Every finding on record at Intercommunity Healthcare & Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure one of eleven sampled residents (Resident 2) right hand was clean, and all of her fingernails on both of her hands were trimmed. The deficient practice resulted in accumulation of a yellowish debris in the palm of Resident 2's right hand and the fingernails on her right and left hand being untrimmed. This deficient practice had the potential for infection and skin injuries to occur.Findings: During a review of Resident 2's admission Record (Face sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 had a diagnosis of polyneuropathy (a medical condition where many nerves throughout the body are damaged at the same time, usually starting in the hands and feet). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 6/12/2026, the MDS indicated Resident 2 was forgetful and was not able to make decisions that were reasonable and consistent. Resident 2 required a two person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 2 was incontinent (loss of control) of bladder and bowel functions. During a review of Resident 2's Care Plan revised 7/5/2023, the Care Plan indicated a goal for Resident 2 to be clean, dry and well-groomed daily with interventions including assisting Resident 2 with her ADLs such as grooming and trimming of her fingernails. During an observation on 8/27/2026 at 11:47 a.m., Resident 2 was noted sitting in a semi upright position in bed, both of her hands were covered with hand mittens. During an observation on 8/27/2026 at 12 p.m., and a concurrent interview, Certified Nursing Assistant (CNA) 1 removed hand mittens from both of Resident 2's hands. The palm of Resident 2's right hand was noted with yellowish debris, and all of her fingernails were untrimmed on both hands. CNA 1 stated it was the responsibility of the nursing staff to make sure the residents were assisted with their personal hygiene during their shower or bed bath which included cleaning of their hands and trimming of their fingernails. During an interview on 8/27/2026 at 12:17 p.m., Licensed Vocational Nurse (LVN)1 stated Resident 2's hands and fingernails should have been cleaned and trimmed by the nursing staff because Resident 2 was dependent on nursing staff for her care and ADLs. During a review of the facility's Policy and Procedure (P/P) titled Activities of Daily Living (ADLs), Supporting revised 3/2023, the P/P indicated the facility shall provide all residents of the facility care, treatment and services to maintain or improve their ability to carry out their ADLs. The P/P indicated the residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene.

Based on observation, interview and record review, the facility failed to ensure one of eleven sampled residents (Resident 2) did not have hand mittens (large, padded, soft mitts worn over a resident's hands to prevent self-injury or the accidental removal of vital medical devices) applied to both of her hands following a physician's order to discontinue their use. This deficient practice resulted in the restriction in movement of Resident 2 hands and complaints of pain. This deficient practice had the potential to cause harm/injury to Resident 2's hands skin.Findings: During a review of Resident 2's admission Record (Face sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 had diagnoses including major depressive disorder ([MDD] a serious medical condition that causes a constant, heavy feeling of sadness and a loss of joy in life), a generalized anxiety disorder (a mental health condition marked by constant, hard-to-control worry about everyday life) and polyneuropathy (a medical condition where many nerves throughout the body are damaged at the same time, usually starting in the hands and feet). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 6/12/2026, the MDS indicated Resident 2 was forgetful and was not able to make decisions that were reasonable and consistent. Resident 2 required a two person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 2 was incontinent (loss of control) of bladder and bowel functions. During a review of Resident 2's Physician Orders dated 3/27/2026, the Physician orders indicated to discontinue the application of a restraint; bilateral (two) hand mittens six times a week for prevention of pulling of her gastrostomy tube ([GT] a feeding tube placed through the skin of the belly directly into the stomach to give food, liquids and medicines). During a review of Resident 2's Care Plan, the Care Plan indicated the use of physical restraints; bilateral hand mittens was resolved and/or discontinued since 6/24/2026. During an observation on 8/27/2026 at 11:47 a.m., Resident 2 was noted sitting in a semi upright position in bed, both of her hands were covered with hand mittens, when her name was called, she responded by showing both of her hands, and saying, it hurts. During an observation on 8/27/2026 at 12 p.m., and a concurrent interview, Certified Nursing Assistant (CNA) 1 removed hand mittens from both of Resident 2's hands and Resident 2 was heard saying her hands hurt. CNA 1 stated Resident 2 was uncomfortable while she had the hand mittens on and acknowledged the hand mittens restricted Resident 2 movements. During an interview on 8/27/2026 at 12:10 p.m., CNA 2 stated Resident 2 had previously pulled out her GT and when she (CNA 2) saw that Resident 2 had hand mittens on both of her hands she just left them on. During an interview on 8/27/2026 at 12:17 p.m., after reviewing Resident 2's Physician's Orders, Licensed Vocational Nurse (LVN) 1 stated there were no orders indicating to apply hand mittens to Resident 2's hands. Resident 2 did not need the hand mittens because she (Resident 2) had an abdominal binder to prevent her from accidentally pulling out her GT. LVN 1 stated she should have double checked Resident 2's orders to prevent unnecessary application of hand mittens to Resident 2. During a review of the facility's Policy and Procedure (P/P) titled Use of Restraints revised 4/2017, the P/P indicated the facility shall only use restraints such as a hand mittens only upon the written order of the physician and after obtaining consent from the resident and/or responsible party.

Based on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 2), did not develop an avoidable unstageable (an injury where the true depth cannot be determined due to the injury being partially or fully covered with eschar (dead tissue brown, black or tan) and or slough (yellowish, soft, moist tissue indicating deeper tissue damage and advancement of the pressure injury) pressure injury (PI - injury to skin and underlying tissue resulting from prolonged, unrelieved pressure on bony areas of the skin) by failing to:1. Follow the physicians' orders dated 4/21/2026 and 4/28/2026 to change Resident 2's dressing once daily, and as needed when the dressing became soiled or dislodged. 2. Implement the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised March 2023, which indicated that a person-centered care plan must include measurable objectives and timetables to meet the resident's needs by updating and implementing Resident 2's care plan to address the significant change in Resident 2's pressure injury, when the pressure injury progressed from a Stage 2 (partial-thickness skin loss, with exposed dermis [the inner layer of the skin]) creating a visible, open wound) on 4/16/2026 to a Stage 4 (full-thickness skin and tissue loss with exposed or directly palpable muscle, tendon, cartilage or bone) on 4/28/2026.3. Implement the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, revised March 2023, which indicated that during skin assessments, staff were to inspect pressure points, including the sacrum (triangle-shaped bone at the base of the spine), buttocks, coccyx (tailbone), elbows, and other areas at risk of pressure injury and reposition residents as indicated on the care plan to prevent the development and progression of pressure injuries. These failures resulted in Resident 2 developing a Stage 4 pressure injury to the sacrococcygeal (the area where the lower spine and the tailbone meat) area on 4/28/2026. Subsequently, Resident 2 was transferred to a general acute care hospital (GACH) on 5/7/2026, where the resident remained hospitalized for 10 days until 5/17/2026, for treatment and management of the Stage 4 pressure injury. Resident 2 was admitted to the GACH on 5/7/2026, for treatment of an infected Stage 4 sacrococcygeal pressure injury, sacral osteomyelitis (infection of the underlying bone tissue) and sepsis (the body's life-threatening response to infection in the blood stream).Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses including nontraumatic (Spontaneous, not caused by an external physical force) subarachnoid hemorrhage (bleeding in the space between your brain and the membrane that covers it), tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs ), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure).During a review of Resident 2's Braden Scale (a standardized tool used by healthcare professionals to assess an individual's risk of developing pressure injuries, or bedsores) assessment dated [DATE], the Braden scale assessment identified Resident 2 as being at high risk for developing pressure injuries.During a review of Resident 2's care plan, dated 3/13/2026, regarding Resident 2's alteration in skin integrity (MASD) related to bowel and bladder incontinence(loss of voluntary control of bowel and bladder), the interventions included to assist with turning and repositioning as needed, keep the skin clean and dry, provide incontinent care as needed and provide treatment as ordered.