Every finding on record at Inland Valley Care and Rehabilitation Center

Based on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 7) was informed in advance about the residents' treatment and care plan.This deficient practice had the potential to violate Resident 7's right to make an informed choice about their treatment.During a review of Resident 7's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and hypertension (high blood pressure).During a review of Resident 7's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 8/20/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 8/12/2026, the MDS indicated Resident 7's cognitive status (ability to think and process information) was intact. The MDS indicated Resident 7 was dependent on staff for toileting hygiene and showering/bathing and transfers. The MDS indicated Resident 7 required substantial/maximal assistance (helper does more than halt the effort to complete the activity) with personal hygiene, dressing, and moving around in bed.During an interview on 8/19/2026 at 2:31 pm with Resident 7, Resident 7 stated that no staff from the facility had explained any treatment plan to Resident 7 and discussed any changes in medications or the treatment plan since resident's admission.During a concurrent interview and record review on 8/20/2026 at 1:15 p.m. with the Assistant Director of Nursing (ADON), Resident 7's Interdisciplinary Team (IDT-a group of different health professionals work together as a team to plan, provide and review resident's care) notes, dated 8/13/2026 and 5/25/2026, were reviewed. ADON stated plan of care was not discussed with Resident 7 and/or Resident 7's representative since Resident 7's admission. ADON stated it was important to discuss plan of care with resident and/or resident representatives, so the resident would be aware of their treatment plan. ADON stated if a resident was not aware of plan of care, It can make resident feel mad and upset because resident is not aware what is going on with him. Resident is most likely to feel ignored. Residents have a right to be informed of their plan of care which didn't happen with this resident (Resident 7).During an interview on 8/20/2026 at 1:55 pm with Director of Nursing (DON), DON stated that the resident and resident's representatives have a right to know about the resident's plan of care and have a right to ask questions/concerns regarding their plan of care and treatments. DON stated, If a resident doesn't know about their plan of care, it can affect them psychosocially and emotionally. It will make them feel sad since they won't have any control over their care. We should have informed the resident (Resident 7) at least twice regarding their plan of care between resident's admission and now which we didn't.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 6/25/2026, the P&P indicated, The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.During a review of the facility's P&P titled, Resident Rights, dated 6/25/2026, P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to 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.

Based on observation and interview, the facility failed to maintain residents' room temperature level between 71 to 81- degree Fahrenheit ( F) as required by the Federal regulation for one of three sampled residents (Resident 1) and one of three rooms checked during an environmental tour.This deficient practice resulted in Resident 1's increased level of discomfort and had the potential to negatively impact Resident 1's quality of life.Findings:During a review of Resident 1's admission Record (AR, Face Sheet), the AR indicated the facility admitted Resident 1 on 3/2/2026 with diagnoses including paraplegia (paralysis of the lower part of the body, including legs), and anxiety disorder (a feeling of excessive worry, nervousness, or fear that can make a person feel tense, uneasy or overwhelmed).During a review of Resident 1's History and Physical (H&P), dated 3/4/2026, the H&P indicated, Resident 1 had the mental capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 6/6/2026, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and required limited assistance of one-person physical assist for activities of daily living. During an concurrent observation and interview with Resident 1 on 8/20/2026 at 11:35 AM, Resident 1 was lying in bed, awake, alert, and oriented to person. Resident 1 was observed wearing a sweater and covered with four blankets. Resident 1 stated Resident 1 was cold and that the resident's room was always cold. Resident 1 stated Resident 1 notified facility's staff, but nothing was done about the temperature in his room.During a concurrent observation and interview on 8/20/2026 at 11:40 AM of the facility, the Maintenance Assistant (MA), The MA checked Resident 1's room temperature and two other rooms using the facility's laser temperature thermometer. Resident 1's room temperature was 61.9-degree Fahrenheit ( F). The MS stated the residents' room temperatures should be between 71 F and 81 F.During an interview on 8/21/2026 at 4 PM with the Director of Nursing (DON), the DON stated that the facility has to maintain a temperature of not less than 71 F or more than 81 F.During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Homelike Environment, revised March 2017, the policy indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: h. Comfortable and safe temperatures (71 F - 81 F).

Based on interview and record review, the facility failed to ensure a resident grievance was documented, tracked, investigated, and resolved in accordance with the facility's grievance process for 1 of 3 sampled residents (Resident 1) when a grievance submitted on 5/5/2026 was misplaced, was not entered into the facility's grievance log, and remained unresolved.This deficient practice violated resident 1's right to have the resident's grievance addressed.Findings:During a review of Resident 1's admission Record (AR, Face Sheet), the AR indicated facility admitted Resident 1 on 3/2/2026 with diagnoses including paraplegia (paralysis of the lower part of the body, including legs), and anxiety disorder (a feeling of excessive worry, nervousness, or fear that can make a person feel tense, uneasy or overwhelmed).During a review of Resident 1's History and Physical (H&P), dated 3/4/2026, the H&P indicated, Resident 1 had the mental capacity to make medical decisions.During a review of Resident 1's Social Service' Note, dated 5/7/2026, the Social Service' note indicated Grievance form was given to Social Services on 5/5/2026.During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 6/6/2026, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and required limited assistance of one-person physical assist for activities of daily living. During an interview on 8/20/2026 at 1 PM with the Social Worker (SW) 1, SW 1 stated she received R1's 5/5/2026 grievance and provided it to the Social Services Director (SSD) responsible for grievances at that time. SW 1 stated the SSD worked at the facility for approximately two weeks and subsequently left employment. SW 1 stated the grievance was misplaced by the former SSD and could not be located.During an interview on 8/21/2026 at 9 AM with the SSD, the SSD confirmed the 5/5/2026 grievance was missing and grievance was unresolved. The SSD confirmed there was no entry for Resident 1's grievance in the May 2026 grievance log.During a review of the facility's policy and procedure (P&P) titled, Grievances, revised 2017, the P&P indicated upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint.

Based on interview and record review, the facility failed to develop and implement an individualized comprehensive care plan for 1 of 1 sampled residents (Resident 1) with documented Post-Traumatic Stress Disorder (PTSD) when the facility failed to develop a care plan addressing the resident's PTSD-related needs, triggers, and individualized interventions despite positive PTSD assessments and psychology documentation identifying PTSD.This deficient practice had the potential to result in inconsistent care and failure to address Resident 1's identified psychosocial and trauma-related needs.Findings:During a review of Resident 1's admission Record (AR, Face Sheet), the AR indicated facility admitted Resident 1 on 3/2/2026 with diagnoses including paraplegia (paralysis of the lower part of the body, including legs), and anxiety disorder (a feeling of excessive worry, nervousness, or fear that can make a person feel tense, uneasy or overwhelmed).During a review of Resident 1's History and Physical (H&P), dated 3/4/2026, the H&P indicated Resident 1 had the mental capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 6/6/2026, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and required limited assistance of one-person physical assist for activities of daily living. During a review of Resident 1's Progress Notes (PN), dated 6/18/2026, the PN from the Nurse Practitioner (NP) indicated that Resident 1 had diagnoses including Major Depressive Disorder, Anxiety Disorder, Primary Insomnia, and PTSD.During an interview on 8/21/2026 at 4 PM with the Director of Nursing (DON), the DON confirmed that the resident did not have a PTSD-specific care plan prior to 8/21/2026.During a review of the facility's policy titled, Trauma Informed Care and Culturally Competent Care, revised August 2022, the policy indicated under Resident Care Planning, the policy directed staff to develop individualized care plans addressing past trauma in collaboration with the resident and family, as appropriate, and to identify and decrease exposure to triggers that may re-traumatize the resident.During a review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the policy indicated care plan interventions were to be derived from a thorough analysis of information gathered as part of the comprehensive assessment. The policy indicated the comprehensive person-centered care plan was to include services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy further indicated services provided or arranged by the facility and outlined in the comprehensive care plan were to be trauma informed. The policy indicated assessments were ongoing and care plans were to be revised as information about the residents and the residents' condition changed

Based on interview and record review, the facility failed to provide trauma-informed care for one (1) of 1 sample resident (Resident 1) by not ensuring that the resident received adequate care and services to address the resident's Post-Traumatic Stress Disorder (PTSD-a mental health condition that can develop after someone has experienced a deeply disturbing or frightening event).This resulted in inadequate attention to Resident 1's specific trauma-related needs.Findings:During a review of Resident 1's admission Record (AR, Face Sheet), the AR indicated the facility admitted Resident 1 on 3/2/2026 with diagnoses including paraplegia (paralysis of the lower part of the body, including legs), and anxiety disorder (a feeling of excessive worry, nervousness, or fear that can make a person feel tense, uneasy or overwhelmed).During a review of Resident 1's History and Physical (H&P), dated 3/4/2026, the H&P indicated, Resident 1 had the mental capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 6/6/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decisions making was intact, and required limited assistance of one-person physical assist for activities of daily living. During a review of Resident 1's Progress Notes (PN), dated 6/18/2026, the PN from the Nurse Practitioner (NP) indicated that Resident 1 had diagnoses including Major Depressive Disorder, Anxiety Disorder, Primary Insomnia, and PTSD.During a concurrent interview and record review on 8/21/2026 at 4 PM with the Director of Nursing (DON), Resident 1's PN were reviewed with DON. The PN indicated Resident 1 was diagnosed with PTSD. The DON acknowledged that facility staff had not adequately assessed Resident 1's individualized PTSD-related needs. The DON confirmed that the facility had not previously identified or assessed Resident 1's specific PTSD triggers or developed individualized interventions addressing Resident 1's PTSD-related needs.During a review of the facility's policy titled, Trauma Informed Care and Culturally Competent Care, revised August 2022, the policy indicated the purpose of the policy was to guide staff in providing trauma-informed care and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy indicated trauma-informed care included recognizing the impact and signs and symptoms of trauma and incorporating knowledge regarding trauma into resident care plans and practices to avoid re-traumatization. The policy further indicated resident screening was to include identification of possible exposure to traumatic events, trauma-related symptoms, historical mental health diagnoses, and physical health concerns, and that the initial screening was to be utilized to identify the need for further assessment and care. Under Resident Assessment, the policy indicated assessment included an in-depth evaluation of the resident's symptoms, their relationship to trauma, as well as identification of triggers.

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2) received adequate supervision to prevent Resident 2 from wandering into Resident 1's room. This failure resulted in Resident 2 wandering into Resident 1 room and had the potential to result in Residents 1 and/or 2 sustaining injury and/or harm while in the care of the facility. Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/10/2024 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), bipolar disorder (a mental illness that causes unusual shifts in a person's mood), and hypertension (high blood pressure).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/19/2026, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1was dependent (helper does all the effort) on staff for assistance with toileting hygiene. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) assistance from staff for personal hygiene. The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort) from staff for dressing, bathing, and oral hygiene.b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 2/29/2024 and readmitted Resident 2 on 4/7/2026 with diagnoses including schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and muscle wasting and atrophy (loss of muscle tissue).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was moderately impaired in cognitive skills. The MDS indicated Resident 2 required supervision (oversight, encouragement or cuing) or touching assistance from staff for bathing, dressing, and toileting, oral, and personal hygiene.During a review of the facilities Census Report (CR), dated 7/29/2026, the CR indicated both Residents 1 and 2 resided in the Memory Care Unit (a secured wing with locked entry ways to prevent wandering) of the facility. The CR indicated Resident 1 resided in room A and resident 2 resided in Room B. During a concurrent interview and record review on 8/3/2026 at 10:47 AM with Licensed Vocational Nurse (LVN) 2, Resident 2's Change in Condition Evaluation (CICE), dated 7/29/2026 was reviewed. The CICE indicated Resident 2 was observed walking out of a female resident's room and Resident 2 was then redirected to the common area. LVN 2 stated that on 7/29/2026 at around 2:30 PM, LVN 1 was in the hallway next to the dining room when LVN 1 heard Resident 1 scream. LVN 2 stated that LVN 2 walked toward Room A and saw Resident 2 exiting Room A. LVN 2 stated residents (in general) were not permitted to enter other residents' (in general) rooms. During an interview on 8/3/2026 at 11:05 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNA 1 was in the hallway facing the north direction when CNA 1 heard Resident 1 scream from inside Resident 1's room. CNA 1 stated CNA 1 turned around, ran toward Room A, and saw Resident 2 exiting from Room A. CNA 2 stated Resident 2's usual behavior included wandering up and down the hallway of the locked unit. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

Based on observation, interview, and record review, the facility failed to provide one of four sampled residents (Resident 3) with a soft touch pad (an assistive medical device designed for patients with severe mobility impairments) to activate the call light (a device used by a resident to signal his or her need for assistance from staff). This failure resulted in Resident 3 feeling frustrated due to the resident being unable to call staff for assistance and had the potential for Resident 3 to experience harm if Resident 3 was unable to alert staff during an emergency.Findings:During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on [DATE] and readmitted Resident 3 on [DATE] with diagnoses including acute and chronic respiratory failure (when the lungs can't get enough oxygen into the blood), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and congestive heart failure (condition in which the heart cannot pump enough blood to all parts of the body).During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 3 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 3 was dependent (helper does all the effort) on staff for all Activities of Daily Living (ADLs, activities related to personal care).During a review of Resident 3's Care Plan Report (CPR), undated, the CPR indicated had a deficit in providing himself ADL self-care due to quadriplegia (the condition in which both the arms and legs are paralyzed). The CPR indicated facility staff (in general) should encourage Resident 3 to use the call light to call for assistance.During a concurrent observation and interview on [DATE] at 10:22 AM with Resident 3 in Resident 3's room, the cord of the call light system was laying at Resident 3's right side. Resident 3 stated Resident 3 had to yell out for assistance from staff (in general) because Resident 3 could not activate the call light button at the end of the cord of the call light system. Resident 3 stated Resident 3 could not use Resident 3's hands to activate the button. Resident 3 stated Resident 3 felt frustrated because Resident 3's voice was not loud and sometimes the staff (in general) could not hear his yelling for assistance.During a concurrent observation and interview on [DATE] at 10:41 AM with Licensed Vocational Nurse (LVN) 1 in Resident 3's room, Resident 3's call light was observed near the resident. LVN 1 stated LVN 1 assisted Resident 3 earlier in the day to make a phone call on Resident 3's personal cell phone because Resident 3 could not use Resident 3's hands to operate Resident 3's personal cell phone. LVN 1 confirmed Resident 3 could not activate Resident 3's call light button.During an interview on [DATE] at 2:26 PM with the Director of Nursing (DON), the DON stated if a resident (in general) was unable to operate the standard call light button, the facility staff (in general) should provide a soft touch pad call light to the resident (in general).During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised 3/2021, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The P&P indicated, The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.In order to accommodate individual needs and preferences, adaptations may he made to the physical environment.

Based on observation, interview, and record review, the facility failed to provide pressure related injury prevention practices for four of five sampled residents (Residents 2, 3, 5 and 6) by failing to ensure nursing staff set residents' low air loss mattress ([LALM], a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, treat pressure sores and prevents pressure sores) according to Residents 2, 3, 5 and 6's weight. These deficient practices placed Residents 2, 3, 5 and 6 at risk for developing pressure injuries (localized area of tissue damage that develops when prolonged pressure or shear forces are applied to the skin and underlying tissues) and put these residents at risk for further skin damage. Findings: 1. During an observation on 7/23/2026 at 1:20 p.m. in Resident 3's room, Resident 3's LALM was set to 400 pounds. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body, causing trouble breathing and fatigue) and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose in the blood and urine). During a review of Resident 3's History and Physical (H&P), dated 3/26/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 7/14/2026, the MDS indicated Resident 3's cognitive skills cognitive skills (reasoning, learning, and problem-solving) for daily decision making was severely impaired. The MDS indicated Resident 3 required moderate assistance (helper does more than half the effort) for eating and oral hygiene. The MDS indicated Resident 3 was dependent on staff for toileting hygiene, shower/bathing, dressing, putting on/taking off footwear, and personal hygiene. During a review of resident 3's Weights Summary, dated 7/2/2026, the weight summary indicated Resident 3 weighed 211 pounds. During a review of Resident 3's Order Summary Report, dated 7/21/2026, the order summary report indicated Resident 3 had an order for a low air loss mattress for skin management. Monitor pressure settings according to patient's weight and comfort every shift. 2. During an observation on 7/23/2026 at 1:30 p.m. in Resident 5's room, Resident 5's LALM was set to 250 pounds. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure and end stage of renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 5's H&P, dated 4/3/2026, the H&P indicated Resident 5 had significant neurologic and communication impairment and may not be able to demonstrate full medical decision-making capacity consistently. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 5 was dependent on staff for all activities of daily living. During a review of Resident 5's Order Summary Report, for July 2026, the order summary report indicated Resident 5 had an order for a low air loss mattress for skin management. Monitor pressure settings according to patient's weight and comfort every shift. During a review of resident 5's Weights Summary, dated 7/6/2026, the weight summary indicated Resident 5 weighed 135 pounds. 3. During an observation on 7/23/2026 at 1:39 p.m. in Resident 6's room, Resident 6's LALM was set fpr 450 pounds. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood) and respiratory failure. During a review of Resident 6's H&P, dated 4/2/2026, the H&P indicated Resident 6 had During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was intact. The MDS indicated Resident 6 required supervision for eating, toileting hygiene and oral hygiene. The MDS indicated Resident 6 required maximal assistance for dressing and personal hygiene. The MDS indicated Resident 6 was dependent on staff for shower/bathing and putting on/taking off footwear. During a review of Resident 6's Order Summary Report, for the month of 2026, the order summary report indicated Resident 6 had an order for a low air loss mattress for wound management. Monitor pressure settings according to patient's weight and comfort every shift. During a review of resident 6's Weights Summary, dated 7/20/2026, the weight summary indicated Resident 6 weighed 87 pounds. 4. During an observation on 7/23/2026 at 1: 47 p.m. in Resident 2's room, Resident 2's LALM was set to 200 pounds. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included right side hemiparesis (neurological condition characterized by weakness, reduced muscle strength, or partial paralysis on one side of the body, affecting the arm, leg, and sometimes the face) and right side Hemiplegia a condition caused by a brain injury, that results in a varying degree of weakness, stiffness and lack of control in one side of the body. During a review of Resident 2's H&P, dated 11/30/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 was dependent on staff for all activities of daily living. During a review of Resident 2's Order Summary Report, for the month of July 2026, the order summary report indicated Resident 2 had an order for a low air loss mattress for skin management/history of pressure injury. Monitor pressure settings according to patient's weight and comfort every shift. During a review of resident 2's Weights Summary, dated 7/21/2026, the weight summary indicated Resident 2 weighed 122 pounds. During an interview on 7/28/2026 at 11:21 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Treatment Nurse (TN) was responsible to check residents LALM. LVN 1 stated LALM pumps must have a sticker labeled with residents' weight to indicate where the LALM pump should be set at. LVN1 stated all licensed nurses can adjust LALM to the correct setting. LVN 1 stated if LALM was underinflated the resident would develop skin wounds because resident would be lying on a low-pressure mattress and it would be like lying on a regular mattress. LVN 1 stated if the LALM was overinflated the mattress would be too hard, uncomfortable, cause pain and had the potential for the resident to fall out of bed. LVN 1 stated it was important to set the LALM to the correct weight for it to be beneficial to residents in preventing skin breakdown. During an interview on 7/28/2026 at 12:42 p.m. with TN, TN stated a LALM was used for wound healing, wound prevention and wound maintenance. TN stated all licensed staff were responsible for checking if LALM was set to resident weight. TN stated if the LALM was overinflated it could cause pain to the resident and it would not help with skin wound prevention or skin wound healing. During a review of Proactive Protekt Aire 2000 operation manual, the manual indicated the Protekt Aire 2000 pump and overlay system, was for the prevention and treatment of any and all stage pressure ulcers. The manual indicated step 6 of the operation instructions was to determine the patient's weight and set the control knob to that weight setting on the control unit.

Based on observation, interview and record review, the facility failed to provide safe oxygen administration practices ([oxygen therapy], is the medical practice of delivering oxygen at a concentration greater than ambient air) for three of four sampled residents (Residents 4, 5, 6) by failing to: 1. Ensure Residents 5, and 6's nasal cannulas (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) were dated with an open/change dates and did not ensure nasal cannula was not touching the floor. 2. Ensure Resident 4 had an order for oxygen administration before administering oxygen to Resident 4. 3. Ensure Resident 4's nasal cannula was dated and placed in a bag when not in use and did not ensure humidifier bottle (a medical device that adds water vapor to dry supplemental oxygen before it reaches a patient) was changed. These deficient practices increased the risk for Residents to acquire a respiratory infection (infectious disease caused by bacteria, viruses, or fungi that affects the respiratory tract, including the nose, sinuses, throat, airways, and lungs) and placed resident 4 at risk for unnecessary oxygen administration. Findings: 1. During an observation on 7/23/2026 at 1:30 p.m. in Resident 5's room, Resident 5 received oxygen therapy at two liters per minute ([LPM] a metric unit used to measure volumetric flow rate, tracking the volume of fluid or gas passing a point in one minute) Resident 5's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not labeled with an open date and was touching the floor. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult for a person to breathe on their own, lungs can't get enough oxygen into the blood) and end stage of renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 5's History and Physical (H&P), dated 4/3/2026, the H&P indicated Resident 5 had significant neurologic and communication impairment and may not be able to demonstrate full medical decision-making capacity consistently. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 5/21/2026, the MDS indicated Resident 5's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was severely impaired. The MDS indicated Resident 5 was dependent on staff for all activities of daily living. 2. During an observation on 7/23/2026 at 1:39 p.m. in Resident 6's room, Resident 6 received oxygen therapy at two LPM. Resident 6's nasal cannula was not labeled with an open date. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood) and respiratory failure. During a review of Resident 6's H&P, dated 4/2/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was intact. The MDS indicated Resident 6 required supervision for eating, toileting hygiene and oral hygiene. The MDS indicated Resident 6 required maximal assistance (helper does more than half the effort) for dressing and personal hygiene. The MDS indicated Resident 6 was dependent on staff for shower/bathing and putting on/taking off footwear. 3. During an observation on 7/24/2026 at 11:10 a.m. in Resident 4's room, Resident 4's oxygen tubing was not attached to resident, it was hung on top of oxygen concentrator (a medical device that pulls in room air, removes nitrogen, and delivers 90% to 95% pure oxygen to people who have trouble breathing). Nasal cannula was not placed in a bag and was exposed to room air. Humidifier bottle (a medical device that adds water vapor to dry supplemental oxygen before it reaches a patient) was dated with 7/12/2026. Oxygen tubing was not dated and was touching the floor. During a review of Resident 4 's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult for a person to breathe on their own, lungs can't get enough oxygen into the blood) and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). During a review of Resident 4's H&P, dated 4/18/2026, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's Care Plan for oxygen therapy, dated 5/12/2026, the care plan indicated Resident 4's goal was for Resident 4 not to have signs of poor oxygen absorption. The Care Plan indicated some of Resident 4's interventions were to monitor for respiratory distress and to suction as necessary. During a review of Resident 4's MDS), dated [DATE], the MDS indicated Resident 4's cognitive skills cognitive skills for daily decision making was intact. The MDS indicated Resident 4 required moderate assistance (helper does more than half the effort) for eating, personal hygiene and oral hygiene. MDS indicated Resident 4 required maximal assistance for toileting hygiene, dressing and putting on/taking off footwear. The MDS indicated Resident 4 received oxygen therapy while a resident at the facility. During a review of Resident 4's electronic medical record, unable to locate Resident 4's order for oxygen administration. During an interview on 7/28/2026 at 11:12 a.m. with Resident 4, Resident 4 stated he received oxygen every night. Resident 4 stated staff removed Resident 4's oxygen during the day because Resident 4 only needed oxygen when Resident 4 was asleep. Resident 4 stated staff did no change oxygen equipment weekly. Resident 4 stated Resident 4 had questioned staff about changing the oxygen equipment and staff told Resident 4 they knew what they were doing and not to worry about it. Resident 4 stated Resident 4 was concerned because Resident 4 did not want to get an infection from using old oxygen equipment. Resident 4 stated staff did not change the humidifier bottle (a medical device that adds water vapor to dry supplemental oxygen before it reaches a patient) and Resident 4 had used that humidifier bottle for a long time. Resident 4 stated the humidifier bottle was dated with 7/12/2026 and water should not be sitting in a bottle for that long. Resident 4 wanted a new humidifier bottle. Resident 4 stated when Resident 4's oxygen was removed the nasal cannula was placed on top of anywhere and never in a plastic bag to keep it clean. During an interview on 7/28/2026 at 12:42 p.m. with Treatment Nurse (TN) 1, TN 1 indicated before a resident received oxygen therapy licensed nurses must make sure resident had an order for oxygen therapy. TN 1 stated oxygen equipment must be dated with open date, make sure oxygen tubing is not touching the floor and tubing must be placed in a dated bag when not in use. TN 1 stated oxygen tubing and humidifier were changed every Sunday by night shift nurse. TN 1 stated it was important to date oxygen equipment to make sure oxygen equipment was changed and it was safe to use. TN 1 stated the risk in not dating oxygen equipment was staff would not know how old equipment was and residents would be at risk in getting an infection from using contaminated oxygen equipment. During an interview on 7/28/2026 at 4:35 p.m. with Respiratory Therapist (RT) 1, RT 1 stated RT 1 did provide care for Resident 4. RT 1 stated RT 1 suction Resident 4's trach, RT 1 provided nebulizer and RT 1 provided oxygen to Resident 4 at night. RT 1 stated Resident 4 received two liters of oxygen at night only. RT 1 stated all residents required a doctor's order for oxygen therapy before starting oxygen therapy to resident. RT 1 stated RT 1 delivered liters of oxygen to residents based on their doctor's order and if there were no orders, RT 1 would not know how many liters to administer to the resident. RT 1 stated oxygen tubing must have a sticky tab that is used to label it with open date. RT 1 stated there was a risk of using undated oxygen equipment because staff would not know how old it was and could be contaminated and cause a respiratory infection. RT 1 stated oxygen equipment must be changed weekly. During a concurrent interview and record review o 7/28/2026 at 4:42 p.m. with RT, Resident 4's Order summary Report was reviewed. RT 1 stated Resident 4 did not have an order for oxygen therapy. RT 1 stated RT 1 thought Resident 4 had an order. RT 1 stated RT 1 had not verified if Resident 4 had orders for oxygen therapy. RT 1 stated Resident 4 required an order for oxygen therapy because Resident 4 required oxygen therapy every night. During an interview on 7/28/2026 at 4:47 p.m. with Registered Nurse (RN) 2, RN 2 stated oxygen therapy required a doctor's order before the start of oxygen therapy. RN 2 stated oxygen therapy required a doctor's order because doctors prescribe it to residents. RN 2 stated if there was no oxygen therapy order, staff would not know how much oxygen to deliver to a resident. RN 2 stated oxygen equipment must dated with open date for infection control. During a review of facility's Policy and Procedure (P&P) titled Oxygen Administration, dated 10/2010, the P&P indicated staff would verify if there was a physician order for oxygen administration. During a review of facility's P&P titled Changing/Cleaning of Disposable and Non-Disposable Equipment, dated 12/1/2019, the P&P indicated its purpose was to minimize risk of infection. The P&P indicated disposable equipment was single patient use only and would be changed as regularly scheduled and on as needed bases. The P&P indicated residents receiving respiratory care would be given a separate and complete set up, no items would be shared by residents and oxygen equipment must be labeled with date. The P&P indicated RTs, RNs, Licensed Vocational Nurses (LVN) were the responsible discipline for these actions. The P&P indicated humidifiers must be changed once a week or as needed.

Based on observation, interview, and record review, the facility failed to administer enteral feeding (delivering liquid food and nutrients directly into the stomach or small intestine) per physician's order for two of four sampled residents (Residents 7 and 8) by failing to ensure Resident 7 and Resident 8 received the correct enteral feeding formula per the physician's order. This deficient practice caused enteral feeding error for Resident 7 and Resident 8, and potentially placed Resident 7 and Resident 8 at risk for adverse effects of the wrong feeding formula (liquid medical food delivered directly into the stomach through an abdominal opening). Findings: 1. During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and respiratory failure (serious condition that makes it difficult for a person to breathe on their own, lungs can't get enough oxygen into the blood). During a review of Resident 7's Medication Administration Record (MAR) for the month of July 2026, the MAR indicated on 7/12/2026 Resident 7 received Nutren 2.0 feeding formula at 40 ml over 18 hours. The MAR indicated the feeding formula was to start at 2:00 p.m. and was to be stopped at 8:00 a.m. During a review of Resident 7's Order Summary Report dated 7/9/2026, Order Summary Report indicated Resident 7 had an order for Nutren 2. 0 (feeding formula for those with elevated caloric requirements and/or a fluid restriction) feeding formula at 40 milliliters (a metric unit of liquid volume equal to one-thousandth of a liter) over 18 hours. The Order Summary Report indicated the feeding formula was to start at 2:00 p.m. and was to be stopped at 8:00 a.m. During a review of Resident 7's Change of Condition Evaluation, dated 7/12/2026, the Change of Condition Evaluation indicated Resident 7 received an incorrect feeding formula. The Change of Condition Evaluation indicated Resident 7 received feeding formula on 7/11/2026 at 8:00 p.m. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 7/13/2026, the MDS indicated Resident 7's cognitive skills for daily decision making was intact. The MDS indicated Resident 7 required maximal assistance (helper does more than half the effort) for oral hygiene and upper body dressing. The MDS indicated Resident 7 was dependent on staff for toileting hygiene, shower/bathing, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 7's nutritional approach was a feeding tube (medical device used to deliver liquid nutrients, fluids, and medications directly into the stomach). During a review of Resident 7's History and Physical (H&P), dated 7/24/2026, the H&P indicated Resident 7 had a diagnosis of gastrostomy status (artificial opening (stoma) into the stomach with a feeding tube, used to receive food, liquids, or medications directly through the stomach. 2. During a review of Resident 8's AR, the AR indicated Resident 8 was admitted to the facility on 6/17//2025 and was readmitted to the facility on [DATE] with diagnoses that included respiratory failure and dysphagia (difficulty or discomfort in swallowing). During a review of Resident 8's Order Summary Report dated 6/17/2026, Order Summary Report indicated Resident 8 had an order for isosource 1.5 at 35 ml over 20 hours. The MAR indicated feeding formula was to start at 2:00 p.m. and end at 10:00 a.m. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8's cognitive skills for daily decision making was intact. The MDS indicated Resident 8 had no speech. The MDS indicated Resident 8 was dependent on staff for all activities of daily living. The MDS indicated Resident 8's nutrition approach was a feeding tube During a review of Resident 8's MAR, for the month of July 2026, the MAR indicated on 7/12/2026 Resident 8 received isosource 1.5 at 35 ml over 20 hours. The MAR indicated feeding formula was to start at 2:00 p.m. and end at 10:00 a.m. During a review of Resident 8's Change of Condition Evaluation, dated 7/12/2026, the Change of Condition Evaluation indicated Resident 8 received an incorrect feeding administration. During an interview on 7/24/2026 at 3:24 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 7 received the wrong feeding formula. LVN 5 stated the feeding formula was started in the morning shift. LVN 5 stated Resident 7 received the whole feeding formula bag. LVN 5 stated two feeding formula bags were switched and given to the wrong residents. LVN 5 stated morning shift nurses were responsible to start feeding formula and to change feeding formula bags. LVN 5 stated other shift LVNs should have noticed that Resident received the wrong feeding formula. During an interview on 7/24/2026 at 3:50 p.m. with LVN 2, LVN 2 stated he was assigned to Resident 7 on 7/11/2026 for evening shift. LVN 2 stated Resident 7 had received the wrong feeding formula and it was administered during morning shift. LVN 2 stated LVN 2 did not notice if Resident 7 had the wrong feeding formula. LVN 2 stated all Licensed nurses were responsible to check residents' feeding formulas. During an interview on 7/28/2026 at 1:30 p.m. with LVN 3, LVN 3 stated morning shift LVNs were responsible to administer feeding formulas. LVN 3 stated feeding formulas were administered based on physician's orders. LVN 3 stated LVNs must administer feeding formulas one resident at a time. LVN 3 stated LVN 3 was assigned to Resident 7 on 7/11/2026 on morning shift. LVN 3 stated while LVN 3 was at work LVN 3 was not aware Resident 7 had received the wrong feeding formula. LVN 3 stated LVN 3 was informed about the incorrect feeding formula incident today (7/28/2026). LVN 3 stated LVN 3 was not informed who administered the incorrect feeding formula. LVN 3 stated it was not LVN 3 that administered the wrong feeding formula. During an interview on 7/28/2026 at 1:51 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 7 received the wrong feeding formula. RN 1 stated Resident 7 was supposed to receive nutrient 2.0. RN 1 stated based on facility's documentation, LVN 3 was assigned to Resident 7 and LVN 3 administered the wrong feeding formula. RN 1 stated on 7/12/2026 morning shift LVN discovered Resident received the wrong feeding formula. RN 1 stated licensed nurses must check physicians' orders before administering feeding formulas. During an interview on 7/28/2026 at 2:29 p.m. with LVN 4, LVN 4 stated LVN 4 was assigned to Resident 7 on 7/12/2026 morning shift. LVN 4 stated Resident 7 received Resident 8's feeding formula and Resident 8 received Resident 7's feeding formula. LVN 4 stated Resident 7's had received the whole feeding formulabag becasue thebag was empty. LVN 4 stated the LVN (LVN 3) from the day before (7/11/2026) during morning shift administered the wrong feeding formulas. LVN 4 stated it was important to administer the correct feeding formulas to residents because feeding formulas are recommended by dieticians, they are based on residents' weight and their diagnoses. LVN 4 stated the risk in receiving the wrong feeding formula was residents may suffer from gastrointestinal distress (physical discomfort or pain in the digestive tract, like belly pain, bloating, gas, nausea, and changes in bowel habits). During an interview on 7/28/2026 at 4:47 p.m. with RN 2, RN 2 stated licensed nurses must check physician orders before administering feeding formulas to residents. RN 2 stated licensed nurses must administer feeding formulas one resident at a time and not move on to the next resident until first resident's administration was complete. RN 2 stated it was important to administer the correct feeding formula to residents for resident safety. During a review of Resident 8's H&P, dated 7/30/2026, the H&P indicated Resident 8 had the capacity to understand and make decisions. The H&P indicated resident 8 was enteral feeding dependent (relied on a feeding tube to get liquid food, water, and medicines straight into the stomach). During a review of facility's Policy and Procedure (P&P), titled Enteral Tube Feeding via Continuous Pump, dated 11/2028, the P&P indicated staff must verify there is a physician order. The P&P indicated staff needed to check enteral nutrition label against order before administration, they must check for resident name, ID, room number, and the type of formula.

