Every finding on record at Huntington Drive Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to promote dignity and privacy for one (1) of three (3) residents (Residents 2) based on the facility's policy and procedure (P&P) titled Dignity. On 7/24/2026, Certified Nurse Assistant 1 (CNA 1) was transferring Resident 2 along the hallway from the shower room going to the resident's room while sitting on the shower chair with the resident's back and buttocks exposed. This deficient practice had the potential to affect Resident 2's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being.Findings:During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2's diagnoses included chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should), gout (a painful form of arthritis) and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 5/19/2026, the MDS indicated Resident 2 has severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 needed partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed- to chair transfer, toilet transfer, and tub/shower transfer, walk 10 and 50 feet. During an observation on 7/24/2026 at 9:54 AM with Licensed Vocational Nurse 1 (LVN 1), in the hallway, Resident 2 came out from the shower room. Certified Nurse Assistant 1 (CNA 1) was pushing Resident 2 towards the resident's room while sitting on the shower chair with the resident's back and buttocks exposed. There were 3 Residents sitting in their wheelchair in the hallway. During a concurrent observation and interview on 7/24/2025 at 9:55AM with CNA 1, inside Resident 2's room, Resident 1 was sitting on the shower with his back exposed to Resident's 2 roommate who was sitting on his (Resident 2 roommate's) bed. Resident 2 stated he was feeling cold. CNA 1 stated It was a mistake to have Resident2's back and buttocks exposed and Resident 2 must be fully covered when they transfer the resident out of the shower room, going to the resident's room because of privacy and dignity. During an interview on 7/24/2026 at 9:57 AM with LVN 1, LVN 1 stated she saw Resident 2's back was exposed while CNA 1 was transferring the resident out of the shower room and in the hallway. LVN 1 stated the staff need to make sure the residents' body was fully covered because of dignity. During an interview on 7/24/2026 at 10:12 AM with Resident 1, Resident 1 was sitting in his wheelchair in the hallway. Resident 2 stated My back was supposed to be covered. the staff should wrap a towel on me before I get out of the shower room. During an interview on 7/24/2025 at 2:48 PM with Director of Staff Development (DSD), DSD stated CNA 1 should fully cover Resident 2 with privacy gown before coming out of the shower. DSD also stated the staff should add towels and blankets if the privacy gown is not enough to fully cover the resident. DSD stated Resident 2's body part should not be visible in public during assistance and Resident 2's body has to be fully covered to ensure dignity and privacy is provided to the resident. During a concurrent interview on 7/24/2026 at 2:50 PM with DSD, the facility's P&P titled Dignity, revised 2/2021 was reviewed, the P&P indicated staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self- esteem. The P& P also indicated Residents are treated with dignity and respect at all times. DSD stated CNA 1 did not follow the policy because she did not fully cover Resident 2 after showering the resident and before transporting the resident back to the resident's room.

Based on interview and record review, the facility failed to inform about one of three sampled residents (Resident 1) the resident's rights and responsibilities to participate in her care and treatment in accordance with the facility's policy This deficient practice has resulted in Resident 1 feeling disrespected and has a potential effect on Resident 1's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting the left dominant side, major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems), hypertension (high blood pressure) and abnormalities of gait and mobility. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right , sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to -chair transfer, toilet transfer and tub/shower transfer. During a review of Resident 1's Advance Beneficiary Notice of Non-coverage (ABN Form CMS-R-131, is issued by providers to original Medicare [fee for service - FFS] beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances) dated [DATE] was reviewed. The ABN Form indicated Resident 1 maximized her benefits for the skilled therapy services (rehabilitation treatments provided by or under the direct supervision of licensed professionals such as physical[help individuals recover from injury, manage chronic pain, and improve mobility or physical function], occupational [helps people of all ages develop, recover, or maintain the skills needed for daily living and working], or speech therapists[clinical treatment that improves a person's ability to talk, understand language, use their voice, and swallow safely]) . During a concurrent interview and record review on [DATE] at 12:01 PM with Resident 1, Resident 1's ABN Form dated [DATE] was reviewed. Resident 1 stated Director of Rehab (DOR) came into her room and asked her to sign the ABN Form. Resident 1 stated she did not ask questions to the DOR because she could not fully understand what was written on the ABN form and DOR marked option 3 before the resident signed the ABN Form. Resident 1 thought she was expected to sign the ABN form and so she signed the form without fully understanding it. Resident 1 was not aware that she could write an appeal regarding the changes to her Physical Therapy (PT, is a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) treatment or ABN form. During an interview on [DATE] at 1:22 PM, DOR stated, DOR did not inform Resident 1's Responsible Party 1 (RP 1) regarding the issue on Resident 1's PT schedule or changes in the resident's treatment. DOR stated Resident 1's RP 1 should be notified with the change of treatment for Resident 1. During a concurrent interview and record review on [DATE] at 10:35 AM with the Business Office Manager (BOM), Resident 1's ABN Form dated [DATE] and [DATE] were reviewed. BOM stated Resident 1's ABN Form indicated expiration date [DATE]. BOM stated if ABN form was the expired version, the ABN Form was not valid. BOM also stated they need to revise the ABN Form for Resident 1 and use the updated version which indicates an expiration date of [DATE]. During an interview on [DATE] at 10:41 AM with the Director of Nursing (DON), the DON stated if the facility used an expired version of the ABN form, it means the form was not updated and it is not valid During a concurrent interview and record review on [DATE], at 3:40 PM, with the DON, Resident 1's Interdisciplinary Team (IDT - group of healthcare professionals from different clinical and support disciplines (such as doctors, nurses, therapists, and social workers) who collaborate to evaluate, plan, and deliver unified care for a patient) Notes dated [DATE] to [DATE] were reviewed. The DON stated there was no IDT Meeting conducted for Resident 1's change of treatment/ physical therapy order. The DON also stated SSD did not have any IDT meeting for Resident 1 since last year (2025) nor with RP 1. During an interview on [DATE] at 4:05 PM with RP 1, RP 1 stated she was not aware of the PT therapy issue or the maximized benefits for Resident 1's treatment. RP1 also stated they have not had IDT with the facility for many months, and the last one was last year (2025). RP 1 added the facility did not inform her about the ABN form that Resident 1 signed. During a review of the facility's policy and procedure (P&P) titled, Resident's Rights, revised 2/2021, P&P indicated, federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:> be informed about his or her rights and responsibilities;be notified of his or her medical condition and of any changes in his or her condition.be informed of, and participate in, his or her care planning and treatment. During a review of Centers for Medicare & Medicaid Services, (CMS, provides health coverage to residents through Medicare, Medicaid) Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) Office of Management and Budget (OMB) Approval Number: 0938-0566 modified [DATE], the FFS ABN indicated:1. On [DATE] the updated ABN is effective now and expires [DATE]. Providers may continue to use the expired version of the ABN until [DATE] but must transition to the approved form no later than that date.2.The ABN Forms instructions also indicated Notifiers must: Deliver the ABN to the patient(resident) or their representative before providing the items or services. Review the ABN with the patient or their representative and answer any questions before it' is signed Deliver the ABN far enough in advance that the patient or representative has time to consider the options and make an informed choice. Give a copy to the patient or representative, if requested, once all blanks are completed and the form is signed.https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abnhttps://www.cms.gov/medicare/medicare-general-information/bni/downloads/abn-form-instructions.pdf

Based on interview and record review, the facility failed to provide Foley catheter (F/C- a hollow tube inserted into the bladder to drain or collect urine) care (includes daily cleaning of a F/C and the surrounding genital area to prevent infection, often using mild soap and water) for one of two sampled residents (Resident 3), in accordance with the care plan. This failure had the potential to result in preventable foley catheter complications including discomfort, urine leakage, infection, or decreased quality of life for Resident 3.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included urethral discharge (secretion of fluid from the urethra that is not associated with normal urination), dementia (a progressive state of decline in mental abilities) and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms. During a review of Resident 3's Order Summary Report, dated 9/22/2025, the order Summary Report indicated F/C size 18 French (Fr- a scale used that measures the external diameter of the foley catheter tube) to bladder sphincter dyssynergia (BSD - a medical condition that causes the bladder muscle and the urinary sphincter to contract at the same time) due to obstructive uropathy (a structural or functional blockage of urine flow in the urinary tract),every shift. During a review of Resident 3's Indwelling Catheter r/t (related to) Obstructive Uropathy Care Plan, revised 1/26/2026, the Care Plan indicated interventions were to provide foley catheter care and change foley/catheter bag per order. During a review of Resident 3's Minimum Data (MDS- a resident assessment tool), dated 4/1/2026, the MDS indicated Resident 3 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all the effort) with oral, toileting, personal hygiene, dressing and bathing self. The MDS also indicated Resident 3 had an indwelling [urinary] catheter. During a concurrent interview and record review on 4/9/2026 at 1:51 PM with Treatment Nurse 2 (TN 2), Resident 3's electronic medical chart, from 10/1/2025 through 4/8/2026 was reviewed. Resident 3's electronic medical chart did not indicate an order for foley care or that foley care was provided. TN 2 stated there was neither a physician's order for foley care nor any documentation indicating that Resident 3 received foley care from 10/1/2025 through 4/8/2026 in the resident's medical chart. TN 2 further stated foley catheter care should have been provided and documented in the medical record daily by the assigned treatment nurse. TN 2 stated foley care included cleaning the genital area with soap and water, monitoring for any signs of infection, ensuring the foley catheter is clean, straight, not kinked, and secured with a stat lock (a securement tool designed to fix a Foley catheter in place, reducing tube movement, bladder spasms, and urethral trauma), and that the foley bag in not touching the floor. TN 2 further stated Resident 3 should be provided foley care because of an already existing [penile] wound which could become infected. During an interview on 4/9/2026 at 2:51 PM with Treatment Nurse 1 (TN 1), TN 1 stated Resident 3 should have had an order for foley care to ensure that it was being done. TN 1 stated all residents with a foley catheter should be receiving foley catheter care to prevent infection and to check for new skin issues, including breakdown, odors, or signs of infection. TN 1 stated if foley catheter care was provided, it should have been documented. During an interview on 4/9/2026 at 3:13 PM with Registered Nurse 2, RN 2 stated the facility do not have policy specific to foley catheter care. RN 2 further stated foley catheter care should be provided to every resident with a foley catheter to ensure they are receiving the proper treatment and care. RN 2 stated Resident 3 should have been receiving foley catheter care from 10/1/2025 through 4/8/2026 and not receiving foley catheter care puts him at risk for infections and/or worsening of his [penile] wound. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person - Centered Care Plan, revised 3/2022, the P&P indicated a comprehensive person-centered care plan that includes measurable objectives . is developed and implemented for each resident.

Based on interview and record review, the facility failed to ensure colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care was provided for one of two sampled residents (Resident 1) as indicated on the physician's order and facility's colostomy policy.This failure had the potential to result in colostomy complications including discomfort, stool leakage or decreased quality of life for Resident 1.Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included partial intestinal obstruction (a partial blockage of the small or large intestine), colostomy status, and chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure).During a review of Resident 1's History & Physical (H&P), dated 8/26/2025, the H&P indicated Resident 1 had a left abdominal colostomy.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 8/29/2026, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene, substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, lower body dressing and dependent (helper does all the effort) with shower/bathing self.During a review of Resident 1's Physician's Orders, dated 8/27/2025, the Physician's Orders indicated colostomy care and empty colostomy bag as needed.During a review of Resident 1's Treatment Administration Record (TAR), the TAR indicated blank entries for colostomy care and colostomy bag emptying from 11/16/2025 through 12/6/2025. During a review of Resident 1's Colostomy status post (s/p - after) Colon Resection; At Risk for Infection care plan, initiated 9/3/2025, the care plan indicated to change appliance per physician's orders.During a concurrent interview and record review on 4/8/2026 at 11:24 AM with Treatment Nurse 1 (TN 1), Resident 1's electronic medical chart from 11/16/2025 through 12/6/2025 was reviewed. Resident 1's electronic medical chart did not indicate that colostomy care or colostomy bag replacement had been provided. TN 1 stated there was no documentation showing that Resident 1 received colostomy care and/or that Resident 1's colostomy bag had been changed from 11/16/2025 through 12/6/2025. TN 1 stated, per facility protocol, if colostomy care was provided, including changing the colostomy bag, this would be documented on the TAR or a progress note in the resident's electronic medical chart.During an interview on 4/8/2026 at 2:04 PM with TN 1, TN 1 stated it was important to ensure colostomy care was provided to ensure residents were monitored for signs of infection, skin breakdown and/or leakage of the colostomy bag.During an interview on 4/8/2026 at 4:37 PM with Registered Nurse 1 (RN 1), RN 1 stated per facility protocol, colostomy care included checking for signs of infection, cleaning the stoma site and emptying or changing the colostomy bag needs to be documented when done. RN 1 also stated it was important to provide colostomy care to prevent colostomy bag leakage or rupture and infections to the colostomy site.During a review of the facility's Policy & Procedure (P&P) titled, Colostomy/Ileostomy Care, revised 10/2010, the P&P indicated when colostomy care is provided the following should be documented:a. Date and time the colostomy care was providedb. Name and Title of staff who provided the colostomy carec. Any breaks in the resident's skin, signs of infectiond. How the residents tolerated the care providede. If the resident refused the care, the reason(s) why and interventions takenf. The signature and title of the person recording the data

Based on observation, interview, and record review, the facility failed to ensure concerns were addressed for two (2) of 2 sampled residents (Resident 1 and 2) when the facility was informed of a resident (Resident 3) not allowing Certified Nursing Assistants (CNAs) to take water from the shared restroom in Room C to provide care for Resident 3's previous roommates and for the previous roommates to use the restroom. This deficient practice violates Resident 1 and 2's rights to be heard and for the resident's previous roommate to have the same access to services/ facility's amenities. Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/13/2026, the MDS indicated Resident 1 had intact skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with putting on/taking off footwear and required supervision (helper provides cues) with lower body dressing and personal hygiene. The MDS further indicated Resident 1 required setup assistance (helper sets up; resident completes activity) with eating, oral and toileting hygiene, shower and upper body dressing. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognitive skills for daily decision making. The MDS also indicated Resident 2 required partial/moderate assistance with shower and required supervision with lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 2 required setup assistance with oral, toileting, and personal hygiene, and upper body dressing. 3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included COPD and history of fall. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognitive skills for daily decision making. The MDS also indicated Resident 3 required setup assistance with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 3 was independent (resident completes the activity by themselves with no assistance from helper) with eating, oral and personal hygiene and upper body dressing. During a record review of the census for midnight of 3/24/2026, it indicated Resident 3's room (Room C) consisted of 2 beds in a room. The census also indicated Resident 2 was in Room A which was next to Room C. During a concurrent observation and interview on 3/25/2026 at 1:30 PM, Resident 1 was observed in her room seated on the wheelchair. Resident 1 stated Resident 3 would not allow her (Resident 3) roommates to use the bathroom in Room C and send the previous roommates to other rooms. Resident 1 also stated she used to be roommates with Resident 3 in Room C, and Resident 3 would not let Resident 1 use the call light button (call system used to alert staff if the resident needed assistance) and the restroom. Resident 1 further stated he spoke to the Administrator (ADM) about the concern and had also brought it up at the resident council (an independent, organized group of nursing home residents who meet regularly to discuss concerns, offer suggestions, and plan activities to improve their quality of life and care) meeting recently (unable to recall when) and was also mentioned in the previous resident council meetings (unable to recall dates) but does not feel the concern was heard. Resident 1 stated the facility would not give Resident 3 a roommate because she (Resident 3) would raise a fuss about having a roommate. During a concurrent observation in Room A (room is next to Room C) and interview on 3/25/2026 at 2 PM, Resident 2 was seated on the wheelchair. Resident 2 stated Resident 3 would not let any of her (Resident 3's) roommates use the shared restroom in Room C and would not let CNAs use the bathroom to get water to clean Resident 3's previous roommates. Resident 2 further stated the CNAs would come to Room A and use Room A's restroom to get water to bathe Resident 3's previous roommate. Resident 2 further stated the Activity Director (AD) knew about the concerns during resident council meetings, but nothing has been done yet. During an interview on 3/25/2026 at 2:31 PM, Certified Nursing Assistant 1 (CNA 1) stated she had to get water from Room A or Room B's restrooms because Resident 3 would not let the CNA use the Room C restroom to get water to give Resident 3's previous roommate a bath. CNA 1 also stated the Director of Staff Development (DSD), the charge nurses and the ADM were all aware of the issue. CNA 1 further stated if Resident 3's roommate had the capacity to walk, that resident would not use the restroom because Resident 3 would tell that resident to use another residents' restroom. During an interview on 3/25/2026 at 2:52 PM, the Social Services Director (SSD), SSD stated Resident 3's previous roommates who had the ability to use the restroom complained about not being allowed to use the restroom in Room C and often requested to move to another room. SSD further stated it was not acceptable to have Resident 3's roommate use another resident's restroom because they also have the same rights to be able to use Room C's restroom. During an interview on 3/25/2027 at 3:30 PM, CNA 2 stated Resident 3 sometimes would not allow CNA 2 to use Room C's restroom anytime CNA 2 provided personal hygiene to Resident 3's previous roommate. During an interview on 3/25/2026 at 3:30 PM, the Director of Nursing (DON) stated she heard about the shared bathroom complaints during one of the recent resident council meetings (unable to remember when) but had not yet spoken to Resident 3. The DON also stated, normally she would talk to Resident 3 and sit down with her (Resident 3) and explain that all the residents in the same room (Room C) as the resident had the right to use the restroom in Room C. The DON further stated the SSD should have talked to the residents concerned during the resident council meeting. The DON also stated there should have been a follow up to the residents who raised their concerns and a closure/ provided them with the resolution to the complaints. During an interview on 3/25/2026 at 4:56 PM, the DON stated the CNAs should be able to use Room C's restroom to get water for Resident 3's roommate because that was a shared restroom and the roommate also has the right to use it. During an interview on 3/25/2026 at 4:38 PM, the Registered Nurse 1 (RN 1) stated he had heard about a resident not allowing CNAs to get water from the shared restroom between the roommates to provide care to the roommate. RN 1 also stated the resident's roommate has the right to use the restroom and should be allowed to get water from there because it is a shared restroom. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, revised 2/2021, the P&P indicated that Federal and state laws guarantee certain basic rights to all residents of this facility and these rights include the resident's right to communication with and access to people and services, both inside and outside the facility, voice grievances to the facility and have the facility respond to his or her grievances.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards for one (1) of 2 sampled residents (Resident 3) when three (3) oxygen tanks (a metal canister storing compressed, 100 percent pure oxygen for people with breathing difficulties) was found inside the resident's restroom and two (2) oxygen tanks outside the resident's restroom located close to the wall by the left side of the resident's room were not removed when not in use as indicated in the facility's policy. This deficient practice had the potential to result in injuries and serious harm in the event of a resident fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support).Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and history of fall. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 3 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS also indicated Resident 3 required setup assistance (helper sets up; resident completes activity) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 3 was independent (resident completes the activity by themselves with no assistance from helper) with eating, oral and personal hygiene and upper body dressing. During a review of Resident 3's Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall) dated 3/3/2026 indicated Resident 3 was at risk for fall. During an observation on 3/25/2026 at 3:47 PM of Resident 3's room with Certified Nursing Assistant 1 (CNA 1), there were 3 oxygen tanks seen in the resident's restroom and 2 outside the resident's restroom close to the wall by the left side of the resident's room. During a concurrent observation and interview on 3/25/2026 at 3:52 PM, Licensed Vocational Nurse 1 (LVN 1) inside Resident 3's room, LVN 1 stated, Resident 3 had so many oxygen tanks inside the resident's room and the resident's restroom. LVN 1 also stated the 3 oxygen tanks in the resident's restroom and 2 oxygen tanks by the food of the resident's bed should be removed because it could become a safety hazard for Resident 3. During an interview on 3/25/2026 at 4:38 PM, Registered Nurse 1 (RN 1) stated oxygen tank should be stored in the oxygen storage room if not being used and not inside the resident's room. RN 1 also stated there should only be 1 oxygen tank inside Resident 3's room that is for the resident's use. RN 1 further stated 5 oxygen tanks inside the resident's room should not be allowed because it is a safety issue and a trip hazard for the residents. During an interview on 3/25/2026 at 4:56 PM, the Director of Nursing (DON) stated the 5 oxygen tanks stored inside Resident 3's room were a big hazard to Resident 3 because the resident could trip, fall and might hit her (Reisdent 3) head on the oxygen tank. The DON further stated oxygen tanks should be stored and placed in the oxygen storage room because it is a fire hazard and should not be stored in the resident's room. During a review of the facility's Policy and Procedure (P&P) titled, Fire Safety and Prevention, revised May 2011, it indicated its purpose was to ensure all personnel must learn methods of fire prevention and must report condition (s) that could result in a potential fire hazard. The P&P also indicated not to store oxygen cylinders in any resident's room or living areas. During a review of the facility's P&P titled, Safety and Supervision of Resident, revised July 2017, it indicated the facility strives to make the environment as free from accident hazards as possible. The P&P also indicated that the resident's safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review, the facility staff failed to promote dignity and respect for five (5) of six (6) sampled residents (Residents 37, 51, 79, 24 and 47 ) reviewed for dignity by failing to:1. Close the curtain while providing care to Resident 37 on 2/23/2026 and 2/24/2026. Resident 37's body was visible to other residents and staff in the room during care.2. Address Resident 51 by the resident's preferred name rather than using the term Mama on 2/25/2026.3. Knock on the door before entering Resident 79's room on 2/26/2026.4. Ensure Resident 24's pants were not wet with urine while Resident 24 sat on his wheelchair in the hallway on 2/23/2026 and did not ensure Resident 24 did not smell like urine in the hallway on 2/24/2026.5. Ensure Resident 47's foley catheter (thin, flexible tube inserted through the urethra [tube that carries urine from the bladder out of the body] into the bladder to continuously drain urine into an external bag) drainage bag was covered with a dignity bag (a discreet pouch designed to cover a urinary drainage bag).These deficient practices had the potential to negatively affect Residents 37, 51, 79, 24, and 47's senses of self-worth and self-esteem which could result in problems with emotional and mental well-being. Findings: 1. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 37's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [are brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms, including involuntary movements, loss of consciousness, and changes in behavior]), major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and dementia (a progressive state of decline in mental abilities) During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool) dated 1/9/2026, the MDS indicated Resident 37 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 37 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer. During an observation on 2/23/2026 at 3:57 PM in Resident 37's room, Certified Nurse Assistant 7 (CNA 7) was changing Resident 37's brief. Resident 37's privacy curtain was halfway open and was not fully pulled to cover Resident 37's body. Resident 37's hip and bilateral legs were visible upon entering Resident 37's room and were also visible to other residents inside the room. Resident 37's roommate was observed staring at Resident 37 while the staff was providing care for the resident. During a concurrent observation and interview on 2/24/2026 at 12:08 PM with CNA 2 inside Resident 37's room, CNA 2 was changing Resident 37's brief and providing morning care. Resident 37's privacy curtain was halfway open and was not fully pulled to cover Resident 37's body. Resident 37's left chest was exposed and not covered by the towel, making it visible to other residents in the room. CNA 2 stated she pulled the curtain down to Resident 37's waist to prevent Resident 37 from reaching for and grabbing the curtain. During an interview on 2/24/2026 at 3:28 PM with CNA 7, CNA 7 stated she did not pull the curtain fully to cover Resident 37. CNA 7 stated they need to close the curtain completely to cover the resident's body when providing care to the residents, to ensure privacy and dignity. During an interview on 2/24/2026 at 3:48 PM with LVN 1, LVN 1 stated they need to close the curtain fully to provide privacy and dignity for Resident 37. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 2. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 51's diagnoses included sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection), chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should), Gastroesophageal reflux disease (GERD, happens when stomach acid flows back up into the esophagus and causes heartburn [ a painful, burning feeling in the middle of your chest]) During a review of Resident 51's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 51 was dependent on shower/bathe self and putting on/ taking off footwear. The MDS indicated Resident 51 also needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, lower body dressing, roll left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/ bed-to-chair transfer, toilet transfer and tub shower transfer. During a concurrent observation on 2/25/2026 at 6:09 AM with LVN 5 inside Resident 51'S room, Resident 51 was awake and lying on her bed. LVN 5 stated, Hold the cup Honey (to Resident 51), you can bring this cup to your mouth. Resident 51 took her medication, LVN 5 stated, Alright Honey, do you want more water? During an interview on 2/25/2026 at 6:13 AM with LVN 5, LVN 5 stated they should not call the residents Honey. LVN 5 stated all the residents, including Resident 51, should be addressed with their first and last names, unless the residents preferred to be addressed differently. LVN 5 stated, to maintain the residents' dignity, they should not use labels when addressing residents. During a concurrent observation on 2/25/2026 at 1:15 PM in Resident 51's room, Resident 51 was awake and lying on her bed. Resident 51 turned on her call light. CNA 3 came inside Resident 51's room and asked Resident 51, Do you want something Mama? Resident 51 requested to move the overbed table and was observed pushing it with CNA3. CNA 3 stated to Resident 51 Good job Mama! Thank you, Mama. During an interview on 2/25/2026 at 1:18 PM with CNA 3, CNA 3 stated, Yes, I called her (Resident 51) Mama. CNA 3 stated she does not know how to address Resident 51. CNA 3 stated they were not supposed to label residents to maintain dignity and respect. During a concurrent observation and interview on 2/25/2026 at 1:20 PM in Resident 51's room, Resident 51 was sitting on her bed watching television. Surveyor asked Resident 51 if it was okay for the staff to call her Honey or Mama. Resident 51 did not answer and looked at the surveyor and shook her head. During a review of the facility's P&P titled, Dignity, revised 2/2021, the P&P indicated Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 3. During a review of Resident 79's admission Record, the admission Record indicated Resident 79 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 79's diagnoses included encephalopathy (a disturbance of brain function), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels) and gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach). During a review of Resident 79's MDS, dated [DATE], the MDS indicated the Resident 79's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 79 was dependent on oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, roll left and right, sit to lying, and lying to sitting on the side of the bed. During an observation on 2/26/26 at 8:36 AM inside Resident 79's room, Resident 79 was lying on her bed, sleeping. admission Coordinator (ADC) walked into Resident 79's room without knocking on the door. ADC was observed proceeding into Resident 79's bedside while looking around the resident's room without acknowledging the resident. During an interview on 2/26/2026 at 8:37 AM with ADC, ADC stated she did not knock on the door before entering Resident 79's room because Resident 79 was sleeping. ADC stated the staff need to knock on the door before going into any residents' room and introduce themselves, so the residents are aware of who is entering. ADC stated it was part of residents' rights and also to maintain dignity and respect. During a review of the facility's undated P&P titled, Dignity, revised 2/2021, the P&P indicated Residents' private space and property are respected at all times. Staff do not handle or move a resident's personal belongings without the resident's permission. Staff are expected to knock and request permission before entering residents' rooms. 4. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included obstructive and reflux uropathy (a blockage in the urinary system that stops urine from flowing out of the body), other hydronephrosis (swelling of the kidneys caused by a backup of urine that cannot properly drain into the bladder due to blockage or obstruction), and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland). During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was assessed having moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 24 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene, personal hygiene, sit to stand, and toilet transfer. The MDS indicated Resident 24 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) with shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 24 had an indwelling catheter (a tube inserted into the bladder to help drain urine). During a concurrent observation and interview on 2/23/2026, at 12:04 PM, in the hallway outside the dining room, Resident 24 was observed sitting in his wheelchair with his eyes closed. Resident 24's pants were soiled with urine. Several unknown facility staff walked by Resident 24 but did not assist Resident 24 back to his room to change him. The Minimum Data Set Coordinator (MDS 1) stated Resident 24's pants were soiled and wheeled Resident 24 back to his room. During a concurrent observation and interview on 2/27/2026, at 10:14 AM, outside Resident 24's room, Resident 24 was observed sitting in his wheelchair outside his room. Resident 24 smelled like urine. Resident 24 stated he was aware that he smelled like urine. Resident 24 stated facility staff were too lazy to smell the urine and keep telling him to wait. Resident 24 stated sitting outside his room smelling like urine made him feel indecent. The Maintenance Supervisor 1 (MS 1) stood next to Resident 24 and stated Resident 24 smelled like urine. MS 1 stated Resident 24 should have been changed as soon as staff noticed he smelled like urine. During an interview on 2/24/2026, at 4 PM, MDS 1 stated facility staff should change the residents' clothing when soiled. MDS 1 stated facility staff were also responsible for making sure the residents were not sitting in soiled clothing in the hallway. MDS 1 stated facility staff should have helped Resident 24 when he smelled like urine outside his room. MDS 1 stated the residents' self-esteem could go down if facility staff did not clean the resident who smelled like urine right away. 5. During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included urinary tract infection, dysphagia (difficulty or discomfort in swallowing), and orthostatic hypotension (a sudden temporary drop in blood pressure that concerns when standing up from a sitting or lying position). During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 47 was assessed having moderately impaired (decisions poor, cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 47 was dependent (helper does all of the effort) with oral/toileting hygiene, shower/bathe self, upper/lower body dressing, and sit to lying. The MDS indicated Resident 47 had an indwelling catheter. During a review of Resident 47's Order Summary Report, dated 2/24/2026, the Order Summary Report indicated a physician order, with a start date of 1/16/2026, for foley catheter (f/c) French (Fr- circumference of f/c tube) 16/10 cubic centimeter (cc- unit of measurement for small liquid doses) to bladder sphincter dyssynergia (BSD- a condition where the bladder contracts but the sphincter remains closed) due to diagnosis of obstructive uropathy (a condition where the normal flow of urine is blocked anywhere along the urinary tract). During a concurrent observation and interview on 2/23/2026, at 9:25 AM, with Certified Nursing Assistant 9 (CNA 9), in Resident 47's room, Resident 47 was awake in bed. Resident 47's foley catheter drainage bag was touching the floor and was not covered with a dignity bag (a discreet pouch designed to cover a urinary drainage bag). CNA 9 stated foley catheter drainage bags should not touch the floor and should always be covered with a dignity bag. During a review of the facility's policy and procedure (P&P), titled, Dignity, revised on 2/2021, the P&P indicated residents are treated with dignity and respect at all times. The P&P further indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents by helping the Resident keep urinary catheter bags covered. During a review of the facility's P&P, titled, Dignity, revised 2/2021, the P&P indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents by promptly responding to a resident's request for toileting assistance.

