Every finding on record at Hollywood Presbyterian Medical Center D/P SNF

Based on observations, interviews, and record review the facility failed to ensure kitchen staff were trained and evaluated for competency skills when: 1.Food Service Worker (FSW2) did not know the proper sanitizer test strip (a small, chemically treated paper or plastic strip used to measure the concentration (strength) of a sanitizing solution) to use for the sanitizer solution (chemical mixture used after cleaning to reduce the number of harmful microorganisms, like bacteria, on food-contact surfaces to a level considered safe by public health standards) used to clean food contact surfaces. FSW2 did not follow manufactures guidance when testing the sanitizer solution used to clean food contact surfaces. 2.Cook1 and Cook2 did not follow standardized recipes when preparing the minced and moist diet (food is cut or ground into very small, soft, moist pieces [about 4mm, or the size of a fork tine gap] that are easy to mash with a fork or tongue, requiring little chewing but needing some to form a cohesive lump, preventing choking and helping residents with chewing/swallowing issues) and were not able to demonstrate the International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) fork test and the IDDSI tilt test to make sure the food is Level 5 Minced and Moist per order (IDDSI Fork Test-the lump size is 4mm which is about the gap between the prongs of standard dinner fork, IDDSI spoon tilt test-sample holds its shape on the spoon and fall off fairly easily if the spoon is tilted not firm or sticky). These deficient practices had the potential to result in unsafe and unsanitary food production that could place 6 out of 67 residents in the facility who received food from the facility's kitchen at risk for food borne illness. These deficient practices also placed the residents at risk for meal dissatisfaction, malnutrition, and choking. Findings:1. During an observation in the cold food preparation area on 12/1/2025 at 10:20AM, FSW2 was asked to test the effectiveness of the sanitizer solution in a red bucket. FSW2 looked for the test strip to use then asked Chef1 for assistance. Chef 1 provided FSW2 with the test strip to use and instructed FSW2 to immerse the test strip in the solution and compare color change on the test strip canister for color chart. FSW2 immersed the wrong end of the test strip and removed quickly then stated there was no change in color. FSW2 stated FSW2 did not test for the effectiveness of the sanitizer and relied on another staff to check the sanitizer solution. During a concurrent observation in the kitchen and interview with Chef1 and the Dietary Manager (DM) on 12/1/2025 at 10:30AM, Chef1 stated all kitchen staff had been trained to check the sanitizer solution effectiveness using the test strips provided. The DM stated kitchen staff recently had an in-service on how to test the sanitizer solutions, and it was expected for staff to know. Chef1 stated it was important for staff to know how to test the sanitizer to make sure the solution was effective in sanitizing food contact surfaces and to prevent cross contamination. Chef 1 stated the staff in-service done on sanitizers was a presentation style in-service. During a review of manufacturer instructions for testing the sanitizer indicated to dip a test strip for 5 seconds, shake excess solution off, wait 10 seconds then compare the color on the test strip with colors on the test strip canister to determine concentration, normal solution had to be between 272-700ppm. During a review of the facility training agenda and roster titled SAFE training dated 7/17/2025 indicated staff participated in the SAFE training, information was presented during the training and its staff responsibility for adhering to the procedures and controls in the programs. There was no competency evaluation checklist post training. During a review of facility Food Service Workers job description (dated 3/5/2012) indicated, adheres to all sanitation procedures; sets up and maintains assigned work area in a neat, clean manner to facilitate efficiency and ensure food safety 2.During an observation in the kitchen of the tray line service for lunch on 12/1/2025 at 11:50AM, the minced and moist turkey chili was observed to be very loose, with a pureed (food that's been blended, ground, or strained until it's a smooth, lump-free, pudding-like consistency, requiring no chewing) consistency. During the serving of the minced and moist turkey chili, the chili was poured from the serving scoop into a bowl and appeared to be a smooth consistency. Sous chef (chef2), chef2 stated the minced and moist was the regular turkey chili except blended so it would be smoother. Chef2 stated kitchen staff served the minced and moist turkey chili in bowls. Chef 2 stated the cooks prepared the minced and moist turkey chili. During a concurrent interview with cook1, cook2 and chef1 on 12/1/2025 at 12:30PM, cook2 stated he prepared the minced and moist turkey chili, cook2 stated the food processor was used to make the turkey chili smooth. Cook2 did not remember how long the turkey chili was in the food processor. Cook1 assisted cook 2 in preparation of the food. Cook1 stated the turkey chili was placed in the food processor and pulsed about 3 times to get a smooth consistency. Cook1 stated minced and moist food should be small enough to fit through the gaps of the fork and juices should not go through the fork. When asked to demonstrate the test to make sure the minced and moist food meets were to the specification of the minced and moist diet per the IDDSI guidelines. Cook1 stated a fork was used to press on the food to make sure it was soft and fit between the gaps of fork and there were no runny juices. Cook1 pressed on the turkey chili and removed some with fork and then stated, the turkey chili might have been pulsed a long time in the food processor, and it was more like a puree. Chef1 stated the turkey chili was already a minced product and should have not been processed a long time to keep the consistency minced and not puree like. During a review of the facility recipe for the turkey chili, it indicated for minced and moist diet to place the regular turkey chili in the food processor and pulse once or twice to achieve the minced texture. During an interview with the DM on 12/1/2025 at 12:30PM, the DM stated the cooks had to follow the recipe for minced and moist to prepare the correct texture. During a review of the IDDSI guideline website titled IDDSI and dated 7/2019, the IDSSI guideline indicated that Level 5 Minced and Moist was usually eaten with spoon or fork, for people who could not bite off pieces of food safely but had some basic chewing ability. The guideline indicated it was important that food was not sticky. The guideline indicated food was to be scooped onto a fork, with no liquid dripping and no crumbles falling off the fork. The guideline indicated the size of the food was to be 4mm, which was about the gap between the prongs of a standard dinner fork. During a review of facility cook's job description (dated 3/5/2023) indicated, Measures and mixes ingredients according to recipe.recognizes and adopts the appropriate menus and recipes to the specific needs of the patient/resident.

Based on observation, interview and record review, the facility failed to ensure proper storage and disposal of expired medications and syringe for three of four medication carts (Medication Cart 3, Medication Cart 7, Medication Cart 9) by:1. Not discarding expired medication and 10 milliliter (mil- unit of measurement) syringes timely.2. Medication that did not have opened date and expiration date on the label were disposed accordingly in Medication Cart 7.3. Unopened insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was stored properly when found in Medication Cart 7 and not in cold storage. 4. Failing to follow facility's Policy and Procedure (P&P) for labeling and storage of pharmaceuticals and disposal of medications. These deficient practices had the potential to result in nursing staff administering expired and not properly stored medications. Findings:A. During a concurrent observation and interview on 12/3/2025 at 2:55 p.m. with Licensed Vocational Nurse 6 (LVN 6) at Medication Cart 3, an expired multiple fiber supplement (used to help with digestion) and insulin lispro (a medication used to manage blood sugar levels) vial was found. The fiber supplements expiration date indicated 11/28/2023, 4/10/2024 and 6/30/2025. The insulin vial was opened on 10/26/25 which had an expiration date of 4/17/2028 and a label that stated to discard after 28 days. LVN 6 stated that fiber supplements and expired insulin must be disposed of as it is ineffective and can cause harm.B. During a concurrent observation and interview on 12/4/2025 at 9:54 a.m. with Licensed Vocational Nurse 7 (LVN 7) at Medication Cart 9, an expired 10 ml syringe (a simple pump device with a barrel and plunger, used to remove or inject fluid) was found. The 10 ml syringe had an expiration date of 11/2025. LVN 7 stated that expired syringe should be discarded.C. During a concurrent observation and interview on 12/4/2025 at 10:19 a.m. with Licensed Vocational Nurse 3 (LVN 3) at Medication Cart 7, it was observed to [NAME]. An opened refresh eye drop (used to relieve dry eyes) without an open date label which had an expiration date of 09/2026.b. An expired prochlorperazine (medication that treat nausea, vomiting and schizophrenia- a mental illness that is characterized by disturbances in thought) which had an expiration date of 11/2025.c. Fenofibrate (medication that used to manage high cholesterol) which was filled on 11/14/2025 without an expiration date label.d. An unopened novolog (medication to manage blood sugar levels) insulin vial not properly stored in cold storage which had an expiration date of 5/31/2027. LVN 3 stated it is important not to administer expired medication because it can harm the resident. During an interview on 12/4/2025 at 11:00 a.m. with Director of Nursing (DON), DON stated that medications must be checked for expiration before administration. DON stated that expired medications should not be kept in the medication and not to be administered due to reduced effectiveness. The DON stated insulin that is not stored properly should be replaced to ensure resident safety.During a review of the facility's P&P, titled, Labeling and Storage of Pharmaceuticals revised on 9/24/2025, the P&P indicated that Expiration dates shall appear on the label whether or not they appear elsewhere on the container. Drugs are to be stored at the recommended temperatures per US Pharmacopeia recommendations. Please note that storage conditions for any medication are printed on the bottle/container in accordance with the law. All multi-dose vials are to be marked with the date of expiration and discarded after 28 days or per manufacturer's recommendation (whichever is sooner). A label as such as affixed on the medication to display the expiration date. During a review of the facility's P&P, titled, Disposal of Medications revised on 9/24/2025, the P&P indicated that outdated/expired pharmaceuticals that are not scheduled/controlled substances are also returned in this manner depending on their vendor/originator. Individual items may be discarded in the pharmacy.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and distribution practices when:1. Five trays of expired raw cookie dough and four large bags of expired crumbled blue cheese were stored in the walk-in refrigerator.2. Two large boxes of raw chicken were thawing inside the walk-in refrigerator with no thaw date (date marked on frozen potentially hazardous food when it is removed from the freezer and placed under refrigeration to thaw).3. One bag of frozen mango was stored in the walk-in freezer with the bag open exposed to the freezer environment.4. Resident food was delivered from the main kitchen located in Building A to the facility located across the street in a food cart crossing through traffic and the public street. These deficiencies 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 foodborne illness in 6 out of 67 residents who received food from the facility.Findings:1. During an observation of the walk-in freezer in the kitchen located in building A on 12/1/2025 at 9:00AM, a cart was observed with uncooked cookies stored in the walk-in refrigerator with a use by date of 11/25/2025 (6 days past use by date). During a concurrent observation of the walk-in freezer in the kitchen located in building A with the Dietary Manager (DM) and executive chef (chef1) on 12/1/2025 at 9:00AM, the DM stated kitchen staff should have discarded the cookies if the cookies were not prepared. Chef1 stated staff took the cookies out of the freezer to thaw in the refrigerator and didn't use it. Chef1 said kitchen staff should have discarded the cookies per use by date because the cookies were old. Chef1 stated kitchen staff were to use all food or discard by the use by date to make sure fresh products were served. Chef1 stated when food items were beyond the use by date the food could be bad quality or have gone bad. During an observation in the kitchen's walk-in refrigerator in the facility's kitchen on 12/1/2025 at 9:15AM, four large bags of crumbled blue cheese with a use by date of 11/26/2025 were observed stored in the walk-in refrigerator for dairy products. During a concurrent observation in the kitchen's walk-in refrigerator in the facility's kitchen with the DM and Chef1 on 12/1/2025 at 9:15AM, the DM stated the four large bags of crumbled blue cheese were old and the DM was observed removing the bags to discard them. Chef1 stated the four large bags of crumbled blue cheese were old and should not have been stored in the walk-in refrigerator. Chef1 stated kitchen staff were assigned to check and discard food items that were expired. Chef 1 stated expired food should not be served because the food could have gone bad. 2. During an observation of the walk-in refrigerator for meat in the facility's kitchen on 12/1/2025 at 10:00AM, two large boxes of raw chicken were observed stored on the bottom shelf with no date. During a concurrent observation of the walk-in refrigerator for meat in the facility's kitchen and interview with Chef1 on 12/1/2025 at 10:00AM, Chef1 sated the boxes of chicken were delivered that morning (12/1/2025). Chef 1 stated it was important to label and date food and to discard expired food items for safe storage. 3. During an observation in the kitchen's walk-in freezer on 12/1/2025 at 10:15AM, one bag of mango chunks was observed stored in the walk-in freezer uncovered, with the contents exposed to freezer environment. During a concurrent interview with Chef1, Chef1 said food Had to be covered tightly to prevent cross contamination. Chef1 was observed removing the bag of mango chunks from freezer to discard. During a review of facility's policy and procedure (P&P) titled Food storage and Labeling dated 1/22/2025, the P&P indicated All TCS food we prepare or open must be labeled and used within 7 days. During a review of facility's quick standard for Food Safety titled thawing dated 5/8/2023, the quick standard indicated, Plan ahead to verify, preferred method of thawing under refrigeration is used . plan enough time to thaw large items.following the chart below: 4 to 12 pounds 1 to 3 days.Ensure all foods are labeled correctly during thawing. A review of the 2022 U.S. Food and Drug Administration Food Code titled Ready to Eat, Time/Temperature control for safety food, Date Marking Code#3-501.17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded. A review of the 2022 U.S. Food and Drug Administration Food Code titled Food storage Code 3-305.11, indicated, Food shall be protected from contamination by storing the food: 1) in a clean, dry location; 2) Where it is not exposed to splash, dust, or other contamination; and 3) at least 6inches above the floor. A review of the 2022 U.S. Food and Drug Administration Food Code titled Miscellaneous Sources of Contamination Code 3-307.11, indicated, Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-301-3-306. See next section for a list of miscellaneous sources of contamination. 4. During an observation in the facility kitchen of the tray line (a system of food preparation, in which trays move along an assembly line) service for lunch on 12/1/2025 at 12:00PM, kitchen staff were observed placing resident meal trays in a food cart. Food service worker (FSW1) was observed pushing the cart out of the kitchen and outside of building A towards the street and traffic light. FSW1 was then observed pushing the cart through the public and across the street from building A to the facility. During an interview with FSW1 on 12/1/2025 at 12:07PM, FSW1 stated during rainy weather the cart was still delivered by going through the street. FSW1 stated when it rained FSW1 would wear a rain jacket, but the cart was not covered. During the same observation, the cart was observed to have doors that were closed but not locked and there were gaps between the door and the frame of the cart resulting in lack of a seal. During an observation of resident lunch service in the facility on 12/1/2025 at 12:15PM, RN5 was observed checking the diet orders for each resident before serving the trays. Fruit cups were observed on the tray opened and tipped over spilling the fresh cut fruits on the trays. RN5 stated the fruits spilled on the tray, and RN 5 was going to leave the fruits like that because the fruits fell while in the cart. During an interview with the DM on 12/1/2025 at 1:15PM, the DM stated kitchen staff had been delivering the food to the nursing facility from Building A in the cart the same way for many years and it had not been an issue. The DM stated the cart was secured with the door but was not locked with a key. The DM stated she (DM) understood the concern with cross contamination. During a review of the 2022 California Building Code Dietetic Service Space 1224.20.2.1, the code indicated, Patient food preparation areas shall be directly accessible to the entry for the food supply deliveries and for the removal of kitchen wastes, interior transportation, storage, etc., without traversing patient or public circulation. Food preparation, service and storage shall be inaccessible to non-dietetic service staff. A review of the 2022 U.S. Food and Drug Administration Food Code titled Miscellaneous Sources of Contamination Code 3-307.11, indicated, Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-301-3-306 (3-301 Preventing contamination by employees; 3-302 preventing Food and ingredient contamination; 3-303 preventing contamination from ice used as coolant; 3-304 preventing contamination from equipment, utensils and linens; 3-305 Preventing contamination from the premises; 3-306 preventing contamination by consumers).