Based on observation and interview, the facility staff failed to assist a dependent resident who was unable to carry out activities of daily living (ADLs) for one of three sampled residents (Resident 2) when: 1. Facility's staff did not ensure Resident 2's nails were clean and trimmed. This deficient practice caused Resident 2's fingernails to dig into Resident 2's palm and had the potential to result in a negative impact on Residents 2's quality of life and Resident 2's quality of care. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included right side hemiparesis (neurological condition characterized by weakness, reduced muscle strength, or partial paralysis on one side of the body, affecting the arm, leg, and sometimes the face) and right side Hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness and lack of control in one side of the body). During a review of Resident 2's History and Physical (H&P), dated 11/30/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 4/13/2026, the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 was dependent on staff for all activities of daily living. During an observation on 7/23/2026 at 1: 47 p.m. in Resident 2's room, Resident 2's fingernails were yellow in color, thick, long, and dirty. Resident 2's hand was contracted, closed and Resident 2's nails were digging into the palms of Resident 2's hands. During an interview on 7/28/2026 at 11:51 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated CNAs were responsible to check residents' nails during shower time. CNA 2 stated CNAs were responsible for cleaning and trim nails as needed. CNA 2 stated it was important to keep residents' nails clean and trimmed to prevent infections and for residents' hygiene. During an observation and interview on 7/28/2026 at 12:42 p.m. with Treatment Nurse (TN) 1 in Resident 2's room, Resident 2's fingernails were yellow in color, thick, long, dirty and were digging into Resident 2's palms of her hands. TN 1 stated Resident 2's nails needed to be cut because the nails were cut into Resident 2's hands. TN 1 stated it was important to keep Resident 2's nails clean and trimmed for infection control and to protect resident from injury. TN 1 stated TN 1 was supposed to check Resident 2's nails when TN 1 provided care for Resident 2 but did not do that (checked Resident 2's fingernails). TN 1 stated TN 1 did not remember the last time when TN 1 checked Resident 2's fingernails. TN 1 stated all staff that provided care to Resident 2 should have noticed Resident 2's nails and had them trimmed. During an interview on 7/28/2026 at 1:05 p.m. with CNA 3, in Resident 2's room, CNA 3 stated she had not noticed Resident 2's nails. CNA 3 stated she was not aware that Resident 2's fingernails were digging into Resident 2's hands. During the review of facility's Policy and Procedure (P&P) titled, Fingernails/Toenails, Care of dated 2/2018, the P&P indicated its purpose was to clean the nail bed, to keep nails trimmed and to prevent infections. The P&P indicated nail care included daily cleaning and regular trimming. The P&P indicated to stop and report to the nurse supervisor if there was evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease. During the review of facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, the P&P indicated residents who are unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review the facility failed to implement its abuse reporting and investigating policy by failing to report an alleged abuse for one of two sampled residents (Resident 9) by failing to: 1. Report an allegation of abuse to the Department of Public Health (DPH) after Resident 9 notified facility's staff of an alleged abuse. 2. Ensure to notify DPH within two hours of an alleged abuse allegation. These deficient practices violated Resident 9's right and resulted in unidentified alleged abuse in the facility and failed to protect Resident 9 from further abuse. Findings: During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included heart failure (progressive heart disease that affects pumping action of the heart muscles, causes fatigue and shortness of breath) and fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue and muscle stiffness). During a review of Resident 9's History and Physical (H&P), dated 7/9/2025, the H&P indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 9's cognitive skills for daily decision making was intact. The MDS indicated Resident 9 required set up or clean-up assistance for eating and oral hygiene. The MDS indicated Resident 9 required moderate assistance (helper does less than half the effort) for upper body dressing. The MDS indicated Resident 9 required maximal assistance (helper does more than half the effort) for shower/bathing, lower body dressing, putting on/taking off footwear and for personal hygiene. The MDS indicated Resident 9 was dependent on staff for toileting hygiene. During an interview on 7/27/2026 at 2:50 p.m. with Resident 9, Resident 9 stated on Friday night (7/24/2026) Certified Nursing Attendant (CNA) 4 was assigned to Resident 9. Resident 4 stated CNA 4 grabbed Resident 9's arm without warning and hurt Resident 9. Resident 9 stated CNA 4 was rushed during care and was rude toward Resident 9. Resident 9 stated Resident 9's back was wet after CNA 4 wiped Resident 9's buttocks and Resident 9 informed CNA 4 that Resident 9's back was wet. Resident 9 stated CNA 4 insisted Resident 9's back was dry and grabbed Resident 9's arm and stretched it back to touch Residents 9's back. Resident 9 stated Resident 9 informed the night shift Licensed Vocational Nurse (LVN) 6 about the CNA 4 being rough during a diaper change and that CNA 4 hurt Resident 9. Resident 9 stated Resident 9 hoped LVN 6 reported the situation because CNA 4 might hurt another resident that is more vulnerable than Resident 9. During an interview on 7/28/2026 at 11:21 a.m. with LVN 1, LVN 1 stated on 7/27/2026 LVN 1 was notified that Resident 9 was talking to surveyor about an alleged abuse that happened with night shift CNA 4. LVN 1 stated she attempted to talk to Resident 9 about the alleged abuse and Resident 9 did not want to talk about it and it was close to the end of LVN 1's shift and LVN 1 decided to talk to Resident 9 about the alleged abuse the following day (7/28/2026). LVN 1 stated on 7/28/2026 LVN 1 attempted to talk to Resident 9 about the alleged abuse but Resident 9 did not want to talk about it. LVN 1 stated LVN 1 did not report the alleged abuse to anyone because LVN 1 did not have any information about the alleged abuse since Resident 9 did not want to talk about it. LVN 1 stated she was supposed to report alleged abuse but LVN 1 did not report it because LVN 1 did not have the details of the alleged abuse. During an interview on 7/28/2026 at 3:24 p.m. with Social Service Assistant (SSA), SSA stated Resident 9 stated during peri care Resident 9 informed CNA 4 that Resident 9's back was still wet. The SSA stated Resident 9 stated CNA 4 grabbed Resident 9's arm and pulled arm back to touch Resident 9's back. The SSA stated Resident 9 stated CNA 4 hurt Resident 9. The SSA stated Resident 9 stated Resident 9 informed the incoming LVN (LVN 6) about the alleged abuse. The SSA stated SSA reported the alleged abuse to the Administrator (Admin), but the SSA did not know if the alleged abuse was reported to the Department of Public Health (DPH). The SSA stated this was an alleged abuse and should have been reported right away. The SSA stated anything that dealt with an alleged abuse must be reported to protect residents. During an Interview on 7/28/2026 at 4:02 p.m. with Admin, the Admin stated on 7/24/2026 Resident 9 notified staff that Resident 9 was not happy with the care Resident 9 received but Resident 9 never said it was an alleged abuse. The Admin stated the Admin was not aware LVN 1 knew of Resident 9's alleged abuse. The Admin stated the Admin did not know Resident 9 told the SSA that it was an alleged abuse. The Admin stated the Admin did not think it was an alleged abuse and that was why it was not reported. During an interview on 7/28/2026 at 4:47 p.m. with Registered Nurse (RN) 2, RN 2 stated all potential abuse must be investigated and reported to the Admin as soon as possible. RN 2 stated alleged abuse must be reported to the DPH within 2 hours. RN 2 stated if alleged abuse was not investigated and not reported within two hours, facility could not prevent abuse from reoccurring again. During an interview on 7/29/2026 at 11:17 a.m. with CNA 4, CNA 4 stated CNA 4 was assigned to Resident 9 on 7/24/2026. CNA 4 stated during Resident 9's diaper change, Resident 9 stated Resident 9's back was still wet. CNA 4 stated CNA 4 told Resident 9 that CNA 4 had dried Resident 9's back three times. CNA 4 stated Resident 9 stated CNA 4 was lying and Resident 9 still felt back wet. CNA 4 stated CNA 4 attempted to touch Resident 9's wrist and Resident 9 screamed and stated CNA 4 hurt Resident 9. CNA 4 stated CNA 4 barely touched Resident 9's wrist when Resident 9 screamed. CNA 4 stated CNA 4 wanted to grab Resident 9's hand to have Resident 9 touch Resident 9's back. CNA 4 stated CNA 4 did not inform or warn Resident 9 before touching Resident 9's hand. CNA 4 stated CNA 4 informed the night nurse (LVN 6) about the situation with Resident 9, and LVN 6 stated it was ok and there was no need to report it. During an interview on 7/30/2026 at 8:38 a.m. with LVN 6, LVN 6 stated Resident 9 told LVN 6 that Resident 9 did not want CNA 4 to provide care for her anymore. LVN 6 stated Resident 9 stated CNA 4 was rushing during care and did not want CNA 4 assigned to care for Resident 9 anymore. LVN 6 stated Resident 9 stated Resident 9 did not like CNA 4. LVN 6 stated Resident 9 informed LVN 6 because Resident 9 wanted someone to know about Resident 9's CNAs request. LVN 6 stated Resident 9 did not mention Resident 9 got hurt. LVN 6 stated CNA 4 did not share any information about the interaction between Resident 9 and CNA 4. During a review of facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 9/2022, the P&P indicated all reports of resident abuse are to be reported to local, state and federal agencies and thoroughly investigated by facility management. The P&P indicated if resident abuse was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated an abuse allegation must be reported within 2 hours of an allegation involving abuse or 24 hours of an allegation that did not involve abuse. The P&P indicated after receiving any allegations of abuse the administrator was responsible for determining what actions are needed for the protection of residents. The P&P indicated all allegations are investigated and are administrator-initiated investigation.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of gnats in one of six nurse stations (station 3).This failure had the potential to place the residents in station 3 at risk of severe eye infections like pinkeye (inflammation or infection of the eyelid and eyeball), ingestion of contaminated food leading to gastrointestinal illness (any condition affecting the digestive tract, which includes the esophagus, stomach, intestines, liver, pancreas, and gallbladder), and psychological distress due to gnats being present in the facility.During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities).During a review of Resident 4's History and Physical (HP), dated 6/24/2026, the HP indicated that Resident 4 can make needs known but cannot make medical decisions.During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2026, the MDS indicated Resident 4 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 4 required Supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for bathing, dressing, putting on/taking off footwear, and personal hygiene.During a concurrent observation and interview on 7/1/2026 at 3:15 PM, with Certified Nursing Assistant (CNA) 4 in station 3, in the hallway, CNA 4 was observed hitting gnats against the wall by using a fly swatter. CNA 4 stated that CNA 4 was using the fly swatter to kill the little flies (gnats) in station 3, including the hallways and residents rooms. CNA 4 stated it was important to maintain infection control to ensure the facility was free from the little flies (gnats).During a concurrent observation and interview on 7/1/2026 at 3:35 PM, with Resident 4 at Resident 4's bedside, little gnats were observed flying inside Resident 4's room. Resident 4 stated inside the room, there were a lot of little flies on the wall next to the door and the facility was not a clean facility.During an interview on 7/7/2026 at 8:38 AM, with the Quality Assurance Nurse (QAN), the QAN stated the QAN witnessed CNA 4 was using a fly swatter to kill little flies in station 3 on 7/1/2026 around 3:30 PM.During an interview on 7/7/2026 at 8:51 AM, with the Infection Preventionist (IP), the IP stated that the facility had no policy on using swatters on the floor. The IP stated that it is important to follow policy to ensure no gnats in the facility for infection control.During an interview on 7/8/2026 at 3:19 PM, with the Maintenance (MA), the MA stated the staff should not use fly swatters in the facility. The MA stated the facility should ensure infection control was maintained by providing a pest free environment.During an interview on 7/8/2026 at 4:00 PM, with the Director of Nursing (DON), the DON stated the facility did not allow staff to use fly swatters and the facility should follow the policy to ensure the facility was free of gnats or pests for infection control.During a review of the facility's policy and procedure (P&P) titled, Pest Control, revised 5/2008, the P&P indicated, facility shall maintain an effective pest control program. The P&P indicated,1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents [.]. [.]4. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility, and all such supplies are stored in areas away from food storage areas.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled alleged staff (Licensed Vocational Nurse 1 [LVN 1]), who was involved in an allegation of staff to resident abuse involving one of three sampled residents (Resident 1), received a performance evaluation (PE - a review based upon an individual's job performance and assigned duties) at least once every twelve (12) months. This deficient practice resulted in the facility's failure to assess and evaluate the skills and competencies of LVN 1 and placed Resident 1 and other residents assigned to LVN 1, at risk for inadequate and unsafe care. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (a long-term condition where the lungs fail to get enough oxygen into the blood), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/6/2026, the MDS indicated Resident 1's cognitive skills (ability to think and process information) for daily decision making were moderately impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 1 had a pressure ulcer (PU - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 1's History and Physical Examination (H&P) dated 5/16/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 6/25/2026, the SBAR indicated Resident 1 handed a note to a staff (unnamed) indicating a staff (unnamed) with a hairy face went to Resident 1's room at 9:30 AM on 6/25/2026 and pulled Resident 1's pants down and raped Resident 1. During a review of Resident 1's Progress Notes (PN) dated 6/26/2026 timed at 1:48 AM, the PN indicated Resident 1 was interviewed by a local police officer (PD 1) at 1:25 AM. The PN indicated Resident 1 communicated with PD 1 by mouthing words and writing down on a writing pad that a bearded man (unnamed) changed Resident 1's wound (PU) patch and pulled his pants down and Resident 1 wanted this man arrested. During an observation on 6/26/2026 at 1:58 PM, Resident 1 was lying in bed, awake, alert, and had a tracheostomy (a surgically created hole in the windpipe to allow air to go to the lungs) attached to a ventilator (a medical device to help support or replace breathing). Resident 1 was non-verbal and communicated by mouthing words and/or gesturing to a staff (unidentified) for suctioning (a medical procedure that uses gentle vacuum pressure to clear mucus, saliva, or other fluids). During an interview on 6/26/2026 at 2:13 PM with Resident 1 in the presence of Certified Nursing Assistant 2(CNA 2), Resident 1 communicated by mouthing words, gesturing and/or writing. Resident 1 stated, a male staff (unnamed) who had a mustache and beard and changed the dressing of Resident 1's PU, put his pants down and attempted to put his hand on Resident 1's private area, right breast and left cheek on 6/25/2026 at 8:00 AM. Resident 1 stated, Resident 1 shoved the male staff's hand away. Resident 1 stated, the drapes and door of Resident 1's room were opened at the time of the alleged incident. During an interview on 6/26/2026 at 4:35 PM with the Director of Nursing (DON), the DON stated the facility suspended LVN 1 on 6/26/2026 at 10:30 AM after the facility reviewed the PN dated 6/26/2026, timed at 1:48 AM. During a telephone interview on 6/30/2026 at 10:04 AM with LVN 1, LVN 1 stated LVN 1 was sent home from work for suspension on 6/26/2026 for an allegation of sexual misconduct to Resident 1. LVN 1 stated, LVN 1 did not pull his pants down and did not touch Resident 1's face, private area, and right breast. During a concurrent interview and record review on 6/30/2026 at 10:51 AM with the Director of Staff Development (DSD), LVN 1's employee personnel file was reviewed. The DSD stated LVN 1 was hired on 3/3/2025. The DSD could not find LVN 1's PE. During an interview on 6/30/2026 at 1:52 PM with the DSD, the DSD stated, a PE was completed annually around the date of hire. The DSD stated, LVN 1's PE should have been conducted, within days of his hire (3/3/2025). The DSD stated completing a PE was important to ensure staff (in general) were able to perform the job and to evaluate the overall performance of the staff and address areas for improvement in order to provide quality care to the residents. During an interview on 6/30/2026 at 3:42 PM with the DSD, the DSD stated the DSD was still searching for LVN 1's PE. During an interview on 6/30/2026 at 3:50 PM with the DON, the DON stated, the PE was a review of a staff's job performance to determine if the staff met the job description expectations throughout the year, recognizing staff's strength and identifying a staff's area of improvement and was important so residents could be provided with quality care. The DON stated a PE was conducted annually, at the minimum, and should be kept in the employee file for tracking. The DON stated a PE for LVN 1 should have been completed in March this year (2026). During a review of the facility's Policy and Procedure (P&P) titled, Job Descriptions and Performance Evaluations, revised August 2010, the P&P indicated the primary purpose of the facility's job descriptions and performance evaluations were to provide uniform guidelines for the implementation of the facility's requirements and the evaluation of the standards of job performance.

Based on interview and record review, the facility failed to promptly notify one of three sampled residents (Resident 4's) Responsible Party Guardian (RPG 1) and FM 1 regarding Resident 4's self-inflicting injury to Resident 4's left wrist.This failure resulted in Resident 4's representatives not being informed of Resident 4's change in condition and not being aware Resident 4 was transferred to General Acute Care Hospital (GACH 1) on [DATE]. During a review of Resident 4's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities). The FS indicated both Resident 4's RPG 1 and F 1 were emergency contact number (#) 1. The FS indicated that the RPG 1's relationship with Resident 4 is Public Guardian (PG).During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 4 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 4 required Supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 4's Progress Notes (PN), dated [DATE], the PN indicated that Resident 4 was observed with self-inflicting injury to left wrist and was sent out to GACH 1 on [DATE]. The PN indicated no notes were found about Resident 4's self-inflicting injury to the left wrist was notified to the RPG 1, RPG 2 or F 1.During a review of Resident 4's Progress Notes (PN), dated [DATE], the PN indicated that RPG 2 was made aware of the transfer on [DATE].During a review of Resident 4's Change in Condition Evaluation form (CICE), dated [DATE], the CICE indicated Resident 4 was observed self-inflicting injury to the left wrist with her pencil and transfer Resident 4 to GACH 1 was ordered.During a review of Resident 4's Hospital Transfer Form (HTF), dated [DATE], the HTF indicated that Resident 4 was transferred to GACH 1 on [DATE] at 7:15 PM.During a review of Resident 4's Care Plan Report (CPR), initiated on [DATE], the CPR indicated Resident 4 has potential/actual impairment to skin integrity of the left wrist self-inflicted abrasion and the facility will educate resident/family/caregivers of causative factor and measures to prevent skin injury.During a review of Resident 4's History and Physical (HP), dated [DATE], the HP indicated that Resident 4 can make needs known but cannot make medical decisions.During an interview on [DATE] at 2:28 PM with Certified Nursing Assistant (CNA) 7, CNA 7 stated that Resident 4 was trying to stab Resident 4's left wrist with a coloring pencil on [DATE] around 12 PM.During a concurrent interview and record review on [DATE] at 3:10 PM with Licensed Vocational Nurse (LVN) 7, Resident 4's SBAR, dated [DATE], was reviewed. LVN 7 stated that LVN 7 did not notify the RPG 1 and F 1 about Resident 4's self-inflicting injury behavior on [DATE]. LVN 7 stated a licensed nurse should notify the resident's (in general) physician and the resident's representative right away after a self-inflicting injury behavior.During a phone interview on [DATE] at 3:40 PM with RPG 1, RPG 1 stated that RPG 1 was not notified about Resident 4 had a self-inflicting injury incident and Resident 4 was transfer to GACH 1 on [DATE].During a concurrent interview and record review on [DATE] at 11:40 AM with Registered Nurse (RN) 4, Resident 4's SBAR, dated [DATE] was reviewed. RN 4 stated that RN 4 did not notify the RPG 1 and F 1 about Resident 4's self-inflicting injury behavior on [DATE]. RN 4 stated a licensed nurse should notify the resident's physician and the resident's representative right away after a resident's self-inflicting injury.During an interview on [DATE] at 4:00 PM with the Director of Nursing (DON), the DON stated licensed nurses stated a licensed nurse should notify the resident's physician and the resident's representative right away after a resident's self-inflicting injury.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 5/2017, the P&P indicated, facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The P&P indicated, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:a. The resident is involved in any accident or incident that results in an injury including injuries or an unknown source;b. There is a significant change in the residents' physical, mental, or psychosocial status;c.;d. A decision has been made to discharge the resident from the facility; and/ore. It is necessary to transfer the resident to a hospital/treatment center.

Based on observation, interview, and records review the facility failed to provide sufficient staffing to accommodate residents' needs when the facility failed to appropriately redistribute resident assignments after Licensed Vocational Nurse 1 (LVN 1) left the facility prior to the completion of LVN 1's shift, resulting in LVN 3 being responsible for approximately 14 residents for one of three shift (Shift 1/Day Shift, 7 am to 3:30 pm).This deficient practice had the potential to result in residents not receiving needed services timely and efficiently during the day shift on 6/14/2026.Findings:During a review of staffing schedules, assignment sheets, and time records for 6/14/26, the records indicated Licensed Vocational Nurse 1 (LVN 1) left the facility prior to completion of LVN 1's scheduled shift (Day Shift). During an interview on 6/18/2026 at 9:30AM with Registered Nurse 1 (RN 1), RN 1 stated it was unsafe for one nurse to be responsible for both assignments (assignments for two Nurses), as resident assignments should be redistributed among the nursing staff to ensure residents' needs are met and residents' safety were maintained. RN 1 stated leaving one LVN responsible for 14 residents could place the residents' safety at risk, particularly in the event of an emergency or change in condition, as the nurse may not be able to respond timely to all resident needs.During an interview on 6/18/26 at 11:50AM with LVN 1, LVN 1 stated she endorsed her assigned residents to LVN 3 before leaving the facility due to a family emergency.During an interview on 6/18/2026 at 3 PM with the Staffing Scheduler (SS), the SS stated on 6/14/2026, when LVN 1 left the facility before LVN 1's shift ended due to an emergency, the replacement staff were not obtained. The SS stated endorsement of all residents to one nurse would not be acceptable and resident assignments should have been distributed among the remaining nursing staff. The SS stated assigning all residents to one nurse could potentially place all the residents' safety at risk in the event of an emergency.During an interview on 6/18/2026 at 3:20 PM with LVN 3, LVN 3 stated (on 6/14/2026) LVN 1 endorsed all LVN 1's assigned residents to LVN 3. LVN 3 stated LVN 3's temporary assignment resulted in LVN 3 caring for both LVN 3's resident assignment and LVN 1's resident assignment for a total of 14 residents.During an interview on 6/22/26 at 10 AM with Director of Nursing (DON), the DON stated assigning one LVN responsibility for 14 residents would constitute a heavy assignment and resident assignments should be redistributed among nursing staff to ensure resident safety and residents' needs are met. The DON stated leaving one nurse responsible for both assignments could place the residents at risk and affect the facility's ability to meet residents' needs.During a review of the facility's policy and procedure titled, Facility Assessment, revised October 2018, the policy indicated the facility shall determine and update its capacity to meet the needs of residents during day-to-day operations. The policy further indicated the facility assessment includes evaluating resident acuity and determining the staffing needed to meet residents' needs and to ensure available resources are aligned with resident care needs.

Based on interview and record review, the facility failed to ensure one of nine sampled residents (Resident 2) and Family Member 1 (FM 1) was informed and involved in the resident's ongoing treatment plan.This failure violated Resident 2's rights and resulted in Resident 1 and FM 1 being unaware of Resident 2's current treatment plan.During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted by the facility on 5/19/2026, with diagnoses that included fracture of the neck of the right femur (a break near the ball of the right hip joint) and dislocation of the right shoulder (when the ball of right upper arm bone popped out of the shoulder socket).During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 5/19/2026, the H&P indicated Resident 2 had the mental capacity to make medical decisions.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 2's cognitive (the ability to think and process information) skills for daily decisions making were intact. The MDS indicated Resident 2 was dependent on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a telephone interview on 6/18/2026 at 8:30 AM, with Family Member 1 (FM 1), FM 1 stated FM 1 requested updates regarding Resident 2's condition and treatment plan. FM 1 stated no one informed FM 1 regarding the status of Resident 2's orthopedic care.During an interview on 6/18/2026 at 10 AM with Resident 2, Resident 2 stated Resident 2 was unaware of the current plan regarding Resident 2's shoulder and hip condition. Resident 2 stated Resident 2 did not know if an orthopedic (physician who treats injuries and diseases of the bones) appointment had been scheduled and was unable to describe Resident 2's current treatment plan. Resident 2 stated Resident 2 was not informed regarding the status of an orthopedic follow-up appointment.During an interview on 6/18/2026 at 11 AM with Social Worker (SW) 1, SW 1 stated FM 1 contacted SW 1 regarding concerns about Resident 2's care. SW 1 stated SW 1 verbally relayed FM1's request for updates to nursing staff (in general) and requested nursing staff (in general) to contact FM 1 regarding Resident 2's treatment plan. SW 1 stated after FM 1 expressed concerns regarding Resident 2's orthopedic care, a physician's order for an orthopedic referral was obtained.

Based on interview and record review, the facility failed to monitor one of three sampled residents' (Resident 1's) response to pain medication when Resident 1's heart rate (HR, the number of times the heart beats in a minute, also known as the pulse rate) was not assessed one hour after pain medication was given to Resident 1.This deficiency practice resulted in Resident 1 not receiving the appropriate care and services on pain management and placed Resident 1 at risk for ineffective pain control.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/4/2026 with diagnoses which included chronic respiratory failure with hypoxia (when the lungs suddenly fail to supply enough oxygen to the body), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing),and end stage renal disease (ESRD-irreversible kidney failure). The AR indicated Resident 1 had a tracheostomy (a surgically created opening in the neck [stoma] and into the windpipe [trachea] to provide an alternative airway for breathing), was dependent on ventilator (medical device to help support or replace breathing) and on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 1's Order Summary Report (OSR), the OSR indicated an active physician's order, dated 6/4/2026, to give Resident 1 two (2) tablets of acetaminophen (medication used as pain reliever and fever reducer) oral tablet 325 milligrams (mg, a measurement unit) via G-Tube (gastrostomy tube is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) every 6 hours as needed for mild pain (1-3)- (scores to measure pain intensity, 0 means no pain, 10 means the worst pain, and 1-3 means mild pain).During a review of Resident 1's Medication Administration Record (MAR), dated 6/2026, the MAR indicated Resident 1 was given two tablets of acetaminophen 325mg for pain level of 3 on 6/9/2026 at 8:12 PM.During a review of Resident 1's Progress Note (PN), dated 6/9/2026 and timed at 8:13 PM, the PN indicated Resident 1's HR was 116 beats per minute which was elevated and acetaminophen was given for pain as ordered.During a review of Resident 1's medical record, including the MAR, there was no follow up HR documented in the medical record after acetaminophen was given to Resident 1 on 6/9/2026 at 8:12 PM.During a phone interview on 6/12/2026 at 2:42 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 gave Resident 1 (acetaminophen) for pain and elevated HR per Resident 1's family request on 6/9/2026. LVN 3 stated LVN 3 should have reassessed and documented Resident 1's HR within one hour after giving (acetaminophen) for pain and elevated HR on 6/9/2026.During a concurrent interview and record review on 6/12/2026 at 1:30 PM with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated there was no follow up HR documented in the medical record after Resident 1 was given acetaminophen on 6/9/2026 at 8:12 PM. The DON stated Resident 1's HR should have been checked and documented to verify the effectiveness of pain medication (acetaminophen) as follow up assessment within one hour after pain medication administration.During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised 10/2022, the P&P indicated pain management is a multidisciplinary care process that includes assessing the potential for pain, recognizing the presence of pain, and monitoring for the effectiveness of interventions and the resident's response to interventions. The P&P indicated tachycardia (fast heart rate) is a possible physiological sign of pain.

Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, a tube surgically placed through the abdomen and into the stomach, and used to administer nutrition, liquids, or medications) flush water bag (used to administer water through the GT) and tubing was changed before exceeding the expiration date (within 24 hours) for one of three sampled residents (Resident 2).This deficiency practice resulted in Resident 2 not receiving the appropriate care and services on feeding tube and placing Resident 2 at risk for health complications.During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 11/23/2022 and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and respiratory failure with hypoxia (when the lungs suddenly fail to supply enough oxygen to the body).During a review of Resident 2's History and Physical (H&P), dated 10/31/2025, the H&P indicated that the resident did not have the capacity to make decisions.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/17/2026, the MDS indicated Resident 2 had severely impaired cognitive skills (ability to make daily decisions). The MDS indicated Resident 2 was dependent on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 2's Order Summary Report (OSR), the OSR indicated an active physician's order for Resident 2 to receive continuous water through the GT at 35 milliliters (ml, a measurement unit) per hour for 20 hours to provide 700 ml per 24 hours via water pump and run from 2 PM and continue until 10 AM or until dose limit is met.During an observation on 6/11/2026 at 11:51 AM inside Resident 2's room at Resident 2's bedside, there was a GT flush water bag, dated 6/10/2026 and timed at 5 AM, hanging on a metal pole and attached to a feeding pump. The manufacturer instruction indicating Do not use for greater than 24 hours was observed on the water bag.During a concurrent observation and interview on 6/11/2026 at 12:12 PM with Licensed Vocational Nurse (LVN) 1 at the bedside of Resident 2 there was a GT water flush bag, dated 6/10/2026 and timed at 5 AM, hanging on a metal pole and attached to a feeding pump. LVN 1 stated the GT flush water bag should be changed within 24 hours and Resident 2's GT flush water bag and tubing exceeded the expiration time and should have been changed before 6/11/2026 at 5 AM.During an interview on 6/12/2026 at 1:30 PM with the Director of Nursing (DON), the DON stated Resident 2's GT flush water bag hanging on the pole and attached to the feeding pump should have been changed before exceeding 24 hours. The DON stated it was important to make sure to change the water bag within 24 hours to prevent infection. During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions revised 11/2018, the P&P indicated, Change administration sets for open-system enteral feedings at least every 24 hours, or as specified by the manufacturer, and Change administration sets for closed-system enteral feedings according to manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to ensure the allegation of abuse for one of two sampled residents (Resident 1) was reported to the California Department of Public Health (CDPH), Ombudsman (agency that helps residents and families with complaints about healthcare services), and the local police within two hours in accordance with the facility's Policy and Procedure (P&P) titled Abuse Reporting and Investigation, when: On 6/3/2026, Certified Nursing Assistant 2 (CNA 2) reported to Licensed Vocational Nurse 2 (LVN 2) that CNA 2 witnessed Resident 2 threw a pitcher filled with water at Resident 1 and hit Resident 1.On 6/4/2026, Resident 1 reported to Registered Nurse 1 (RN 1) that Resident 2 threw a pitcher filled with water at Resident 1 on 6/3/2026, which hit Resident 1's head. These deficient practices resulted in the failure to timely report an allegation of abuse to the required agencies/authorities within two hours and had the potential to result in further abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paraplegia (a condition involving partial or complete loss of movement and sensation in the lower half of the body) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical Examination (H&P) dated 1/8/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2026, the MDS indicated Resident 1 had intact cognition (ability to understand) and was dependent (a helper does all the effort to complete the activity) on staff for toileting hygiene and shower/bathe. The MDS indicated Resident 1 required maximal assistance (a helper does more than half of the effort) for lower body dressing and putting on/taking off footwear. During a review of Resident 1's Health Status Note (HSN - a progress note about a resident that is documented by licensed nurses) dated 6/4/2026, the HSN indicated Resident 1 reported that Resident 1's roommate threw a water pitcher filled with water and hit Resident 1 in the head, yesterday (6/3/2026) between 2:50 PM - 3:00 PM and was witnessed by a CNA. Upon assessment, there was no tenderness noted but the resident complained of pain upon palpation (examining the body using the sense of touch); Administrator and DON were made aware. During a review of Resident 2's AR, the AR indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including history of traumatic brain injury (a disruption in normal brain function caused by an outside physical force) and bipolar disorder (a mental health condition that causes extreme, uncontrollable shifts in mood, energy, and activity levels). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident had severely impaired cognition for daily decision making. During a concurrent observation and interview on 6/9/2026 at 10:13 AM with Resident 1 inside Resident 1's room, Resident 1 was sitting in bed. Resident 1's room had two beds. Resident 1's bed was located farthest from the room door, while Resident 2's (roommate) bed was located closest to the door. Resident 1 stated that on 6/3/2026 between 2:00 PM to 3:00 PM, Resident 1 had woken up from sleep when CNA 2 enter the room that Resident 1 shared with Resident 2. Resident 1 stated Resident 2 was lying in bed. Resident 1 stated when CNA 2 entered, Resident 2 suddenly grabbed the water pitcher that was on top of Resident 2's bedside table and threw it at Resident 1, hitting the left side of Resident 1's head. Resident 1 stated cold water splashed all over Resident 1. Resident 1 stated the water pitcher was heavy, so it hurt when it hit Resident 1. Resident 1 stated Resident 2 looked mad and was cussing after Resident 2 threw the water pitcher at Resident 1. Resident 1 stated Resident 1 told CNA 2 to report the incident right away. Resident 1 stated CNA 2 replied CNA 2 was going to report what had happened and CNA 2 exited the room. Resident 1 stated Resident 1 did not see any other nursing staff, besides CNA 2, come to Resident 1's room on 6/3/2026 after the incident. Resident 1 stated the following day on 6/4/2026, Resident 1 went to Nursing Station 4 and reported to RN 1 the incident involving Resident 2 that occurred on 6/3/2026. Resident 1 stated Resident 1 told RN 1 that Resident 2 threw a water pitcher that hit Resident 1's head. Resident 1 stated Resident 1 told RN 1 that Resident 1 did not want Resident 2 to be Resident 1's roommate and requested Resident 2 be moved to another room. During an interview on 6/9/2026 at 10:47 AM with CNA 2, CNA 2 stated on 6/3/2026 at around 2:00 PM, CNA 2 went to Resident 1's room with the intention of changing/cleaning Resident 1. CNA 2 stated as CNA 2 entered Residents 1 and 2's shared room, CNA 2 saw Resident 2 grab a water pitcher while in bed and toss it at Resident 1, which hit Resident 1. CNA 2 stated Resident 2 then turned Resident 2's body toward Resident 1, and Resident 2 started speaking really fast. CNA 2 stated CNA 2 told Resident 2 not to throw things, and Resident 2 replied by yelling at CNA 2 to get out of the room. CNA 2 stated CNA 2 picked up the water pitcher which landed on Resident 1's left side and placed it away from Resident 2's reach. CNA 2 stated Resident 1 was upset and told CNA 2 to tell the nurse. CNA 2 stated CNA 2 exited Residents 1 and 2's shared room and reported the incident to LVN 2. CNA 2 stated CNA 2 told LVN 2 that CNA 2 saw Resident 2 grab a water pitcher, threw it, and hit [Resident 1] with it. CNA 2 stated LVN 2 replied it was Resident 2's usual behavior. CNA 2 stated after reporting to LVN 2, CNA 2 returned to Resident 1's room and changed/cleaned Resident 1. CNA 2 stated the facility's abuse policy required certified nursing assistants to report to the charge nurse right away when they see or suspect resident abuse. CNA 2 stated the facility was supposed to report within two hours if it's violence. During an interview on 6/9/2026 at 11:26 AM with LVN 2, LVN 2 stated CNA 2 reported to LVN 2 that Resident 2 threw a water pitcher, and the floor in Resident 1 and Resident 2's shared room was wet. LVN 2 stated right after CNA 2 reported, LVN 2 went to Resident 1's room and saw water on the floor between Residents 1 and 2's beds. LVN 2 stated Resident 1 did not state Resident 2 threw a water pitcher at Resident 1 which hit Resident 1's head. LVN 2 stated Resident 1 stated Resident 1 got wet. LVN 2 stated LVN 2 did not document the incident because [Resident 2] was known to throw things on the floor all the time. LVN 2 stated LVN 2 did not report the incident to anyone. LVN 2 stated a few days after the incident, Resident 1 reported to RN 1 that Resident 2 threw a water pitcher that hit Resident 1's head. LVN 2 stated nursing staff needed to report allegations of abuse within two hours. LVN 2 stated even if it was a suspicion of abuse or complaints, it should be reported within two hours. During a subsequent interview on 6/9/2026 at 12:14 PM with CNA 2, CNA 2 stated on 6/3/2026, CNA 2 reported to LVN 2 that CNA 2 saw Resident 2 grab a water pitcher and threw it at Resident 1, which hit Resident 1. CNA 2 stated: I told [LVN 2] what I saw that [Resident 2] threw the pitcher and it hit [Resident 1]. During an interview on 6/9/2026 at 12:35 PM with the Interim Administrator (IA), the IA stated on 6/5/2026 at approximately 11:30 PM, the IA entered the shared room of Residents 1 and 2 to check on Resident 2 because Resident 2 had recently bit a staff member. The IA stated Resident 2 was asleep when IA entered the room, but Resident 1 was awake. The IA stated the IA asked how Resident 1 was doing and Resident 1 replied that Resident 2 had grabbed a water pitcher and threw it at Resident 1 which landed on [Resident 1's] head. The IA stated the IA completed the SOC 341 form (a specific form facilities use to report suspected dependent adult/elder abuse to designated public agencies/authorities) regarding what Resident 1 reported to the IA, and IA submitted the form via fax to CDPH, Ombudsman and the local police on 6/5/2026. During a review of the facility's submitted SOC 341 involving Residents1 and 2, dated 6/5/2026, the facility submitted the SOC 341 to CDPH via fax on 6/5/2026 at 1:27 PM. During a phone interview on 6/9/2026 at 1:19 PM with RN 1, RN 1 stated on 6/4/2026 at approximately 8:00 PM, Resident 1 reported to RN 1 that on 6/3/2026, Resident 2 threw a pitcher filled with water which hit the left side of Resident 1's head. RN 1 stated Resident 1 also reported that CNA 2 was present and saw the incident. RN 1 stated residents and staff who were involved in an incident should be interviewed, and the incident should be reported to the abuse coordinator, which is the facility's administrator. RN 1 stated there was a two-hour window to report the incident to the Department of Public Health, Ombudsman, and the police. RN 1 stated an SOC 341 form should have been completed regarding the incident involving Residents 1 and 2. During a concurrent interview and record review on 6/9/2026 at 2:02 PM with the Director of Nursing (DON), the facility's P&P titled, Abuse Reporting and Investigation dated 5/2025 was reviewed. The P&P indicated it was the responsibility of any and all staff members to exercise their right as a mandated reporter to ensure the SOC 341 is sent to appropriate authorities within two hours and to notify the facility APC [abuse prevention coordinator] and their supervisor immediately. The DON stated all staff members were mandated reporters (required by law, rule, or authority to report) anytime they suspect or see an abuse. The DON stated staff members have been instructed to report to the abuse coordinator and to the DON. The DON stated nursing staff should know how to complete and submit the SOC 341 form. During an interview on 6/9/2026 at 2:48 PM with the IA, the IA stated the timeframe to report allegations of abuse was within two hours from becoming aware of the allegation. The IA stated anybody could complete and submit the SOC 341 form. During a review of the facility's P&P titled, Abuse Reporting and Investigation, dated 5/2025, the P&P indicated The Facility staff will report ALL allegations of abuse, unless indicated below, as required by law and regulations to the appropriate agencies within two hours.

Based on interview and record review, the facility failed to protect a residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of three sampled residents (Resident 8) when Resident 9 pushed Resident 8 during an altercation on [DATE]. This failure resulted in Resident 8 falling to the floor, sustaining a laceration (a pattern of injury in which skin and underlying tissues are cut or torn) to the back of Resident 8's head and a fracture (broken bone) to Resident 8's right elbow. Findings: a. During a review of the facility's Midnight Census Report (MCR), dated [DATE], the MSR indicated Residents 8 and 9 were roommates of the same room while at the facility. During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 8 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 8 required partial/moderate (helper does less than half the effort) assistance from staff for toileting and personal hygiene, and dressing. During a review of Resident 8's Change in Condition Evaluation (CIC), dated [DATE], the CIC indicated, Resident (Resident 8) with her roommate (Resident 9) argue in their room.when CNA (Certified Nursing Assistant 4) and charge nurse (unknown) heard the sound and came to check immediately. Resident (Resident 8) falling on floor due to roommate (Resident 9) pushing her (Resident 8). Pt (Resident 8) got a small cut back of head and with.minimal bleeding.Pt (Resident 8) also reported her Left elbow and left thigh hurting. The CIC indicated Resident 8's Physician ordered for Resident 8 to be transferred to a General Acute Care Hospital (GACH) 1. During a review of Resident 1's GACH 1 Emergency Department (ED) Note Physician (ED Note), dated [DATE], the ED Note indicated Resident 8 presented to GACH 1 ED on [DATE] with a laceration to the back of the head. The ED Note indicated Resident 8 was pushed by Resident 8's roommate, fell, and hit the back of Resident 8's head. The ED Note indicated Resident 8 complained of right elbow and right hip pain. The ED Note indicated Resident 8's laceration to the head was repaired with one staple (specialized staples that are used instead of sutures to mend skin wounds). The ED Note indicated Resident 8 was placed in a right long-arm splint (a medical device used to immobilize and support the arm after an injury) and was given a sling (a supportive device used to immobilize and protect an injured arm or shoulder). During a review of Resident 8's Diagnostic Radiology (DR), dated [DATE], the DR indicated Resident 8's right elbow was x-rayed (x-ray, type of medical imaging that uses a small amount of radiation to create pictures of the inside of the body) due to pain and status post assault with blunt trauma. The DR indicated Resident 8 had a fracture at the back of the right elbow. b. During a review of Resident 9's AR, the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interfere with daily functioning), encephalopathy (brain disease that alters brain function or structure), and anxiety disorder. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 was severely impaired in cognitive skills. The MDS indicated Resident 9 required partial/moderate assistance from staff for toileting and personal hygiene, lower body dressing, and bathing. During a review of Resident 9's Care Plan Report (CPR), undated, the CPR indicated the facility initiated a care plan on [DATE] with the focus being, The resident is/has potential to be physically aggressive r/t (related to) throwing items on the floor, and The resident is/has potential to be verbally aggressive r/t screaming/yelling at staff. The care plan indicated an intervention was to closely observe Resident 9. During a review of Resident 9's CIC, dated [DATE], the CIC indicated, on [DATE] Resident (Resident 9) with her roommate (Resident 8) argue in their room.CNA (4) and charge nurse (LVN 1) came to check immediately, resident (Resident 9) pushes her roommate (Resident 8) out of the room on the ground. During an interview on [DATE], at 10:30 AM with Resident 9, Resident 9 stated Resident 8 would always open Resident 8's privacy curtain. Resident 9 stated Resident 8 was taking Resident 9's clothes out of the closet. Resident 9 stated Resident 8 was trying to take Resident 9's blanket from Resident 9 so Resident 9 pushed Resident 8. Resident 9 stated Resident 8 fell. During an interview on [DATE], at 3:30 PM with CNA 4, CNA 4 stated that at around 8:30 PM on [DATE], CNA 4 heard what sounded like arguing coming from the direction of Resident 8 and Resident 9's room. CNA 4 stated CNA 4 was heading toward the room when CNA 4 saw Resident 8 falling backward out of Resident 8's room. CNA 4 stated Resident 8 fell backward and hit Resident 8's head on the floor. CNA 4 stated CNA 4 saw blood on the back of Resident 8's head. CNA 4 stated Resident 9 informed CNA 4 that Resident 9 had pushed Resident 8 because Resident 8 was trying to push Resident 9. During an interview on [DATE], at 10:20 AM with CNA 5, CNA 5 stated Resident 9 had a behavior of losing her temper. CNA 5 stated Resident 9 would get mad at residents (in general) when they walked past Resident 9 in the hallway. CNA 5 stated Resident 9 would also yell angrily at residents (in general) who were sitting in chairs when Resident 9 walked past the residents (in general). CNA 5 stated Resident 9 would argue with other residents (in general). During a review of the facility's policy and Procedure (P&P) titled, Resident-to-Resident Altercations, revised [DATE], the P&P indicated: 1. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff.2. Behaviors that may provoke a reaction by residents or others include:a. verbally aggressive behavior. such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating:b. physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; .d. taking, touching, or rummaging through others property, ande. Wandering into others rooms/space.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) received care and services to prevent maggot (immature, worm-like stage in the life cycle of flies) infestation (when fly larvae (maggots) develop in a living organism's tissues or decaying organic matter) inside Resident 1's right ear, right nostril (openings in the nose) and mouth, by failing to: a. Ensure Certified Nurse Assistant (CNA 4) obtained help from licensed nurses (Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs) and/or Respiratory Therapists (RTs) in the facility's Sub Acute Unit (SAU- specialized area for residents requiring more intensive skilled nursing care) to provide oral care (the practices and procedures aimed at maintaining and improving the health and well-being of the oral cavity, including the teeth, gums, tongue, and mouth) to Resident 1 in accordance with the facility's Policies and Procedure (P&P) titled Mouth Care, and Activities of Daily Living (ADL, basic self-care tasks that individuals perform to maintain their health and well-being) Supporting, to prevent the buildup of thick white material on Resident 1's tongue and dried reddish-brown dirt on Resident 1's teeth and the gums (tissue that surrounds the teeth). b. Ensure facility's doors were closed and the screen doors (an exterior door with a mesh screen, typically made of wire or plastic, that allows air to pass through while blocking insects and other small debris from entering a building) were intact to prevent flies (insects) going inside the facility in accordance with the facility's P&P titled, Pest Control. As a result, on 6/20/25, an in-house (within the facility) Dialysis (procedure to remove waste products from the blood) Technician (DT) 1, LVN 1 and RN 1 noticed five to eight maggots coming from Resident 1's right ear, right nostril, and mouth. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 6/20/25 at 4:20 pm and was diagnosed with septic shock (serious medical condition when an infection spreads throughout the body and causes very low blood pressure (force of blood). On 6/26/25 at 4:02 pm, while onsite at the facility, the State Survey Agency (SSA) called 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) situation. The IJ was called in the presence of the Administrator (ADM), due to the facility's failure to ensure Resident 1 was free from maggot infestation. The ADM was aware that the deficient practice resulted in serious harm that threatened the health and safety of Resident 1. On 6/27/25, the ADM provided an acceptable IJ Removal Plan (IJRP, a detailed plan that includes interventions to immediately correct the deficient practices in the IJ) for the facility's failure to ensure Resident 1 was free from maggot infestation in the facility. While onsite at the facility, the surveyor verified/confirmed implementation of the IJRP through observation, interview and record review, and determined the IJ situation of maggot infestation was no longer present. The surveyor removed the IJ on 6/27/25 at 8:08 pm in the presence of the ADM, Assistant Director of Nursing (ADON), Registered Dietitian (RD), Social Services Director (SSD), Dietary Services Supervisor (DSS), Quality Assurance (QA) Nurse, and Clinical Consultants. The facility provided an acceptable IJRP as follows: A. Immediate Corrective Actions: 1.On 6/20/25, Resident 1's nasal, ears and oral cavities were cleaned by facility medical team. A full body assessment was completed to check for additional infestations, none was identified. Resident 1 was transferred to GACH 1 for further evaluation. 2, On 6/20/25, the ADON verified all residents in the SAU received oral care, and scheduled shower and bed bath were provided. All residents in the SAU unit were assessed by the facility clinical team, complete body assessment done and no other resident was identified to be affected. 3. On 6/20/25, Resident 1's room underwent deep cleaning and was thoroughly disinfected by the housekeeping team. B. Preventive and Corrective Actions: 1. From 6/24/25 - 6/25/25- Subacute Consultant provided in-service to all LVNs, RNs and RTs on Oral Care Procedure, Tracheostomy Site (a surgically created opening in the trachea [windpipe] that allows for the insertion of a tracheostomy tube) Care and Use and Handling of Toothbrush with Suction. The SAU Consultant conducted Clinical Skills Competency Checklist on nursing team and Respiratory Therapists. 2. On 6/26/25, the Exterminator company was called to service the conference room and surrounding areas of the facility. 3. On 6/27/25, the Administrator placed an order for four heavy duty rubber curtains to be installed at the patio doors to provide additional support and prevent insects from entering the facility. Three additional Fly Trap Lights were installed by Maintenance staff by the patio doors next to the social services office, smoking patio and hallway next to the kitchen. The Maintenance staff placed large fans by the patio doors to help blow air towards the patio and prevent insects flying inside the facility. The Maintenance Supervisor, Infection Preventionist (IP) and Clinical Consultants conducted a visual inspection of Resident 1's room, including furniture, under the bed, door frame and storage areas. The Clinical Consultant provided in-service to subacute clinical staff on the process to store supplies according to infection prevention practices. The Clinical Consultant provided in-service to housekeeping staff on ensuring all doors including patio, cabinets, bed frames, and furniture are kept clean and sanitized. C. Systematic Change: 1. As of 6/27/25, all patients in the SAU have an updated order for oral care for ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured) and non-ventilator residents as ordered by the residents' health practitioners. The completion of oral care will be documented in the residents' clinical records. 2. As of 06/27/25, the Director of Staff Development (DSD) updated the annual in-service calendar to include oral care/hygiene every month for the first three months and quarterly thereafter. 3. The pest control vendor will increase frequency during the summer season to a minimum of twice a month and as needed. 4. The facility initiated the use of Chlorhexidine (a chemical compound used as an antiseptic and disinfectant) for oral care of residents in subacute unit for all residents with tracheostomy. Orders were obtained and carried out by the licensed nurses. 5. The facility initiated the use of the Suction Toothbrush System (a toothbrush with suction machine using electric suction, it clears saliva and food particles from the mouth, ensuring a comfortable experience), orders were placed, and the facility will start once the supply arrives. 6. The DON, ADON, IP, QA, and RN Supervisor will monitor resident hygiene at a minimum of twice a week by randomly selecting a minimum of three residents at different stations and visually inspecting and assessing to ensure oral care has been provided. Any negative findings will immediately be corrected, and additional training will be provided if deemed necessary. The findings will be reported to the Administrator and/or DON. 7. Nurse Managers would inspect the assigned rooms two to three times a week utilizing Adherence Compliance Review Tracking Log. The inspection included checking that the Fly Trap Lights were kept on, presence of flies in resident's rooms, windows/sliding doors are kept closed, and trash bins were kept clean. Any non-compliance will immediately be reported to the Administrator, IP Nurse and Maintenance for immediate corrective actions. 8. Additional Fly Trap lights would be installed by the Maintenance Department throughout the facility as soon as the order has arrived. 9. The Maintenance Department would install Heavy Duty Door Curtain at patio doors to prevent insects and flies entering the facility as soon as the order has arrived. 10. The IP Nurse will conduct random rounds for a minimum of three times a week in the SAU to check for flies, other insects, open doors and trash bins. Any negative findings will be immediately corrected and will be reported to the ADM and/or DON. 11. During the facility's monthly scheduled QAPI meetings, the results of the inspections and audits will be analyzed by the ADM and/or DON. Any findings or non-compliance identified with this deficient practice will be reported to the Quality Assurance and Performance Improvement (QAPI, a systematic, comprehensive, and data-driven approach to maintaining and improving the quality of care and services in healthcare settings) Committee monthly for review and further recommendations. Cross Reference- F925 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility of 6/13/25 with diagnoses including metabolic encephalopathy ( brain dysfunction due to chemical imbalance in the body), respiratory failure ( a condition when the lungs cannot get enough oxygen into the blood), attention to tracheostomy (surgical opening in the throat in which a tube is placed for the resident's breathing) and end stage renal disease ( ESRD- is a medical condition in which a person's kidneys cease functioning on a permanent basis ) and dependent on renal dialysis (procedure to remove metabolic waste products or toxic substances from the bloodstream ). During a review of Resident 1's Physician's Order (PO) dated 6/12/25, the PO indicated bedside dialysis on Monday, Wednesday and Friday, one time a day for ESRD. During a review of Resident 1's Physician History and Physical (H&P) dated 6/14/25, the H&P indicated Resident 1 was on mechanical ventilation (a machine that supports breathing) secondary to pulmonary edema (fluid buildup in the lungs making it hard to breathe). During a review of Resident 1's Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their patients) Conference Record dated 6/16/25 at 8:34 pm, the IDT conference record indicated Resident 1 required total assistance with bed mobility (ability to move and change positions in bed), toileting, dressing, and bathing. During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 6/17/25, the MDS indicated Resident 1 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 1 was dependent (helper does all the effort and the resident does none of the effort to complete the activity) with staff for oral hygiene, toileting, bathing, and personal hygiene. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR- communication tool used in healthcare setting to help share important information among team members) form, dated 6/20/25, untimed, the SBAR indicated DT 1observed whitish moving objects coming from the resident's right nostril, mouth and right ear. During a review of Resident 1's Progress Note (PN) dated 6/20/25, the PN indicated on 6/20/25 at 1:30 p.m. Treatment Nurse 1 (TN1) informed RN 1 of whitish moving bodies (maggots) from Resident 1's mouth. RN 1 assessed Resident 1's mouth and removed the whitish moving bodies from the mouth, right ear, and right nostril. The PN indicated Resident 1 was transferred to GACH 1 on 6/20/25 at 4:20 PM. During a review of Resident 1's GACH 1 Intensive Care Discharge Summary (ICDS) dated 7/1/25, the ICDS indicated Resident 1 had hypotension (low blood pressure) and tachycardia (fast heart rate) upon arrival at the Emergency Department (ED). The ICDS indicated Resident 1 was given medications to increase Resident 1's blood pressure. The ICDS indicated Resident 1 was non-responsive to painful stimuli (to create a reaction) in the ED with multi-organ failure (a critical condition that occurs when two or more organs fail to function) a debilitated condition (a state of physical or mental weakness that decreases normal function). The ICDS indicated Resident 1 was placed on comfort care (medical care focused on relieving pain rather than curing/treating an illness). The ICDS indicated Resident 1 had discharge diagnoses including septic shock, severe sepsis (infection spreads throughout the body) and meal worm in naris (nostrils). During an observation on 6/24/25 at 12:01pm, the facility's trash dumpster located outside of the facility, in front of the back double door, near the SAU was uncovered. The dumpster's lid was open and overflowing with trash. During an interview on 6/24/25 12:05pm with Certified Nurse Assistant (CNA 3), CNA 3 stated CNA 3 have seen flies in some of the residents' rooms (unable to recall which rooms). CNA 3 stated all the screen doors needed to be closed and fly lights should be working. CNA 3 stated CNA 3 saw flies inside of the facility this morning (6/24/25). During an observation inside of the conference room, on 6/24/25 at 1:45 pm, one live fly was flying up and down in the conference room. During an interview on 6/24/25 at 2:15pm with the Maintenance Assistant (MA), the MA stated, it was important that nurses (in general) report right away when they see pests or flies due to some residents not being able to move and the flies and gnats could get on the residents. During an observation in the conference room on 6/25/25 at 9:45 am, one live gnat was observed flying inside the conference room. During an observation in the hallway on 6/25/25 at 11:33 am, one live fly was flying back and forth from the hallway. During an interview on 6/26/25 at 9:10 am with the ADON, the ADON stated in the SAU where Resident 1 was housed, oral care was done by RTs, and licensed nurses. The ADON stated CNAs only clean the outside of the residents' (residents in the SAU) mouth. The ADON stated oral care to residents in the SAU must be done every shift and as needed. The ADON stated the oral care must be documented on the RT flow sheet and nurses' notes. The ADON stated suctioning was done by RTs or licensed nurses. The ADON stated it was important to check the windows and ensure the doors were closed to prevent flies and insects from going into the facility and into the residents' rooms, lay eggs and develop maggot infestation on the residents (residents in the SAU). The ADON stated, in the SAU, residents were immobile, unresponsive and unable to protect themselves nor remove the bugs/pests. The ADON stated, this time of the year with the hot weather, there would be a lot of bugs/pests that could go inside the facility. The ADON stated licensed nursing staff should ensure oral care was provided to the residents, especially those residents with tracheostomy and or on ventilator. During an interview on 6/26/15 at 9:38 am with RN 1, RN 1 stated Resident 1 was transferred to GACH 1 on 6/20/25 and had not returned back to the facility. RN 1 stated, on 6/20/25 during Resident 1's dialysis session, DT 1, Resident 1's family member and TN 1 saw two little white moving objects (maggots) coming out of Resident 1's right nostril, one coming outside Resident 1's right ear, and five coming out of Resident 1's mouth. RN 1 stated it was important not to have flies in the facility because the residents in the SAU cannot move on their own and flies could lay eggs inside their mouth and tracheostomy. RN 1 stated she had not performed oral care to Resident 1 on the morning of 6/20/25 due to Resident 1's dialysis session. During an interview with LVN 1 on 6/26/25 at 10:45 am, LVN 1 stated, Resident 1 slept with Resident 1's mouth wide open. LVN 1 stated Resident 1always kept Resident 1's mouth open. LVN 1 stated Resident 1 had a thick white layer on Resident 1's tongue that was not easily removed when LVN 1 provided oral care to Resident 1 on 6/20/25. LVN 1 stated there were flies in the SAU hallway and stated after Resident 1 was found with maggots on 6/20/25, flies could still be found in the facility. LVN1 stated on 6/20/25 at 4:30 pm, the dialysis RN supervisor came to inform LVN 1 that DT 1 noticed worms/maggots coming from Resident 1's nose. LVN 1 stated LVN 1 accompanied TN 1 to assess Resident 1 and found one worm hanging from Resident 1's right nostril. LVN 1 stated TN 1 went to get RN 1. LVN 1 stated RN 1 removed the worms and had to dig into Resident 1's mouth to remove all of them (5 maggots). LVN 1 stated there was also one worm on the right side of Resident 1's pillow and others in Resident 1's nose. LVN 1 stated, RN1 described the moving objects from Resident 1's mouth and nose as whitish moving objects, but the RN Dialysis Supervisor and DT 1 stated they were worms/maggots. During an interview on 6/26/25 at 2:26 pm with CNA 4, CNA 4 stated CNA 4 took care of Resident 1 on the night shift (11pm-7am) of 6/19/25. CNA 4 stated CNA 4 performed oral care for Resident 1, but CNA 4 only cleaned around Resident 1's lips. CNA 4 stated CNA 4 did not clean the inside of Resident 1's mouth because Resident 1's mouth was closed. CNA 4 stated CNA 4 did not ask the assigned RT or licensed nurse for Resident 1 to assist CNA 4 with oral care due to Resident 1's mouth looked clean from the outside. During an interview on 6/26/25 at 2:35 pm with DT 1, DT 1 stated, on 6/20/25 during Resident 1's dialysis session, while talking to Resident 1's sister, DT 1 noticed something was moving on Resident 1's beard, and something coming out of Resident 1's nostrils. DT 1 stated it was a maggot or something like a worm. DT 1 called Dialysis RN and Dialysis RN saw more than five worms coming out of Resident 1's nostrils. DT 1 stated Resident 1 kept Resident 1's mouth open all the time. DT 1 stated DT 1 did not check the inside of Resident 1's mouth and DT 1 assumed Resident 1's mouth was clean. During a review of the facility's P&P titled, Mouth Care, revised 2/2018, the P&P indicated to keep the resident's lips and oral tissues moist, to cleansed and freshen the resident's mouth and to prevent oral infection. The P&P indicated for staff to thoroughly wipe the roof of a resident's mouth, inside the cheeks, the tongue, and teeth with an applicator. The P&P indicated to change the applicators frequently and to moisten the inside of the resident's mouth, tongue and lips using a prepared swab or water-soluble lubricant (lubricant that dissolves in water). During a review of the facility P&P titled Activities of Daily Living (ADL) Supporting, revised 3/2018, the P&P indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLS. The P&P indicated residents who are unable to carry out ADL independently will receive the services necessary to maintain good grooming and personal and oral hygiene. During a review of the facility's P&P titled Pest Control, revised 5/2018, the P&P indicated the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. The P&P indicated windows are screened at all times.