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/19/2026, the MDS indicated Resident 2 was dependent (helper does all the effort while the resident does none of the effort to complete the activity) on staff for self-care activities such as eating, hygiene, bathing, and getting dressed. The MDS indicated Resident 2 was dependent on facility staff for mobility such as rolling from left to right. The MDS indicated Resident 2 was always incontinent of bladder and bowel and did not have pressure injuries upon admission and was at risk of developing pressure injuries.During a review of Resident 2's Braden Scale assessment dated [DATE], the Braden scale assessment identified Resident 2 as continuing to be at very high risk for developing pressure injuries.During a review of Resident 2's Change of Condition Evaluation (COC), dated 4/16/2026 at 9:00 a.m., the COC indicated Resident 2 had reddish moist tissue presenting as a shallow opening, (Stage 2- Pressure Injury- a break in the skin where the outer layer and part of the inner layer are damaged, leaving a visible, open wound without exposing fat, muscle, or bone) to the coccyx area. There were no measurements of the area documented. The COC indicated Resident 2 was not admitted with any wounds.During a review of Resident 2's Care Plans for the month of April 2026, there were no care plans in place for Resident 2's Stage 2 Pressure Injury (PI) to the sacrococcyx area documented on 4/16/2026.During a review of Resident 2's physician's orders dated 4/16/2026, the physician's orders indicated cleanse the Stage 2 PI on the sacrococcyx with normal saline (medical grade mix of water and salt used for cleaning wounds), cover with dry dressing daily and as needed when dressing becomes soiled or dislodged for 21 days every day.During a review of Resident 2's Certified Nursing Assistant (CNA) daily task documentation for toileting hygiene for April 2026, the documentation indicated toileting hygiene was completed during each of the three shifts (7 a.m. to 3 p.m., 3 p.m. - 11 p.m., and 11 p.m. to 7 a.m.) on 4/16/2026 through 4/25/2026 and on 4/27/2026, for a total of 33 documented episodes of toileting hygiene. During a review of Resident 2's Treatment Administration Record (TAR) for April 2026, the TAR indicated the dressing change for Resident 2's Stage 2 coccyx pressure injury was documented as completed once daily during the 7 a.m. to 3 p.m. shift on 4/2/2026 through 4/16/2026 and 4/27/2026, for a total of 11 documented dressing changes. The TAR contained no documentation that additional dressing changes were performed during the 3 p.m. to 11 pm or 11 p.m. to 7 a.m. shifts when the dressing became soiled or dislodged, as ordered.During a review of Resident 2's COC, dated 4/28/2026 at 9:00 am, the COC indicated Resident 2's pressure injury had slough to the wound bed of the sacrococcyx area indicating the wound had deteriorated. No measurements were documented.During a review of Resident 2's Skin Issues Note, dated 4/28/2026 at 11:44 am, the Skin Issues Note indicated Resident 2's sacrococcyx pressure injury had deteriorated, and the pressure injury was now an unstageable pressure injury due to slough 60% and eschar, the wound measured Length 5.1 cm X width 5.1 cm. No depth was documented.During a review of Resident 2's physician's order dated 4/28/2026, the physician's orders indicated treatment for the sacrococcyx pressure injury; cleanse with normal saline, pat dry, apply skin barrier to peri-wound (a product applied to skin to protect from moisture) area of the skin that surrounds the outer edges of a wound) and Santyl ointment (a prescription medicine used to remove dead tissue from wounds) to the wound bed, cover with dry dressing daily and as needed when dressing becomes soiled or dislodged for 30 days.During a review of Resident 2's daily CNA daily tasks for toileting hygiene dated April 2026, and May 2026 the CNA daily task list indicated Resident 2's toileting hygiene was completed three times a day (during the 7 a.m. to 3 p.m. shift, during the 3 p.m. to 11 p.m. shift and during the 11p.m. - 7 a.m. shift) on 4/28/2026, 4/29/2026, 4/30/2026, 5/1/2026, 5/2/2026,5/3/2026, 5/4/2026, 5/5/2026, 5/6/2026, and 5/7/2026. (30 times).During a review of Resident 2's TAR for April 2026 and May 2026, the TAR indicated the dressing change for Resident 2's (Stage 2) coccyx pressure injury was documented as completed once daily during the 7 a.m. to 3 p.m. shift, on 4/16/2026, 4/17/2026, 4/18/2026, 4/19/2026 and 4/20/2026, 4/21/2026, 4/22/2026, 4/23/2026, 4/24/2026, 4/25/2026 and 4/27/2026, for a total of 11 times. The TAR contained no documentation that additional dressing changes were performed during the 3 p.m. to 11p.m. shift and the 11 p.m. to 7 a.m. shifts, as needed, when the dressing became soiled or dislodged.During a review of a Nursing Progress Note dated 5/7/2026 at 9:00 am, the Nursing Progress Note indicated the Treatment Nurse (TN) noted Resident 2's sacrococcyx pressure injury had a foul odor, and the tissue surrounding the pressure injury was warm to the touch (indicating the wound was infected).During a review of Resident 2's physician's orders dated 5/7/2026 at 9:10 a.m., the physician's orders indicated to transfer Resident 2 to the GACH for Sacrococcyx pressure injury management.During a concurrent interview and record review on 7/30/2026 at 11:51 a.m., with the TN, Resident 2's admission skin assessment dated [DATE], the Braden scale dated 3/13/2026, Resident 2's COCs dated 4/2/2026, 4/16/2026 and 4/28/2026, the TAR's for 4/2026 and 5/2026, the nurses progress notes dated 5/7/2026 and Resident 2's care plans for the months of 4/2026 and 5/2026 were reviewed. The TN stated Resident 2's sacrococcyx PI would get worse if the wound care treatments were not being completed when the wound dressing got soiled or dislodged in addition to the once daily wound dressing. The TN stated all licensed staff are trained to perform wound care and if Resident 2 was soiled at any time, the licensed staff could provide treatments as ordered. The TN stated CNAs cleaned Resident 2 and reported any abnormal skin changes, soiled or dislodged wound dressing to the Licensed Vocational Nurse (LVN) and the LVN then reported the findings to the Registered Nurse (RN).During an interview on 7/30/2026 at 1:24 p.m., with CNA 5, CNA 5 stated that she changed Resident 2's adult briefs due to soilage, she (CNA 5) did not notify the charge nurse she just changed Resident 2, and the wound dressing may need to be changed.During an interview on 7/30/2026 at 4:26 p.m., with LVN 5, LVN 5 stated she had performed the dressing change once or twice for Resident 2 when it was soiled on her shift (did not recall exact dates), but it was not done consistently when it was soiled.During an interview on 7/30/2026 at 5:12 p.m., with the Director of Nursing (DON), the DON stated if staff observed that a resident was soiled, the licensed nursing staff should assist the Certified Nursing Assistants (CNAs) with providing hygiene and perform wound treatments as indicated. The DON stated Resident 2's wound treatment should have been provided as needed, including during shifts when the Treatment Nurse was not working, because the physician's order indicated the treatment was to be provided daily and as needed. The DON stated wounds could worsen, become larger, and deepen if wound care was not provided in a timely manner. The DON further stated Resident 2's pressure injury was avoidable if appropriate interventions had been provided timely and as needed when the wound dressing became dislodged or soiled, especially because Resident 2 was at very high risk for skin breakdown.During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, revised March 2023, the P&P indicated a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and must be developed and implemented for each resident.During a review of the facility's P&P titled Prevention of Pressure Injuries, revised March 2023, indicated assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. inspect the skin daily when performing or assisting with personal care or activities of daily living.inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, etc.wash the skin after any episodes of incontinence, skin cleanser. reposition resident as indicated on the care plan.clean promptly after episodes of incontinence.use a barrier product to protect skin from moisture.use incontinence products with high absorbency.do not rub or otherwise cause friction on skin that is at risk of pressure injuries.use facility-approved protective dressings for at risk individuals.reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. evaluate, report and document potential changes in the skin .review the interventions and strategies for effectiveness on an ongoing basis