Based on observation, interview, and record review, the facility failed to ensure one of eighteen sampled residents (Resident60): Failed to ensure Resident 60 were assessed for risk of entrapment from bed rails prior to installation was completed. Failed to review the risk and benefits of bed rails with the resident representative and obtain consent prior to installation. These failures had the potential to result in compromised resident safety associated with unassed bed rail use.Findings: During a record review of Resident 60's admission record indicated Resident 60 was admitted on [DATE] with a diagnoses of chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), basal cell carcinoma of the skin (a type of skin cancer that most often develops on areas of skin exposed to the sun), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident60's Minimum Data set [MDS)] resident assessment tool), dated 11/07/25 indicated that Resident's cognitive was impaired. The MDS indicated that Resident 60's is dependent (helper does all of the efforts) 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) of oral hygiene, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During an observation on 12/2/2025 at 2:01 p.m. in resident 60's room, resident 60 was observed lying in bed facing the doorway with elbows bend towards the chest, bilateral arms resting on chest, and both hands clenched in a fist. A white linen blanket was pulled up to resident60's waist, the bed was in the low position, bilateral SCD boots were in place with the machine on, both side rails raised. During a review of Resident60's medical record on 12/2/2025 at 12:09 p.m. revealed no documented bed rail risk assessment for entrapment, no documentation of alternatives attempted, and no evidence of the resident's or Representative's informed consent for bed rail use. There was no care plan addressing bed rail use or potential entrapment. During an interview on 12/02/2025 at 3:15p.m. with Minimal Data Set Nurse 1 (MDS 1), MDS 1 stated that the nursing staff do not assess for risk of entrapment from bed rails prior to having side rails on because all residents have standing orders from admission to have side rails for positioning and as enabler. MDS1 further stated that staff conduct bed rail assessments only for residents who are alert, and if resident is not alert, there was no need to assess them for risk of entrapment for bed rail use. During a concurrent interview and record review with RN 4 on 12/04/25 at 9:42 a.m., RN 4 stated that there was no risk assessment done for Resident 60's side rail use during admission, nor was any consent form for siderail use as an enabler obtained. RN 4 emphasized the importance of assessing residents before siderails are used for safety reasons, as some residents may be at risk of entrapment, and not all the residents can safely use siderails for mobility. Resident 60's MDS functional abilities, documented on 11/7/2025, indicated impairment (loss of function) on both sides. RN 4 stated that resident 60 cannot use the siderails due to impairment of both upper extremities (shoulder, elbow, wrist, hand). During a review of the facility's policy and procedure titled, Restraints- Physical: Guidelines for use and assessment (Sub-Acute) dated on 06/14/2025, indicated, this facility to assess resident prior to implementation of restraints to ensure appropriate protocols have been followed.

Based on observation, interview and record review, the facility failed to provide oral care to one of five residents (Resident 8) when Resident 8 was observed with teeth covered with white secretions, and sticky matter. This failure had the potential to result in dental deterioration, aspiration, and infection.Findings:During a review of Resident 8's admission Record (Face sheet) the admission Record indicated the facility admitted Resident 8 on 1/17/2021 with diagnoses including chronic respiratory failure (a condition where your lungs gradually stop doing their main job over time), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dependence on respirator/ventilator a medical device to help support or replace breathing).During a review of Resident 8's History and Physical (H&P), dated 9/7/2025 indicated that Resident 8 did not have the capacity to understand and make decisions.During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 6/23/2025, indicated Resident 8's cognitive skills (the mental abilities your brain uses to think, process information, remember things, pay attention, and solve problems) for daily decision making was severely impaired. The MDS indicated Resident 8 had functional impairment in range of motion on both upper and lower extremities, and was dependent on staff for oral hygiene. During a review of Resident 8's care plan for self-care deficits, revised on 7/25/2025 indicated that Resident 8 required total assistance with her Activities of Daily Living (ADLs). The care plan goal indicated Resident 8 would be clean, dry and well-groomed daily. The care plan interventions included providing oral care daily and assisting as needed.During an observation on 12/01/2025 10:12 a.m., Resident 8 was observed to have dry mouth, and caked with dry white secretions.During an observation on 12/2/2025 at 10:30 a.m., in Resident 8's room, Resident 8 observed Resident 8 sitting supine at a 45-degree angle in bed. Resident 8 had a bubbling sound in her throat, indicating the presence of secretions. There was dried and sticky white secretions between and covering her entire bottom teeth and her mouth was dry and cracked. During an interview on 12/01/2025 10:12 a.m. with Certified Nursing Assistant (CNA) 3, in Resident 8's room, CNA 3 was observed inspecting Resident 8's secretions and stated the licensed nurse does oral care. During an observation and interview on 12/01/2025 10:20 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed inspecting Resident 8's mouth. LVN stated if the resident has cracked lips or secretions, the resident could aspirate and can cause deterioration of teeth and decay. During a review of the facility's P&P titled, ADL (Activities of Daily Living Program), dated 2017, indicated the purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth and to prevent oral infection. Activities to be included in the ADL Program are dressing, bathing, grooming and hygiene, feeding, bowel and bladder training and the use of adaptive equipment.

Based on interviews and record reviews, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel, by failing to: 1. Ensure the Director of Food Services met the state and federal requirements for the position and did not have other leadership responsibilities outside of the Dietetics Services department. The Dietary Manager (DM) did not receive at least six hours of in-service training on the specific California dietary service requirements contained in CCR title 22 (health and safety code 1265.4). 2. Ensure the hours dedicated to the oversight of the Food and Nutrition Services by the Director of Food Services were adequate for the scope and complexity of the food service operation. The DM was the Director of Food Services and was also overseeing patient transport, environmental services and overhead operations. These deficient practices had the potential to compromise the safety and nutritional status of residents via cross contamination (transfer of germs and/or bacteria from one surface to another), and decreased meal satisfaction and intake.Cross Reference: F802, F812Findings:During an interview with the Dietary Manager (DM) on 12/1/2025 at 1:00PM regarding kitchen supervision, the DM stated DM was a full-time employee overseeing food service department, patient transport, Environmental services and overhead operations. The DM stated everyday DM stopped by the kitchen to make sure everything was ok. The DM stated Chef1, and the retail manager (RM) assisted the DM with the daily operation of the kitchen. The DM stated both chef1 and RM did not have dietary manager credentials. The DM stated the DM recently received the Dietary manager certification and did not know that the DM also needed to complete required 6 hours of California State dietary service requirements. The DM stated the DM's time was split into overseeing different departments within the facility and was not always in the kitchen. The DM's office was not located in the kitchen. A review of DM's credentials on 12/1/2025 at 9:00AM, indicated the DM had a certification from an accredited certified dietary manager program effective through 8/31/2026. However, the DM did not receive at least six hours of in-service training on the specific California dietary service requirements contained in CCR title 22 (health and safety code 1265.4). During an interview with the Registered Dietitian (RD) on 12/1/2025 at 9:30AM, the RD stated RD was the clinical Nutrition Manager and supervised three full time dietitians and part time dietitians. The RD assisted with in-services for the kitchen staff and stated the DM was mainly overseeing the kitchen. During a review of facility job description for Food Service Supervisor dated 6/27/2011, the job description indicated Supervises production.observes methods of food preparation and cooking, size of portions etc. To ensure food is prepared in prescribed manner.enforces nutrition and sanitation standards for unit. During a review of the California Health and Safety Code (HSC) 1265.4, the HSC indicated, .a) A licensed health facility . shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. (b) The dietetic services supervisor shall have completed at least one of the following educational requirements:(1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility.(2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration.(3) A graduate of a dietetic assistant training program approved by the American Dietetic Association.(4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility .

Based on observation, interview, and record review, the facility failed to ensure a resident, who was receiving feeding through a gastrostomy tube ([GT] a soft tube surgically placed into the stomach to provide nutrition and medications), did not have a significant weight loss (a weight loss greater than five percent (%) in one month, or greater than 7.5% in three months, and greater than 10% in six months) for one of 3 sampled residents (Resident #12). The facility failed to ensure: 1. The licensed nurses initiated a change of condition (COC- internal document) assessment and monitored Resident 12 for weekly weights, and signs and symptoms of malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function), and dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) to address the nutritional need of Resident 12 on 11/19/2025.2. The licensed nurses notified Resident 12's responsible party (RP) of Resident 12's 8.43 percent (%) significant weight loss identified on 11/19/2025 and 11.45% weight loss identified on 11/26/2025.3. The licensed nurses notified Resident 12's Primary Physician and Registered Dietician (RD) of Resident 12's 11.45 % continued weight loss on 11/26/2025.4. The Interdisciplinary Team ([IDT] a team of different health care professionals working together to develop care interventions for a resident), including the RD met after Resident 12's significant weight loss was first identified on 11/19/2025, and then on 11/26/2025, to develop and discuss interventions to prevent further weight loss.5. The IDT developed an individualized care plan with measurable goals to address Resident 12's weight loss identified on 11/19/2025 and 11/26/2025. These deficient practices resulted in Resident 12 having a significant weight loss of 14 pounds ([lbs.] a unit of weight measurement) in 19 days which was 8.43 % of Resident 12's body weight on 11/19/2025, and 19 lbs. weight loss in 26 days on 11/26/2025 which was 11.45% of Resident 12's body weight. Findings: During a review of Resident 12's admission Records, the admission Records indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, traumatic subdural hemorrhage (when blood collects under the brain's outer covering after a head injury, causing pressure that can damage the brain) , anoxic brain damage (when the brain gets zero oxygen, causing brain cells to die), urinary tract infection ([UTI] an infection in the bladder/urinary tract) and had a GT in place. During a review of Resident 12's Minimum Data Set ([MDS] a resident assessment tool) dated 11/06/2025, the MDS indicated Resident 12 was comatose. The MDS indicated that Resident 12's current weight as of 11/12/2025 was 166 lbs. The MDS indicated Resident 12 was receiving a therapeutic (a meal plan that controls the intake of certain foods or nutrients) diet and was receiving 51% or more of his total calories through a feeding tube. During a review of Resident 12's Weight Summary, dated 10/31/2025, the Weight Summary indicated Resident 12's weight was 166 lbs. (admission weight). The Weight Summary has the following:On 11/5/2025 indicated Resident 12's weight was 166 lbs. On 11/12/2025 indicated Resident 12's weight was 162 lbs. On 11/19/2025 indicated Resident 12's weight was 152 lbs. (lost 14 lbs. from admission)On 11/26/2025 indicated Resident 12's weight was 147 lbs. (lost 19 lbs. in 26 days). During a review of Resident 12's Nutrition assessment dated [DATE], the assessment indicated the nutritional goal for Resident 12 was mild weight loss towards 150 lbs. range or stable weight and good labs.During a review of Resident 12's Progress Notes and Assessments, the Progress Notes and Assessments for the month of 11/2025 it indicated no records of COC assessment when the resident had a significant weight loss of 14 lbs. in 19 days, which was 8.43 % of Resident 12's body weight on 11/19/2025, and 19 lbs. weight loss in 26 days on 11/26/2025 which was 11.45% of Resident 12's body weight. During a review of Resident 12's Multidisciplinary Care Conference, dated 11/4/2025, the Multidisciplinary Care Conference indicated that Resident 12's desired body weight (DBW) was 124 - 136 lbs., and initial goal was 150 - 160 lbs. The Multidisciplinary Care Conference indicated weight loss history suspected by sister, saying that Resident 12 used to appear heavier prior to hospitalization. The Multidisciplinary Care Conference indicated Resident 12's bowel pattern was one to three times a day, mostly loose. The Multidisciplinary Care Conference indicated nutritional goal for Resident 12 was good tube feeding tolerance and adequate nutrition to be evidenced by tube feeding providing above 90% estimated kilocalorie ([kcal] measurement the energy in food) and protein needs, mild weight loss towards 150 lbs. range or stable weight and good labs. There was no other Multidisciplinary Care Conference assessment noted. During a review of Resident 12's untitled Care Plan initiated 11/21/2025, the Care Plan indicated Resident 12 had a significant weight loss suspected related to diuretic (medication that helps to remove extra fluid from the body) use and edema (swelling) upon admission. The untitled Care Plan indicated Resident 12's weight would be maintained in the 150 lbs. range or within normal limits (WNL) for DBW range, or as medically feasible. The Care Plan interventions include weighing resident weekly for four weeks and monthly after or as per medical doctor (MD) order. During a concurrent interview and record review on 12/03/2025 at 11:52 AM with Registered Nurse (RN) 3, RN 3 stated that resident weighs are checked during admission, then weekly for four weeks. After, RD evaluates resident nutritional needs and how often the residents need to be weighed. Licensed nurses record the weight results into PointClick Care ([PCC] electronic health record system used in the facility). Abnormal weights are reported to Medical Doctor (MD) and RD. RN 3 stated she was unable to locate COC assessment when Resident 12's had the significant weight loss on 11/19/2025 and on 11/26/2025. RN 3 was unable to locate RP notification of Resident 12's COC. RN 3 stated that any change in resident's condition must be communicated with MD and RP. RN 3 stated RDs document their progress notes in Paragon (electronic health record system used in hospitals but not for Skilled Nursing). RN 3 stated that care plans must be documented as soon as there is identified concern, to address resident needs as soon as possible to prevent further decline. During a concurrent interview and record review on 12/03/2025 at 12:56 PM with RD, the RD stated that when the residents experience significant weight loss, weight is rechecked for accuracy. Then RD evaluates the DBW and assesses the need for nutritional adjustment. Resident 12's Weight Summary indicated the resident had a significant weight loss of 14 lbs. in 19 days, which was 8.43 % of Resident 12's body weight on 11/19/2025, and 19 lbs. weight loss in 26 days on 11/26/2025 which was 11.45% of Resident 12's body weight. RD stated that she noted weight loss of 8.43% for Resident 12 on 11/21/25. Resident 12's weight loss was addressed to one of the RNs in the facility along with recommendations. RD stated she could not recall which RN she spoke to. RD stated that communication regarding resident's weights is done in between her and the Director of Nursing (DON). RD stated that she is in contact with DON constantly and exchanging with residents' status information almost every other day. During a review of Resident 12's Nutrition Daily assessment dated [DATE] with RD, the Nutrition Daily Assessment revealed that Resident 12 experienced significant weight loss suspected related to improving edema. The assessment revealed that the resident would benefit from having weight and additional labs checked. RD informed RN of her recommendations to check comprehensive metabolic panel ([CMP] - a blood test to assess body's chemical balance) and weight with next planned weights. RD stated that she noted and addressed Resident 12's weight loss of 11.45% documented on 11/26/2025, only on 12/1/2025 because she had been on vacation during the week of 11/26/2025.RD stated that she initiated a weight loss care plan on 12/1/25, however, she backdated the initiation date as 11/21/2025 since the first significant weight loss was discovered on 11/21/2025. The dietitian was unsure how soon the care plan needed to be initiated when a change in resident condition was noted. During a review of Resident 12's Nurses Progress Notes dated 11/21/2025, the Nurses Progress Notes revealed that Resident 12 was seen and examined by RD with recommendations, physician notified. Physician ordered Complete Blood Count ([CBC] - a blood test to measure red blood cells, white blood cells and platelets) and CMP to be completed on 11/23/2025, and check weight one time. During a concurrent interview and record review on 12/04/2025 at 11:10 AM with DON, the DON stated that expected/desired weight loss is not documented as COC, however it should reflect on IDT meetings. The DON stated if physician order includes check weight one time, the order must be carried out and completed within 24 hours. Failure to properly complete physician orders may result in insufficient care planning and potential negative outcomes for the resident.During a review of Resident 12's Order Summary Report dated 11/22/2025 with the DON, the Order Summary Report indicated that an order to check weight one time was placed on 11/22/25. Resident 12 was weighed 4 days later on 11/26/2025 and it indicated 147 lbs. The DON stated that weight check ordered on 11/22/2025 for Resident 12 was delayed, which lead to delayed care planning, compromising Resident 12's health, causing further weight loss.During a subsequent interview on 12/4/2025 at 11:10 a.m. and record review of Resident 12's all Order Summary Reports and Progress notes for 11/2025 with the DON, the Order Summary Reports and Progress notes revealed no new orders regarding Resident 12's weight loss of 11.45% on 11/26/2025.The DON stated that Resident 12's weight loss of 11.45% on 11/26/2025 had not been reported to MD and IDT to addressed on time. The DON further added delay in assessment and implementing intervention can lead to further decline in medical needs, unmet nutritional needs, and further unintended weight loss. The DON stated that care plans must be completed within 24 hours of problem identification. Care plan initiation date must be current and cannot be backdated. The DON stated that care plan initiation for weight loss was delayed. She further stated that the care plan initiated on 12/1/2025 in not complete. She further stated that the interventions must be more specific to address resident needs. The DON stated that Multidisciplinary Care Conference meetings are held twice a week. She confirmed that the last Multidisciplinary Care Conference meeting for Resident #12 was documented on 11/4/2025. The DON was unsure if there was another Multidisciplinary Care Conference meeting after 11/4/2025. The DON was unable to locate documentation for Multidisciplinary Care Conference meetings after 11/4/25.The DON stated that Resident #12's family/responsible party had not been notified regarding resident's significant weight loss. The DON stated that failure to notify the resident's family of significant weight loss compromises the family's right to be informed of COC. During a review of the facility's (P&P) titled Standards of Nutrition Care for the Long Term Care/Sub Acute Unit reviewed in November 2023, indicated The Registered Dietitian identifies nutritional risk factors and recommends nutritional interventions, based on a resident's medical condition, nutritional needs and goals. The Dietitian monitors the resident's response to nutritional interventions and adjusts goals and nutrition plans, as needed. 1. A Care Plan is developed for each resident. The care plan is prepared by an interdisciplinary team that includes the dietitian. The care plan includes measurable objectives and specific interventions recommended to maintain adequate nutritional status, relative to condition and prognosis.2. The dietitian will document on the appropriate care plans. The Care Plan will include information gathered from the nutrition assessment and reflect the residents' nutritional status, goals, preferences as well as the planned nutrition intervention and monitoring criteria.3. The residents' care plans will be updated quarterly, or more often as needed; e.g., as conditions change, goals are met, or interventions are determined to be ineffective. If nutritional goals are not achieved, different or additional approaches are considered and implemented as indicated. The dietitian monitors and responds to weight changes. Significant weight changes are defined as:1 month - 5% (significant loss), Greater than 5% (severe loss)3 months - 7.5% (significant loss), Greater than 7.5% (severe loss)6 months - 10% (significant loss), Greater than 10% (severe loss). The dietitian is a member of the Interdisciplinary Team. The dietitian will attend appropriate meetings and rounds and document attendance.The appropriateness of the selected residents' care plans is discussed at weekly Interdisciplinary Team meetings, with recommendations for modifications and/or changes presented and revised as needed. During a review of facility's P&P titled Nutritional Screening, Assessment and Reassessment of the Patient reviewed in September 2025, the policy indicated The RD documents on the Interdisciplinary Care Plan following the initial assessment or evaluation of a patient. During a review of facility's P&P titled Residents' Rights and Responsibilities reviewed in September 2024, the policy indicated A facility must immediately inform the resident, consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental or psychosocial status. During a review of facility's P&P titled Change of Condition, Notification revised in September 2025 the policy indicated The primary physician will be notified for unplanned loss or gain of greater than 5% of body weight within a 30-day period. Document physician notification in the resident's record, including time, name of person contacted, and any orders received. If the resident's physician cannot be reached within a reasonable amount of time, (i.e. by the end of the shift) notify the Director of Nursing and/or Medical Director.Notify the resident's family/caregiver of unexpected changes in resident's condition and document such communication in the medical record.

