/2024 at 9:25 AM, Resident 1 had another fall in the facility, and the resident was sent to GACH 2 via 911 (universal emergency number throughout the United States to request emergency assistance). Resident 1 sustained right hip prosthesis (man-made joint that replaces a damaged hip joint during hip replacement surgery) dislocation (occurs when the ball of a hip implant moves out of the socket) requiring closed reduction (a procedure for treating a hip dislocation without surgery, using manipulation of thigh bone to put the hip back in place). Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fracture (partial or complete break in a bone) of the right femur (thigh bone), dislocation of right hip prosthesis, muscle weakness (lack of muscle strength), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), dementia with behavioral disturbance (loss of cognitive functioning such as thinking, remembering and reasoning that interferes with daily activities with agitation including verbal and physical aggression, and wandering), depression (constant feeling of sadness and loss of interest which stops one from doing normal activities), and repeated falls. During a record review of Resident 1's Morse Fall Scale (a method for determining a resident's likelihood of falling which are completed during a resident's admission, quarterly and after each sustained fall) Report dated 4/6/2024 and 7/8/2024, indicated Resident 1 is at high risk for falls. During a record review of Resident 1's Care Plan for high risk for fall initiated on 7/9/2024 indicated Resident 1 was a high risk for falls related to gait/balance problems, unaware of safety needs, and use of psychotropic medications (relating to or denoting drugs that affect a person's mental state). The care plan indicated the goal to minimize risk or major injury within 90 days. The care plan did not indicate specific interventions on how to monitor/ supervise to prevent resident from falling. During a review of Resident 1's History and Physical (H&P) dated 7/10/2024, indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Date Set ([MDS] a standardized assessment and care screening tool) dated 7/15/2024, indicated Resident 1 had severe cognitive impairment (ability to think, learn, remember, use judgement and making decisions) and was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) for tub/shower transfer (ability to get on and off the toilet), required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for sit to stand position, chair/bed-to-chair transfer and toilet transfer. During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR-a technique used to provide a framework for communication between members of the health care team) communication form dated 7/24/2024, timed at 4:33 PM, the note indicated Resident 1 had a fall witnessed by a Certified Nurse Assistant (CNA, not specified). The SBAR indicated per CNA, Resident 1 slid down from the wheelchair, and CNA was unable to hold Resident 1 and assisted the resident to sit down on the floor. The SBAR also indicated Resident 1 was transferred to GACH 1 for evaluation. During a review of GACH Emergency Department (ED-the department of a hospital that provides immediate treatment for acute illnesses and trauma) record dated 7/24/2024, indicated Resident 1 had a chief complaint of right hip pain and per report, Resident 1 was on a wheelchair and slid hitting the resident's right hip. During a review of Computed Tomography (CT, a medical imaging technique used to obtain detailed internal images of the body) of pelvis (area of the body below the abdomen that contains the hip bones, bladder and rectum) without contrast (test being performed without use of a contrast, which is a special dye injected into the body to enhance the visibility of certain tissues and structures on the scan, allowing for a clearer image) from GACH, dated 7/24/2024 timed at 10:19 PM, impression indicated fracture right femoral head/neck which is comminuted (bone that is broken in at least two places), angulated (the two ends of the broken bone are at an angle to each other), and displaced (fracture where ends of the bone have moved out of alignment, creating a gap). During a review of GACH's Surgery and Procedure Reports dated 7/26/2024 time at 6:17 AM, indicated a right hip hemiarthroplasty was performed for Resident 1 on 7/25/2024. During a review of Resident 1's progress notes from the facility dated 7/29/2024 timed at 10:47 PM, the progress notes indicated Resident 1 was