Based on interview and record review, the facility failed to ensure nursing progress notes were accurately and individually documented by two Licensed Vocational Nurses (LVN 3 and LVN 4). LVN 3 and LVN 4 entered identical progress notes for one of 1 sampled resident (Resident 97).This failure had the potential to create an inaccurate legal medical record by failing to accurately identify which licensed nurse provided care and communicated with the Physician and Resident 97's Responsible Party. Findings: During a record review of Resident 97's admission record, the admission record indicated Resident 97 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD, permanent kidney failure requiring dialysis), dependence on renal dialysis (ongoing dialysis treatment), heart failure (impaired ability of the heart to pump blood effectively), atrial fibrillation (irregular heart rhythm), chronic kidney disease-related anemia (low red blood cell count associated with kidney disease), hypertension (high blood pressure), dysphagia (difficulty swallowing), dementia (progressive cognitive impairment).During a record review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE], Resident 97 was assessed as cognitively intact with a Brief Interview for Mental Status (BIMS - a short, standardized Resident 97st used by healthcare providers in nursing homes and rehabilitation centers to evaluate a person's memory, thinking, and orientation) score of 15, indicating intact cognition. Required assistance with dressing, bathing, toileting, transfers, walking, and wheelchair mobility, was dependent bed mobility.During a review of Resident 97's nursing progress notes dated [DATE], two LVN (LVN 3 and LVN 4) documented separate progress notes for the same event. The progress note indicated created and entered by LVN 4 at 11:07:51 p.m., and another progress note, created and entered by LVN 3 at 7:05:25 p.m., contained identical documentation stating that Resident 97 was found unresponsive at approximately 6:07 p.m., a code blue (an emergency alert meaning a patient has experienced cardiac arrest (heart has stopped) or respiratory arrest (breathing has stopped)).was initiated, cardiopulmonary resuscitation (CPR - a life-saving emergency procedure used when someone's breathing or heartbeat stops, combining chest compressions and rescue breaths to keep blood flowing to vital organs) was performed, paramedics arrived at 6:10 p.m. and assumed care at 6:12 p.m., and Resident 97's RP was notified at 6:15 p.m. During a concurrent interview on [DATE] at 1:26 p.m. with LVN 3, LVN 3 stated that Licensed Nurses are not permitted to copy another LVN's documentation and that each licensed nurse is responsible for documenting their own individual assessment or any communication transcribed. LVN 3 stated that she was the one who called the Physician and LVN 3 was the one who informed the RP because she had a good relationship with the RP. LVN 3 stated that she does not know why LVN 4 has the same identical progress notes, but it should not be like that. LVN 3 stated whoever created the progress note is authorized to edit or amend their documentation with and all changes tracked by an electronic time stamp.During a concurrent interview with the Director of Nursing (DON) on [DATE] at 5:50 p.m., the DON stated that licensed nurses are expected to document accurately, and resident-specific documentation based on their own assessment and must not be copied by another nurse. The DON stated the nurse who created a progress note may amend or correct the documentation and that all edits are electronically tracked by date and time stamps. The DON stated that duplicate documentation does not accurately identify which licensed nurse provided care or communicated with the physician and the resident's family and is not consistent with the facility's documentation standards. The DON stated that when duplicate, altered, or inaccurate documentation is identified, the facility investigates the incident, provides staff education, and implements corrective action, including adding an addendum to the medical record when appropriate.During a record review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, revised [DATE], the policy stated that all services provided to the resident, progress toward care plan goals, and any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The policy stated that documentation in the medical record must be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to address the following for one of 10 sampled residents (Resident 78) by failing to: Failing to initiate a care plan for Resident 78's abuse allegation, monitor Resident 78 for 72 hours when there was a chance of condition (COC), and conduct an Interdisciplinary Team (IDT Resident healthcare team consisting of various specialties) meeting post abuse allegation. This deficient practice increased the risk for Resident 78 to continue feeling unsafe and subjected to continued neglect, verbal, mental, and physical abuse. Findings: During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted on [DATE] and with diagnoses including encephalopathy (any damage or disease that affects the brain), dysphagia (difficulty swallowing), and urinary tract infection (UTI, an infection in any part of the urinary system). During a review of Resident 78's history and physical (H&P) dated 6/18/2026, the H&P indicated Resident 78 had the capacity to understand and make decisions. During a review of Resident 78's Minimum Data Set (MDS, a resident assessment tool), dated 6/19/2026, the MDS indicated Resident 78 had mild cognitive (ability to think and make decisions) impairment. The MDS indicated Resident 78 was dependent on staff for toileting hygiene, required substantial assistance (helper does more than half for bathing, upper (above waist) and lower (below waist) dressing, required partial assistance (helper does less than half the effort) for personal hygiene, rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, required supervision with oral hygiene, and required set up for eating. During a review of Resident 78's Change of Condition (COC) dated 7/21/2026 at 8:00 p.m., the COC indicated Resident 78 stated Certified Nursing Assistant (CNA) 4 took her to shower and were putting water in her face and was not able to breathe. During a review of Resident 78's care plan, titled, Resident making false accusations, dated 7/21/2026, the care plan interventions indicated acknowledge resident's concerns without confirming or denying the allegation, ensure resident safety and provide reassurance, assess the resident for pain, unmet needs, emotional distress, communicate findings and interventions as appropriate, and communicate patterns of behavior during shift report to ensure consistent responses. During a review of Resident 78's Licensed Nurses Note dated the following, there was no documentation of staff addressing Resident 78's allegations of abuse. 7/21/2026 at 12:47 a.m.7/21/2026 at 1:43 p.m.7/22/2026 at 12:51 a.m.7/22/2026 at 3:48 p.m.7/23/2026 at 2:55 p.m.7/23/2026 at 11:56 p.m. During an interview on 7/28/2026 at 4:35 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated when she was informed of the incident by Resident 78's family member, she notified the Director of Nursing (DON) and completed an incident report. LVN 2 stated when there was an allegation of abuse made by a resident, a COC was created, the doctor was informed, and staff would monitor the resident for three days. LVN 2 stated an IDT meeting would also be conducted. LVN 2 stated they initiated care plans to address the allegations of abuse reported by the resident. LVN 2 stated a care plan should be initiated when there was a COC for Resident 78. LVN 2 stated care plans were initiated to monitor how the resident was improving and indicated that with no care plans, they would not be able to monitor progress to ensure improvement. During a concurrent interview and record review on 7/30/2026 at 12:08 p.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 stated the care plan titled Resident making false accusations, did not address the main allegation and indicated there should be a care plan for the actual incident that occurred. RNS 2 stated the care plan should be related to the COC so the staff could develop a plan and understand how to care for the resident, otherwise staff would not know how to take care of the resident. RNS 2 stated IDT meetings were done as soon as possible when there was an incident to ensure the resident was safe and the allegation was addressed accordingly. During a concurrent interview and record review on 7/30/2026 at 12:25 p.m. with RNS 2, Resident 2's Progress notes were reviewed. RNS 2 stated the follow up documents dated the following: 7/22/2026 at 12:51 a.m. 7/22/2026 at 3:48 p.m. 7/23/2026 at 2:55 p.m. did not address how the resident was feeling or doing since the COC. RNS 2 stated after a COC, the Resident 78 should be monitored for 72 hours to identify if there were any changes in behavior or if new physical injury arose. During an interview on 7/30/2026 at 4:49 p.m. with the Director of Nursing (DON), the DON stated when there was an allegation that CNA 4 had sprayed water in Resident 78's face making it difficult for Resident 78 to breath, during a shower, staff should monitor Resident 78's behavior and condition of the resident for 72 hours. The DON stated monitoring the Resident 78 for 72 hours benefited the resident, because the staff could track Resident 78's progress and be sure they were provided with the care needed. The DON stated without proper monitoring, it was difficult to assess the residents condition and staff could miss the signs of decline or improvement. The DON stated Resident 78 did not have a care plan for the residents specific abuse allegation that CNA 4 sprayed water in her face during a shower, making it hard for her to breath. The DON stated a specific care plan would be created to address the issue and indicated with no care plans, they would not be able to monitor and see the outcome. The DON stated an IDT would be held within the next day or when the resident/family representative was available. The DON stated IDT's were conducted in order to discuss interventions, care plans, and corrective actions to prevent the incident from happening again. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised date 2/2021, the P&P indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse and be informed of, and participate in, his or her care planning and treatment. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised date 9/2022, the P&P indicated the resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, revised date 11/28/2022, the P&P indicated the facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse. Resident assessments and Care Planning are performed to monitor resident needs and address behaviors that may lead to conflict. The facility will reassess the resident following the abuse incident to determine if the resident's medical, nursing, physical, mental or psychosocial needs or preferences have changed as a result of the incident of abuse and initiate or update the care plan as indicated.