Based on observation, interview, and record review, the facility failed to ensure a resident with indwelling catheter received appropriate care and services to prevent urinary tract infections ([UTI] - an infection in the bladder/urinary tract) for one of 17 sample residents (Resident 12), by failing to employ infection prevention and control practices in managing catheter.This deficient practice had the potential for Resident 12's existing UTI to worsen due to contamination from the urinary catheter's (a hollow tube inserted into the bladder to drain or collect urine) dignity bag (a bag covering the catheter bag) contacting the floor.Findings: During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, traumatic subdural hemorrhage (when blood collects under the brain's outer covering after a head injury, causing pressure that can damage the brain) , anoxic brain damage (when the brain gets zero oxygen, causing brain cells to die), urinary tract infection ([UTI] an infection in the bladder/urinary tract) and had a GT in place. During a review of Resident 12's Minimum Data Set ([MDS] a resident assessment tool) dated 11/06/2025, the MDS indicated Resident 12 was comatose. The MDS indicated that Resident 12 dependent (helper does all of the effort) with all activities of daily living (ADL). During an observation on 12/01/2025 at 11:02 AM in Resident 12's room, it was noted Resident 12's urinary catheter dignity bag was in contact with the floor. During a concurrent observation and interview on 12/3/2025 at 11:17 AM with Certified Nurse Assistant (CNA) 4, CNA stated that dignity bags covering urinary catheters must be positioned below the level of the resident but must not touch the floor. Observed Resident 12's dignity bag covering urinary catheter bag touching the floor. CNA 4 stated the dignity bag was touching the floor. During concurrent observation and interview on 12/3/2025 at 11:43 AM with Licensed Vocational Nurse (LVN) 9, LVN 9 confirmed dignity bag covering urinary catheter bag was touching the floor. LVN 9 stated that the dignity bag should not touch the floor, as this may contaminate the bag and increase the risk of UTI for the residents. During an interview on 12/3/2025 at 12:15 PM with Director of Nursing (DON), the DON stated that dignity bags covering urinary catheter bags must remain off the floor and be positioned below the level of the resident. The DON explained that when a dignity bag touches the floor, it can contaminate the urinary catheter, potentially leading to a urinary tract infection (UTI) and causing harm to the resident.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident60 and Resident 38) received proper care as follows: Failed to notify Resident 60's physician order of a change in condition (COC) on 11/14/2025Failed to update the care plan to reflect the change of condition on 11/14/2025 for Resident 60.Failed to monitor resident 60 every shift for 72 hours following the change in condition beginning 11/14/2024 4.Failed to implement treatment consistent with physician orders by not holding docusate sodium (a medication that helps soften the stool) oral liquid administration through gastrostomy tube ([GT] a soft tube surgically placed into the stomach to provide nutrition and medications) when loose stools are noted. These failures had the potential to contribute to deterioration of Resident 60's and Resident 38 health, delay necessary medical intervention and increase the risk of complications related to the change in condition. Findings:a. During a record review of Resident 60's admission record indicated Resident 60 was admitted on [DATE] with a diagnoses of chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), basal cell carcinoma of the skin (a type of skin cancer that most often develops on areas of skin exposed to the sun), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident60's Minimum Data set [MDS)] resident assessment tool), dated 11/07/25 indicated that Resident's cognitive was impaired. The MDS indicated that Resident 60's is dependent (helper does all of the efforts)) 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) of oral hygiene, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a record review of electronic medical records under the Change of Condition (COC) dated 11/14/2025 at 19:42 , the record indicated that Resident 60 had a scratch on the left back of the neck, with recommendation to follow wound care as ordered. There was no documentation that the physician had been notified of the COC, no evidence that care plan, was updated and no documentation that resident 60 was monitored every shift for 72 hours following the COC. During interview and record review on 12/03/2025 at 1:58 p.m. with Treatment Nurse 1(TX1) of Resident 60's change of condition (COC) from 11/14/2025, TX1 stated that Resident 60 experienced a change in condition at on 11/14/2025 at 7:43 p.m., documented in the progress notes as patient has a scratch on the left back of the neck. TX1 acknowledged that the physician was not notified of the change in condition, explaining that she was assisting the nursing staff at the time. TX1 further stated that no documentation was entered into Resident 60's chart because the required steps had not been completed by any staff. She admitted to forgetting to initiate a care plan for Resident 60, reiterating that she was just helping, and confirmed that no care plan was completed. During concurrent interview and record review with the Director of Nurses (DON) on 12/04/2025 11:14 a.m., the DON stated that the facility's expectations for managing a COC include the following: the physician must be notified of any changes in condition; any orders given must be carried out; the resident's family must be informed, the care plan must be updated ; and residents must be monitored every shift for any adverse reaction to treatment. The DON stated that Resident 60 was not monitored for 72 following the change in condition due to lack of documentation done from staff. A review of the facility's policy and procedure titled. Change of Condition, Notification revised on 09/10/25, indicated Document physician documentation in the resident's record, including time, name of person contacted, and any orders received. Notify the residents family/caregiver of unexpected changes in resident's condition and document such communication in the medical record. b. During a review of Resident 38's admission Records, the admission Records indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (a condition where lungs cannot move oxygen and carbon dioxide properly), type 2 Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), anoxic brain damage (brain injury caused by lack of oxygen). During a review of Resident 38's Minimum Data Set ([MDS] a resident assessment tool) dated 6/5/2025, the MDS indicated Resident 38 was rarely/never understood. The MDS indicated that Resident 38 dependent (helper does all of the effort) with all activities of daily living (ADL). The MDS indicated that Resident 38 is always bowel incontinent (no episodes of continent bowel movements). During a concurrent interview and record review on 12/02/2025 at 3:01 PM with Registered Nurse (RN) 3 of Resident 38's physician order dated 5/30/2025 , the order indicated that the physician ordered docusate sodium oral liquid 100 mg/10 ml, give 10 ml via GT one time a day for constipation (hold for loose stools). During a subsequent interview and record review on 12/2/2025 at 3:01 p.m. with Resident 38's Bowel and Bladder Elimination record for 11/2025 the records indicated the following: On 11/18/2025 at 6:43 AM Resident 38's bowel movement had loose consistency. On 11/18/2025 at 1:43 PM Resident 38's bowel movement had loose consistency. On 11/18/2025 at 8:41 PM Resident 38's bowel movement had loose consistency. On 11/22/2025 at 6:06 AM Resident 38's bowel movement had loose consistency. On 11/22/2025 at 1:20 PM Resident 38's bowel movement had loose consistency. On 11/23/2025 at 5:09 AM Resident 38's bowel movement had loose consistency. On 11/23/2025 at 1:24 PM Resident 38's bowel movement had loose consistency. On 11/23/2025 at 10:24 PM Resident 38's bowel movement had loose consistency. During a record review of Resident 38's Medication Administration Record (MAR) for 11/2025 revealed the following: Resident 38 received docusate sodium on 11/18/2025, 11/22/2025 and 11/23/2025 RN 3 stated that Resident 38's physician order to hold docusate sodium administration when loose stool was noted and had not been followed. RN 3 further stated that administering stool softener to a resident with loose stools can potentially lead to resident's dehydration, cause skin integrity problems, and harm the resident. During an interview on 12/03/2025 at 12:15 PM with Director of Nursing (DON), the DON stated when a resident is having loose stools, and the medication order indicates to hold the medication, staff must follow the physician's order. Administering a stool softener when a resident is having loose bowel movement can potentially lead to dehydration, skin breakdown, and can harm the resident.

Based on observation, interview and record review, the facility failed to ensure care planning for two of five sample residents as follows:Resident 20's care plan for right hand mitten was updated. Care plan was not initiated prior to implementation of Resident 80's side rails use.These failures had the potential for delayed provision of appropriate care and monitoring. Findings: a. During a review of Resident 20's admission Record, the admission Record indicated the facility initially admitted Resident 20 on 7/5/2023, and readmitted the resident on 01/17/2024, with the diagnosis that included chronic respiratory failure, dependence on respirator (ventilator - a medical device to help support or replace breathing), and hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following nontraumatic intracerebral hemorrhage (bleeding within the brain). During a review of the Minimum Data Set (MDS - a resident assessment) dated 10/10/2025, the MDS indicated Resident 20's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Patient 20 was dependent on staff for all activities of daily living (ADL - routine tasks/activities such as bathing, dressing, and toileting) a person performs daily to care for themselves). During an observation on 12/1/2025, at 11:18 a.m., Resident 20 was observed lying in bed with right hand mitten on. During an interview on 12/3/2025 at 11:00 a.m. with Director of Nursing (DON), DON stated care plan is created during admission and reviewed quarterly, annually and when there is a change of condition. DON stated for restraints, the care plan is updated every time there is a new order. DON stated a mitten is a restraint and care plan would need to be updated for resident with mitten on. During a concurrent interview and record review on 12/3/2025 at 11:05 a.m. with Minimum Data Set Nurse (MDS) 2 and DON of Resident 20's Care Plan dated 12/3/2025, the care plan indicated the goals and interventions for physical restraints - right hand mitten was last revised 10/10/2025 by MDS 2. The DON and MDS 2 stated the care plan were not updated. The DON stated the care plan should have indicated a review every seven days for the use of mitten to match the doctor's orders. The DON stated it is important that the care plan is updated for it to be current for nurses to know the residents' risks, problems and interventions for the residents. During a review of facility's P&P titled, Interdisciplinary Care Plan dated 1/24/2024, the P&P indicated, To ensure that all resident's care needs are identified though continuous assessments and those needs are care planned with corresponding measurable objectives and adequate interventions. All residents will have a comprehensive care plan to meet their individual needs that is prepared by an interdisciplinary team (IDT) after admission and periodically reviewed and revised after subsequent assessments or change of condition. b. During a review of Resident 80's admission Record, the admission Record indicated the facility admitted Resident 80 on 11/29/2025, with the diagnosis that included chronic respiratory failure, dependence on respirator and pleural effusion (condition in which excess fluid builds around the lungs). During a review of Resident 80's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/2/2025, the H&P indicated resident awake, no command following, no movements, no agitation, no confusion, no anxiety. During a review of Resident 80's Admit/Readmit Screener (clinical tool used to quickly assess resident at admission), dated 11/29/2025, the Admit/Readmit Screener indicated Resident 80's is alert, non-verbal and unresponsive. The Admit/Readmit Screener indicated Resident 80 as total dependence with bed mobility, transfer, dressing, and personal hygiene. During an observation on 12/1/2025 at 11:25 a.m., 2:03 p.m., and on 12/2/2025 at 9:03 a.m., Resident 80 was observed awake, lying in bed with 4 side rails up. During a concurrent observation and interview on 12/3/2025 at 2:38 p.m. with LVN 5, observed Resident 80's side rails x2 up. LVN 5 stated the side rails x2 are up for Resident 80 for safety and repositioning. During a concurrent interview and record review on 12/3/2025 at 2:44 p.m. with RNS, Resident 80's Physician Order dated 11/29/2025 and Care Plan dated 12/3/2025 was reviewed. The Physician Order indicated, may use side rails x2 for positioning and ease of mobility as an enabler. The RNS indicated Resident 80 had an order for side rails x2, however, it is not in the Care Plan. RNS stated the side rails should be in the Care Plan. RNS stated there should be care plan for the side rails because it lets staff know the goals, interventions, and what needs to be evaluated and reported to the doctor. RNS stated a care plan is necessary to provide appropriate care. During a review of facility's P&P titled, Interdisciplinary Care Plan dated 1/24/2024, the P&P indicated, To ensure that all resident's care needs are identified though continuous assessments and those needs are care planned with corresponding measurable objectives and adequate interventions. All residents will have a comprehensive care plan to meet their individual needs that is prepared by an interdisciplinary team (IDT) after admission and periodically reviewed and revised after subsequent assessments or change of condition.

Based on interview, and record review the facility failed ensure the Minimum Data Set (MDS- standardized data collection tool used to assess cognitive brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions] and functional status, and care needs) section I -Active Diagnosis (a physician-documented illness or condition that is currently impacting a patient's health status, treatment, or plan of care) was accurately documented for one of four sampled residents (Resident 2). By failing to document Resident 2's diagnosis of anxiety (a feeling of worry or fear in response to stress that becomes excessive, persistent, and interferes with daily life) in the MDS dated [DATE]. This failure had the potential for Resident 2 not to receive a care plan for behavior monitoring.Findings: During a review of Resident 2's admission Record, the admission record indicated the facility admitted the resident on 1/8/2025 with a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive state of decline in mental abilities), and anxiety. During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident was oriented to time but was challenged with recall. The MDS indicated the diagnosis anxiety was not triggered (documented) under section I -Active Diagnosis. During a concurrent interview and record review on 12/4/2025 at 8:39 AM with the Minimum Data Set Nurse (MDSN) 1, MDSN 1 reviewed Resident 2's MDS dated [DATE], the Medical Diagnoses on the admission Record, and the Physician's Order dated 11/24/2025. MDSN 1 reviewed Resident 2's medical diagnosis and MDS 1 confirmed the resident was diagnosed with anxiety. MDSN 1 reviewed Resident 2's Physician's Order dated 11/24/2025 and confirmed the resident was prescribed Ativan (short term management of anxiety symptoms) for anxiety. MDSN 1 reviewed Resident 2's MDS dated [DATE] and confirmed the resident had not been triggered for anxiety under Section I - Medical Diagnosis. The MDS 1 stated Resident 2 should have been triggered for anxiety because the resident was prescribed an antianxiety medication. The MDS 1 stated Resident 2 would be at risk for misdiagnosis. During an interview on 12/4/2025 at 9:24 AM with the Director of Nursing (DON), the DON stated all medications were required to have a diagnosis (to indicate why the medication was prescribed). The DON stated the MDS should have been triggered first, then a seven day look back should be seen. The DON stated Resident 2 would be at risk for not having a care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to monitor for side effects of anxiety medications and would be at risk for a lack of behavior monitoring. During a review of the facility's policy and procedures (P&P) titled Psychotherapeutic Medications in the Chalet, dated 3/26/2025, the P&P indicated psychotherapeutic medications included but were not limited to antipsychotic, antidepressants, antianxiety and mood stabilizing medications. The policy indicated psychotherapeutic medications were used only when indicated by assessment and medical necessity. The P&P indicated any order for psychotherapeutic medication had to include the name of drug and dosage, frequency and indication of use. During a review of the facility's P&P titled Coding Procedure, Sub Acute, dated 1/24/2024, the P&P indicated the facility would use information while the resident (unspecified) was in house to determine the diagnoses for the MDS and to be in compliance with regulatory agencies for timely completion of the medical record.