Based on interview and record review, the facility failed to promptly (quickly/timely) notify the physician for, one of 16 sampled residents (Resident 1), who experienced a change of condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) in accordance with the facilities policies and procedures (P&P) titled, Change in a Resident's Condition or Status, Resident Assessment and Examination, and Resident 1's Care Plan (CP) titled, Constipation ( difficulty in emptying the bowels), by failing to: 1. Ensure Registered Nurse (RN) 2 and RN 3 notified Resident 1's primary care physician/Medical Doctor (MD) 1 of Resident 1's COC, on [DATE] at 8 am, when Resident 1 experienced abdominal distension (bloating and swelling in the belly area), abdominal firmness (abdomen feeling hard or tight to the touch), and complained of (unspecified/unrated) abdominal pain. 2. Ensure RN 4 notified MD 1 on [DATE] when Resident 1's constipation (a problem with passing stool, hard stools, generally means passing fewer than three stools a week or having a difficulty passing stools), abdominal distension, and abdominal firmness did not improve after Resident 1 received magnesium citrate (medication used to treat occasional constipation and usually results in a bowel movement [BM, an act of defecation (expelling feces )/movement of feces] within 30 minutes from the time of medication administration) on [DATE] at 4:38 pm. 3. Ensure RN 4,and Licensed Vocational Nurse (LVN) 4 notified MD 1 on [DATE] at 11:10 pm when Resident 1 was noted to have shortness of breath (SOB, sensation of not being able to breathe enough air, or the feeling of suffocating or struggling to breathe), required supplemental oxygen (O2, colorless odorless gas, medical treatment that provides additional oxygen to individuals with breathing difficulties or have low blood oxygen levels), had abdominal distension with hypoactive bowel sounds (decreased/reduced sound made by the movement of the intestines/bowel [long tubed shaped organ in the abdomen that completes the process of digestion (the breakdown of food)] as the intestines push food through, indicating?slowed intestinal activity), and had a hard abdomen. 4. Ensure RN 4, and LVN 4 notified MD 1 on [DATE] at 12:15 am, when Resident 1 complained of acute (fast/sudden) onset (beginning of something unpleasant) of 8 out of 10 pain (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt, 7 to 9 indicates severe pain) to Resident 1's abdomen. As a result of these failures, on [DATE] at 1:09 am, LVN 4 found Resident 1 unresponsive (a state in which an individual is unconscious and does not respond to stimuli such as voice, touch, or pain) in Resident 1's bed. Resident 1 had coffee ground emesis (act of vomiting, appears dark brown, coffee-ground-like substance). Resident 1 was not breathing and did not have a pulse (heartbeat). LVN 4 asked Certified Nursing Assistant (CNA) 5 to called [DATE] (phone number used to contact Emergency Medical Services [EMS, a system that responds to emergencies in need of highly skilled prehospital clinicians, also known as ambulance services] in the event of a medical emergency) and began cardio-pulmonary resuscitation (CPR - emergency lifesaving procedure performed when the heart stops or breathing is inadequate). Resident 1 was pronounced dead by Emergency Medical Technician (EMT, a person who is specially trained and certified to administer basic emergency services to victims of trauma or acute illness) at the facility on [DATE] at 1:42 am. On [DATE] at 5:57 pm, while at the facility, the State Survey Agency (SSA) identified 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). The IJ was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to notify MD 1 when Resident 1 had a COC. On [DATE], while onsite at the facility, the facility provided an acceptable IJ Removal Plan (IJRP, a detailed plan that includes interventions to immediately correct the deficient practices of the IJ) for the facility's failure to notify MD 1 of Resident 1's COC. While onsite, the SSA verified and confirmed the facility's full implementation of the IJRP through observations, interviews, and record reviews, and determined the IJ situation, under Federal Code of Regulation (CFR) 483.10: Resident Right - Notify of Changes, was no longer present. The SSA removed the IJ on [DATE] at 5:29 pm in the presence of the ADM and the DON. The acceptable IJRP included the following immediate corrective actions: 1. On [DATE], an in-service (training session) was initiated by the DON and the Assistant DON (ADON) to all licensed nursing staff (all RNs and LVNs). The facility employed a total of 84 LVNs and 20 RNs. On [DATE] and on [DATE] a total of 45 of 84 LVNs and 11of 20 RNs were in-serviced (trained) on COCs. The DON and the ADON will continue the in-services until all licensed and registered nurses are trained. Any Licensed Nurses (LNs) that are currently on medical leave or vacation will receive the training before they provide patient care. The in-service included: a. Contacting the physician as soon as possible for any resident's COCs specifically for residents with constipation, abdominal pain, abdominal distention, and abdominal firmness. b. Contacting the resident's physician as soon as possible when there is a delay in medication and when a resident's symptoms do not improve or worsen during a COC. c. Ensure accurate, complete, and timely documentation. d. Complete an accurate assessment of the residents' overall condition and thorough documentation. 2. On [DATE], the DON provided an in-service to direct care staff including nursing assistants in recognizing subtle but significant changes in the resident condition and how to communicate these changes to the LNs. The facility employed 119CNAs and Restorative Nursing Aides (RNAs, nursing aide program that helps residents maintain their function and joint mobility) combined. On [DATE] and [DATE] a total of 32 CNAs/RNAs were in-serviced. The DON and the Director of Staff Development (DSD) will continue training until all CNAs and RNAs are re-educated. Any CNA/RNA that was on medical leave or vacation will be trained before they provide patient care. CNAs were re-educated and encouraged to use the Stop and Watch Early Warning Tool (form used when a resident is not his/her usual self to help staff recognize and respond when the resident is becoming unwell) to communicate subtle changes in the residents' condition. 3. On [DATE] and [DATE], the medical records team conducted an audit of change in a resident's condition or status with emphasis on timely physician notification. A total of 172 residents are currently on bowel regimen (a schedule of medicines that help keep a person's BMs regular) to prevent constipation. The audit results showed 3 residents were identified as not having a BM for three days. 4. On [DATE], the facility identified Resident 4, Resident 5, and Resident 6 who had no BM for three days, the residents were assessed by assigned LNs and the steps stated below were followed. The audit results are reviewed by the RN Supervisor to ensure: a. Any changes to the residents' condition are communicated to the primary physician for any recommendations and for new orders. b. The nursing team has documented in the residents' medical record relative to changes in the residents' medical/mental condition or status. c. The residents' CP is updated to reflect the residents' COCs. d. The licensed nursing staff documents in the residents' clinical record for the COC reported or assessed by licensed nursing staff. e. The RN Supervisor has validated the completion of the SBAR (structured communication framework that helps teams share information about the condition of a resident) by LNs. 5.On [DATE], the DON and Regional Clinical Consultant initiated Competency Skill Checks for all RNs on COCs, notification of physicians, changes/worsening conditions, specific system assessment with emphasis on bowel management (bowel regimen, a schedule of medicines that helps a person have BMs), Point Click Care, (PCP, a healthcare software used for electronic health records) clinical alert and hand-off communication (up-to-date information regarding patient care, treatment and service, condition, and any recent or anticipated changes). A total of 8 of 20 RN Competency Skill Checks were completed. The DON will continue completing the Competency Skill Checks for the rest of the RNs. Competency Skill Checks will be completed for any RN currently on medical leave or vacation before providing patient care. In-services will be continued by the DON until all licensed staff are re-educated. 6. On [DATE], the facility has created a bowel management tool for significant COCs identifying the need to notify the physician. Starting [DATE], the LNs are responsible for identifying significant COCs on bowel management mentioned below: a. License nurses will identify Residents who have not had BMs for 72 hours, with new or worsening symptoms, and other associated abnormal changes but not limited to frequency and consistency of bowel, abdominal pain, abdominal distension, decreased peristalsis (digestion of food), and signs of gastrointestinal (GI, refers to the organs of the body that play a part in food digestion) bleeding. b. Upon identification LNs will utilize the tool and document the notification of the physician. c. LNs will continue documenting the COCs through the Situation, Background, Assessment, and Recommendation (SBAR) in the clinical health records. d. LNs will obtain recommendations from the physicians and will carry [the recommendations] out. e. The tool will be completed daily [during] each shift by the charge nurses, the tool will be collected by medical record staff and retained for review. 7. On [DATE], the medical records team also conducted an audit of the alert system in PCC. The PCC alert notifies the nursing team when a resident does not have BMs for 24 hours or more. Cross Refence: F641, F842 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility initially admitted Resident 1 on [DATE] and readmitted the resident on [DATE] with diagnoses that included psychosis (refers to symptoms that happen when a person is disconnected from reality), muscle wasting, and atrophy (wasting away). During a review of Resident 1's CP titled, Constipation, initiated on [DATE], reevaluated ,d+[DATE], the CP indicated Resident 1 was at risk for constipation due to medication use and decreased mobility (the ability to move or be moved freely and easily). The CP indicated Resident 1 had a history of constipation. The CP's interventions indicated for LNs to monitor medications that may cause constipation and to notify MD 1 if Resident 1 was unable to relieve constipation. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene. During a review of Resident 1's Progress Notes (PN), dated [DATE], timed at 7:51 am, the PN indicated on [DATE], at 6:05 am, Resident 1 complained of not having a BM for two days. The PN indicated Resident 1 complained of abdominal pain (unrated), bloating, and feeling uncomfortable during the night shift (11 pm to 7 am, from [DATE] to [DATE]). During a review of Resident 1's SBAR form, dated [DATE], timed at 8 am, the SBAR indicated Resident 1 had a COC due to constipation or impaction (hardened stool that is stuck in the rectum [the last section of the large intestine, a long, continuous tube that connects to the colon [the longest part of the large intestine] and the anus [the end of the large intestine] due to long lasting constipation). The SBAR indicated Resident 1's last BM was on [DATE]. The SBAR indicated RN 3 notified MD 1 regarding Resident 1's constipation and received the recommendation to administer magnesium citrate. During a review of Resident 1's Physician Telephone Orders (PO), dated [DATE], timed at 10:20 am, the PO indicated to administer magnesium citrate oral solution, give 296 milliliters (ml- unit of measurement) by mouth, one time only, for constipation until [DATE] at 11:59 pm. The PO indicated RN 2 signed the PO. During a review of Resident 1's Medication Administration Record (MAR, a log initialed and/or signed by the LNs with the date and time a medication was administered to a resident) dated [DATE], timed at 4:38 pm, the MAR indicated LVN 3 administered 296 ml of magnesium citrate oral solution to Resident 1. During a review of Resident 1's SBAR Communication Form, dated [DATE], untimed, the SBAR indicated Resident 1 had a COC. The SBAR indicated on [DATE] at 10:55 pm, Resident 1 was in bed with Resident 1's eyes closed, and Resident 1 had stable vital signs (VS - measurements of the body's most basic functions such as body temperature, heart rate, respiration rate, and blood pressure are within normal limits). The SBAR indicated at 11:10 pm (on [DATE]), Resident 1 was heard, by LVN 4, calling out for O2. The SBAR indicated Resident 1's O2 saturation (sats, percentage of O2 in the blood) was 97 percent (%, unit of measurement) while receiving 3 liters (L, unit of measurement) per minute (LPM, unit of expressed flow rate) of O2 via nasal cannula (NC, a device that delivers extra oxygen through a tube and into the nose). The SBAR indicated Resident 1's abdomen was distended. The SBAR indicated on [DATE] between 12:15 am and 12:30 am, Resident 1 complained of 8 out of 10 pain (severe/intense pain) to Resident 1's abdomen. The SBAR indicated Resident 1 accepted Norco (medication used to treat moderate to severe pain) for abdominal pain. The SBAR indicated MD 1 was notified of Resident 1's expiration (death) on [DATE], at 2 am. During a review of Resident 1's untitled EMS Report (EMSR), dated [DATE], timed at 1:10 am, the EMSR indicated the facility notified the EMS on [DATE] at 1:10 am. The EMSR indicated the EMTs arrived at the facility on [DATE] at 1:17 am and were with Resident 1 at 1:18 am. The EMSR indicated Resident 1 was found supine (face up), unresponsive, and pulseless (without a heart rate). The EMSR indicated the EMTs administered O2, performed CPR, administered two rounds (doses) of one milligram (mg- unit of measurement) of epinephrine (primary drug administered during CPR used to improve blood flow) for cardiac arrest via intraosseous (IO, insertion of a needle into the bone to deliver fluids, medications, and blood products), and a total of 1000 ml of Intravenous [IV, soft, flexible tube placed inside a vein used to administer fluids and medication directly into the bloodstream] fluids were administered to Resident 1. The EMSR indicated Resident 1 did not have a return of spontaneous circulation (ROSC, when the heart begins to beat on its own and blood circulates after CPR is performed) after 20 consecutive minutes [of CPR]. The EMSR indicated Resident 1's time of death was on [DATE] at 1:42 am. During a review of Resident 1's PN, dated [DATE], time at 8:25 am, LVN 4 documented (on [DATE]) between 1:06 am and 1:09 am, LVN 4 made rounds (visually checking residents) to assess the effectiveness of Resident 1's pain medication (Norco), and LVN 4 found Resident 1 unresponsive. The PN indicated the RN [RN 4] was notified and [DATE] was called. The PN indicated resuscitative efforts were immediately initiated while waiting for EMS. The PN indicated (on [DATE]), between 1:16 am and 1:42 am, the EMTs arrived, presumed care, and [continued] resuscitative efforts for Resident 1. The PN indicated the EMTs pronounced Resident 1's time of death on [DATE], at 1:42 am. During a telephone interview on [DATE] at 3:37 pm, with LVN 4, LVN 4 stated on [DATE] at 11:10 pm, Resident 1 asked for an increase in O2 because Resident 1, felt like it was hard to breathe. LVN 4 stated LVN 4 increased Resident 1's O2 from 2 LPM to 3 and a half LPM via NC. LVN 4 stated, on [DATE] at 12:15 am, Resident 1 complained of 8 out of 10 abdominal pain and Resident 1 had abdominal distension. LVN 4 stated Resident 1 received Norco for the abdominal pain. LVN 4 stated, 30 minutes after administering Norco, LVN 4 went to reassess Resident 1's pain, but Resident 1 was found unresponsive. LVN 4 stated Resident 1 had emesis coming out of Resident 1's nose and mouth and went down the sides of Resident 1's face. LVN 4 stated, the emesis was thick, watery, chunky, burgundy and black in color. LVN 4 stated there was, A lot of emesis mixed with blood. LVN 4 stated, It smelled like blood. LVN 4 stated LVN 4 checked Resident 1's carotid (artery [blood vessel that carries blood from the heart to the tissues and organs in the body] located on each side of the neck) and radial (artery located in the wrist) pulses and both pulses were missing. LVN 4 stated Resident 1's eyes did not respond to light. LVN 4 stated LVN 4 immediately started CPR and called a code blue (activation of an alert during a medical emergency such as cardiac arrest). LVN 4 stated LVN 4 informed RN 4 when LVN 4 increased Resident 1's O2 (on [DATE] at 11:10 pm) and when Resident 1 complained of ,d+[DATE] abdominal pain, on [DATE] at 12:15 am, because these situations were COCs for Resident 1. LVN 4 stated when Resident 1 experienced a COC, LVN 4 was supposed to assess Resident 1 and notify MD 1. LVN 4 stated LVN 4 only informed RN 4 but did not notify MD 1 of Resident 1's COC. During an interview on [DATE] at 7:50 am, with CNA 5, CNA 5 stated, on [DATE] at 11 pm, Resident 1 complained Resident 1's whole stomach was hurting. CNA 5 stated CNA 5 touched Resident 1's stomach and it was, rock hard. CNA 5 stated CNA 5 asked LVN 3 and LVN 4 when Resident 1 was going to be sent to the hospital because Resident 1 was requesting to be sent to the hospital. CNA 5 stated LVN 4 responded by stating LVN 4 needed to speak to RN 4 to see what RN 4's opinion was. CNA 5 stated Resident 1 continued to complain of stomach pain throughout the night. CNA 5 stated CNA 5 attempted to make Resident 1 as comfortable as possible within CNA 5's scope of practice (activities and duties that a healthcare professional is permitted to undertake). CNA 5 stated CNA 5 also went to the nurses' station to talk to LVN 4 and RN 4. CNA 5 stated CNA 5 asked LVN 4 and RN 4 if they were going to send Resident 1 out [to the hospital] because Resident 1 did not look like Resident 1 was in good condition. CNA 5 stated LVN 4 told CNA 5 they needed to wait for RN 4's instruction. CNA 5 stated LVN 4 went to check on Resident 1 after administering the pain medication (Norco) and LVN 4 came out of Resident 1's room asking CNA 5 to call [DATE]. CNA 5 stated CNA 5 called [DATE]. CNA 5 stated after the EMTs pronounced Resident 1 dead, RN 4 asked CNA 5 to clean Resident 1. CNA 5 stated as soon as CNA 5 walked into Resident 1's room, CNA 5 observed Resident 1's skin was pale, and there was, Black sludge [thick, soft, wet mixture of liquid and solid components], all around Resident 1's head area, bed railing, and all over the floor. CNA 5 stated, It [the emesis] looked like black bean chunks. CNA 5 stated, It [the emesis] smelled rotten [bad smelling]. CNA 5 stated CNA 5 finished cleaning Resident 1, but Resident 1 continued to bleed out of Resident 1's nose. During a telephone interview on [DATE] at 9:29 am, with LVN 4, LVN 4 stated on [DATE] at 11:10 pm, when LVN 4 increased Resident 1's O2, LVN 4 told RN 4 that LVN 4 wanted to send Resident 1 to the hospital because Resident 1's, Stomach was distended. LVN 4 stated Resident 1's abdomen was, hard. LVN 4 stated Resident 1's abdominal distension, scared, LVN 4 because LVN 4 had cared for Resident 1 the last six months and LVN 4 had never seen Resident 1's stomach look like that (distended). LVN 4 stated, I don't know why Resident 1 was not sent out [to the hospital] earlier for some kind of test. LVN 4 stated, even hours after receiving magnesium citrate, Resident 1's abdomen was still distended and hard. LVN 4 stated LVN 4 called RN 4 a second time on [DATE] between 12:15 am and 12:30 am, to inform RN 4 Resident 1 had 8 out of 10 pain on Resident 1's abdomen. LVN 4 stated RN 4 and RN 5 suggested giving Norco first to Resident 1 for the severe abdominal pain. LVN 4 stated LVN 4 wanted to, Use the chain of command [a formal transfer of authority and responsibility for a unit from one commanding to another] and LVN 4 did not know if it was okay for LVN 4 to call MD 1 or [DATE]. LVN 4 stated if LVN 4 would have known, It was okay to send Resident 1 to the hospital despite consulting RN 4, LVN 4 would have sent Resident 1 to the hospital because Resident 1's condition was not good. LVN 4 stated, A fully distended, rock-hard stomach doesn't just happen. LVN 4 stated Resident 1 should not have died that quickly. LVN 4 stated Resident 1 should have been sent to the hospital earlier on [DATE]. During a telephone interview on [DATE] at 11:48 am, with RN 4, RN 4 stated, on [DATE] around 11:10 pm, LVN 4 informed RN 4 that Resident 1 needed an increase in O2. RN 4 stated at around 11:30 pm (on [DATE]), RN 4 assessed Resident 1 and Resident 1's abdomen was distended and hard to touch. RN 4 stated RN 4 did not auscultate (examination of the resident by listening to bowel sounds to assess for intestinal function) Resident 1's abdomen. RN 4 stated Resident 1 had distension, and a hard to touch, abdomen even after receiving magnesium citrate. RN 4 stated MD 1 should have been notified of Resident 1's COC because Resident 1 had other symptoms beside constipation. RN 4 stated RN 4 needed to notify MD 1 because Resident 1 needed an increase in O2, had abdominal distension, and acute onset of severe abdominal pain. RN 4 stated, there must have been something serious going on with Resident 1. RN 4 stated MD 1 was not notified, and Resident 1 had a rapid decline in condition. During a telephone interview on [DATE] at 12:36 pm, with RN 3, RN 3 stated on [DATE] at, around 4 am, Resident 1 complained of not having a BM, feeling bloated, and feeling pain (unrated) in the abdomen. RN 3 stated Resident 1 had a distended abdomen. RN 3 stated RN 3 did not assess Resident 1's abdomen, listen to bowel sounds, nor ask Resident 1 the pain level Resident 1 felt in Resident 1's abdomen. RN 3 stated RN 3 informed MD 1 Resident 1 was constipated. RN 3 stated RN 3 did not inform MD 1 of Resident 1's abdominal distension, feeling bloated, or the unrated abdominal pain. RN 3 stated providing all [pertinent] information helped MD 1 determine the treatment needed for Resident 1. During a telephone interview on [DATE] at 12:57 pm with MD 1, MD 1 stated MD 1 was informed by facility nursing staff (unable to identify) on [DATE] at 7:44 am, Resident 1 was constipated. MD 1 stated MD 1 was notified Resident 1 continued to be constipated even after Resident 1 had received lactulose (synthetic, non-absorbable sugar used primarily as a laxative to treat constipation) and a water enema (procedure where water is introduced into the rectum to cleanse the bowel and treat constipation). MD 1 stated staff requested a KUB (Kidney/Ureter [thin tubular structure that connects the kidneys to the urinary bladder [hollow muscular organ that acts as a reservoir for urine]/Bladder) X-ray (imaging study that takes pictures of the bones and soft tissues), but MD 1 recommended the administration of magnesium citrate first. MD 1 stated facility staff did not inform MD 1 Resident 1 had abdominal distension, severe abdominal pain, and abdominal firmness/hardness. MD 1 stated staff (unidentified) notified MD 1 again on [DATE] at 6:26 am that Resident 1 was found unresponsive, EMS could not achieve ROSC, and Resident 1 passed away (on [DATE] at 1:42 am). MD 1 stated when magnesium citrate was not effective in relieving constipation, pain, abdominal distension, and hardness, LNs needed to contact MD 1 so MD 1 could provide additional orders. MD 1 stated MD 1 would have ordered a KUB X-ray for Resident 1. MD 1 stated when Resident 1 experienced SOB and needed an increase in O2, had severe abdominal pain, and had a distended abdomen, LNs needed to notify MD 1 because Resident 1 needed higher level care. MD 1 stated LNs did not notify MD 1 of Resident 1's symptoms and this [not notifying MD 1 of Resident 1's COC] stopped Resident 1 from receiving higher level care and being treated for those symptoms. MD 1 stated MD 1 was not notified about Resident 1 having coffee ground emesis when Resident 1 was found unresponsive. MD 1 stated coffee ground emesis indicated Resident 1 may have had GI bleeding. MD 1 stated signs and symptoms of GI bleeding included, abdominal distension and pain, decreased bowel sounds, nausea, vomiting, decreased O2 sats, or an increased need for O2. During a telephone interview on [DATE] at 2:40 pm, with RN 2, RN 2 stated, on [DATE] before 10 am, Resident 1 informed RN 2 Resident 1 did not have a BM for two days. RN 2 stated RN 2 assessed Resident 1 and Resident 1 had hypoactive bowel sounds, abdominal distension, and firmness. RN 2 stated Resident 1 complained of abdominal pain, but RN 2 did not ask/assess Resident 1's pain level. RN 2 stated based on RN 2's assessment of Resident 1, Resident 1 had ,d+[DATE] pain (severe pain). RN 2 stated RN 2 did not relay RN 2's assessment to MD 1 because Resident 1's main complaint was constipation. RN 2 stated RN 2 was supposed to inform MD 1 of Resident 1's full assessment because Resident 1's situation could worsen. During an interview on [DATE] at 4:44 pm with the DON, the DON stated when Resident 1 complained of constipation, LNs were supposed to assess Resident 1's abdomen by listening to bowel sounds, checking for dehydration, (state of having too little water in the body), distension, bloating, and pain. The DON stated the assessment could determine the next steps/interventions to be taken and escalating the assessment findings to MD 1 for new orders. The DON stated if LNs did not relay Resident 1's full assessment and symptoms to MD 1, It could affect Resident 1's treatment and outcome. The DON stated Resident 1's condition may not improve and could worsen. The DON stated when Resident 1 had new symptoms or when symptoms became more severe, MD 1 needed to be notified immediately (instantly) so MD 1 could decide the best course of treatment, provide more medication, or send Resident 1 to the hospital. The DON stated when MD 1 ordered the medication (magnesium citrate) and the medication was not effective, or did not relieve symptoms of constipation, MD 1 needed to be notified. During a review of the facility's undated P&P titled, Resident Examination and Assessment, the P&P indicated The purpose of the P&P was to examine and assess the resident for any abnormalities in health status, which provided a basis for the CP. The P&P indicated The GI assessment included to assess for: abdominal distension and hardness, constipation, and bowel sounds in all four quadrants (four sides of the abdomen); hypoactive (reduced bowel sounds, can indicate the intestines are not working properly), normal, or hyperactive (increased bowel sounds) sounds. The P&P indicated Notify the physician of any abnormalities such as, but not limited to abnormal vital signs, labored breathing (struggle to breathe), distended, hard abdomen, or absence of bowel sounds, and worsening of pain, as reported by the resident. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised ,d+[DATE], the P&P indicated The facility promptly notified the resident, his or attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. The P&P indicated The nurse will notify the resident's attending physician or physician on-call when there has been a(an) significant change in the resident's physician/emotional/mental condition, a need to alter the resident's medical treatment significantly, need to transfer the resident to a hospital or treatment center, and/or specific instructions to notify the physician of changes in the resident's condition. The P&P indicated Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted on the Interact SBAR Communication Form. The P&P indicated The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 1) who was assessed as high risk for fall by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1), the CNA 1 who was assigned to take care of Resident 1, had the knowledge that Resident 1 needed supervision or touching assistance [helper provides verbal cues and/or tactile (touch) cues or contact guard assistance (place one or two hands on the resident's body to help with balance) while the resident completes activity] and provided supervision (the act of overseeing, monitoring or watching over someone) to Resident 1 while Resident 1 was walking in the room and was using the bathroom (toilet use, the act of using a toilet). 2. Ensure Licensed Vocational Nurse 2 (LVN 2) and Registered Nurse 1 were aware of Resident 1's care plans interventions such as encourage Resident 1 to call for assistance, provide assistance as needed, and provide supervision with toilet use, transfer, walking in the room as indicated in Resident 1's Care Plans titled, Activities of Daily Living (ADLs, daily tasks that people perform to care for themselves and maintain independence) and Fall Risk. As a result, on 8/3/2024, at around 9 AM, Resident 1 fell in the bathroom. Resident 1 experienced pain (unrated) on the left shoulder and was transferred to General Acute Care Hospital 1 (GACH 1) via Emergency Transportation (ambulance services) for further evaluation. At GACH 1 Resident 1 was found to have a left humeral (upper arm bone) neck impacted fracture (occurs when the broken ends of the bone are jammed together by force of the injury) and the greater tuberosity (bony bump at top of humerus) had mildly displaced fracture fragment (occurs when a broken bone moves enough to create a gap around the fracture, and the pieces of the bone are no longer aligned). Cross Reference F656 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/27/2021 and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM2- elevated blood sugar level) with diabetic chronic kidney disease (damage to the kidneys so they cannot filter blood properly), dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time). During a review of Resident 1's Fall Risk Assessment (FRA) dated 11/27/2023, the FRA indicated Resident 1 was assessed as high risk for falls due to intermittent (occurring at irregular intervals; not continuous or steady) confusion, currently taking three - four medications (unspecified) and had one - two predisposing disease condition (unspecified). During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 5/21/2024, the MDS indicated Resident 1 had moderately impaired cognition (ability to think and process information). The MDS indicated Resident 1 required supervision or touching assistance for toilet transfer (ability to get on and off a toilet or commode) and walking at least 10 feet in a room, corridor (a long passage in a building from which doors lead into rooms), or similar space. During a review of Resident 1's Care Plan (CP) titled, Fall Risk, dated 5/21/2024, the CP indicated Resident 1 was at risk for fall related to depression (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities) secondary to dementia, use of anti-depressants (medication to treat depression) and poor safety awareness. The CP interventions included for staff (in general) to encourage Resident 1 to call for assistance as needed, assist Resident 1's ADL as needed, and conduct frequent visual checks of Resident 1. During a review of Resident 1's CP titled, ADL, dated 5/21/2024, the CP indicated Resident 1 had ADL deficit related to dementia and depression. The CP indicated Resident 1 required supervision with toilet use, transfer, walking in the room and walking in the corridor. The CP interventions included for staff to assist Resident 1 with ADL as needed and to monitor Resident 1 for ADL needs. During a review of Resident 1's History and Physical Examination (H&P) dated 8/1/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions due to dementia. During a review of Resident 1's Situation-Background-Assessment-Recommendation Summary for Providers (SBAR- communication tool about a resident's condition), dated 8/3/2024 and timed at 9:30 AM, the SBAR indicated on 8/3/2024 (untimed) the Charge Nurse/Registered Nurse 1 (RN 1) was alerted by a scream and found Resident 1 lying on the floor. Resident 1 complained of left shoulder pain (unrated). The SBAR indicated Resident 1 refused to get up due to shoulder pain (unrated). The SBAR indicated Resident 1 did not use the call light for assistance. The SBAR indicated Resident 1's Primary Care Provider/Medical Doctor 1 (MD 1) recommended sending Resident 1 to GACH 1. The SBAR indicated Resident 1 was transferred to GACH 1 on 8/3/2024 at 9:30 AM via emergency services. During a review of Resident 1's MD 1's physician order dated 8/3/2024, the MD 1's physician order indicated to send Resident 1 to GACH 1 for status post (after) fall on 8/3/2024. During a review of Resident 1's GACH 1 Radiology (X-ray a photographic or digital image of tissues and structures inside the body) Report of the left humerus dated 8/3/2024 at 10:08 AM, the X-ray report indicated Resident 1 sustained a left humeral neck impacted fracture, the greater tuberosity had mildly displaced fracture fragment, and there was diffused osteopenia (a condition in which there is a lower-than-normal bone mass or bone mineral density). During an interview on 8/7/2024 at 1:30 PM with RN 1(assigned RN for Resident 1), RN 1 stated Resident 1 had an unwitnessed fall on 8/3/2024 at around 9 AM. RN 1 stated RN 1 found Resident 1 on the bathroom floor after Resident 1 walked to the bathroom unsupervised. RN 1 stated, Resident 1 could walk independently and did not need supervision with walking. RN 1 stated Resident 1 only needed redirection at times due to confusion from dementia. During a concurrent observation of Resident 1 in Resident 1's room and interview with Resident 1 on 8/7/2024 at 3:37 PM, Resident 1 was awake, lying in bed, using a blue arm sling (a device that supports and keeps an injured arm still, or immobilizes it) on the left arm. Upon interview, Resident 1 stated her left arm was injured from playing football with doctors. Resident 1 stated she had no concerns. Resident 1 did not answer additional questions. During an interview on 8/7/2024 at 3:49 PM with LVN 2, LVN 2 stated LVN 2 took care of Resident 1 before the fall on 8/3/2024. LVN 2 stated Resident 1 would ambulate to the bathroom independently without the need for supervision. LVN 2 stated LVN 2 was unaware Resident 1 required supervision during ADL. During a concurrent interview and record review on 8/9/2024 at 9:54 AM with MDS Nurse 1 (MDS 1), Resident 1's MDS dated [DATE] was reviewed. The MDS under Section GG (Functional Abilities and Goals - a section of the MDS which assesses a resident's functional abilities and goals by indicating assistance level needed to complete an activity) indicated Resident 1 needed supervision or touching assistance for ambulation and supervision for toileting transfer. MDS 1 stated, based on the MDS (dated 5/21/2024), Resident 1 required a staff member (any staff member) to be present when Resident 1 walked or used the bathroom/restroom for safety. MDS 1 stated Resident 1's fall could have been prevented if staff supervision was provided (on 8/3/2024). During an interview on 8/9/2024 at 10:46 AM with MDS Nurse 2 (MDS 2), MDS 2 stated, MDS 2 completed Resident 1's MDS dated [DATE]. MDS 2 stated when Resident 1 walked to the restroom, a staff member (any staff member) needed to be present to watch and supervise Resident 1. MDS 2 stated, supervision meant a staff member needed to be with Resident 1 and provided constant visual checks. During an interview on 8/9/2024 at 1:16 PM with CNA 1, CNA 1 stated she was the assigned CNA for Resident 1 during the fall on 8/3/2024. CNA 1 stated Resident 1 did not require assistance or supervision to walk to the bathroom/restroom or inside the room. CNA 1 stated when Resident 1 fell , CNA 1 was in the dining room monitoring other residents. During an interview on 8/9/2024 at 2:27 PM with the Lead Licensed Vocational Nurse (Lead LVN), the Lead LVN stated Resident 1 was not always alert and would be confused at times. Lead LVN stated Resident 1 needed supervision in the room and bathroom. Lead LVN stated when Resident 1's MDS assessments and care plans interventions (provide supervisions) for fall prevention and ADLs were not followed, it resulted in serious harm and injury to Resident 1. During a review of the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, revised 12/2007, the P&P indicated, based on previous evaluations and current data, the staff identified 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. During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated, resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The P&P indicated, the care team targeted interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated, implementing interventions to reduce accident risks and hazards included communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, and ensuring that interventions were implemented. The P&P indicated, resident supervision was a core component of the systems approach to safety. The type and frequency of supervision may vary among residents and over time for the same residents. During a review of the facility's P&P titled, Care Plans - Comprehensive, revised 9/2010, the P&P indicated for policy implementation, the facility develops and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. During a review of the facility's P&P titled, Activities of Daily Living (ADL) Supporting, revised 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 the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking) and elimination (toileting). The P&P indicated, a resident's ability to perform ADLs will be measured using clinical tools, including the MDS.