Based on observation interview and record review, the facility failed to provide reasonable accommodation of resident needs by ensuring 2 of four (4) sampled residents (Residents 29 and 43) call light device (one of the major communication technologies that links nursing home staff to the needs of residents) was within reach and answered timely. This failure had the potential to cause a delay in care for Resident 43 and 29 and prevent the residents from receiving the necessary care and services, which could lead to illness or serious injury.Findings: 1.During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was initially admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), hypertension (high blood pressure), dependence on renal dialysis ( a life-sustaining, long-term requirement for individuals with end-stage renal disease (ESRD, kidneys no longer function well enough to sustain life ). During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 29's cognitive skills (processes of thinking and reasoning) for daily decision making was moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. The MDS indicated that Resident 29 was partial/moderate assistance (helper does less than half the effort. helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on oral hygiene (The ability to use suitable items to clean teeth), upper body dressing (the ability to dress and undress above the waist), Personal hygiene( the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying, face and hands (excludes baths, showers, and oral hygiene), lying to sitting on side of bed (the ability to move from lying on the back to sitting on the side of the bed and with no back support), Chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). During a review of Resident 29's care plan date initiated 2/3/2026, the care plan indicated Resident 29 was at risk for fall risk for falls with injury related to limited mobility fracture, history of falls. The care plan indicated the residents need a working and reachable call light. During an observation and interview on 2/23/2026 at 10:14 AM in the presence of License Vocational Nurse (LVN 3), LVN 3, Resident 29's call light was observed at the left side of the bed facing down towards the floor. Resident 29 was trying to reach her call light and stated she could not reach it. Resident 29 also stated that call lights at night shift are not being answered. 2.During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was initially admitted to the facility on [DATE] with diagnosis of major depressive disorder (disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), bipolar disorder (mental disorder characterized by episodes of mania [extreme highs] and depression [extreme lows]). During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43's cognitive skills for daily decision making were cognitively intact. The MDS also indicated Resident 43 was partial/moderate assistance on Upper body dressing, personal hygiene and roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). During a review of Resident 43's care plan date initiated 1/14/2022, the care plan indicated potential for fall or injury related to impaired physical mobility due to abnormalities of gait and mobility. The care plan also indicated that staff should orient Resident 43 to the use of the call light, keep the call light within reach, and answer call lights promptly. During concurrent observation and interview on 2/23/2026 at 10:46 AM at the hallway, Room A's call light was observed to be on. License Vocational Nurse (LVN 6) was talking to the resident's family, and two license nurses were sitting at the nursing station. The call light sound was heard, and the light was visibly seen from the hallway. LVN 6 stated that the two nurses at the nursing station should have answered the call light; however, they did not respond. During an interview on 2/23/2026 at 10:50 AM with Resident 43, Resident 43 stated, nurses don't usually answer the call light. I got used to it. I have to wait until nurses' answer. During an interview on 2/25/2026 at 1:31 PM with the Director of Staff and Development (DSD), the DSD stated the call lights are the call light was the resident's way of communication, and to alert the facility staff when the resident needs assistance. It should be within reach all the time. DSD also stated The residents might feel ignored, needs not meet, residents emotional state will be affected. There's no excuse. The DSD also stated call lights are supposed to be answered as soon as possible. During an interview on 2/26/2026 at 9:19 AM with the Registered Nurse (RN 1), RN1 stated that all call lights need to be answered. RN1 also stated that at the nursing station there is a call light board where staff can hear and see the light and sound when residents press their call light. RN1 also stated that answering call light promptly is important for the safety of the residents. If call lights are not answered, residents may feel ignored and this could also lead to potential harm such as falls. During a review of facility's Policy and Procedure (P&P) titled Call Light, revised date 1/2024, the P&P indicated that the residents are provided with a mean to call staff for assistance through a communication system that directly alert member or a centralized workstation. The purpose of this procedure is to ensure timely response to the residents' requests and needs. The P&P also indicated that upon admission, and as needed the resident call light shall be kept within reach. The P&P also indicated that the staff must answer the resident's call light in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure two (2) of four (4) sampled residents (Residents 104 and 107) reviewed for activities of daily living (ADL) were provided care and services to maintain good grooming and personal hygiene by failing to:Provide toileting assistance to Resident 104 when residents asked to use the restroom and and was instructed by facility staff to urinate in the resident's diaper. 2.a. Provide toileting assistance to Resident 107 when resident needed to urinate and was instructed by facility staff to urinate in the resident's diaper.2b. Give Resident 107 a bath from 2/18/2026 to 2/23/2026.These deficient practices have the potential for Residents 104 and 107 to develop skin issues/complications and affect the residents' quality of life and self-esteem.Findings: During a review of Resident 104's admission Record, the admission Record indicated Resident 104 was admitted to the facility on [DATE] with diagnoses that included lack of coordination, abnormalities in gait (the manner or pattern of how someone walks, runs, or moves on foot) and mobility, and fracture of second lumbar vertebra (one of the bones that make up the spinal column). During a review of Resident 104's Minimum Data Set, (MDS- a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 104 had moderate impairment in Cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS also indicated Resident 104 was dependent (helper does all the effort) on toileting hygiene, shower and putting on/taking off footwear and required substantial/maximal assistance with lower body dressing. The MDS further indicated Resident 104 required partial/moderate assistance (helper does less than half the effort) with upper body dressing and setup assistance (helper sets up; resident completes activity) with oral hygiene. During an interview on 2/24/2026 at 9:15 AM, Family Member 1 (FAM 1) for Resident 104 stated that on the night of 2/23/2026 the resident pressed his call light and requested assistance to use the restroom. FAM 1 stated the Certified Nursing Assistant (CNA, not identified) staff told the resident he could urinate in his diaper instead of assisting him to the restroom. FAM 1 further stated that Resident 104 expressed concerns about the care he received and stated he wanted to go home. During a concurrent observation and interview on 2/24/2026 at 10:22 AM, Resident 104 was observed lying in bed with a diaper (under brief). The resident stated that on the night of 2/23/2026, he pressed on his call light and requested assistance to use the restroom. He stated the CNA did not respond for more than an hour, and he had already urinated in his diaper before the staff arrived. The resident stated the CNA told him he could urinate in his diaper. Resident 104 reported he remained in a wet diaper throughout the night and was changed the following morning. The resident stated he only needed assistance with undoing his diaper so he could use his urinal and was disappointed with the care provided. He stated he had expressed to Family Member 1 a desire to go home due to his concerns. Resident 104 further stated that the same situation occurred on the night of 2/22/2026, when no staff responded to his call light, and he remained in a wet diaper the entire night. During an interview on 2/24/2026 at 4:43 PM, Registered Nurse 1 (RN 1) stated that residents may feel embarrassed when they experience accidents, especially because many struggles with loss of independence. RN 1 stated residents should not be told they can urinate in their diapers and should be treated with respect and dignity. During an interview on 2/26/2026 at 12:14 PM, Licensed Vocational Nurse 3 (LVN 3) stated that telling Resident 104 he could urinate in his diaper and leaving him wet is a dignity concern. LVN 3 stated that such actions could cause the resident to feel unhappy with the care provided and to feel that staff do not care about him. During a review of the facility's Policy and Procedure (P&P) titled, Supporting Activities of Daily Living, revised 3/2018, the P&P indicated that resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL. 2. During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE] with diagnoses that included displaced midcervical fracture of right femur (injury where the neck of the upper thigh bone is broken and misaligned), abnormalities of gait and mobility (change from a normal, smooth, and effortless walking pattern), and muscle weakness. During a review of Resident 107's admission Assessment, dated 2/18/2026, the admission Assessment indicated Resident 107 was continent (able to voluntarily control) bladder and bowel functions. During a review of Resident 107's Minimum Data Set (MDS- a resident assessment tool), dated 2/23/2026, the MDS indicated Resident 107 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 107 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and toilet transfer. The MDS indicated Resident 107 required supervision or touching assistance with sit to lying, sit to stand, and walking 10 feet (ft- unit of measurement). The MDS indicated Resident 107 was independent (Resident completes the activity by themselves with no assistance from a helper) with eating. During a review of a facility form titled, Documentation Survey Report v2 (clinical documentation for ADLs), from 2/1/2026 to 2/28/2026, the Documentation Survey Report indicated Resident 107 did not receive a bath from 2/18/2026 to 2/22/2026. During a review of the Nurse's Station (NS) Shower Schedule, the Shower Schedule for Room B (room [ROOM NUMBER]) was scheduled every Monday and Friday. During an interview, on 2/23/2026, at 11:37 AM, with Resident 107, Resident 107 stated she was admitted to the facility the evening of 2/18/2026. Resident 107 stated she was put in a room that did not have its own bathroom when she was admitted to the facility. Resident 107 stated that an unknown Certified Nursing Assistant (CNA) instructed her to just pee (urinate) in her diaper the night of 2/18/2026, when she requested assistance to go to the bathroom. Resident 107 stated this made her feel bad and degraded and wanted to leave the facility the next day. During the same interview, on 2/23/2026, at 11:37 AM, with Resident 107, Resident 107 stated she has not bathed or showered since she was admitted to the facility. Resident 107 stated when she asked an unknown CNA if she could get a bath, the CNA told her she had to wait until 2/23/2026. Resident 107 stated not bathing for five days made her feel horrible and made her not want to entertain visitors because she felt dirty. During an interview, on 2/25/2026, at 10:48 AM, with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 107 was scheduled to shower every Monday and Friday. CNA 4 stated Resident 107 should have been given a bath or shower on 2/20/2026 if Resident 107 was admitted on [DATE]. CNA 4 stated facility staff should not wait until the scheduled shower day to give residents a shower. CNA 4 stated CNAs should accommodate the residents request for a bath on the same day they request it. CNA 4 stated not giving the residents a bath can make them feel that no one cares about them. During the same interview, on 2/25/2026, at 10:48 AM, with CNA 4, CNA 4 stated it was not acceptable for facility staff to tell Resident 107 to pee in her diaper because Resident was continent as was able to walk to the bathroom with assistance. CNA 4 stated facility staff should have assisted Resident 107 to the bathroom or offered her a bedpan (a shallow shaped container used as a portable toilet for people who cannot reach a bathroom) instead. During an interview, on 2/25/2026, at 2:34 PM, with the Director of Staff Development (DSD), DSD stated Resident 107 should have been given or offered a bath on 2/20/2026. DSD stated it was not okay for a resident to wait five days to get a bath in the facility. DSD stated it was not good for Resident 107's morale that she felt dirty and did not want any visitors. During the same interview, on 2/25/2026, at 2:34 PM, with DSD, DSD stated newly admitted residents were not allowed to get up from bed until an evaluation was done by the physical therapist. DSD stated if this was the case, the unknown CNA should have offered Resident 107 a bedpan when she needed to urinate. DSD stated facility staff should not tell a resident to pee in her diaper. DSD stated urinating in bedpan was more dignified than telling a resident to urinate in her diaper. During a review of the facility's policy and procedure (P&P), titled, Activities of Daily Living, Supporting, revised on 3/2018, the P&P indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the Resident and in accordance with plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to ensure the residents bed were at the lowest position for two (2) of four (4) residents (Resident 81 and 86) reviewed for accidents, as indicated on the care plan. This deficient practice has the potential to cause injury and/or fall to Resident 81 and 86.Findings: 1. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 81's Minimum Data Set (MDS- a resident assessment tool), dated 2/2/2026, the MDS indicated Resident 81 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 81 was dependent (helper does all the effort) with putting on/taking off footwear and required substantial/maximal assistance (helper does more than half the effort) with toileting and personal hygiene, shower, upper and lower body dressing. The MDS further indicated Resident 81 required setup assistance (helper sets up; resident completes activity) with eating and oral hygiene. During a review of Resident 81's Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall) dated 2/2/2026, the fall risk assessment indicated Resident 81 was at risk for fall. During a review of Resident 81's Care Plan initiated on 2/3/2021 and revised on 2/5/2026, it indicated the resident has the potential for fall/injury related to impaired physical mobility and history of fall with an approach plan of ensuring the resident's bed was at the lowest level and checking resident's environment for any hazards that can affect the resident's safety. During an observation on 2/23/2026 at 9:58 AM, Resident 81 was asleep in bed with both right and left middle section of the bedside rails up with the bed height left at approximately three (3) feet from the floor. During a concurrent observation and interview on 2/25/2026 at 12:57 PM, Licensed Vocational Nurse (LVN 2) stated Resident 81's bed was not and should have been placed in the lowest position (when the bed motor automatically stops and no longer moves downward) to prevent injuries from falling. LVN 2 also stated the facility staff should always lower the bed to the lowest level.2. During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included epilepsy (brain activity that cause sudden uncontrollable electrical disturbance in the brain and sometimes loss of awareness), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a medical condition that occurs when brain tissue dies due to a lack of blood flow and oxygen). During a review of Resident 86's Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall) dated 11/20/2025, the fall risk assessment indicated Resident 86 was at risk for fall.During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86 had intact cognitive skills for daily decision making. The MDS also indicated Resident 86 was dependent with shower and required substantial/maximal assistance with toileting and personal hygiene, lower body dressing and with putting on/taking off footwear. The MDS further indicated Resident 86 required partial/moderate assistance (helper does less than half the effort) with upper body dressing and required setup assistance with eating and oral hygiene. During an observation on 2/23/2026 at 8:12 AM, Resident 86 was in bed awake with both right and left middle section of the bedside rails up with the bed height left at approximately 3 feet from the floor.During a review of Resident 86's Care Plan initiated on 11/30/2022 and revised on 8/26/2025 indicated the resident was at risk for fall/injury related to seizure disorder with an approach plan of ensuring the resident's bed was at the lowest level and checking resident's environment for any hazards that can affect the resident's safety. During an interview on 2/25/2026 at 1:08 PM, Registered Nurse 1 (RN 1) stated Residents 81 and 86's beds should be at the lowest position. During an interview on 2/26/2026 at 11:24 AM, the Director of Nursing (DON) stated the residents' beds should be in the lowest position for the residents' safety and to prevent injuries related to fall. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated that based on previous evaluation and current data, the staff will identify interventions related to the residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P also stated that environmental factors that contribute to the risk of falls included incorrect bed height or weight.

Based on observation, interview, and record review, the facility failed to provide the necessary proper care and services for two (2) of two sampled residents (Resident 24 and Resident 47) reviewed for indwelling catheter (a tube that allows urine to continuously drain from the bladder) as indicated in the facility's policy and procedure (P&P) by failing to ensure: Resident 47's indwelling catheter drainage bag (a bag used to collect urine from an indwelling catheter) was not touching the floor.This deficient practice resulted in contamination of Resident 47's care equipment and placed Resident 47 at risk for infection. 2a. Facility staff emptied Resident 24's leg bag at least twice a day in accordance with the manufacturer's instructions .This deficient practice resulted in Resident 24's leg bag to constantly getting disconnected from the foley catheter (thin, flexible tube inserted through the urethra [tube that carries urine from the bladder out of the body] into the bladder to continuously drain urine into an external bag) and cause urine spills. b. Facility staff used aseptic technique(a technique that involves rigorous hand hygiene, wearing non-sterile gloves, and preventing contamination of the catheter/bag connectors) when Resident 24's leg bag was changed on 2/25/2026. c. Facility staff followed Resident 24's physician order to insert a 16 French (Fr- circumference of f/c tube) 16/10 cubic centimeter (cc- unit of measurement for small liquid doses) foley catheter. Resident 24 had an 18 Fr foley catheter on 2/25/2026. d. Resident 24's indwelling catheter was securely anchored with a securement device to prevent potential pulling and accidental dislodgement. These deficient practices can result in accidental dislodgement and urinary tract infections (UTI- an infection in any part of the urinary system) for Resident 24. Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included urinary tract infection, dysphagia (difficulty or discomfort in swallowing), and orthostatic hypotension (a sudden temporary drop in blood pressure that concerns when standing up from a sitting or lying position). During a review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 47 was assessed having moderately impaired (decisions poor, cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 47 was dependent (helper does all of the effort) with oral/toileting hygiene, shower/bathe self, upper/lower body dressing, and sit to lying. The MDS indicated Resident 47 had an indwelling catheter. During a review of Resident 47's Order Summary Report, dated 2/24/2026, the Order Summary Report indicated a physician order, with a start date of 1/16/2026, for foley catheter Fr 16/10 cc to bladder sphincter dyssynergia (BSD- a condition where the bladder contracts but the sphincter remains closed) due to diagnosis of obstructive uropathy (a condition where the normal flow of urine is blocked anywhere along the urinary tract). During a concurrent observation and interview on 2/23/2026, at 9:25 AM, with Certified Nursing Assistant 9 (CNA 9), in Resident 47's room, Resident 47 was awake in bed. Resident 47's foley catheter drainage bag was touching the floor and was not covered with a dignity bag (a discreet pouch designed to cover a urinary drainage bag). CNA 9 stated foley catheter drainage bags should not touch the floor. During an interview on 2/24/2026, at 3:28 PM, with Treatment Nurse 1 (TN 1), TN 1 stated bacteria can enter Resident 47's foley catheter drainage bag which can cause an infection if the drainage bag touches the floor. TN 1 stated a basin should be placed underneath the drainage bag to prevent the bag from touching the floor. TN 1 stated the drainage bag should also cover the drainage bag to prevent other staff and visitors from seeing Resident 47's urine. TN 1 stated CNAs and Licensed Nurses were responsible for making sure Resident 47's drainage bag was not touching the floor. During a review of the facility's P&P titled, Catheter Care, Urinary Level III, revised on 8/2022, the P&P, under Infection Control, indicated to be sure the catheter tubing and drainage bag are kept off the floor During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included obstructive and reflux uropathy (a blockage in the urinary system that stops urine from flowing out of the body), unilateral inguinal hernia (when the abdominal tissue pushes through a weak spot in the abdominal muscles on one side of the groin, creating a huge bulge), and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland). During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was assessed having moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 24 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene, personal hygiene, sit to stand, and toilet transfer. The MDS indicated Resident 24 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) with shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 24 had an indwelling catheter. During a review of Resident 24's Order Summary, dated 2/24/2026, the Order Summary Report indicated a physician order for the following:F/C Fr 16/10 cc to BSD due to diagnosis of obstructive uropathy, with a start date of 1/10/2026Change foley catheter Fr 16/10 cc and bag as needed (prn) if leaking, plugged, or pulled out, obstruction, excessive sedimentation or when the closed system is compromised, once a month every 1 month starting on the 16th for 28 days for f/c change.Change foley catheter leg bag every Sunday and prn when leaking. During a concurrent observation and interview on 2/24/2026, at 10:14 AM, Resident 24 was observed sitting in his wheelchair outside his room. Resident 24 stated he smelled like urine because facility staff did not always empty his urine bag when it was full. Resident 24 stated sometimes he has to empty his own urine bag because his leg bag gets disconnected when it is too full. During an interview on 2/24/2026, at 3:33 PM, with TN 1, TN 1 stated Resident 24's leg bag was ordered to be changed every Sunday or as needed but she frequently changes it because it would always get disconnected. TN 1 stated Resident 24's leg bag getting disconnected was an ongoing problem because Resident 24 moves too much or tries to empty his own leg bag. TN 1 stated Resident 24 empties his leg bag because CNAs do not regularly empty Resident 24's leg bag and it gets too full. TN 1 stated Resident 24 should not empty his leg bag without assistance or supervision because Resident 24 has limited mobility and could fall and or injure himself when he stands and undresses himself before emptying his leg bag. During an interview on 2/25/2026, at 8:41 AM with CNA 5, CNA 5 stated Resident 24 empties his leg bag when it is full and when staff does empty it right away. CNA 5 stated there where incidents when she started her shift at 7 AM that Resident 24's leg bag was full and not emptied during the night. CNA 5 stated Resident 24's leg bag would get disconnected from the foley catheter when it was full of urine. CNA 5 stated Resident 24's leg bag should be emptied at least twice a shift to prevent the leg bag from getting disconnected from the foley catheter. During a concurrent observation and interview on 2/25/2026, at 11:16 AM, TN 1 and TN 2 informed Resident 24 that Resident 24's leg bag was going to be changed. TN 1 and TN 2 donned (to put on) non-sterile gloves (clean, single-use gloves that have not undergone sterilization to remove all microorganisms) and gowns and entered Resident 24's room. TN 1 removed Resident 24's diaper and TN 2 stated Resident 24 had an 18 Fr (red) foley catheter inserted. TN 1 and TN 2 stated Resident 24's foley catheter was not secured with a device. TN 2 held Resident 24's foley catheter as TN 1 twisted and disconnected the leg bag from Resident 24's foley catheter. TN 1 flushed the foley catheter with 60 milliliters (ml- unit of measurement) of normal saline and connected the new leg bag to Resident 24's foley catheter. TN 1 did not clean the area where the foley catheter connected with the leg bag before disconnecting and connecting the new leg bag. During an interview on 2/25/2026, at 11:16 AM with TN 1 and TN 2, TN 1 and TN 2 stated aseptic technique should be followed when changing the leg bag and during foley catheter care. TN 1 stated she did not but should have cleaned the foley catheter connection site before disconnecting and connecting the new leg bag. TN 1 stated not cleaning the foley catheter tubing could cause Resident 24 to get a urinary tract infection. TN 2 stated they have never secured Resident 24's foley catheter to prevent it from getting accidentally pulled. TN 1 stated she did not know why an 18 Fr foley catheter instead of a 16 Fr as ordered was inserted into Resident 24. TN 1 stated it was important for Resident 24 to wear the right foley size because it could cause Resident 24 discomfort if it was too big. During an interview on 2/26/2026, at 3:27 PM, with the Director of Nursing (DON), the DON stated Resident 24's leg bag should be emptied every shift of as needed when full. The DON stated TN 1 and TN 2 should have followed the aseptic technique and cleaned Resident 24's foley catheter connection site with alcohol before disconnecting. The DON stated Resident 24's foley catheter should have been secured with a device to prevent accidental dislodgement and tugging on the bladder which could cause bleeding and pain. During a review of the facility's P&P, titled, Indwelling (Foley) Catheter Insertion, Male Resident, revised 8/2022, the P&P indicated to secure the catheter tubing and/or bag to resident with approved catheter securement device. During a review of the facility's P&P, titled, Catheter Care, Urinary Level III, revised 8/2022, the P&P indicated the following:Empty the collection bag at lease every eight (8) hours using a separate, clean collection container for each resident. Avoid splashing and prevent contact of the drainage spigot with the non-sterile container.Ensure the catheter remains secured with a securement device to reduce friction and movement at the insertion site.Use aseptic technique when handling or manipulating the drainage system. During a review of the Medline Leg Bag Manufacturer's Instructions, the Manufacturer's Instructions indicated the following:To change leg bag: Wash hands with soap and water. Pinch off the catheter tube above the leg bag connection so urine does not leak out. Be careful not to pull on the catheter. Disconnect catheter tube from leg bag using a twisting motion while keeping the catheter tube pinched. A catheter plug may be used to keep the foley from draining, otherwise place a towel underneath the catheter to collect any drips. Clean catheter funnel and leg bag connection port with isopropyl alcohol, wiping away from the opening. Insert drain bag port into catheter funnel. Minimize number of times you switch between bags to reduce risk of infection.Empty leg bag when half-full, or at least twice a day.

Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) as indicated on the physician's order for two (2) of two sampled residents (Resident 71 and 15) reviewed for respiratory/oxygen. This deficient practice had the potential to place Resident 71 and 15 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to irreversible damages of health and/or death. Findings:1. During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 71's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your respiratory system [organs/ structures in the body that allow you to breath such as lungs]), pulmonary edema (when fluid collects in the air sacs of the lungs, making it difficult to breathe) and history of pneumonia (a lung infection). During a review of Resident 71's Minimum Data Set (MDS, a resident assessment tool), dated 2/17/2026, the MDS indicated Resident 71 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 71 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe sit-to stand, self, upper and lower body dressing, putting on/taking off footwear, sit to lying, and sit-to stand. During an observation on 2/23/2026 at 8:45 AM in Resident 71's room, Resident 71 was awake in bed. Resident 71's oxygen tubing was observed around her head and the nasal cannula (NC) was on the resident's neck. The oxygen concentrator was running with the oxygen at 2 liters per minute (lpm) with humidifier. During a concurrent interview and record review on 2/24/2026 at 3:34 PM with Licensed Vocational Nurse 3 (LVN 3), the Physician Order (PO) dated 2/13/2026 was reviewed. The PO indicated oxygen at 2 lpm via nasal cannula continuously every shift for shortness of breath and pneumonia. LVN 3 stated the nasal cannula was not on Resident 71's nostrils; the oxygen tubing and nasal cannula were positioned on top of her head. The nasal cannula should be placed on her nostrils because Resident 71 can experience low oxygen saturation (the percentage of oxygen in a person's blood. It shows how well oxygen is being carried from the lungs to the rest of the body.) During a concurrent interview and record review on 2/24/2026 at 3:40 PM with LVN 3, Resident 71's Care Plan (CP) for altered respiratory status / difficulty of breathing, revised on 2/16/2026 was reviewed. The CP indicated interventions were to administer oxygen per order and monitor for effectiveness. LVN 3 stated the CP was not followed, because the nasal cannula fell out from Resident 71's nostrils, therefore the resident was not receiving oxygen as ordered. During a concurrent observation on 2/25/2026 at 6:53 AM with LVN 4 in Resident 71's room, Resident 71 was sleeping and the nasal cannula was not on the resident's nostrils. The nasal cannula was observed hanging on the right upper bed rail (is a safety device [typically a metal or plastic bar] attached to the side of a bed to prevent falls, aid in repositioning, and provide support when getting in or out of bed). During an interview on 2/25/2026 at 6:55 AM, LVN 4 stated Resident 71 needed to have the nasal cannula on her nostrils and receive oxygen continuously to prevent the resident from experiencing low oxygen levels. 2. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 15's diagnoses included chronic respiratory failure (occurs when a person does not have enough oxygen in the blood) with hypoxia, asthma (a condition in which the airways narrow and swell and may produce extra mucus), and morbid obesity (weight more than 100 pounds over the ideal body weight and experiencing severe health effects) During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 had intact cognitive skills for daily decision making. The MDS indicated Resident 15 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, lying to sitting on the side of the bed and chair/ bed-to-chair transfer. During a record review of Resident 15's PO, dated 3/10/2025, the PO indicated oxygen at 3 lpm via nasal cannula continuously for diagnosis of respiratory failure. During a record review of Resident 15 CP for oxygen therapy related to respiratory illness, acute and chronic respiratory failure with hypercapnia (occurs when a patient with a pre-existing, long-term condition that causes high carbon dioxide levels experiences a sudden, acute worsening of the condition), dated 1/16/2025, the CP indicated Resident 15 has oxygen via nasal prongs(cannula)/mask at 3 lpm continuously. During an observation on 2/26/2026 at 9:14 AM in Resident 15's room, Resident 15 was lying supine on the bed. The nasal cannula was on top of Resident 15's upper lip and not on her nostrils. Oxygen concentrator was running with the oxygen at 3 lpm. During an observation on 2/26/2026 at 9:15 AM with LVN 4 in Resident 15's room, Resident 15 was awake and lying supine on the bed. LVN stated she had to fix the placement of the nasal cannula so it could be in Resident 15's nostrils for the resident to receive oxygen as ordered. During an interview on 2/26/2026 at 9:21 AM, LVN 4 stated Resident 15's nasal cannula should always be checked for proper placement because if it was not positioned properly on her nostrils, Resident 15 can have a lower oxygen level. During a record review of facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated,11.Securely anchor the tubing so that it does not rub or irritate the Resident's nose, behind the Resident's ears, etc.12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened.13. Observe the resident upon set up and periodically thereafter to be sure oxygen is being tolerated.