Based on interview and record review, the facility failed to address the following for one of 10 sampled residents (Resident 2) by failing to initiate and implement a care plan for Resident 2, who developed a stage 2 pressure ulcer (a partial-thickness skin loss where the outer layer epidermis and part of the second layer dermis are damaged) that progressed to a unstageable pressure ulcer (a severe full-thickness tissue loss where the true depth and exact stage cannot be seen) and ultimately becoming a stage 4 pressure ulcer (a severe, deep wound with full-thickness tissue loss). This deficient practice resulted in Resident 2's wound becoming a stage 4 pressure injury. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included nontraumatic subarachnoid hemorrhage (a type of bleeding in the space around the brain, caused by a burst brain or high blood pressure), acute embolism (a sudden blockage in a blood vessel by a stray clot, fat, or air), tracheostomy (a tube placed into a surgically created hole through the front of the neck and into the windpipe-trachea), and nontraumatic intracranial hemorrhage (a sudden bleed inside the brain tissue caused by damaged blood vessels).During a review of Resident 2's History and Physical (H&P), dated 5/18/2026, 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 3/19/2026, the MDS indicated Resident 2 could not complete the brief interview for mental status. The MDS indicated Resident 2 was dependent (helper does all the effort while resident does none of the effort to complete the activity) for self-care activities such as eating, hygiene, bathing, and dressing. The MDS indicated Resident 2 was dependent on mobility such as rolling from left to right. The MDS indicated Resident 2 was always incontinent with bladder (urination) and bowel (bowel movement).During a review of Resident 2's Change of Condition Evaluation ([COC], a sudden clinical deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition), dated 4/16/2026, timed at 9:00 a.m., the COC indicated Resident 2 had reddish moist tissue presenting as a shallow open area (a minor break in the skin where the outer layer and part of the inner layer are damaged, leaving a visible, superficial open sore without exposing fat, muscle, or bone) to the coccyx (tailbone) area.During a review of Resident 2's Care Plans, there was no care plan to address the newly identified shallow open area located on the coccyx area.During a concurrent interview and record review on 7/30/2026 at 1:35 p.m., with the Treatment Nurse (TN), the Care Plan and the COC were reviewed. The TN stated that a care plan should have been initiated for the newly identified shallow wound located in the coccyx area. The TN stated a care plan serves as a structured approach for resident care, outlining specific goals and interventions to address the needs of residents within the facility. The TN stated that upon identification of a stage 2 pressure ulcer, it was essential to promptly initiate a care plan and implement appropriate interventions to prevent further deterioration of the wound.During an interview on 7/30/2026 at 5:12 p.m., with the Director of Nursing (DON), the DON stated that a care plan should have been initiated immediately upon identification of the stage 2 pressure ulcer. The DON stated that appropriate interventions for managing the pressure ulcer include repositioning residents every two hours as needed, maintaining residents' skin cleanliness and dryness, conducting weekly and as-needed skin assessments, and considering recommendations such as the use of a low air loss mattress (a therapeutic medical bed system that uses a continuous stream of air escaping through tiny laser holes in the fabric) to support wound healing and prevention. The DON stated the wound could have been avoidable if proper interventions were provided in timely manner, that if staff were aware of the wound, they should follow the interventions right away.During a review of the facility's policy and procedures titled Care Plans, Comprehensive Person-Centered, revised March 2023, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. the comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. the interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to protect two of three sampled residents (Resident 1 and Resident 2) when: 1. Certified Nursing Assistant (CNA) 1 reported to Licensed Vocational Nurse (LVN) 3 that Resident 2 accused her (CNA1) of abuse on 3/1/2026. CNA 1 was reassigned to another area in the facility away from Resident 2 and on 3/2/2026 she was assigned to care for two residents who were Resident 2's roommates instead of suspending CNA 1 and removing her from the facility. 2. Registered Nurse (RN) 1 reassigned LVN 1 to care for other residents in the facility instead of suspending her and removing her from the facility when she was made aware of an allegation that LVN 1 inappropriately touched Resident 1. These deficient practices resulted Resident 1, Resident 2, and other residents' who resided in the facility being unprotected while CNA 1 and LVN 1 remained on the facility premises after being accused of abuse. These deficient practices placed Resident 1, Resident 2 and other residents' who resided in the facility at risk for abuse.Findings: a. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 2 had diagnoses including primary essential hypertension ([HTN] high blood pressure), peripheral vascular disease ([PVD] a slow progressive narrowing of the blood flow to the arms and legs), and hypothyroidism (a deficiency of the hormone causing the body to slow down). During a review of Resident 2's Minimum Data Set Assessment ([MDS] a resident assessment tool) dated 2/4/2026, the MDS indicated Resident 2's cognition (ability to think and reason) was intact. Resident 2 required set up or clean up assistance to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) During a review of Resident 2's Care Plan dated 6/19/2024, the Care Plan indicated residents and/or their responsible party were made aware the facility identifies abuse, practices and omissions that lead to abuse, neglect, and misappropriation of property. The goal of the Care Plan was for the facility to promptly identify and take appropriate measures to protect residents' from abuse. The Care Plan's interventions included immediate suspension of the employee if they were identified as the aggressor, escort them out of the facility and to notify the abuse coordinator as soon as the allegation of abuse was made (within 15 minutes of occurrence). During a review of Resident 2's Change of Condition (COC)/Interact Assessment form ([SBAR] situation, background, assessment, recommendation, a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/2/2026 and timed at 1 p.m., the COC/SBAR indicated Resident 2 reported CNA 1 was rough with her, grabbed her wrist and twisted her arm, so she (Resident 2) tried to kick CNA 1 to get away from her. During an interview on 3/9/2026 at 9:56 a.m., Resident 2 stated, via CNA 1, who translated for Resident 2, on 3/1/2026 (time unknown) she was in bed and CNA 1 came to her room in a bad mood, grabbed her left arm tight and pressed her fingers into her left ankle hard. Resident 2 stated she did not think to tell anyone. During an interview on 3/9/2026 at 12 p.m., CNA 1 stated on 3/1/2026 she went into Resident 2's room to change her adult brief. Resident 2 was in bed, and she (CNA 1) rolled her from left to right while putting the adult brief on her. Resident 2 got upset and accused her (CNA 1) of grabbing her left arm and abusing her. CNA 1 stated she left the room and told LVN 3 that Resident 2 accused her of abuse. CNA 1 stated she was reassigned to another resident and CNA 2 took over her assignment with Resident 2. The next day (3/2/2026) during the 7 a.m. to 3 p.m. shift, she was not assigned to care for Resident 2 but was assigned to care for two residents who shared a room with Resident 2. CNA 1 stated when she went to the room to care for the two residents assigned to her, Resident 2 started cursing at her and blocking the doorway with her wheelchair to keep her from entering the room. During an interview on 3/9/2026 at 12:17 p.m., CNA 2 stated she worked with CNA 1 on 3/1/2026 when Resident 2 accused her (CNA 1) of abuse. CNA 2 stated she was standing with CNA 1 when CNA 1 reported the allegation of abuse made by Resident 2 to LVN 3. During an interview on 3/9/2026 at 12:30 p.m., LVN 3 stated CNA 1 told her on 3/1/2026 that Resident 2 called her the B word and that Resident 2 was being aggressive towards her (CNA 1) so she changed CNA 1's assignment and assigned CNA 2 to care for Resident 2. On 3/2/2026 (time unknown) Resident 2 told her about CNA 1 twisting her left arm on 3/1/2026. LVN 3 stated on 3/2/2026 CNA 1 was not assigned to care for Resident 2 instead she was assigned to care for two other residents who occupied the room with Resident 2. During an interview on 3/9/2026 at 3:45 p.m., RN 2 stated she did not recall CNA 1 telling her that Resident 2 accused her of abuse on 3/1/2026, she remembered CNA 1 requesting to be removed from her assignment with Resident 2 and Resident 2 not wanting CNA 1 to care for her anymore. RN 2 stated she did not ask CNA 1 why she did not want to care for Resident 2 anymore, and she did not ask Resident 2 why she did not want CNA 1 to care for her, she just asked LVN 3 to change CNA 1's assignment. b. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1 had diagnoses including aphasia (a disorder that makes it difficult to speak) following a cerebral infarction (where blood flow to the brain has been blocked). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. Resident 1 was dependent (helper does all the effort) on staff to complete his ADLs. During a review of Resident 1's Care Plan dated 1/15/2026, the Care Plan indicated residents and/or their responsible party were made aware the facility identifies abuse, practices and omissions that lead to abuse, neglect, and misappropriation of property. The goal of the Care Plan was for the facility to promptly identify and take appropriate measures to protect residents' from abuse. The Care Plan's interventions included immediate suspension of the employee if they were identified as the aggressor, escort them out of the facility and to notify the abuse coordinator as soon as the allegation of abuse was made (within 15 minutes of occurrence). During a review of Resident 1's COC/SBAR dated 3/5/2026 and timed at 11:58 a.m., the COC/SBAR indicated during the Interdisciplinary Team meeting ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) Resident 1's Family Member (FM) accused LVN 1 of lifting Resident 1's sheet, touching Resident 1's diaper, then LVN 1 placed the sheet back over Resident 1 and walked out of the room during the 11: p.m. - 7 a.m. shift on 3/4/2026. During an interview on 3/6/2026 at 10:48 a.m., Resident 1's FM stated on 3/4/2026 she was in Resident 1's room in the dark when LVN 1 came in, put her hand under Resident 1's sheet, bent over and whispered something in Resident 1's ear, LVN 1 did not see her (FM) there. Later that night (time unknown), Resident 1 told her a nurse touched him inappropriately, when LVN 1 came back to the room, she asked Resident 1 if LVN 1 was the one who touched him inappropriately, he said yes. The FM stated she used a letter board (alphabets used to spell out words) to communicate with Resident 1, when Resident 1 reported this to her, she reported the allegation to LVN 2, who told her he would report it to RN 1. During a telephone interview on 3/6/2026 at 12:45 p.m., LVN 1 stated during the beginning of the shift 11 p.m. to 7 a.m., (3/4/2026), she went to Resident 1's room to see if Resident 1 was cold and Resident 1's FM yelled at her to get out. LVN 1 stated she reported to RN 1 what the FM said to her and LVN 3 removed her from the assignment caring for Resident 1. During a telephone interview on 3/6/2026 at 1:12 p.m., RN 1 stated on 3/4/2026 at 11:15 p.m., Resident 1's FM told her she did not want LVN 1 to take care of Resident 1 because LVN 1 stressed Resident 1 out. Later during the shift at approximately 2 a.m., Resident 1's FM told her LVN 1 touched Resident 1's private area inappropriately, so she moved LVN 1 to a different assignment. RN 1 stated she knew the policy on abuse, and she should have sent LVN 1 home to protect Resident 1 and other residents pending an investigation. During an interview on 3/9/2026 at 11:30 a.m., the DON stated when there was an allegation of abuse against a facility staff, the staff should be suspended immediately because we do not want to put other residents at risk while we investigate the complaint. During an interview on 3/10/2026 at 2:46 p.m., the Administrator (ADM) stated when there was an allegation of abuse against a staff, the staff should be suspended until an investigation was completed. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Neglect Exploitation or Misappropriation - Reporting and Investigating revised 9/2022, the P&P indicated upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of an unknown source, the administrator is responsible in determining what actions (if any) are needed for the protection of residents. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on interview, and record review, the facility failed to immediately report an allegation of abuse for two of three sampled residents (Resident 1 and Resident 2) when: 1. Certified Nursing Assistant (CNA) 1 reported to Licensed Vocational Nurse (LVN) 3 that Resident 2 accused her of abuse on 3/1/2026 and Resident 2 reported to her that CNA 1 twisted her (Resident 2) arm on 3/2/2026 but LVN 3 did not report the allegation of abuse to the Administrator (ADM), who is the facility's abuse coordinator. 2. Registered Nurse (RN) 1 was made aware of an allegation that LVN 1 inappropriately touched Resident 1 on 3/4/2026 but she did not report the allegation of abuse to the ADM. These practices resulted in the ADM, who was the facility's abuse coordinator, not knowing about the allegations of abuse made against CNA 1 and LVN 1, and the CDPH's inability to investigate the allegations of abuse in a timely manner. These deficient practices had the potential for information pertinent to the investigation to be lost and/or forgotten. Findings: a. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 2 had diagnoses including primary essential hypertension ([HTN] high blood pressure), peripheral vascular disease ([PVD] a slow progressive narrowing of the blood flow to the arms and legs), and hypothyroidism (a deficiency of the hormone causing the body to slow down). During a review of Resident 2's Minimum Data Set Assessment ([MDS] a resident assessment tool) dated 2/4/2026, the MDS indicated Resident 2's cognition (ability to think and reason) was intact. Resident 2 required set up or clean up assistance to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) During a review of Resident 2's Change of Condition (COC)/Interact Assessment form ([SBAR] situation, background, assessment, recommendation, a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/2/2026 and timed at 1 p.m., the COC/SBAR indicated Resident 2 reported CNA 1 was rough with her, grabbed her wrist and twisted her arm, so she (Resident 2) tried to kick CNA 1 to get away from her. During an interview on 3/9/2026 at 9:56 a.m., Resident 2 stated, via CNA 1, who translated for Resident 2, on 3/1/2026 (time unknown) she was in bed and CNA 1 came to her room in a bad mood, grabbed her left arm tight and pressed her fingers into her left ankle hard. Resident 2 stated she did not think to tell anyone. During an interview on 3/9/2026 at 12 p.m., CNA 1 stated on 3/1/2026 she went into Resident 2's room to change her adult brief. Resident 2 was in bed, and she (CNA 1) rolled her from left to right while putting the adult brief on her. Resident 2 got upset and accused her (CNA 1) of grabbing her left arm and abusing her. CNA 1 stated she left the room and told LVN 3 that Resident 2 accused her of abuse. During an interview on 3/9/2026 at 12:17 p.m., CNA 2 stated she worked with CNA 1 on 3/1/2026 when Resident 2 accused her (CNA 1) of abuse. CNA 2 stated she was standing with CNA 1 when CNA 1 reported the allegation of abuse made by Resident 2 to LVN 3. During an interview on 3/9/2026 at 12:30 p.m., LVN 3 stated CNA 1 told her on 3/1/2026 that Resident 2 called her the B word and that Resident 2 was being aggressive towards her (CNA 1). LVN 3 stated she told RN 2 what Resident 1 reported to her and was told by RN 3 to change CNA 1's assignment. On 3/2/2026 (time unknown) Resident 2 told her that CNA 1 twisted her left arm on 3/1/2026 and she LVN 3) reported this allegation to the Administrator (ADM) 3/2/2026. b. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1 had diagnoses including aphasia (a disorder that makes it difficult to speak) following a cerebral infarction (where blood flow to the brain has been blocked). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. Resident 1 was dependent (helper does all the effort) on staff to complete his ADLs. During a review of Resident 1's COC/SBAR dated 3/5/2026 and timed at 11:58 a.m., the COC/SBAR indicated during the Interdisciplinary Team meeting ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) Resident 1's Family Member (FM) accused LVN 1 of lifting Resident 1's sheet, touching Resident 1's diaper, then LVN 1 placed the sheet back over Resident 1 and walked out of the room during the 11: p.m. - 7 a.m. shift on 3/4/2026. During an interview on 3/6/2026 at 10:48 a.m., Resident 1's FM stated on 3/4/2026 she was in Resident 1's room in the dark when LVN 1 came in, put her hand under Resident 1's sheet, bent over and whispered something in Resident 1's ear, LVN 1 did not see her (FM) there. Later that night (time unknown), Resident 1 told her a nurse touched him inappropriately, when LVN 1 came back to the room, she asked Resident 1 if LVN 1 was the one who touched him inappropriately, he said yes. The FM stated she used a letter board (alphabets used to spell out words) to communicate with Resident 1, when Resident 1 reported this to her, she reported the allegation to LVN 2, who told her he would report it to RN 1. During a telephone interview on 3/6/2026 at 12:45 p.m., LVN 1 stated during the beginning of the shift 11 p.m. to 7 a.m., (3/4/2026), she went to Resident 1's room to see if Resident 1 was cold and Resident 1's FM yelled at her to get out. LVN 1 stated she reported to RN 1 what the FM said to her. During a telephone interview on 3/6/2026 at 1:12 p.m., RN 1 stated on 3/4/2026 at 11:15 p.m., Resident 1's FM told her she did not want LVN 1 to take care of Resident 1 because LVN 1 stressed Resident 1 out. Later during the shift at approximately 2 a.m., Resident 1's FM told her that LVN 1 touched Resident 1's private area inappropriately. RN 1 stated she called the Director of Nursing on 3/5/2026 (time unknown) but did not get an answer back and did not report this to the DON. During an interview on 3/10/2026 at 2:46 p.m., the ADM stated he was never notified of the abuse allegation made by Resident 1's FM on 3/4/2026 until 3/5/2026 during an IDT meeting with the family. The Administrator stated he was not aware of Resident 2's allegation of abuse on 3/1/2026 until 3/2/2026. The ADM stated staff should notify him of any allegation of abuse immediately. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Neglect Exploitation or Misappropriation - Reporting and Investigating revised 9/2022, the P&P indicated if resident abuse, neglect, exploitation, misappropriation of resident's property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or resulting in serious bodily injury; or within 24 hours if an allegation that does not involve abuse or results in serious bodily injury.