admitted back to the facility from GACH at 2:30 PM with admitting diagnosis of right hip hemiarthroplasty. During a record review of Resident 1's Morse Fall Scale Report dated 7/29/2024, indicated Resident 1 is at high risk for falls. During a review of Resident 1's SBAR communication form dated 8/2/2024 entered by LVN 1 at 10:42 AM, the note indicated, at 9:25 AM, Charge Nurse (LVN 1) was notified by a CNA (CNA 1) that she had observed resident slowly slip off her wheelchair; CNA had attempted to prevent resident from touching the ground but was unable to fully support resident; resident was assisted slowly and carefully to the floor. The SBAR also indicated, Resident 1 was observed by Charge Nurse (LVN 1) in the hallway, at the East Station, on the floor, in kneeling position, with CNA at her side and Resident 1 stated repeatedly, I am hurt, whilst guarding her right hip and leg. During a review of GACH Emergency Department (ED) record dated 8/2/2024 timed at 10:51 AM, indicated Resident 1 was bib (brought in by ambulance) for a fall from chair, coming in from a SNF (skilled nursing facility) for rehabilitation from recent right hip surgery for fracture, arrived with internally rotated right hip, complained of severe pain. Resident 1's Xray (a form of electromagnetic radiation, similar to visible light. Medical x-rays are used to generate images of tissues and structures inside the body) of the right hip and pelvis dated 8/2/2024 timed at 11:50 AM, result showed right hip replacement, right hip dislocation. The ED record also indicated, right hip hemiarthroplasty posterior (back part) dislocation after falling from her wheelchair on 8/2/2024 status post close reduction. The ED record indicated Resident 1 will likely require non-emergent revision with primary surgeon as right hip grossly unstable following reduction. During an interview on 8/19/2024 at 1:50 PM with CNA 1, CNA 1 stated, on 8/2/2024 (unable to recall time) she was wheeling a resident to the activities room when she passed by Resident 1 in her wheelchair, asleep in the hallway across the East Nursing Station. CNA 1 added, Resident 1 did not have an order to apply a lap belt (a seat belt that goes around a person's lap used while a resident is in a wheelchair to prevent sliding out of the wheelchair) prior to the resident falling from 4/6/2024-8/2/2024. CNA 1 stated when she came back, Resident 1 was already on the floor, right foot was still in the wheelchair footrest and left knee on the floor, head leaning on the side of the treatment cart. CNA 1 stated, there was no facility staff present at the time she passed by Resident 1. During an interview on 8/19/2024 at 2:15 PM with CNA 2, CNA 2 stated, on 8/2/2024 after giving Resident 1 morning care, she got her up to the wheelchair and left resident in the hallway across the Nurses' station where LVN 1 was there to monitor resident and other staff that pass by can also see the resident. CNA 2 stated, I assumed LVN 1 will monitor Resident 1. CNA 2 stated, it is not safe to leave fall risk resident alone in the hallway while sitting on the wheelchair as they may get up and fall, especially Resident 1 since resident has a history from falling out from her wheelchair. CNA 2 stated, she knew not to leave resident alone in the room that was why she left the resident in the hallway assuming other staff can see resident. During a concurrent interview and record review on 8/19/2024 at 2:54 PM with LVN 1, SBAR notes dated 8/2/2024 was reviewed in the electronic chart. The SBAR indicated, at 9:25 AM, Charge Nurse (LVN 1) was notified by a CNA that she had observed resident slowly slip off her wheelchair; CNA had attempted to prevent resident from touching the ground but was unable to fully support resident; resident was assisted slowly and carefully to the floor. LVN 1 stated she did not see Resident 1 sliding off her wheelchair and she was only called by CNA 1 to notify her that Resident 1 had fallen. LVN 1 stated she was in another room when the incident happened, and she was not notified by CNA 2 that she will leave Resident 1 at the hallway. LVN 1 added, she last saw Resident 1 on 8/2/2024 at 9:10 AM when she gave Resident 1 Lorazepam (medication to treat anxiety and can make you feel sleepy) one tablet PRN (meaning pro re nata in latin meaning as needed) for verbal aggression and fidgeting in her wheelchair. LVN 1 also gave Tramadol (medication used to treat moderate to severe pain, for example after an operation or a serious injury. Common