Based on interview and record review, the facility failed to ensure competencies and skills sets to provide nursing and related services were completed for two (2) of four (4) nursing staff in accordance with the facility assessment and policy and procedures (P&P). This deficient practice had the potential to cause increased risk for improper resident assessments, and inadequate documentation which could negatively impact the quality of care provided to the residents.Findings: 1. During a concurrent interview and record review on 2/25/2026 at 2:26 PM with Director of Staff Development (DSD), Treatment Nurse (TN1, a licensed vocational nurse) employee records were reviewed. DSD stated TN 1 was hired on 10/17/2022. DSD stated TN1 did not have documented evidence of completed competency and training for Foley catheter (tube that drains urine from the bladder into a drainage bag) care. During an interview on 2/25/2026 at 2:06 PM with TN 1, TN 1 stated she was not evaluated for Foley catheter care. During an interview on 2/25/2026 at 2:19 PM with TN 2, TN 2 stated she does not remember if she was evaluated for Foley care. 2. During a concurrent interview and record review on 2/26/2026 at 10:49 PM with DSD, TN 2 (a licensed vocational nurse) employee records were reviewed. DSD stated TN 2 was hired on 9/22/2021. DSD stated TN2 did not have documented evidence of completed competency for Foley catheter care. DSD also stated the competencies and training for Foley catheter care, intermittent catheterization (procedure where thin (catheter) temporarily inserted to the bladder to drain urine and then removed after the bladder is empty) , and indwelling catheter (tube inserted into the bladder to drain urine and left in place for period of time) should have been completed in accordance with the facility assessment. During an interview with the DSD on 2/26/2026 at 11:52AM, the DSD stated licensed nurses' competencies including indwelling catheter care are completed upon hire and as needed to ensure residents are provided the proper care. During a record review of the Facility Assessment, dated 9/1/2025, the Facility Assessment indicated under Areas Facility Assessment Informed: Training, Competencies that Action to be taken this year was to provide training on Medication Pass, Foley Care . training. During a review of facility's P&P titled, Staffing, Sufficient and Competent Nursing, revised 8/2022, the P&P indicated that the facility provides sufficient number of nursing staff with the appropriate skills and competencies necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The P&P also indicated the competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. All nursing staff must meet the specific competency requirements of their respective licensure and certifications as defined by state law.

Based on observation, staff interviews, and review of facility records, the facility failed to correctly measure the calorie and sugar content of breakfast meals for 14 of 14 residents who were ordered to receive a fortified diet (an enhanced meal meant to provide extra protein, calories, and nutrients).This deficient practice had the potential for residents on fortified diet to not receive the increased nutrients, protein and calories required which could result in malnutrition or weight loss.Findings:During a review of the facility's menu from 2/22/2026 to 2/28/2026, the menu indicated hot or cold cereal was served for breakfast on 2/24/2026.During a review of the facility's menu, titled, Super Cereal (fortified cream of wheat), the menu indicated the following ingredients:Evaporated milk 5/8 cup (c)Water 1 1/8 quart (qt- unit of measurement for volume of liquid)Dry milk powder 1/2 cRolled oats 2 1/2 cEvaporated milk 1 3/4 cMargarine 1 1/4 cLight brown sugar 10 ounce (oz- unit of measurement for weight in cooking)Granulated sugar 3/4 cDuring a review of the facility's menu, titled, Super Cereal Method, the menu indicated the following:Choose type of cereal to be prepared for the day. Prepare as close to serving time as possible and keep covered until served. This will prevent the cereal from drying.In a stockpot of kettle combine the 1st amount of evaporated milk and the dry milk powder; mix well and bring to boil.Add cereal and cook for 5 minutes.Add remaining ingredients and stir until creamy. Cereal should thicken and be creamy but not sticky. (diabetic diets: omit the sugar)Place cooked cereal in a 4 inch dep steamtable pan, serve with a 6 oz ladle per portion. During an observation on 2/25/2026, at 7:03 AM, in the kitchen, during the serving of breakfast lunch trays, Dietary [NAME] (DC) was informed by an unknown kitchen staff that the cream of wheat needed to be fortified. DC opened one 12 fluid ounce (fl oz- unit of measurement for liquid capacity) can of evaporated milk and poured the entire can of evaporated milk into the stock pot containing cream of wheat. DC opened one 16 oz bag of brown sugar with a knife and poured half of the contents into the same stock pot containing cream of wheat. DC also added a splash of vanilla flavor in the stock pot. DC did not measure the brown sugar before adding it to the cream of wheat. DC stated she did not know the recipe indicated to add granulated sugar to the recipe.During an interview, on 2/25/2026, at 10:42 AM, with DC, DC stated she was not familiar with the menus in the facility and would sometimes have to look for the menus. DC stated she did not look at or follow the facility's fortified cream of wheat (super cereal) menu for this morning. DC stated she cooked the fortified cream of wheat based on the menu that she learned from the previous facility where she worked before. DC stated she did not measure the brown sugar before she added it to the cream of wheat. DC stated she did not check if the amount of evaporated milk in the can was the same amount indicated in the menu. DC stated she added the vanilla flavor to make the cream of wheat smell better. DC stated not following the menu could cause residents to get sick. DC stated not following the menu can cause the blood sugars of the diabetic residents to go up.During a concurrent interview and record review, on 2/25/2026, at 1:20 PM with the Registered Dietician (RD), the facility's menu for Super Cereal was reviewed. RD stated residents were ordered fortified diets because they needed extra calories and weight management. RD stated the menu for super cereal indicated to add 1 3/4 cups of evaporated milk to the cereal. RD stated DC added 12 oz of evaporated milk from the can which was equivalent to only 1 1/2 cups. RD stated DC did not add enough evaporated milk to the fortified super cereal. RD stated the recipe was not followed when DC poured approximately half the bag of brown sugar into the pan. RD stated it was okay for kitchen staff to eyeball recipe measurements if the kitchen staff was skilled enough. RD stated she was unsure if the policy indicated it was okay to eyeball measurements but stated it was safer for kitchen staff to get the exact measurement of the ingredient. RD stated DC should have added granulated sugar to the cream of wheat as indicated in the recipe. RD stated DC did not follow the recipe when DC added vanilla flavor to the cereal. RD stated it was important to follow the recipe to ensure proper nutrition was being provided to the staff. RD stated not following the recipe could cause food intolerances, weight loss, malnutrition, or skewed laboratory results. RD stated DC should have used and followed the menu for Super Cereal.During an interview on 2/26/2026, at 9:03 AM with the Dietary Supervisor (DS), the DS stated DC should have followed the recipe for super cereal. DS stated DC should not have poured the bag of brown sugar directly into the pot and should have used a measuring cup to measure the brown sugar. DS stated it was important for DC to follow the recipe so the residents can meet the required calories and nutritional value of the food.During a review of the facility's policy and procedure, titled, Standardized Recipes, revised 4/2017, the policy indicated, standardized recipes shall be developed and used in the preparation of foods.

Based on observation, interview, record review, facility failed to provide food that accommodated food preferences and offer meal substitutes of the same nutritive values for two (2) of two sampled residents (Resident 107 and Resident 75) reviewed for food. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (when the body does not get the right amount of nutrients, either too little or too much, causing health problems).Findings:During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE] with diagnoses that included displaced midcervical fracture of right femur (injury where the neck of the upper thigh bone is broken and misaligned), abnormalities of gait and mobility (change from a normal, smooth, and effortless walking pattern), and muscle weakness. During a review of Resident 107's Minimum Data Set (MDS- a resident assessment tool), dated 2/23/2026, the MDS indicated Resident 107 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 107 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and toilet transfer. The MDS indicated Resident 107 was independent (Resident completes the activity by themselves with no assistance from a helper). During an interview on 2/23/2026, at 11:37 AM, Resident 107 stated facility staff had not asked her what foods she liked or disliked since she was admitted to the facility on [DATE]. Resident 107 stated she did not eat red meat and pork, but the kitchen staff have been serving her red meat and pork since she was admitted . Resident 107 stated she wrote her food dislikes on her meal ticket every time she was served red meat or pork, but the facility kept sending her pork and red meat. Resident 107 stated she started asking family members to bring her food because she needed to eat and the facility did not listen to her food preferences. During an observation of Resident 107's lunch food tray on 2/23/2026, at 1:20 PM, Resident 107 was served spaghetti with meat in red sauce, green beans and garlic bread. During a concurrent interview and record review on 2/23/2026 at 1:20 PM, with Resident 107, Resident 107's lunch Meal Ticket was reviewed. Resident 107's Meal Ticket indicated Resident 107 was served spaghetti with meat sauce for lunch. The Meal Ticket did not indicate Resident 107's preferred beverage and what foods she liked or disliked. The Meal Ticket had a handwritten note that stated Resident 107 liked fish, chicken, hot water, and 2% milk and disliked red meat and pork. Resident 107 stated she once again wrote what food and beverage she liked and disliked on the meal ticket because she was served red meat for lunch. Resident 107 stated she did not understand why the facility kept serving her red meat and pork when she always wrote her food preferences on the meal ticket. Resident 107 said the staff should see and take note of what she preferred to eat since she writes it on her meal ticket and leaves it on the tray. Resident 107 stated facility staff knew when she did not eat her food but never asked her the reason why. Resident 107 stated facility staff did not offer her an alternate meal when she did not eat her food. During a concurrent interview and record review, on 2/25/2026, at 9:21 AM, with the MDS Coordinator, Resident 107's Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a resident) meeting, dated 2/19/2026 was reviewed. MDS stated Resident 107's IDT form did not indicate any of Resident 107's food preferences. During a concurrent interview and record review, on 2/25/2026, at 9:21 AM with MDS Coordinator, Resident 107's Dietary Profile/Preference form was reviewed. MDS Coordinator stated Resident 107's Dietary Profile/Preference form, which indicated that Resident 107 disliked pork, bacon, sausage, ham, beef, coffee, and cold cereal, was not documented and signed by DS until 2/24/2026. MDS Coordinator stated the Dietary Supervisor (DS) was the staff responsible for assessing and documenting the residents' Dietary Profile/Preference form. MDS Coordinator, stated Resident 107's Dietary Profile/Preference form should have been assessed upon admission or sooner than 2/24/2026 to make sure she received food that she could eat and liked. During an interview on 2/25/2026, at 9:32 AM, the DS stated the residents' dietary preferences and allergies were assessed within 24 hours after admission. DS stated if a resident was admitted in the middle of the night, then the dietary assessment was done the following day. DS stated she did not assess Resident 107's dietary preference until five days after she was admitted to the facility because she was too busy. DS stated it was important to assess the residents' dietary preference upon admission to prevent residents from getting food that they did not like. During an interview on 2/25/2026, at 9:53 AM, the Registered Dietician (RD) stated DS had three days or 72 hours to assess and note Resident 107's dietary preference and restrictions. RD stated DS should have assessed Resident 107's dietary preference by 2/21/2026 if she was admitted to the facility on [DATE]. RD stated residents will feel frustrated and lose weight if residents do not eat the food in the facility. RD stated facility staff should have offered Resident 107 a substitute meal or asked Resident 107 the reason why she did not eat her food. During a review of Resident 75's admission Record, the admission Record indicated Resident 75 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included polyosteoarthritis (a form of arthritis affecting five or more joints), dysphagia (difficulty in swallowing), and chronic pain syndrome (a condition where pain lasts for more than 3 to 6 months often persisting long after an initial injury or illness has healed). During a review of Resident 75's MDS, dated [DATE], the MDS indicated Resident 75 was assessed having intact memory and cognitive skills for daily decision making. The MDS indicated Resident 75 was independent with eating, oral/toileting hygiene, sit to lying, and toilet transfer. The MDS indicated Resident 75 required setup or clean-up assistance (helper sets up or cleans up; Resident completes activity) with shower/bathe self and personal hygiene. During a concurrent observation and interview on 2/23/2026, at 2:45 PM, with Resident 75 in Resident 75's room, a plate of uneaten sandwich with light brown bread was observed at the foot of Resident 75's bed. Resident 75 stated the sandwich was her lunch and she did not eat it because she only ate white bread. Resident 75 stated she did not eat or return the plate because she wanted to show DS that the kitchen continues to give her wheat bread even after she informed DS that she only ate white bread. During an observation on 2/24/2026, at 12:49 PM, Resident 75's lunch was observed. Resident 76 was served a sandwich with light brown bread covered in plastic. Resident 75 stated she was served wheat bread instead of white bread. Resident 75 returned the tray to an unknown Certified Nursing Assistant (CNA) and informed the CNA she did not eat wheat bread. During an interview on 2/25/2026, at 9:40 AM, DS stated she was informed by Resident 75 a month ago that Resident 75 only wanted to eat white bread because it was easier for her to digest. DS stated she has not updated Resident 75's food preference in her meal ticket. DS stated she should have updated resident 75's meal ticket to prevent the kitchen staff from serving wheat bread. DS stated Resident 75 should not have been given white bread. DS stated she did not know why Resident 75 was served wheat bread on 2/23/2026 and 2/24/2026. DS stated not giving Resident 75 the food she preferred could make her feel upset and sad and not eat her meals, which could lead to unplanned weight loss. During an interview on 2/25/2026, at 10:01 AM, the RD stated DS should have updated Resident 75's meal ticket and dietary profile when she was informed by Resident 75 that she preferred to only eat white bread. RD stated this could have prevented Resident 75 from getting served wheat bread. RD stated serving the residents food that they disliked could lead to frustration and feeling ignored by the facility. During a concurrent interview and record review on 2/26/2026, at 1:21 PM, with MDS Coordinator, Resident 75's care plans were reviewed. MDS Coordinator stated Resident 75 did not have a care plan addressing Resident 75's dietary preferences. MDS Coordinator stated Resident 75 should have had a care plan addressing her dietary preference, so facility staff were aware of what resident 75 liked and did not like to eat. During a review of the facility's Policy and Procedure (P&P), titled, Resident Food Preferences, revised on 7/2017, the P&P indicated the following:Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent.Upon the resident's admission (or within twenty-four hours after his/her admission) the dietician or nursing staff will identify a resident's food preferences.When possible, staff will interview the Resident directly to determine current food preferences based on history and life patterns related to food and mealtimes.Nursing staff will document the residents' food and eating preferences in the care plan. During a review of the facility's P&P titled, Nutritional Assessment, revised on 10/2017, the P&P indicated the following:The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that placed the resident at risk for impaired nutrition.The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least following components: food preferences and dislikes (including flavors, textures, and forms.Individualized care plans shall address, to the extent possible the resident's personal preferences.

Based on observation, interview, and record review, the facility failed to prepare and store food in a sanitary manner in accordance with facility policy by failing to ensure:Soaps and cleaning solutions were not combined with food items.Kitchen equipment and surfaces were free from food debris and cleaned after use.Food items stored in the refrigerator were labeled and dated.Opened food item in the freezer was properly sealed.Multiple clear bags of brown bread in the dry storage room were labeled.Dietary [NAME] (DC) changed gloves and performed hand hygiene in between documentation, checking the food temperature during the tray line assembly, food preparation, and before serving the residents' meal trays.DC's apron did not come in contact with the residents' clean plates and DC did not touch the center of the clean plates during tray line assembly. These deficient practices had the potential to result in chemical and pathogen (germ) exposure to residents' food and placed the residents at risk for developing foodborne illness (food poisoning- any illness resulting from consuming food or drinks contaminated with harmful bacteria, viruses, parasites, or chemicals) with symptoms including an upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and could lead to other serious medical complications and hospitalization.Findings:During a concurrent observation of the kitchen and interview, on 2/23/2026, at 7:45 AM, with the Dietary Supervisor (DS) the following were observed:One (1) green and 1 red bucket containing liquid with used white towels were observed next to an uncovered bin containing yellow and red potatoesDried yellow debris on the inside door and black debris on the bottom of Oven 1 (OV 1)Seven (7) unlabeled and undated bags of half sandwiches in Refrigerator 1 (REF 1)1 unlabeled bag of sandwich in REF 1.1 opened bag of frozen chicken dumplings tied at the top with a clear plastic wrap in Freezer 1 (FRZ 1)Multiple clear plastic bags of unlabeled brown bread inside the dry storage room. DS stated the red and green bucket should not have been placed next to the potatoes. DS stated the 8 sandwich bags inside REF 1 were the residents' snacks. DS stated the bags should have been labeled and dated with the preparation date. DS stated the opened bag of chicken dumplings should not have been tied with a clear plastic wrap. DS stated the bag of chicken dumplings should have been placed and sealed in a storage bag before it was returned back inside FRZ 1. DS stated the bags of bread were wheat bread and should have been labeled as soon as they were delivered to the facility. During an observation of the kitchen tray line assembly on 2/25/2026, at 6:57 AM, the following were observed:DC held a thermometer with gloved hands and checked the temperatures of each food item on the steam table. After checking the temperature of each food item, DC wrote the temperature on the food temperature log. DC did not change her gloves and wash her hands between checking the food temperature and holding the pen and paper.DC checked the temperature of the oatmeal on top of the stove with gloved hands. DC held the thermometer and pen in her right hand. DC's right hand was inside the pot of oatmeal. DC did not remove her gloves and wash her hands after checking the oatmeal's temperature and returned to the steam table to continue with tray line assemblyWith the same gloved hands, DC used the metal can opener to open a can of evaporated milk and poured the evaporated milk in a large stock pot. DC turned the oven burner knob and cracked two raw eggs into a small metal skillet. DC did not remove her gloves and wash her hands after holding the can of evaporated milk, turning the oven burner knob, and cracking two raw eggsDC's black apron touched the residents' clean plates when she scooped the eggs and sausage from the steam table.DC's gloved hand touched the center of the residents' plates each time she slid the plates across the tray line table. During an interview on 2/25/2026, at 10:42 AM, with DC, DC stated she did not change her gloves and wash her hands after she touched the pen and before she checked the food temperature with the thermometer. DC stated the pen was dirty and not changing her gloves after touching the pen could contaminate the food. DC stated she always checked and wrote the food temperature in the food temperature log by herself. DC stated bacteria could get passed to the residents when she did not change her gloves after opening the can, turning the oven knob, and cracking the eggs. During the same interview on 2/25/2026, at 10:42 AM with DC, DC stated her apron was dirty and should not have touched the residents' plates. DC stated bacteria on her apron could get on the plate and contaminate the residents' food. DC stated the inside or top of the plate should not be touched because it can contaminate the plate. DC stated plates should only be touched on the side or edge of the plate. DC stated contaminated plates and food could cause the residents to get sick and end up in the hospital. During an interview on 2/25/2026, at 1:20 PM, with the Registered Dietician (RD), RD stated it was not acceptable for DC's apron to touch the food or the plate. RD stated the apron touching the plate could cause bacteria to end up on the food and to the residents which could cause and spread a gastrointestinal (GI- stomach and intestines) infection. RD stated DC should have changed her gloves after touching the pen and before checking the temperature of the food. RD stated DC should have asked for assistance and the process of checking the temperature of the food should have been performed by two kitchen staff: one staff to check the temperature and the other staff to write the temperature in the log. RD also stated DC should not have had the pen in the same hand as the thermometer when she checked the temperature of the oatmeal because it was dirty and could fall into the pot. RD stated not changing gloves after opening the can of evaporated milk, touching the oven knob, and cracking the eggs ran the risk of cross contamination (the process by with bacteria are unintentionally transferred from one substance or object to another with harmful effect). During the same interview on 2/25/2026, at 1:20 PM with RD, RD stated plates should only be touched on the bottom or the edge and not on the inside or center. RD stated food items in the kitchen should be labeled and dated. RD stated it was important for food items to be labeled to know what the items were and to prevent residents from ingesting inappropriate food or foods they were allergic to. RD stated it was important to write the used by date on the food to know the expiration date of the food. RD stated the red bucket found in the bottom shelf next to the potatoes contained sanitizer and the green cleaning bucket contained soap and water. RD stated buckets containing chemicals used for cleaning should be placed away from food items to prevent splashes and contamination. RD stated she was not sure what the policy was for storing the opened frozen chicken dumpling in the freezer but stated the bag should not have been tied with a clear plastic wrap and placed back in the freezer. RD stated best practice for storing open food items in the freezer was to place the opened bag in a sealed bag to prevent frostbite or spoilage which could cause GI upset. RD stated OV 1 should have been cleaned after use to prevent malfunction and grease built up. During an interview on 2/26/2026, at 9:03 AM, with DS, DS stated DC should have checked to see if her apron was loose to prevent it from touching the plates during tray line assembly. DS stated contaminated food and plates could cause residents to get sick and end up in the hospital. DS stated kitchen staff should not wait until the weekly deep cleaning to clean the oven. DS stated the ovens in the kitchen should be cleaned every day and as soon as something was spilled during use. DS stated OV 1 should have been cleaned right after it got dirty. DS stated it was important to always keep kitchen equipment clean and sanitized to prevent contamination and to be able to continue cooking. During a review of the facility's policy and procedure (P&P), titled, Food Receiving and Storage, revised 11/2022, the P&P indicated the following:Foods shall be received and stored in a manner that complies with safe food handling practices.All food stored in the refrigerator or freezer are covered, labeled, and dated ( use by date).Wrappers of frozen foods must stay intact until thawing.Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. During a review of the facility's P&P, titled, Sanitization, revised 11/2022, the P&P indicated the following:The food service area is maintained in a clean and sanitary manner.All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use of proper cleaning. Seals, hinges and fasteners are kept in good repair.All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. During a review of the facility's P&P, titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised 11/2022, the P&P indicated the following:Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.Employees must wash their hands:before coming in contact with any food surfaces;after handling raw meat, poultry or fish and when switching between working with ray food and working with ready-to-eat food;after handling soiled equipment of utensils;during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/orafter engaging in other activities that contaminate the handsGloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed and gloves replaced: between handling ray meats and ready-to-eat foods

Based on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home-like environment for three (3) of four (4) sampled residents (Resident 15, 29 and 37) reviewed for environment by failing to ensure: 1.a. Resident 15's room was free of soiled diaper and a used cup containing chocolate on the floor.1.b. Resident 15's electric fan was free of sticky gunk (any thick, sticky, greasy, or slimy substance, often representing unwanted, dirty, or unidentifiable residue). 2. Resident 29's floor was free of used wet wipes. 3. Resident 37's curtain was free of brownish colored stains. These deficient practices caused an unsanitary environment for Resident 15, 29 and 37 and had the potential to result in the spread of diseases and infection.Findings: 1. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), depression (severe feelings on sadness and hopelessness), and hypertension (high blood pressure). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 2/9/2026, the MDS indicated Resident 15's cognitive skills (processes of thinking and reasoning) for daily decision making was moderately impaired skills for daily decision making were moderately impaired. The MDS indicated Resident 15 was dependent (helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) on lower body dressing (the ability to dress and undress below the waist), personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). During observation on 2/23/2026 at 9:35 AM at Resident 15's room, a used diaper was observed on the floor under the head of Resident 15's head of bed, and a cup containing chocolate was also observed on the floor. In addition, the electric stand fan in Resident 15's room had sticky gunk at the bottom part and base of the electric stand fan. 2. During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was initially admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus, hypertension, dependence on renal dialysis ( a life-sustaining, long-term requirement for individuals with end-stage renal disease [ESRD, kidneys no longer function well enough to sustain life ] or severe acute kidney failure, as their kidneys can no longer filter waste or excess fluid). During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29's cognitive skills for daily decision making was moderately impaired skills for daily decision making were moderately impaired. The MDS indicated that Resident 29 was partial/moderate assistance (helper does less than half the effort. helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on oral hygiene, upper body dressing, personal hygiene, lying to sitting on side of bed (the ability to move from lying on the back to sitting on the side of the bed and with no back support), and chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). During a review of Resident 29's care plan, date initiated 2/3/2026, the care plan indicated Resident 29 was at risk for fall with injury related to limited mobility, fracture, and a history of falls. The care plan also indicated that the residents require a safe environment with even floors free from spills and/or clutter and adequate, glare-free light. During observation on 2/25/2026 at 6:01 AM in Resident 29's room, two (2) used disposable perineal wipes were on the floor. The perineal wipes appeared crumpled and partially soiled with brown-colored residue. During an interview on 2/25/2026 at 1:21 PM with the Director of Staff and Development (DSD), the DSD stated that a used diaper, a cup containing chocolate, used perineal wipe left on the floor, and electric fan with sticky gunk were not acceptable. The DSD also stated that the residents' room should be free of clutter and should be maintained in a clean condition. During a concurrent interview and record review on 2/25/2026 at 1:25 PM with the DSD, the facility's Policy and Procedures (P&P) titled Cleaning and Disinfection of Environmental Surfaces, revised date 8/2019, was reviewed. The DSD stated the P&P indicated that the environmental surfaces will be disinfected or cleaned on a regular basis when surfaces are visibly soiled. The DSD also stated the P&P indicated that walls, blinds, and window curtains in the resident areas will be cleaned when these surfaces are visibly contaminated or soiled. The DSD stated that the presence of odor and dirt does not promote healthy environment for residents' wellbeing. The DSD also stated that the facility's P&P was not followed. During an interview on 2/26/2026 at 9:33 AM with the House Keeping (HK 1), HK 1 stated that the surfaces and the floors should be cleaned and disinfected every day. HK1 also stated that residents should be provided with a safe, clean and comfortable environment. 3. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 37's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [are brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms, including involuntary movements, loss of consciousness, and changes in behavior]), major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and dementia (a progressive state of decline in mental abilities) During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool) dated 1/9/2026, the MDS indicated Resident 37 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 37 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer. During an observation on 2/23/2026 at 3:58 PM inside Resident 37'S room, CNA 7 was changing Resident 37's briefs. Resident 37's curtain had a brownish colored stain. CNA 7 stated Resident 37's curtain was dirty from Resident 37's hands. Resident 37 grabs and pulls the curtain when they were changing her. Resident 37 was on left side lying position when observed trying to reach and grab the curtains while being changed. During an interview on 2/24/2026 at 3:29 PM with CNA 7, CNA 7 stated Resident 37's curtain had food stains, it was the brown colored stains. Resident 37 kept on grabbing and pulling the curtains. CNA 7 stated they need to keep Resident 37's environment clean because of infection control. During an interview on 2/24/2026 at 3:53 PM with LVN 1, LVN 1 stated they need to keep the Resident's room or environment clean, to prevent spread of germs and infection. During an interview on 2/26/2026 at 2:08 PM with Director of Staff Development (DSD), DSD stated we need to keep the environment clean for the residents, to make sure residents will not get sick and for infection control. During a review of the facility's Policy and Procedure (P&P) titled, Homelike Environment, revised 2/2021, the P&P indicated residents are provided with a safe clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment

Based on observation, interview, and record review, the facility failed to inform one (1) of 22 sampled residents (Resident 86) the risks and benefits of the use of bilateral bedside rails (a metal or plastic bars attached to the sides of the bed) in accordance with the facility's policy. This deficient practice had the potential for Resident 86 not to be able to exercise their right to choose his treatment plan.Findings: During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included epilepsy (brain activity that cause sudden uncontrollable electrical disturbance in the brain and sometimes loss of awareness), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a medical condition that occurs when brain tissue dies due to a lack of blood flow and oxygen). During a review of Resident 86's Minimum Data Set (MDS- a resident assessment tool), dated 11/25/2025, the MDS indicated Resident 86 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 86 was dependent (helper does all the effort) on showering and required substantial/maximal assistance (helper does more than half the effort) with toileting and personal hygiene, lower body dressing and with putting on/taking off footwear. The MDS further indicated Resident 86 required partial/moderate assistance (helper does less than half the effort) with upper body dressing and required setup assistance with eating and oral hygiene. During an observation on 2/23/2026 at 8:12 AM, Resident 86 was in bed with bilateral middle section of the bedside rails up. Resident 86 refused to answer any questions asked. During a concurrent interview and record review on 2/24/2026 at 4:31 PM, Registered Nurse 1 (RN 1) stated Resident 86 did not have an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for bilateral bedside rails use. RN 1 also stated an informed consent should have been obtained prior to use of bedside rails to ensure Resident 86 understood the risk and benefits of its use. During a concurrent interview and record review on 2/26/2026 at 10:33 AM, the MDS Coordinator stated Resident 86 a consent prior to use of the bedside rail because the resident should be informed of the risk and benefits of its use. MDS Coordinator stated this includes the potential risk for entrapment (a dangerous situation where a resident gets stuck in the gaps between the mattress, bed frame, or side rails) During an interview on 2/26/2026 at 11:11 AM, the Director of Nursing (DON) stated Resident 86 did not have an informed consent for the use of bedside rails. The DON also stated a consent should have been obtained before initiating side rails so that Resident 86 was aware of the risk involved. During a review of the facility's Policy and Procedure (P&P) titled, Bed Safety and Bed Rails, revised 8/2022, the P&P indicated that before using bed rails for any reason, the staff shall inform the resident or resident representative about the benefits and potential hazards associated with bed rails and obtain informed consent. During a review of the facility's P&P titled, Resident Rights, revised 2/2021, the P&P indicated that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to be informed of, and participate in, his or her care, planning and treatment.