Based on observation, interview, and record review the facility failed to ensure that signs were posted at the facility entrance indicating the presence of Coronavirus Disease ([COVID-19] a potentially severe respiratory illness caused by coronavirus and characterized by fever, coughing, and shortness of breath) cases in the facility. This deficient practice had the potential to increase the risk of further spreading COVID-19 to visitors, staff, family members, and the community. Findings:During an observation on 9/26/2025 at 8:08 a.m., at the facility entrance, there were no postings indicating there were COVID-19 cases in the facility. During a review of the facility's COVID-19 Line List, dated 9/2025, the Line List indicated there were two residents (Resident's 1 and 2) who tested positive for COVID-19. The Line List indicated Resident 1 tested positive on 9/23/2025 and Resident 2 tested positive on 9/25/2025. During an interview on 9/25/2025 at 9:58 a.m., the Infection Preventionist (IP) stated Resident 1 tested positive for COVID-19 on 9/23/2025 and Resident 2 tested positive on 9/25/2025. The IP confirmed that no public notifications or postings were made upon entrance to the facility to inform staff, residents, or visitors about the outbreak or the presence of COVID-19 after Resident's 1 and 2 tested positive for COVID-19.During an interview on 9/26/2025 at 2:45 p.m., the Director of Nursing (DON), stated the facility should provide COVID-19 outbreak postings to safeguard the public, staff, and visitors about the potential risk for infections upon entry in the facility. During a review of the facility's policy and procedure (P&P) titled, COVID-19 Policy, dated 5/1/2025, the P&P indicated the facility will notify residents/responsible parties of the facility COVID status as needed. The P&P indicated the facility will post visual alerts (signs, posters) at entrances and in strategic places providing instruction on hand hygiene, social distancing, etc. The P&P indicated the facility will follow CDC/CDPH guidelines, notifying residents/responsible parties of COVID cases.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1. five boxes of tea bags were stored in the dry storage area with no date and label.2. An opened Clorox disinfecting wipes stored in the dry storage area.3. Three gallons of rainbow sherbet were stored in freezer #2 with no date and label.4. Dietary Aide 1 (DA 1) did not wear hair covering in the food preparation area.These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 45 out of 80 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 7/22/2025 at 8:22 a.m., with the Dietary Service Supervisor (DSS) in the dry storage area, there were five boxes of tea bags with no date and label. The DSS stated all food items stored in the dry storage area should be labeled with received date and use by date. The DSS stated giving expired food items to resident would affect their health and safety and possible food poisoning. 2. During a concurrent observation and interview on 7/22/2025 at 8:27 a.m., with the DSS in the dry storage area, one bottle of opened Clorox disinfecting wipes was observed. The DSS stated he had no idea who placed the disinfecting wipes in the dry storage area. The DSS stated all disinfecting wipes, and chemical solution should be placed in the designated chemical room due to possible cross contamination with the food items in the dry storage area. 3. During a concurrent observation and interview on 7/22/2025 at 8:30 a.m., with the DSS in the freezer #2, found 3 gallons of rainbow sherbet was observed with no label with an open date. The DSS stated it was important to label frozen food items to know when it will be expired and to ensure the likelihood of cross contamination is reduced. 4. During a concurrent observation and interview on 7/23/2025 at 11:55 a.m., in the food preparation area with DA 1, the DA 1 was observed getting hot water in the dispenser machine with no hair covering. The DA 1 stated all staff that works in the kitchen should use a hair net in that way the hair does not go into the food and to prevent cross contamination. During a review of the facility's undated Policy and Procedure (P&P), titled Dating and Labeling, the P&P indicated, To ensure food safety and prevent contamination within the facility, all food items should be properly covered, dated, and labeled in dry storage and refrigerator/freezer areas. During a review of the facility's undated P&P titled, Storage of Canned and Dry Goods, the P&P indicated, No chemicals or cleaning products will be stored with food items. Separate storage area should be available for chemical and cleaning products. During a review of the facility's undated P&P titled, Sanitation and Infection Control, the P&P indicated, A hair net or head covering which completely covers all hair should be worn at all times.

Based on observation, interview and record review, the facility failed to implement infection control measures by failing to follow its policy regarding monitoring and documenting the temperature of laundry equipment (water temperature for washers and temperature for dryers) and logs daily.This failure had the potential to result in compromised infection control measures of the facility laundry and the spread of infection from bacteria (microorganisms that can cause infectious disease) throughout the facility.Findings:During a concurrent interview and record review on 7/25/2025, at 10:55 a.m., with Laundry Aid (LA) 1, the facility's Water Temperature Log (WTL), dated 7/2025 was reviewed. The WTL indicated, water temperature for washers 1 and 2 were 140 Fahrenheit (F-a temperature scale) from 7/1/2025 to 7/25/2025. LA 1 stated, she was not sure where 140 F was referring from. LA 1 stated, the thermometer (an instrument for measuring and indicating temperature) above the washers indicated 120 F. LA 1 stated, she did not know what type of laundry machines were in the laundry room. LA 1 stated, she did not know what water temperature range was acceptable per policy. LA 1 stated, she did not document temperature for dryers and did not know the proper temperature range for dryers.During an interview on 7/25/2025, at 11:19 a.m., with Laundry Supervisor (LS), LS stated, he was not sure, but he thought the washers were low temperature water with bleach. LS stated he did not know the proper water temperature range for washers. LS stated, he believed the temperature requirement for dryers was 180 F. LS stated, staff should have known type of equipment, proper water temperature range for washer, and proper temperature range for dryer. LS stated monitoring and documentation of the temperature was important to ensure that it was on right range to effectively kill bacteria. During a concurrent observation and interview on 7/25/2025, at 11:40 a.m., with the Maintenance Supervisor (MS), the temperature for dryers 1 and 2 were measured by MS. The temperature of dryer 1 was 120 F and the temperature of dryer 2 was 122 F with multiple tries. MS stated, he believed they are lower than requirement. MS stated, if the temperature did not reach the proper level, it would not effectively remove germs that could cause illness.During an interview on 7/25/2025, at 12:49 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated, she realized there are three different policies for laundry washer water temperature. The IPN stated that the facility should have provided the uniform and clear policy and procedure to staff. The IPN stated, washer and dryer temperature should be monitored for certain temperatures to effectively kill bacteria and germs because laundry was part of infection prevention. During a telephone interview on 7/25/2025, at 1:10 p.m. with Contracted Laundry Machine Service Company Representative (CLMSCR) 1, CLMSCR 1 stated, the facility's washers are low temperature (71F-77F) machine with chlorine. CLMSCR 1 stated that the company's washers work best when the water temperature is lower than 120 F, but the facility should develop and follow their own policy.During an interview on 7//25/2025, at 2:23 p.m., with the Director of Nursing (DON), the DON stated, monitoring the temperature was important to ensure infection prevention effectively. The DON stated, the facility should have clear policy regarding laundry policy and procedures especially monitoring water temp for washer and temp for dryer to kill microbes effectively without any confusion. The DON stated, if the temperature was out of range, the staff should reach out to contracted maintenance company to fix.During a review of the facility's Policy and Procedure (P&P) titled, Laundry Dryer Temperature, undated, the P&P indicated, Procedure: 3. C Proper drying and cool down temperature must be maintained.[NAME]: 180-190 F, Sheets and Pillowcases:160-170 F, Table Napery: 140-160 F, Blankets: 150-170 F, Diapers: 140-150 F.During a review of the facility's Policy and Procedure (P&P) titled, Laundry Water Temperature, undated, the P&P indicated, Procedure: 1. The maintenance Supervisor will maintain laundry temperature of the water within a range of 70 F to 135 F. 2. The Laundry personnel will maintain a log of daily laundry water temperatures to ensure that water is maintained at the appropriate temperature to provide proper disinfection of soiled linen.During a review of the facility's Policy and Procedure (P&P) titled, Manufacturer Suggested Operating Procedures, dated 3/2019, the P&P indicated, Verifying Bacteria Reduction (Disinfection): Water temperatures between 60 F to 130 F are used with the system, disinfection is achieved anywhere in this temperature range.During a review of the facility's Policy and Procedure (P&P) titled, Laundry System Agreement, dated 11/3/ 2023, the P&P indicated, There are three acceptable methods for processing laundry.2. Low temperature washing, in the range of 71 F-77F, with high levels of chlorine at 125 ppm.

Based on interview and record review, the facility failed to:1. Complete and transmit the Minimum Data Set ([MDS]- a resident assessment tool ) within the regulatory timeframe to the Center of Medicare and Medicaid Service (CMS) for two of two sampled residents (Resident 56 and 82). This deficient practice had the potential to result in a billing error and inaccurate data on resident care needs. Findings: A. During a review of Resident 56's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 56 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 56's diagnoses included squamous cell carcinoma (type of cancer), dysphagia (difficulty of swallowing), and malignant neoplasm of the glottis (a cancerous tumor that originates in the middle part of the voice box). During a review of Resident 56's MDS assessment, dated 3/11/2025, the MDS indicated, Resident 56's had modified independence (some difficulty in new situations only) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 56 required moderate assistance (helper does less than half the effort) from staff with oral hygiene, upper and lower body dressing, and personal hygiene. During a review of the CMS MDS 3.0 Nursing Home (NH) Validation Report, the CMS MDS 3.0 NH Validation Report, indicated Resident 56's MDS assessment was submitted more than 13 days after the entry date. During a concurrent interview and record review on 7/24/2025 at 9:42 a.m., with the Minimum Data Set Nurse (MDSN), Resident 56's MDS 5-day assessment, dated 3/11/2025 was reviewed. The MDSN stated she put Resident 56's last entry to the facility as 2/27/2025 instead of 3/7/2025. The MDSN stated she completed Resident 56's MDS assessment late because of wrong entry date. The MDSN stated Resident 56's modified assessment was completed and transmitted to the CMS on 7/23/2025. B. During a review of Resident 82's admission Record, the admission Record indicated, Resident 82 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 82's diagnoses included metabolic encephalopathy (a disorder that affects brain function), respiratory failure (a serious condition that makes it difficult to breathe on your own), and sepsis (a life-threatening blood infection). During a review of Resident 82's discharge MDS assessment, dated 8/24/2023, the MDS indicated, Resident 82's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 82 required maximum assistance (helper does more than half the effort) from staff with shower, upper and lower body dressing. During a review of the CMS MDS 3.0 NH Validation Report, the CMS MDS 3.0 NH Validation Report, indicated Resident 82's MDS assessment was submitted more than 14 days after the Assessment Reference Date ([ARD] - the specific date used as the endpoint of the observation period when assessing resident's condition). During a concurrent interview and record review on 7/24/2025 at 9:22 a.m., with the MDSN, Resident 82's discharge MDS assessment, dated 8/24/2023 was reviewed. The MDSN stated Resident 82's ARD was 8/24/2023. The MDSN stated Resident 82's discharge MDS assessment was completed late on 9/18/2023 and transmitted late to the CMS on 9/25/2023. The MDSN stated Resident 82's discharge MDS assessment should have been completed within 14 days from the ARD. The MDSN stated it is important to notify the CMS of Resident 82's discharge from the facility in a timely manner for billing and tracking purposes of resident's location. During a review of the facility's policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, dated 7/2017, the P&P indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.