Based on interview and record, the facility failed to promptly (quickly/timely) notify the physician for one of three sampled residents (Resident 1) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in Resident 1's Care Plan titled, Atrial Fibrillation (A-fib- irregular and often very rapid heart rhythm) and the facility's policies and procedures titled, Resident Examination and Assessment, and Change in a Resident's Condition or Status, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 5, LVN 6, LVN 7 and LVN 8 notified Resident 1's Primary Physician (PP)/Medical Doctor (MD 1), on 12/3/2024 at 9 pm, 12/4/2024 at 9 am and 9 pm, 12/5/2024 at 9 am, 12/7/2024 at 9 am, and 12/8/2023 at 9:00 am when LVN 5, LVN 6, LVN 7, and LVN 8 held (did not give/administer) Resident 1's amiodarone (medication used to treat certain types of abnormal heart rhythms that have not improved with other medications) and labetalol (medication used to treat high blood pressure) when Resident 1's heartrate (HR- heart beat/pulse) was below 60 beats per minute (BPM)(Normal HR was between 60 BPM to 100 BPM). 2. Ensure LVN 5 notified MD 1 instead of Resident 1's nephrologist (MD 2, a medical doctor who specialized in kidney care and treating diseases of the kidneys) who was seeing Resident 1 for the very first time on 12/8/2023 at 3:24 pm, when Resident 1's HR dropped to 46 BPM and Resident 1 appeared comatose. As a result, on 12/8/2023, from 9:00 am to 5:30 pm, Resident 1 experienced sustained bradycardia (continued HR below 60 BPM) and Resident 1's HR dropped to as low as 42 BPM. Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1's Intensive Care Unit (ICU- unit in hospital providing intensive care for critically ill or injured residents/patients) on 12/8/2023 at 5:31 pm for further evaluation and treatment. Cross Reference F656 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with diagnoses that included atrial fibrillation, ventilator dependence (dependent on mechanical life support to sustain daily respiration for any part of the day), and heart failure (a condition in which the heart muscle is unable to pump blood as well as it should). The AR indicated, MD 1 was Resident 1's PP. During a review of Resident 1's Admission Assessment (AA), dated 11/13/2023, timed at 7 pm, the AA indicated, Resident 1 had an irregular pulse rhythm (abnormal heartbeat). During a review of Resident 1's Care Plan (CP) titled, Atrial Fibrillation, dated 11/13/2023, the CP indicated, Resident 1 was at risk for irregular pulse/irregular heartbeat, chest pain, and shortness of breath (SOB) due to A-fib. The CP indicated, for staff to monitor Resident 1 for chest pain or abnormal HR and report to the physician. During a review of Resident 1's Physician Orders (PO), dated 11/13/2023, the PO indicated to administer amiodarone hydrochloride (HCL) 100 milligrams (mg- unit of measurement) tablet, give one (1) tablet by gastrostomy tube (GT- tube inserted through the stomach to deliver nutrition and/or medication) every 12 hours for A-fib and hold (do not give) amiodarone for a HR less than (<) 60 BPM. During a review of Resident 1's PO, dated 11/17/2023, the PO indicated to administer labetalol HCL 100 mg tablet, give 1 tablet by GT every 12 hours at 9 am and 9 pm for hypertension, and hold labetalol for systolic blood pressure (SBP- top number of the blood pressure reading; pressure in the arteries when the heart beats) of 110 millimeters of mercury (mmHg, unit of measurement) or HR < 60 BPM. During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 11/17/2023, the MDS indicated, Resident 1 was not in a persistent vegetative state (complete unawareness of self and environment accompanied by sleep-wake cycle) or no discernible consciousness (coma). The MDS indicated, Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated, Resident 1 was dependent (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, and personal hygiene. During a review of Resident 1's Medication Administration Record (MAR- a report that serves as a legal record of the medications administered to a resident) for December 2023, the MAR indicated the following: 1. LVN 6 held the amiodarone and labetalol on 12/3/2024 at 9 pm for HR of 56 BPM. 2. LVN 7 held the amiodarone and labetalol on 12/4/2024 at 9 am for HR of 59 BPM. 3. LVN 6 held the amiodarone and labetalol on 12/4/2024 at 9 pm for HR of 58 BPM. 4. LVN 7 held the amiodarone and labetalol on 12/5/2024 at 9 am for HR of 58 BPM. 5. LVN 8 held the amiodarone and labetalol on 12/7/2024 at 9 am for HR of 58 BPM. 6. LVN 5 held the amiodarone and labetalol on 12/8/2024 at 9 am for HR of 50 BPM. During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations), dated 12/8/2023, timed at 3:24 pm, the SBAR indicated, Resident 1's HR was 46 BPM. The SBAR indicated, Resident 1's blood pressure (BP- the pressure circulating blood against the walls of blood vessels; abnormal BP was less than 120/80 mmHg and above140/90 mmHg was considered high blood pressure) was 149/90 mmHg. The SBAR indicated, Resident 1 appeared comatose (state of deep unconsciousness for a prolonged or indefinite period because of severe illness or injury). The SBAR indicated, LVN 5 notified Resident 1's nephrologist (MD 2) on 12/8/2023 at 3:24 pm regarding Resident 1 had a HR of 46 BPM. During a review of Resident 1's Departmental Notes (DN), dated 12/8/2023, timed at 7:33 pm, the DN indicated, (on 12/8/2023) at 3:30 pm, MD 2 evaluated/assessed Resident 1. The DN indicated, Resident 1's BP was 168/91 mmHg and HR was 46 BPM. The DN indicated, MD 2 ordered to transfer Resident 1 to GACH 1 for further evaluation and treatment if Resident 1 sustained a low HR. The DN indicated, (on 12/8/2023) at 5:01 pm, Resident 1's HR was 42 BPM. Registered Nurse Supervisor (RNS) 1 notified MD 2 and MD 2 ordered to transfer Resident 1 to GACH 1. The DN indicated, RNS 1 called 911 (emergency medical services) and paramedics (healthcare professional trained to give emergency medical care to people who are injured or ill outside of a hospital) arrived at the facility at 5:07 pm. The DN indicated, Resident 1 left the facility at 5:20 pm. During a review of Resident 1's GACH 1 Emergency Department Physician Note (EDPN), dated 12/8/2023, timed at 5:31 pm, the EDPN indicated, Resident 1 presented in the emergency room with persistent (continuing firmly) and significant (important and deserving attention) bradycardia with HR in the 40's BPM. The EDPN indicated, Resident 1 had elevated troponin (protein found in heart muscle that leaks into the blood stream within 6 hours after a heart attack). The EDPN indicated, Resident 1 had sustained a non-ST elevated myocardial infarction (NSTEMI- type of heart attack that happens when the heart's need for oxygen cannot be met), and acute-on-chronic- kidney injury (medical emergency characterized by rapid fall in kidney function). The EDPN indicated, Resident 1 was admitted to the ICU for post-stabilization care (covered services, related to an emergency medical condition that are provided after a patient was stabilized to maintain the stabilized condition). During a review of Resident 1's GACH 1 Discharge Summary (DS), dated 12/27/2023 at 4:06 am, the DS indicated, Resident 1 was admitted to the ICU with acute-on-chronic respiratory failure (occurs suddenly and emergently from injury or illness, that makes it difficult to breathe on one's own), sepsis (the body's extreme response to infection and is a life-threatening medical emergency), and NSTEMI. The DS indicated, Resident 1 was not improving and was unresponsive (unable to react or respond to stimuli due to injury, illness, or the dying process) in a comatose state. The DS indicated, Resident 1 had minimal brain activity. The DS indicated, Resident 1 was put on comfort care (physical, emotional, social, and spiritual support for patients and their families). During an interview on 2/8/2024 at 10:39 am with LVN 3, LVN 3 stated abnormal vital signs (VS- measurements of the body's most basic functions consisting of body temperature, pulse [HR], respiratory [breathing] rate, blood pressure, and oxygen levels) were considered as COC. LVN 3 stated when a resident (in general) had a COC, LVN 3 would complete a SBAR and notify the resident's physician (in general) and report all findings promptly. During an attempted telephone interview on 2/8/2024 at 12:30 pm with RNS 1, RNS 1 was not available and did not return the call. During a concurrent telephone interview and record review on 2/8/2024 at 6:45 pm with MD 1, Resident 1's MAR for the month of December 2024 and the SBAR dated 12/8/2023 were reviewed. MD 1 stated MD 1 was Resident 1's PP; However, LVN 5, 6, 7, and 8 did not notify MD 1 of Resident 1's HR below 60 BPM and when the LVNs (LVN 5, 6, 7, and 8) held amiodarone and labetalol to Resident 1 due to Resident 1's HR was below 60 BPM (on 12/3/2024 at 9 pm, 12/4/2024 at 9 am and 9 pm, 12/5/2024 at 9 am, 12/7/2024 at 9 am, and 12/8/2024 at 9 am). MD 1 stated LVN 5 did not notify MD 1 of Resident 1's change of condition on 12/8/2023 at 3:24 pm. MD 1 stated LVN 5 notified MD 2. MD 1 stated a facility staff (unidentified) notified MD 1 of Resident 1's COC when Resident 1 was transferred to GACH 1 via 911 (on 12/8/2023 at around 5:20 pm). MD 1 stated MD 2 is a nephrologist and MD 2 first saw Resident 1 at the facility on 12/8/2023. MD 1 stated if the facility had notified MD 1 of Resident 1's bradycardia, MD 1 would have ordered to transfer Resident 1 to GACH 1 right away due to Resident 1's comorbidities (more than one disease/condition is present in a person at the same time and associated with worse health outcomes and more complex clinical management). During a telephone interview on 2/8/2024 at 7:16 pm with LVN 5, LVN 5 stated if a resident's (in general) HR was below 60, LVN 5 would notify the RNS on duty and notify the resident's PP (in general). The telephone call with LVN 5 got disconnected. During an attempted telephone interview on 2/8/2024 at 7:25 pm with LVN 5, LVN 5 stated LVN 5 did not want to answer any more questions during non-working hours. During an interview on 2/8/2024 at 7:34 pm with the Director of Nursing (DON), the DON stated the licensed nurses (LVN 5, LVN 6, LVN 7, and LVN 8) needed to notify MD 1 when Resident 1's HR was below 60 BPM. The DON stated the licensed nurses (LVN 5, LVN 6, LVN 7, and LVN 8) needed to notify MD 1 when the licensed nurses (LVN 5, LVN 6, LVN 7, and LVN 8) held Resident 1's amiodarone and labetalol for two consecutive days. The DON stated Resident 1's HR below 60 BPM was not within normal limits. The DON stated bradycardia was considered a COC. The DON stated licensed nurses (in general) had to notify the resident's PP when there was a change in resident's condition because the PP, knew the resident's history best. The DON stated licensed nurses (in general) needed to recheck a resident's HR below 60 BPM soon. During a review of the facility's Policy and Procedure (P&P) titled, Resident Examination and Assessment, revised in 2/2014, the P&P indicated, vital signs were part of the physical exam. The P&P indicated to notify the physician of any abnormalities such as: abnormal vital signs and change in cognitive, behavioral, or neurological behavior status from baseline. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised in 5/2017, the P&P indicated, the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status (such as changes in level of care). The P&P indicated, the nurse would notify the resident's attending physician or physician on-call when there has been a significant change in the resident's physical/emotional/mental condition. The P&P indicated, a significant change of condition was a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (that are not self-limiting). The P&P indicated, prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR Communication Form.

Based on observation, interview, and record review, the facility failed to provide a sanitary (clean) environment to prevent the spread of infections to one of five sampled residents (Resident 1) by failing to ensure: 1. Flies from outside of the facility did not enter Resident 1's room and lay eggs behind Resident 1's left ear. 2. The fly light (insect trap that used light to attract insects/flies) in the subacute unit (area of the facility where residents with tracheostomy tubes [tube inserted into the front of the neck to help the residents breathe] reside) was powered on and plugged in the electrical outlet. 3. Certified Nursing Assistant 2 (CNA 2) cleansed Resident 1's ears during the bed bath. These failures resulted in Certified Nursing Assistant 3 (CNA 3) finding 5 maggots (small, wormlike, larvae [immature and wingless forms of an insect that hatch from the eggs] of a fly) behind Resident 1's left ear on 7/25/2023, at 8 pm. Cross Reference: F925 Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted Resident 1 on 12/21/2016, and readmitted Resident 1 on 3/16/2023. The Admission Record indicated Resident 1's diagnoses included respiratory failure (when the lungs cannot get enough oxygen into the blood or remove carbon dioxide [waste gas made in the body's cells] from the blood), dependence on ventilator (machine used to deliver breaths to a person who is unable to breathe on their own), and functional quadriplegia (complete inability to move due to severe disability or weakness caused by another medical condition without injury or damage to the spinal cord). The Admission Record indicated Resident 1 had a tracheostomy tube. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/7/2023, the MDS indicated Resident 1 had severely impaired cognitive (ability to think and reason) skills for decision making. The MDS indicated Resident 1 was non-verbal and was totally dependent on three or more persons for bed mobility, dressing, eating, toileting, bathing, and personal hygiene (includes combing hair, brushing teeth, shaving, applying make-up, washing/drying face, and hands). During a review of Resident 1's Situation, Background, Appearance/Evaluation, Review/Notify (SBAR, a standardized communication tool between healthcare providers) Communication form, dated 7/26/2023, timed 12:46 am, the SBAR Communication form indicated on 7/25/2023, at 8 pm, maggots were noted along the hairline behind Resident 1's left ear. During a review of Resident 1's Nurses' Note, dated 7/26/2023, at 9:50 pm, the Nurses' Note signed by the Director of Clinical Operations (DCO) indicated on 7/25/2023, at 8 pm, while providing care to Resident 1, CNA 3 found five maggots along Resident 1's hairline behind Resident 1's left ear. The Nurses' Note indicated CNA 3 notified Registered Nurse Supervisor 1 (RNS 1) immediately, and RNS 1 checked Resident 1's skin and noted redness (size not indicated) behind Resident 1's left ear (where the maggots were found). During a review of Resident 1's Care Plan, dated 7/27/2023, the Care Plan indicated Resident 1 had maggots and non-blanchable redness (redness of the skin that did not turn white when pressed) along the hairline behind Resident 1's left ear. The Care Plan indicated the nursing interventions included: to clean behind Resident 1's left ear with soap and water and apply triple antibiotic ointment (medication used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) every day, and as needed for seven days. The nursing interventions included to ensure windows and doors were always closed; to ask the wound care consultant to evaluate the area behind Resident 1's left ear; to monitor the area behind Resident 1's left ear for increased redness, tenderness, and pain; and to notify Resident 1's Medical Doctor (MD 1) for any changes. During an interview on 7/27/2023, at 2:52 pm, with the DCO, the DCO stated on 7/25/2023, at 8:09 pm, RNS 1 notified the DCO that CNA 3 found maggots along the hairline behind Resident 1's left ear. The DCO stated Resident 1's left ear was reddish raw. The DCO stated MD 1 ordered to wash the reddish raw area (behind Resident 1's left ear) with soap and water, apply triple antibiotic ointment, and cover the reddish raw area with gauze dressing. The DCO stated she spoke with CNA 2, who took care of Resident 1 during the morning shift on 7/25/2023, from 7 am to 3 pm, and CNA 2 told the DCO she gave Resident 1 a bed bath on 7/25/2023, (untimed), but she did not clean behind Resident 1's ears. The DCO stated RNS 3 (another RNS/morning shift RNS) told the DCO that she saw some flies in the subacute unit on 7/25/2023. During an observation on 7/27/2023, at 3:12 pm, in Nursing Station 2 (located in the subacute unit), the fly light located in the hallway was turned off. During a concurrent observation and interview on 7/27/2023, at 3:15 pm, with Licensed Vocational Nurse 1 (LVN 1), in Nursing Station 2, LVN 1 stated she saw one fly last Monday (7/24/2023) in the subacute unit's hallway, and she killed the fly with a towel. LVN 1 stated when she came to work today (7/27/2023), LVN 1 brought her own fly swatter. LVN 1 took the fly swatter out of the medication cart and stated she had not used the fly swatter yet. LVN 1 stated, when LVN 1 killed the fly with the towel, LVN 1 informed the RNS (unidentified). LVN 1 stated the subacute unit exit door was located at the end of the hallway and used as an emergency exit. LVN 1 stated the flies flew inside the facility whenever the emergency exit door was opened. LVN 1 stated the facility's dumpster (a large metal container for holding trash) was located right outside the emergency exit door in the back of Nursing Station 2. LVN 1 stated it was important not to have flies inside the facility especially in the subacute unit because residents (in general) in this unit had tracheostomies (an incision in the windpipe made to relieve an obstruction to breathing and flies flew inside the residents' mouth. LVN 1 stated residents (in general) in the subacute unit could not move and LVN 1 worried the residents might get maggots. During a concurrent observation and interview on 7/27/2023, at 3:28 pm, with LVN 2, in Nursing Station 2, LVN 2 stated the fly light was turned off (time unknow). LVN 2 unplugged the computer located on top of the medication cart from the electrical outlet and plugged the fly light in the same electrical outlet. LVN 2 stated Nurses (unidentified) unplugged the fly light so they could charge the computer. LVN 2 stated it was important for the fly light to stay on so that flies did not fly inside the residents' (in general) rooms. During an interview on 7/27/2023, at 3:44 pm, with Resident 2, Resident 2 stated she would occasionally (unable to recall dates and times) see flies in the facility, especially during mealtime. During a concurrent observation and interview on 7/27/2023, at 3:57 pm, with LVN 4, at Resident 1's bedside, Resident 1's left ear had a dark reddish-brown scab (dry, rough skin formed over a cut or wound during healing) and redness above the left ear canal (a small, tube-like pathway that extends from the outer ear to the eardrum [separates outer ear from middle ear]). Resident 1 also had red open areas behind the left ear that extended to Resident 1's hairline. LVN 4 stated it was important to not have flies in the subacute unit because some residents in the subacute unit were not able to swat the flies. LVN 4 stated You don't want maggots on the residents. During an interview on 7/27/2023, at 4:09 pm, with Resident 4, in the subacute unit, Resident 4 stated, Once in a while, I see a fly here. During an interview on 7/27/2023, at 4:13 pm, with Resident 5, in the subacute unit, Resident 5 stated, Two days ago, I saw a fly here in the room. During an interview on 7/27/2023, at 4:17 pm, with RNS 2, RNS 2 stated it was important to keep the fly light on to prevent flies from landing and laying eggs on the residents. During an interview on 7/27/2023, at 4:27 pm, with the Housekeeping Supervisor (HKS), the HKS stated it was important to keep the fly light on to deter and catch flies. The HKS stated doors needed to be kept closed to prevent flies from entering the facility. During a review of the facility's Final Investigation Report, dated 7/28/2023, the Investigation Report indicated on 7/25/2023, at 8 pm, CNA 3 informed RNS 1 that Resident 1 had five small maggots behind her left ear. The Investigation Report indicated LVN 5 saw a few flies in the hallways in the subacute unit on 7/25/2023, and RNS 3 (another RNS) instructed LVN 5 to ensure the flies did not fly inside Resident 1's and other residents' rooms. The Investigation Report indicated the Respiratory Therapist (RT, a medical professional who care for persons with breathing problems) noticed flies on 7/25/2023. During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated 5/2008, the P&P indicated, the facility needed to ensure that the building was kept free of insects and rodents. During a review of P&P titled, Shower/Tub Bath, dated October 2010, the P&P indicated for nursing staff to promote cleanliness and provide comfort and to observe the condition of the residents' skin. During a review of the Centers for Disease Control and Prevention's (the national public health agency of the United States) Guidelines for Environmental Infection Control in Health-Care Facilities, updated in July 2019, the Guidelines indicated, Insects can serve as agents for the mechanical transmission of microorganisms (organisms visible only under a microscope, i.e. bacteria, virus, or fungus), or as active participants in the disease transmission process by serving as a vector (an agent that carries and transmits an infectious pathogen [disease-causing microorganism] into another living organism). The Guidelines indicated closing doors to the outside can help with pest control. Insects should be kept out of all areas of the health-care facility. [Source: https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html]

Based on interview and record review, the facility failed to provide hemodialysis (HD, removing of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function) treatment for one (1) of two (2) residents (Resident 1) by failing to: 1) Carry out the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Implement consistent transportation to HD center as indicated on the care plan titled, Transportation/Missing [CONDITION(S)]. As a result, Resident 1 missed 18 HD treatments from 11/23/2021 to 3/3/2022. On 3/4/2022 at 6:30 am, Resident 1 had shortness of breath (SOB), was transferred to the general acute care hospital 1 (GACH 1) via 911 (emergency services) and admitted to Intensive Care Unit (ICU, specialized treatment given to patients who are acutely unwell and require critical medical care). Findings: A review Resident 1's Face Sheet (Admission Record), indicated Resident 1 was initially admitted to the facility on [DATE] and with a most recent readmission on 2/25/2022. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's weight on initial admission was 370 lbs. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan titled, Renal [CONDITION(S)], dated 11/18/2021, indicated Resident 1 needed [CONDITION(S)] every Tuesday, Thursday, and Saturday and the goal was to be free of substance and have fluid regulated through scheduled [CONDITION(S)]. Staff intervention included was to notify primary doctor of possible complications that may occur. A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 11/23/2021, indicated Resident 1's brief interview of mental status (BIMS, screening that aids in detecting cognitive impairment) score was 15 (a score of 13-15 represents intact cognition [mental action or process of acquiring knowledge and understanding]). The MDS also indicated Resident 1 required extensive one person assist for dressing, toilet use and personal hygiene. Resident 1 required total dependence for bed mobility from 1 staff. A review of the Departmental Notes, dated 12/4/2021, timed at 6:42 pm, Resident 1 was sent out to GACH via 911 due to missed HD treatment. A review of the Departmental Notes, dated 12/5/2021, timed at 3:15 pm, Resident 1 was readmitted from GACH with no new orders. It indicated Resident 1 was dialyzed at GACH on 12/4/2021. A review of the Departmental Notes dated 12/13/2021 at 12:07 pm, Resident 1 was sent out to GACH via 911 for further evaluation due to missed HD treatment. A review Resident 1's Face Sheet, indicated Resident 1 was readmitted to the facility on [DATE]. A review of Resident 1's Doctors Progress Notes, dated 2/2/2022, indicated assessment/plan for [CONDITION(S)] was for Resident 1 not to miss hemodialysis. Progress notes also indicated Resident 1 declined HD treatment due to transportation issue secondary to gurney being too small. A review of the Departmental Notes (Progress Notes), dated 2/24/2022, timed at 5:30 pm, Resident 1 was sent out to GACH via 911 due to SOB. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/22/2022 at 2:55 pm, LVN 1 stated Resident 1 had missed episodes of HD treatment (unable to verify dates) because the facility could not find a transportation to accommodate Resident 1's size. LVN 1 stated Resident 1 would have agreed to go for his HD treatment if the appropriate size of gurney was provided by the transportation company. During a concurrent interview with Registered Nurse 1 (RN 1) and record review of the Departmental Notes on 6/14/2022 at 2:44 pm, RN 1 stated Resident 1's Departmental Notes, dated 2/1/2022 at 7:19 pm indicated Resident 1 missed his scheduled hemodialysis due to transportation issues. RN 1 stated transportation did not arrive to pick up Resident 1 to go to his HD appointment. RN 1 stated, if Resident 1 continue to miss his HD treatments, he might end up with fluid overload (the condition of having too much water in your body), difficulty of breathing, or eventually lead to death. During a concurrent interview with RN 2 and record review of Resident 1's Departmental Notes on 6/14/2022 at 2:56 pm, RN 2 stated she worked on 12/2/2021 and verified Resident 1 missed his HD treatment due to transportation issues, which was documented on the Departmental Notes on 12/2/2021 at 6:58 pm. RN 2 stated transportation did not show up to pick up Resident 1. RN 2 stated she also worked on 1/22/2022 and verified Resident 1 refused HD treatment on that day. RN 2 stated the gurney brought by the transportation company was too small for Resident 1. RN 2 stated this was documented on the Departmental Notes on 1/22/2022 at 4:33 pm. RN 2 stated if Resident 1 continued to miss his [CONDITION(S)], resident could have [CONDITION(S)] (life-threatening condition that occurs when the body's response to an infection damages its own tissues), fluid overload, and cardiac tamponade (happens when extra fluid builds up in the space around the heart and puts pressure on the heart and prevents it from pumping well). During a concurrent interview with Director of Nursing (DON) and record review of Resident 1's Departmental Notes on 6/15/2022 at 10:39 am, DON stated the Department Notes indicated Resident 1 missed his scheduled HD treatments as ordered on the following dates with the following reasons: 1) 11/23/2021 - Per transportation company (Transport 1), Resident 1 was not on the list for 8:30 am pickup time. It was rescheduled to a later time, at 10 am, but transportation company did not come to pick up Resident 1. 2) 11/27/2021 - Transport 1 did not show up as scheduled. Resident 1 refused to go to a later time for HD treatment. 3) 12/2/2021 - Transport 1 did not show up as scheduled to pick up Resident 1. Physician was made aware and gave order to reschedule HD treatment. 4) 12/4/2021 - Transport 1 did not show up as scheduled to pick up Resident 1. Physician ordered to transfer Resident 1 to GACH via 911. 5) 12/11/2021 - Transport 1 went to Resident 1's home address instead of the facility. Physician was made aware and ordered GACH transfer, but Resident 1 refused. 6) 12/30/2021 - Missed HD treatment due to Resident 1 testing positive for Corona Virus 19 (COVID-19, a respiratory illness that can spread from person to person), a change in the HD center was needed since current HD center did not cater to Residents who were Covid 19 positive. 7) 1/2/2022 - Transportation issue (unspecified) 8) 1/12/2022 - Transportation company (unspecified) did not pick up Resident 1 as scheduled. Physician was made aware and ordered to continue monitoring Resident 1. HD treatment rescheduled for the next day, 1/13/2022 9) 1/22/2022 - Transport 2 arrived at the facility to pick up Resident 1 but brought a small sized gurney. Resident 1 refused to be transported since he did not want to be in pain and felt unsafe due to inability to raise the siderails. 10) 1/29/2022 - Transport 1 did not show up. 11) 2/1/2022 - Transportation issue (unspecified) 12) 2/2/2022 - Transportation company (unspecified) arrived with a bariatric wheelchair (suitable for larger or heavier users with a wider seating and a higher weight capacity), however Resident 1 preferred bariatric gurney (a flat, padded stretcher with a variable-height and [MEDICATION(S)] sturdy wheeled frame used by medical professionals to accommodate and transport patients of 300 pounds or more who require medical care). 13) 2/7/2022 - Transportation company (unspecified) did not show up. HD treatment was rescheduled arranged with a different transportation company. 14) 2/18/2022 - Transport 3 did not show up. Facility staff followed up and was made aware, transportation company will not be able to pick up due to Resident's weight. 15) 2/19/2022 - Transportation issue (unspecified). Resident refused to be transferred to GACH per physician's recommendation. 16) 2/21/2022 - Transportation company (unspecified) did not show up. 17) 2/23/2022 - Missed HD treatment due to unspecified reason. Resident refused to be transferred to GACH as per physician's recommendation. 18) 2/28/2022 - Missed HD treatment scheduled to be given at GACH due to Ambulance refusal to transport Resident 1 since this was not an emergency. During an interview on 6/15/2022 at 10:51 am, DON stated if Resident 1 continued to miss his HD treatment, resident could have a potential for fluid overload, SOB and could lead to death. DON also stated they should have arranged transportation from other transportation company that could provide the proper gurney size for Resident 1. DON added, they should have tried more resources to ensure Resident 1 not miss his HD treatment. During an interview on 6/15/2022 at 10:54 am, Administrator (Adm) stated, facility should have arranged a different transportation company, talk to Resident 1's family to encourage resident to be transferred to GACH until transportation issues have been resolved. Adm stated, the facility should have tried harder to find other alternatives to ensure a more consistent transportation to meet Resident 1's needs. Adm stated, the facility should have paid a different transportation company to ensure Resident 1 does not miss HD treatment as ordered. During a concurrent interview with Social Services Director (SSD) and record review of Resident 1's Departmental Notes on 6/15/2022 at 11:26 am, SSD stated social services was responsible to look for appropriate transportation to bring resident to HD center. SSD stated, administration should have paid for the transportation services that could provide a bariatric gurney on a consistent basis so Resident 1 would not miss any HD treatment scheduled days. During a concurrent interview with SSD and record review of Resident 1's Vendor Request form, dated 1/5/2022, on 6/15/2022 at 12:27 pm, SSD stated the form included description of specific services requested to be provided by the vendor. SSD stated, Resident 1's Vendor Request form indicated request for [CONDITION(S)] transportation, however it should have included the request for bariatric gurney so the company would know what kind of transportation the resident needed. SSD stated, it was important that the proper gurney should have been requested from the transportation company to ensure Resident 1 could be transferred to the HD center safely. During an interview with SSD and concurrent record review of Resident 1's Progress Notes on 6/15/2022 at 11:48 am, SSD stated due to Resident 1's medical insurance, securing a transportation with bariatric gurney to accommodate Resident 1's size was difficult. During an interview on 6/15/2022 at 2:53 am, physician stated, he was aware Resident 1 missed his HD treatment schedule due to transportation issues. The physician stated facility should have tried to accommodate Resident 1's need to be transported to HD by providing the proper gurney size. During a concurrent interview with RN 3 and record review of Resident 1's Departmental Notes on 6/17/2022 at 8:02 am, RN 3 stated the Departmental Notes, dated 3/4/2022 at 7:28 am, indicated Resident 1 had difficulty breathing and was transferred to GACH via 911 since he missed most of his HD treatment as ordered. RN 3 stated, mostly due to transportation issues, Resident 1 could not get his HD treatments. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - a technique provides a framework for communication between members of the health care team about a patient's condition), dated 3/4/2022 at 7:41 am, indicated Resident 1 complained of SOB, with oxygen saturation (test that measures the amount of oxygen being carried by red blood cells) of 88 percent (%) and sent to GACH via 911. A review of Resident 1's GACH History and Physical (H&P) Reports, dated 3/4/2022 timed 3:53 pm, indicated Resident 1 was brought in by ambulance to the emergency department on 3/4/2022 at 12:16 am due to Resident 1 missing hemodialysis treatment for one week and a half due to difficulty with transportation. A review of Resident 1's GACH Operative Procedural Documentation, dated 3/6/2022 timed 5:25 pm, indicated Resident 1 was found to have cardiac tamponade and 1000 cubic centimeter (cc) of hemorrhagic fluid (bloody fluid from the heart) was obtained via ultrasound guided pericardiocentesis (procedure done to remove fluid that has built up in the sac around the heart (pericardium). A review of Resident 1's Certificate of Death, dated 3/6/2020 and timed at 10 pm, indicated Resdient 1's immediate cause of death were cardiac arrest (the abrupt loss of heart function, breathing and consciousness [being awake]), cardiac tamponade and chronic renal failure.