Based on interview and record review, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR, initial screening for all applicants to Medicaid-certified nursing facilities [meets federal and state standards for care and is approved to receive payment from Medicaid {a government health insurance program that provides free or low-cost coverage to eligible low-income individuals and families} for services provided to eligible residents] for possible serious mental disorder [MD, a health condition characterized by clinically significant alterations in thinking, mood, or behavior associated with distress and/or impaired functioning], intellectual disability [ID, a condition characterized by significantly subaverage intellectual functioning and substantial limitations in adaptive behavior] or a related condition, which is completed prior to admission to a nursing facility) was completed and was accurate for two (2) of six (6) sampled residents (Resident 71 and 81) reviewed for PASARR, in accordance with the facility's policy. This deficient practice had the potential to result in inappropriate placement of Resident 71 and 81 and had the potential for not receiving the necessary and appropriate level of treatment and evaluation in the facility.Findings: 1. During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 71's diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychosis (a mental disorder characterized by a disconnection from reality), and dementia (a progressive state of decline in mental abilities) During a review of Resident 71's Minimum Data Set (MDS, a resident assessment tool), dated 2/17/2026, the MDS indicated Resident 71 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 71 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) toileting hygiene, shower/ bathe, sit-to stand, self, upper and lower body dressing, putting on/taking off footwear, sit to lying, and sit-to stand. During a review of Resident 71's PASARR dated, 1/13/2026, the PASARR indicated Level I was negative for serious mental illness. The PASARR indicated Resident 71 was not diagnosed with serious mental illness and was not taking any psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications. During a review of Resident 71's Physician's Order (PO) Summary, dated 2/24/2026, the PO Summary indicated Resident 71 was prescribed: 1. On 1/14/2026, Duloxetine (Cymbalta, used to treat depression and anxiety [is a feeling of fear, dread, and uneasiness]) 60 milligrams (MG, unit of mass) by mouth one time a day for depression manifested by (m/b) expressing feelings of sadness. 2. On 1/30/2026, Olanzapine (Zyprexa, is an antipsychotic that can treat schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) 2.5MG by mouth as needed for psychosis at bedtime m/b refusing care and agitation. During a concurrent interview and record review on 2/25/2026 at 2:15 PM with the Director of Nursing (DON), the PASRR dated 1/13/2026 was reviewed. The DON stated PASARR indicated Resident 71 was not diagnosed with serious mental illness and was not taking any psychotropic medications. The DON stated the PASARR was completed at the General Acute Hospital (GACH). The DON stated Resident 71's PASARR was incorrectly filled out because it should have indicated that Resident 71 had a diagnoses of psychosis, dementia, and depression. The DON stated Resident 71 was also taking Olanzapine and Duloxetine at the GACH and were continued at the facility. During an interview on 2/25/2026 at 2:18 PM with the DON, DON stated it was important to have an accurate PASARR to ensure Resident 71 was placed in the right facility and be provided with the appropriate care. 2. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and unspecified psychosis. During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81 had intact cognitive skills for daily decision making. The MDS also indicated Resident 81 was dependent with putting on/taking off footwear and required substantial/maximal assistance (helper does more than half the effort) with toileting and personal hygiene, shower, upper and lower body dressing. The MDS further indicated Resident 81 required setup assistance (helper sets up; resident completes activity) with eating and oral hygiene. During a review of Resident 81's Medical Records, Residents 81's medical records indicated a negative PASARR 1 screening on 2/3/2021 despite diagnosis of mental illness. Residents 81's PASSAR 1 screening sections were not filled out completely, which included an assessment of mental illness (refers to a serious mental illness that cause significant functional limitations that warrants a deeper Level II [a comprehensive evaluation conducted by the appropriate state-designated authority that determines whether an individual has MD, ID or a related condition as defined above, determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs]) evaluation before nursing facility During a concurrent interview and record review on 2/25/2026 at 3:40 PM, the Director of Nursing (DON) stated Resident 81 had an incomplete and inaccurate PASSAR level 1 screening because the PASARR did not reflect the resident's psychiatric diagnoses. The DON also stated the facility should have reviewed the PASSAR level 1 screening from General Acute Care Hospital (GACH) for completeness and accuracy. The DON further stated Resident 81 should have been re-screened for PASSAR level 1 upon admission to ensure the screening was accurate and Resident 81 was appropriately placed in a proper environmental setting. During a review of the facility's Policy and Procedure (P&P) titled, admission Criteria, revised 3/2019, the P&P indicated that all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The P&P also stated that the facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. &P further indicated that if the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level IE (evaluation and determination) screening process.

Based on observation, interview, and record review, the facility staff failed to keep one (1) of six (6) sampled residents (Resident 37) reviewed for Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) face and blanket clean and free of food particles on 2/26/2026, as indicated on the facility's dignity policy. This deficient practice had the potential to result in a negative effect on Resident 37's quality of life and self-esteem.Findings:During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 37's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [are brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms, including involuntary movements, loss of consciousness, and changes in behavior]), major depressive disorder (or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and dementia (a progressive state of decline in mental abilities) During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool) dated 1/9/2026, the MDS indicated Resident 37 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 37 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, sit to stand and chair/ bed-to-chair transfer. During a concurrent observation and interview on 2/26/2026 at 8:44 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 37 was sitting on her bed with breakfast tray in front of her. Resident 37 had a white liquid coming out of her mouth and running down her chin, and there was white cream-like substance on her blanket and on the towel placed on her chest. Certified Nurse Assistant 8 (CNA 8) entered the room and took out Resident 37's breakfast tray. LVN 1 looked at Resident 37 and stated Resident 37 was dirty and that she would call CNA 8 to clean Resident 37. During a concurrent observation and interview on 2/26/2026 at 8:50 AM with CNA 8, inside Resident 37's room, CNA 8 stated it was not acceptable for Resident 37 to have food coming out of her mouth, running down her chin, or to have food debris on her blanket because it affects her dignity. CNA 8 also stated they should always keep Resident 37 clean. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out AOLs independently, with the consent of the residents and in accordance with the plan of care, including appropriate support and assistance with:a. hygiene (bathing, dressing, grooming, and oral care)

Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraints (any device attached or adjacent to the body that cannot be easily removed and restricts freedom of movement) for one of two sampled residents (Resident 1). Certified Nursing Assistant (CNA) 1 tied Resident 1 with a bed sheet by the waist and around the wheelchair with a knot tied at the back to prevent the resident from sliding off the wheelchair and falling on 2/16/22 during the 3 p.m. to 11 p.m. shift. CNA 2 tied Resident 1 with a bedsheet around the resident ' s lap to prevent the resident from falling and another bed sheet tied around the wheels of Resident 1 ' s wheelchair to prevent the wheelchair from moving, on 2/16/22, during the 11 p.m. to 7 a.m. shift. This deficient practice resulted in Resident 1 ' s rights being violated, and Resident 1 being abused and held against her will and had the potential to result in psychological distress and accidents that may result to physical injury, hospitalization and/or death. Findings: On 2/23/22 at 4:07 p.m., an Immediate Jeopardy (IJ, a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility ' s administrator (ADM), regarding the facility ' s failure to ensure Resident 1 were free from physical restraints and other 69 residents who had the potential for the same deficient practice. On 2/24/22 at 4:21 p.m., the IJ was removed after the ADM submitted an acceptable IJ Removal Plan (Removal Plan, interventions to remove the immediacy and correct the deficient practices). The surveyor verified and confirmed the implementation of the IJ Removal Plan while onsite, through observation, interview, and record review. The IJ was removed in the presence of the ADM. The accepted IJ Removal Plan included the following: 1. In service was provided to licensed and unlicensed nursing staff, including facility administration on abuse, use of restraints, timely reporting and investigation by Clinical Resource on 2/23/2022 and ongoing until all facility staff have been in serviced completed by 02/26/22. Additional training will be upon hire and twice annually and as needed. 3. ADM met with responsible party for resident 1 on 02/23/2022 to discuss findings of investigation. - 4. The Interdisciplinary Team (IDT- a health care team made up of professionals from different disciplines to provide therapeutic approach to problems and matters) was scheduled for a care plan conference with Resident 1 ' s responsible party on 02/24/2022 to discuss interventions for fall prevention. 5. ADM conducted rounds with all the facility ' s residents and did not observe any other residents who were affected by this deficient practice on 2/24/22. 6. ADM conducted in-service on 2/17/22 regarding the unsafe practice of unapproved use of restraints and bed sheet or any device as a restraint to facility staff. 7. Licensed nurses to visually monitor and document each resident ' s response to interventions intended to reduce falling or the risk of falling using resident identifiers to include in the facility ' s Falling Leaf Program. If the resident continues to fall despite alternatives interventions, the licensed nurse will assess residents who may require an alarm for safety starting, 2/23/22and ongoing to identify any residents who have the potential for falls and/or injury. If any residents are identified, licensed nurses must contact the Director of Nursing (DON) designee and ADM prior to making changes to the resident ' s plan of care. IDT meeting to be scheduled to reassess current interventions and possible alternatives. 8. DON designee to provide guidance to licensed nurses in the notification of the treating physician for further order for tab alarm, bed alarm, or wheelchair alarm, as needed. 9. DON designee and RN supervisor to oversee licensed nurses and CNAs by conducting daily visual monitoring. 10. All facility staff will be provided dementia in-service and cognitive decline by 2/27/22. 11. Administrator, director of staff development and department heads to provide oversight through frequent visual rounding of each resident, each shift and provide written room round report in daily stand-up meeting. Any irregular findings will be added to the facility ' s monthly Quality Assurance and Performance Improvement (QAPI- a quality improvement program composed by the IDT dealing with the full range of services offered by the facility) for monitoring and follow up and as needed. A review of Resident 1's face sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s History and Physical (H&P) dated 1/22/22, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's care plan, titled Potential for fall/injury dated 1/24/22, indicated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan interventions included for nursing to administer medication as ordered, ensure resident uses non-skid shoes or socks while ambulating (walking), and handle the resident gently during care or transfers. The care plan interventions also included keeping the resident ' s bed at the lowest level, observe for possible side effects from medications, orient the resident to the use of call lights-keep call light within reach, and for nursing staff to answer call light promptly and to provide prompt toileting assistance and care, verbal cues, and reminders for safety. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 1/31/22 indicated the resident was severely impaired with cognitive (thought process) skills for daily decision-making. The MDS indicated Resident 1 was assessed requiring one-person extensive (resident involved in activity; staff provide guided weight bearing support) physical assistance for transfers, walking, dressing, eating, toilet use and personal hygiene. The MDS did not indicate the resident was assessed or required physical restraints during the assessment and observation period of the MDS. A review of the facility ' s report of Suspected Dependent Adult/Elder Abuse form sent by the facility to the Department of Public Health on 2/17/2022, indicated On 2/16/22, administrator conducting rounds and observed Resident 1 with sheet secured around her waist to prevent her from slipping from her chair. Administrator and charge nurse removed sheet, charge nurse assessed Resident 1, with no injury noted and assisted patient (Resident 1) to bed. Administrator came to facility (next day) on 11 p.m. to 7 a.m. shift, at 6:30 AM, to in-service staff on unsafe practices, and observed Resident 1 sitting quietly in her doorway with sheet around her waist to support her from slipping from her chair. Charge nurse notified for assessment, no injury or anxiety noted, client (Resident 1) asked for assistance to go back to bed. Administrator asked (facility staff) who was placing this on the patient (Resident 1), and Registry CNA (CNA 2) was noted to have placed for support. Registry (CNA 2) was asked to clock out, text message was sent to Registry company. Patient (Resident 1) remains safe and secure, without any further incidents. A review of a handwritten statement by CNA 1 dated 2/16/22, indicated CNA 1 received Resident 1 free from restraints at the beginning of her shift (3 p.m. to 11 p.m. shift). The handwritten statement indicated CNA 1 did not observe Resident 1 restrained to her wheelchair. The handwritten statement indicated Licensed Vocational Nurse (LVN) 1 notified CNA 1 at 5 p.m that Resident 1 had been restrained with a bed sheet tied in a knot around her back. A review of a handwritten statement by LVN 2 dated 2/17/22, indicated LVN 2 informed CNA 2 of Resident 1 ' s behavior of getting out of bed unassisted and instructed CNA 2 to keep a close watch on her. The handwritten statement indicated LVN 2 had seen Resident 1 multiple times awake that night free from restraints and sitting calmly on her wheelchair. The handwritten statement indicated that at 6:30 am ADM informed LVN 2 that Resident 1 was observed restrained to her wheelchair with a bedsheet tied around her lap and another bed sheet tied around the wheels of Resident 1 ' s wheelchair to prevent the wheelchair from moving. A review of a handwritten statement by CNA 2 dated 2/18/22, indicated CNA 2 worked during the nightshift (11 p.m. to 7 a.m.) of 2/16/22 at the same Nursing Station with LVN 2. The handwritten statement indicated CNA 2 observed Resident 1 wandering around the rooms almost falling. The handwritten statement indicated CNA 2 was alone taking care of 15 residents. The handwritten statement indicated CNA 2 stated he tied a bed sheet to Resident 1 as a form of lap belt (a seat belt worn across the lap) to prevent Resident 1 from falling. During an interview, on 2/23/22 at 11:40 a.m., the ADM stated she first observed Resident 1 tied to her wheelchair on 2/16/22, around 6:30 p.m., (3 p.m. to 11 p.m. shift) while she was rounding the facility. The ADM stated she informed LVN 1 that Resident 1 was restrained to her wheelchair and asked LVN 1 to remove the restraint and asses the resident. ADM stated she left the facility for the evening (2/16/22) and did not report the incident to anyone else other than LVN 1 or investigate immediately about the incident, on 2/16/22. ADM stated she came back to the facility the next day, on 2/17/22 at 6:30 a.m. (11 p.m. to 7 a.m. shift of 2/16/22) to conduct an in-service with the night shift staff. ADM stated she observed Resident 1 sitting on her wheelchair restrained with a bed sheet for the second time. The administrator stated CNA 1 and CNA 2 had been terminated (end employment from the facility). During an observation on 2/23/22 at 12:10 p.m. Resident 1 was observed in her room sitting on her wheelchair awake and calm during a visitation with a family member (Family 1). During an interview on 2/23/22 at 12:10 p.m. with Family 1, Family 1 stated Resident 1 tends to wander while on her wheelchair and needs to be monitored constantly. Family 1 stated the facility staff informed her they were short on staff the day (2/16/22) the ADM observed Resident 1 sitting on her wheelchair with a bedsheet tied around her waist. During an interview with Resident 1 on 2/23/22 at 12:20 p.m., Resident 1 did not respond directly to questioning when asked to recall being tied up in the wheelchair. During an interview and concurrent record review of Resident 1 ' s physician orders, on 2/23/22 at 12:24 p.m. with LVN 3, LVN 3 stated there was no documented evidence that Resident 1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview, on 2/23/21 at 2:05 p.m. with LVN 1, LVN 1 stated on 2/16/22 the ADM stated she was notified by LVN 1 that Resident 1 was found restrained to her wheelchair. LVN 1 went to Resident 1 ' s room and observed Resident 1 sitting on her wheelchair with a flat bed sheet tied around the waist and around the wheelchair with a knot at the back. LVN 1 stated she informed CNA 1 that restraining a resident was not allowed in the facility. LVN 1 stated that CNA 1 responded and stated Resident 1 slides from her wheelchair and was worried Resident 1 would fall. During a telephone interview, on 2/24/22 at 10:00 a.m., LVN 2 stated LVN 1 did not endorse or informed him that Resident 1 was observed with a bedsheet tied around the wheelchair, on 2/16/22. LVN 2 stated he was not informed the need to monitor Resident 1 for psychological distress from being restrained that night of 2/16/22. LVN 2 stated that on 2/16/22, he verbally instructed CNA 2 at the beginning of the 11 p.m. to 7 a.m. shift, to keep visual observation of Resident 1 because Resident 1 had an unsteady gait and a high fall risk. During an interview with the DON designee on 2/24/22 at 12:50 p.m., the DON designee stated the use of physical restraints was not a facility practice. The DON designee stated that licensed nurses should always assess the residents for behavior and should try to figure out the cause of the behavior. The DON stated the licensed nurses should try to figure out if the resident needed one-to-one monitoring and should not restrain the resident. The DON stated he was not aware of Resident 1 being restrained until 2/17/22, when he arrived at the facility. A review of the facility's policy and procedure titled, Use of Restraints, revised in April 2017, indicated restraints shall only be used to treat the resident's medical symptoms (s) and never for discipline or staff convenience, or for the prevention of falls.