Based on interview and record, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for two of 18 sampled residents (Residents 54 and 49) by failing to: 1. Ensure Resident 54 who was receiving Restorative Nursing Assistant ([RNA], nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services seven times a week and receiving splint (knee braces that improve range of motion and assist with contracture management) placement had an accurate assessment.2. Ensure Resident 49 had accurate documentation in the MDS to reflect his current tobacco use. These deficient practices resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Residents 54 and 49.Findings: 1. During a review of Resident 54’s admission Record, the admission Record indicated Resident 54 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition where the lungs are unable to adequately breath) anoxic brain damage (occurs when the brain is deprived of oxygen resulting in), tracheostomy (a surgical procedure to create an opening in the windpipe to help with breathing), and gastrotomy (plastic tube surgically placed in the stomach to provide nutrition and medication). During a review of Resident 54’s History and Physical (H&P), dated 4/8/2025, the H&P indicated Resident 54 did not have the capacity to understand and make decisions. During a review of Resident 54’s MDS dated [DATE], the MDS indicated Resident 54 was dependent (helper does all of the effort to complete the task) on self-care abilities such as oral hygiene, toileting and personal hygiene, shower/bathe self, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 54 was dependent on mobility functions such as rolling left and right, sitting to lying position, lying on side of bed, bed to chair transfers, and shower transfers. The MDS indicated Resident 54 was receiving RNA services five times a week in the last seven calendar days for passive range of motion and no splint or brace assistance. During a review of Resident 54’s Order Summary Report, the Order Summary Report indicated RNA for passive range of motion exercises ([PROME], a type of range of motion exercises that involves a helper moving a person's joint through its range of motion) on bilateral upper extremity ([BUE], both arms)/ bilateral lower extremity ([BLE], both legs) on all joints, then apply left knee extension splint, bilateral hand wrist orthotics([BHWO], wrist brace used to treat injuries and strains to the wrist, hand), bilateral elbows orthotics (devices worn on both elbows to provide support, stability, and/or controlled movement) for four to six hours every day seven times a week or as tolerated ordered on 5/13/2025. During a review of Resident 54’s Documentation Survey Report for RNA Task dated May 2025, June 2025 and July 2025, the Documentation Survey Report for RNA Task indicated Resident 54 was receiving RNA services every day, seven days a week with no missing gaps in services. During an observation on 7/22/2025 at 10:32 a.m., in Resident 54’s room, Resident 54 was receiving RNA services by RNA staff. RNA staff provided PROME on the left upper extremity ([LUE] left arm), then right upper extremity ([RUE, right arm) for 15 repetitions each. RNA staff applied splints on the right arm, and right hand, then on the left arm and then on left hand. RNA staff provided PROME on the right lower extremity ([RLE, right leg) then left lower extremity ([LLE], left leg) for 15 repetitions each, then applied a splint on the left leg. During a concurrent interview and record review on 7/25/2025 at 10:42 a.m. with MDS Nurse (MDSN), the MDS dated [DATE], the Order Summary Report and the Documentation Survey Report for RNA Task dated May 2025 were reviewed. MDSN stated the Order Summary Report and the Documentation Survey Report for RNA Task indicated Resident 54 was receiving RNA services seven times a week, but the MDS dated [DATE] indicated Resident 54 was receiving RNA services five times a week and no splint assistance was provided. MDSN stated if the MDS assessment was not coded correctly based on resident assessment, the plan of care for the residents was not accurate and care may be affected. MDSN stated the MDS assessment should be coded accurately so all facility staff are on the same page in terms of resident care and what the services resident was receiving. During an interview on 7/25/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated the MDS assessment was based on each individual resident. DON stated the MDS assessment was a document where staff should focus on the residents’ care, it was their baseline care and the MDS assessment should be accurate based on resident’s assessment. The DON stated if MDS was not accurate, it was not accurately displaying what the resident's needs are. During a review of the facility’s policy and procedure (P&P) titled Resident Assessments, dated 3/2022, indicated, a comprehensive assessment of every resident’s needs is made at intervals…. all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. During a review of the facility’s P&P titled Certifying Accuracy of the Resident Assessment, dated 11/2019, indicated any person completing a portion of the minimum data set/MDS (resident assessment instrument) must sign and certify the accuracy of that portion of the assessment….any person who completes any portion of the MDS assessment, tracking form, or corrective request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 2. During a review of Resident 49’s admission Record (front page of the chart that contains a summary basic information about the resident), the admission Record indicated, Resident 49 was admitted to the facility on [DATE]. Resident 49’s diagnoses included personal history of nicotine (a highly addictive stimulant found in tobacco and vaping devices), anemia (a condition where the body does not have enough healthy red blood cells), and abnormal posture. During a review of Resident 49’s History and Physical (H&P), dated 2/13/2025, the H&P indicated, Resident 49 could make decisions for activities of daily living. During a review of Resident 49’s Smoker Risk Assessment, dated 2/12/2025, the Smoker Risk Assessment indicated, Resident 49 required supervision from staff when smoking. During a review of Resident 49’s MDS assessment, dated 2/16/2025, the MDS indicated, Resident 49 had the ability to make self-understood and understand others. The MDS indicated, Resident 49 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene and upper and lower body dressing. During a concurrent interview and record review on 7/23/2025 at 9:40 a.m., with the Minimum Data Set Nurse (MDSN), Resident 49’s MDS assessment, dated 2/16/2025, was reviewed. The MDSN stated Resident 49’s MDS was completed inaccurately. The MDSN stated Resident 49’s MDS, Section J1300 (Current Tobacco Use) was coded 0 (No), however it should have been coded as 1 (Yes) because the resident still uses tobacco to smoke. The MDSN stated MDS assessment drives the plan of care for the resident. The MDSN stated inaccuracy of MDS assessment would lead to inefficient interventions that would be provided to the resident. During an interview on 7/25/2025 at 9:57 a.m., with the Director of Nursing (DON), the DON stated it is very important to complete MDS assessment accurately in order to meet the needs of the resident. During a review of the facility’s policy and procedure (P&P), titled “Certifying Accuracy of the Resident Assessment,” dated 11/2019, the P&P indicated, “Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment”.