side effects include feeling sleepy, tired, dizzy, or spaced out) PRN for pain at 7:00 AM. During a concurrent interview and record review on 8/19/2024 at 4:26 PM with Minimum Data Set Nurse (MDSN), Resident 1's record of falls dated from 6/30/2024 to 8/2/2024 were reviewed. The records indicated Resident 1 had incident of fall on 6/30/2024, 7/24/2024, and 8/2/2024. MDSN stated Resident 1 had a fall on 6/30/2024 and was transferred to GACH 1 and returned to the facility on [DATE]. During concurrent interview and record review on 8/19/2024 at 4:26 PM with MDSN, Resident 1's GACH 1 record dated 6/30/2024 to 7/1/2024 indicated, resident came in with chief complaint of right hip pain status post fall. The GACH 1 record (ED notes) dated 6/30/2024 indicated, Resident 1's Xray of pelvis (area below the abdomen that contains the hip bones, bladder and rectum) indicated consistent with right femoral neck fracture (thigh bone that connects the lower leg bones to the pelvic bones) connecting the femoral head to the femoral shaft). The GACH 1 record (orthopedic [doctor that specializes in bone injuries/ diseases] notes) dated 7/1/2024 indicated, due to nondisplaced fracture (broken bones, but the pieces weren't moved far enough during the break to be out of alignment), Resident 1 has a chance to heal without surgical intervention. During the same concurrent interview and record review on 8/19/2024 at 4:26 PM with Minimum Data Set Nurse (MDSN), care plans from 6/30/2024 to 8/19/2024 were reviewed. MDSN stated there were no care plans initiated for Resident 1's actual falls on 6/30/2024, 7/24/2024 and 8/2/2024. MDSN stated, if care plan was initiated for the actual fall on 6/30/2024 and/or 7/24/2024, interventions to avoid fall such as monitoring/supervising Resident 1 while in the wheelchair or use of a lap belt while resident is in the wheelchair, Resident 1's falls on 7/24/2024 and 8/2/2024 could have been prevented. During a concurrent interview and record review on 8/20/2024 at 9:18 AM, with LVN 1, Care Plan focused on Impaired Cognition dated 7/8/2024 and 7/30/2024 were reviewed. Care plan indicated intervention to supervise as needed. LVN 1 stated, supervision was not specific to Resident 1, because it did not indicate how often the facility staff needs to supervise Resident 1. During the same interview and record review on 8/20/2024 at 9:18 AM, with LVN 1, Care Plans dated 7/8/2024 and 7/30/2024 were reviewed. LVN 1 stated, the care plan focused on High risk for falls did not include interventions to not leave resident unattended while in the wheelchair and provide frequent supervision. LVN 1 stated leaving Resident 1 unattended, without supervision was unsafe. LVN 1 added that resident-centered care plans were important for the resident's safety and needs, for staff to know what to do for that specific resident and important to revise when there were new behaviors manifested and new problems that arose. During a concurrent interview and record review on 8/20/2024 at 10:55 AM with MDSN, Care Plan for high risk for fall dated 7/9/2024 and 7/30/2024 were reviewed. Resident 1's care plan indicated goal to minimize risk of major injury for 90 days, interventions did not include constant and visual monitoring. MDSN stated for high fall risk residents, interventions should include constant, visual monitoring, and if residents were anxious-check the cause. MDS added with the additional interventions mentioned, fall would have been prevented. During a concurrent interview and record review on 8/20/2024 at 10:55 AM with MDSN, Resident 1's Care Plan titled At risk for Impaired Cognition, dated 7/8/2024 and 7/30/2024 were also reviewed. The care plan indicated interventions included to cue, reorient, and supervise as needed. MDSN stated the intervention to supervise as needed was general and should be specific to what the resident need. MDSN stated it should include how often the resident should be supervised, how and/ or when should resident be supervised like for example while in the wheelchair since resident had a history of falling or sliding out from the wheelchair last 7/24/2024 and resident sustained an injury and needed surgery at that time. During a review of facility's Policy and Procedure (P&P), titled Care Plans - Comprehensive, revised on 11/2023, indicated to include interventions unique to this resident and avoid routine standard of practice that is provided to all residents. During a review of facility's P&P, titled Fall Prevention Policy and Procedure, revised in March 2023, indicated falls and recommendations will be discussed by the Interdisciplinary Team (IDT, staff involved in resident's care) at the weekly Medicare Meeting and any new interventions will be added to the plan of care. The P&P interventions may include but are not limited to anti-roll back brakes on wheelchair, room reassignments, personal alarms, lap cushion/tray, special pads, visual checks, high-risk color-coded bracelet, and monitoring of the resident.