Based on observation, interview, and record review the facility failed to ensure 69 (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, and 69) out of 75 residents residing in the facility were free from neglect, when residents were not given their scheduled medications as prescribed by their physician and in accordance with residents' plan of care, and the facility's policy and procedure for the months of January and February 2022. After investigation, it was determined that the facility had failed to provide oversight of the licensed nurses' administration of scheduled medications to multiple residents in the facility, resulting in neglect and the potential to cause adverse reactions, health complications from missing required medications, hospitalization s, and death. Cross referenced to F760. Findings: On 2/10/2022 at 7:50 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's administrator (ADM), regarding the facility's failure to administer scheduled medications as ordered by the physician to multiple residents in the facility. On 2/13/2022 at 5:08 PM the IJ was removed after the ADM submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the IJ Removal Plan while onsite through observation, interview, and record review. The IJ was removed in the presence of the ADM. The acceptable IJ Removal Plan included the following actions: 1. All residents that were identified as having missed medications will be assessed and monitored for adverse reactions. 2. Notification to physician, family and/or representative has been completed regarding missed medication administration on 02/12/2022. 3. Physician, family and/or representative have been called regarding missed medication administration, with follow up documentation in the progress note completed on 02/12/2022. Written notification to be either hand delivered to self-responsible patient or mailed to the responsible party on 2/14/2022. 4. Requested Pharmacy Nurse consultant to in-service all licensed nurses on the importance of proper medication administration and management, medication preparation and infection control dated 02/08/2022. Pharmacy Nurse consultant to conduct frequent audits and in-services to ensure all licensed staff have received proper training, on-going. 6. January and February Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Verbal notification to the physician, family and or responsible party regarding missed medication administration had been completed as of 02/12/2022. The residents identified will be assessed and monitored for adverse reaction. A letter had been created to notify patients and responsible party of the missed medication administration. 7. RN supervisor/Designee to provide e-MAR/resident oversight prior to the end of each shift to ensure completion of medication pass and documentation prior to end of shift for all licensed nurses. 8. Each outgoing licensed nurse to assess and provide care for and will endorse a complete (green) e-MAR for all residents assigned with the oncoming nurse. Oncoming licensed nurse to validate completion of the outgoing licensed nurse e-MAR. To ensure no missed documentation on e-MAR, all residents should be in color (Green). Any resident in color (RED) would be corrected immediately. 9. Medical Records/ designee to audit daily compliance of e-MAR completion. Any non-compliant issues shall be brought to the Administrator/designee. 10. RN MDS Coordinator (Interim DON) will provide clinical oversight for the facility to ensure compliance 7 days a week either in person or by phone with communication and collaboration with clinical resource and/or Medical Director as needed. RN MDS/Interim DON will provide oversight to residents to ensure that all required nursing services are provided such as medication administration, dietary needs, and other physician orders. RN Clinical Resource will be in the facility 2 to 3 times a week to provide guidance and support. 11. Medical Director to provide in-services to licensed staff regarding the importance of medication administration and adverse effects of missed medications starting 02/13/2022, ongoing, until all licensed nurses have been in-serviced. Medical Director to provide assistance to RN MDS/Interim DON as needed. Medical Director to meet monthly to go over any discrepancy at the monthly Quality Assurance and Performance Improvement (QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) or as needed. Medical Director to be informed of any missed medication or medication error for further guidance. 12. Administrator reviewed daily staffing for each shift on 2/11/2022. Administrator identified opening in staffing needs for the next 10 days. The DSD to assist with the daily scheduling as of 02/13/2022. Administrator and DSD to oversee the facility need for staffing. Administrator and DSD to utilize Nursing Registry as needed and ongoing to ensure staffing requirements are met. 13. Administrator/DSD to ensure the necessary staff are scheduled in the COVID unit (Red Zone) to provide services and oversight to meet the needs of each resident. Licensed nurses are scheduled throughout the month of February for both 7 AM to 7 PM, and 7 PM to 7 AM shifts. These shifts will be covered by Facility Licensed nurses. If there is a gap in the days, Administrator and DSD to secure Nursing Registry to staff appropriately. Licensed nurses are responsible for medication administration and documentation and assessing residents every 2 hours for any possible change of condition. 14. For staff call outs, the employee will contact the facility for notification then call either Administrator, RN MDS, and/or DSD to inform them of their call off. RN MDS and/or DSD to initiate search for replacement by asking current staff working to work a double, and call staff who are off that day to cover that shift. Nursing Registry will also be called as needed. 15, If no staff is available to cover a shift, the RN Supervisor, and/or LVN Charge nurse will look into the distribution of assignments to ensure all care and services were provided for that shift. This includes medication pass for licensed nurses. 16. In-service to be provided by DSD starting 02/13/2022 and until all licensed nurses have in-serviced. In-service for licensed nurses to educate them regarding call offs and re-assignment of available staff. 17. If outgoing licensed nurse leaves the facility and not replaced, DSD, IP Nurse, RN supervisor or any licensed nurse should cover the resident assignments appropriately and document the distribution of the resident assignments on the Staffing Assignment Sheets and indicate who was reassigned and responsible to cover that shift. 18. Facility to schedule in-house Licensed Nurses for the facility's Red Zone whenever possible. Nursing Registry to only be used as a backup for the Red Zone. 19. DSD created a specific Staffing Assignment Sheet titled CNA Assignments for the Red Zone on 02/13/2022. This assignment sheet includes the name of the licensed nurse, charge nurse for that shift and the bed numbers that the charge nurse and CNA are assigned to. A review of the list provided by the facility to the Department of Public Health included in the facility's January and February 2022 Medication Administration audit indicated 63 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, and 63) were found to be affected by the deficient practice (missed medications administrations). During an interview, on 2/10/2022 at 4:25 pm, LVN 1 stated the facility was short staffed. LVN 1 stated there were no licensed nurses assigned in Nursing Station Center 1 and the resident's rooms in the 20's to pass medications on 1/31/2022 and 2/7/2022 during the 7 am to 3 pm shift. LVN 1 stated that on these dates (1/31/2022 and 2/7/2022) LVN 1 was at the facility and passed (administered) medications for his assigned areas in the resident rooms located in the room [ROOM NUMBER]'s. LVN 1 stated that LVN noticed that there was no licensed nurse to pass medication for Nursing Station Center 1 and the Resident's room [ROOM NUMBER]'s. LVN 1 stated the ADM and the DSD knew there were no licensed nurses to cover certain shifts based on the staffing schedule. LVN 1 stated that the DSD would ask licensed nurses scheduled to work in the Red Zone, to pass meds in the Green Zone before going to the Red Zone. During a concurrent interview and record review of the facility's electronic medication administration records (e-MAR) with LVN 1, on 2/10/2022 at 6:05 pm, LVN 1 stated there were a number of medications not administered for several residents in the facility. LVN 1 stated, when the resident's profile showed pink in color in the e-MAR, it meant medications were not administered or signed out for that specific resident. During the continued review of random residents' e-MAR, LVN 1 showed the e-MAR profile of those residents in the facility that did not receive their scheduled medications on 1/24/22; 1/31/22; 2/5/22; 2/7/22; 2/9/22; and 2/10/22. The following information were noted during a review of the facility's e-MAR: 1. On 1/24/2022 (Monday), nine residents (Residents 3, 4, 8, 12, 30, 31, 35, 52, 63) did not receive scheduled medications during the morning shift (7 am to 3 pm). 2. On 1/31/2022 (Monday), 28 residents (Residents 3, 4, 5, 8, 10, 12, 16, 18, 20, 21, 22, 28, 30, 31, 35, 38, 42, 48, 49, 52, 56, 62, 63, 64, 65, 66, 67, 68) did not receive scheduled medications during the morning shift. 3. On 2/5/2022 (Saturday), eight residents (Residents 17, 24, 34, 39, 57, 58, 60, 69) did not receive scheduled medications during the morning shift. 4. On 2/7/2022 (Monday), 28 residents (Residents 3, 4, 5, 8, 9, 12, 16, 18, 20, 21, 22, 24, 25, 28, 30, 31, 38, 39, 42, 43, 48, 49, 50, 52, 58, 56, 64, 66) did not receive scheduled medications during the morning shift (7 am to 3 pm). On the same date, 2/7/2022, eight residents did not receive scheduled medications during the afternoon shift (3 pm to 11 pm). 5. On 2/10/2022 (Thursday), three residents (Residents 24, 43, 50) did not receive their scheduled medications during the morning shift. A review of residents' Medication Administration Records indicated the following information: 1. A review of Resident 60's Admission Record indicated the facility admitted the resident on 5/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 60's Minimum Data Set (MDS) care area assessment tool dated 2/4/2022, indicated the resident's cognition was intact. The MDS indicated Resident 60 was able to understand others and be understood. A review of the facility's resident census indicated Resident 60 was residing in the facility's Red Zone from 2/2/2022 to 2/14/2022. A review of Resident 60's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/10/2022 and 2/7/2022 at 5 pm, [MEDICATION(S)] (HCL) (antidepressant and nerve pain medication) 30 milligram (mg) one capsule by mouth two times a day. b. On 2/7/2022 and 2/10/2022 at 5 pm, [MEDICATION(S)] (anti-diabetic medication to control blood sugar levels) HCL 500 mg 1 tablet by mouth two times a day. c. On 2/7/2022 and 2/10/2022 at 5 pm, Vitamin C (supplements) tablet 500 mg by mouth two times a day. d. On 2/5/2022 at 1 pm, 2/7/2022 at 5 pm, and 2/10/2022 at 5 pm, [MEDICATION(S)] capsule (anti-convulsant and nerve pain medication to control [CONDITION(S)] activity) 300 mg 5 capsule by mouth 3 times a day. e. On 2/5/2022 at 12 pm, 2/7/2022 at 6 pm, and 2/10/2022 at 6 pm, ropinrole (medication used to treat symptoms of restless leg syndrome) HCL tablet 4 mg by mouth 3 times a day. f. On 2/5/2022 at 12 pm, and 2/7/2022 at 6 pm, [MEDICATION(S)] Aerosol Solution (inhalation medication to prevent bronchospasm [chest feels tight, and hard to catch breath] and shortness of breath), 2 inhalations every 6 hours for COVID-19 infection for 6 days. e. On 2/1/2022, [MEDICATION(S)] (antibiotic) tablet 500 mg, 1 tablet by mouth one time only. A review of Resident 60's Progress Notes indicated no documented evidence that the attending physician was notified of the missing medication administrations for 2/1/2022, 2/5/2022, 2/7/2022, and 2/10/2022. 2. A review of Resident 39's Admission Record indicated the facility admitted the resident on 1/21/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 39's MDS, dated [DATE] indicated the resident's cognition was intact. The MDS indicated Resident 39 was able to understand others and be understood. A review of the facility's resident census indicated Resident 39 was residing in the facility's Red Zone from 2/3/2022 to 2/10/2022. A review of Resident 39's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/7/2022 and 2/10/2022 at 5pm, [MEDICATION(S)] (used to relieve nerve pain) 300 mg one capsule by mouth two times a day. b. On 2/7/2022 and 2/10/2022 at 5 pm, [MEDICATION(S)] (blood thinners for history of blood clots/prevent blood clot formation) 150 mg one capsule by mouth two times a day. c. On 2/3/2022, [MEDICATION(S)] (antibiotic) 500 mg, one tablet by mouth. A review of Resident 39's Progress Notes indicated no documented evidence that the attending physician was notified of the missing medication administrations for 2/3/2022, 2/7/2022, and 2/10/2022. 3. A review of Resident 34's Admission Record indicated the facility admitted the resident on 2/28/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 34's MDS dated [DATE], indicated the resident's cognition was severely impaired. The MDS indicated Resident 34 was able to usually understand others and be usually understood. A review of the facility's resident census indicated Resident 34 was residing in the facility's Red Zone from 2/3/2022 to 2/10/2022. A review of Resident 34's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/7/2022 and 2/10/2022, [MEDICATION(S)] (immunosuppressive medication that blocks immune signaling molecules [particles]/medication used to prevent organ rejection for individuals who have had kidney transplant) 50 mg, 0.5 tablet by mouth two times a day. b. On 2/7/2022 and 2/10/2022, [MEDICATION(S)] sodium (stool softener to prevent constipation) 100 mg, one tablet by mouth two times a day for constipation. c. On 2/7/2022 and 2/10/2022, [MEDICATION(S)] (anti-[CONDITION(S)] medication) 250 mg, one tablet by mouth two times a day. d. On 2/7/2022 and 2/10/2022, [MEDICATION(S)] sodium (gastric acid reducing medication) 40 mg, 1 tablet by mouth two times a day. e. On 2/5/2022 at 1 pm, 2/7/2022 and 2/10/2022 at 5 pm, Prostat (nutrition supplement) 30 cubic centimeter (cc), per os (PO), three times a day (TID). A review of Resident 34's Progress Notes indicated no documented evidence that the attending physician was notified of the missing medication administrations for 2/5/2022, 2/7/2022, and 2/10/2022. 4. A review of Resident 50's Admission Record indicated the facility admitted the resident on 11/18/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 50's MDS dated [DATE], indicated the resident's cognition was severely impaired. The MDS indicated Resident 50 was able to sometimes understand others and be sometimes understood. A review of the facility's resident census indicated Resident 50 was residing in the facility's Green Zone in February 2022. A review of Resident 50's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/1/2022 at 9 am and 1 pm, 2/8/2022 at 1 pm, 2/9/2022 at 9 am and 1 pm, 2/10/2022 at 9 am, 1 pm and 5 pm, [MEDICATION(S)] (blood pressure medication to control high blood pressure) HCL Tablet 50 mg, 1 tablet by mouth three times a day. b. On 2/8/2022 at 1 pm, 2/9/2022 at 9 am and 1 pm, 2/10/2022 at 9 am, 1 pm, and 5 pm, [MEDICATION(S)] (antipsychotic medication/treat mental or mood disorder) tablet 100 mg by mouth three times a day. c. On 2/9/2022 and 2/10/2022 at 9 am, Calcium 500 mg with Vitamin D (vitamin supplements) 200 international unit (IU), one tablet by mouth one time a day. d. On 2/9/2022 and 2/10/2022 at 9 am, [MEDICATION(S)] sodium 100 mg Capsule, one capsule by mouth one time a day. e. On 2/9/2022 and 2/10/2022 at 9 am, multivitamin with minerals, one tablet by moth one time a day. f. On 2/9/2022 at 9 am and 2/10/2022 at 9 am and 5 pm, [MEDICATION(S)] Tablet (anti-[CONDITION(S)] medication) Delayed Release 250 mg, 1 tablet by mouth two times. g. On 2/9/2022 at 9 am and 2/10/2022 at 9 am and 5 pm, [MEDICATION(S)] (cognition-enhancing medication for dementia [a group of symptoms that affects memory, thinking and interferes with daily life]) tablet 5 mg, one tablet by mouth two times a day. h. On 2/10/2022 at 9 pm, [MEDICATION(S)] (antiseizure medication) delayed release tablet 750 mg by mouth at bedtime. A review of Resident 50's Progress Notes indicated no documented evidence that the attending physician was notified of the missing medication administrations for 2/1/2022, 2/8/2022, 2/9/2022, and 2/10/2022. 5. A review of Resident 24's Admission Record indicated the facility admitted the resident on 8/3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 24's MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated Resident 24 was able to understand others and be understood. A review of the facility's resident census indicated Resident 24 was residing in the facility's Red Zone from 2/3/2022 to 2/10/2022. A review of Resident 24's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/7/2022 and 2/10/2022 at 5 pm, [MEDICATION(S)] (anti-coagulant/ blood thinner to prevent blood clot formation) tablet 5 mg, 1 tablet by mouth two times a day. b. On 2/7/2022 and 2/10/2022 at 5 pm, Vitamin C Tablet, 500 mg by mouth two times a day. A review of Resident 24's Progress Notes indicated no documented evidence that the attending physician was notified of the missing medication administrations for 2/7/2022 and 2/10/2022. 6. A review of Resident 35's Admission Record indicated the facility admitted the resident on 7/18/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 35's MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated Resident 35 was able to understand others and be understood. A review of the facility's resident census indicated Resident 35 was residing in the facility's Green Zone in February 2022. A review of Resident 35's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 1/8/2022 at 9 pm, [MEDICATION(S)] (sedative for [CONDITION(S)]/difficulty falling asleep) tablet 5 mg, 1 tablet by mouth. b. On 1/8/2022 at 9 pm, [MEDICATION(S)] (supplement that helps induce sleep) tablet, 6 mg by mouth at bedtime. c. On 1/8/2022 at 9 pm, [MEDICATION(S)] (cholesterol medication) tablet 40 mg, 1 tablet by mouth at bedtime. d. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (antibiotic) DS Tablet 800-160 mg, one tablet by mouth two times a day. e. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (heart medication) tablet 12.5 mg, one tablet by mouth two times a day. f. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] sodium (stool softener/prevent constipation) capsule, 100 mg by mouth two times a day. g. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (anti-epileptic medication/control [CONDITION(S)] activity) capsule, 300 mg, one capsule by mouth two times a day. h. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, naproxen (nonsteroidal anti-[CONDITION(S)] drug) tablet 500 mg, one tablet by mouth two times a day. i. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (antiseizure medication) tablet 300 mg, one tablet by mouth two times a day. j. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (eye drop for itching and eye redness due to allergies) solution, instill one drop in both eyes two times a day. k. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (medication to prevent and control seizures) tablet 200 mg, one tablet by mouth two times a day. l. On 1/8/2022 at 5 pm, 1/24/2022 at 1 pm, 1/24/2022 at 1 pm, 1/31/2022 at 9 am and 1 pm, Benadryl Allergy tablet 25 mg, one tablet by mouth three times a day. m. On 1/8/2022 at 5 pm, 1/24/2022 at 1 pm, and 1/31/2022 at 9 am and 1 pm, [MEDICATION(S)] (antiseizure medication) tablet 1000 mg, one tablet by mouth three times a day. n. On 1/9/2022 at 6:30 am, omeprazole (gastric acid reducing medication) capsule delayed release 20 mg, one capsule by mouth in the morning before breakfast. o. On 1/31/2022 at 9 am, calcium tablet, 500 mg by mouth one time a day. p. On 1/31/2022 at 9 am, Cranberry Capsule 425 mg, 425 mg by mouth one time a day. q. On 1/31/2022 at 9 am, [MEDICATION(S)] (water pills for blood pressure) Tablet 40 mg, 1 tablet by mouth one time a day. r. On 1/31/2022 at 9 am, loratadine (allergy medication) tablet 10 mg, one tablet by mouth. s. On 1/31/2022 at 9 am, [MEDICATION(S)] (blood pressure medication) tablet 50 mg, one tablet by mouth. t. On 1/31/2022 at 9 am, [MEDICATION(S)] sulfate (iron supplement) 325 mg, one tablet by mouth two times a day. u. On 1/31/2022 at 9 am, potassium chloride (supplement for potassium levels) packet 20 milliequivalents (MEQ), by mouth one time a day. v. On 1/31/2022 at 9 am, [MEDICATION(S)] Capsule (anti-depressants) 20 mg, one capsule by mouth one time a day. w. On 1/31/2022 at 9 am, sodium chloride, 500 mg by mouth one time a day. x. On 1/31/2022 at 9 am, Vitamin D3 (vitamin supplement) tablet, 3000 IU (units) by mouth one time a day. A review of Resident 35's Progress Notes indicated no documented evidence that the attending physician was notified of the missing medication administrations for 1/8/2022, 1/9/2022, 1/24/2022, and 1/31/2022. 7. A review of Resident 52's Admission Record indicated the facility admitted the resident on 9/9/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 52's MDS dated [DATE], indicated the resident's cognition was moderately impaired. The MDS indicated Resident 52 was able to understand others and be understood. A review of the facility's resident census indicated Resident 52 was residing in the facility's Green Zone in February 2022. A review of Resident 52's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 1/3/2022, 1/7/2022, and 1/9/2022 at 9 am, and 1/31/2022 at 9 am, [MEDICATION(S)] (blood pressure medication to control high blood pressure) tablet 50 mg, one tablet by mouth one time a day. b. On 1/3/2022, 1/9/2022, and 1/31/2022 at 9 am, [MEDICATION(S)] (vitamin supplement) tablet, 400 mg by mouth one time a day were not administered. c. On 1/3/2022, 1/9/2022, and 1/31/2022 at 7:30 am, [MEDICATION(S)] HCL (diabetes medication to treat high blood sugar) tablet 500 mg, one tablet by mouth in the morning. d. On 1/3/2022, 1/9/2022, and 1/31/2022 at 9 am, multivitamin with minerals, one tablet by mouth one time a day. e. On 1/3/2022, 1/9/2022, 1/24/2022, and 1/31/2022 at 9 am, Trokendi (anti-[CONDITION(S)] medication) extended release (XR) capsule extended release 24-hour 50 mg, one capsule by mouth one time a day. f. On 1/3/2022, 1/9/2022, and 1/31/2022 at 9 am, [MEDICATION(S)] (antihistamine medication) HCL solution 0.05%, one drop in both eyes two times a day. g. On 1/3/2022, 1/9/2022, and 1/31/2022 at 9 am, [MEDICATION(S)] (non-steroidal anti-[CONDITION(S)] medication) capsule 200 mg, one capsule by mouth two times a day. e. On 1/3/2022, 1/9/2022 and 1/31/2022 at 9 am, [MEDICATION(S)] HCL (treats depression and anxiety) capsule delayed release particles 20 mg, one capsule by mouth two times a day. f. On 1/3/2022, 1/9/2022 and 1/31/2022 at 7:30 am, [MEDICATION(S)] sulfate 325 mg, 1 tablet by mouth two times a day. g. On 1/3/2022, 1/9/2022 and 1/31/2022 at 9 am, [MEDICATION(S)] ([[MEDICATION(S)]] antiseizure medication) tablet 500 mg, one tablet by mouth every 12 hours. h. On 1/3/2022, 1/9/2022, and 1/31/2022 at 9 am, [MEDICATION(S)] (antipsychotic medication) tablet, 0.5 mg by mouth two times a day. i. On 1/3/2022 at 9 am and 1 pm, 1/7/2022 at 1 pm, 1/9/2022 at 9 am and 1 pm, 1/24/2022 at 1 pm, and 1/31/2022 at 9 am and 1 pm, artificial tears solution 1%, one drop in both eyes three times a day. j. On 1/3/22 at 9 am and 1 pm, 1/7/2022 at 1 pm, 1/9/2022 at 9 am and 1 pm, 1/24/2022 at 1 pm and 1/31/2022 at 9 am and 1 pm, pregablin (anti-[CONDITION(S)] medication) capsule 50 mg, one capsule by mouth three times a day. A review of Resident 52's Progress Notes indicated no documented evidence that the attending physician was notified of the missing medication administrations for 1/3/2022, 1/7/2022, 1/9/2022, 1/24/2022, and 1/31/2022. 8. A review of Resident 43's Admission Record indicated the facility admitted the resident on 9/9/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 43's MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated Resident 43 was able to understand others and be understood. A review of the facility's resident census indicated Resident 43 was residing in the facility's Green Zone in February 2022. A review of Resident 43's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 1/4/2022, 1/9/2022, 1/23/2022, 1/27/2022, 1/29/2022, and 1/30/2022 at 6:30 am, [MEDICATION(S)] sodium tablet delayed release 40 mg, one tablet by mouth in the morning. b. On 1/8/2022, 1/9/2022, 1/21/2022, 1/22/2022, 1/23/2022, 1/24/2022, 1/25/2022 1/28/2022, and 1/29/2022 at 9 pm, [MEDICATION(S)] (lipid [bad cholesterol] lowering medication) calcium tablet 80 mg, 1 tablet by mouth at bedtime. c. On 1/8/2022, 1/9/2022, 1/21/2022, 1/22/2022, 1/23/2022, 1/24/2022, 1/25/2022, 1/28/2022, and 1/29/2022 at 9 pm, [MEDICATION(S)] ([MEDICATION(S)]) tablet 8.6 mg, two tablets by mouth at bedtime. d. On 1/8/2022 and 1/9/2022 at 9 am, 1/21/2022 and 1/22/2022 at 9 am and 5 pm, 1/23/2022, 1/24/2022, 1/25/2022 at 5 pm, 1/26/2022 at 9 am, 1/28/2022 at 5 pm, and 1/29/2022 at 9 am, [MEDICATION(S)] (anti-coagulant [anti-blood clot medication]) tablet 5 mg, one tablet by mouth two times a day. e. On 1/8/2022 and 1/9/2022 at 5 pm, 1/21/2022 and 1/22/2022 at 9 am and 5 pm, 1/23/2022, 1/24/2022 and 1/25/2022 at 5 pm, 1/26/2022 at 9 am, 1/28/2022 at 5 pm, and 1/29/2022 at 9 am, [MEDICATION(S)] capsule 300 mg, one capsule by mouth two times a day. f. On 1/8/2022 and 1/9/2022 at 5 pm, [MEDICATION(S)] (antibiotic) calcium ointment 2 %, 1 application in each nostril two times a day. g. On 1/8/2022 and 1/9/2022 at 5 pm, 1/21/2022 and 1/22/2022 at 9 am and 5 pm, 1/23/2022, 1/24/2022 1/25/2022 at 5 pm, 1/26/2022 at 9 am, 1/28/2022 at 5 pm, and 1/29/2022 at 9 am, potassium chloride (supplement for potassium levels), 10 mEq by mouth two times a day. h. On 1/21/2022, 1/22/2022, and 1/29/2022 at 9 am, [MEDICATION(S)] (heart medication) HCL tablet 200 mg, one tablet by mouth one time a day. i. On 1/21/2022, 1/22/2022, 1/26/2022, and 1/29/2022 at 9 am, [MEDICATION(S)] sodium capsule 250 mg, one capsule by mouth one time a day. j. On 1/21/2022, 1/22/2022, 1/26/2022, 1/29/2022 at 9 am, [MEDICATION(S)] HCL capsule delayed release Particles 30 mg, 1 capsule by mouth one time a day. k. On 1/21/2022, 1/22/2