Based on observation, interview and record review, the facility failed to ensure that one of eighteen sampled residents (Resident 71) had access to a functional call light. This deficient practice had the potential to result in negative impact on Resident 71 safety.Findings:During a review of admission record , the admission Record indicated that Resident 71 was admitted initially on the facility on 08/03/2024 with diagnoses including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) with tracheostomy (a surgical opening through your neck and into your windpipe to establish a direct airway for breathing), on ventilator (a medical device to help support or replace breathing), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral ischemic stroke (loss of blood flow to a part of the brain), muscle weakness and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 11/07/2025, indicated Resident 71's cognitive (mental action or process of acquiring knowledge and understanding) skills suggests that the individual has a severe level of cognitive impairment. The MDS indicated Resident 71 requires maximum assistance from the staff for activities of daily living ADLs (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During the initial tour on 12/1/2025 at 9:25 a.m., Resident 71 had no call light system in place. During a concurrent observation and interview on 12/1/2025 at 9:50 a.m. with Treatment Nurse 2 (TX 2) in Resident 71's bedside, TX 2 stated there was no call light in place attached to the call system. TX 2 stated there should be a call light here but maybe they took it out.During an interview on 12/4/2025 at 08:49 a.m. with Registered Nurse 4 (RN 4), RN 4 stated that staff must always keep the call light within the resident's reach, as it is crucial for residents to request assistance and prevent falls. RN 4 stated without call light their delayed responses to residents' needs can compromise their safety.During an interview on 12/4/2025 at 11:00 a.m. with Director of Nursing (DON), DON stated the importance of providing residents with access to a call light for their safety as it allows residents to request assistance when needed.During a review of Resident 71's Order Summary Report dated 12/4/2025, the order summary indicated an order was initiated on 8/19/2025 stated appropriate call light within reach every shift for safety.During a review of Resident 71's care plan titled Care Plan Report initiated date on 08/15/2024, the resident has an ADL self-care performance deficit related to limited mobility. Interventions stated as follows: encourage the resident to use bell to call for assistance.During a review of the facility's policy and procedure (P&P), titled, Call Light System revised on 10/2024, the P&P indicated, ensure call light is within the reach of the patient/resident at all times. As soon as the request is addressed, ensure call light device is positioned and placed appropriately before leaving the bedside.

Based on interview and record review, the facility failed to ensure one of eighteen sampled residents (Resident60), representatives were notified of changes in condition on 11/14/2025.This failure resulted in the resident's representative not being notified of the new skin breakdown and being unable to participate in decisions regarding necessary treatment and monitoring. Findings: During a record review of Resident 60's admission record indicated Resident 60 was admitted on [DATE] with a diagnoses of chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), basal cell carcinoma of the skin (a type of skin cancer that most often develops on areas of skin exposed to the sun), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident 60's Minimum Data set [(MDS)] resident assessment tool), dated 11/07/25 indicated that Resident's cognitive was impaired. The MDS indicated that Resident 60's is dependent (helper does all of the efforts) Resident 60 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) of oral hygiene, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a record review of Resident's 60 electronic medical records progress notes on 12/02/2025 at 10:49 a.m., a review of the change of condition (COC) dated 11/14/2025 at 19:42 indicated that Resident 60 had a scratch on the left back of the neck, with recommendation to follow wound care as ordered. There was no documentation that the family had been notified. During a concurrent interview and record review on 12/03/2025 at 1:58 p.m. with Treatment Nurse 1(TX1) of Resident 60's COC, TX1 stated that Resident 60 experienced a change of condition on 11/14/2025 at 19:43, it indicated patient has a scratch on left back of the neck. TX1 stated that Resident 60's Representative was not notified of the new skin scratch. TX1 stated that she forgot to contact Resident60's representative because she was not assigned to Resident 60 and was assisting the nursing staff. During concurrent interview and record review on 12/4/2025 at 11:14 a.m. with Director of Nursing (DON) on 12/04/2025 at 11:14 a.m., the DON stated that License staff are expected to notify the resident's physician and responsible representative of all changes in condition, including new skin issues. The DON stated that the notification was not completed for Resident 60's COC initiated on 11/14/2025. DON stated that it is important to notify the residents responsible representative of any changes because representatives are responsible for participating in care decisions and have the right to know what is going on with their loved ones. A review of the facility's policy and procedure titled. Change of Condition, Notification revised on 09/10/25, indicated Notify the resident's family/caregiver of unexpected changes in resident's condition and document such communication in the medical record.

Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for three of nine residents when the facility failed to:Ensure two of four residents (Resident 35, Resident 24) had physician orders for side rails (protective barrier or structural support along the edge of something, most commonly a bed to prevent falls).Release Resident 20's right hand mitten every 2 hours as indicated in the Residents care plan. These deficient practices had the potential for lack of monitoring and potential harm or injury.Findings: During a review of Resident 20's admission Record, the admission Record indicated the facility initially admitted Resident 20 on 7/5/2023, and readmitted the resident on 01/17/2024, with the diagnosis that included chronic respiratory failure, dependence on respirator (ventilator – a medical device to help support or replace breathing), and hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following nontraumatic intracerebral hemorrhage (bleeding within the brain). During a review of the Minimum Data Set (MDS – a resident assessment tool) dated 10/10/2025, the MDS indicated Resident 20's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Patient 20 was dependent on staff for all activities of daily living (ADL – routine tasks/activities such as bathing, dressing, and toileting) a person performs daily to care for themselves). During an observation on 12/1/2025, at 11:18 a.m., Resident 20 was observed lying in bed with right hand mitten on. During an interview on 12/2/2025, at 3:19 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated the order is to release the mitten every 2 hours for 15 minutes to check on Resident 20's circulation and skin integrity. LVN 5 stated LVN assigned to the resident is the nurse responsible for releasing the restraint every 2 hours, check circulation and integrity. LVN 5 stated the last time she released the mitten was at 12:35 p.m. and that she was supposed to release again at 2:30p.m. LVN 5 stated it is important to release the mitten every 2 hours as ordered to check and make sure the mitten is not causing problems with circulation or skin integrity. During a concurrent interview and record review of Restraints assessment dated [DATE]-[DATE] on 12/3/2025 at 10:05 a.m. with Registered Nurse (RN) 4, the Restraints Assessment indicated the restraints were released, skin and pulse checked on: 11/30/2025 at 6:00 p.m., thereafter at 8:51 p.m. 12/1/2025 at 4:40 a.m., thereafter at 8:00 a.m. 12/2/2025 at 12:34 p.m., thereafter at 3:30 p.m. RN 4 stated Resident 20's mitten was not released and re-applied according to Physician's order of every 2hours. RN 4 stated it is important to release the mitten timely every 2 hours to make sure the restraint is not causing circulation and skin integrity problems to the resident. During review of the facility's policy and procedure (P&P) titled, Restraints – Physical: Guidelines for Use and Assessment (Sub-Acute), dated 1/14/2024, the P&P indicated All residents will be released for repositioning, checked for application, circulation, and pressure a minimum of every 2hours. The release and restraint checks will be documented on the designated nursing restraint assessment under actions taken. During a review of Resident's 35's admission Record, the admission Record indicated the facility admitted Resident 35 on 7/24/2024 with the diagnosis including epilepsy (brain disorder characterized by recurrent seizures, which are sudden surges of abnormal electrical activity in the brain) and schizophrenia (serious, chronic mental disorder that disrupts how a person thinks, feels, and behaves, causing a distorted view of reality). During a review of Resident 24's admission Record, the admission Record indicated the facility admitted Resident 24 on 7/28/2025 with diagnosis including epilepsy traumatic brain injury (damage to the brain from an external physical force), and obstructive hydrocephalus (A blockage in the brain's cerebrospinal fluid (a clear, watery fluid that surrounds and protects your brain and spinal cord) pathways. During a review of Resident 24's MDS dated [DATE], the MDS indicated the resident was impaired on both sides for the upper and lower extremities (the outermost parts of the body, specifically the arms and legs (upper and lower limbs). The MDS indicated Resident 24 was dependent on all self-care needs. The MDS indicated that bed rails were not used as a restraint. During a review of Resident 35's MDS dated [DATE], the MDS indicated the resident's cognition was severely impaired. The MDS indicated that Resident 35 was dependent on all self-care needs. The MDS indicated that bed rails were not used as a restraint. During a review of Resident 24's Care Plan Report dated 11/14/2025, the Care Plan report indicated Resident 24 had a seizure disorder at risk for injury. The Care Plan report indicated the intervention included padded side rails up times four for seizure precautions. During a review of Resident 35's Care Plan Report dated 11/15/2025, the Care Plan Report indicated Resident 35 had a risk for seizures related to motor vehicle accident with traumatic brain injury. The Care Plan Report indicated the interventions included for padded side rails up times two for seizure precautions. During an observation on 12/1/2025 at 10:36 AM in Resident 35's room, Resident 35 was lying in bed, the upper side rails were up times two, the call light was within reach. During an observation on 12/1/2025 at 10:58 AM in Resident 24's room, Resident 24 was lying in bed, the upper side rails were up two times, the call light was within reach. During a review of Resident 35's Physician order dated 12/1/2025, the Physician Order indicated padded side rails up times two for seizure precautions every shift. The Physician Order was done at 07:00 PM. During a review of Resident 24's Physician order dated 12/1/2025, the Physician Order indicated padded side rails up times two for seizure precautions every shift. During a concurrent, observation, interview and record review on 12/2/2025 at 9:16 AM with Registered Nurse (RN) 1, Resident 35's Physician's order was reviewed. The physician order indicated padded side rails up times two for seizure precautions dated 12/1/25. Resident 35 was observed to have side rails up times four. RN 1 stated there was no physician's order noted for side rails to be up times four. RN 1 stated that maybe the CNA put the side rails up times four. RN 1 stated the physician order for padded siderails to be up times two was dated 12/1/2025 at 17:22. RN 1 stated Resident 35 always had a physician's order for padded side rails to be up times two for seizure precautions. During an interview on 12/3/2025 at 1:45 PM with the Minimum Data Set Nurse (MDSN), the MDSN stated the facility had a standard order for side rails either for mobility positioning enabler (any device, equipment, or technique that helps a person with physical impairments maintain a comfortable and safe body posture or move around more easily) and for seizure diagnoses. The MDSN stated there is a specific coding for side rails in the MDS for restraints but would not be triggered. During an interview on 12/3/2025 at 1:47PM with the Director of Nursing (DON), the DON stated that they will use side rails to be up times four, for restraints or per resident request. The DON stated that assessments are done, then the MDS does an entry assessment and 7-14 days and initiate a baseline care plan. During an interview on 12/4/2025 at 8:54 AM with the Certified Nurse Assistant (CNA) 2, CNA 2 stated if residents (unspecified) are moving around in the bed then the side rails would be up times four, and if the charge nurse gave them instructions with a Physician's order. CNA 2 stated Resident 35 does not have side rails up times four. CNA 2 stated Resident 35 does not move around in bed. During an interview on 12/4/2025 at 8:59 AM with Registered Nurse (RN) 2, RN 2 stated that her superiors reminded the staff (unspecified) to check for all residents (unspecified) physician orders for padded side rails. RN 2 stated she put in the order for padded side rails up times two for Resident 35 and Resident 24. RN 1 stated there weren't any orders for side rails up times two or four for Resident 24 or Resident 35. RN 2 stated the side rails up times four would be appropriate for those residents (unspecified) who are confused and moving a lot and restless. RN 2 stated padded side rails up times two would be a standing order and does not need a consent. RN 2 stated side rails need to be padded when up times four. RN 2 stated the risk to the residents without an order for side rails up times four would be the side rails would be considered a restraint, which must have an order and monitoring for risk of falls and checking skin integrity. During an interview on 12/4/2025 at 9:12 AM with the DON, The DON stated they decided to reach out to the doctors (unspecified) and if appropriate get an order for side rails for those residents with seizure diagnosis. The DON stated in discussions with the nurses (unspecified), if residents (unspecified) had seizure diagnosis that it's appropriate to have side rails up times four. The DON stated the nurses (unspecified) had confusion which is why the physicians order for side rails up times 2 was placed. The DON stated the risk to Resident 24 and 35 without physician's order for side rails could be lack of guidance regarding resident (unspecified) safety. The DON stated at the end of the day, it's the residents (unspecified) will suffer. During a review of the facility's policy and procedures (P&P) titled, Restraints – Physical: Guidelines for use and Assessment (Sub-Acute), dated 5/14/2025, the P&P indicated all restraints will require a physician order and restraint use will be reflected in the resident's plan of care. During a review of the facility's policy and procedures (P&P) titled, Provider Orders: Inpatient and Outpatient, dated 8/27/2024, the P&P indicated a provider order is required to admit, place in observation, discharge, transfer and for all tests services therapies and procedures for a patient.