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) who was assessed as having severely impaired cognition, required constant re-directing/cueing, high risk for falls, and exhibited wandering behavior with an increased need of supervision was provided a safe environment by failing to: 1. Identify an environmental hazard, to prevent and control adverse outcomes as indicated in the facility's policy for accident prevention, by removing an unsecured nylon-like curtain cord (string) hanging freely forming a loop (twist) on a traverse rod mounting (a metal rod or track with a pulley mechanism for drawing curtains) attached to the ceiling by the window inside the room of Resident 1. 2. Conduct an assessment for a change in behavioral condition to identify Resident 1's need for constant (occurring continuously over a period of time) monitoring and supervision. Certified Nurse Assistants (CNAs) 1 and 2 did not notify Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 of Resident 1's constant need for supervision on the night shift of [DATE], when CNAs 1 and 2 observed Resident 1 have behaviors of restlessness, getting out of bed four times and walking without assistance, refusal to stay in bed and stay seated. As a result, Resident 1, was found hanged in her room on [DATE] at 5:58 A.M., with a curtain cord attached from the ceiling around her neck, after Certified Nurse Assistant (CNA) 1 left Resident 1 sitting on the chair between the hours of 5:50 to 5:58 A.M., inside the resident's room. The facility called Emergency [DATE] services on [DATE] at 6:25 A.M. and Resident 1 was pronounced dead at the facility at 6:40 A.M. Findings: A review of Resident 1's Face sheet (Admission Record) indicated the facility initially admitted Resident 1 on [DATE] with diagnoses that included transient cerebral ischemic attack (a condition that occurs when there isn't enough blood flow to the brain to meet metabolic demand), asthma (a condition in which your airways narrow and swell and may produce extra [MEDICATION(S)]), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and senile (showing the weaknesses or diseases of old age) degeneration of the brain. A review of Resident 1's care plan dated [DATE], indicated Resident 1 was at risk for limited physical mobility related to gait (manner of walking) instability (unstable) and impaired cognition (thought process). The care plan interventions included weight bearing (any activity that one performs on one or both feet) as tolerated and to supervise the resident during ambulation (walking) with set up assistance. A review of Resident 1's care plan dated [DATE], indicated Resident 1 had impaired cognition related to impaired decision making and short-term memory loss. The care plan indicated Resident 1 had difficulty focusing, was easily distracted, or having difficulty keeping track of what was said. A review of Resident 1's care plan dated [DATE], indicated Resident 1 had behavior problems of refusing care and wandering. The care plan interventions included staff doing visual monitoring of the resident's whereabouts, encouraging to attend group activities, listening, and addressing Resident 1's complaint and concern, re-directing, and re-orienting when confused. A review of Resident1's care plan dated [DATE], indicated Resident 1 was at risk for falls and had a recent fall with no injury (no date). The care plan interventions included Encouraging Resident 1 not to change positions suddenly and monitor Resident 1 frequently. A review of Resident 1's Multi-Interdisciplinary Care Conference record dated [DATE], indicated Resident 1 remained confused and disoriented, required constant re-directing and cueing. The care conference record indicated Resident 1 was capable of ambulation (walking) with slow gait (pace; step) but constantly forgets to use her four-wheeled walker. The care conference record indicated the resident was able to walk around her room and feed herself. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool) dated [DATE], indicated Resident 1 had severely impaired cognition (thought process). The MDS indicated Resident 1 was assessed having minimal difficulty hearing and highly impaired vision. The MDS indicated the resident was assessed having clear speech and responds to simple, direct communication only. The MDS indicated Resident 1 exhibited wandering behavior that occurred one to three days in the week. The MDS indicated Resident 1 required one-person extensive (resident is involved in activity, staff provide weight bearing support) physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) to walk in room, walk in corridor, and locomotion on unit. The MDS indicated Resident 1 required a walker as a mobility device. A review of Resident 1's Progress Notes dated [DATE] indicated the following events: 1. At 2:30 A.M., Certified Nurse assistant (CNA) 1 was notified by the coworker covering her assignment (CNA 2) of Resident 1's behavior of attempting to get out of bed two times. The Progress Notes indicated that CNA 2 nicely and safely reoriented the resident back to rest. Offered resident other methods of comfort, in which she (Resident 1) had no reply (sic). 2. At 3:20 A.M., CNA 1 noted Resident 1's third attempt to get up. Resident 1 re-offered comfort measures. Resident 1 noted trying to self-ambulate, aided to ambulation. Resident reoriented back to bed, questioned for any needs, patient remained non-verbal to respond, resident aided back to bed. Resident 1's brief checked and changed by CNA 1, Resident 1 is clean and free from soils. All patient's needs met, call light left within reach, bed at lowest position for safety (sic). 3. At 5:50 A.M., Licensed Vocational Nurse (LVN) 1 saw CNA 1 inside Resident 1's room, Resident 1 observed restless with new attempts to get out of bed and self-ambulate (walk). CNA 1 reoriented resident back and explained it's best to stay seated for safety, Resident 1 physically refused to stay and non-verbal. Resident 1 offered to stay seated in chair, Resident 1 refused verbal and physical prompts to stay seated. The Progress Note indicated that after re-orientation, Resident 1 refused to stay seated . After 5 minutes of observation, CNA 1 continued her rounds . 4. At 5:58 A.M., CNA 1 and CNA 2 walked inside Resident 1's room . CNA 1 observed Resident 1 seated on the floor with her back towards the wall and the blind (curtain) cord in front of Resident 1's neck. LVN 1 was immediately notified . Resident 1 was aided back to bed, thoroughly assessed for respirations, vital signs unappreciated (not found; not heard). Skin observed around the neck with skin discoloration and abrasion coming from the cord, all other body parts intact, no other visible signs of bruising (sic). 5. At 6:00 A.M., [DATE] was called and notified. Doctor notified at 6:05 A.M. Paramedics on site pronounced time of death at 6:40 A.M. Family and police notified. Coroner arrived at the facility; body picked up at 8:45 A.M. DON called by receptionist to notify of event (sic). A review of Resident 1's LAFD (Los Angeles Fire Department) report, dated [DATE], indicated AOS (arrived on scene) to find Resident 1 lying in bed covered in sheet. The report indicated Resident 1 was last seen by facility staff at 5:45 A.M. (sic). The record indicated Resident 1 was found in her room with the cord from blinds wrapped around the resident's neck. The record indicated Resident 1 was cold to touch, lividity (usually begins 30 minutes to 4 hours after death; it is the reddish- to bluish-purple discoloration of the skin due to the settling and pooling of blood following death) in the resident's lower back and flanks (the side of a person's body between the ribs and the hip), and discolored neck. During an observation and concurrent interview in Resident 1's room in the presence of the Director of Nursing (DON), on [DATE] at 11:10 A.M., Resident 1's room was observed with a metal traverse rod mounting, attached to the ceiling next to the window. Halfway between the bed and the window, a white nylon-like white curtain cord was observed hanging freely, measuring about 6 feet from the ceiling to the bottom where the cord formed a loop [twist] on the right side of the traverse rod mounting. The DON stated the white curtain cord was used to move the drapery curtains that hung along the window frame and removed from the resident's room in [DATE]. The DON stated it did not look like the white curtain cord in Resident 1's room was ever secured or anchored to the wall. The DON