Based on observation, interview, and record review, the facility failed to ensure that residents were free from significant medication (medications which causes the resident discomfort or jeopardizes his or her health and safety) errors and follow its policy and procedure to administer medications as ordered by the physician for nine reviewed residents out of 69 sampled residents with missed dosed medications in the facility for two months, for the months of January and February 2022. These deficient practices had the potential to cause adverse reactions, health complications from missing dose of medications that could lead to hospitalization s, and death. Cross referenced to F600. Findings: On 2/10/2022 at 7:50 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's administrator (ADM), regarding the facility's failure to administer scheduled medications as ordered by the physician to multiple residents in the facility. On 2/13/2022 at 5:08 pm the IJ was removed after the ADM submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the IJ Removal Plan while onsite through observation, interview, and record review. The IJ was removed in the presence of the ADM. The acceptable IJ Removal Plan included the following actions: 1. All residents that were identified as having missed medications will be assessed and monitored for adverse reactions. 2. Notification to physician, family and/or representative has been completed regarding missed medication administration on 02/12/2022. 3. Physician, family and/or representative have been called regarding missed medication administration, with follow up documentation in the progress note completed on 02/12/2022. Written notification to be either hand delivered to self-responsible patient or mailed to the responsible party on 2/14/2022. 4. Requested Pharmacy Nurse consultant to in-service all licensed nurses on the importance of proper medication administration and management, medication preparation and infection control dated 02/08/2022. Pharmacy Nurse consultant to conduct frequent audits and in-services to ensure all licensed staff have received proper training, on-going. 6. January and February Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Verbal notification to the physician, family and or responsible party regarding missed medication administration had been completed as of 02/12/2022. The residents identified will be assessed and monitored for adverse reaction. A letter had been created to notify patients and responsible party of the missed medication administration. 7. RN supervisor/Designee to provide e-MAR/resident oversight prior to the end of each shift to ensure completion of medication pass and documentation prior to end of shift for all licensed nurses. 8. Each outgoing licensed nurse to assess and provide care for and will endorse a complete (green) e-MAR for all residents assigned with the oncoming nurse. Oncoming licensed nurse to validate completion of the outgoing licensed nurse e-MAR. To ensure no missed documentation on e-MAR, all residents should be in color (Green). Any resident in color (RED) would be corrected immediately. 9. Medical Records/ designee to audit daily compliance of e-MAR completion. Any non-compliant issues shall be brought to the Administrator/designee. 10. RN MDS Coordinator (Interim DON) will provide clinical oversight for the facility to ensure compliance 7 days a week either in person or by phone with communication and collaboration with clinical resource and/or Medical Director as needed. RN MDS/Interim DON will provide oversight to residents to ensure that all required nursing services are provided such as medication administration, dietary needs, and other physician orders. RN Clinical Resource will be in the facility 2 to 3 times a week to provide guidance and support. 11. Medical Director to provide in-services to licensed staff regarding the importance of medication administration and adverse effects of missed medications starting 02/13/2022, ongoing, until all licensed nurses have been in-serviced. Medical Director to provide assistance to RN MDS/Interim DON as needed. Medical Director to meet monthly to go over any discrepancy at the monthly QAPI or as needed. Medical Director to be informed of any missed medication or medication error for further guidance. 12. Administrator reviewed daily staffing for each shift on 2/11/2022. Administrator identified opening in staffing needs for the next 10 days. The DSD to assist with the daily scheduling as of 02/13/2022. Administrator and DSD to oversee the facility need for staffing. Administrator and DSD to utilize Nursing Registry as needed and ongoing to ensure staffing requirements are met. 13. Administrator/DSD to ensure the necessary staff are scheduled in the COVID unit (Red Zone) to provide services and oversight to meet the needs of each resident. Licensed nurses are scheduled throughout the month of February for both 7 AM to 7 PM, and 7 PM to 7 AM shifts. These shifts will be covered by Facility Licensed nurses. If there is a gap in the days, Administrator and DSD to secure Nursing Registry to staff appropriately. Licensed nurses are responsible for medication administration and documentation and assessing residents every 2 hours for any possible change of condition. 14. For staff call outs, the employee will contact the facility for notification then call either Administrator, RN MDS, and/or DSD to inform them of their call off. RN MDS and/or DSD to initiate search for replacement by asking current staff working to work a double, and call staff who are off that day to cover that shift. Nursing Registry will also be called as needed. 15, If no staff is available to cover a shift, the RN Supervisor, and/or LVN Charge nurse will look into the distribution of assignments to ensure all care and services were provided for that shift. This includes medication pass for licensed nurses. 16. In-service to be provided by DSD starting 02/13/2022 and until all licensed nurses have in-serviced. In-service for licensed nurses to educate them regarding call offs and re-assignment of available staff. 17. If outgoing licensed nurse leaves the facility and not replaced, DSD, IP Nurse, RN supervisor or any licensed nurse should cover the resident assignments appropriately and document the distribution of the resident assignments on the Staffing Assignment Sheets and indicate who was reassigned and responsible to cover that shift. 18. Facility to schedule in-house Licensed Nurses for the facility's Red Zone (area in the facility where all positive COVID-19 residents were housed) whenever possible. Nursing Registry to only be used as a backup for the Red Zone. 19. DSD created a specific Staffing Assignment Sheet titled CNA Assignments for the Red Zone on 02/13/2022. This assignment sheet includes the name of the licensed nurse, charge nurse for that shift and the bed numbers that the charge nurse and CNA are assigned to. A review of residents' Medication Administration Records indicated the following residents had significant medications missed for January and February 2022: 1. A review of Resident 60's Admission Record indicated the facility admitted the resident on 5/11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 60's Minimum Data Set (MDS) care area assessment tool dated 2/4/2022, indicated the resident's cognition was intact. The MDS indicated Resident 60 was able to understand others and be understood. A review of the facility's resident census indicated Resident 60 was residing in the facility's Red Zone from 2/2/2022 to 2/14/2022. A review of Resident 60's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/10/2022 and 2/7/2022 at 5 pm, [MEDICATION(S)] (HCL) (antidepressant and nerve pain medication) 30 milligram (mg) one capsule by mouth two times a day. b. On 2/7/2022 and 2/10/2022 at 5 pm, [MEDICATION(S)] (anti-diabetic medication to control blood sugar levels) HCL 500 mg 1 tablet by mouth two times a day. c. On 2/7/2022 and 2/10/2022 at 5 pm, Vitamin C (supplements) tablet 500 mg by mouth two times a day. d. On 2/5/2022 at 1 pm, 2/7/2022 at 5 pm, and 2/10/2022 at 5 pm, [MEDICATION(S)] capsule (anti-convulsant and nerve pain medication to control seizures) 300 mg 5 capsule by mouth 3 times a day. e. On 2/5/2022 at 12 pm, 2/7/2022 at 6 pm, and 2/10/2022 at 6 pm, ropinrole (medication used to treat symptoms of restless leg syndrome) HCL tablet 4 mg by mouth 3 times a day. f. On 2/5/2022 at 12 pm, and 2/7/2022 at 6 pm, [MEDICATION(S)] Aerosol Solution (inhalation medication to prevent bronchospasm [chest feels tight, and hard to catch breath] and shortness of breath), 2 inhalations every 6 hours for COVID-19 infection for 6 days. e. On 2/1/2022, [MEDICATION(S)] (antibiotic) tablet 500 mg, 1 tablet by mouth one time only. A review of Resident 60's care plan created on 8/14/2021, revised on 8/14/2021 and 10/28/2021, indicated the resident had problems with Diabetes Mellitus with potential for fluctuating blood sugar. The interventions included administering medications as ordered and monitoring for signs and symptoms or [CONDITION(S)] (low blood sugar) and [CONDITION(S)] (high blood sugar). A review of Resident 60's Progress Notes indicated no documented evidence that the attending physician was notified of the above missing significant medication administrations. 2. A review of Resident 39's Admission Record indicated the facility admitted the resident on 1/21/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 39's MDS, dated [DATE] indicated the resident's cognition was intact. The MDS indicated Resident 39 was able to understand others and be understood. A review of the facility's resident census indicated Resident 39 was residing in the facility's Red Zone from 2/3/2022 to 2/10/2022. A review of Resident 39's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/7/2022 and 2/10/2022 at 5pm, [MEDICATION(S)] (used to relieve nerve pain) 300 mg one capsule by mouth two times a day. b. On 2/7/2022 and 2/10/2022 at 5 pm, [MEDICATION(S)] (blood thinners for history of blood clots/prevention of blood clot formation) 150 mg one capsule by mouth two times a day. c. On 2/3/2022, [MEDICATION(S)] (antibiotic) 500 mg, one tablet by mouth. A review of Resident 39's care plan created on 1/22/2022 and 2/5/2022, revised on 2/5/2022, indicated the resident had problems with DVT (deep vein [CONDITION(S)] [blood clots], polyneuropathy, acute embolism and [CONDITION(S)] of unspecified deep veins or left lower extremity. The interventions included administering medications as ordered, observe for pain, severity, location, duration, and evaluate effectiveness of pain meds. A review of Resident 39's Progress Notes indicated no documented evidence that the attending physician was notified of the above missing significant medication administrations. 3. A review of Resident 34's Admission Record indicated the facility admitted the resident on 2/28/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 34's MDS dated [DATE], indicated the resident's cognition was severely impaired. The MDS indicated Resident 34 was able to usually understand others and be usually understood. A review of the facility's resident census indicated Resident 34 was residing in the facility's Red Zone from 2/3/2022 to 2/10/2022. A review of Resident 34's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/7/2022 and 2/10/2022, [MEDICATION(S)] (immunosuppressive medication that blocks immune signaling molecules [particles]/used to prevent organ rejection for individuals who have had kidney transplant) 50 mg, 0.5 tablet by mouth two times a day. b. On 2/7/2022 and 2/10/2022, [MEDICATION(S)] (anti-[CONDITION(S)] medication) 250 mg, one tablet by mouth two times a day. A review of Resident 34's care plan created on 3/4/2021, revised on 6/11/2021, indicated the resident had problems with [CONDITION(S)] Disorder, Potential for injury during [CONDITION(S)]. The interventions included administering medication as ordered, post [CONDITION(S)] treatment, [CONDITION(S)] documentation, and [CONDITION(S)] precautions. A review of Resident 34's Progress Notes indicated no documented evidence that the attending physician was notified of the above missing significant medication administrations. 4. A review of Resident 50's Admission Record indicated the facility admitted the resident on 11/18/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 50's MDS dated [DATE], indicated the resident's cognition was severely impaired. The MDS indicated Resident 50 was able to sometimes understand others and be sometimes understood. A review of the facility's resident census indicated Resident 50 was residing in the facility's Green Zone in February 2022. A review of Resident 50's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/1/2022 at 9 am and 1 pm, 2/8/2022 at 1 pm, 2/9/2022 at 9 am and 1 pm, 2/10/2022 at 9 am, 1 pm and 5 pm, [MEDICATION(S)] (blood pressure medication to control high blood pressure) HCL Tablet 50 mg, 1 tablet by mouth three times a day. b. On 2/8/2022 at 1 pm, 2/9/2022 at 9 am and 1 pm, 2/10/2022 at 9 am, 1 pm, and 5 pm, [MEDICATION(S)] (antipsychotic medication/treat mental or mood disorders) tablet 100 mg by mouth three times a day. c. On 2/9/2022 at 9 am and 2/10/2022 at 9 am and 5 pm, [MEDICATION(S)] Tablet (anti-[CONDITION(S)] medication) Delayed Release 250 mg, 1 tablet by mouth two times. d. On 2/9/2022 at 9 am and 2/10/2022 at 9 am and 5 pm, [MEDICATION(S)] (cognition-enhancing medication for dementia [a group of symptoms that affects memory, thinking and interferes with daily life]) tablet 5 mg, one tablet by mouth two times a day. e. On 2/10/2022 at 9 pm, [MEDICATION(S)] (anti-[CONDITION(S)] medication) delayed release tablet 750 mg by mouth at bedtime. A review of Resident 50's care plan created on 11/18/2021, indicated the resident had problems with [CONDITION(S)] Disorder, Potential for injury during [CONDITION(S)]. The interventions included administering medication as ordered, post [CONDITION(S)] treatment, [CONDITION(S)] documentation, and [CONDITION(S)] precautions. A review of Resident 50's Progress Notes indicated no documented evidence that the attending physician was notified of the above missing significant medication administrations. 5. A review of Resident 24's Admission Record indicated the facility admitted the resident on 8/3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 24's MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated Resident 24 was able to understand others and be understood. A review of the facility's resident census indicated Resident 24 was residing in the facility's Red Zone from 2/3/2022 to 2/10/2022. A review of Resident 24's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 2/7/2022 and 2/10/2022 at 5 pm, [MEDICATION(S)] (anti-coagulant/prevent blood clot formation) tablet 5 mg, 1 tablet by mouth two times a day. A review of Resident 24's care plan created on 8/3/2021 8/4/2021, 8/22/2021, revised on 8/14/2021, 11/3/2021, indicated the resident had problems with DVT to bilateral lower extremities (BLE), chronic embolism and [CONDITION(S)] of BLE, bleeding r/t use of anticoagulant medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included administering medications as ordered, observe for pain, evaluation of effectiveness of medications, and monitor for signs and symptoms of complications. A review of Resident 24's Progress Notes indicated no documented evidence that the attending physician was notified of the above missing significant medication administrations. 6. A review of Resident 35's Admission Record indicated the facility admitted the resident on 7/18/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 35's MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated Resident 35 was able to understand others and be understood. A review of the facility's resident census indicated Resident 35 was residing in the facility's Green Zone in February 2022. A review of Resident 35's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 1/8/2022 at 9 pm, [MEDICATION(S)] (sedative for [CONDITION(S)]) tablet 5 mg, 1 tablet by mouth. b. On 1/8/2022 at 9 pm, [MEDICATION(S)] (cholesterol medication) tablet 40 mg, 1 tablet by mouth at bedtime. c. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (antibiotic) DS Tablet 800-160 mg, one tablet by mouth two times a day. d. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (heart medication) tablet 12.5 mg, one tablet by mouth two times a day. e. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (anti-epileptic medication/anti-[CONDITION(S)] medication) capsule, 300 mg, one capsule by mouth two times a day. f. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (antiseizure medication) tablet 300 mg, one tablet by mouth two times a day. g. On 1/8/2022 at 5 pm and 1/31/2022 at 9 am, [MEDICATION(S)] (medication to prevent and control seizures) tablet 200 mg, one tablet by mouth two times a day. h. On 1/8/2022 at 5 pm, 1/24/2022 at 1 pm, and 1/31/2022 at 9 am and 1 pm, [MEDICATION(S)] (antiseizure medication) tablet 1000 mg, one tablet by mouth three times a day. i. On 1/31/2022 at 9 am, [MEDICATION(S)] (water pills for blood pressure) Tablet 40 mg, 1 tablet by mouth one time a day. k. On 1/31/2022 at 9 am, [MEDICATION(S)] (blood pressure medication) tablet 50 mg, 1 tablet by mouth. l. On 1/31/2022 at 9 am, potassium chloride (supplement for potassium levels) packet 20 milliequivalents (MEQ), by mouth one time a day. m. On 1/31/2022 at 9 am, Vitamin D3 (vitamin supplement) tablet, 3000 IU (units) by mouth one time a day. A review of Resident 35's care plan created on 7/19/2018, revised 7/19/2018 and 7/28/2021 indicated the resident had problems with [CONDITION(S)] Disorder related to developmentally delayed, [CONDITION(S)]. The interventions included give [CONDITION(S)] medication as ordered, monitor/document side effects and effectiveness, post [CONDITION(S)] treatment, [CONDITION(S)] documentation, and [CONDITION(S)] precautions. A review of Resident 35's Progress Notes indicated no documented evidence that the attending physician was notified of the above missing significant medication administrations. 7. A review of Resident 52's Admission Record indicated the facility admitted the resident on 9/9/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 52's MDS dated [DATE], indicated the resident's cognition was moderately impaired. The MDS indicated Resident 52 was able to understand others and be understood. A review of the facility's resident census indicated Resident 52 was residing in the facility's Green Zone in February 2022. A review of Resident 52's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 1/3/2022, 1/7/2022, and 1/9/2022 at 9 am, and 1/31/2022 at 9 am, [MEDICATION(S)] (blood pressure medication to control high blood pressure) tablet 50 mg, one tablet by mouth one time a day. b. On 1/3/2022, 1/9/2022, and 1/31/2022 at 7:30 am, [MEDICATION(S)] HCL (diabetes medication to treat high blood sugar) tablet 500 mg, one tablet by mouth in the morning. c. On 1/3/2022, 1/9/2022, 1/24/2022, and 1/31/2022 at 9 am, Trokendi (anti-[CONDITION(S)] medication) extended release (XR) capsule extended release 24-hour 50 mg, one capsule by mouth one time a day. d. On 1/3/2022, 1/9/2022 and 1/31/2022 at 9 am, [MEDICATION(S)] HCL (treats depression and anxiety) capsule delayed release particles 20 mg, one capsule by mouth two times a day. e. On 1/3/2022, 1/9/2022 and 1/31/2022 at 9 am, [MEDICATION(S)] ([[MEDICATION(S)]] antiseizure medication) tablet 500 mg, one tablet by mouth every 12 hours. f. On 1/3/2022, 1/9/2022, and 1/31/2022 at 9 am, [MEDICATION(S)] (antipsychotic medication) tablet, 0.5 mg by mouth two times a day. g. On 1/3/22 at 9 am and 1 pm, 1/7/2022 at 1 pm, 1/9/2022 at 9 am and 1 pm, 1/24/2022 at 1 pm and 1/31/2022 at 9 am and 1 pm, pregablin (anti-[CONDITION(S)] medication) capsule 50 mg, one capsule by mouth three times a day. A review of Resident 52's care plan created on 9/9/2021 and revised on 9/9/2021, indicated the resident had problems with [CONDITION(S)] disorder with potential for injury during [CONDITION(S)], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included to administer medications as ordered, post [CONDITION(S)] treatment, [CONDITION(S)] documentation, and [CONDITION(S)] precautions. A review of Resident 52's Progress Notes indicated no documented evidence that the attending physician was notified of the above missing significant medication administrations. 8. A review of Resident 43's Admission Record indicated the facility admitted the resident on 9/9/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 43's MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated Resident 43 was able to understand others and be understood. A review of the facility's resident census indicated Resident 43 was residing in the facility's Green Zone in February 2022. A review of Resident 43's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 1/8/2022, 1/9/2022, 1/21/2022, 1/22/2022, 1/23/2022, 1/24/2022, 1/25/2022 1/28/2022, and 1/29/2022 at 9 pm, [MEDICATION(S)] (lipid [bad cholesterol] lowering medication) calcium tablet 80 mg, 1 tablet by mouth at bedtime. b. On 1/8/2022 and 1/9/2022 at 9 am, 1/21/2022 and 1/22/2022 at 9 am and 5 pm, 1/23/2022, 1/24/2022, 1/25/2022 at 5 pm, 1/26/2022 at 9 am, 1/28/2022 at 5 pm, and 1/29/2022 at 9 am, [MEDICATION(S)] (anti-coagulant [anti-blood clot medication]) tablet 5 mg, one tablet by mouth two times a day. c. On 1/8/2022 and 1/9/2022 at 5 pm, 1/21/2022 and 1/22/2022 at 9 am and 5 pm, 1/23/2022, 1/24/2022 and 1/25/2022 at 5 pm, 1/26/2022 at 9 am, 1/28/2022 at 5 pm, and 1/29/2022 at 9 am, [MEDICATION(S)] capsule 300 mg, one capsule by mouth two times a day. d. On 1/8/2022 and 1/9/2022 at 5 pm, 1/21/2022 and 1/22/2022 at 9 am and 5 pm, 1/23/2022, 1/24/2022 1/25/2022 at 5 pm, 1/26/2022 at 9 am, 1/28/2022 at 5 pm, and 1/29/2022 at 9 am, potassium chloride (supplement for potassium levels), 10 mEq by mouth two times a day. e. On 1/21/2022, 1/22/2022, and 1/29/2022 at 9 am, [MEDICATION(S)] (heart medication) HCL tablet 200 mg, one tablet by mouth one time a day. f. On 1/21/2022, 1/22/2022, 1/26/2022, 1/29/2022 at 9 am, [MEDICATION(S)] HCL capsule delayed release Particles 30 mg, 1 capsule by mouth one time a day. g. On 1/21/2022, 1/22/2022, 1/26/2022, and 1/29/2022 at 9 am, [MEDICATION(S)] (NSAID and blood thinner) Low Strength Tablet Delayed Release 81 mg, 1 tablet by mouth one time a day. h. On 1/21/2022, 1/22/2022, 1/26/2022, 1/29/2022 at 9 am, [MEDICATION(S)] (medication to control high blood sugar levels) Solution 100 Unit/ML, inject 45 unit subcutaneously one time a day. i. On 1/21/2022, 1/22/2022, 1/26/2022, 1/29/2022 at 9 am, [MEDICATION(S)] (water pills) tablet 40 mg, 40 mg by mouth one time a day. A review of Resident 43's care plan created on 7/15/2019, revised on 6/7/2021, indicated the resident had problems with diabetes mellitus with potential for fluctuating blood sugar, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 43's Progress Notes indicated no documented evidence that the attending physician was notified of the above missing significant medication administrations. 9. A review of Resident 62's Admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 62's MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated Resident 62 was able to understand others and be understood. A review of the facility's resident census indicated Resident 62 was residing in the facility's Yellow Zone from 1/3/2022 to 1/12/2022 and 1/21/2022 to 1/24/2022 1/27/2022 to 1/31/2022. Resident 62 was not in the facility (acute hospital) from 1/13/2022 to 1/26/2022. Resident 62 was in the Green Zone in February 2022. A review of Resident 62's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 1/8/2022 at 9 pm, [MEDICATION(S)] calcium tablet, 20 mg by mouth at bedtime. b. On 1/8/2022 at 9 pm, [MEDICATION(S)] (sedative medication) tablet, 0.5 mg, 2.5 mg by mouth at bedtime. c. On 1/8/2022 at 4 pm and 8 pm and on 1/9/2022 at 4 am, [MEDICATION(S)] (narcotic medication for pain due to [CONDITION(S)]) tablet 5-325 mg, 1 tablet by mouth every 4 hours. d. On 1/8/2022 at 5 pm, [MEDICATION(S)] Tablet 5 mg, 1 tablet by mouth two times a day. e. On 1/28/2022 at 9 am, [MEDICATION(S)] (blood pressure medication) tablet 50 mg, one tablet by mouth one time a day. f. On 1/8/2022 at 5 pm, [MEDICATION(S)] (diabetes medication) HCL Tablet, 1000 mg by mouth in the evening. g. On 1/8/2022 at 8 pm, [MEDICATION(S)] (anti-[CONDITION(S)] medication) capsule 100 mg, one capsule by mouth three times a day. h. On 1/9/2022 at 5:45 am, [MEDICATION(S)] ([CONDITION(S)] medication) sodium tablet, 150 mcg by mouth in the morning. i. On 1/28/2022 at 9 am, [MEDICATION(S)] (blood pressure medication) Tablet 50 mg, 1 tablet by mouth one time. i. On 1/28/2022 at 9 am, [MEDICATION(S)] (anti-[CONDITION(S)] medication) capsule 100 mg, 1 capsule by mouth one time a day. k. On 1/28/2022 at 9 am, [MEDICATION(S)] (blood pressure medication) 10 mg, one time a day. l. On 1/28/2022 at 9 am, [MEDICATION(S)] (antidepressant) tablet 100 mg, 1.5 tablet by mouth one time a day. m. On 1/28/200 at 9 am, [MEDICATION(S)] (blood pressure medication) tablet 100 mg, 0.5 tablet by mouth one time a day. n. On 1/28/2022 at 9 am, [MEDICATION(S)] (a blood thinner medicine that reduces blood clotting) tablet 5 mg, one tablet by mouth two times a day. o. On 1/28/2022 at 9 am, [MEDICATION(S)] Capsule 100 mg, 1 capsule by mouth two times a day. p. On 1/28/2022 at 9 am, [MEDICATION(S)] tablet 0.5 mg, 0.5 mg by mouth two times a day. q. On 1/28/2022 at 7:30 am and 12:30 pm, on 1/31/2022 at 12:30 pm, [MEDICATION(S)] (diabetes medication for blood sugar levels) tablet 2 mg, one tablet by mouth three times a day. r. On 1/28/2022 at 9 am and 1 pm, [MEDICATION(S)] ([MEDICATION(S)] and ammonia reducer medication) solution 10 gram (GM)/ML, 30 ml by mouth four times a day. s. On 1/28/2022 at 8 am, 9 am, 10 am, 11 am, 12 pm, 1 pm, 2 pm, [MEDICATION(S)] solution (an opioid pain medicine used to treat breakthrough cancer pain that is not controlled by other medicines) 1500 MCG/30 ML, inject 80 mcg subcutaneously every hour. t. On 1/31/2022 at 2 am, 3 am, 4 am, 5 am, 6 am, 12 pm, 1 pm, 2 pm, [MEDICATION(S)] solution 1500 MCG/30 ML, inject 100 mcg subcutaneously every hour. A review of Resident 62's care plan created on 7/30/2021, 8/5/2021, revised 10/29/2021, indicated the resident had problems with [CONDITION(S)] disorder with potential for injury during [CONDITION(S)] and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interviews and record review, the facility failed to ensure there were sufficient number of nursing staff to provide nursing care, supervision, and related services to respond to each resident's needs and safety that included the weekends for Direct Care Service Hours Per Patient Day ([DHPPD] a legally required form which indicated if the facility is providing the sufficient amount of nursing staff) reviewed for two sampled days out of 30 days for the month of [DATE] ([DATE]- Friday, [DATE] -Saturday), three out of 31 days for the month of [DATE] ([DATE] -Saturday, [DATE] Sunday, and [DATE]- Monday). Failure of the facility to provide adequate nursing staff to address each resident's needs resulted in negative outcomes for two of two sampled residents; Resident 1, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross reference with F689 Findings: A review of the facility's documented CMS 612 form titled Census and Direct Care Service Hours Per Patient Day (DHPPD), dated [DATE], indicated the facility's Actual DHPPD was 3.66 (minimum staffing standard was 3.5) and the Actual CNA DHPPD was 2.03 (minimum staffing standard was 2.4). A review of the facility's CMS 612 form titled Census and Direct Care Service Hours Per Patient Day (DHPPD), dated [DATE] indicated the Actual DHPPD was 3.27 and the Actual CNA DHPPD was 1.83. A review of the facility's CMS 612 form titled Census and Direct Care Service Hours Per Patient Day (DHPPD), dated [DATE] indicated the Actual DHPPD was 2.69 and the Actual CNA DHPPD was 1.16. A review of the facility's CMS 612 form titled Census and Direct Care Service Hours Per Patient Day (DHPPD), dated [DATE] indicated the Actual DHPPD was 2.67 and the Actual CNA DHPPD was 1.35. A review of the facility's CMS 612 form titled Census and Direct Care Service Hours Per Patient Day (DHPPD), dated [DATE] indicated the Actual DHPPD was 3.25 and the Actual CNA DHPPD was 1.70. A review of the All Facilities Letter (AFL), titled, Guidelines for 3.5 Direct Care Service Hours Per Patient Day (DHPPD) Staffing Audits, indicated for compliance with the 3.5 DHPPD staffing requirements, of which a minimum of 2.4 DHPPD shall be performed by certified nursing assistants (CNAs). The AFL indicated only direct caregivers shall count toward the 3.5 and 2.4 DHPPD staffing standard. The AFL indicated any facility that falls below either the 3.5 or 2.4 DHPPD staffing requirement for any audited day is out of compliance, unless the California Department of Public Health (CDPH) has approved a staffing requirement waiver for the facility. 1. A review of Resident 1's Admission Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. The Face Sheet indicated Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Quarterly Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated [DATE], The MDS indicated Resident 1 sometimes understood and sometimes understands others and Resident 1's cognition was modified independence. The MDS indicated Resident 1 required supervision with one-person physical assistance for dressing, eating, and personal hygiene. A review of Resident 1's Quarterly Risk Data Collection Tool, dated [DATE], indicated Resident 1 was at risk for elopement and that a care plan had been initiated for elopement risk. A review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation) Communication Form, dated, [DATE], indicated Res. (Resident) found by staff @ EXP Boiling [sic] parking lot with # bottles of E+J Brandy @ 7:30 am. The SBAR form indicated to monitor Resident 1 for 72 hours related to leaving the facility. A review of Resident 1's Change in Condition Evaluation, form dated [DATE] and timed at 9:34 am, indicated Res. found by staff @ EXP Boiling [sic] parking lot with # bottles of E+J Brandy @ 7:30 am. The evaluation indicated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Care Plan regarding elopement and wandering r/t (related to): cognitive loss, impaired decision making, wandered outside of facility property, [CONDITION(S)] disorder, [CONDITION(S)], indicated the care plan was initiated on [DATE] (3 days after Resident 1 eloped from the facility). The care plan indicated to have frequent visual checks of Resident 4's whereabouts. During an interview with Certified Nursing Assistant (CNA) 1 on [DATE] at 10:57 am, CNA 1 stated that Resident 1 eloped due to the facility being short staffed. CNA 1 stated Resident 1 eloped during the night shift and was found at a Convenience Store. CNA 1 stated one facility staff was driving to work and saw Resident 1 by the Convenience Store. During an interview with the DON on [DATE] at 3:13 pm, the DON stated she could not find documented evidence that the facility staff had conducted monitoring of Resident 1's whereabouts after the elopement incident. The DON stated they did not know anything about the resident's elopement. The DON stated she could not find documented evidence that when Resident 1 was returned to the facility, the licensed nurses should have done a body check, notified the physician, and updated the facility's elopement binder with the resident's photo, a face sheet, and elopement history. The DON stated after a 72-hour change of condition, the licensed nurses should check the resident's condition and location every shift. During a concurrent record review of Resident 1's elopement assessments on [DATE] at 3:28 pm, the DON and LVN 5 stated there was no elopement reassessments completed for Resident 1 after Resident 1 eloped on [DATE]. The DON and LVN 5 stated there was a care plan initiated on [DATE] (3 days after actual elopement) for at risk for elopement, but not for an actual incident of eloping. The DON stated there was no documented evidence available to show monitoring was conducted or if the attending physician was notified. During an interview with Registered Nurse (RN) 1 on [DATE] on 3:33 pm, RN 1 stated she was not aware Resident 1 eloped from the facility. RN 1 stated the resident's documented evidence of monitoring should be documented in the electronic Medication Administration Record. During a concurrent review of Resident 1's SBAR and interview with the DON on [DATE] at 4:09 pm, Resident 1's SBAR indicated the resident's elopement incident occurred on [DATE] but the SBAR was documented by the licensed nurse on [DATE] (3 days after the actual elopement). The DON stated Resident 1s attending physician was not notified and there was no elopement/wandering reassessment conducted to Resident 1. During a telephone interview with LVN 8 on [DATE] at 6:49 am, LVN 8 stated Resident 1 eloped from the facility a few months ago (aside from the [DATE] elopement incident). During a telephone interview with RN 2 on [DATE] at 2:31 pm, RN 2 stated she worked on the am shift when Resident 1 eloped. RN 2 stated she asked the night shift facility staff that morning when Resident 1 eloped, and they did not know where Resident 1 was. RN 2 stated Resident 1 always asks to go out of the facility. RN 2 stated three facility staff went to drive around looking for Resident 1, a few months ago (prior to the [DATE] elopement incident). During a telephone interview with CNA 1 on [DATE] at 10:46 am, CNA 1 stated Resident 1 was a wanderer. CNA 1 stated no one knew what time Resident 1 left the facility, on [DATE]. CNA 1 stated Resident 1 had gone outside the facility before and was found at the parking lot of the Convenience Store, and no one had said or implemented interventions of the incidents. CNA 1 stated the facility had never provided in-services regarding wandering and elopement because they were so short on staff. CNA 1 stated the importance of learning safety interventions would be good to know and just in case a situation like that happened, they would know what to do and for the safety of their residents. 2. A review of Resident 4's Admission Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE]. The Face Sheet indicated Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's Quarterly Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated [DATE], indicated Resident 4's cognition was severely impaired. The MDS indicated Resident 4 understood and understands others. The MDS indicated Resident 4 required extensive assistance with a one-person for bed mobility, transferring, and toilet use. A review of Resident 4's Quarterly Risk Data Collection Tool, dated [DATE] at 12:21 pm, indicated Resident 4 had one to two falls within the last six months. The tool indicated Resident 4 was at risk for falls. A review of Resident 4's care plan regarding an actual fall, initiated on [DATE], indicated Resident 4 was found on the floor inside his room. Resident 4's care plan indicated Resident 4 stated he did not feel well, and his mind was empty. The care plan indicated Resident 4 tried to get out of bed and fell on the floor. A review of Resident 4's Change in Condition Evaluation, dated [DATE] and timed at 10:01 am, indicated Resident 4 had a fall and had a slight sctach [sic] in back. A review of Resident 4's Progress Notes, dated [DATE] and timed at 3:30 am, indicated Resident 4 did not feel well and his mind was empty. Resident 4's Progress Note indicated the only way to feel better was for Resident 4 to sit in his wheelchair and eat. The Progress Note indicated he tried to get out of bed and fell on the floor. The Progress Note indicated Resident 4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Note indicated Resident 4's body assessment was done and was noted a slight scratch on his back. During a telephone interview with CNA 2 on [DATE] at 7 am, CNA 2 stated usually each CNA was assigned to care for 15 to 18 residents. CNA 2 stated during the past Saturday, she had to care for 28 to 29 residents directly assigned to her. CNA 2 stated staffing was worst during the weekends and facility management was not doing anything about it. CNA 2 stated poor staffing had negatively affected the residents. CNA 2 stated on [DATE], Resident 4 fell because of not having enough staff to attend timely to assist Resident 4. CNA 2 stated there were only four CNAs with about 22 residents each. CNA 2 stated there was no one there to assist the residents right away. CNA 2 stated Resident 4 thought he could get up by himself, but he could not and that is why Resident 4 had a fall. CNA 2 stated Resident 4 had scratches on his back due to the fall. During an interview with CNA 1 on [DATE] at 10:57 am, CNA 1 stated he had 10 to 14 residents assigned to him Mondays through Fridays (AM shift). CNA 1 stated on the weekends, he had about 19 residents. CNA 1 stated the facility are short staffed all the time. CNA 1 stated one time during resident endorsements, the west side of the facility was filled and smelled urine. CNA 1 stated being short staffed affected the residents because sometimes the AM shift CNAs had to endorse the resident showers to the PM shift CNAs. CNA 1 stated sometimes they would get the residents up late in the morning, especially those that required the use of a Hoyer lift (a mobility tool used to help seniors with mobility challenges get out of bed or the bath without the assistance of another person). CNA 1 stated residents were complaining that they were not able to get them up and out of bed on time. During an interview with LVN 3 on [DATE] at 11:08 am, LVN 3 stated she was assigned to provide care to about 28 to 30 residents for medication administration. LVN 3 stated CNAs were short staffed as well. LVN 3 stated 19 residents were assigned to the CNAs during the weekdays and weekends. LVN 3 stated this affected resident care because the residents could not be attended to right away. LVN 3 stated sometimes she could not take a break. During an interview with LVN 4 on [DATE] at 11:29 am, LVN 4 stated call lights should be attended and answered right away whether residents were assigned to them or not. LVN 4 stated she usually had 28 residents assigned to her for medication administration. LVN 4 stated there were not enough CNAs and they were short staffed. LVN 4 stated residents were affected because they don't get changed on time, their needs were not attended immediately, and their needs are not fulfilled 100 percent. During an interview with LVN 1 on [DATE] at 11:47 am, LVN 1 stated CNAs have 19 residents each and she had to be on hand to help the CNAs. LVN 1 stated being short-staffed affects residents because CNAs rush when they give care. LVN 1 stated as soon as the call light beeps, it needs to be answered, even if it is not assigned to them. During an interview with the DON on [DATE] at 12:09 pm, the DON stated the facility are short staffed with CNAs and RNAs (Restorative Nursing Assistants). The DON stated they are not meeting the DHPPD staffing requirements. The DON stated they call their sister facilities for staffing, but the facility does not use Nursing Registry. The DON stated CNAs should have 12 to 14 residents on weekdays. The DON stated 19 residents during the weekends was not acceptable. During an interview with the Administrator (ADM) on [DATE] at 2:41 pm, ADM stated she realizes the facility has a staffing problem, but the facility is actively hiring. The ADM stated they are not using Nursing Registry because they did not show up in the past. The ADM stated they are reaching out to sister facilities. During an interview with Resident 4 on [DATE] at 9:46 am, Resident 4 stated he had been residing in the facility for nine months. Resident 4 stated that he could not walk and had to use a wheelchair. Resident 4 continued the interview but was not answering questions appropriately. Resident 4 was observed falling asleep in his wheelchair. During a telephone interview with ADM on [DATE] at 11:15 am, the ADM stated the facility had a staffing waiver before, but it expired, and the facility is not eligible to reapply. During a telephone interview with ADM on [DATE] at 11:35 am, ADM stated it is important to maintain adequate staffing to ensure care and safety for the residents and to prevent staff burn out. A review of the facility's policy titled, Wandering and Elopements with a revision date of ,d+[DATE], indicated: 1. The facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 2. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy titled Falls and Fall Risk, Managing, revised on ,d+[DATE] indicated based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. A review of the facility's policy titled, Staffing with a revision date of ,d+[DATE], indicated the facility would provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents.