Based on record review, observation and interview, the facility failed to ensure 1 of 3 sampled residents (Resident 1), when Resident 1 did not have access to an appropriate call light (remote with button used to call staff for help) system in accordance with the facility's policy and procedure titled Call Light System.This deficient practice had the potential for Resident 1's self-esteem, emotions, and physical care to be affected. Findings:During a review or Resident 1's History and Physical (H&P), dated 6/16/2025, the H&P indicated Resident 1's medical history included quadriplegia (paralysis [no movement] from the neck down, affecting all four limbs) and chronic respiratory failure (long term condition in which not enough oxygen passes from the lungs into the blood) with tracheostomy (an artificial opening through the neck usually for the relief of difficulty in breathing) on a ventilator (a medical device to help support or replace breathing).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/23/2025, indicated Resident 1's cognitive (ability to think and process information) skills for daily decision making was intact, and required two person physical assistance for activities of daily living (bathing, dressing, toileting, transferring, feeding). Resident 1 had the ability to make self understood and understand others. The MDS also indicated Resident 1 had impairment on both sides of the upper and lower extremities (arms and legs) and was dependent on staff to help with movement.During a concurrent observation and interview on 7/15/2025 at 4:12 p.m. with Resident 1 in Resident 1's room, Resident 1 was alert, had a tablet (electronic device) on his table in front of him, and a call light (remote with a button used to call staff for help) next to his head. Resident 1 stated he could not move his arms because he was quadriplegic (paralysis [no movement] from the neck down, affecting all four limbs). Resident 1 stated he was not given a different call light that he could access. Resident 1 stated he calls for help by making two clicking sounds. Resident 1 stated, Sometimes they (staff) don't hear me and I have to wait long.During an interview on 7/17/2025 at 8:18 a.m. with the Director of Engineering (DOE), DOE stated there is an adaptive (made accessible for individuals with difficulty using an object) call light system that could be used. DOE stated, If requested we can provide the pad or the call bell for the residents. The DOE stated the adaptive call light is like a round pad that they (the resident) can touch with their cheek and could be used for quadriplegic residents. DOE stated the department would notify engineering if needed and will send someone to change from a regular hand call light to the special call button or pad.During an interview on 7/17/2025 at 8:40 a.m. with Director of Nursing (DON), DON stated adaptive call system use depends on the assessment to make sure the residents are using appropriate call system. DON stated no residents were currently using the tap/pad call light. DON acknowledged it would be appropriate for someone who is unable to use their arms to use a tap/pad call light system. DON stated Resident 1 had the regular call light now and Resident 1 should have the appropriate call light system.During a review of the facility's policy and procedure titled, Call Light System, dated 11/26/2024, the P&P indicated: A. Ensure that the call light is always within easy reach of the patient/resident. B. For paraplegic patients/residents who may have limited upper body mobility, adaptive call light devices should be provided to ensure they can easily signal for assistance.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2) received the appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: -Ensure Resident 1 received hand rolls (devices used to assist with finger extension [the act of straightening a finger at its joints] and prevent finger flexion contractures [a condition where one or more fingers become permanently bent in a flexed position]) in both her hands as ordered by the physician. -Ensure Resident 2 received a hand roll in her right hand as ordered by the physician. These deficient practices had the potential for Resident 1 and Resident 2 to develop worsened contractures and injury. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility readmitted the resident on 1/20/2025 with diagnoses that included chronic respiratory failure (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period), hemiplegia (total paralysis of the arm, leg, and truck on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body), cerebral infarction (stroke, loss of blood flow to a part of the brain), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the left hand, contracture of the right hand, tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe), gastrostomy (G-Tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach), and dependence on the ventilator (a serious medical condition that occurs when a patient requires mechanical ventilation to breathe). During a review of the Physician's Order dated 1/21/2025, indicated for the Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) to don (put on) bilateral (both sides) hand rolls on at all times/or as tolerated for contracture management. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 2/21/2025, indicated the resident had severely impaired cognitive skills (never/rarely made decisions) for daily decision making. The MDS further indicated Resident 1 was dependent on help for oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's Care Plan (CP) revised 2/26/2025, the care plan indicated the resident needed restorative nursing because the resident was at risk for developing contracture or a decrease in ROM. The CP indicated a goal for Resident 1 to maintain her current joint ROM. The CP further indicated interventions that included the RNA to don bilateral hand rolls on at all times/or as tolerated for contracture management. During a review of Resident 1's Restorative Nursing Assistant Record (RNAR) dated 2/1/2025-2/28/2025, the RNAR indicated on 2/1/2025, 2/6/2025, 2/7/2025, 2/13/2025, 2/15/2025, 2/18/2025, 2/21/2025, 2/23/2025, 2/27/2025, and 2/28/2025 there was no documentation bilateral hand rolls were donned for Resident 1. During a review of Resident 1's RNAR dated 3/1/2025 - 3/10/2025, the RNAR indicated on 3/4/2025 and 3/7/2025 there was no documentation bilateral hand rolls were donned for Resident 1. During a review of Resident 1's Progress Notes (PN) dated 2/1/2025 - 3/10/2025, the PN did not indicate there was documentation that the resident could not tolerate hand rolls. During a review of Resident 2's Admission Record, the Admission Record indicated the facility admitted the resident on 1/7/2025 with diagnoses that included chronic respiratory failure, cerebral palsy (a group of movement disorders that affect a person's ability to control their muscles, balance, and posture), contracture of other specified joint, tracheostomy, gastrostomy, intellectual disabilities (a lifelong condition that impacts a person's ability to learn and function in daily life), and dependence on supplemental oxygen. During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition. The MDS further indicated Resident 2 was dependent on help for oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of the Physician's Order dated 1/9/2025, indicated the resident was to don right hand rolls on at all times or as tolerated while monitoring for skin breakdown and comfort. During a review of Resident 2's RNAR dated 2/1/2025-2/28/2025, the RNAR indicated on 2/1/2025, 2/13/2025, 2/15/2025, 2/21/2025, 2/23/2025, 2/27/2025, and 2/28/2025 there was no documentation that a hand roll was donned to Resident 2's right hand. During a review of Resident 2's RNAR dated 3/1/2025 - 3/10/2025, the RNAR indicated on 3/4/2025, and 3/7/2025 there was no documentation that a hand roll was donned to Resident 2's right hand. During a review of Resident 2's Progress Notes (PN) dated 2/1/2025 - 3/11/2025, the PN did not indicate there was documentation that the resident could not tolerate hand rolls. During a concurrent interview and record review on 3/11/2025 at 10:50 AM, Resident 1 and 2's physician's orders, RNAR dated 2/1/2025 - 2/28/2025, and RNAR dated 3/1/2025 - 3/10/2025 were reviewed with RNA 1. RNA 1 stated he performed RNA services for Resident 1 and Resident 2. RNA 1 stated Resident 1 and Resident 2 both had physician's orders for hand rolls; Resident 1 was to have bilateral hand rolls and Resident 2 was to have hand rolls in her right hand. RNA 1 stated if a resident was given hand rolls it would be documented on the RNAR. RNA 1 stated the days when there was no documentation on the RNAR means the resident did not receive hand rolls. RNA 1 stated hand rolls should be on every day 24 hours a day to prevent contractures from getting worse. During a concurrent observation and interview on 3/11/2025 at 11 AM, in Resident 2's Room, Resident 2 was observed with RNA 1 and the Interim Director of Nursing (IDON). Resident 2 was observed lying in bed on her back with pillows beneath her legs. Resident 2's right hand was observed without a hand roll. RNA 1 and the DON confirmed Resident 2 did not have a hand roll in her right hand. RNA 1 stated Resident 2 should have a hand roll in her right hand. RNA 1 stated hand rolls should be on at all times. During a concurrent observation and interview on 3/11/2025 at 11:25 AM, in Resident 1's Room, Resident 1 was observed with RNA 1. Resident 1 was observed lying in bed on her back. Resident 1's hands were observed without hand rolls. RNA 1 confirmed Resident 1 did not have hand rolls in her hands. RNA 1 stated that hand rolls were supposed to be on at all times to prevent contractures. During a concurrent interview and record review on 3/11/2025 at 2:11 PM, Resident 1 and Resident 2's physician's orders, RNAR dated 2/1/2025 - 2/28/2025, and RNAR dated 3/1/2025 - 3/10/2025 were reviewed with the IDON. The IDON confirmed Resident 1 and Resident 2 had physician's orders to don hand rolls at all times or as tolerated. The IDON confirmed during the observations of Resident 1 and Resident 2, both residents were observed without hand rolls. The IDON confirmed Resident 1 and Resident 2 had missing documentation for the donning of hand rolls on the RNARs dated 2/1/2025 - 2/28/2025 and 3/1/2025 - 3/10/2025. The IDON stated if a resident was not tolerating hand rolls it would have been documented in the nursing progress notes. The IDON further stated the hand rolls were supposed to be used to help prevent contractures from worsening. During a review of the facility's Policy & Procedure (P&P) titled, Range of Motion/Joint Mobility Management, reviewed 9/25/2024, the P&P indicated Purpose: To maintain the resident's optimal level of functioning, mental and psychosocial function to assist and achieve the resident's highest possible level of self-care, and functional independence and wellbeing. It is the policy that the Therapist will: Develop RNA program appropriate to the resident's identified needs. Develop specific measurable goals and document goals and interventions and implement on the resident's RNA care plan. Procedure: The therapist will assess the Range of Motion of each resident's extremities and document in the medical record to include range of motion with any limitations. The policy indicated the therapist will implement strategies for preventing further limitations and maintenance of the joint range of motion. The therapist will obtain a physician's order for RNA treatment (program). Implementation is guided from the assessment, reassessment and plan of care .Charge nurse is responsible to carry out the RNA orders and place the resident in the RNA program, and to initiate and maintain the Plan Of Care, to monitor the RNA personnel, and to communicate with physician and therapy service for resident ' s progress and condition .In the event when there is no RNA available, CNA and Charge Nurse are responsible to carry out the program for continuity of care.

Based on observation, interview, and record review, the facility failed to ensure that proper personal protective equipment (PPE) was supplied and utilized by staff when showering a patient (Patient 1). This deficient practice regarding infection control protocols increases the risk of cross-contamination. Without proper PPE, staff and patients may be exposed to blood, bodily fluids, or other potentially infectious materials, increasing the likelihood of transmitting infections. This poses a potential threat to the safety and health of both patients and staff. Findings: During a review of Patient 1's History and Physical (H&P), dated , the H&P indicated, Patient 1 past medical history and present illness include neuromuscular disease (a wide-range of diseases affecting the peripheral nervous system, which consists of all the motor and sensory nerves that connect the brain and spinal cord to the rest of the body), functional quadriplegia (the complete inability to move due to severe disability or frailty), wheelchair limited since eight years old, severe scoliosis (abnormal lateral curvature of the spine), and mechanical ventilator (a machine that takes over the work of breathing when a person is not able to breathe enough on their own) dependence. During a concurrent observation and interview on 1/29/2025 at 11:15 a.m. with the Director of Nursing (DNS) in the shower room located on the East/South of the subacute ( a level of care that is defined as a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) unit, two staff members (CNA 1 and CNA 2) were showering Patient 1. Patient 1 was lying on a standard gurney rather than an appropriate gurney. Both staff are standing in water, and the entire floor of the shower room was wet. Notably, CNA 1 was not wearing shoes covers, and the bottom of their pants appeared wet. Patient 1 was positioned on their side, with CNA 1 holding onto the torso and shoulder to prevent them from rolling over, while CNA 2 was spraying water on the patient's back. Water was running off the side of the gurney onto CNA 1's shoes. DNS also stated that both shower gurneys had been broken for a few months, which is why the facility had utilized standard gurneys for showering patients. NDS stated today staff will be showering 20 patients. The NDS confirmed that Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 were showed this morning using the standard gurney. During an interview on 1/30/2025 1:06 p.m. with Nursing Director of the subacute unit (NDS), NDS stated both shower gurney was broken and taken out of service since September 2024 (four month ago) the facility could not find a rental and was not able to secure a delivery date for the new shower gurney. NDS also confirmed that there is a safety concern regarding the use of a standard gurney, which is not designed for showering patients. Despite the safety concerns, after discussion with the facility administrator, the decision was made to use the standard gurney as a shower gurney. During an interview on 1/29/2025 at 11:20 a.m. with CNA 3, CNA 3 stated shower gurney had been broken for about four to five months. Using the standard gurney makes it difficult to shower patients safely, and water goes on their feet. Additionally, transferring the patient is not safe. During an interview on 1/29/2025 at 11:30 a.m. with CNA 4, CNA 4 stated during showering, their feet get wet and that it is difficult to transfer patients using the standard gurney. During an interview on 1/29/2025 at 11:30 a.m. with CNA 2, who was observed at 11:15 a.m. showering patient 1, CNA 2 stated that they would be showering 21 patients today. CNA 2 also confirmed that the shower gurney had been broken for over four to five months. Stated the standard gurney complicates safe transfer patient due to the wet floor there is risk of slipping and falling. They mentioned that when their socks become soaked, they have to change them. During a concurrent observation and interview on 1/29/2025 at 11:35 a.m. with CNA 1 in the DNS's office, CNA 1's lower pants appear wet. CNA 1 stated during showering of Patient 1, he went to the bathroom and returned to the shower room but forgot to put on the shoe covers. The shoe covers used by staff were provided by CNA 2. Upon examination, the shoe covers supplied by the facility was found not to be water-resistant and were not made of plastic. The box that the shoe covers come in indicated, Poly-coated .Footwear users should be aware that risk of slipping exits. During an interview on 1/30/2024 at 11:41 a.m. with the Clinical Educator (CES), CES stated they are not aware that the subacute unit is utilizing the standard gurney to shower patients. Stated for safety of the patients and staff appropriate personal protective equipment (PPE, equipment used to prevent or minimize exposure to hazards) must be worn during shower of the patient. CES stated the staff should don gloves, gown, and shoe covers. CES confirmed that PPE should be water-resistant to prevent the staff from getting wet and to minimize the risk of cross-contamination and risk of slipped and fall. During an interview on 1/30/2024 at 12:20 p.m. with the Infection Preventionist (IP), IP stated they are not aware the subacute unit has been utilizing the standard gurney to shower patients. IP stated during the shower process, it is important for staff to don appropriate PPE, such as gown, gloves and shoes protection to prevent getting wet during the shower process. IP stated all PPE worn should be water-resistant, as wet shoes and ankles pose significant issues regarding infection control and increase the risk of cross-contamination. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment (PPE), dated 6/28/2023, the P&P indicated, To establish individual responsibilities to minimize the transmission of transmissible microorganisms to, from, and between patients, and all other persons at Hollywood (name of the facility). To provide a safe environment by preventing the transmission of infectious diseases throughout the facility, and to provide consistent care for all patients regardless of the nature of their illness . Standard Precautions: An alternative concept to Universal Precautions that defines all blood, body fluids and substances as infectious. Standard Precautions are used whenever there is a risk of exposure to blood, body fluids, broken skin, mucous membranes and items soiled with other potentially infectious materials (OPIM). Occupational Exposure: Reasonably anticipated skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious materials that may result from employees performing their duties. Employees whose job classifications are determined to have occupational exposure to blood or regulated medical waste are responsible for compliance with Standard Precautions procedures. Managers are responsible for providing and maintaining availability of personal protective equipment (PPE), and for ensuring the training of employees regarding PPE. Personal Protective Equipment Protective equipment/supplies will be placed in convenient locations in all patient care areas throughout the medical center. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention Risk Assessment and Plan, dated 2023 , the P&P indicated, The plan serves as the foundation for the prevention, identification, and prevention of healthcare-associated infections through ongoing surveillance, evidence-based intervention, education, and evaluation to effectively improve delivery of health and serve the health needs of caregivers, patients, and visitors within the facility and the surrounding community . Infection Prevention Activities: To identify areas of priority, maintain a system to identify, report, and evaluate infections among patients and hospital caregivers . To communicate Infection Prevention Committee findings and recommendations to appropriate individuals and departments . Employee Centered Responsibilities (in partnership with Employee Health) includes but not limited to the following: Adherence/compliance with infection prevention and control measures and activities. Consultations for infection Prevention issues.

Based on observation, interview, and record review, the facility failed to ensure the safety of fourteen of fourteen sampled Patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) was compromised when the facility failed to utilize an appropriate shower gurney designed specifically with safety features for use in a wet environment. This deficient practice placed Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 in an unsafe situation, creating a risk of falling off the gurney, as standard gurneys may lack the necessary safety features to secure a patient during showering. Regular gurneys are not engineered to provide the requisite support for patients in wet conditions. If the gurney becomes slippery due to water exposure, it may not offer adequate stability to keep the patient securely in place. Findings: During a review of Patient 1's History and Physical (H&P), dated , the H&P indicated, Patient 1 past medical history and present illness include neuromuscular disease (a wide-range of diseases affecting the peripheral nervous system, which consists of all the motor and sensory nerves that connect the brain and spinal cord to the rest of the body), functional quadriplegia (the complete inability to move due to severe disability or frailty), wheelchair limited since eight years old, severe scoliosis (abnormal lateral curvature of the spine), and mechanical ventilator (a machine that takes over the work of breathing when a person is not able to breathe enough on their own) dependence. During a concurrent observation and interview on 1/29/2025 at 11:15 a.m. with the Director of Nursing (DNS) in the shower room located on the East/South of the subacute (a level of care that is defined as a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) unit, two staff members (CNA 1 and CNA 2) were showering Patient 1. Patient 1 was lying on a standard gurney. The gurney's side rail was inadequate, featuring bars with approximately twelve-inch gaps, allowing water to flow freely out of these openings as the patient was being showered. There was an absence of barriers at both the head and foot of the gurney. Both staff members were standing in water, and the entire floor of the shower room was soaked. CNA 1 was not wearing shoes covers, and the bottom of their pants appeared damp. Patient 1 was positioned on their side, with CNA 1 holding onto the torso and shoulder to prevent them from rolling while CNA 2 was sprayed water on the Patient1's back. Water was running off the side of the gurney and onto CNA 1's shoes. DNS stated that staff should be wearing shoes covers and confirmed that wet shoes can increase risk for slipping and falling, as well as create infection control issues. DNS also stated that both shower gurneys had been broken for a few months, which is why the facility had utilized standard gurneys for showering patients. NDS stated today staff will be showering 20 patients. The NDS confirmed that Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 were showerd this morning using the standard gurney. During an interview on /30/2025 at 10:30 a.m. with the Director of Supply Chain Operations (DSCO), the DSCO stated that in September, when both shower gurneys were broken, there was a plan to repair them. However, when the repair engineer arrived on 12/12/2024, they could not locate the broken shower gurneys anywhere in the facility. They then called for rentals but were unsuccessful. The facility subsequently decided to purchase new shower gurneys. An order was placed, but there is no estimated date for when the new shower gurneys will be received. The DSCO stated that the Supply Chain Department does not have records of how may shower gurneys the subacute unit has. Therefore, the order for shower gurneys must indicate STAT (without delay; immediately) to ensure it is prioritized. However, the DSCO stated that there were no orders indicating that the subacute unit needed the shower gurneys on a STAT basis. During an interview on 1/30/2025 1:06 p.m. with Nursing Director of the subacute unit (NDS), NDS stated both shower gurney was broken and taken out of service since September 2024 (four month ago) the facility could not find a rental and was not able to secure a delivery date for the new shower gurney. NDS also confirmed that there is a safety concern regarding the use of a standard gurney, which is not designed for showering patients. Despite the safety concerns, after discussion with the facility administrator, the decision was made to use the standard gurney as a shower gurney. During a review of the facility's policy and procedure (P&P) titled, Environment of Care Safety Management Plan, dated September 2024, the P&P indicated, The Environment of Care (EOC) Safety Management Plan outlines the methods and practices used to design, implement and monitor a program to minimize safety risks for patients and all others who enter (name of the facility) .The EOC Safety Management Plan provides a framework for managing the environment of care and addresses six areas of the environment of care: safety, security, hazardous materials and waste, fire safety, medical equipment and utility systems. Separate management plans are available for the Emergency Management and Life Safety programs. The objective of the EOC Safety Management Plan is to provide a guideline for the development of a safety management program that will enable the hospital: o To comply with all relevant safety standards and regulations o To develop or maintain effective program elements that contribute to an overall reduction in workplace injuries and improved patient safety o To improve employee performance through effective safety education and training o To develop standards to monitor, assess, measure and improve EOC performance o To monitor the effectiveness of the safety program A. The CEO is responsible for assuring the existence and effectiveness of a comprehensive safety program by providing the vision, leadership, financial and administrative support to facilitate the ongoing activities of the EOC committee. The CEO shall designate a member of the Executive Staff to serve as the administrative representative on the committee . The EOC Committee oversees and monitors the hospital's safety management program . Subcommittees and working groups may be established to help identify and resolve safety issues .The committee analyzes environment of care issues in a timely manner through monthly and quarterly reports to the committee. The results of data analysis are used to identify opportunities to resolve environmental safety issues. Action is taken on identified opportunities, and changes are evaluated to determine if they have resolved the identified issues . During a review of the operation manual provided by the facility for the standard gurney that was utilized by the facility because their shower gurneys were broken on 9/10/2024 (more than four months and 19 days since both shower gurney was taken out of service) titled [NAME] Operations Manual, not dated, the operation manual indicates that while Model 1015 stretchers can be power washed, it emphasizes that proper procedures must be followed. Key points from the manual include: the stretcher must not be submerged or used inappropriately. Cleaning solutions should not pool on any components. Stretchers must have maintenance performed after a minimum of every fifth washing. Refer to the maintenance manual for specific lubrication instructions . Do not allow cleaning solutions or other fluids to pool on the display unit.