stated the curtain cord should had been secured/anchored to the wall or removed since it served no purpose. During a telephone interview on [DATE] at 12:21 P.M. with LVN 1, LVN 1 stated that CNA 1 called her to Resident 1's room during the night shift of [DATE] around 5:55 A.M. LVN 1 stated when she entered Resident 1's room she saw Resident 1 on the floor, in a sitting position, with the resident's back leaning against the wall. LVN 1 stated she observed that the curtain cord hanging freely from Resident 1's window was around the resident's neck and underneath Resident 1's chin. LVN 1 stated prior to the incident she did not hear any noise from inside the resident's room. LVN 1 stated she walked inside the room with CNA 1. LVN 1 stated she removed the curtain cord from Resident 1's neck and with the help of CNA 1, they carried Resident 1 in bed. LVN 1 stated she checked Resident 1's respirations and pulse but did not feel or hear anything. During a telephone interview on [DATE] at 1:40 P.M., CNA 1 stated Resident 1 was very confused. CNA 1 stated that on [DATE] around 5:50 A.M. Resident 1 was trying to get up from the bed. CNA 1 stated she tried to get Resident 1 back to bed but Resident 1 refused. CNA 1 stated she assisted Resident 1 to sit in the chair on the left side of the bed and place Resident 1's walker in front of her before she left the room. CNA 1 stated she returned to Resident 1's room with CNA 2 around 5:58 A.M. and saw Resident 1 sitting on the floor by the right side of the bed with her back against the wall. CNA 1 stated she observed the curtain cord over Resident 1's head in front of the resident's neck under her chin. CNA 1 stated CNA 2 went to call LVN 1. CNA 1 stated when LVN 1 came to Resident 1's room both CNA 1 and LVN 1 checked on Resident 1's respiration (breathing). CNA1 stated that prior to the incident, she informed LVN 1 that Resident 1 was restless and kept getting out of bed, but LVN 1 just stated OK. During the interview, on [DATE] at 1:40 P.M., CNA 1 was asked if Resident 1's care plan to conduct frequent visual monitoring was implemented and if there was documented evidence of visual monitoring due to the resident's wandering behavior. CNA 1 stated they do not document the visual monitoring conducted for Resident 1. During a telephone interview on [DATE] at 2:47 P.M. with Family 1. Family 1 stated Resident 1 was arthritic (a person who suffers from painful inflammation and stiffness of the joints) and had no strength. Family 1 stated that Resident 1 could walk feebly (frailly) and very slowly. Family 1 stated Resident 1 could not stop herself if she falls. Family 1 stated Resident 1 had dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Family 1 stated the facility informed them (Family members) that Resident 1 liked going to other resident's rooms and would wander. During an interview on [DATE] at 10:17 A.M with the facility's Chief Engineer (1), Chief Engineer 1 stated he did not know why the traverse rod mount and curtain cords were left in Resident 1's room when the curtains were actually removed in [DATE]. Chief Engineer 1 stated as he observed Resident 1's wall adjacent to the window, the wall did not have any markings to indicate that the curtain cord was ever secured to the wall prior to the incident. Chief Engineer 1 stated he did not have a record or a log of how often he inspected the resident's rooms for potential environmental hazards. During a telephone interview on [DATE] at 10:39 A.M. with LVN 1, LVN 1 stated she was not informed by CNA1 or CNA 2 that Resident 1 had been attempting to get out of bed or was restless on [DATE]. LVN 1 stated during her rounds that night ([DATE]) she had seen CNA 1 and CNA 2 sitting in the hallway, so she did not suspect that anything was wrong with anyone. LVN 1 stated she did not know that Resident 1 was trying to get out of bed and walk by herself. LVN 1 stated after the incident, she asked CNA 1 what happened, and CNA 1 stated Resident 1 was Restless and trying to get up. LVN 1 stated that CNA 1 also informed her that Resident 1 was trying to walk away but did not specify where. LVN 1 stated if CNA 1 or CNA 2 had reported or asked for her assistance that Resident 1 was trying to get up so much that night, then she would have assessed Resident 1, notified the registered nurse (RN 1) since LVN 1 was not familiar with Resident 1's behavior. During a telephone interview on [DATE] at 4:50 P.M. with RN 1, RN 1 stated she was not notified by facility staff (CNAs 1 