Based on interview, and record review, the facility failed to have a system in place to provide behavioral health care and services for one of two sampled residents (Resident 1) who had suicidal (saying or doing something that reveals a self-destructive desire) threats and attempts in the facility by failing to: 1. Identify and address Resident 1's suicidal threats on 10/8/2021. 2.Develop and implement a person-centered care plan that included and support the behavioral healthcare needs of Resident 1's suicidal ideations/threats. 3. Supervise, identify, and remove environmental hazards, such as items that could potentially be used by Resident 1 to harm himself in his room. 4. Ensuring Resident 1 was transferred out on 5150 hold (code for a California law which allows a person to be detained for 72 hours for mental help when they are a danger to themselves or others) on 10/8/2021 as ordered by the physician. 5. Ensuring staff caring for the resident were informed and alerted of Resident 1's verbalization of wanting to kill himself on 10/8/2021 to ensure the resident was monitored and supervised closely to prevent the resident from attempting suicide. As a result, on 10/12/2021 at 10PM, Resident 1 wrapped a thermostat wire around his neck by using a nail clipper to cut through the facility's air conditioning (AC) panel mounted in the resident's room wall in an attempt to kill himself. This placed Resident 1 at risk for death. The facility staff called 911 (emergency services) and Resident 1 was transferred to a General Acute Care Hospital (GACH) on 10/12/2021 at 10:30 PM. This deficient practice had the potential for the other 56 identified residents in the facility receiving antipsychotic medications (medication used to treat [CONDITION(S)] [a serious mental disorder characterized by defective or lost contact with reality] and other mental and emotional conditions) and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment or death to a resident) situation on 10/14/2021 at 5:15 PM, in the presence of the Administrator (ADM), Director of Nursing (DON) and Vice President of Operations. The ADM and DON were informed of the facility's failure to have systems in place to ensure Resident 1 was provided supervision and safe environment to prevent Resident 1's attempt to kill himself, transfer to GACH on a 5150 hold as ordered by physician on 10/8/21 and notify all staff regarding Resident 1's verbalization of wanting to kill himself on 10/8/21. On 10/17/2021 at 3:41PM, IJ was removed after verification of the Plan of Action (POA, a detailed plan to address findings) through observations, interviews, and record review, in the presence of ADM, DON, and Vice President of Operations. The POA was as follows: a. On 10/14/2021, Quality Assurance Nurse/Designee screened interviewable Residents for Suicidal ideations. A Situation Background Assessment and Recommendation (SBAR) was initiated, physician and family were notified of change of condition for the Residents who verbalized thoughts of suicidal ideation (thoughts of killing oneself). b. On 10/14/2021, an inservice on Suicide Warnings, Immediate Communication to Nursing Supervisor and Administration, Documentation on 24 hour log and Incident Report, Notification of Physician and Family and One to One Monitoring was initially conducted by DON and Director of Staff Development (DSD) to all facility staff. c. On 10/14/2021, an inservice on 5150 or Acute Incident Management, Admission Assessment and Care Planning Process was initially conducted by DON and DSD to all Licensed Nursing Staff. c. On 10/15/2021, Licensed Vocational Nurse 2 (LVN 2) received a written one to one disciplinary action from the DON regarding responding to change of condition (COC) and suicidal ideation. d. On 10/15/2021 DON further assessed the 56 identified residents in the facility on antipsychotic medications and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . e. Medical Record Director (MRD)/Designee will conduct daily audits of 24 hour/COC log, incident reports, SBARs, Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A report will be provided daily to DON or Designee for follow up and intervention. f. MRD/Designee will complete weekly audit log on all behavior monitoring logs to ensure behaviors are monitored and appropriately addressed for follow up and intervention. g. Environmental rounds for rooms with Residents identified with Suicidal Ideation risk will be conducted by Maintenance Director/ Designee. h. MRD will report monthly to the Quality Assurance Performance Improvement Committee for the next three months and quarterly thereafter and will be overseen by the DON. Findings: A review of Resident 1's Face Sheet (admission record) indicated the facility admitted Resident 1 on 10/5/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's undated History and Physical (H&P), indicated the resident was able to make needs known, but unable to make medical decisions. A review of Resident 1's Care Plan titled, [CONDITION(S)], dated 10/5/2021, indicated Resident 1 was at risk for confusion and disordered thoughts (disorganized way of thinking that leads to abnormal ways of expressing language when speaking and writing). The care plan interventions included keeping the environment free of hazards and to notify the physician if the resident's behavior interfered with functioning. A review of Resident 1's Care Plan titled, Impaired Behavior Status, dated 10/7/2021, indicated Resident 1 had multiple behavioral issues that included being verbally and physically abusive, resisting care and medications, being sexually inappropriate, and having episodes of eating his own feces. The care plan interventions included monitoring the resident's medications and behavior manifestations and providing a safe environment. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Departmental Notes, dated 10/8/2021 at 5:36 PM, indicated at 4:45 PM on 10/8/2021, Resident 1 was observed ripping the curtains off the ceiling, throwing his dresser and the drawers, and began punching himself in the head. The notes indicated Resident 1 told Certified Nursing Assistant 1 (CNA1) he wanted to kill himself and asked Licensed Vocational Nurse 2 (LVN2) for him to be taken to a mental hospital as Resident 1 was punching himself in the head. The notes indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes did not indicate Resident 1 was transferred as ordered. A review of Resident 1's (SBAR) form, dated 10/8/2021, indicated the Resident 1 was displaying aggressive behavior towards staff and had suicidal ideation (considering or planning suicide). The SBAR form also indicated Resident 1 was a danger to himself and others, would not allow staff in his room and would throw things at the staff when they attempted to enter Resident 1's room. The SBAR form also indicated Resident 1 told the nursing staff he wanted to kill himself and wanted to be transferred to a mental hospital as he punched himself in the head. The SBAR form indicated Resident 1 was to be sent out on a 5150. The SBAR form did not indicate Resident 1 was sent out to another facility. A review of Resident 1's Psychiatry Initial Evaluation, dated 10/9/2021, indicated Resident 1 was aggressive and was verbally abusive towards the psychiatrist. The evaluation indicated the psychiatrist wanted Resident 1 to go to any psychiatric facility that had a bed available. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Departmental Notes, dated 10/9/2021 at 2:59 PM, indicated Resident 1 was still at the facility and was noted to yell and hit his tattoo on his arm. A review of Resident 1's Departmental Notes, dated 10/9/2021 at 5:05 PM, indicated Nurse Practitioner 1 (NP 1) was at the facility to see Resident 1. The notes did not indicate why Resident 1 had not been transferred for psychiatric assessment or if NP1 was notified about Resident 1's suicidal ideation. A review of Resident 1's Departmental Notes, dated 10/10/2021 at 7:50 PM, indicated Resident 1 was throwing urine and feces at staff. A review of Resident 1's Interdisciplinary Team (IDT, involving two or more disciplines) notes, dated 10/12/2021, indicated Resident 1 had been eating his own stool, refusing medications, displayed multiple behaviors such as violent and sexual behaviors toward staff and had suicidal ideations. The notes indicated other referrals were necessary but did not indicate which specific referrals were needed. A review of Resident 1's Departmental Notes, dated 10/12/2021 at 3:20 PM, indicated around 11:00 AM on 10/12/2021, Resident 1 was very agitated and was hitting/punching himself. The notes indicated the physician was notified and an order was received to transfer Resident 1 to GACH for evaluation. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Departmental Notes, departmental notes dated 10/12/2021 at 5:28 PM, indicated GACH was notified of Resident 1's transfer on 5150. The notes indicated the GACH would call the facility back with bed availability. A review of Resident 1's Departmental Notes, dated 10/12/2021 at 11:17 PM, indicated Registered Nurse Supervisor 1 (RNS1) entered Resident 1's room to provide him with a blanket and noticed Resident 1 looked pale. The notes indicated RNS1 returned to Resident 1's room with LVN1 and found Resident 1 with an electrical wire from the wall wrapped around his neck. The notes indicated Resident 1 destroyed the air conditioning panel with a nail clipper and pulled out the electrical wire. A review of Resident 1's Departmental Notes, dated 10/13/2021 at 12AM, indicated around 10PM on 10/12/2021, RNS1 informed LVN1 Resident 1 looked pale and sound like he was praying. The notes indicated LVN1 went to check on Resident 1 and found the door to Resident 1's room closed. The notes indicated LVN1 opened the door and found Resident 1 pulling the thermostat from the wall and wrapped it around his neck. The notes indicated LVN1 attempted to talk to Resident 1 and the resident became very upset and threatening. The notes indicated RN1 called 911 and Resident 1 was transferred to the local emergency room for 5150 evaluation. During an interview and record review on 10/14/2021 at 11AM, LVN2 stated suicidal ideation meant resident verbalizing wanting to kill him/herself. LVN2 stated the resident should then be monitored with a staff nearby and any dangerous items such as utensils, metal, and the call light with cord should be removed from the room. LVN2 reviewed the Departmental Notes, dated 10/8/2021 at 5:36 PM and stated the physician was notified of Resident 1's suicidal ideation and an order was received to transfer Resident 1 out on a 5150. LVN2 stated Resident 1 was not transferred out because there were no available beds at the receiving facility. LVN2 stated she notified RNS1 of Resident 1's suicidal ideation on 10/8/2021 and RNS1 was called to check on Resident 1 in his room. LVN2 also stated Resident 1's call light should have been removed from the resident's room because the resident could have used the call light cord to harm himself. During a concurrent record review of Resident 1's Departmental Notes, dated 10/08/2021 at 5:36 PM and interview on 10/14/2021 at 12:46 PM, DON stated Resident 1 should have been transferred out of the facility on 10/8/2021 via 5150 as ordered by NP 1. The DON stated the facility should have implemented 1:1 monitoring for the resident's safety. The DON stated Resident 1 needed to be closely monitored, especially after expressing the desire to kill himself and for the safety of others. During an interview on 10/14/2021 at 2:23 PM, NP 1 stated he was never informed Resident 1 had verbalized wanting to commit suicide on 10/8/2021. NP1 stated he went to the facility on [DATE] and visited Resident 1 and was informed by RNS1 of Resident 1's aggressive behavior but was not informed of the resident's suicidal ideation. NP1 stated he was notified of Resident 1's suicidal ideation on 10/12/21 (4 days after the resident verbalized wanting to kill himself). NP1 stated the facility was a new environment for Resident 1 and it was very important for the staff to communicate Resident 1's mental status to the NP. NP1 stated he never received a follow up call from the facility on the resident's mental status. NP1 stated if the facility had informed him of Resident 1's desire to commit suicide on 10/8/2021, NP1 would have ordered a 1:1 sitter (continuous staff observation to safeguard patients judged likely to harm themselves or others) and would have transferred the resident out for psychiatric evaluation. NP1 stated the incident on 10/12/2021 when Resident 1 tried to kill himself could have been prevented. During an interview on 10/14/2021 at 4:23 PM, RNS1 stated she was not informed on 10/8/2021 that Resident 1 stated he wanted to kill himself. RNS1 stated she was informed Resident 1 was mad, threatening the staff, and had an order to be transferred out. RNS1 stated she called the receiving facility, but no bed was available. RNS1 stated if she had been notified Resident 1 had suicidal ideation on 10/8/2021, RNS1 would have prevented the incident that happened on 10/12/2021 when the resident tried to commit suicide. RNS1 stated there were no safety interventions implemented for Resident 1 to prevent suicide on and after 10/8/2021. RNS1 stated Resident 1 should have been placed on close monitoring, transferred out of the facility, and care plans created to prevent further harming himself. During an interview on 10/14/2021 at 4:39 PM, LVN1 stated on 10/12/2021 at 11:00 AM, LVN1 saw Resident 1 punching himself in the head. LVN1 stated around 9:30 PM on 10/12/2021, Resident 1 was sitting next to the door of his room, screaming and yelling. LVN1 stated Resident 1 was not placed on 1:1 monitoring, but LVN 1 checked on Resident 1 frequently. LVN1 stated RNS1 asked [NAME] to check on Resident 1. LVN1 noticed the door to Resident 1's room was closed. LVN1 stated when he opened Resident 1's door, Resident 1 was holding the wire from the thermostat attempting to wrap it around his neck. LVN1 stated he immediately stopped Resident 1 and took the wire away from him. LVN1 stated RNS1 called 911 while he stayed with Resident 1 in his room. LVN1 stated could not do a full assessment due to Resident 1 being aggressive. LVN1 stated 911 personnel came and took Resident 1 to a local hospital. LVN1 stated he did not know Resident 1 had verbalized wanting to kill himself on 10/8/21. LVN1 stated he had informed the physician about Resident 1's behavior of punching/hitting himself in the head. LVN1 stated Resident 1's suicide attempt could have been prevented if his verbalization of wanting to kill himself had been communicated among the facility staff. LVN1 stated Resident 1 should have been assigned a sitter to monitor him and all the cords should have been removed from Resident 1's room. During a follow up interview on 10/14/2021 at 4:55 PM, DON stated Resident 1's suicide attempt could have been prevented if there was a physician/NP and DON notification, care plan was developed, and monitoring have been done. The DON stated 911 (call for emergency assistance) should have been called on 10/8/2021 when Resident 1 verbalized wanting to kill himself. A review of the facility's policy titled, Suicide Threats, dated December 2017, indicated resident suicide threats needed to be taken seriously. The policy indicated all staff caring for the resident were to be informed of suicide threats and to report changes in the resident's behavior immediately. The policy indicated if the resident was in the facility during the suicide threat, the staff were required to monitor the resident's moods and behavior, and update care plans until a physician determined the risk of suicide was no longer present. A review of the facility's policy titled, Safety and Supervision of Residents, dated December 2007, indicated safety and environmental hazards needed to be identified on an ongoing basis. The policy indicated resident supervision was a core component of the approach to safety and the frequency was determined by the resident's condition and would need to be increased when hazards were identified. The policy indicated environmental risk factors included electrical safety.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) requiring a [CONDITION(S)] (a T shaped tube surgically created in the neck to the trachea to allow oxygen delivery) with continuous oxygen therapy to breathe maintained a patent airway (ability of a person to breathe) by: 1. Preventing accidental extubation (removal of [CONDITION(S)]) or decannulation (removal of [CONDITION(S)]) and maintained open airway in accordance with Resident 1's care plan (process that identifies individual's existing needs, as well as recognizing potential needs or risks. Communication among nurses, their patients and other healthcare providers to achieve health care outcomes). 2. Monitoring Resident 1's [CONDITION(S)] site to ensure placement of [CONDITION(S)] tubing in accordance with the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Implementing facility's policy and procedure by identifying changes in Resident 1's medical condition assuring patency of the resident's airway. 4. Addressing and identifying Resident 1's episodes of pulling out the [CONDITION(S)] to prevent further accidental decannulation and injury to the resident. On [DATE] at 11:25 pm, LVN 1 found Resident 1 lying on the floor unresponsive, with no pulse (heartbeat) and no respiration (not breathing). The resident's [CONDITION(S)] was not in place (inserted in resident's neck). Resident 1 was transferred to the general acute care hospital (GACH 1) via [DATE] (emergency services) after cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was attempted. Resident 1 remained unconscious in the GACH for three (3) days. On [DATE] at 5:37 pm, Resident 1 died in the GACH. The resident's immediate cause of death was [CONDITION(S)] (a serious condition that develops when the lungs cannot get enough oxygen into the blood) and [CONDITION(S)] [CONDITION(S)] (caused by a complete lack of oxygen to the brain, which results in the death of brain cells). Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], indicated Resident 1's cognitive skills (ability to think, understand, and reason) for daily decision making was severely impaired. Resident 1 was also assessed totally dependent with bed mobility moving side to side while in bed, transferring from bed to chair, getting dressing, and personal hygiene. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan titled, Respiratory Care, dated [DATE], indicated Resident 1 had impaired gas exchanged related to accidental extubation (removal of [CONDITION(S)]) or decannulation (removal of [CONDITION(S)]) and the goal was to maintain a patent airway, optimal oxygenation and ventilation and to reduce the incidence of accidental extubation or decannulation. The care plan interventions included were for the nursing staff to assess for any changes in respiratory status as needed and during patient care rounds, monitor oxygen saturation, [CONDITION(S)] site care daily and as needed, and to check and secure [CONDITION(S)] tie every two hours and as needed. A review of Respiratory Therapy Progress Notes (Respiratory therapists care for patients who have trouble breathing), dated [DATE] at 4:10 pm, indicated Resident 1 had no shortness of breath (difficulty of breathing) during this time, was on oxygen therapy of four (4) liters per minute (LPM) T-piece [CONDITION(S)]. Resident 1's oxygen saturation was 97%, heart rate was 68 beats per minute, and respiration breathing rate was 18 breaths per minute. A review of the Nursing Flow Sheet Form, dated [DATE] at 8 pm, indicated Resident 1 was alert, receiving three liters of oxygen per minute via Tracheal T bar (T-shaped tubing connected to a tracheal tube to deliver oxygen) and with oxygen saturation of 98%. During an interview with the Director of Nursing (DON) on [DATE] at 3pm, DON stated, Resident 1 was found unresponsive on the floor without her [CONDITION(S)] in place on [DATE] at 11:25 pm. DON stated Resident 1 was transferred to the acute hospital on [DATE] where Resident 1 later died on [DATE]. During an interview on [DATE] at 6:54 am, Licensed Vocational Nurse 1 (LVN 1) stated, he found Resident 1 unresponsive to any stimuli while lying on the floor on [DATE] at 11:25 pm. LVN 1 stated Resident 1 did not have a pulse and [CONDITION(S)] was not in place. LVN 1 stated, Resident 1 was transferred to bed, and the unidentified Respiratory Therapist (RT - medical professionals who treat problems of the lungs or breathing) reinserted the [CONDITION(S)] back to the resident and started CPR. LVN 1 stated, Registered Nurse 1 (RN 1) called [DATE] (emergency services) and Resident 1 was transferred to GACH. LVN 1 further stated Resident 1 was at risk and had attempted to pull out her [CONDITION(S)] at least twice in the past. LVN 1 then stated, Resident 1 had weakness to one side of the body and had made attempts to sitting on the side of the bed without assistance. During a telephone interview on [DATE] at 8:51am, LVN 3 stated, on [DATE], Resident 1 had an episode of pulling out her [CONDITION(S)] and noted bleeding on the site. LVN 3 stated, Resident 1 needed close monitoring to prevent pulling out the [CONDITION(S)]. During a telephone interview on [DATE] at 9:39 am, RN 1 stated, she found Resident 1 lying on the floor on her back the night of [DATE]. RN 1 stated Resident 1 was unresponsive, did not have a pulse, and was not breathing. RN 1 stated, Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 also stated, Resident 1 needed frequent visual checks and monitoring and would have benefited from one-to-one supervision (continuous observation) for frequent monitoring but was never provided. During an interview on [DATE] at 10:24 am, RT 1 stated, Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RT 1 stated she had to reinsert the tracheal tube at least two times in early ,d+[DATE]. During an interview on [DATE] at 10:54 am, Nurse Practitioner (NP) stated, there was no documented evidence or verbal report of Resident 1 having episodes of pulling out her [CONDITION(S)] or any change of condition on [DATE] and [DATE]. During a concurrent record review of Resident 1's clinical record and interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:18 am, ADON stated, Resident 1 pulled out her [CONDITION(S)] on [DATE] and on [DATE]. ADON stated Resident 1's care plan should have been updated and implemented on [DATE] to include interventions such as frequent visual check and 72-hour monitoring, which could have prevented Resident 1 from pulling her [CONDITION(S)] on [DATE]. A review of Resident 1's clinical record for the month of [DATE] indicated no documented evidence that the NP or Physician was made aware of Resident 1's episodes of pulling out the [CONDITION(S)] or attempts of sitting up on the side of the bed unassisted. A notification to the NP or Physician could have allowed for an alteration of the resident's treatment, plan of care, and/or nursing interventions that could potentially have benefited the resident's clinical outcome. A review of a facility form titled, Departmental Notes (Progress Notes), dated [DATE], at 5:21 am, it indicated on [DATE] at 11:20 pm, Resident 1 was found on the floor lying on her back, unresponsive, with no pulse and no respirations. The notes also indicated Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was started. The notes indicated that RN 1 called [DATE] at 11:25 pm and Resident 1 was transferred to GACH at 12:02 am. A review of Resident 1's Prehospital Care Report Summary (Paramedic Report), dated [DATE], indicated emergency services arrived at the facility on [DATE] at 11:41 pm. Resident was in [CONDITION(S)] (the abrupt loss of heart function, breathing and consciousness [being awake]). Prehospital Care Report Summary indicated [MEDICATION(S)] (a medication that can help to open up air passages and make breathing easier for people with various lung problems) was administered by the paramedics on 11:45 pm and 11:50 pm while the resident was in the facility. Report summary indicated at [DATE], at 11:51 pm pulse rate and respiration were restored. A review of GACH laboratory chemistry (screening blood test that measures the levels of several substances in the blood) result dated [DATE] timed at 12:43 am, result showed critical high [MEDICATION(S)] venous, the blood level result lactic acid (produced when oxygen levels become low in cells within the areas of the body) of 11.6 millimoles per liter (mmol/L - shows the concentration of a substance in a specific amount of fluid) with reference range of 0.5 to 2.2 mmol/L. (According to https://labtestsonline.org/tests/[MEDICATION(S)] , high levels of [MEDICATION(S)] in the blood indicated lack of oxygen in the blood.) A review Emergency Department (ED) Note Physician, dated [DATE], timed at 4:32 am, indicated Resident 1 was brought in the ED after being found down next to her bed, [CONDITION(S)] was apparently somewhat dislodged (removed) and was unresponsive. ED Physician notes indicated paramedics were able to get return of pulses after two rounds of CPR and [MEDICATION(S)] (indicated in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . It also indicated Resident 1 had lactic acidosis (lactic acid build up in the bloodstream). A review of the Discharge Summary at GACH, dated [DATE] and timed 6:02 pm, indicated the MRI test (Magnetic Resonance Imaging is a test that uses a magnetic field and radio waves to produce images of the brain and the brain stem) obtained on [DATE] at 4:15 pm, showed Resident 1 had global hypoxic injury (type of brain injury that occurs when the whole brain is deprived of oxygen, causing severe damage). A review of Resident 1's Certificate of death, dated [DATE] and timed at 5:37 pm, indicated the immediate cause of death was [CONDITION(S)] and [CONDITION(S)] [CONDITION(S)] (caused by a complete lack of oxygen to the brain, which results in the death of brain cells). A review of the undated Policy and Procedure (P&P) titled, Ventilator Flow Sheet Charting Guidelines, indicated to monitor the patient or resident ventilator system (machines that blow air-or air with extra oxygen-into airways and lungs) and identify changes in the patient or resident's condition and to verify that the ventilator is operating properly, assuring patency of the airway and maintaining the ordered settings. A review of the P&P titled, Care Plans-Comprehensive dated ,d+[DATE], indicated the Care Planning/Interdisciplinary Team is responsible for the review and update of care plan when there has been a significant change in the resident's condition. A review of the P&P titled, Change in a Resident's Condition or Status, dated ,d+[DATE], indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status.

Based on observation, interview, and record review the facility failed to protect one of two sampled residents (Resident 1) from physical abuse (an intentional act causing injury or trauma to another person by way of bodily contact) who had a restraining order (a criminal protection order issued by a state court which requires one person to stay away and stop harming another person) against a male individual prior to admission on 6/11/2021. The facility was aware of the Resident 1's restraining order but did not have a plan of care to address the restraining order to protect Resident 1 from physical harm. In addition, the facility did not prevent the male individual from an unlawful entry (when a person enters the property of another without consent from the owner) to the facility. This deficient practice resulted in Resident 1 to experience physical abuse and feeling afraid with the potential for serious harm to the resident and other residents in the facility (two hundred-eleven). On 7/28/2021 at 4:15 pm, the Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment or death to a resident) situation in the presence of the Director of Nursing (DON) and the Administrator (ADM). The DON and ADM were informed of the facility's failure to have systems in place to ensure Resident 1 was protected from physical abuse. On 7/30/2021 at 12:45 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA). The POA included: 1. Resident 1 was assessed and did not have signs and symptoms of injuries and was placed on a one to one staff supervision (to provide continuous observation for an individual) to protect the resident from further abuse. 2. Care plans were developed related to incident and police was contacted. 3. On 7/28/2021 Resident 1 was moved to a different room that did not have a sliding glass door. 4. The facility conducted every two hours door checks by assigned staff and monitored 140 entry points, including but not limited, windows, and doors. 5. Education and training for staff was initiated with regards to intruders and the safety & security of facility doors and windows. 6. Facility obtained a description of the male intruder and have included that information on a No-Access List, maintained at the front desk and nurse's stations and advised all staff to be on the look-out for a person matching those descriptions and to prohibit such persons from entering the facility. 7. Facility implemented a security guard to monitor the exterior of the premises. Cross Reference F689 Findings: On 7/27/2021 at approximately 3:35 am, Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) observed an unknown male individual inside Resident 1's room sitting on the floor to the left side of the resident's bed. LVN 1 told the unknown male that she was going to call the police and left the resident's room to notify Registered Nurse 1 (RN 1) to call 911 emergency (a life or death emergency that requires the immediate response of emergency service such as police, fire or paramedic). Resident 1 alleged the unknown male hit her on the left lower side of her face before leaving the room. The male individual then left the room using the sliding door located in the resident's room. Resident 1 stated the male individual could have been the male individual whom she had a restraining order against. A review of Resident 1's Police Incident Report dated 6/10/2021, and timed at 2:04 pm, indicated Resident 1 was a victim of a domestic violence (violent or aggressive behavior within the home, typically involving the violent abuse of a spouse or partner) felony that occurred on 6/10/2021 while the resident resided at another facility. The police report indicated the suspect was Resident 1's ex-boyfriend. The police report indicated that a 100 yard stay away order (restraining order) was issued to the ex-boyfriend on 12/23/2020 and expires on 12/23/2023. A review of the Admission Record for Resident 1 indicated the facility originally admitted the resident on 6/11/2021, and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS, an assessment and care screening tool) for Resident 1, dated 6/17/2021, indicated Resident 1 had the ability to make self-understood and understand others with intact cognitive skills (ability to think, understand, and reason). The MDS indicated Resident 1 required limited assistance from staff for mobility, transfer to and from bed or wheelchair, walk between locations in her room and corridors of the unit, dressing, toilet use, and personal hygiene, and needed supervision for eating. A review of Resident 1's clinical record indicated no documented evidence the resident had a restraining order with a history of domestic violence from 6/11/2021 (date of admission) to 7/27/21 (date of incident). A review of Resident 1's Progress Notes (PN), dated 7/27/2021 and timed late entry at 12:17 pm by RN 1, indicated LVN 1 reported to RN 1 there was an unknown person in Resident 1's bed on 7/27/2021 at approximately 3:35 am. The PN indicated CNA 1 witnessed an unknown male person entering Resident 1's room and immediately notified the charge nurse, LVN 1. The PN indicated LVN 1 immediately checked Resident 1's room and ask Resident 1 if there was somebody with the resident, and the resident responded, No. As LVN 1 got closer to Resident 1's bed, she noted that there was an unknown male person on the floor by the left side of Resident 1's bed. The PN indicated LVN 1 notified RN 1 regarding the situation and at 3:38 am, 911 was immediately activated. The PN indicated two police officers arrived at 3:42 am. The police officers interviewed Resident 1 and looked around the resident's room and out the sliding door but did not see anyone. The PN indicated, as per Resident 1, she alleged that the unknown person hit the left side of her jaw. The PN indicated that Resident 1 told RN 1 to tell police that she had a restraining order on a person named Boyfriend 1 but was unable to state whether the unknown person was the person she had restraining order against. During an interview on 7/28/2021 at 11:15 am, the Quality Assurance Nurse, LVN 2, stated that Resident 1 was transferred to another unit and room after the incident. LVN 2 stated Resident 1's former roommate, Resident 2, was asked about the incident but stated that she did not know anything about the incident. LVN 2 stated that Resident 2 was also assessed (physical and psychosocial assessment) and monitored for safety after the incident. LVN 2 stated that on 7/27/2021, at around 3:35 am, CNA 1 saw a man enter Resident 1's room and sat on the resident's bed next to the Resident 1. LVN 2 stated CNA 1 reported to the charge nurse, LVN 1. LVN 2 stated LVN 1 checked Resident 1's room and saw the man under the resident's bed. LVN 2 stated that all the exit/entrance doors were locked 24/7 and they did not know how the male intruder entered the building. During an observation of Resident 1's previous room at the time of the incident, and interview with LVN 2, on 7/28/2021 at 11:40 am, it was noted that Resident 1's bed was beside a sliding door leading outside to a small patio. This sliding door was locked and opened to a small patio with block fence and a locked iron gate leading to the street. The room was one room away to the end of the unit hallway. At the end of the hallway was a double glass door which lead to the outside of the facility. The double glass door was locked at the time of the observation. LVN 2 stated that the double glass doors are always locked and was only opened for 911 emergency personnel. LVN 2 stated that only the Registered Nurse (RN) supervisor on duty had the key to disarm the alarm and open the door. During observation on 7/28/2021 at 12:05 pm, and interview with Resident 1 inside Resident 1's new room, Resident 1 stated at the time of the incident, the resident's bed was in bed A. Bed A was next to the front door entrance of the room leading to the end of the unit hallway which had a double glass door exit to the outside of the facility. The double glass door was locked. The sliding glass window, which was locked at the time of the visit, opened to a small patio that had a block fence and gated access to the outside of the facility. There was no one to one (continuous observation) staff supervision (a staff staying with the resident at all times) with Resident 1 or any staff present at the vicinity of Resident 1's room at the time of the visit. Resident 1 was observed in bed awake and was snacking on some chips. Resident 1 had a cast (a supportive bandage that is solid and wraps all the way around the extremity) with internal fixation rods (large nails surgically inserted into the center of the bone to stabilize and support the fractured bone until it heals) on her left leg. Resident 1 stated that she could get up from bed by herself and did not need help to transfer to and from her wheelchair. When asked about the incident, Resident 1 stated she was asleep and was awaken when the man came in the room through the front bedroom door and touched her arm. Resident 1 stated the man came in the room through the front door not the sliding door. Resident 1 said the man told her to move aside and wanted to lay down by her side when a staff came by outside her room and asked how she was doing. She stated she answered that she was okay because she was afraid. Resident 1 said moments later CNA 1 and LVN 1 came in her room to check on her, but the staff did not see the man. When CNA 1 and LVN 1 walked away, the man hit her on the left side of her face and left the room through the sliding glass door. The resident stated she got scared when she heard noises outside her room thinking the man might come back and hurt her. Resident 1 stated the man who entered her room could have been her ex-boyfriend whom she had a restraining order against. During record review and interview with LVN 2 on 7/28/2021 at 12:55 pm, Resident 1's care plans regarding resident's safety was reviewed. LVN 2 stated Resident 1 did not have a plan of care for safety in relation to the restraining order or a safety care plan specific for people wanting to hurt resident. LVN 2 stated they were not aware of any restraining order and reason to develop a care plan for people wanting to hurt the resident. LVN 2 stated before a resident was admitted to the facility, nursing staff are supposed to review the residents' medical history and reason for admission to verify if facility can provide care services to residents. LVN 2 stated, Resident 1 was admitted from another skilled nursing facility but there was no mention in the resident's medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with ADM on 7/28/2021 at 1:40 pm, she stated she knew Resident 1 had a restraining order when the resident was admitted to the facility and validated no safety measures were placed to protect the resident from the male individual coming in the building prior to the incident. ADM stated that the police officer who came to investigate also confirmed to her that the restraining order was still in effect. ADM stated they were not able to establish how the unknown individual got in the building but have started checking every couple of hours to make sure windows and doors were locked. Although, she was aware of the restraining order, she stated no attempts were made to retrieve the restraining order or history of abuse from the other facility where the resident was transferred from. A review of the facility's policy and procedure on abuse reporting and investigation, updated on November 2018, indicated the facility promptly and thoroughly investigated report of resident abuse. The facility's policy and procedure indicated that when the Abuse Prevention Coordinator (APC, administrator of the facility) received a report of incident, the APC would initiate an investigation immediately and provide for a safe environment for the resident as indicated by the situation. A review of the facility's policy and procedure on safety and supervision of residents, revised on December 2007, indicated staff should use various sources to identify risk factors for residents, including information obtained from medical history, physical exam, observation of the resident, and the MDS. The policy and procedure indicated the interdisciplinary care team (a group of health care professionals with various areas of expertise who work together toward the wellbeing of the residents) should analyze the information obtained to identify any specific accident hazards or risk for that resident and target interventions to reduce the potential for accidents.