Based on interview and record review, the facility failed to ensure adequate administration services as the facility's administrator did not have an administrator's license and failing to ensure the facility had a designated administrator. The deficient practice had the potential for the facility resident's to not have their concerns and needs addressed in a timely manner. Cross Reference F725 Findings: A review of the Administrator's Job Description dated 3/20/2023, indicated she held the title of Chief Nursing Officer (CNO). The Job Description indicated the CNO coordinated and directed the operations of the Nursing Departments, ensured quality patient care was given across the continuum with appropriate level of care, and was actively involved, at the executive level, in the leadership of the organization. The CNO organized and administered areas of Patient Care services to attain the hospital's objectives established by the Governing Body, identified and articulates the vision and strategic direction for the discipline of Nursing and collaborates on the implementation of strategies to achieve them and directs performance improvement and continuous quality improvement (CQI) activities. The Job Description indicated a current Registered Nurse (RN) License was required for the CNO position. A review of the organizational chart for General Acute Care Hospital (GACH) 1 dated 11/6/2024, indicated the facility Administrator was the CNO for GACH 1. A review of the undated organizational chart for the facility, indicated the Administrator held the title of Administrator for the facility. During an initial tour of the facility on 12/9/2024 at 9 AM, there was no posted Administrator license observed on the facility's bulletin board. During an interview on 12/10/2024 at 12:17 PM, the Director of Nursing (DON) stated and confirmed there was no posted Administrator license on the facility's bulletin board. The DON stated the previous administrator resigned from the facility in 4/2024 and when the previous administrator left, the CNO of GACH 1 became the Administrator for the facility. The DON stated she was not sure if the current Administrator (CNO) had an administrator's license. The DON stated the Administrator came to the facility every day. During an interview on 12/10/2024 at 12:22 PM, Licensed Vocational Nurse (LVN) 6 stated the facility did not have an administrator and the DON had been the only one they had seen in the facility. LVN 6 stated they had not seen the CNO for GACH 1 at the facility. During an interview on 12/10/2024 at 12:27 PM, LVN 7 stated the facility had no administrator. LVN 7 stated the facility solely had a DON and that the CNO for GACH 1 rarely came to the facility. LVN 7 stated sometimes the CNO for GACH 1 did not come at all. During an interview on 12/11/2024 at 2:53 PM, the Administrator (CNO) stated she was the CNO for GACH 1 and the Administrator for the facility. The Administrator stated she had been the CNO for GACH 1 for two years and started as the Administrator for the facility in 4/2024. The Administrator (CNO) stated she had a RN license and did not have an Administrator's license. The Administrator (CNO) stated she did not have a set number of hours that she spent at the facility or at GACH 1 but spent time at both. The Administrator (CNO) stated she met with the DON as frequently as she could. The Administrator (CNO) further stated she had no set time to come to the facility but would come as needed and would go back and forth between GACH 1 and the facility. During an interview on 12/12/2024 at 3:52 PM, the Medical Director (MD) 1 stated the facility's previous Administrator left in 4/2024. MD 1 stated the facility did not have a dedicated Administrator and that the CNO for GACH 1 had been the facility's acting Administrator since the previous administrator resigned. MD 1 stated with the facility not having a dedicated Administrator there was a potential for the facility residents to be impacted when it comes to having the resident and/or family concerns addressed. MD 1 stated he and the DON could not address all administrative concerns because there were too many people. MD 1 stated there was no one to immediately address resident and family concerns. A policy and procedure regarding Administration was requested from the facility but was not provided.

Based on interview and record review, the facility failed to ensure its residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for two of three sampled residents (Resident 6 and 72). -The facility failed to provide Resident 6 with Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises on both lower extremities (BLE, hip, knee, ankle, feet) five times a week, both upper extremities (BUE, shoulder, elbow, wrist and hand) five times a week, and bilateral knee and elbow splints five times a week for three to four hours as ordered by the physician. -The facility failed to provide Resident 72 with RNA treatment for PROM on BUE and BLE five times a week, bilateral elbow splints five times a week for three to five hours, right knee splint five times a week for three to four hours, and bilateral hand splints five days a week for a maximum of four hours as ordered by the physician. This deficient practice had the potential to cause further decline in functional mobility, ROM, and quality of life for Residents 6 and 72. Findings: a. A review of Resident 6's Admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnosis including anoxic brain injury damage (occurs when the brain is completely deprived of oxygen, which results in brain cell death) and dependent on ventilator (when a patient cannot breathe independently and requires a mechanical ventilator [machine that helps people breathe]). A review of Resident 6's physician's order dated 8/23/2023 indicated RNA to perform PROM exercises to the left lower and upper extremity once daily five times a week or as tolerated, the right lower and upper extremity once daily five times a week or as tolerated and to apply left and right elbow splint, once daily three to four hours a day for five times a week or as tolerated. A review of Resident 6's care plan revised 3/28/2024 indicated the resident had a need for restorative nursing related to resident was at risk for developing contracture or decrease in ROM. The interventions included RNA to apply bilateral elbow and knee splints three to four hours a day for five times a week or as tolerated and RNA to perform PROM bilateral upper and lower extremities once daily five times a week or as tolerated. A review of Resident 6's physician's order dated 5/11/2024 indicated RNA to apply bilateral knee splints once daily three to four hours a day for five times a week or as tolerated. A review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/8/2024 indicated the resident's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 6 was dependent (helper does all of the effort) with toileting, shower, oral, and personal hygiene. The MDS indicated Resident 6 had impairment on both sides of the lower and upper extremity, received restorative nursing programs, and received five days of passive range of motion and six days of splint or brace assistance. A review of Resident 6's Joint Mobility assessment dated [DATE] indicated the resident maintained assessed mobility without new changes and would continue the RNA program. A review of Resident 6's Restorative Nursing Assistant Documentation for October 2024 indicated the resident did not receive PROM to the BUE and BLE and bilateral elbow and knee splints on 10/8, 10/10, 10/11, and 10/12/2024. A review of Resident 6's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BUE and BLE and bilateral elbow and knee splints on 11/14 - 11/16/2024, 11/19, 11/22, and 11/23/2024. A review of Resident 6's Restorative Nursing Assistant Documentation for December 2024 indicated the resident did not receive PROM to the BUE and BLE and bilateral elbow and knee splints on 12/1, 12/3 and 12/4/2024. During a concurrent interview and record review, on 12/12/2024 at 9:51 AM with the Director of Nursing (DON), Resident 6's Restorative Nursing Assistant Documentation for October 2024, November 2024, and December 2024 were reviewed. The DON stated and confirmed Resident 6 was on the RNA program for the following: PROM to the BLE and BUE extremity once daily five times a week or as tolerated and bilateral knee and elbow splints once daily three to four hours a day for five times a week or as tolerated. The DON stated the x on the Restorative Nursing Assistant Documentation meant the resident did not receive RNA service on that day. The DON confirmed two treatments for the week of 10/6/2024, one treatment for the week of 11/10/2024 and 11/17/2024, and one treatment for the week of 12/1/2024 were missed. The DON stated it was important the resident received the ordered RNA treatment to prevent decline in mobility and contractures. A review of the facility's policy and procedure (P&P) titled, Range of Motion/Joint Mobility Management, dated 10/2024, indicated the therapist would develop the RNA program appropriate to the resident's identified needs and in the event there was no RNA available, CNA and charge nurse were responsible to carry out the program for continuity of care. A review of the facility's undated job description titled, CNA/Restorative Nurse Assistant, indicated the RNA implements and incorporates restorative activities across the continuum by effectively communicating with physicians, staff, and other disciplines. The job description indicated the CNA/RNA provides positioning/splinting equipment for appropriate patients and monitors correct use of the equipment and performs ROM, strengthening exercises and ambulation for residents in the RNA Program. b. A review of Resident 72's Admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnosis including traumatic subdural hemorrhage (bleeding near your brain that can happen after a head injury) with loss of consciousness and dependent on ventilator (when a patient cannot breathe independently and requires a mechanical ventilator [machine that helps people breathe]). A review of Resident 72's physician's order dated 7/25/2024 indicated RNA to perform PROM exercises to the BLE an BUE once daily five times a week or as tolerated, and RNA to apply bilateral elbow splints once daily three to four hours a day for five times a week or as tolerated. A review of Resident 72's physician's order dated 8/17/2024 indicated RNA to apply right knee splint once daily three to four hours a day for five times a week or as tolerated and RNA to don (put on) bilateral hand splints five times a week for a maximum of four hours. A review of Resident 72's MDS dated [DATE] indicated the resident was in a persistent vegetative state (a chronic condition where a person appears to be awake but shows no signs of awareness of their surrounding). The MDS indicated Resident 72 was dependent (helper does all of the effort) with toileting, shower, oral, and personal hygiene. The MDS indicated Resident 72 had impairment on both sides of the lower and upper extremity. The MDS indicated Resident 72 received restorative nursing programs and had received five days of passive range of motion and splint or brace assistance. A review of Resident 72's Joint Mobility assessment dated [DATE] indicated the resident had maintained assessed mobility without new changes. The assessment indicated Resident 72 would continue the RNA program. A review of Resident 72's Restorative Nursing Assistant Documentation for October 2024 indicated the resident did not receive PROM to the BUE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on 10/8, 10/10, 10/11, 10/12/2024. A review of Resident 72's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on 11/14 - 11/16/2024. A review of Resident 72's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BUE extremities and bilateral elbow splints on 11/19, 11/20, 11/22, and 11/23/2024. A review of Resident 72's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BLE extremities, bilateral hand splints, and right knee splint on 11/19, 11/22, and 11/23/2024. A review of Resident 72's Restorative Nursing Assistant Documentation for December 2024 indicated the resident did not receive PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on 12/1, 12/3, and 12/4/2024. A review of Resident 72's care plan revised 12/12/2024 indicated the resident had a need for restorative nursing related to resident was at risk for developing contracture or decrease in ROM. The interventions included RNA to perform PROM bilateral upper and lower extremities once daily five times a week or as tolerated and bilateral elbow splints five times a day for three to five hours or as tolerated. During a concurrent interview and record review on 12/12/2024 at 10:13 AM with the Director of Nursing (DON), Resident 72's Restorative Nursing Assistant Documentation for October 2024, November 2024, and December 2024 were reviewed. The DON stated and confirmed Resident 72 was on the RNA program for the following: PROM to the BLE and BUE extremity once daily five times a week or as tolerated, bilateral elbow splints three to five hours a day for five times a week or as tolerated, right knee splint for three to four hours daily for five times a week or as tolerated, and bilateral hand splint five days a week for a maximum of four hours. The DON stated the x on the Restorative Nursing Assistant Documentation meant the resident did not receive RNA service on that day. The DON confirmed the following treatments for October 2024 were missed: two treatments for the week of 10/6/2024 for the order of PROM to the BUE, hand splints, elbow splints, and R knee splint, three treatments for the week of 10/6/2024 for the order for PROM to the BLE. The DON confirmed for November 2024 the following treatment were missed: one treatment for the order of PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on the week of 11/10/2024, two treatments for BUE extremities and bilateral elbow splints on the week of 11/17/2024, and one treatment for BLE extremities, bilateral hand splints, and right knee splint on the week of 11/17/2024. The DON confirmed for December 2024 the following treatments were missed: one treatment for PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on the week of 12/1/2024. The DON stated it was important the resident received the ordered RNA treatment to prevent decline in mobility and contractures. During an interview on 12/12/2024 at 12:15 PM, RNA 1 stated when the CNA's were short staffed, RNA's get pulled to do the CNA work. RNA 1 stated it happened often (cannot say how often) and when he had gotten pulled to do CNA work, he could not do his RNA work. RNA 1 stated it was important for the residents to receive RNA treatment to maintain the mobility and prevent contracture. A review of the facility's policy and procedure (P&P) titled, Range of Motion/Joint Mobility Management, dated 10/2024, indicated the therapist will develop RNA program appropriate to the resident's identified needs and in the event there was no RNA available, CNA and charge nurse were responsible to carry out the program for continuity of care. A review of the facility's undated job description titled, CNA/Restorative Nurse Assistant, indicated the RNA implements and incorporates restorative activities across the continuum by effectively communicating with physicians, staff, and other disciplines. The job description indicated the CNA/RNA provides positioning/splinting equipment for appropriate patients and monitors correct use of the equipment and performs ROM, strengthening exercises and ambulation for residents in the RNA Program.