Based on interviews and record reviews, the facility failed to ensure to follow the facility's COVID-19 Mitigation Plan to manage the impact of COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus) to 21 (1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 25) of 25 sampled residents and 4 of 4 sampled staff by failing to: 1. Ensure residents that test positive from COVID-19 and asymptomatic (does not manifest physical signs and symptoms of COVID-19) was isolated for 10 days from the date of their positive test (as long as they have not subsequently developed symptoms). Resident 1, who was confirmed positive of COVID-19 and asymptomatic, stayed in the facility's Red Zone (area/cohort in the facility where all Covid-19 confirmed positive residents were placed) for 19 days. This deficient practice had the potential for Resident 1 to experience prolonged symptoms of Covid-19, loneliness, and psychological distress from being in the Red Zone longer than required. Resident 1 was found not breathing in her room, in the facility's Red Zone, on [DATE] at 8:57 pm. 2. Ensure Resident 3, who was confirmed positive of COVID-19, was placed in the facility's Red Zone immediately after confirming COVID-19 positive test result. Resident 3 stayed in the facility's Yellow Zone (area/cohort in the facility where all residents that were admitted and asymptomatic, readmissions, exposed, PUI [person under investigation], indeterminate test results, and [CONDITION(S)] residents were placed) for 12 days. The facility's census record indicated Resident 3 was moved to the Red Zone on [DATE], instead of [DATE] (12 days) when Resident 3 tested positive on COVID-19 Antigen test result and presented symptoms of COVID-19. This deficient practice had the potential for the transmission of COVID-19 virus to the facility staff assigned to care for Resident 3 and to other residents residing in the facility. 3. Ensure to provide testing results for residents and staff within a clinically valuable timeframe (within 48 hours) as indicated in the facility's COVID-19 Mitigation Plan. The facility's COVID-19 test results for Residents 1 and 3 were not received timely within a turn-around time of 48 hours or less, and four facility staff. Licensed vocational nurse (LVN) 1's COVID-19 positive test result was received after 5 days, LVN 2's COVID-19 negative test result was received after 8 days, LVN 5's COVID-19 positive result was received after 4 days, and Certified Nursing Assistant (CNA) 1's COVID-19 negative test result was received after 7 days. This deficient practice resulted in receiving delayed COVID-19 test results and a delay in the required isolation of COVID-19 positive residents/staff and required quarantine of known exposed residents/staff. 4. Ensure Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21 (18) other sampled residents that were COVID-19 positive were tested repeatedly after the facility received their COVID-19 positive results. This deficient practice resulted to the facility's inability to track the number of isolation and quarantine days of residents who contracted and/or exposed to COVID-19 virus in the facility. 5. Ensure to test Resident 5 for the COVID-19 virus upon admission to the facility on [DATE]. Resident 5 did not have records of a negative COVID-19 testing, 72 hours prior to admission to the facility. Resident 5 was roomed in with Resident 25 from [DATE] to [DATE]. Resident 25 was discharged to home on [DATE]. Resident 5's initial COVID-19 testing was conducted in the facility on [DATE] (five days after admission) and COVID-19 positive result was received on [DATE]. 6. Ensure to notify Resident 25 and responsible party about the facility's COVID-19 (a potentially severe, primarily respiratory illness caused by a coronavirus) outbreak (an incident in which two or more persons experience a similar illness after a common exposure) in the facility on [DATE] status post [MEDICAL RECORD OR PHYSICIAN ORDER] 7. Ensure to notify Resident 25 and responsible party that Resident 25 shared the same room with Resident 5 on [DATE] to [DATE] with COVID-19 positive result received on [DATE]. These deficient practices delayed the early identification of COVID-19 virus in Resident 5 and placed Resident 25 at risk for COVID-19 exposure and early identification of COVID-19. As a result, Resident 25 was transferred to the General Acute Care Hospital emergency room (GACH ER) for COVID-19 symptoms, after five days of being discharged to home. Resident 25 expired at the GACH on [DATE] from severe respiratory distress, pneumonia and died from COVID-19 on [DATE]. As a result of these deficient practices, the facility yielded a total of 56 positive COVID-19 residents and 26 positive COVID-19 facility staff during the facility's COVID-19 outbreak from [DATE] to [DATE]. Findings: 1. A review of Resident 1's Admission Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical dated [DATE], indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Quarterly Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated [DATE], indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 sometimes understood and sometimes understands others. The MDS indicated Resident 1 required extensive assistance with a one-person physical assistance for dressing, eating, and personal hygiene. A review of Resident 1's Covid-19 test results, collected on [DATE] at 11:31 am, indicated the results was reported to the facility on [DATE] (after six days) at 9:32 am. The laboratory result indicated COVID-19 was not detected. A review of Resident 1's Covid-19 test results, collected on [DATE] at 7:28 am, indicated the results was reported to the facility on [DATE] (after five days) at 9:15 am. The laboratory result indicated COVID-19 was not detected. A review of Resident 1's COVID-19 test results collected on [DATE] at 9:11 am, indicated the results was reported to the facility on [DATE] (after five days) at 7:54 am. The laboratory result indicated COVID-19 was detected from Resident 1. A review of Resident 1's COVID-19 test results indicated another COVID-19 PCR test was collected on [DATE] at 12:10 PM. The PCR test result indicated the result was reported to the facility on [DATE] (after nine days) at 4:47 AM. The laboratory result indicated COVID-19 was detected from Resident 1. A review of a facility document titled Change in Condition, dated [DATE], indicated Resident 1 was confirmed COVID-19 positive with both rapid antigen testing and laboratory Polymerase Chain Reaction (PCR [detects genetic material of the virus) tests. A review of Resident 1's Progress Notes dated [DATE] and timed at 4:15 pm, indicated a Social Services Note that showed the facility's social services supervisor (SSS) spoke to Resident 1's family member (FM 1) regarding Resident 1's positive COVID-19 test result. SSS informed FM 1 that Resident 1 would be changing rooms (Red Zone). A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Progress Notes from [DATE] to [DATE] indicated the following events in Resident 1's status and duration of stay in the facility's Red Zone: a. [DATE] timed at 11:35 am, indicated Resident 1 had no signs or symptoms of any acute distress, no shortness of breath, or cough. b. [DATE] timed at 1:39 pm, indicated Resident 1 had no signs or symptoms of any acute distress, no shortness of breath, or cough. c. [DATE] timed at 1:30 am, indicated Resident 1 was on monitoring for Covid-19 positive results and that isolation precautions were always maintained. The Progress Notes indicated Resident 1 did not have fever, chills, cough, shortness of breath, difficulty breathing, or nausea/vomiting. d. [DATE] timed at 10:08 am, indicated Resident 1 had no signs or symptoms of any acute distress, no shortness of breath, or cough. e. [DATE] timed at 1:14 am, indicated Resident 1 did not have acute distress, breathing was even and unlabored (without difficulty), skin was warm and dry to touch, and no complaint of pain or discomfort. The Progress Notes indicated Resident 1 did not have a fever, chills, cough, shortness of breath, difficulty breathing, or nausea/vomiting. f. [DATE] timed at 11:56 am, indicated Resident 1 did not have signs or symptoms of any acute distress, no shortness of breath, or cough. g. [DATE] timed at 3:06 pm, indicated Resident 1 did not have acute distress, breathing was even and unlabored, skin was warm and dry to touch, and no complaint of pain or discomfort. The Progress Notes indicated Resident 1 did not have a fever, chills, cough, shortness of breath or difficulty breath, or nausea/vomiting. h. [DATE] timed at 10:35 am, indicated Resident 1 did not have any signs or symptoms of any acute respiratory distress and no shortness of breath or cough. i. [DATE] timed at 11:10 am, indicated FM 1 spoke with the facility's case manager (LVN 4) and expressed frustration, wanting Resident 1 to be moved back to her previous room (and removed from the Red Zone). The Progress Note indicated LVN 4 informed FM 1 that they have spoken to the Public Health Nurse (PHN) and that residents who were symptomatic of COVID-19 are treated with 20 days of isolation during an outbreak. LVN 4 stated to FM 1 if they are asymptomatic, residents are isolated for 14 days. LVN 4 stated to FM 1 that the facility team will do what they can, and that Resident 1's room change (back to the Green Zone [facility unit for residents that were Covid Recovered, never had symptoms, asymptomatic, completed 14-day quarantine, covid negative]) should take place on or about [DATE] per the guidance. j. [DATE] timed at 10:08 am, indicated Resident 1 did not have a fever, did not have any signs or symptoms of respiratory distress, and did not have any signs or symptoms of any acute distress or discomfort. k. [DATE] timed at 5:30 pm, indicated Resident 1 did not have a fever, did not have any signs or symptoms of respiratory distress, and did not have any signs or symptoms of any acute distress or discomfort. l. [DATE] timed at 10:53 am, indicated Resident 1 did not have a fever, did not have any signs or symptoms of respiratory distress, and did not have any signs or symptoms of any acute distress or discomfort. m. [DATE] timed at 7:22 pm, indicated Resident 1's breathing was even and unlabored, did not have a cough or congestion, and did not have any acute distress. n. [DATE] timed at 8:20 pm, indicated CNA 1 reported to LVN 1 hearing Resident 1 coughing and observed the resident coughing out phlegm and stopped breathing. The Progress Note indicated that LVN 1 went into Resident 1's room at 8:25 pm and saw the resident pale looking and no breathing. The Progress Note indicated that cardiopulmonary resuscitation (CPR) was started, and [DATE] emergency services was called and continued CPR. o. [DATE] timed at 12:26 am, indicated Resident 1 expired at 8:57 pm on [DATE]. The Progress Note indicate Resident 1 was still in the same room inside the facility's Red Zone when she passed away. A review of Resident 1's care plans for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview with FM 1 on [DATE] at 3:40 PM, FM 1 stated Resident 1 was in the Red Zone too long. FM 1 stated they wanted to know why Resident 1 stayed in the facility's Red Zone for so long. During a telephone interview with the Infection Preventionist (IP) Nurse 2 on [DATE] at 1:22 pm, IP Nurse 2 stated she was not working in the facility during the time of the outbreak from [DATE] to [DATE]. IP Nurse 2 stated Resident 1 was moved to the Red Zone on [DATE]. IP Nurse stated Resident 1 was asymptomatic. IP Nurse 2 stated Resident 1 was in the facility's Red Zone from [DATE] until [DATE] and that was a total of 19 days. IP Nurse 2 stated if Resident 1 was in the Red Zone longer than the required isolation time, Resident 1 could have been more exposed and a higher risk of developing new symptoms. IP Nurse 2 stated residents staying longer in the Red Zone could be crying and affect them emotionally and physically. IP Nurse 2 stated the facility should have checked Resident 1 since she was asymptomatic and based on the facility's mitigation plan, Resident 1 should have been placed back in the Green Zone, after 14 days (10 days in the facility's MP) if she did not have symptoms. IP Nurse 2 stated during a concurrent record review of Resident 1's Progress Notes from [DATE] to [DATE], looked like Resident 1 did not have any COVID-19 symptoms. During a telephone interview with LVN 1 on [DATE] at 4:11 pm, LVN 1 stated CNA1 heard Resident 1 coughing and found out Resident 1 stopped breathing. LVN 1 stated CNA1 called for help. LVN 1 stated she was with Resident 1 while RN 2 found out Resident 1's code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop). LVN 1 stated Resident 1 was full code (all resuscitation procedures will be provided to keep them alive, including CPR [cardiopulmonary resuscitation is the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation]). LVN 1 stated they started CPR until the paramedics arrived. LVN 1 stated the paramedics continued CPR, but Resident 1's breathing/pulse did not restart. During a telephone interview with RN 2 on [DATE] at 4:25 pm, RN 2 stated during Resident 1's code, he remembered they called 911 (emergency phone number) emergency services. RN 2 stated he could not remember the incident anymore. During a telephone interview and concurrent review of Resident 1's Progress Notes dated [DATE] and timed at 11:10 am, with LVN 4 on [DATE] at 12:37 PM, LVN 4 stated Resident 1 was not eating well and was not thriving. LVN 4 stated Resident 1 was not doing too well during that time. LVN 4 stated the guidance was to monitor the resident and not expose Resident 1. LVN 4 stated during the facility outbreak, it went back and forth if Resident 1 was truly symptomatic. LVN 4 stated Resident 1's family stated she was not symptomatic, and that the facility stated Resident 1 needed more monitoring. During a telephone interview with DON 2 on [DATE] at 1:05 pm, DON 2 stated she did not know who the CNA that was working on the date of Resident 1's death. DON 2 stated she was looking for the facility's January Assignment Sheets but could not find it because the facility did not have copies of the Assignments Sheets anymore. During a telephone interview with IP nurse 2 on [DATE] on 1:37 pm, IP Nurse 2 clarified that residents that test positive and were asymptomatic should be isolated for 10 days from the date of their positive test results. During another telephone interview and concurrent review of Resident 1's Change of Condition document with IP Nurse 2 on [DATE] at 2:30 pm, IP Nurse 2 stated there was no rapid antigen testing conducted for Resident 1. IP Nurse 2 stated she did not know why the facility documented in the resident's records that Resident 1 had a rapid antigen testing on [DATE] or any days during the facility's COVID-19 outbreak. A review of Resident 1's Certificate of Death dated, [DATE] and timed at 8:57 pm, indicated Resident 1's cause of death as [CONDITION(S)] (sudden, unexpected loss of heart function, breathing, and consciousness) and COVID-19. 2. A review of Resident 3's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE]. The Face Sheet indicated Resident 3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's Quarterly MDS, dated [DATE], indicated Resident 3 was severely impaired of cognition. The MDS indicated Resident 3 was usually understood and usually understands others. The MDS indicated Resident 3 required limited assistance with a one-person physical assist for transferring, dressing, and toilet use. A review of Resident 1's History and Physical dated [DATE] indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3's COVID-19 test results, collected on [DATE] at 9:17 am, indicated the results was reported to the facility on [DATE] (after eight days) at 11:01 am. The laboratory result indicated COVID-19 was not detected. A review of Resident 3's COVID-19 test results, collected on [DATE] at 11:55 am, indicated the results was reported to the facility on [DATE] (after 15 days) at 4:46 am. The laboratory result indicated COVID-19 was detected. A review of Resident 3's Change in Condition, dated [DATE] at 11:11 am, indicated Resident 3 had a decline in ADL's (Activities of Daily Living), fatigue and weakness were noted, and had a positive Rapid Antigen COVID-19 test which was conducted on [DATE]. A review of Resident 3's COVID-19 Antigen test results, collected on [DATE], indicated COVID-19 was detected. A review of Resident 3's COVID-19 PCR test results, indicated another PCR COVID-19 test was collected on [DATE] at 11:48 am indicated the result was reported to the facility on [DATE] (after four days) at 6:10 am. The laboratory result indicated COVID-19 was detected. A review of the facility's census from [DATE] to [DATE] indicated Resident 3 stayed in the facility's Yellow Zone after testing positive for COVID-19 Rapid Antigen test (while waiting for the PCR test result collected on [DATE] and [DATE]), was received by the facility on [DATE] (11 days). The facility's census record indicated Resident 3 was moved to the Red Zone on [DATE]. A review of Resident 3's Progress Notes dated [DATE] and timed at 4:42 am, indicated Resident 3 was being monitored for a positive COVID-19 rapid test. A review of Resident 3's Progress Notes dated [DATE] and timed at 2:34 pm, indicated Resident 3 was being monitored closely in the facility's Yellow Zone with vital signs, temperature, and oxygen saturation checks. A review of Resident 3's Progress Notes dated [DATE] and timed at 11:39 am, indicated Resident 3 was on oral antibiotics for a Rapid positive COVID-19 test. The Progress Note indicated Resident 3 would be monitored closely in the facility's Yellow Zone with vital signs, temperature, and oxygen saturation checks. A review of Resident 3's MAR from [DATE] to [DATE] indicated the licensed nurses' monitoring of Resident 3's COVID-19 symptoms which included: fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion, runny nose, nausea or vomiting. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's care plans for the management of Resident 3's COVID-19 symptoms, was initiated on [DATE] (6 days after Resident 3 was confirmed positive). A review of Resident 3's Progress Notes dated [DATE] timed at 10:57 am indicated the resident continued on intravenous fluids administration due to poor appetite and refusal to eat and drink. At 2:40 pm, the Progress Note indicated Resident 3 passed away with no respiration, no pulse noted. During a telephone interview with IP Nurse 2 on [DATE] at 3:41 pm, IP Nurse 2 stated that Resident 3 was in the Yellow Zone from [DATE] until [DATE]. IP Nurse 2 stated Resident 3's COVID-19 test was collected on [DATE], received on [DATE], and the results were reported on [DATE]. IP Nurse 2 stated Resident 3 had an Antigen Rapid test done on [DATE] and the results were positive. IP Nurse 2 stated Resident 3 should have been placed in the Red Zone immediately on [DATE] to isolate the resident appropriately and to prevent the transmission and further spread of COVID-19 in the facility. IP Nurse 2 stated Resident 3 was not placed in the Red Zone, according to the facility census and Progress Notes. IP Nurse 2 stated she did not know why Resident 3 was not moved to the Red Zone because she was not the facility's IP Nurse during that outbreak. IP Nurse 2 stated Resident 3 was moved to the Red Zone on [DATE]. 3. A review of random facility staff's COVID-19 PCR Test Results indicated the following information: a. For Licensed Vocational Nurse (LVN) 1 COVID-19 test results collected on [DATE] at 3:33 pm, indicated the result was reported to the facility on [DATE] (after three days) at 12:58 pm. The laboratory result indicated COVID-19 was not detected. COVID-19 test results collected on [DATE] at 3:30 pm, indicated the result was reported to the facility on [DATE] (after five days) at 12:42 pm. The laboratory result indicated COVID-19 was detected. b. For Licensed Vocational nurse (LVN) 2 COVID-19 test results, collected on [DATE] at 3:35 pm, indicated the result was reported to the facility on [DATE] at 5:10 pm (after six days). The laboratory result indicated COVID-19 was not detected. COVID-19 test results collected on [DATE] at 3:02 pm, indicated the result was reported to the facility on [DATE] at 4:08 am (after four days). The laboratory result indicated COVID-19 was not detected. COVID-19 test results collected on [DATE] at 6:01 am, indicated the result was reported to the facility on [DATE] (after seven days) at 1:14 am. The laboratory result indicated COVID-19 was not detected. COVID-19 test results collected on [DATE] at 7:10 am indicated the result was reported to the facility on [DATE] (after seven days) at 10:16 am. The laboratory result indicated COVID-19 was not detected. COVID-19 test results collected on [DATE] at 6:40 am indicated the result was reported to the facility on [DATE] at 10:40 am (after seven days). The laboratory result indicated COVID-19 was not detected. COVID-19 test results collected on [DATE] at 8:20 am indicated the result was reported to the facility on [DATE] at 6:31 am (after eight days). The laboratory result indicated COVID-19 was not detected. COVID-19 test results collected on [DATE] at 11:34 am indicated the result was reported to the facility on [DATE] at 4 am (after six days). The laboratory result indicated LVN 2's specimen was unsatisfactory. COVID-19 test results collected on [DATE] at 11:40 am indicated the result was reported to the facility on [DATE] at 11:18 am (after three days). The laboratory result indicated COVID-19 was not detected. COVID-19 test results collected on [DATE] at 9:53 am indicated the result was reported to the facility on [DATE] at 6:07 am (after five days). The laboratory result indicated COVID-19 was not detected. c. For Licensed Vocational Nurse (LVN) 5 COVID-19 test results collected on [DATE] at 7:25 am indicated the result was reported to the facility on [DATE] at 1:46 am (after four days). The laboratory result indicated COVID-19 was detected. d. For Certified Nurse Assistant (CNA) 1 COVID-19 test results, collected on [DATE] at 12:16 pm, indicated the result was reported to the facility on [DATE] at 3:45 pm (after four days). The laboratory result indicated Covid-19 was not detected. COVID-19 test results, collected on [DATE] at 8:56 am, indicated the result was reported to the facility on [DATE] at 4:30 am (after three days). The laboratory result indicated Covid-19 was not detected. COVID-19 test results, collected on [DATE] at 4:52 am, indicated the result was reported to the facility on [DATE] at 1:15 am (after seven days). The laboratory result indicated COVID-19 was not detected. During a telephone interview and concurrent review of Resident 1's COVID-19 test results on [DATE] at 12:47 pm, IP Nurse 2 stated COVID-19 test results should take two days. IP Nurse 2 stated for Resident 1's COVID-19 test that was collected on [DATE], the results were reported on [DATE] and that was a five-day delay. IP Nurse 2 stated for Resident 1's COVID-19 test that was collected on [DATE], the results were reported on [DATE], 13 days later. IP Nurse 2 started working in the facility in [DATE] and did not know how the facility managed the previous outbreak. IP Nurse 2 stated she could not find the documented evidence of the IP Nurse 1's (resigned) line listing and tracking of the residents and staff. IP Nurse 2 stated the importance of receiving timely COVID-19 test results was so that if a resident was positive, the facility could place them in their proper cohort, prevent the transmission of COVID-19, and and be treated and monitored properly. IP Nurse 2 stated there was definitely a delay with Resident 1's COVID-19 test results. IP Nurse 2 stated if she did not receive COVID-19 test results within two days, the right thing to do was conduct a Rapid Antigen COVID-19 test. During a telephone interview with Director of Nursing (DON) 2 (Previous DON [1] of the facility during Resident 1's stay at the facility, resigned) on [DATE] at 1:05 pm, DON 2 stated Resident 1 being in the Red Zone for 19 days was overstaying. DON 2 stated Resident 1 did not need to be in the Red Zone for more than the required isolation period, since she did not have symptoms. DON 2 stated if Resident 1 was in the Red Zone much longer than required, Resident 1 would be isolated in her room, away from her family and other healthcare workers. DON 2 stated there could be an emotional impact as COVID-19 residents would have depression and anxiety. DON 2 stated COVID-19 positive residents are decreasing but the mental effect is increasing. During another telephone interview on [DATE] at 1:20 pm, the IP Nurse 2 stated the previous Administrator (ADM 1) stated he informed the Department of Health ([DPH] State Agency) regarding the delay in COVID-19 testing results but did not remember who he spoke to and did not remember what they advised. IP Nurse 2 could not find documented evidence that attempts to find another laboratory that could deliver timely results were attempted. During a telephone interview, on [DATE] at 1:53 pm, Resident 1's Antigen Rapid test documented on [DATE] in the resident's SBAR form was clarified with IP Nurse 2. IP Nurse 2 stated there was no Antigen Rapid test done for Resident 1 on [DATE] while waiting for the PCR test result to come back. IP Nurse 2 stated Resident 3's PCR test was collected on [DATE] and the results were reported on [DATE]. During the same telephone interview, IP Nurse 2 stated there was an Antigen Rapid test done for Resident 3 on [DATE] and the result was positive. During the same telephone interview and concurrent review of LVN 2's COVID-19 test results with IP Nurse 2, IP Nurse 2 stated LVN 2's COVID-19 test results on [DATE] at 11:34 am were noted as specimen unsatisfactory which indicated that the results were rejected. IP Nurse 2 stated if COVID-19 test results were unsatisfactory, then the facility should re-swab the resident or staff member and conduct an Antigen Rapid testing. IP Nurse 2 stated there was no rapid testing conducted for LVN 2 on [DATE]. IP Nurse 2 stated that another COVID-19 PCR test was done for LVN 2 on [DATE]. During the same telephone interview, IP Nurse 2 stated there was no documentation that LVN 1 had a rapid test done, after her COVID-19 PCR test was collected on [DATE] and results were reported on [DATE]. During the same interview, IP Nurse 2 stated CNA 1's COVID-19 test results were collected by the facility on [DATE] and the results were reported by the laboratory on [DATE] (seven days delay). IP Nurse 2 stated the facility did not conduct a Rapid Antigen test to CNA 1. However, IP Nurse 2 stated, CNA 1 went to her private physician and was tested for COVID-19 on [DATE]. IP Nurse 2 stated CNA 1's COVID-19 test result from the private physician indicated COVID-19 was detected. IP Nurse 2 stated that LVN 1, LVN 2, and CNA 1's COVID-19 test results' turnaround time in the facility should had been two days (48 hours). IP Nurse 2 stated that IP Nurse 1 or the facility should have conducted rapid testing if COVID-19 PCR test results were not received timely or within the 48 hours' timeframe or if the specimen was rejected. 4. A review of the facility's PCR COVID-19 test results for residents and facility staff indicated residents and facility staff were retested after testing positive to COVID-19: a. Resident 4 was tested on [DATE] and the positive COVID-19 results were reported on [DATE]. Resident 4 was retested on [DATE] and the positive COVID-19 results were reported on [DATE]. b. Resident 5 was tested on [DATE] and the positive COVID-19 results were reported on [DATE]. Resident 5 was retested on [DATE] and the positive COVID-19 results were reported on [DATE]. c. Resident 6 was tested on [DATE] and the positive COVID-19 results were reported on [DATE]. Resident 6 was retested on [DATE] and the positive COVID-19 results were reported on [DATE]. d. Resident 7 was tested on [DATE] and the positive COVID-19 results were reported on [DATE]. Resident 7 was retested on [DATE] and the positive COVID-19 results were reported on [DATE]. e. Resident 8 was tested on [DATE] and the positive COVID-19 results were reported on [DATE]. Resident 8 was retested on [DATE] and the positive COVID-19 results were reported on [DATE]. f. Resident 9 was tested on [DATE] and the positive COVID-19 results were reported on [DATE]. Resident 9 was retested on [DATE] and the positive COVID-19 results were reported on [DATE]. g. Resident 10 was tested on [DATE] and the positive COVID-19 results were reported on [DATE]. Resident 10 was retested on [DATE] and the positive COVID-19 results were reported on [DATE]. h. Resident 11 was tested on [DATE] and the positive COVID-19 results were reported on [DATE]. Resident 11 was retested on [DATE] and the positive COVID-19 results were reported on [DATE]. i. Resident 12 was tested on [DATE] and the positive COVID-19 results were reported on [DATE]. Resident 12 was retested on [DATE] and the posit[TRUNCATED]