Based on observation, interview, and record review the facility failed to supervise and ensure one of two sampled residents (Resident 1) who had a restraining order (a criminal protection order issued by a state court which requires one person to stay away and stop harming another person) and was a victim of domestic violence (violent or aggressive behavior within the home, typically involving the violent abuse of a spouse or partner), was free from physical harm by a male individual who entered the facility on [DATE] at approximately 3:35 am,. The facility was aware of the Resident 1's restraining order but did not have a plan of care to address the restraining order to supervise and protect Resident 1 from physical harm. In addition, the facility did not prevent the male individual from an unlawful entry (when a person enters the property of another without consent from the owner) to the facility. This deficient practice resulted in an unlawful entry (When a person enters the property of another without consent from the owner) of a male individual to the facility inflicting harm, with potential for serious physical and psychosocial (mental and social wellbeing) harm to Resident 1 and other residents who reside in the facility. On [DATE] at 4:15 pm, the Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment or death to a resident) situation in the presence of the Director of Nursing (DON) and the Administrator (ADM). The DON and Administrator were informed of the facility's failure to have systems in place to ensure Resident 1 was safe and protected from physical harm. On [DATE] at 12:45 pm, during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action. The plan of action included: 1. Resident 1 was assessed and did not have signs and symptoms of injuries and was placed on a one to one staff supervision (to provide continuous observation for an individual) to protect the resident from further abuse. 2. Care plans were developed/triggered related to incident and police was contacted. 3. On [DATE] Resident 1 was moved to a different room that did not have a sliding glass door. 4. The facility conducted every two hours door checks by assigned staff and monitored 140 entry points, including but not limited, windows, doors, sliding. 5. Education and training for staff was initiated with regards to intruders and the safety & security of facility doors and windows. 6. The facility obtained a description of the male intruder and have included that information on a No-Access List maintained at the front desk and nurse's stations and advised all staff to be on the look-out for a person matching those descriptions and to prohibit such persons from entering the facility. 7. The facility implemented a security guard to monitor the exterior of the premises. Cross Reference F600 Findings: On [DATE] at approximately 3:35 am, Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) observed an unknown male individual inside Resident 1's room sitting on the floor to the left side of the resident's bed. LVN 1 told the unknown male that she was going to call the police and left the resident's room to notify Registered Nurse 1 (RN 1) to call 911 emergency (a life or death emergency that requires the immediate response of emergency service such as police, fire or paramedic. Resident 1 alleged the unknown male hit her on the left lower side of her face before leaving the room. The male individual then left the room using the sliding door located in the resident's room. Resident 1 stated the male individual could have been her ex-boyfriend whom she had a restraining order against. A review of a police report provided by the local police department, dated [DATE], indicated Resident 1 was a victim of a domestic violence felony that occurred on [DATE], while the resident resided at another facility. The police report indicated the suspect was Resident 1's ex-boyfriend. The police report indicated that a 100 yard stay away order (restraining order) was issued to the ex-boyfriend on [DATE] and expired on [DATE]. A review of the Admission Record for Resident 1 indicated the facility originally admitted the resident on [DATE], and readmitted on [DATE] with diagnoses that included chronic embolism (occurs when a piece of a blood clot, foreign object, or other bodily substance becomes stuck in a blood vessel) and [CONDITION(S)] (occurs when a thrombus, or blood clot, develops in a blood vessel and reduces the flow of blood through the vessel) of unspecified deep veins of the lower extremities, and chronic [CONDITION(S)] (a severe, persistent, and sometimes incapacitating infection of bone and bone marrow). A review of the Minimum Data Set (MDS, an assessment and care screening tool) for Resident 1, dated [DATE], indicated Resident 1 had the ability to make self-understood and understand others with intact cognitive skills (ability to think, understand, and reason). The MDS indicated Resident 1 required limited assistance from staff for mobility, transfer to and from bed or wheelchair, walk between locations in her room and corridors of the unit, dressing, toilet use, and personal hygiene, and needed supervision for eating. A review of Resident 1's Progress Notes (PN), dated [DATE] and timed late entry at 12:17 pm by RN 1, indicated LVN 1 reported to RN 1 that there was an unknown person in Resident 1's bed. The PN indicated CNA 1 witnessed an unknown male person entering Resident 1's room and immediately notified the charge nurse, LVN 1. The PN indicated LVN 1 immediately checked Resident 1's room and ask Resident 1 if there was somebody with her and she responded No, As LVN 1 got closer to Resident 1's bed, she noted that there was an unknown male person on the floor by the left side of Resident 1's bed. The PN indicated LVN 1 notified RN 1 regarding the situation and at 3:38 am, 911 was immediately activated. The PN indicated two police officers arrived at 3:42 am. The police officers interviewed Resident 1 and looked around the Resident 1's room and out the sliding door but did not see anyone. The PN indicated, as per Resident 1, she alleged that the unknown person hit the left side of her jaw. The PN indicated that Resident 1 told RN 1 to tell police that she had a restraining order on a person named Boyfriend 1 but was unable to state whether the unknown person was the person she had restraining order against. During an interview on [DATE] at 11:15 am, the Quality Assurance Nurse, LVN 2, stated that Resident 1 was transferred to another unit and room after the incident. LVN 2 stated Resident 1's former roommate, Resident 2, was asked about the incident but stated that she did not know anything about the incident. LVN 2 stated that Resident 2 was also assessed (physical and psychosocial assessment) and monitored for safety after the incident. LVN 2 stated that on [DATE], at around 3:35 am, CNA 1 saw a man enter Resident 1's room and sat on the resident's bed next to the Resident 1. LVN 2 stated CNA 1 reported to the charge nurse, LVN 1. LVN 2 stated LVN 1 checked Resident 1's room and saw the man under the resident's bed. LVN 2 stated that all the exit/entrance doors were locked ,d+[DATE] and they did not know how the male intruder entered the building. During an observation of Resident 1's previous room at the time of the incident, and interview with LVN 2, on [DATE] at 11:40 am, it was observed that Resident 1's bed was beside a sliding door leading outside to a small patio. This sliding door was locked and opened to a small patio with block fence and a locked iron gate leading to the street. The room was one room away to the end of the unit hallway. At the end of the hallway was a double glass door which lead to the outside of the facility. This double glass door was locked at the time of the observation. LVN 2 stated the double glass doors are always locked and was only opened for 911 emergency personnel. LVN 2 stated that only the Registered Nurse (RN) supervisor on duty had the key to disarm the alarm and open the door. During observation on [DATE] at 12:05 pm, and interview with Resident 1, inside of Resident 1's new room, Resident 1 stated at the time of the incident on [DATE] at approximately 3:35 am , the resident's bed was in bed A. Bed A was next to the front door entrance of the room leading to the end of the unit hallway which had a double glass door exit to the outside of the facility. The double glass door was locked. The sliding glass window, which was locked at the time of the visit, opened to a small patio that had a block fence and gated access to the outside of the facility. There was no one to one (continuous observation) staff supervision (a staff staying with the resident at all times) with Resident 1 or any staff present at the vicinity of Resident 1's room at the time of the visit. Resident 1 was observed in bed awake and was snacking on some chips. Resident 1 had a cast (a supportive bandage that is solid and wraps all the way around the extremity) with internal fixation rods (large nails surgically inserted into the center of the bone to stabilize and support the fractured (broken) bone until it heals) on her left leg. Resident 1 stated that she could get up from bed by herself and did not need help to transfer to and from her wheelchair. When asked about the incident, Resident 1 stated she was asleep and was awaken when the man came in the room through the front bedroom door and touched her arm. Resident 1 stated the man came in the room through the front door not the sliding door. Resident 1 said the man told her to move aside and wanted to lay down by her side when a staff came by outside her room and asked how she was doing. She stated she answered that she was okay because she was afraid. Resident 1 said moments later two CNA 1 and LVN 1 came in her previous room to check on her, but the staff did not see the man. When the two staff walked away, the man hit her on the left side of her face and left the room through the sliding glass door. The resident stated she got scared when she heard noises outside her room thinking the man might come back and hurt her. Resident 1 stated the man who entered her room could have been the male individual whom she had a restraining order against. During record review and interview with LVN 2 on [DATE] at 12:55 pm, LVN 2 stated Resident 1 did not have a plan of care for safety in relation to the restraining order or a safety care plan specific for people wanting to hurt resident. LVN 2 stated they were not aware of any restraining order and reason to develop a care plan for people wanting to hurt the resident. LVN 2 stated before a resident was admitted to the facility, nursing staff are supposed to review the residents' medical history and reason for admission to verify if facility can provide care services to residents. LVN 2 stated, Resident 1 was admitted from another skilled nursing facility but there was no mention in the resident's medical history of physical abuse while the resident resided at the other facility. During an interview with ADM on [DATE] at 1:40 pm, she stated she knew Resident 1 had a restraining order when the resident was admitted to the facility and validated no safety measures were placed to protect the resident from the male individual coming in the building prior to the incident. ADM stated that the police officer who came to investigate also confirmed to her that the restraining order was still in effect. ADM stated they were not able to establish how the unknown individual got in the building but have started checking every couple of hours to make sure windows and doors were locked. Although, she was aware of the restraining order, she stated no attempts were made to retrieve the restraining order or history of abuse. A review of the facility's policy and procedure on safety and supervision of residents, revised on [DATE], indicated staff should use various sources to identify risk factors for residents, including information obtained from medical history, physical exam, observation of the resident, and the MDS. The policy and procedure indicated the interdisciplinary care team (a group of health care professionals with various areas of expertise who work together toward the wellbeing of the residents) should analyze the information obtained to identify any specific accident hazards or risk for that resident and target interventions to reduce the potential for accidents.

Based on observation, interview, and record review, the facility failed to provide range of motion exercises (activity aimed at improving movement of a specific joint, a point where two bones make contact) to 11 of 12 sampled residents (Resident 75, 183, 91, 167, 146, 27, 136, 163, 151, 40, and 103) as indicated in the facility's Rehabilitative (helping to restore to good condition) Nursing Care policy. This deficient practice resulted for Resident 75 to experience pain and decline in mobility that caused severe contractures (deformity and joint stiffness) of the resident's right hand and both legs. Findings: Cross reference F656, F686, and F725 a. A review of Resident 75's Face Sheet (Admission Record) indicated the facility admitted Resident 75 on 4/19/2019 and readmitted the resident on 11/15/2019 from a general acute care hospital (GACH) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 75's Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]), Evaluation and Plan of Treatment, dated 11/16/2019, indicated Resident 75's right arm range of motion (ROM, the full movement potential of a joint) was within normal limits (normal joint movement). The OT Evaluation document indicated Resident 75's left arm ROM was within functional limits (sufficient joint movement to functionally complete daily routines) and the resident's left shoulder had limited motion. A review of Resident 75's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 11/16/2019, indicated Resident 75's ROM in both legs were within functional limits. A review of Resident 75's Rehabilitation Functional ROM and Voluntary Movement Screen, dated 2/15/2020, indicated Resident 75 had no ROM limitations in both legs and both hands. A review of Resident 75's OT Discharge Summary, dated 2/22/2020, indicated Resident 75 was discharged with recommendations for a Restorative Range of Motion Program (to restore as much independence as possible and/or prevent decline in function) for both arms. A review of Resident 75's PT Discharge Summary, dated 2/22/2020, indicated a Restorative Program was not indicated for Resident 75's legs because Resident 75 was transferred to hospice care (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure). A review of Resident 75's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/4/2021, at 8:42 a.m., Director of Rehabilitation (DOR) stated therapists provided education to RNA staff prior to transitioning residents to RNA services. A review of Resident 75's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 2/25/2020 indicated Resident 75 was moderately impaired with cognitive (thinking and memory) skills for daily decision making. The MDS indicated Resident 75 had clear speech, usually expressed ideas and wants, and understood others. The MDS indicated Resident 75 did not have any limitations in functional ROM in both arms and legs. A review of Resident 75's care plan titled, Activities of Daily Living Deficit, dated 2/25/2021, indicated the interventions were to provide ROM exercises to the resident. A review of Resident 75's RNA Flow Sheets indicated Resident 75 received range of motion exercises to both arms in 2/2020 and 4/2020. A review of Resident 75's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 75's Joint Mobility Assessment, dated 5/14/2020, 8/12/2020, and 11/11/2020, indicated minimum loss of ROM (25-50%) on Resident 75's right hip and right knee and moderate loss of motion (60-75%) on the left shoulder. A review of Resident 75's Joint Mobility Assessment, dated 2/20/2021, indicated the resident had moderate loss of ROM on Resident 75's left shoulder, both hips and both ankles. The Joint Mobility Assessment indicated Resident 75 had severe loss of motion (75-100%) on Resident 75's right hand, right fingers, and right knee. During an observation on 5/3/2021 at 12:40 pm, inside Resident 75's room, Resident 75 was lying in bed. Resident 75's right leg crossed midline over the left leg and dangled over the left side of the bed. Resident 75's left leg was crossed underneath the right leg with the left hip positioned in external rotation (hip rotated away from the body) and knee bent. Resident 75's left leg position resembled sitting on the floor with legs crossed in front of the body. Resident 75 complained of left leg pain. During an interview on 5/4/2021 at 2:49 pm, Certified Nursing Assistant 6 (CNA 6) stated the Resident 75's legs were always crossed. During an interview on 5/5/2021 at 8:53 am, Licensed Vocational Nurse 8 (LVN 8) stated both of Resident 75's legs were contracted (deformed with joint stiffness). LVN 8 stated it was difficult to turn the resident to either side since Resident 75 screamed from discomfort. During an interview on 5/6/2021, at 11:59 am, MDS Nurse 2 (MDS 2) stated if there was no RNA Flow Sheet in the clinical record, then the resident was not seen for RNA exercises. During an interview on 5/6/2021, at 3:54 p.m., Occupational Therapist 1 (OT 1) stated Resident 75 was able to sit in a wheelchair for activities of daily living, like hygiene, grooming, and lower body dressing. OT 1 stated that she recommended a Restorative Nursing Program for Resident 75 to maintain ROM to both arms since Resident 75 was a long-term care resident with limited cognition, making Resident 75 at risk for developing contractures. During an interview on 5/6/2021, at 4:24 p.m., the facility's Director of Nursing (DON) stated residents on hospice care such as Resident 75, should continue to receive basic nursing care while residing in the facility, which included but was not limited to hygiene, feeding, activities, medication administration, and mobility. During an observation on 5/7/2021, at 7:55 am, in Resident 75's room, Resident 75 was eating using the left hand to hold onto a bowl while the right-hand thumb and index finger held the utensil. Resident 75's right-hand middle, ring, and small fingers were observed in a flexed position. During an observation and concurrent interview on 5/7/2021, at 7:59 am, in Resident 75's room, LVN 8 was unable to extend Resident 75's right hand middle, ring, and small fingers which were in a flexed (bent) position touching the right palm. Resident 75 expressed pain upon LVN 8's attempts to extend the fingers. LVN 8 then repositioned Resident 75's legs. Resident 75 became tearful and stated that the left leg was painful. LVN 8 stated Resident 75 did not like to be turned due to the contractures in both legs. During an interview on 5/7/2021, at 9:57 am, Director of Rehabilitation (DOR) stated Resident 75's ROM further declined on 2/20/2021 as compared to the assessment on 11/11/2020. During an interview on 5/7/2021, at 10:58 am, the DON stated restorative nursing care was a continuation of nursing care for residents to maintain mobility and maximize function. DON stated restorative nursing care did not exclude hospice residents. DON stated Resident 75's contractures were avoidable as the facility failed to provide any restorative nursing care for range of motion. During an interview on 5/7/2021, at 12:05 pm, Medical Records 2 (MR 2) stated she was unable to locate Resident 75's RNA Flow Sheets for PROM exercises on both arms for 3/2020, 5/2020, 6/2020, 7/2020, 8/2020 and 9/2020. A review of the facility's policy titled, Rehabilitative Nursing Care, with a revised date of 7/2013, indicated the facility's rehabilitation nursing care program was designed to assist each resident to achieve and maintain an optimal level of self-care and independence. The policy indicated the program included assisting residents to carry out prescribed therapy exercises. b. A review of Resident 183's Face Sheet indicated Resident 183 was readmitted to the facility on [DATE]. Resident 183's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 183's MDS, dated [DATE], indicated Resident 183's cognition was intact. Resident 183 required total assistance with bed mobility, transfers, dressing, and hygiene. The MDS indicated Resident 183 had functional ROM limitations on both arm and both legs. A review of Resident 183's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It also indicated to apply bilateral (both sides) ankle foot orthosis (AFO, brace to hold the foot and ankle in the correct position) for both legs, five times per week for four to six hours or as tolerated. A review of Resident 183's Restorative Record, dated 4/2021, indicated the following dates with an X and blank dates: 4/3/21, 4/4/21, 4/5/21, 4/6/21, 4/10/21, 4/11/21, 4/17/21, 4/18/21, 4/20/21, 4/23/21, 4/24/21, 4/25/21, 4/29/21, and 4/30/21. During an interview on 5/4/21, at 8:42 am, RNA 1 stated a blank date in a resident's Restorative Record indicated the resident was not seen that day for RNA. During an interview on 5/6/21 at 12:24 pm, RNA 4 stated an X on the Restorative Record indicated the resident was not seen for RNA services on that specific date or dates. During an interview on 5/6/21 at 12:50 pm, MDS 2 stated Resident 183 was not seen for RNA per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS 2 stated residents could develop contractures without the provision of RNA services. c. A review of Resident 91's Face Sheet indicated Resident 91 was readmitted to the facility on [DATE]. Resident 91's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 91's MDS, dated [DATE], indicated Resident 91's cognition was intact. Resident 91 required extensive assistance with bed mobility, transfers, and hygiene. The MDS indicated Resident 91 had functional ROM limitations on both arms and both legs. A review of Resident 91's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 91's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 5/6/21 at 9:10 am, Resident 91 moved both arms, but complained of left shoulder pain. During an interview on 5/6/21, at 9:33 am, RNA 3 stated a blank date in a resident's Restorative Record indicated the resident was not seen for RNA. RNA stated Resident 91 needs to be medicated prior to RNA exercises. RNA 3 stated Resident 91 can develop contractures and further pain if not seen for RNA exercises. A review of Resident 91's Restorative Record for 4/2021 indicated the following blank dates: 4/1/21, 4/2/21, 4/3/21, 4/4/21, 4/5/21, 4/7/21, 4/8/21, 4/9/21, 4/13/21, 4/14/21, 4/25/21, 4/26/21, 4/27/21, and 4/30/21. A review of Resident 91's Restorative Record for 5/2021 indicated the following blank dates: 5/1/21, 5/2/21, and 5/4/21. During an interview on 5/6/21, at 9:33 am, RNA 3 stated Resident 91 was not seen on 5/4/21 since it was RNA 3's day off. In a follow-up interview on 5/6/21 at 10:02 am, RNA 3 stated Resident 91 was not seen per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RNA 3 stated that RNA staff were pulled to perform Certified Nursing Assistant duties. d. A review of Resident 167's Face Sheet indicated Resident 167 was readmitted to the facility on [DATE]. Resident 167's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 167's MDS, dated [DATE], indicated Resident 167's cognition was intact. Resident 167 required limited assistance with bed mobility and transfers, and required extensive assistance with dressing. The MDS indicated Resident 167 had functional ROM limitations on one arm. A review of Resident 167's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 167's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 5/3/21, at 10:35 am, Resident 167 was observed with left sided weakness and was not wearing a splint. stated Resident 167 was supposed to receive ROM exercises and wear a splint to the left arm. Resident 167 denied receiving any ROM exercises and stated the splint was not applied. A review of Resident 167's Restorative Record for April 2021 was completely blank. During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA. During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated Resident 167 was not seen for RNA per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS 2 stated residents could develop contractures without the provision of RNA services. e. A review of Resident 146's Face Sheet indicated Resident 146 was admitted to the facility on [DATE]. Resident 146's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 146's MDS, dated [DATE], indicated Resident 146 was severely impaired with daily decision making, required extensive assistance with bed mobility and dressing, and required total assistance with transfers and eating. The MDS indicated Resident 146 had functional range of motion (ROM) limitations in one arm and one leg. A review of Resident 146's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated was unable to locate Resident 146's Restorative Record for April and May 2021. MDS 2 stated Resident 146 was not seen for RNA exercises since 4/29/21. f. A review of Resident 27's Face Sheet indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 27's MDS, dated [DATE], indicated Resident 27's cognition was intact, was independent with eating, and required limited assistance for dressing. The MDS indicated Resident 27 had functional range of motion limitations in both legs. During an observation and interview on 5/3/21, at 11:30 a.m., Resident 27 was observed with contractures to both legs. Resident 27 stated Resident 27 was supposed to receive range of motion exercises three times per week. Resident 27 denied receiving exercises. A review of Resident 27's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 27's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA. A review of Resident 27's Restorative Record for April 2021 indicated blank dates on 4/1/21, 4/2/21, 4/3/21, 4/4/21, 4/5/21, 4/6/21, and 4/7/21. During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated Resident 27 was not seen for RNA per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS 2 stated residents could develop contractures without the provision of RNA services. g. A review of Resident 136's Face Sheet indicated Resident 136 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 136's MDS, dated [DATE], indicated Resident 136 was moderately impaired for daily decision making and required total assistance for bed mobility, transfers, dressing, hygiene, and eating. During an observation on 5/3/21 at 10:26 a.m., Resident 136 was lying in bed with the right arm positioned into shoulder internal rotation (rotated toward the body), elbow bent, wrist bent down, and fingers bent at the knuckles. Resident 136 was not wearing a splint (material used to restrict, protect, or immobilize a part of the body to support function, assist, and/or increase range of motion) on the right arm. A review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - 10/16/19: PROM to both legs, five times per week as tolerated. - 10/17/19: PROM to the right arm, five times per week as tolerated. - 2/3/20: RNA to apply right elbow splint, five times per week for 4-6 hours or as tolerated. - 12/19/20: PROM exercises to right arm, five times per week as tolerated. - 12/19/20: Apply right elbow splint for 4-6 hours, five times per week as tolerated. - 12/21/20: Gentle PROM on right leg, five times per week or as tolerated. - 12/21/20: Gentle active assistive range of motion (AAROM, movement of a joint of limb in which the person provides some effort but also receives some assistance from an outside force) on left leg, five times per week or as tolerated. During an interview on 5/4/21, at 9:25 am, RNA 2 stated there were 89 residents that received RNA services. During a follow-up interview on 5/4/21, at 10:59 a.m., RNA 2 stated Resident 136 was not seen for RNA on 5/3/21 since there was only one RNA staff. RNA 2 stated that residents could develop contractures and experience a decline in function without the provision of RNA services. During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA. A review of Resident 136's Restorative Record for April 2021 indicated the following blank dates: 4/1/21, 4/2/21, 4/3/21, 4/4/21, 4/5/21, 4/6/21, 4/7/21, 4/8/21, 4/9/21, 4/10/21, 4/12/21, 4/13/21, 4/14/21, 4/16/21, 4/18/21, 4/19/21, 4/20/21, 4/21/21, 4/22/21, 4/23/21, 4/24/21, 4/25/21, 4/26/21, 4/27/21, 4/29/21, and 4/30/21. During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated residents were not seen for RNA per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS 2 stated residents could develop contractures without the provision of RNA services. h. A review of Resident 163's Face Sheet indicated Resident 163 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 163's MDS, dated [DATE] indicated Resident 163 was severely impaired for daily decision making and required total assistance for bed mobility, transfers, dressing, and hygiene. The MDS indicated Resident 163 had functional range of motion limitations in both arms and both legs. A review of Resident 163's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 163's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/4/21, at 9:25 am, RNA 2 stated there were 89 residents that received RNA services. During a follow-up interview on 5/4/21, at 10:59 a.m., RNA 2 stated residents in Stations 1 and 3, including Resident 163, were not seen for RNA on 5/3/21 since there was only one RNA staff. RNA 2 stated that residents could develop contractures and experience a decline in function without the provision of RNA services. A review of Resident 163's Restorative Record for May 2021 indicated the following blank dates: 5/1/21, 5/2/21, and 5/3/21. During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA. i. A review of Resident 151's Face Sheet indicated Resident 151 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 151's MDS, dated [DATE], indicated Resident 151's cognition was intact but required total assistance for bed mobility, dressing, eating, and hygiene. The MDS indicated Resident 151 had functional limitations in range of motion in both legs. During an observation and interview on 5/3/21 at 10:30 a.m., Resident 151 was lying in bed and observed with weakness and contractures in both arms. Resident 151 denied receiving consistent range of motion exercises. A review of Resident 151's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/4/21, at 8:42 a.m., RNA 1 stated that a blank date in a resident's Restorative Record indicated that the During an interview on 5/4/21, at 8:42 a.m., RNA 1 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA. RNA 1 stated there were 40 residents in the facility's subacute area that received RNA. RNA 1 was the only RNA staff on 5/3/21 and unable to perform RNA exercises with 24 subacute residents, including Resident 151. During an interview on 5/6/21 at 12:24 p.m., RNA 4 stated putting an X on the Restorative Records for the dates the resident was not seen for RNA. A review of Resident 151's Restorative Record for April 2021 indicated the following dates with an X and blank dates: 4/3/21, 4/4/21, 4/9/21, 4/10/21, 4/11/21, 4/12/21, 4/13/21, 4/16/21, 4/17/21, 4/18/21, 4/20/21, 4/21/21, 4/25/21, 4/27/21, and 4/28/21. A review of Resident 151's Restorative Record for May 2021 indicated the following dates with an X and blank dates: 5/1/21, 5/2/21, and 5/3/21. During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated residents could develop contractures without the provision of RNA services. j. A review of Resident 40's Face Sheet indicated Resident 40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 40's MDS, dated [DATE], indicated Resident 40 cognition was moderately impaired for daily decision making and required total assistance for transfers, bed mobility, hygiene, dressing, and bathing. The MDS indicated Resident 40 had functional range of motion limitations in both legs. A review of Resident 40's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 40's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/4/21 at 1:31 p.m., Resident 40 stated feeling stronger but needed more exercises. Resident 40 stated Resident 40 received exercises every three days for five minutes. During an interview on 5/4/21, at 8:42 a.m., RNA 1 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA. RNA 1 stated there were 40 residents in the facility's subacute area that received RNA. RNA 1 was the only RNA staff on 5/3/21 was unable to perform RNA exercises 24 subacute residents, including Resident 40. A review of Resident 40's Restorative Record for May 2021 indicated the following blank dates for RNA to provide AROM to both arms: 5/1/21, 5/2/21, 5/3/21, 5/4/21, and 5/5/21. A review of Resident 40's Restorative Record for May 2021 indiated the following blank dates for RNA to provide AAROM to both legs: 5/4/21 and 5/5/21. k. A review of Resident 103's Face Sheet indicated Resident 103 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 103's MDS, dated [DATE], indicated Resident 103 was severely impaired for daily decision making and required total assistance for bed mobility, transfers, dressing, and bathing. The MDS indicated Resident 103 had functional range of motion limitations in both arms and both legs. A review of Resident 103's Physician Orders, dated 2/10/21, indicated for RNA to provide the following: - Both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist, and/or increase range of motion), five times per week for 4-6 hours per day or as tolerated. - Gentle PROM on both arms, five times per week or as tolerated. - Right grip hand splint 4-6 hours per day, five times per week or as tolerated. - PROM to both legs, five times per week or as tolerated. - Apply right elbow extension split 4-6 hours per day, five times per week or as tolerated. During an interview on 5/4/21, at 9:25 am, RNA 2 stated there were 89 residents that received RNA services in the facility's skilled nursing area. During a follow-up interview on 5/4/21, at 10:59 a.m., RNA 2 stated residents in Stations 1 and 3, including Resident 103, were not seen for RNA on 5/3/21 since there was only one RNA staff. RNA 2 stated that residents could develop contractures and experience a decline in function without the provision of RNA services. During an interview on 5/6/21, at 9:33 a.m., RNA 3 stated that a blank date in a resident's Restorative Record indicated that the resident was not seen that day for RNA. A review of Resident 103's Restorative Record for April 2021 indicated the following blank dates: 4/1/21, 4/2/21, 4/4/21, 4/6/21, 4/7/21, 4/8/21, 4/9/21, 4/10/21, 4/11/21, 4/12/21, 4/13/21, 4/14/21, 4/17/21, 4/19/21, 4/20/21, 4/21/21, 4/22/21, 4/23/21, 4/25/21, 4/26/21, 4/29/21, and 4/30/21. A review of Resident 103's Restorative Record for May 2021 indicated the following blank dates: 5/1/21, 5/2/21, and 5/3/21. During an interview on 5/6/21, at 11:59 a.m., MDS 2 stated RNA staff were pulled to perform Certified Nursing Assistant duties in April 2021. MDS 2 stated residents could develop contractures without the provision of RNA services. A review of the facility's policy entitled, Rehabilitative Nursing Care revised July 2013, indicated that the facility's rehabilitation nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. The program included assisting residents to carry out prescribed therapy exercises.

Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care of a resident's [MEDICAL CONDITION] (surgical opening of the trachea or windpipe) for two of two sampled residents (Residents 1 and 2) in accordance to facility's policy and procedure. For Resident 1, the facility's Respiratory Therapist 3 (RT 3) failed to use the correct size and same brand of [MEDICAL CONDITION] (the outer tube that holds the [MEDICAL CONDITION] open), when RT 3 decided to change the [MEDICAL CONDITION] of Resident 1. The facility also failed to activate 911 (medical telephone emergency) call after RT 3 was unable to insert Resident 1's [MEDICAL CONDITION] on the third attempt as in accordance with the facility's policy and procedure. For Resident 2, the facility failed to have an obturator (also called as introducer, a medical equipment that guides the [MEDICAL CONDITION] into the trachea before it is quickly removed) available on the resident's bedside at all times as indicated on the facility's policy and procedure. These deficient practices resulted in Resident 1 having extensive pneumomediastinum (presence of air in the mediastinum or a membranous partition between two organs in the lungs), pneumoperitoneum (air in the abdominal cavity) and subcutaneous (soft tissue under the skin) [MEDICAL CONDITION] (air in the tissues or layer of the skin) which required a transfer to the General Acute Care Hospital 2 (GACH 2). The facility's failure also had the potential to cause a delay in Resident 2's [MEDICAL CONDITION] replacement, in the event of an accidental decannulation (removal) of the [MEDICAL CONDITION]. Findings: 1.A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was originally admitted in the facility, on 12/6/19, and readmitted , on 11/25/20 at 3:10 p.m., from the GACH 1 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a resident assessment and care planning screening tool) dated 09/8/20, indicated Resident 1 had severe impaired cognition (ability to remember, understand and make decisions). Resident 1's functional status was totally dependent (resident involved in activity and staff provided weigh bearing support) on staff assistance. A review of Resident 1's Physicians (Respiratory) Orders, dated 11/25/20, at 7:00 p.m., indicated the resident was on a ventilator (a machine that helps you breathe) and an order to change [MEDICAL CONDITION] every month and as needed. A review of Resident 1's Respiratory Care Initial Evaluation, dated 11/25/20, indicated Resident 1 was using a [MEDICATION NAME] 8 cuff (a [MEDICAL CONDITION] brand and size 8 with a balloon). A review of Resident 1's care plan titled, Respiratory Care, dated 11/25/20, indicated a concern the resident had impaired gas exchange related to ineffective airway clearance, pneumonia (lung infection), accidental extubation or decannulation (removal of the [MEDICAL CONDITION]), and turning. The care plan goal included to maintain a patent airway, optimal oxygenation, oxygen saturation more than 92 percent (%), mobilization of secretions, prevention of aspiration, and reduction of the incidence of accidental extubation or decannulation. The facility approaches included monitoring oxygen saturation (the amount of oxygen in the bloodstream), suctioning Q2 (every 2 hours), and [MEDICAL CONDITION] site daily and PRN (as needed). A review of Resident 1's Vent Flow Sheet (RT notes), dated 11/26/20 timed 10:30 a.m., indicated RT 3 attempted to suction the resident by [MEDICAL CONDITION] a couple of times, was unable to direct the suction catheter (a medical device used to extract bodily secretions such as saliva) deep enough to suction, and felt resistance with the catheter. RT 3 attempted to replace [MEDICAL CONDITION] with an extra-long tube (XLT) Shiley ([MEDICAL CONDITION] brand) with various [MEDICAL CONDITION] sizes that included a number 5, 6, and 7, but none of the [MEDICAL CONDITION] provided airway patency. While Resident 1 was being bagged (rescue breathing) on 15 liters per minute (unit of measurement) of oxygen, Resident 1's oxygen saturation dropped to 70 % (critical low level, the adult normal range of oxygen saturation were 94 % to 100 %). RT 3 used [MEDICATION NAME] 6 [MEDICAL CONDITION] size for temporary patency of airway. Resident 1 was transferred to the GACH 2 via 911 (medical emergency transport). A review of Resident 1's Departmental Notes, dated 11/26/20 timed 11:43 a.m. indicated Resident 1 was transferred to GACH 2 at 10:45 a.m., on 11/26/20, by 911 due to the issue with the [MEDICAL CONDITION] and was unable to maintain patent airway. The RT changed [MEDICAL CONDITION] to different sizes, and the problem persisted with subcutaneous [MEDICAL CONDITION] while Resident 1 was being bagged. The paramedics transferred the resident to GACH 2. Resident 1's physician and responsible party were notified regarding the resident's change in condition. A review of Resident 1's GACH 2 records, titled Emergency Department (ED) Physician Note, dated 11/26/20, indicated Resident 1 seen in the ER at 10:57 a.m. Resident 1 was brought in because of a dislodged (removed) [MEDICAL CONDITION]. The note also indicated Resident 1 will be admitted to the Intensive Care Unit (ICU) due to significant amount of air in the chest and abdomen. A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, a communication tool used in healthcare setting) 4.0 Communication Tool, dated 11/26/20, timed 2:43 p.m. indicated Resident 1's condition was evaluated, and the symptoms of his desaturation (low level of oxygen in the blood) was due to possible blockage in the trachea. Resident 1 was lethargic (sluggish and sleepy) and regained consciousness (alert) after rescue breathing (ambu-bag) was provided. The SBAR indicated Resident 1 was a full code (full resuscitation - a process to restore patient by means of chest compression, intubation (inserting an artificial breathing tube), and defibrillation (a treatment in a form of electric shock for a life-threatening heartbeat). A review of Resident 1's GACH 2 records, titled Computed Tomography (an x-ray imaging of body part) of the abdomen and pelvis (lower part of the torso and located between the abdomen and the legs), dated 11/26/20 and electronic signed at 5:16 p.m., indicated an extensive subcutaneous air within the lower chest, abdomen and pelvis (the lower part of the trunk of the human body between the abdomen and the thighs), a moderate pneumomediastinum and an extensive pneumoperitoneum. A review of Resident 1's GACH 2 records, titled History and Physical (H & P), dated 11/26/20, indicated Resident 1 was admitted with the chief complaint of [MEDICAL CONDITION] dysfunction and extensive pneumomediastinum, pneumoperitoneum and soft tissue [MEDICAL CONDITION]. A review of Resident 1's GACH 2 records, titled Critical Care Consultation, notes dated 11/26/20, indicated that Resident 1's [MEDICAL CONDITION] was dislodged with unclear reason and was replaced with a [MEDICATION NAME] 6 (a size 6 [MEDICAL CONDITION]). The notes indicated a large leak was still present that required further evaluation. A review of Resident 1's GACH 2 records, titled Consultation Notes, General Surgery Consultation, dated 11/26/20, indicated Resident 1 had a dislodged [MEDICAL CONDITION] that was replaced with a smaller size. Resident 1 was placed on positive pressure respiration (a type of oxygen delivery given to a resident), which resulted in the development of a subcutaneous [MEDICAL CONDITION]. A review of Resident 1's GACH 2 records, titled Operative Procedural Documentation, dated 12/03/20, indicated Resident 1 underwent a [MEDICATION NAME] via [MEDICAL CONDITION] (a medical procedure using a [MEDICATION NAME], a type instrument that was inserted into the airways, usually through the nose or mouth or through the [MEDICAL CONDITION]) and [MEDICAL CONDITION] was changed. During an interview, on 12/09/20 at 2:51 p.m., Respiratory Therapist 3 (RT 3) stated night shift reported at 6 a.m. on 11/26/20 regarding Resident 1's suctioning (to extract body secretions using a suction machine) difficulties. He stated at around 7 a.m., he saw Resident 1 awake and required suctioning. RT 3 stated he was not able to farther advance the suction catheter and had resistance during the insertion. RT 3 stated he tried to reposition the [MEDICAL CONDITION] in a certain angle but failed. RT 3 stated he decided to change Resident 1 [MEDICAL CONDITION]. RT 3 stated he was qualified to do the procedure. RT 3 stated he tried several sizes of [MEDICAL CONDITION] but still had difficulty putting it in. RT 3 stated he could not recall the exact [MEDICAL CONDITION] size, and if he did size up or down of the [MEDICAL CONDITION] size. During an interview, on 12/16/20 at 4:25 p.m., Medical Doctor 1 (MD 1) was asked the cause of an extensive amount of air in the peritoneal cavity. MD 1 stated it must be, Traumatic [MEDICAL CONDITION] changes. MD 1 further stated a qualified person only has a couple of seconds to reinsert back the [MEDICAL CONDITION]. During an interview, on 12/18/20 at 9:17 a.m., RT 3 stated he could not recall Resident 1's breath sounds (noises produced by the structures of the lungs during breathing) after the [MEDICAL CONDITION] was in place. RT 3 stated there was no policy that indicated the limit number of attempts for [MEDICAL CONDITION] insertion. RT 3 stated maybe he attempted three times and his lead RT (RT 1) attempted couple of times. RT 3 stated a total of five to six attempts to insert the [MEDICAL CONDITION]. RT 3 stated he and RT 1 were working with Resident 1 for approximately 5-10 minutes (on 11/26/20). A review of the facility's policy and procedure, undated, titled [MEDICAL CONDITION] Change, indicated in procedure number 15, indicated, In the event you are unable to insert a tube of the same size as the one removed, immediately follow the last step with a tube one size smaller. The policy and procedure also indicated assessment of bilateral breath sounds once the resident was given rescue breathing (bagging the resident). If unable to insert third attempt, the 911 system should be activated. 2. A review of Resident 2's Face Sheet indicated Resident 2 was admitted in the facility, on 11/13/20 with [DIAGNOSES REDACTED].). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 did not have any impairment in cognitive skills (a mental action of acquiring knowledge and understanding). Resident 2's functional status (a person's ability to perform activities of daily living independently) required total dependence from one facility staff. A review of Resident 2's care plan titled, Respiratory Care, dated 11/13/20, indicated Resident 2 care concerns included accidental extubation or decannulation. The care plan approaches included check and secure [MEDICAL CONDITION], and if accidental decannulation occurs to replace the [MEDICAL CONDITION] with a spare [MEDICAL CONDITION] kept at the bedside. During an interview on 12/2/20 at 4:11 p.m., RT 2 stated when a [MEDICAL CONDITION] was dislodged, an obturator would be needed during insertion and then removed after tracheotomy tube insertion. During a concurrent observation and interview, on 12/02/20 at 5:02 p.m., there was no obturator at Resident 2's bedside. RT 1 stated an obturator had to be kept at Resident 2's bedside at all times. RT 1 stated an obturator was needed during [MEDICAL CONDITION] insertion. During an interview, on12/16/20 at 1:46 p.m., RT 1 stated the obturator was available and accessible in sub-acute supply room and in the crash cart (emergency cart) located at the nurse station if needed. During an interview, on 12/16/20 at 4:25 p.m., Medical Doctor 1 (MD 1) stated an obturator was needed during [MEDICAL CONDITION] insertion. During an interview on 12/17/20 at 3:42 p.m., MD 2 stated generally you only have few seconds to insert and reinsert [MEDICAL CONDITION] back in place. MD 2 stated an obturator was needed during [MEDICAL CONDITION] insertion. A review of undated policy and procedure titled, [MEDICAL CONDITION] Change, indicated in the equipment section included, A [MEDICAL CONDITION] of the appropriate size with the obturator (have two spare [MEDICAL CONDITION]. One the same size and the other one size smaller readily available).