Based on observations, interviews and record reviews, the facility failed to have a ventilator alert system that would notify the respiratory therapist (RT) and the licensed nurses of the specific room and resident when the ventilator alarms are triggered, converts to blinking or silence for of 52 ventilator assisted residents (require mechanical aid for breathing to assist or replace spontaneous ventilatory efforts (any mode of mechanical ventilation where every breath is spontaneous such as patient triggered and patient cycled) to achieve medical stability or maintain life) of 76 residents in the facility; 27 of the 52 ventilator assisted residents were on isolation (the prevention of contagious diseases from being spread from a patient to other patients, health care workers, and visitors, or from outsiders to a particular patient). Resident 53, a ventilator dependent (machine that helps the person breath) resident, who was on isolation precautions, had ventilator alarm on silent, indicating a high pressure (means there is an blockage somewhere along the system of tubes that lead to the air sacs in the lungs) with no facility staff present. The facility staff had no knowledge of who silenced the alarm and the length of time the alarm had been triggered. This resulted in a situation of the facility's non-compliance with a delay in a respiratory assessment and intervention as evidenced by: a. Resident 53's ventilator alarm was silenced, and there was no staff present. b. The facility staff were required to monitor the hallways for the location of alarm inside the rooms, which occupied two to three residents. c. There were two L-shaped sections of the facility layout, where one respiratory therapist (RT) had to monitor two separate hallways. d. Staff verbalized short staffing at night and if the nurse and RT assigned to the same assignment were busy, there were no staff to monitor the hallway for a quick response to the resident's alarms. e. During a family interview stated sometimes the staff failed to answer the alarms in a timely manner. These deficient practices had the likelihood to cause, serious injury, harm, impairment or death of ventilator assisted residents. The facility's Chief Nursing Officer, Clinical Nurse Coordinator and Clinical Educator were informed of the Immediate Jeopardy (IJ) on 10/18/18 at 10 p.m. The non-compliance related to the IJ was identified to have existed on 10/18/18 (the date Resident 53's alarm was silenced) continued through 10/19/18 when Resident 10's and 35's ventilator alarm settings for high pressure (limits highest pressure allowed by ventilator; causes of high pressure alarm may include coughing, accumulation of secretions, kinked tubing, pneumothorax (a collapsed lung), decreased lung compliance) and positive end expiratory pressure ((PEEP) pressure maintained in lungs at end of letting the air out, used to improve oxygenation by opening collapsed alveoli, improving ventilation/perfusion, increasing oxygenation) was tuned off, making it hard for the staff to notice a resident was having difficulty breathing. The IJ was removed on 10/19/18 at 10:22 p.m., based on the acceptable Plans of Action (POA) developed and implemented by the facility. Findings: During initial tour of the facility on 10/18/18 at 8:04 p.m., the licensed vocational nurse (LVN 5) acknowledged Resident 53's ventilator high pressure indicator was blinking and there was no audible sound to alert the staff when the resident was having trouble breathing. The silenced reset button had an illuminating red light. Concurrently, during an interview, when asked if she had knowledge of Resident 53's ventilator high pressure alarm, LVN 5 stated she would call RT. On 10/18/18 at 8:04 p.m., during an interview RT 1 stated the blinking of a high pressure alarm indicated the alarm was triggered and no one heard it because it was on silent mode. When asked if he knew or if someone reported to him Resident 53's alarm was in progress, RT 1 stated he did not know who silenced the alarm and nobody notified him during change of shift. RT 1 further explained the facility's system for ventilator alarms was to physically stay in hallway to hear the alarms and then required RT or a nurse to walk through the hallway to find out where the alarm was coming from. RT 1 verified the facility had no system outside of the residents' rooms or any other place on the unit to provide visual notification which room the ventilator alarm was coming from. A review of Resident 53's admission Face Sheet indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 53's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/24/18, indicated the resident required a ventilator for breathing and was totally dependent (full staff performance every time) on staff for all activities of daily living, such as dressing, eating, toileting, personal hygiene, and bathing. A review of Resident 53's monthly physician order [REDACTED]. During an observation of the facility's ventilators alarm response system on 10/18/18 at 8:08 p.m., RT 1 was in with a resident's room when the ventilator alarm of an isolation room was triggered, however, there was no other staff in the hallway. RT 1 was observed exiting the room at 8:11 p.m., donned (put on) on personal protective equipment ((PPE) refers to protective clothing, helmets, gloves, face shields, goggles, facemask and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) and entered the resident room with the triggered alarm. During an interview on 10/18/18 at 8:21 p.m., a randomly selected family member was asked if facility staff answers ventilator alarms quickly and in a timely manner, the family member stated staff did not answer alarms timely. During a subsequent hallway observation on 10/18/18 at 8:26 p.m., the ventilator alarm in a resident's room, triggered. However, there was no facility staff monitoring the hallways to ensure quick response to the ventilator alarm. During an interview on 10/18/18 at 8:58 p.m., the registered nurse (RN 3) stated there were five RTs scheduled for the night shift and one of five was the lead RT, who came from the hospital to made rounds every two hours. RN 3 stated the four RTs had to monitor different hallways and had 13 of 13 ventilator assisted residents each to monitor. During an interview on 10/18/18 at 9:04 p.m. with a RT stated the facility currently had two different types of ventilators in use. When asked about ventilator high pressure alarms, RT stated ventilator high pressure alarm triggered due to the pressure back from the machine when the resident was coughing. RT stated if the resident was not assessed when the ventilator's high pressure alarm was on, the worst possible scenario could be the resident's lungs could blow up or get decannulated (accidental removal of a [MEDICAL CONDITION] a curved tube that is inserted into a [MEDICAL CONDITION] stoma (the hole made in the neck and windpipe)). The RT continued to explain the ventilator alarms could silence themselves if the problem resolves by itself. When asked how staff verified ventilators alarms were functional, RT stated the ventilators did not have a test button thus, the staff either lowered the setting levels or capped the machine to verify the alarms were functional. When asked about staffing the RT stated the assignment for tonight (10/18/18) was 13 residents for each RT, when the usual ratio was 10 residents per one RT. The RT stated lately the facility had been short staffed and sometimes one RT had 14 to 16 residents. When asked about the worst possible scenario due to short staffing, the RT stated if a resident was decannulated due to turning and the RT was replacing the cannula and another ventilator alarm went off for another resident there would be no RT available for that resident. The RT further stated nurses had to call for another RT and there was one assignment where the RT had to monitor two L-shaped hallway. The RT further stated the RTs always had to stay on their run. A review of the undated most recent Facility Assessment (the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies) indicated the average resident census of the facility was 73 to 75 residents with an average of 10 RT per day in a 24 hour period, more based on acuity. The Facility Assessment failed to include an evaluation of the care required by the resident population considering other pertinent facts that were present within that population (e.g., assistance with mobility, activities of daily living) to account for care time verses time staff had to monitor the hallways. A review of the RT Department Patient Master List for 10/18/18, indicated a total of 4.7 RTs for night shift. The staffing instructions indicated to round up staffing if 0.5 and above, meaning on 10/18/18 a total of 5 RTs were required. There were 4 RTs present on 10/18/18. The facility's Chief Nursing Officer, Clinical Nurse Coordinator and Clinical Educator were informed of the Immediate Jeopardy (IJ) on 10/18/18 at 10 p.m. due to the following concerns: a. Resident 53's ventilator alarm was silenced, and there was no staff present. b. The facility staff were required to monitor the hallways for the location of alarm inside the rooms, which occupied two to three residents. c. There were two sections of the facility layout, which was an L-shaped, where one respiratory therapist (RT) had to monitor two separate hallways. d. Staff verbalized short staffing at night and if the nurse and RT assigned to the same assignment were busy, there were no staff to monitor the hallway for a quick response to the resident's alarms. e. During a family interview stated sometimes the staff failed to answer the alarms in a timely manner. These deficient practices had the likelihood to cause, serious injury, harm, impairment or death to ventilator assisted residents. The non-compliance related to IJ was identified to have existed on 10/18/18 (the date Resident 53 alarm was silent) and continued through 10/19/18 when Resident 10's and 35's ventilator alarm settings for high pressure (limits highest pressure allowed by ventilator; causes of high pressure alarm may include coughing, accumulation of secretions, kinked tubing, pneumothorax, decreased lung compliance) and positive end expiratory pressure (PEEP/pressure maintained in lungs at end of expiration used to improve oxygenation by opening collapsed alveoli, improving ventilation/perfusion, increasing oxygenation) were off. During a follow up observation and interview, of the IJ called on 10/18/18, on 10/19/18 at 5:29 p.m., the following observations were made with RT 1 from room [ROOM NUMBER] to 38: two of 52 residents, Resident 10 and 35, who were on ventilators were observed with their ventilator settings turned off. The monitor indicated high and low (H&L) PEEP Off. Concurrently, during an interview, RT 2 stated Resident 35's ventilator H&L PEEP setting should not be off. The RT 2 stated the ventilator would not turn off the setting by itself, someone had to turn it off. The RT 2 stated he had reset the ventilator. The RT 2 stated when the PEEP setting was off, the machine would not alert staff in the event the resident had a high PEEP. The RT 2 stated having a high PEEP was not good. Continuing with the follow up observations, Resident 10's ventilator machine also indicated H&L PEEP off. The RT 2 stated when the alarm was turned off, there was no alert to let staff know if there was a problem with the resident. The RT 2 was observed to don (put on) the PPE, which included gown and gloves to go inside the resident's room to check and reset the ventilator machine. a. A review of Resident 35's Admission Face Sheet (an admission record) indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 35's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/1/18, indicated the resident rarely/never made self-understood or understood others and had severely impaired cognitive skills for daily decision making. Resident 35 required a total dependence (full staff performance every time) from staff for all activities of daily living (ADLs), such as dressing, eating, toileting, personal hygiene, and bathing. A review of Resident 35's monthly physician order [REDACTED]. A review of Resident 10's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. b. A review of Resident 10's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/18/18, indicated the resident had persistent vegetative state/no discernible consciousness. Resident 10 required a total dependence (full staff performance every time) from staff for all activities of daily living (ADLs), such as dressing, eating, toileting, personal hygiene, and bathing. A review of Resident 10's monthly physician order [REDACTED]. During an interview on 10/19/18 at 6 p.m., with the Director of Respiratory Services (DR) provided the ventilator manual for Resident 53's ventilator. According to the manual if someone silenced the ventilator alarm the audible alarm would be silent for 60 seconds and then it would be audible again. When asked what the illuminated silence button meant, DR stated it the ventilator alarm was silenced. DR stated a high pressure alarm was most common when the resident was coughing, had a [MEDICATION NAME] (a tightening of the muscles that line the airways the lungs) that required a breathing treatment (medication to help breathing easier), a kink in the tubing or obstruction (secretions or water) in tubing. These conditions would trigger the high pressure alarm. The DR further stated if the alarm was silenced it would reset in 60 seconds. When asked what could happen to a resident with a high pressure alarm in 60 seconds, DR stated the resident might have had difficulty breathing that required clearance of airway due to an obstruction. A review of the Facility's Policy titled Respiratory Therapy dated 5/25/16, indicated ventilator should not be manipulated except in an emergency. The IJ was removed on 10/19/18 at 10:22 p.m. when the facility presented acceptable POA that were developed and implemented by the facility. The following included in the plan: 1. Assessment of Resident 53 for signs and symptoms of distress and check of ventilator with manufacturer's settings and recommendations. 2. Assessed the other 51 residents' ventilators and signs of distress. 3. Increased respiratory therapy staff by one per shift, to ensure continuous monitoring of the residents until call system was in place. 4. The duties of roving RT are: a. Verify all ventilator alarm settings are active and set per policy b. Implementation of the verification audit tool once a shift c. Assist in response to residents requiring ventilator intervention 5. Project for alert call system 6. Policy revision staff shall not silence alarms unless at bedside with a resident 7. Facility Assessment utilization for determining staffing level of the facility.

Based on observation, interview, and record review, the facility failed to ensure a resident who enters the facility without limited range of motion (ROM - full movement to a joint) does not experience reduction in ROM unless it is unavoidable due to the medical condition for one Randomly Selected Resident (RSR 17), including: 1. Failure to refer RSR 17 to Physical Therapist (PT) for evaluation upon re-admission to the facility on [DATE], to ensure preventive ROM exercises were provided prevent functional decline in ROM. 2. Failure to evaluate RSR 17's need for Restorative Nursing Assistant (RNA - nursing assistant program that help residents maintain any progress made after therapy intervention to maintain their function) services for ROM when RSR 17 was identified with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to left wrist and fingers on March 30, 2017 and a splint to the left hand was ordered. 2. Failure to provide RSR 17 with passive range of motion (PROM - amount of motion at a given joint when moved by another person) to left wrist, hand and fingers before splint was applied as ordered by the physician on August 24, 2017. 3. Failure to implement the Joint Mobility/ROM Care Plan dated June 1, 2017, for RSR 17's high risk for developing contractures due to physical limitations by not referring to rehabilitation staff for evaluation of any changes in the ROM status. As a result, RSR 17 developed contractures to the left wrist/hand/fingers and loss of the ability to flex the right fingers (unable to close the hand) requiring an special call light button and was no longer able to type on a keyboard. Findings: On October 14, 2017 at 6:20 p.m., during an interview, RSR 17 stated he had not been receiving physical therapy (PT) for his hands and fingers and could not extend his left fingers and could not close his right hand (unable to flex the fingers). RSR 17 was observed wearing a splint (a rigid device used to prevent motion of a joint) to his left hand. RSR 17 stated he received a new call light the day prior (October 13, 2017), because he could not press on the call light button to call for assistance. A review of the Admission Record indicated RSR 17 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. system mistakenly attacks healthy cells), and [MEDICAL CONDITION] (a disease where the immune system attacks the protective sheath that covers nerve fibers and causes communication problems between your brain and the rest of the body). Upon re-admission, there was no documented order for RNA to provide RSR 17 with ROM exercises to the hands and wrists. A review of the Joint Mobility assessment dated [DATE], indicated left and right finger extensions were within functional limits (WFL). A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated November 29, 2016 and September 1, 2017 indicated RSR 17's cognitive (memory and thinking skills) impaired and required total care. The MDS indicated RSR 17 had functional limitation in the ROM to both sides of the upper and lower extremities (hands, arms, legs and feet). A review of the physician's orders [REDACTED]. May release and re-apply every two hours for 15 minutes. Check skin integrity and circulation for contracture management. There was no documented order for RNA to provide RSR 17 with ROM exercises to right and left hands. A review of the Joint Mobility/ROM Care Plan with a review date of June 1, 2017, for RSR 17's high risk for developing contractures due to physical limitations, had a goals to minimize further decline in ROM and maintain the current joint mobility status. The interventions included assessing RSR 17's joint mobility status when giving care, referring to rehabilitation staff if any decline, and using a left wrist and hand finger flexion splint as ordered. A review of the physician's orders [REDACTED]. Monitor for circulation and skin integrity before and after splint application. However, there was no documented the order was implemented for RNA to provide RSR 17 with ROM exercises. A review of the Interdisciplinary Team (IDT - several disciplines of the health care team including the resident and/or representative) Conference Notes dated September 6, 2017, indicated RSR 17's responsible party attended the meeting and requested PT evaluation. A review of the Joint Mobility assessment dated [DATE], indicated left finger extension to be moderate (50% to 75%) and right finger extension to be minimal (75% to 100%). There was no documented order for RNA to provide RSR 17 with ROM exercises. There was no documented evaluation by PT as requested by RSR 17's responsible party on September 6, 2017. On October 15, 2017 at 2:07 p.m., during an interview with RNAs 1 and 2, RNA 1 stated RNAs were not providing PROM exercises to RSR 17 because there was no order for it. RNA 2 confirmed there was no order for PROM. On October 16, 2017 at 4:45 p.m. during further record review with the MDS Nurse stated there was no order for PROM exercise since re-admission on November 23, 2016 or on March 30, 2017 when the resident was identified with left hand contractures. On October 15, 2017 at 5:10 p.m., during a telephone interview, Physical Therapist 1 (PT 1) stated RSR 17 was in and out of the hospital and a new order had to be placed upon re-entry but this was not done. PT 1 explained WFL indicated the fingers were able to spread out and there were no obvious or visible contractures and moderate meant, Half of what the full ROM should be. On October 16, 2017 at 5:45 p.m., during an interview, the Administrator stated when RSR 17 was readmitted on [DATE], PT was not notified of the need to evaluate RSR 17. On October 16, 2017 at 6 p.m., during a follow-up interview, RSR 17 stated he used to type on a keyboard before he was admitted to the facility, but now he could not which made him feel bad. A review of facility's policy and procedures titled Inpatient Physical Therapy Evaluation revised on April 2016 and approved on May 25, 2016 indicated physical therapy evaluation shall document the resident's ability to complete tasks that included range of motion and gross strength: assessment of active/passive range of motion all extremities, neck and trick, joint mobility, soft tissue limitations and indicate joints with limitations outside normal functional limits.