and 2 and LVN 1) of Resident 1's restlessness and multiple attempts to ambulate on [DATE]. RN 1 stated she was familiar with Resident 1's behavior and had never witnessed Resident 1 attempting to get out of bed more than a couple of times a night. RN 1 stated when a resident has a change in behavior she would assess and visually monitor the resident, fill out a change in behavior note, and inform the primary physician. RN 1 stated that if the CNAs or LVN 1 had notified her of Resident 1s multiple attempts to get up that night and refusal to stay seated or in bed, she would have place Resident 1 by the Nursing Station for closer visual monitoring. On [DATE] at 12:46 P.M., another CNA (CNA 3) who was familiar to Resident 1 was interviewed. CNA 3 stated she was familiar with Resident 1 before the incident happened on [DATE]. CNA 3 stated Resident 1 used to like wandering and there was always someone to watch her because they knew she would always be in someone's room. CNA 3 stated when Resident 1 starts wandering around the facility, the facility staff would usually walk with her or take her back to her room. On [DATE] at 12:59 P.M., during a concurrent interview with the DON and record review of the facility's policy for accident prevention, titled IIPP (Injury and Illness Prevention Program)/Safety Management Program- Hazard Communication, Identification and Control, revised on [DATE] indicated it is the policy of the facility to comply with Cal/OSHA (Occupational Safety and Health Act - protects and improves the health and safety of working men and women in California) regulations by periodically identifying workplace hazards and taking action to prevent and control adverse outcomes. The policy indicated the facility would promote and maintain a safe and healthy environment by preventing workplace illness and exposures through early identification and promote corrective action. The DON stated this policy also applied to residents and resident care areas. The DON stated the facility had now started to develop a different policy after Resident 1's incident happened. During a telephone interview, on [DATE] at 2:23 P.M., with Coroner 1 and Family 1, Coroner 1 stated the things observed and found upon arrival of the coroner investigator in the scene (Resident 1's room) on the date of the incident ([DATE]) were two nursing beds, a nightstand, a chair, and a walker. Coroner 1 stated that on the side wall there was a window with blinds, above the window was the track to hang the curtains with the side strings to move them, there were no curtains hanging, the side strings were long against the wall and had a piece of plastic hanging down which was damaged, the plastic piece guides the string to move, there were no ties of knots noted on the string, there was a night stand with a pillow near the strings, the nursing bed was next to the night stand and the resident was found supine in bed with a sheet over her body. During the same telephone interview, on [DATE] at 2:23 P.M., Coroner 1 stated that she had conducted a full autopsy (a detailed dissection of a deceased person, done to determine why they died ) of Resident 1's body and had found the cause of death consistent with a hanging which was consistent with the circumstances presented that Resident 1 was partially suspended by the curtain cord around her neck. Coroner 1 stated she had found no other evidence of trauma but documented other contributing factors as remote non-traumatic intracerebral hemorrhage, history of cognitive impairment and dementia, speaking towards where there may have been some confusion or inability to right herself. Coroner 1 stated that based on the facts and the understanding of when the body goes to the process of hanging, it takes minutes for death to occur. Coroner 1 stated she could not be more specific as to the number of minutes Resident 1 had been dead since facility staff stated the resident was last seen but had listed death had occurred in minutes because it was the generally accepted scientific idea of how long it takes for hanging to occur. Coroner 1 stated that that the information that she had received from the facility was that it was eight minutes when Resident 1 was last seen alive. Coroner 1 stated that Resident 1 had other health conditions too and potentially the deficits and how the change in blood pressure had affected her body, Coroner 1 stated she could not speculate (to form opinions about something without having the necessary information or facts).