Based on observation, interview and record review, the facility failed to provide nutrition to prevent weight loss for one of two sampled residents (Resident 58) by failing to: 1. Ensure Resident 58 received gastrostomy tube feedings ([DEVICE], a tube inserted through the belly that brings nutrition directly to the stomach) as recommended by the Registered Dietitian (RD, food and nutrition expert) to increase the [DEVICE] feeding to meet the recommended daily nutritional intake and prevent significant weight loss (a loss of 4.5 kilogram (kg)/9.9 pounds (lbs) or > 5 percent (%) of the usual body weight in one month). 2. Monitor and record Resident 58's weight weekly, for four weeks, as ordered by the physician and recommended by the RD. These deficient practices resulted in Resident 58 losing 12 lbs/8% of the usual body weight within five weeks (1/26/20 to 3/4/20) and placed the resident at risk for delayed in pressure sores (bedsores) healing. Findings A review of Resident 58's Admission Record indicated the facility admitted the resident on 12/12/19 and readmitted the resident on 1/26/2020 with [DIAGNOSES REDACTED]. A review of Resident 58's Minimum Data Set (MDS, standardized assessment and care-planning tool), dated 12/18/19, indicated the resident has severely impaired cognitive skills (ability to think and process information). The MDS indicated Resident 58 was totally dependent with one-person physical-assist for bed mobility, transfers, eating, dressing and personal hygiene. The MDS indicated Resident 58 had a [DEVICE] for medication and nutrition. A review of Resident 58's Malnutrition Risk Assessment, dated 1/26/2020 indicated the resident had a score of 13 (a score of 10 or greater considered a high risk for malnutrition (lack of sufficient nutrients in the body)). A review of Resident 58's Physician Orders, dated 1/26/20, indicated for staff to administer Diabetisource AC (formula designed for residents with diabetes), 50 cubic centimeter (cc) per hour (hr) for 20 hrs, to provide a total of 1000 cc/1200 calories (Kcal, amount/unit of food energy) to infuse from 2 PM to 10 am. Prostat (protein supplement), 30 cc via [DEVICE], three times per day for wound management. A review of Resident 58's Admission Weight Log, dated 1/27/2020, indicated the resident's admission weight was 150 lbs. A review of Resident 58's History and Physical (H&P), dated 1/28/2020, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 58's Vital Sign (signs of life including heart beats and temperature) and Weight Record Log, dated 1/29/2020 to 3/4/2020, indicated the resident's weights were as follows: 1. 1/29/20 = 150 lbs. 2. 2/5/20 = 146 lbs (four lbs of weight loss in 5 days). 3. 2/12/20 = 140 lbs (six lbs of weight loss in seven days/10 lbs of weight loss in 12 days). 4. 2/19/20 = No weight recorded. 5. 2/26/20 = No weight recorded. 6. 3/4/20 = 138 lbs (12 lbs of weight loss in one month and six days). A review of Resident 58's Care Plan for Feeding Tube, dated 1/31/20, indicated the resident had the potential for malnutrition secondary to receiving [DEVICE] feeding. The goal was for the resident to be free from malnutrition daily for the next 90 days. The approached interventions were for staff to administer [DEVICE] feeding as ordered and refer to the RD for adequacy of current feeding formula and flow rate. A review of Resident 58's Care Plan for Weight Loss, dated 1/31/20, indicated the resident was at risk for weight loss. The goal was for Resident 58 to be free from significant weight loss of 5 lbs per month for the next 90 days. The care plan was updated on 2/12/2020 with an intervention for staff to increase the [DEVICE] feeding. A review of Resident 58's Nutrition Screening and Assessment, dated 1/31/2020, indicated the resident's current/desired body weight was 68.2 kg/150 lbs. Resident 58's calorie needs were 1705 - 2046 Kcal per day. The assessment indicated RD 1 recommended to increase the Diabeticsource AC feeding from 50 to 60 cc/hr for 20 hours to provide 1200 cc/1440 Kcal, plus Prostat to equal to 1740 Kcal, 117-gram (gm) protein (the assessment did not indicate the type nor how many cc of Prostat). A review of Resident 58's Physician Order, from 1/31/2020 to 2/12/2020, indicated there was no order to increase the [DEVICE] feed as indicated in the Nutrition Screening and Assessment. A review of Resident 58's Nurses Note, from 1/31/2020 to 2/12/2020, indicated there was no explanation to why the physician was not notified regarding the RD 1's recommendation to increase the [DEVICE] feeding from 50 to 60 cc/hr. A review of Resident 58's Medication Administration Record [REDACTED]. A review of Resident 58's Interdisciplinary (IDT, team meeting among healthcare professionals to discuss the resident's plan of care) Weight Variance Review Report, dated 2/12/2020, completed by RD 2, indicated Resident 58 lost 10 lbs. The report indicated RD 2 recommend increasing the [DEVICE] feeding with Diabeticsource AC to 65 cc/hr, for 20 hours, to equal 1,300 cc/1560 Kcal with Prostat supplement to equal to 1860 Kcal per day due to the current tube feeding was inadequate. RD 2 recommended for staff to continue to weigh Resident 58 once a week for four weeks. A review of Resident 58's Physician Orders, dated 2/13/2020, indicated for staff to administer Diabetisource AC 65 cubic centimeter (cc) per hour (hr) for 20 hours to provide a total of 1200 cc/1440 Kcal to infuse from 2 PM to 10 am. A review of Resident 58's Physician Orders, dated 2/13/2020, indicated for staff to weigh the resident once a week for four weeks. A review of Resident 58's MAR, from 2/14/2020 to 3/5/2020, indicated the resident received [DEVICE] feed with Diabetisource AC, at 65 cc/hr for 20 hours from 2 PM to 10 am. A review of Resident 58's MAR, from 2/21/2020 to 3/8/2020, indicated the resident received [DEVICE] feed with Diabetisource AC, at 60 cc/hr for 20 hours from 2 PM to 10 am. (from 2/21/2020 to 3/8/2020, nursing staff documented they administered [DEVICE] feeding on both MARs). A review of Resident 58's Physician Orders, dated 2/21/20, indicated for staff to administer Diabeticsource AC, at 60 cc/hr for 20 hours, to provide a total of 1,200 cc/1440 Kcal and to infuse from 2 PM, to 10 am, or until dose is met. During an observation on 3/4/2020, at 10 am, Resident 58 was receiving Diabeticsource AC at 60 cc/hr via [DEVICE] feeding. A review of Resident 58's Physician Orders, dated 3/5/2020, indicated to discontinue the resident [DEVICE] feeding of Diabeticsource AC at 65 cc/hr for 20 hours. During a concurrent interview and review of Resident 58's IDT Weight Variance report on 3/6/2020, at 3:55 PM, RD 1 stated she and RD 2 assess Resident 58 once a month and as needed to evaluate for significant weight changes. RD 1 stated when Resident 58 had a significant weight change, RD 1 and RD 2 wrote their recommendations in the resident's Nutritional Progress Notes and the IDT Weight Variance Review and handed their recommendations to the Facility's Dietary Supervisor (DS). RD 1 stated the DS's job is to deliver the RDs' recommendations to the charge nurses or the Registered Nurse Supervisors. RD 1 stated they (RD 1 and RD 2) did not attend the IDT meeting to discuss Resident 58's significant weight loss. During a concurrent observation and interview with RD 1, on 3/6/20 at 4:32 PM, Resident 58 was receiving Diabeticsource AC at 60 cc/hr via [DEVICE] feeding. RD 1 stated the setting on the [DEVICE] feeding was wrong and Resident 58's [DEVICE] feeding should be set at 65 ml/hr according to the RD's recommendations. During an interview on 3/6/2020 at 4:33 PM, Registered Nurse Supervisor 4 (RN 4) stated she placed a request for a RD consultant for Resident 58 due to the resident had a significant weight loss. During an interview and concurrent review of Resident 58's Nutrition Screening and Assessment and the IDT Weight Variance Review Report, on 3/9/2020 at 9:34 am, RD 2 stated it is important to increase Resident 58's Diabeticsource AC via [DEVICE] to 65 cc/hr due to the resident suffered from significant weight loss and unhealed bedsores. RD 2 stated it is important for Resident 58's weight to be stable to prevent further wounds (bedsores) deterioration. RD 2 stated losing weight would compromise Resident 58's skin integrity and delayed wound healing due to the resident did not receive enough calories. During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 03/9/2020 9:49 am, Resident 58 was receiving Diabeticsource AC at 60 cc/hr. LVN 1 turned the [DEVICE] feeding pump (a machine that deliver the formula via [DEVICE]) off. LVN 1 stated Resident 58 received a total of 1200 cc/1440 Kcal in 20 hours (not 1560 Kcal as recommended by the RD 2). During an interview on 3/10/2020, at 7:29 am, Restorative Nurse Assistant 1 (RNA 1) stated he did not weigh Resident 58 weekly due to the charge nurse did not inform him to weigh the resident weekly. During an interview on 3/10/2020, at 3 PM, the Director of Nurses (DON) stated that it was important for nursing staff to monitor Resident 58's weight weekly as ordered by the physician. The DON stated the RDs and the license nurses are responsible for notifying the physician of the RD recommendations and monitor Resident 58's weight on a weekly basis. The DON stated there was no specific licensed nurse assigned to monitor Resident 58's weights but all licensed nurses were responsible to monitor the weights. The DON stated the facility does not have a policy and procedure for staff to follow regarding weekly weight. A review of the facility's Policy and Procedures titled, Nutritional Assessment, revised in September 2011, indicated the Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and change in condition that places the resident at risk for impaired nutrition. The policy indicated the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting date and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. The policy indicated the nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the usual body weight and recent events that may have affected a resident's nutritional status and risk factors.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for one out of 35 sampled residents (Resident 162). This deficient practice had the potential to put the resident at risk for receiving unnecessary medication. Findings: A review of Resident 162's Admission Record (Face Sheet) indicated he was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 162's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/4/20, indicated he was cognitively (a mental action of acquiring knowledge and understanding) intact, he required total assistance with a mobility and activities of daily living (ADL's) and he was given antipsychotic medication. During an interview and concurrent record review of the Physician Orders, on 3/10/20, at 10:54 a.m., with the assistant director of nursing (ADON) she stated Resident 162 was given [MEDICATION NAME] 10 mg, by mouth (PO), every day (QD), started on 7/29/18. The ADON was not able to provide documentation of a gradual dose reduction (GDR) attempt for [MEDICATION NAME] 10 mg. She stated the physician was unable to attempt a GDR because Resident 162 goes in and out of the facility. A record review of the physician's orders [REDACTED]. A record review of the Physician Orders, dated 3/2020, indicated Resident 162 was given [MEDICATION NAME] 10 mg, PO, QD and documentation of a GDR attempt was not found in the clinical record. A record review of the facility's policy and procedure (P&P), revised 3/2015, titled, [MEDICAL CONDITION] Medication Use, indicated [MEDICAL CONDITION] medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reductions. The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences.

Based on interview, and record review, the facility failed to provide respiratory care and treatment consistent with professional standards of practice for one of two sampled residents (Resident 1), who required oxygen administration, including: 1. Failure to monitor Resident 1's respiratory status. 2. Failure to develop an individualized care plan to address Resident 1's respiratory care needs as indicated in the facility's policy. 3. Failure to follow the physician's orders [REDACTED]. One method uses a device that shines light through a finger). 4. Failure to implement the facility's policy on Oxygen Administration by not recording in Resident 1's clinical record the date and time of the oxygen administration, the rate of oxygen flow, route, and rationale, and the frequency and duration of the treatment including the reason for PRN (as needed) administration and how Resident 1 tolerated the procedure. 5. Failure to implement the facility's policy on Pulse Oximetry (assessing the oxygen saturation utilizing a sensor attached to a finger) by not notifying the physician when the oxygen saturation was less than acceptable level for the resident's condition and not recording the reading on the Oxygen Saturation Flow Sheet. As a result, on [DATE] Resident 1 experienced severe respiratory distress requiring transfer to General Acute Care Hospital 1 (GACH 1) where he expired on the same day. Findings: A review of the Admission Record indicated Resident 1's admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated [DATE], indicated Resident 1 was able to communicate, had moderate impairment in cognition (mental process involved in knowing, learning, and understanding things), required limited assistance with bed mobility, and extensive assistance with transfers and personal hygiene. The MDS indicated Resident 1 had no shortness of breath and did not receive oxygen therapy during the last 14 days. A review of the Physician order [REDACTED]. A review of the Licensed Nurses Progress Notes dated [DATE] and timed at 5:30 p.m., indicated Resident 1 was bending over and feeling discomfort. Resident 1's oxygen saturation was 89%. Resident 1 received oxygen at two 2 - 3 L/min via nasal cannula and a breathing treatment. The oxygen saturation went up to 93%, and Resident 1 was feeling, Ok. There was no further documentation to indicate the licensed nurses continuously monitored Resident 1's respiratory condition. A review of the Licensed Nurses Progress Note dated [DATE] at 1:30 p.m., indicated Family Member 1 (FM 1) told Licensed Vocational Nurse 1 (LVN 1) Resident 1 looked, Different. LVN 1 told FM 1 she (LVN 1) did not notice any changes in Resident 1's condition. This information was confirmed by LVN 1 during an interview on [DATE] at 3:14 p.m. A review of the SBAR (Situation-Background-Assessment-Recommendation) Communication form dated [DATE] at 10 a.m., indicated Resident 1 had shortness of breath and the oxygen saturation was 76% on room air (with no supplemental oxygen). The heart rate was 116 beats per minutes (bpm - normal rate from 60 to 100 bpm), and the respiratory rate was 28 to 30 breaths per min (normal range from 12 to 20 breaths per minute). The licensed nurse administered Resident 1 oxygen at 5 L/min via nasal cannula. Resident 1's oxygen saturation went up to 89 - 90%. Respiratory Therapists 1 and 2 (RT - health professional trained to evaluate and treat people who have breathing problems or other lung disorders) administered care until 911 (paramedics - emergency transport) arrived. A review of the Licensed Nurses Progress Note dated [DATE] at 11 a.m., indicated notifying Registered Nurse 1 (RN 1) of Resident 1 having respiratory distress. Resident 1 was on continuous oxygen at 6 L/min via a simple mask (a disposable mask made of clear plastic used to provide oxygen therapy). Resident 1 was sitting at the edge of his bed, leaning forward towards his bedside table (over-the-bed table) and having shortness of breath. RN 1 assessed Resident 1 as wheezing (a high-pitched [MEDICATION NAME] sound that occurs with breathing. It is caused by narrowed airways or inflammation and may be a symptom of a severe breathing problem) on the right lung. A review of the Licensed Nurses Progress Note dated [DATE] at 11 a.m., indicated Resident 1's oxygen saturation improved at 96% with oxygen at 15 L/min via a non-rebreather mask (a method for delivering high concentrations of oxygen. It consists of a face mask with an attached oxygen reservoir bag and a one-way valve, which prevents the victim's exhaled air from mixing with the oxygen in the reservoir bag). The licensed nurse notified the attending physician, who ordered to transfer Resident 1 to GACH 1 via 911 (emergency transport). Resident 1 remained alert, coherent to answer questions, and the oxygen saturation was 96% upon transfer to GACH 1. A review of GACH 1 Emergency Department (ED) Provider Documentation Report, dated [DATE], timed at 10:54 a.m., indicated Resident 1 was alert and interactive and reported an increasing cough with increased sputum production. A review of GACH 1 Discharge Summary dated [DATE], indicated Resident 1 was admitted for acute [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] ([MEDICAL CONDITION], a chronic [MEDICAL CONDITION] lung disease that makes it difficult to breathe) exacerbation. Resident 1 remained unresponsive, and the family elected comfort care only. Resident 1 expired on [DATE] at 8:44 p.m. During an interview on [DATE] at 9:37 a.m., FM 1 stated on [DATE], Resident 1 was having difficulty breathing, and she informed the staff, who checked Resident 1's oxygen saturation, gave oxygen and respiratory treatment. FM 1 stated Resident 1 continued to have difficulty breathing through the week and was not acting like his usual self. FM 1 stated she reported her concerns to the staff daily and left a voicemail message to the Director of Nursing (DON) to discuss Resident 1's condition and plan of care but did not receive a callback. During an interview on [DATE] at 3:14 p.m., LVN 1 stated Resident 1 had a physician's orders [REDACTED]. LVN 1 stated Resident 1 did not have episodes of shortness of breath during her shifts. LVN 1 stated she checked Resident 1's oxygen saturation daily on room air, and it was usually 96 - 97% but could not provide documentation she did. During an interview on [DATE] at 3:58 p.m., the DON stated licensed nurses should monitor and document oxygen saturation levels and oxygen administration on the Medication Administration Record [REDACTED]. The DON reviewed Resident 1's clinical record and was unable to find an individualized care plan to address Resident 1's respiratory care needs. During an interview on [DATE] at 9:33 a.m., Certified Nursing Assistant 1 (CNA 1) stated on [DATE], Resident 1 looked a little weak and complained that he was not feeling well. CNA 1 notified LVN 1, and LVN 1 gave oxygen to Resident 1. CNA 1 stated Resident 1 was talking more with the oxygen, and the resident kept the oxygen on during her shift (7 a.m. to 3 p.m.). There was no documented evidence that Resident 1 received oxygen on [DATE]. A review of the facility's policy and procedure titled, Care Plans - Comprehensive dated ,[DATE], indicated an individualized comprehensive care plan is developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. The Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. A review of the facility's policy and procedure titled, Oxygen Administration dated ,[DATE], indicated to verify there is a physician's orders [REDACTED]. Before administering oxygen and during oxygen therapy, assess for the following signs and symptoms (s/s) of cyanosis (i.e. blue tone to the skin), [MEDICAL CONDITION] (low oxygen characterized by rapid breathing, rapid pulse rate, restlessness, and confusion), vital signs, lung sounds, arterial blood gases, and oxygen saturation. Record in the resident's clinical record the date and time of the procedure, the name, and title of the individual who performed the procedure, the rate of oxygen flow, route, and rationale, and the frequency and duration of the treatment including the reason for PRN administration and how the resident tolerated the procedure. A review of the facility's policy and procedure titled Pulse Oximetry (Assessing Oxygen Saturation) dated ,[DATE], indicated to review the physician's orders [REDACTED]. Assess the resident for signs and symptoms of impaired oxygen saturation such as altered respirations, difficulty breathing, abnormal breath sounds, a cyanotic (bluish or purplish discoloration) appearance of nail beds, lips, skin and mucous membranes, restlessness, irritability, and confusion and loss of consciousness. If the oxygen saturation is less than acceptable level for the resident's condition, notify the physician. An oxygen saturation flow sheet should be placed in the medical record and should include the date and time of the procedure, the type of probe and location of placement, the assessment data gathered prior to the procedure, the resident's response to the procedure, any unusual findings and action taken, and the signature and title of the person performing the procedure.

Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent avoidable pressure sore development to one of 10 residents with pressure sores in a sample of 30 (Resident 9) by failing to: 1. Identify an accurate assessment in the Minimum Data Set Assessment for skin conditions for the most recent quarterly and annual assessments. 2. Implement Resident 9's initial and quarterly care plans 3. Follow the facility's pressure sore prevention policy 4. Follow the manufacturer's recommendations for the use of low air loss mattresses for residents with pressure ulcers 5. Ensure professional standards of practice were met in pressure ulcer prevention by failing to turn the resident at least every two hours in bed or one hour in a chair and failing to keep the resident off of his/her back. These deficient practices resulted in Resident 9's development of an avoidable Stage III pressure sore (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed) to the sacro-coccygeal area (lower back above the buttocks). Findings: On February 16, 2016 at 3:00 PM, a record review indicated in the admission assessment that Resident 9 was admitted with blancheable redness (reddened skin may turn a lighter shade when applying and removing pressure to it) to the sacro-coccygeal area and to the right and left buttocks on November 25, 2014, Resident 9 ' s date of admission. Resident 9 was assessed to be at high risk for the development of pressure sores on the Norton Plus Pressure Ulcer Scale dated 11/25/14 with a score of 9 (This is an assessment tool in the resident's medical record used by nurses to determine if a resident is at risk for the development of a pressure ulcer. A resident who is at high risk earns a score of 10 or less) on the date of admission. During the record review on February 16, 2016, the facility documented Resident 9 was not at risk for a pressure sore and documented the resident did not have one or more unhealed pressure ulcer(s) Stage 1 or higher under the skin conditions in section M of the Minimum Data Set (MDS) Version 3.0 (a resident assessment and care screening document completed annually, quarterly, and when a resident experiences a change in condition) for the most current annual assessment on November 30, 2015 and on September 1, 2015. Resident 9's care plan identified Coccyx open area was initiated on November 5, 2015. The goal stated will be resolved in 21 days. The initial MDS on December 2, 2014 indicated Resident 9 was at risk of developing pressure ulcers. It also indicated that the resident had 4 Stage I pressure ulcers (non-blancheable redness). The MDS on March 2, 2015 indicated Resident 9 was at risk for developing pressure ulcers. This MDS also indicated that the resident did not have any unhealed pressure ulcers, stage one or higher. The MDS on June 2, 2015 indicated Resident 9 was at risk for developing pressure ulcers. This MDS also indicated that the resident did not have any unhealed pressure ulcers, stage one or higher. The MDS on September 1, 2015 indicated Resident 9 was not at risk for developing pressure ulcers. This MDS also indicated that the resident did not have any unhealed pressure ulcers, stage one or higher. The MDS on November 30, 2015 indicated Resident 9 was not at risk for developing pressure ulcers. This MDS also indicated that the resident did not have any unhealed pressure ulcers, stage one or higher. Interventions listed included APP (alternating positive pressure) mattress for wound management . keep area clean and dry . monitor progress weekly . supplements for wound healing .(and) Tx (treatment) as ordered. The care plan on potential for pressure ulcer development due to mobility problem and incontinence revised on December 8, 2015 (1 year later) had a goal stating will have intact skin, free of redness, blisters, or discoloration by/through review date with a target date of March 6, 2016. Interventions listed included provide assistance turn/reposition at least every 2 hours, more often as needed or requested . provide good perineal (diamond shaped area that includes the anus and the vagina) care after each incontinence (unable to retain urine or feces)) . (and) provide pressure relieving/reducing device on bed/chair. During the month of February 2016 on the Nursing Assistant Daily Flow Sheets for Resident 9, reviews of the CNAs documentation indicated Resident 9 was not consistently repositioned every 2 hours. The day shift documented N for 11 out of 18 shifts that the resident was repositioned every two hours. The PM shift documented N or NA (No or Not Applicable) for 18 out of 18 shifts for repositioned every two hours. The night shift documented Y (Yes) for repositioning every two hours. All shifts documented D for bed mobility/position 2qh indicating that Resident 9 was dependent for bed mobility and turning. During the month of January 2016 on the Nursing Assistant Daily Flow Sheets for Resident 9, reviews of the CNAs documentation indicated Resident 9 was not consistently repositioned every 2 hours. The day shift documented N for 31 out of 31 shifts that the resident was repositioned every two hours. The PM shift documented N or NA (No or Not Applicable) for 30 out of 31 shifts for repositioned every two hours. The night shift documented Y (Yes) for repositioning every two hours for 31 out of 31 shifts. All shifts documented D for bed mobility/position 2qh indicating that Resident 9 was dependent for bed mobility and turning. During the month of December 2015 on the Nursing Assistant Daily Flow Sheets for Resident 9, reviews of the CNAs documentation indicated Resident 9 was not consistently repositioned every 2 hours. The day shift documented N for 28 out of 31 shifts that the resident was repositioned every two hours. The PM shift documented N or NA (No or Not Applicable) for 31 out of 31 shifts for repositioned every two hours. The night shift documented Y (Yes) for repositioning every two hours for 31 out of 31 shifts. All shifts documented D for bed mobility/position 2qh indicating that Resident 9 was dependent for bed mobility and turning. The wound assessment by Treatment Nurse 3, dated January 31, 2016, it was identified the wound was a Stage II (topmost layer of the skin is broken) measuring a length of 1.6 centimeter (cm), a width of 0.5 cm, and a depth of 0.1 cm. The nurse documented that there was a small amount of yellowish exudate (fluid that has leaked out of the blood vessel) drainage. During the record review the nurse practitioner (NP) documented on February 8, 2016 Resident 9 had developed a Stage III pressure ulcer measuring 4 cm in length and 0.7 cm in width over the sacrococcygeal (tailbone) area. The NP documented the resident ' s wife requests to evaluate Resident 9 that morning due to worsening wound of the back. The NP progress notes indicated the treatment nurse informed the NP the wound opened up again about one week ago. The NP on February 8, 2016, ordered wound care with [MEDICATION NAME] (skin cleanser) and normal saline. Pat dry. Apply [MEDICATION NAME] to wound bed; Dermaseptin cream to surrounding area. Cover with dry dressing as needed for soiled or dislodged dressing for 21 Days and every day shift for 21 Days. The NP ordered to add a low air loss mattress. In the NP ' s progress notes on February 15, 2016, NP indicated to continue using the low air loss mattress and frequent turning. On February 8, 2016, a Short Term Problem care plan was initiated for a problem indicating sacrococcyx now c (with) yellow slough (dead outer skin). The plan included Tx as ordered . supplements for wound healing . labs as ordered . LAL (low air loss) mattress for wound mgt. (management) . (and) inform MD for any changes of condition. The target date was set for February 29, 2016. On February 17, 2016, at 7:34 AM in Resident 9's room, the resident was observed being slouched (not positioned straight in bed with the body curving toward a side) in bed and positioned in a semi-side-lying (a position in bed where a person is lying on a side of their body, not completely on their back and not completely on their side) position on their right side, facing the door. At 8:41 AM, the resident was in the same position. At 9:42 AM, the resident continued to remain in the same position. At 10:44 AM, the resident was in the same position. The resident was not turned or repositioned for at least 3 hours during this observation. A record review of the Nursing Assistant Daily Flow Sheet documented Resident 9 was dependent (the resident requires total care) and was not consistently repositioned every two hours by the nursing assistants charting for the Day shift and PM shift. During an interview with LVN 5 on February 19, 2016, at 11:05 and an interview with Treatment Nurse 3 on February 22, 2016, at 2:20 PM, both nurses verbalized that they were not aware of the nursing assistant charting inconsistencies. During an interview with CNA 4 on February 19, 2016, at 10:40 AM, the CNA verbalized that a patient at risk for pressure sores needs to be turned every two hours. CAN 4 verbalized that they did not know the facility ' s policy on pressure ulcer prevention or where to find the policy if needed. During the record review, the facility failed to specifically document what position the resident was placed in throughout the day, the date and time any skin care was provided to the resident, and if care or repositioning was refused during the shift in addition the reason for refusal. These failures in documentation are not in compliance under the documentation section of the facility ' s Prevention of Pressure Ulcers Policy. The policy indicated that for a person in a chair: change position at least every two hours and use foam, gel, or air cushion as indicated to relieve pressure. During an observation on February 18, 2016, at 9:25 AM, Resident 9 was placed flat on his back in a Gerri-chair (a chair for the elderly that reclines) and taken to the dining room. At 11:30 AM, observed resident in the same position on the Gerri-chair. There were no pressure relief cushions or pads under the resident during the observation. During an interview with Treatment Nurse 3 on February 22, 2016, stated that the facility normally gives nutritional supplements and gel cushions for residents who are at high risk for pressure ulcers. According to Medical Surgical Nursing Ninth Edition, pages 186-187, it is indicated: Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure ulcer. During a treatment observation for Resident 9 with Treatment Nurse 3 on February 19, 2016, at 9:10 a.m., it was observed that the sacrococcygeal area was surrounded by non-blancheable redness. The treatment nurse stated the skin was not blancheable, it stays red. The treatment nurse also stated it was always a Stage II and it turned into a Stage III, when asked about Resident 9 ' s stage history of the pressure ulcer during the observation. Resident 9 was lying on a low air loss mattress (a specialized mattress with a pump attached to it which promotes pressure ulcer healing). The resident had a flat sheet folded in half and a disposable absorbent pad made of plastic underneath him. The resident was also wearing an adult diaper. During an observation on February 23, 2016, at 2:20 PM, the resident was lying on top of the low air loss mattress that had a fitted sheet on the bed and a regular reusable absorbent pad. The resident was also wearing a diaper. At this time, Treatment Nurse 3 was asked if fitted sheets should be placed on low air loss mattresses. Treatment Nurse 3 stated It shouldn ' t be like that, it ' s defeating the whole purpose. The Treatment Nurse did not know where the manufacturer ' s manual was or where to find it at the time of the interview. During an interview with LVN 5 on February 23, 2016, at 10:00 AM, the LVN was asked if he/she received training on the proper use of low air loss mattress. The LVN stated he/she did not receive training. The facility's Linen Protocol for Powered Support Surfaces indicated that Low Air Loss mattress therapy is a therapy that contains air cells that emit air flow through the top sheet to provide air exchange for moisture control in the management of pressure ulcers. The protocol indicated that an additional linen top sheet is not necessary for these therapy surfaces unless specifically requested by the resident. The protocol indicated residents who are incontinent of the bowel and/or bladder should follow several, the manufacturer's specific guidelines. The first indicated products containing plastic should never be used on low air loss surfaces because they inhibit the effects of low air loss which allows for air exchange and moisture control. The second indicated Diapers should be avoided with low air loss therapy and wounds located on the trunk region and that if the resident or family members insist on plastic disposable diapers then provide the appropriate education and care planning. The third indicated linens must always be kept to a minimum. Avoid multiple layers of linens under the resident. A single cotton draw sheet may be used for turning and to absorb incontinence. The manufacturer's guidelines indicated at the end of the document that a resident should not be found on low air loss with a linen top sheet, a draw sheet, and an incontinence pad.