Based on observation, interview and record review, the facility licensed nurses did not provide necessary treatment and services to prevent development of a pressure sore (a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure) for Resident 8, who had an intact skin upon re-admission and developed a pressure sore to the left gluteal (buttock) area which progressed to a Stage IV pressure sore and did not prevent a pressure sore from potential healing delay for Resident 7, who was admitted with a Stage IV pressure sore to the coccyx area sore by failing to: 1. Consistently assess Resident 8's pressure sore weekly and provide the necessary treatment. Accurately assess Resident 8's skin condition when initially identified skin damage to the left gluteal are due to the resident's incontinence and re-evaluate/update Resident 8's care plan when the resident's pressure sore was identified increased in size. 2. Ensure Resident 8's number of linen and incontinence pads used while on a low air loss mattress, was limited to the minimum of a single layer. 3. Ensure Resident 7, who had A Stage IV pressure sore to the coccyx area, would have a limited number of linen used while on a low air loss mattress. These deficient practices resulted in Resident 8 developing a Stage IV pressure sore to the left gluteal area and placed Resident 7 and 8 at risk for the delay in healing of pressure sores. Findings: 1. According to Resident 8's admission record the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 8's Admission Assessment Inquiry under the section of Integumentary dated June 30, 2016 indicated the resident had no wounds present, integrity was intact, turgor was normal, skin color was within resident's norm and temperature/moisture was warm and dry. According to the Braden Scale for Predicting Pressure Sore Risk Resident 8 was assessed as 16 out of 23 representing a moderate risk for developing a pressure sore. A review of Resident 8's clinical record indicated there was no documented evidence a care plan addressing the risk for developing a pressure sore with preventative intervention was developed. A review of Resident 8's Daily Assessment Inquiry indicated the following : a. On July 24, 2016, Resident 8 was identified to have a skin damage to the left gluteal area which was measured 2.0 centimeters (cm) by 2.0 cm by 0.1 cm. A review of Resident 8's clinical record indicated there was no care plan developed to address identified skin damage with intervention to prevent further damage. b. On August 10, 2016, it was documented Resident 8 had a Stage II pressure sore to the left gluteal area which was measured 2.0 cm by 2.0 cm. A care plan was developed to address this concern. c. On August 16, 2016, it was documented Resident 8 had an unstageable pressure sore to the left gluteal area which was measured 3.0 cm by 4.0 cm. There was no updated care plan made. d. On August 18, 2016, it was documented there were no changes in the pressure sore to the left gluteal area. e. On August 24, 2016, it was documented Resident 8 had an unstageable pressure sore to the left gluteal area which was measured 6.0 cm by 3.0 cm by 0.2 cm. There was no documented evidence the care plan updated to reflect the deterioration of the pressure sore. f. On August 30, 2016, it was documented Resident 8 had an unstageable pressure sore to the left gluteal area which was measured 6.0 cm by 3.0 and cm. g. On September 7, 2016, it was documented Resident 8 had an unstageable pressure sore to the left gluteal area which was measured 5.0 cm by 4.0 cm by 0.2 cm. h. On September 13, 2016, it was documented Resident 8 had an unstageable pressure sore to the left gluteal area which was measured 5.5 cm by 4.0 cm by 0.5 cm. There was no documented evidence a care plan updated/ re-evaluated to address the increase in size of the pressure sore. i. On September 21, 2016, it was documented Resident 8 had an unstageable pressure sore to the left gluteal area which was measured 5.2 cm by 1.0 cm. j. On September 27, 2016, it was documented Resident 8 had unstageable pressure sore which was measured 6.0 cm by 3.0 cm. There was no documented evidence a care plan was re-evulated/ updated to address pressure sore's increase in size. k. On October 5, 2016, it was documented Resident 8 had an unstageable pressure sore which was measured 6.0 cm by 5.0 cm by 3.0 cm. There was no documented evidence a care plan was re-evaluated/ updated to address pressure sore's increase in size. l. On October 11, 2016, it was documented Resident 8 had an unstageable pressure sore which was measured 6.0 cm by 3.0 cm by 1.0 cm. m. There was no documented evidence Resident 8's pressure sore to the left gluteal area was assessed weekly on October 18 and 25, 2016. There was no pressure sore assessment between October 11, 2016, and November 2, 2016. n. On November 2, 2016, it was documented Resident 8 had a Stage IV pressure sore to the left gluteal area which was measured 4.0 cm by 4.5 cm by 2.0 cm. 2. During the initial tour of the unit on November 2, 2016 at 1:05 p.m. with the registered nurse 1 (RN 1), Resident 8 was observed lying on a low air loss mattress with incontinent pad (a small impermeable multi-layered sheet with high absorbency that is used in the incontinence and health-care industries) and two folded linen underneath the resident buttock. During treatment observation of Resident 8'a pressure sore to the left gluteal area on November 3, 2016, at 9:40 a.m., Resident 8 was observed lying on a low air loss mattress with three disposable incontinence pads and two folded linen. On November 2 and 3, 2016, the resident was observed lying in a special bed on her back. Concurrently, during observation, the licensed vocational nurse (LVN 2) was interviewed and stated there should be a single layer of linen underneath the resident when on a low air loss mattress, to assist in the re-circulating the air and in healing of the pressure sore. 3. According to Resident 7's admission record, the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Assessment Inquiry indicated Resident 7 had a Stage IV sacrum coccyx which was measured 3.5 cm by 4.0 cm, with undermining (a tract, or tunnel, or a channel extending from one part of the pressure sore through subcutaneous tissue or muscle to another part of the pressure sore) and was described to have scant exudate (a fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues) and intact surrounding skin. During the initial tour of the unit with RN 1 on November 2, 2016, at 1:05 p.m., Resident 7 was observed lying on a low air loss mattress. There were two incontinent pads and two folded linen. During the medication pass observation on November 3, 2016, at 8 a.m., the resident was observed lying on a low air loss mattress with two disposable incontinent pads and a linen underneath the resident. A review of the facility's Linen Protocol for Low Air Loss Therapy indicated linen must always be kept to a minimum. Avoid multiple layers of linen under the resident. A single draw sheet may be used for turning resident. Specialized incontinence pads may also be used as long as they do not contain plastic such as Dry-Flow pad. A resident should not be found on a Low Air Loss Mattress with a fitted sheet, a draw sheet, diaper and an incontinent pad. Too many linens will inhibit the therapeutic benefits of Low Air Loss Therapy and will cause bunching under the resident which is contra-indicated with skin management.

Based on observation, interview, and record review, the facility failed to ensure: 1. A certified nursing assistant 1 (CNA) 1 provided safe handling to one of 15 sampled residents (Resident 13). CNA 1 did not obtain assistance to turn the Resident 13 onto her side while rendering care. Resident 13's bed side rail dropped down, resulting in the resident's upper body falling forward, and the resident's face striking the ventilator (breathing machine). Resident 13 sustained a laceration to her lower right lip, which required the resident's transfer to the acute care hospital for suturing (a stitch or row of stitches holding together the edges of a wound). 2. CNA 1 was inserviced on safe handling of the residents including turning and repositioning the residents. Findings: On November 3, 2016, at 10:15 a.m., Resident 13 was observed lying on a low air loss mattress (special mattress that reduces pressure on the body) and breathing through a [MEDICAL CONDITION] (a surgical opening into the trachea, or air passage,in order to provide air to the lungs) that was connected to a ventilator (breathing machine, a machine that supports breathing or does all the breathing). Resident 13 was non-responsive and was receiving feeding through a gastrostomy tube ((GT) -a tube that is surgically inserted into the stomach for purposes of nutrition provision, and medication administration). Resident 13 was observed to have two linear scars on the lower right lip that appeared to be two centimeters (cm) in length with a small scabbed area at the top. During an observation Resident 13's family member was present at the resident's bedside. In a concurrent interview, Resident 13's family member stated that approximately one month ago, while CNA 1 was turning Resident 13 by herself, the resident struck her right lower lip on the ventilator, which caused a large laceration (cut). Resident 13 had to go to the acute care hospital Emergency Department (ED) for suturing. A review of Resident 13's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].) According to the Minimum Data Set (MDS) a standardized assessment and care screening tool, dated September 20, 2016, Resident 13 had severely impaired cognitive skills for daily decision making and was totally dependent on staff for activities of daily living. According to the MDS the resident was totally dependent on staff for mobility in bed and required one person physical assist for re-positioning the resident from side to side in the bed. According to Resident 13's monthly weight log, the resident weighed 248 pounds at the time of the incident. According to the care plan for the risk of falls dated August 10, 2016, the goal for Resident 13 was to be free of falls daily within 90 days and interventions included to anticipate safety needs of patient to lessen risk factors and complications, and to reinforce safety awareness among caregivers and patient/family/significant other when doing activities of daily living (ADL). A review of the confidential incident report, dated September 26, 2016, completed by the evening charge nurse, indicated that on September 26, 2016, at approximately 9:40 p.m., CNA 1 was turning Resident 13 onto her right side in order to clean her when the side rail closest to the resident dropped. CNA 1 ran around the bed and was able to catch Resident 13 from falling on the floor, as the resident's upper body was partially off the bed. When the charge nurse entered Resident 13's room, she observed CNA 1 supporting Resident 13's upper body. The resident was then repositioned back in bed. CNA 1 informed the charge nurse that she was turning Resident 13 onto her right side, away from CNA 1, when the right bed side rail dropped down and Resident 13's head and shoulders fell forward. According to the report Resident 13 was assessed with [REDACTED]. Resident 13's vital signs were stable, the physician was notified and ordered to transfer the resident to the acute care hospital ED for evaluation and treatment. A review of the ED record, dated September 26, 2016, at 11:02 p.m., indicated Resident 13 had an extensive laceration on the right lip measured six centimeters (cm), and a laceration repair was performed on the resident's right and left lower lip. A review of Resident 13's facial computerized tomography (CT - X-ray images taken from different angles to produce cross-sectional images) scan report, from the acute care hospital, dated September 27, 2016, indicated Resident 13 had a moderate soft tissue swelling overlying the right side of the jawbone without evidence of underlying fracture. On November 3, 2016, at 10:25 a.m., an interview and review of Resident 13's MDS was conducted with the Administrative Director (AD). The AD stated that on September 26, 2016, CNA 1, who was from a registry, was turning Resident 13 by herself, when the resident's face struck the ventilator. The AD stated CNA 1 should have gotten another staff member to assist with turning Resident 13. The AD also stated that the MDS assessment should have indicated that two persons physical assistance was required to reposition the resident in bed. On November 6, 2016 at 9 a.m., during an interview, CNA 2 stated she was regularly assigned to care for Resident 13, and that two staff members were required in order to turn and re-position the resident because the resident was heavy. CNA 1 was unavailable for interview. On November 6, 2016 at 9:15 a.m., during another interview, the AD was questioned regarding what type of training CNA 1 had for safe turning and handling of residents. The AD stated each registry staff member was given a copy of the facility's document titled Annual Mandatory Update-2014 to review, the first time they worked for the facility. A review of the aforementioned document indicated safe handling precautions for the actual turning and re-positioning of patients was not addressed. A review of CNA 1's personnel file, provided by the registry, indicated CNA 1 was not provided with any inservices regarding safe turning and handling of residents.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 6), out of 16 sampled residents, received emergency dental care when the resident developed sores and bleeding in his mouth. On the initial tour, Resident 6 was observed with thick, caked blood, liberally covering the residents tongue, gums, sides of mouth, and between his teeth. Blister-like spots were visible on the roof of his mouth. There was a whitish coating on his tongue, which was crusted with blood. The resident was moaning and groaning. On the second observation, a gurgling/choking/coughing noise was heard coming from the back of the Resident 6's mouth. Closer examination revealed Resident 6 had brownish black areas down to the gum line, and active bleeding was visible around some of the teeth. There was no documented evidence in Resident 6's record between August 5, 2011 and October 9, 2011, that the resident was assessed and re-assessed for bleeding in the mouth, blisters, loose teeth, cavities and mouth pain as indicated in the resident care plan. Findings: During the initial tour of the facility on October 11, 2011, at 9:45 a.m., Resident 6 was observed in his bed, mouth wide open, with dried blood visible around mouth and on his lips. Close visual inspection of the resident's mouth revealed thick, caked blood, dried, and wet, liberally covering the residents tongue, gums, sides of the mouth, and between his teeth. Clear, blister-like spots were visible on the roof of his mouth. There was a whitish coating on his tongue, which was coated with blood. The resident was moaning/groaning, and moving his head from side to side. Licensed Nurse (LN) 3, who was present during the observation on October 11, 2011 at 9:45 a.m., disclosed at the time, "He has a loose tooth. The doctor was notified and a dental consult was requested." An administrative staff member, LN 1, reported during an interview on October 11, 2011 at 3:20 p.m., that a nurse " just noticed " the loose teeth (on October 10, 2011). The dental consultant was contacted, but he was unable to go out to the facility. A second observation was conducted on October 12, 2011, at 10:40 a.m. Resident 6's mouth was open, and a sharp metallic odor was noticed when his bed was approached. In reply to a question about the groans and moans the resident made, LN 6, a medication nurse who was brought in to assist with the observation, stated, "He's crying. He does that when he is in pain." He added that he usually gives medication for the pain when he is passing morning medications. "He will be able to rest then." On the same observation on October 12, 2011, at 10:40 a.m., the resident's lips and outer oral cavity appeared to have been cleaned of the blood, but a gurgling/choking/coughing noise was coming from the back of the resident's mouth. Closer examination revealed some of Resident 6 had brownish black areas down to the gum line, and active bleeding was visible around some of the teeth. When questioned on October 12, 2011 at 10:40 a.m., LN 6 agreed the gurgling and choking sounds the resident made were possibly caused by the blood draining down the resident's throat. A suction jar on the nightstand table across from the foot of Resident 6's bed was filled approximately 1/3 with pink-tinged mucus/saliva. LN 6 reported, "I suctioned him earlier, and gave oral care." He stated the coloring in the suction container was blood mixed with the fluids in Resident 6's mouth when he was suctioned. He added, "I reported it to the charge nurse; she said a (dental) consult was ordered." On October 12, 2011, a review of the admission face sheet indicated Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment tool, dated May 5, 2011, included an assessment of oral/dental status (Section L), which asked, if Resident 6 had "inflamed or bleeding gums, or loose natural teeth." The MDS was marked, "None present. " The quarterly MDS report, dated August 5, 2011, indicated Resident 6 was unable to make his needs known and was totally dependent upon staff to attend to his ADLs (activities of daily living). The resident was unable to make deliberate, goal-directed movements, was contracted in his upper and lower extremities, and was receiving nutrition via gastrostomy tube feeding (a tube inserted through the skin and stomach wall so food could be delivered directly into the stomach). The same report indicated there was no mouth or facial pain. A care plan entitled, "Dental Status/Care," dated August 5, 2011, was initiated for "Dependent with staff for oral hygiene needs." Interventions included assessing and re-assessing the resident daily when giving care for new dental problems, such as ulcers, blisters, sores and cavities, and reporting findings or observations and referring to the physician and interdisciplinary team for treatment and dental consult. The monthly recapitulated physician's orders [REDACTED]." The order included directions to provide "dental consult and treatment as needed." According to the Dental form dated May 19, 2011, Resident 6 had a dental consult and the plan was to extract tooth #10. Another Dental form dated June 7, 2011, indicated Resident 6 ' s tooth was extracted on June 7, 2011. There was no documentation that assessments of the resident ' s mouth had been performed following the extraction. A review of the Nursing Assistant Daily Flow Sheets dated from July 2011 to August 2011 in the resident's clinical record disclosed Resident 6 was totally dependent on staff for daily oral hygiene. None of the documentation on the form included any report of cavities, loose teeth, or bleeding in the mouth. A review of the Licensed Weekly Summary (notes), dated between July 19, 2011 and September 21, 2011, revealed there was no documentation that indicated the licensed nurses had assessed and re-assessed Resident 6's oral/dental status for bleeding in the mouth, blisters, loose teeth, cavities or mouth pain, as required in the resident care plan. A review of the Licensed Personnel Progress Notes, dated from August 24, 2011 to September 28, 2011, did not contain any documentation that the licensed nurses had assessed and re-assessed Resident 6 ' s oral/dental status for bleeding in the mouth, blisters, loose teeth, cavities or mouth pain as required in Resident 6's care plan. Resident 6's electronic record contained a form entitled, "Daily Assessment Inquiry," dated between September 2, 2011 and October 9, 2011 indicated the resident was totally dependent on staff for oral hygiene. There was no documentation of any reports of cavities, loose teeth, or bleeding in the mouth. The "Daily Focus Assessment Report," dated between October 1 and October 9, 2011, also reported Resident 6 was totally dependent on staff for oral hygiene. There was no documentation that the licensed nurses had assessed and re-assessed the resident's oral/dental status for bleeding in the mouth, blisters, loose teeth, cavities or mouth pain as required in the resident care plan. A review of Resident 6 ' s care plan entitled, "Dental Status/Care," dated August 5, 2011, revealed the notation, "dental evaluation due to loose upper and lower teeth" was added under the heading, " Interventions," on October 10, 2011. On a "Daily Assessment Inquiry" form, dated October 10, 2011, at 1 p.m., a licensed nurse documented that a staff member from the dental office was informed of Resident 6 ' s loose teeth on the upper and lower teeth and the dry blood in the mouth. The dental staff member said to proceed with the dental evaluation and provide mouth care. There was no evidence the resident's other issues, like blisters/sores or mouth pain, was assessed and reported, as directed in Resident 6 ' s care plan. October 11, 2011 at 2 p.m., a licensed nursed documented in the resident ' s electronic record on a form entitled, "Daily Focus Assessment Report" that a dental office staff member stated that insurance coverage was required for Resident 6 to receive dental services, or the facility would have to pay for the resident's dental care. Once payment was established, a dental appointment would be scheduled. During an interview on October 12, 2011, at 3:05 p.m., LN 14 stated the staff members should have seen Resident 6's teeth were in bad condition "before this," and not wait until his gums were actually bleeding before they got a dental consult. On the "Daily Focus Assessment Report," dated October 12, 2011, at 5:13 p.m., a licensed nurse indicated the resident's dental concern was referred to the social worker so arrangements could be made for an appointment to a dental clinic for further evaluation of the bleeding and " other oral problems" in the resident's mouth. According to the Social Service Note, dated October 13, 2011, the social service designee (SSD) had left a telephone message that day with the "School of Dentistry" to schedule a dental appointment for Resident 6. A note (untitled) from the social service designee dated, October 14, 2011, disclosed that according to the "School of Dentistry," full mouth x-rays and a referral letter from the facility's in-house dentist were needed to be completed before they could schedule a dental appointment for Resident 6. The social service designee documented in an untitled note dated, October 17, 2011, that the dental office of the facility's in-house dentist was informed that the facility's administration would pay for the x-rays, and asked them to come to the facility to perform the x-rays for Resident 6. On October 17, 2011, by the close of the survey, Resident 6 had not been seen by a dentist.