Based on interview, and record review, the facility failed to ensure one of two sampled residents were free from neglect by providing care, treatment, and services to avoid physical harm, pain, and emotional distress (Resident 1), who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Provide Resident 1 with pain management (the process of alleviating pain) by not assessing the presence of the resident's pain; identifying the characteristics of pain (intensity, pattern, location, frequency and duration); addressing the underlying causes of the pain; developing and implementing approaches to pain management by providing non-pharmacological interventions, assessing the resident's pain prior to medication administration, and providing medications as ordered; and monitoring for the effectiveness of the pain medication given. Resident 1 received pain medication on 5/19/2021 at 9 PM. Resident 1 did not receive pain medication on 5/20/2021 as requested by the resident. 2. Prevent Resident 1 from receiving delayed treatment from the Licensed Vocational Nurses and Registered Nurse (RN 1, LVN 1, LVN 2, LVN 5) by not recognizing Resident 1's change of condition of having abdominal (stomach area) pain and not notifying the resident's physician (Physician 1) of the resident's other symptoms such as nausea and worsening pain on 5/19/2021 and 5/20/2021. 3. Prevent Resident 1 from receiving delayed treatment by not notifying Physician 1 that Resident 1 did not have bowel movements on 5/12, 5/13, 5/14, and 5/15/2021 (4 days) in order for the resident to receive relief from not having bowel movements and a treatment plan. As a result, Resident 1 experienced constant and unrelieved moderate to severe pain from 2 AM to 11:30 AM (9.5 hours) on 5/20/2021, requiring transfer to General Acute Care Hospital (GACH). Resident 1 was found to have small bowel obstruction and bowel perforation (a small hole in the small intestine) which led to a surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE]. The Face Sheet indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 2/10/2021 indicated Resident 1's cognition (thought process) and communication (speech and understanding) was intact for daily decision-making. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provided weight-bearing support) with one person for transferring and the resident was unable to walk. The MDS indicated Resident 1 was able to move between locations using his wheelchair requiring supervision with one person. The MDS indicated Resident 1 had no pain or did not receive any pain medication in the last five days look back period. A review of Resident 1's Pain Care Plan, revision date 2/22/2021, indicated a goal that the resident would verbalize comfort with current intervention and demonstrate comfort as manifested by free facial grimace. Interventions include observe for pain, severity, location, duration; administer pain medication as ordered; evaluate effectiveness of pain medication; and notify physician if current pain medication is ineffective. A review of the Resident 1's GACH's Emergency Department (ED) Provider Note dated 5/20/2021, indicated Resident 1's chief complaint of abdominal pain at 8 out of 10 pain level (8/10, 10 being the most severe pain level and 1 is the lowest pain level) and 4 out of 10 after position change. The record indicated mid (middle) abdominal pain and distention (swollen due to pressure from inside) with nausea started since 2 AM the previous night (5/20/2021). A physical examination of Resident 1 revealed a distended abdomen with soft, positive bowel sounds, mid-abdominal tenderness (a state in which pain is felt on the release of pressure) on palpation (a method of feeling with the fingers or hands during a physician examination) with positive guarding (involuntary reaction to protect an area of pain). A review of Resident 1's GACH History and Physical (H&P), dated 5/20/2021, indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The GACH H&P indicated that Resident 1 was doing well until the early morning of 5/20/2021 when the resident experienced severe abdominal pain. A review of Resident 1's computerized tomography ([CT] combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images [slices] of the bones, blood vessels and soft tissues inside the body) scan of the abdomen dated 5/20/2021, indicated distended (swollen or bloated) small bowel loops measuring up to 5 centimeters (cm, a unit or measurement) in diameter (a straight line passing from side to side through the center of the body) in the mid-right abdomen. The CT findings indicated it was compatible with small bowel obstruction. During an interview, on 6/8/2021 at 11:47 AM, Resident 1 stated on 5/20/2021 at around 2 AM, he complained of nausea (uneasiness of the stomach) and 6 out of 10 pain (6/10, 6 being moderate pain) in the stomach to License Vocational Nurse 1 (LVN 1), the charge nurse during the 11 PM to 7 AM shift. Resident 1 stated that he asked for pain medication and requested to be transferred to GACH. Resident 1 stated LVN 1 did not listen to him. Resident 1 stated LVN 1 gave him medication for his nausea but did not give him pain medication. Resident 1 stated when he woke up the same morning, his stomach pain had become worst at 10 out of 10 (severe pain) pain level. Resident 1 stated he reported his severe stomach pain to LVN 2 (7 AM to 3 PM shift charge nurse) and requested for a pain medication between 8 AM to 9 AM, on 5/20/2021, but LVN 2 did not do anything. On the same interview, on 6/8/2021 at 11:47 AM, Resident 1 stated at 10 AM, he requested to be transferred to GACH to Registered Nurse 1 (RN 1). Resident 1 stated that RN 1 told him he had to wait for an hour for the ambulance to arrive. Resident 1 stated he wanted to call a taxi and go to GACH himself, but RN 1 told him he would be AMA (leaving hospital/facility against medical advice) if he leave the facility. Resident 1 stated he was in a lot of pain and had to call the Ombudsman, a resident advocate, to talk to the facility charge nurse. Resident 1 stated the licensed nurses did not do any interventions while he was waiting to be transferred to GACH. Resident 1 stated after a few minutes of talking to the Ombudsman, he was transferred to GACH via 9-1-1 emergency services. Resident 1 stated, I ended up in surgery. During an interview on 6/8/2021 at 1:10 PM., RN 1 stated that she recalled Resident 1 informed LVN 2 on 5/20/2021 (7AM to 3 PM shift) that he had pain in his abdomen for a long time and wanted to go to the GACH. RN 1 stated that LVN 2 had called Resident 1's Physician 1 at around 9:30 AM and received an order to transfer to the GACH at 10:44 AM. RN 1 stated they were working on getting an ambulance for Resident 1 during that time. During a concurrent interview and Resident 1's Medication Administration Record (MAR) review dated 5/19/2021 through 5/20/2021, on 6/8/2021 at 1:15 PM, RN 1 stated LVN 5 (3 PM to 11 PM shift nurse) administered [MEDICATION(S)] (narcotic pain medication) 5/325 milligrams (mg) tablet to Resident 1 on 5/19/2021 at 9 PM. There was no pain assessment documented prior to pain medication administration (on 5/19/2021 at 9 PM). The pain reassessment (3 PM to 11 PM shift on 5/19/2021) indicated 0 pain and the medication intervention were effective. RN 1 stated that the nurse (LVN 5) should have done pain assessment prior to giving the pain medication (on 5/19/2021 at 9 PM). RN 1 stated there was no documented evidence in the MAR that Resident 1 received pain medications during the 11 PM to 7 AM shift on 5/20/2021. On the same interview and review of Resident 1's MAR and licensed nurses progress notes dated 5/20/2021, on 6/8/2021 at 1:15 PM, RN 1 stated that she could not find documented evidence that LVN 2 had assessed Resident 1's pain (during the 7 AM to 3 PM shift on 5/20/2021). RN 1 stated the licensed nurse (LVN 2) should have assessed Resident 1's pain and provided interventions such as pain medication. RN 1 stated that Resident 1 was so upset that day (on 5/20/2021) and RN 1 recalled Resident 1 was yelling because of pain and wants to go to hospital. During an interview, on 6/8/21 at 1:35 p.m., LVN 4 stated that she remembered Resident 1, on 5/20/2021 at 9 AM, was very upset and yelling and complained of pain and wanted to be transferred to the hospital. During a telephone interview, on 6/10/2021 at 10:30 AM, Ombudsman 1 stated Resident 1 called the Ombudsman's office around 9:30 AM on 5/20/2021 and stated he was in pain since 2 AM (on 5/20/2021) and the facility did not do anything. Resident 1 told Ombudsman 1 that his pain level around 9 AM (on 5/20/2021) was 10 out of 10 and at nighttime (on 5/20/2021, time not specified) was 5 out of 10. Resident 1 told Ombudsman 1 that he wanted to call 9-1-1 but RN 1 told him he would be discharged against medical advice (AMA) if he did that. Ombudsman 1 stated they (and another Ombudsman on the line, not identified) had talked to RN 1 and asked what the facility was doing for Resident 1's severe pain. RN 1 informed Ombudsman 1 that they will call 9-1-1 emergency services for Resident 1. During a telephone interview, on 6/29/2021 at 6:20 AM, LVN 1 (the charge nurse during the 11 PM to 7 AM shift on 5/19/2021) stated Resident 1 was up late that night on 5/19/2021 and complained of nausea. LVN 1 stated Resident 1 told him he was not feeling too good because of nausea and the resident's facial expression looked like as if he ate something sour like lime. LVN 1 sated she did not recall Resident 1 complained of abdominal pain. LVN 1 stated she administered nausea medication to Resident 1. LVN 1 stated she did not report this to the RN supervisor or Physician 1. LVN 1 stated she did not document Resident 1's nausea and assessment of Resident 1's condition in the resident's records. During a follow up interview with RN 1 on 7/1/2021 at 11:56 AM, RN 1 stated she conducted a visual assessment (on 5/20/2021) and Resident 1 was pointing to his stomach. RN 1 stated she did not document and conducted a comprehensive pain assessment of Resident 1's condition (on 5/20/2021). RN 1 stated that it was important to know the underlying cause of Resident 1's pain. RN 1 stated she could not find documented evidence of a timely pain assessment or reassessment on 5/20/2021. RN 1 stated the licensed nurses did not implement Resident 1's care plan for pain such as to assess quality, location, and duration of pain, positioning, and provide pain medication. During a concurrent interview and record review of Resident 1's activities of daily living (essential and routine tasks, such as bed mobility, transfer, walking in room and corridor, dressing, eating, toilet use, and personal hygiene) documentation titled Documentation Survey Report, for the month of May 2021, on 7/1/2021 at 4:23 PM, the MDS coordinator stated Resident 1 did not have bowel movements (BM) on 5/12, 5/13, 5/14, and 5/15/2021 (4 days). The report indicated Resident 1 had bowel movements on 5/16/2021 which was medium size and loose BM during the 11 PM to 7 AM shift and medium size and soft BM during the 7 AM to 3 PM shift. The report indicated Resident 1 did not have BM on 5/17, 5/18, 5/19, and 5/20/2021 (prior to the GACH transfer on this day). During the concurrent review of Resident 1's MAR with the MDS coordinator, the MDS coordinator stated Resident 1 did not receive a stool softener ([MEDICATION(S)] sodium 100 milligrams [mg, a unit of measurement] capsule every 12 hours as needed) as ordered for constipation (when bowel movements become less frequent, and stools become difficult to pass). The MDS coordinator stated the order did not specify how many days Resident 1 would not have a BM for the licensed nurses to administer the medication. During a concurrent interview and record review of Resident 1's care plans, on 7/21/2021 at 1:48 PM, the Director of Nursing (DON 2) stated the resident did not have a care plan for constipation and for the resident's care plan for managing bowel and bladder alteration, the intervention will not be effective in managing constipation. During a telephone interview, on 7/22/2021 at 3:30 PM, Physician 1 stated he did not receive a report that Resident 1 did not have bowel movements (BM) on 5/12, 5/13, 5/14, and 5/15/2021 (4 days). Physician stated if he had received a report, he would order a different treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview, on 7/22/2021 at 4:08 PM, DON 2 stated the licensed nurses (LVN 1 and 2) should have followed the standard practice and based on standard practice, the physician should have been informed that Resident 1 did not have bowel movements (BM) on 5/12, 5/13, 5/14, and 5/15/2021 (4 days). A review of the facility's policy and procedure, titled Abuse Prevention Program, undated, indicated, the residents have the right to be free from neglect. The administration will develop and implement policies and procedures to aid the facility in preventing neglect. A review of the facility's policy and procedures titled, Pain Assessment and Management , revised on 3/2020, indicated that Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that included: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. The policy indicated that Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The policy indicated to Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. A review of the facility's policy and procedures titled, Change in a Resident's Condition or Status Revised February 2021, indicated that facility will notify resident's attending physician of significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; need to transfer the resident to a hospital/treatment center. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of the facility's policy and procedures titled, Acute Condition Changes - Clinical Protocol Revised March 2018, indicated the nurse shall assess and document/report the following baseline information: Current level of pain, and any recent changes in pain level; Level of consciousness; Cognitive and emotional status; Onset, duration, severity. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the Nurse. A review of the facility's policy and procedures titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol Revised September 2017, indicated as part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. Examples of lower gastrointestinal tract conditions and symptoms include alteration in bowel movements. In addition, the nurse shall assess and document/report the following: Abdominal assessment; Digital rectal test that (examines a person's lower rectum, pelvis, and lower belly) examination; Onset, duration, frequency, severity of signs and symptoms. Check for diffuse or localized tenderness and listen for bowel sounds in area of suspected ileus (a painful obstruction of the ileum or other part of the intestine or obstruction). The staff and physician will monitor the individual's response to interventions and overall progress, for example, overall degree of comfort or distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain.

Based on interview and record review, the facility failed to provide pain management (the process of alleviating pain) for one of two sampled residents (Resident 1), including: 1. Failure to assess the intensity, pattern, location, frequency and duration of Resident 1's abdominal (stomach region) pain from 2 AM to 11:30 AM (9.5 hours). Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Failure to implement Resident 1's Pain Care Plan by the licensed nurse not evaluating the effectiveness of the pain medication given on 5/19/2021 at 9 PM and not administering pain medication as ordered when the resident complained of pain on 5/20/2021. 3. Failure to implement the facility's policy and procedure on Pain Assessment and Management, by not recognizing the presence of Resident 1's pain, identifying the characteristics of pain (intensity, pattern, location, frequency and duration); addressing the underlying causes of pain; developing and implementing approaches to pain management by providing non-pharmacological interventions, assessing the resident's pain prior to medication administration, and providing medications as ordered; and monitoring for the effectiveness of the pain medication given. Resident 1 received pain medication on 5/19/2021 at 9 PM. Resident 1 did not receive pain medication on 5/20/2021 as requested by the resident. As a result, Resident 1 experienced constant and unrelieved moderate to severe pain for 9.5 hours on 5/20/2021, requiring transfer to General Acute Care Hospital (GACH). Resident 1 was found to have small bowel obstruction and bowel perforation (a small hole in the small intestine) which led to a surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE]. The Face Sheet indicated resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 2/10/2021 indicated Resident 1's cognition (thought process) and communication (speech and understanding) was intact for daily decision-making. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provided weight-bearing support) with one person for transferring and the resident was unable to walk. The MDS indicated Resident 1 was able to move between locations using his wheelchair requiring supervision with one person. The MDS indicated Resident 1 had no pain or did not receive any pain medication in the last five days look back period. A review of Resident 1's Pain Care Plan, revision date 2/22/2021, indicated a goal that the resident will verbalize comfort with current intervention and demonstrate comfort as manifested by free facial grimace. Interventions include observe for pain, severity, location, duration, administer pain medication as ordered, evaluate effectiveness of pain medication, and notify physician if current pain medication is ineffective. A review of Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Order dated 3/30/2021, to administer [MEDICATION(S)] (a medication to prevent vomiting) four (4) milligrams (mg, a unit of measurement) by mouth every six (6) hours as needed for nausea (a feeling of sickness with an inclination to vomit). b. Order dated 3/30/2021, to administer [MEDICATION(S)] (a narcotic [a drug that affects mood and behavior] pain medication) one tablet 5/325 (5 mg of [MEDICATION(S)] [a narcotic medication] and 325 mg of acetaminophen [a pain reliever]) mg by mouth every 6 hours as needed for moderate to severe pain. A review of the Resident 1's GACH's Emergency Department (ED) Provider Note dated 5/20/2021, indicated Resident 1's chief complaint of abdominal pain at 8 out of 10 pain level (8/10, 10 being the most severe pain level and 1 is the lowest pain level) and 4 out of 10 after position change. The record indicated mid (middle) abdominal pain and distention (swollen due to pressure from inside) with nausea started since 2 AM the previous night (5/20/2021). A physical examination of Resident 1 revealed a distended abdomen with soft, positive bowel sounds, mid-abdominal tenderness (a state in which pain is felt on the release of pressure) on palpation (a method of feeling with the fingers or hands during a physician examination) with positive guarding (involuntary reaction to protect an area of pain). A review of Resident 1's GACH History and Physical (H&P), dated 5/20/2021, indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The GACH H&P indicated that Resident 1 was doing well until the early morning of 5/20/2021 when the resident experienced severe abdominal pain. A review of Resident 1's computerized tomography ([CT] combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images [slices] of the bones, blood vessels and soft tissues inside the body) scan of the abdomen dated 5/20/2021, indicated distended (swollen or bloated) small bowel loops measuring up to 5 centimeters (cm, a unit or measurement) in diameter (a straight line passing from side to side through the center of the body) in the mid-right abdomen. The CT findings indicated it was compatible with small bowel obstruction. A review of the GACH Operative Report dated 5/20/2021, indicated Resident 1 had a small bowel perforation with generalized peritonitis (inflammation or swelling of the lining of the abdomen) that appeared to have been at the site of the resident's prior small bowel resection. The Resident 1's GACH Operative Report indicated Resident 1 had undergone another small bowel resection with abdominal washout (a technique in which the inside of the abdominal cavity is irrigated with a sterile solution to clean the abdominal cavity), enterorrhaphy (incision of the intestines), wound debridement (removal of dead or infected skin tissue to help wound healing), and appendectomy (a surgical operation to remove the appendix [a tube-shaped sac attached to the lower end of the large intestine]). During an interview, on 6/8/2021 at 11:47 AM, Resident 1 stated on 5/20/2021 at around 2 AM, he complained of nausea (uneasiness of the stomach) and 6 out of 10 pain (6/10, 6 being moderate pain) in the stomach to License Vocational Nurse 1 (LVN 1), the charge nurse during the 11 PM to 7 AM shift. Resident 1 stated that he asked for pain medication and requested to be transferred to GACH. Resident 1 stated LVN 1 did not listen to him. Resident 1 stated LVN 1 gave him medication for his nausea but did not give him pain medication. Resident 1 stated when he woke up the same morning, his stomach pain had become worst at 10 out of 10 (severe pain) pain level. Resident 1 stated he reported his severe stomach pain to LVN 2 (7 AM to 3 PM shift charge nurse) and requested for a pain medication between 8 AM to 9 AM, on 5/20/2021, but LVN 2 did not do anything. On the same interview, on 6/8/2021 at 11:47 AM, Resident 1 stated at 10 AM, he requested to be transferred to GACH to Registered Nurse 1 (RN 1). Resident 1 stated that RN 1 told him he had to wait for an hour for the ambulance to arrive. Resident 1 stated he wanted to call a taxi and go to GACH himself, but RN 1 told him he would be AMA (leaving hospital/facility against medical advice) if he leave the facility. Resident 1 stated he was in a lot of pain and had to call the Ombudsman, a resident advocate, to talk to the facility charge nurse. Resident 1 stated the licensed nurses did not do any interventions while he was waiting to be transferred to GACH. Resident 1 stated after a few minutes of talking to the Ombudsman, he was transferred to GACH via 9-1-1 emergency services. Resident 1 stated, I ended up in surgery. During an interview on 6/8/2021 at 1:10 PM., RN 1 stated that she recalled Resident 1 informed LVN 2 (between 8 AM to 9 AM) on 5/20/2021 that he had pain in his abdomen for a long time and wanted to go to GACH. RN 1 stated that LVN 2 had called Resident 1's attending physician (Physician 1) at 9:30 AM and LVN 2 received an order to transfer Resident 1 to GACH at 10:44 AM. RN 1 stated they were working on getting an ambulance for Resident 1 during that time. RN 1 stated Resident 1 did not want to wait for the ambulance and wanted to get a taxi to go to GACH. RN 1 stated he told Resident 1 that he will be discharged AMA if he leaves the facility on a taxi. RN 1 stated the Ombudsman called and after that, they (staff not identified) called 9-1-1 emergency services, on 5/20/2021 and Resident 1 was transferred to GACH right away. During a concurrent interview and Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no pain assessment documented prior to pain medication administration (on 5/19/2021 at 9 PM). The pain reassessment on 5/19/2021 (3 PM to 11 PM shift) indicated 0 pain and the medication intervention were effective. RN 1 stated that the nurse (LVN 5) should have done pain assessment prior to giving the pain medication (on 5/19/2021 at 9 PM). RN 1 stated there was no documented evidence in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On the same interview and review of Resident 1's MAR for 5/19/2021 and 5/20/2021 and licensed nurses progress notes (during the 7 AM to 3 PM shift on 5/20/2021) dated on 6/8/2021 at 1:15 PM, RN 1 stated that she could not find documented evidence that LVN 2 had assessed Resident 1's pain. RN 1 stated the licensed nurse (LVN 2) should have assessed Resident 1's pain and provided interventions such as pain medication. RN 1 stated that Resident 1 was so upset that day (on 5/20/2021) and RN 1 recalled Resident 1 was yelling because of pain and wants to go to hospital. During an interview, on 6/8/2021 at 1:35 PM, LVN 4 stated that she remembered Resident 1, on 5/20/2021 at 9 AM, was very upset, yelling complaining of pain and wanted to be transferred to the hospital. During a telephone interview, on 6/10/2021 at 10:30 AM, Ombudsman 1 stated Resident 1 called the Ombudsman's office around 9:30 AM on 5/20/2021 and stated he was in pain since 2 AM (on 5/20/2021) and the facility did not do anything. Resident 1 told Ombudsman 1 that his pain level around 9 AM (on 5/20/2021) was 10 out of 10 and at nighttime (on 5/19/2021, time not specified) was 5 out of 10. Resident 1 told Ombudsman 1 that he wanted to call 9-1-1 but RN 1 told him he would be discharged against medical advice (AMA) if he did that. Ombudsman 1 stated they (and another Ombudsman on the line, not identified) had talked to RN 1 and asked what the facility was doing for Resident 1's severe pain. RN 1 informed Ombudsman 1 that they will call 9-1-1 emergency services for Resident 1. During a telephone interview, on 6/29/2021 at 6:20 AM, LVN 1 (the charge nurse during the 11 PM to 7 AM shift of 5/19/2021) stated Resident 1 was up late that night on 5/19/2021 and complained of nausea. LVN 1 stated Resident 1 told him he was not feeling too good because of nausea and the resident's facial expression looked like as if he ate something sour like lime. LVN 1 sated she did not recall Resident 1 complained of abdominal pain. LVN 1 stated she administered medication for nausea ([MEDICATION(S)]) to Resident 1. LVN 1 stated she did not report this to the RN supervisor or Physician 1. LVN 1 stated she did not document Resident 1's nausea and assessment of Resident 1's condition in the resident's records. During a follow up interview with RN 1 on 7/1/2021 at 11:56 AM, RN 1 stated she conducted a visual assessment (on 5/20/2021) and Resident 1 was pointing to his stomach. RN 1 stated she did not document and conduct a comprehensive pain assessment of Resident 1's condition (on 5/20/2021). RN 1 stated that it was important to know the underlying cause of Resident 1's pain. RN 1 stated she could not find documented evidence of a timely pain assessment or reassessment on 5/20/2021. RN 1 stated the licensed nurses did not implement Resident 1's care plan for pain such as to assess quality, location, and duration of pain, positioning, and provide pain medication. A review of the facility's policy and procedures titled, Pain Assessment and Management, revised on 3/2020, indicated that Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that included: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. The policy and procedure titled, Pain Assessment and Management, revised on 3/2020, indicated that Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The policy indicated to Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program.

Based on observation, interview and record review, the facility failed to prevent and eradicate (destroy) cockroach infestation (the presence of an unusually large number of cockroaches (roach-a small insect that can carry and spread infectious diseases)) in the facility for 67 of 67 residents who were eating food and drinking/consuming water from the facility's kitchen. This deficient practice resulted in the presence of six German cockroaches (a small species of cockroach) in the kitchen, and placed 67 residents at risk of serious diseases caused by contaminating human food with germs (small living things/cells, especially one which cause diseases) that the cockroaches pick up in the toilets and garbage dumps in and outside of the facility. On August 4, 2020, at 11:55 a.m., an Immediate Jeopardy (IJ-a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was declared and the facility's Administrator was notified of the findings. On August 6, 2020, at 2:50 p.m., the IJ was removed in the presence of the Administrator after the implementation of the Plan of Action (POA, interventions to correct the deficient practice) was verified and confirmed on an onsite visit through observation, interview and record review. The acceptable POA included the following actions: 1. The new pest (destructive insects that attack food) control company increased pest control treatments from one every three months to twice for the first week and then twice per month. 2. The Dietary Supervisor and the Administrator provided in-services regarding cockroach infestation to dietary staff and instructed staff to report any pests and penetrations in the kitchen walls to the Dietary Supervisor or designee for immediate corrective action. 3. The Maintenance Supervisor repaired the damaged and/or deteriorated floor tiles and sealed all cracks and gaps on the walls in the kitchen. Findings: A review of the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation, undated, retrieved from: publichealth.alcounty.gov/eh/docs/specializedvencor_management) indicated that cockroaches may become pests in any structure that has food preparation or storage areas. Cockroaches contaminate food, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. When cockroaches that live outdoors and come into contact with human excrement (waste matter/feces) in sewers or with animal fecal matter and has the potential to transmit bacteria that cause food poisoning when they enter the structures. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated July 1, 2019, retrieved from: https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html) indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. The guidelines indicated pest included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms (small living thing/cell), or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens/germs) to animals or humans. A review of the facility's most current Pest Control Service Report, dated May 15, 2020, indicated a Pest Control Technician (PCT 1) applied treatment (pesticides/chemicals to kill or control pests) in the kitchen's interior and there were no signs or presence of cockroaches. There were no pest control service reports for June and July of 2020. A review of the facility's census report, dated August 4, 2020, indicated there were 67 residents residing in the facility including: a. 39 residents on regular diet. b. 17 residents on mechanical soft diet (soft food for residents who have trouble chewing or swallowing). c. Five residents on purred diet (soft, moist and smooth food that have the same texture with pudding for residents who have trouble chewing and swallowing). d. Six residents on gastrostomy feeding (a feeding device that inserted thru the abdomen so that food, water and medication can be delivered directly into the stomach bypassing the mouth and throat). During a kitchen observation with the Maintenance Supervisor (MS 1) on August 4, 2020, at 9:55 a.m., three adult German cockroaches were seen on the floor at the dishwashing area. (German cockroach could spread different forms of gastroenteritis (food poisoning, diarrhea, and other illnesses). Their droppings give off an unpleasant smell that may cause people to exhibit sneezing, congestion of nasal passages)). MS 1 stated he saw three cockroaches. During an interview on August 4, 2020, at 10:03 a.m., the Dietary Supervisor (DS 1) stated on July 31, 2020, during the morning shift, the Kitchen Staff (KS 1) notified her that they saw cockroaches. DS 1 stated she immediately informed MS 1 that there was cockroach infestation in the facility's kitchen. DS 1 stated MS 1 called the pest control company for pest control treatment. During a concurrent review of the facility's most current Pest Control Service Report, dated May 15, 2020 and an interview with MS 1 on August 4, 2020, at 10:20 a.m., he stated that the facility had no pest control service for two months. MS 1 stated when DS 1 informed him regarding the cockroach infestation in the kitchen, he immediately treated the kitchen (apply pesticide/chemicals to kill cockroaches). A review of the Registered Environmental Health Official Inspection Report, dated 8/4/20, indicated there were two live cockroaches, near the floor, under the dishwashing machine, one live cockroach crawling on the wall, near a storage cabinet, and three dead cockroaches on the floor, under the dishwashing machine. A review of the facility's undated pest control policy and procedure, titled Pest Control, indicated that the facility utilizes pesticides in a safe and efficient manner to control pests with the least amount of contamination to the environment.

Based on interview and record review, the facility failed to provide supervision to one of 18 sampled residents (Resident 5) while standing up holding on to the four wheel walker (FWW). This resulted in the resident to fall unsupervised and sustained a left hip fracture. As a result, Resident 5 was transferred to the acute hospital, and was hospitalized for [REDACTED]. This had the further potential to result in serious complications and death. Findings: On October 13, 2015, at 10:50 a.m., during the initial tour of the facility, Resident 5 was interviewed. Resident 5 stated she fell (unable not remember when) at the facility when a CNA (certified nursing assistant) left her unattended at the foot of her bed. The CNA had to move the roommate's wheelchair that was blocking the door to the bathroom. Resident 5 also stated, she fractured (broke) her left hip because of the fall. On October 14, 2015, a review of Resident 5's clinical record indicated Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On October 14, 2015, a review of The Fall Risk assessment dated [DATE], indicated Resident 5 was unable to independently come to a standing position, exhibited loss of balance while standing and had a decrease in muscle coordination for the Gait Analysis. The Fall Risk Assessment also indicated the resident had a history of [REDACTED]. The assessment also indicated the resident had a predisposing condition of vertigo (lightheadedness or dizziness). On October 14, 2015, a record review of the Minimum Data Set (MDS-an assessment tool), dated August 3, 2015 and August 23, 2015, indicated Resident 5 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one person physical assistance when walking in the room and participating in activities. The resident also used an assistive device such as a front wheel walker (FWW). On October 14, 2015, a record review of the Change of Condition (SBAR - Situation Background Appearance Request) dated September 3, 2015, at 7:17 p.m., indicated the resident had a fall while walking with a FWW (front wheel walker). The CNA was assisting the resident to the bathroom, and suddenly the resident lost balance and fell , landing on her buttocks. The physician was on site and ordered X-ray for left the hip on 9/3/15 at 9:17 p.m. A review of the pain assessment dated [DATE] at 9:41 p.m., identified the resident was restless, crying in pain on the left hip. Percocet 5/325 mg was indicated for pain. On September 4, 2015, at 3:57 a.m., the X-ray result was received indicating acute left hip fracture. On September 4, 2015 at 4:20 a.m., the physician was notified with new order to transfer the resident to the emergency room via ambulance. On September 4, 2015 at 4:25 a.m., the resident was transferred to the hospital emergency room via ambulance. A record review of the admission records dated September 4, 2015, from the acute hospital indicated another X-ray was ordered and disclosed the resident had a subcapital fracture (an extracapsular fracture of the neck of the femur (thigh bone), at the point where the neck of the femur joins the head ) of the left hip from a fall at the nursing home. A record review of the acute hospital CT (computed tomography-special X-ray tests ) hip images results dated September 4, 2015, indicated the resident had an impacted (or incomplete) subcapital fracture of the left femoral neck. (an intracapsular fracture of the neck of the femur, at the point where the neck of the femur joins the head). A record review of the operative report dated September 5, 2015, from the acute hospital indicated surgery was performed where four (4) screws were placed on the left femoral neck fracture. On October 15, 2015, at 8:20 a.m., during an interview with Resident 5, she stated CNA 1 got her up from the bed to go to the bathroom and left her unattended at the foot of the bed holding on to the front wheel walker (FWW), while CNA 1 went to move the roommate's wheelchair that was blocking the bathroom door. The resident further stated she lost balance and fell to the floor between the television set and the foot of the bed. The resident also stated she was in the worst pain she ever felt before and cannot walk around in the facility with her friends anymore. On October 15, 2015, at 9:02 a.m., during a phone interview with CNA 1, she stated on September 3, 2015, she took Resident 5 out of bed to take her to the bathroom, using a FWW. CNA 1 also stated she left Resident 5 unattended and unsupervised (unable to tell how long) in order to move a wheelchair belonging to Resident 5's roommate, which was blocking the door to the bathroom. CNA 1 further stated Resident 5, fell on the floor. She stated she was six to 10 feet away from Resident 5 when she fell . CNA 1 stated she should have put the resident back in bed before leaving, and never should have left her by herself, or should have called another CNA or charge nurse to help her. On October 15, 2015, at 10:25 a.m., during an interview with Employee A, he stated CNA 1 should ask a co-worker for help or clear the pathway before helping a resident to the bathroom. He also stated CNA 1 should have sat the resident back to bed before moving the wheelchair as prevention for falls and or accidents. On October 15, 2015, at 2:55 p.m., during an interview with the Employee B, she stated that the CNA 1 should have called someone for help or let the resident sit down first before leaving the resident unattended to prevent falls. On October 16, 2015, at 2:45 p.m., during an interview with CNA 2, she stated she was called to Resident 5's room by CNA 1 on September 3, 2015, to help CNA 1 and the charge nurse to lift Resident 5 off the floor and into the wheelchair. CNA 2 also stated they (CNA 1 and charge nurse) took the resident to the bathroom after the fall. CNA 2 further stated she would have Resident 5 sit back down on the bed before clearing the pathway to the bathroom to prevent falls or accidents. On October 15, 2015, at 1:40 p.m., during an interview with Employee C, she stated that nursing staff should not have left Resident 5 standing up holding on to the FWW unattended. She also stated Resident 5 required close stand by assistance (assistance should have been within reach and readily available). The physical therapist further stated it is not a stand by assist if the CNA was six to 10 feet away from the resident. The physical therapist stated to have the resident sit down first, and then move the equipment (wheelchair) as a preventive measure to prevent falls or accidents. On 10/15/15, a review of the PT assessment dated [DATE], identified a goal for gait training of 40 feet on level surfaces with supervised use of the FWW to increase level of independence. The facility's policy and procedures, Falls and Fall Risk, Managing, revised December 2007, indicated, Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 1. The staff will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once).