Based on interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for one of three sampled residents (Resident 66), when Resident 66 was non-compliant by refusing to open his mouth for dental assessments during multiple dental staff visits.This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 66 to prevent him from achieving his highest practical well-being. Findings:During a review of Resident 66's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including tracheostomy tube (a surgical procedure that creates a small opening in the neck, inserts a tube into the windpipe to help with breathing), dependence of respirator ventilator status (a person relying on a mechanical ventilator to breathe due to impaired lung function or respiratory muscle weakness), and gastrostomy (surgically created opening into the stomach for the insertion of a feeding tube, known as a gastrostomy tube [G-tube]).During a review of Resident 66's History and Physical (H&P) dated 4/25/2025, the H&P indicated Resident 66 does not have the capacity to understand and make decisions.During a review of Resident 66's Minimum Data Set ([MDS], a resident assessment tool) dated 4/11/2025, the MDS indicated Resident 66 was dependent (helper does all the effort to complete the task) on self-care abilities such as oral hygiene, toileting and personal hygiene, shower/bathe self, upper and lower body dressing, and putting on/taking off footwear. The MDS also indicated Resident 66 was dependent on mobility functions such as rolling left and right, sitting to lying position, lying on side of bed, bed to chair transfers, and shower transfers.During a review of Resident 66's Dental Consult Note dated 1/6/2025, the dental consult note indicated not able to do, resident could not follow instructions to open mouth.During a review of Resident 66's Dental Consult Note dated 4/7/2025, the dental consult note indicated Resident 66 was on a tracheotomy tube with very limited function and cooperation, very difficult to gain access to mouth due to resident clenches/shut the mouth tight.During a review of Resident 66's untitled care plan dated 1/16/2025, the untitled care plan did not indicate a refusal or noncompliance to the dental treatment and services from dental staff.During an interview on 7/25/2025 at 10:07 a.m., with the Director of Staff Development (DSD), the DSD stated care plan was how the facility staff provide the care needed for the residents. The DSD stated if residents refuse any type of care, or if residents were noncompliant with care, it should be added to their care plan. The DSD stated any noncompliance with care would alert staff of the refusal, and the care plan should be updated and revised. The DSD stated if a resident refused oral and/or dental care, it should be care planned.During an interview on 7/25/2025 at 2:23 p.m. with the Director of Nursing (DON), the DON stated the importance of a care plan was to meet the residents' needs. The DON stated the care plan should be individualized and personalized. The DON stated if residents were non-compliance with their care, there should be a care planned for the refusal of care so facility staff are aware, and the interventions can be revised.During a review of the facility's policy and procedures (P&P) titled Care Plan, Comprehensive Person-Centered, dated 3/2023, indicated, a comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.the interdisciplinary team ([IDT], a collaborative gathering of healthcare professionals from various disciplines to discuss and coordinate patient care, ensuring a holistic approach to treatment), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.when possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.assessments of residents are ongoing an care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review the facility failed to ensure medications, syringes, hand sanitizers and wound cleanser were not stored beyond their expiration dates in one of one disaster boxes (a container filled with emergency supplies e.g., medications, flashlights, extension cords, items for use in case of an emergency) stored in the Station 1 medication room.This deficient practice had the potential to result in the administration or use of expired medications and products, which had reduced effectiveness and the protentional to cause adverse effects to residents. Findings: During an observation on 7/23/2025 at 2:45 p.m., in the Station 1 medication room a disaster box the following expired items were found: 1 . Medline Acetaminophen bottle 100 tablets - expiration date 20022. Walgreens Ibuprofen bottle 100 tablets - expiration date 20213. [NAME] wound cleanser - expiration date 20224. 25 Medline Insulin syringes - expiration date 20245. 25 Medline spectrum 4oz hand sanitizers - expiration date 2019During an interview on 7/23/2025 at 2:45 p.m., with Licensed Vocational Nurse (LVN), LVN 1 stated, the expired items should not be in our disaster box, they could be given to a resident by mistake. During an interview on 7/25/2025 at 9:49 a.m., with the Director of Nursing (DON), the DON stated, expired medications are not given to residents.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated March 2023, the P&P indicated, outdated or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy and destructed as indicated.

Based on observation, interview, and record review, the facility failed to label and properly disposed discontinued medications per the facility's policy.This deficient practice had the potential to result in the residents accidentally ingesting unknown medications and increased the risk of diversion (any use other than that intended by the prescriber) of unknown medications.Findings:During a concurrent observation and interview on [DATE], with Licensed Vocational Nurse (LVN) 4, in medication storage room for station 1 and 2, there was an unlocked discontinued medication storage cabinet observed with 24 opened and unlabeled medications in a plastic cup inside of the cabinet. There was no pharmaceutical waste bin (a container, often color-coded, designed for the safe disposal of unused, expired, or contaminated medications) observed nearby. LVN 4 stated that all discontinued medications should be labeled and disposed of in blue pharmaceutical waste bins for safety to prevent accidental ingestion. LVN 4 stated, the license staff only document when the discontinued medications were disposed of with two witnesses, but the staff would not know what medications were in the discontinued medication cabinet. LVN 4 stated that the medications were disposed twice a week by night shift nurses.During an interview on [DATE], at 12:39 p.m., with the Director of Staff Development (DSD), the DSD stated, all medications should be labeled. The DSD stated that discontinued and unused medications should be discarded with proper pharmaceutical waste bins as soon as possible to prevent accidental ingestion or misuse. The DSD stated, if the medications cannot be discarded immediately, the staff should document and place them in a locked place for safety.During an interview on [DATE], at 2:53 p.m., with the Director of Nursing (DON), the DON stated that all discontinued medications should be documented when they are brought into discontinued medication cabinet, so the licensed staff knows which medications to discard. The DON stated, all medications should be labeled and not placed in a plastic cup. The DON stated that the staff should have disposed of discontinued medications in pharmaceutical waste bins to prevent accidental ingestion. The DON stated the discontinued medication cabinet should be locked in a safe place. During a review of the facility's Medication Disposition Record Log (MDRL), dated 7/2025, the MDRL indicated, there was no record of the 24 opened and unlabeled medications in a plastic cup.During a review of the facility's Policy and Procedure (P&P) titled, Storage of Medications, revised 3/2023, the P&P indicated, Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destructed as indicated.6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.During a review of the facility's Policy and Procedure (P&P) titled, Discarding and Destroying Medications, revised 4/2019, the P&P indicated, Policy Interpretation and Implementation: 6. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste fol1owing the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance.d. Document the disposal on the medication disposition record. e. Include the signature(s) of at least two witnesses. 10. The medication disposition record will contain the following information: a. The resident's name: b. Date medication disposed; c. The name and strength of the medication; d. The name of the dispensing pharmacy; e. The quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses.During a review of the facility's Policy and Procedure (P&P) titled, Labeling of Medication Containers, revised 3/2023, the P&P indicated, Policy Interpretation and Implementation: 1. Medication labels must be legible at all times. 2. Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received treatment and care in accordance with professional standards of practice by failing to ensure Resident 2 was not administered Carvedilol (used to treat high blood pressure) when Resident 2's systolic blood pressure (SBP) was less than 110 and when heart rate (HR) was lower than 60 beats per minute (BPM) as ordered by physician. This deficient practice had the potential to cause Resident 2 hypotension (blood pressure is too low) with dizziness and fainting which can lead to fall and injuries. Findings: During a review of Resident 2's admission Record dated 3/17/2025, the admission record indicated the resident was admitted to the facility on [DATE], and was readmitted on [DATE], to the facility with diagnoses of, but not limited to, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Atrial-Fibrillation (an irregular heartbeat, or arrhythmia that can lead to blood clots, stroke, heart failure and other heart-related complications). During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 2's cognition (thought process) was moderately impaired. The MDS indicated Resident 2 required substantial/maximal assistance partial (helper does more than half the effort) from staff for activities of daily living (ADL's - routine tasks/activities such as bathing, dressing, toileting a person performs daily to care for themselves). During a review of Resident 2's physician orders dated 7/1/2025, indicated to administer Carvedilol 25 milligrams (mg) by G-tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) two times a day for hypertension (HTN-high blood pressure) hold if systolic blood pressure is less than 110 or heart rate is less than 60 During a review of Resident 2's medication administration record (MAR) dated 7/17/2025 at 5:00 p.m., it indicated that the resident had a heart rate reading of 59 but Carvedilol was administered. On 7/18/2025 at 5 p.m., heart rate reading was 58 but carvedilol was administered. On 7/22/2025 at 5 p.m., SBP 102 but carvedilol was administered. During an interview with Licensed Vocational Nurse 5 (LVN 5) on 7/24/2025, at 2:10 p.m., LVN 5 stated the license nurse should have held the medication as ordered by physician. During a review of facility's policy and procedure (P&P) titled, Administering Medications dated 3/2023, indicated that vital signs if necessary are to be obtained prior to administration of medications.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 73) was informed of the dental treatment recommendation for tooth extraction (the process of removing a tooth from its socket in the jawbone).This deficient practice violated Resident 73's rights to be fully informed and had the potential to result in delay of care and services. Findings: During a review of Resident 73's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 73 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 73's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent unprovoked seizures), hypertension ([HTN] - high blood pressure), and congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 73's History and Physical (H&P), dated 5/29/2025, the H&P indicated, Resident 73 had the capacity to understand and make decisions.During a review of Resident 73's Minimum Data Set ([MDS] - a resident assessment tool), dated 7/3/2025, the MDS indicated, Resident 73 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 73 required moderate assistance (helper does less than half the effort) from staff with oral hygiene and upper body dressing. During a review of Resident 73's Dental Notes, dated 6/30/2025, the Dental Notes indicated, Resident 73 was evaluated because of molar (a large, flat tooth located at the back of the mouth, used for grinding and chewing food) pain. The Dental Notes indicated, treatment recommendation for X (extraction) B (buccal-outer surface of the tooth, facing the cheek). During a review of Resident 73's Interdisciplinary Note Team([IDT] - team members from different disciplines who come together to discuss resident care), dated 7/14/2025, the IDT Note did not indicate Resident 73 was notified of the dental treatment recommendation for tooth extraction. During an interview on 7/22/2025 at 10:53 a.m. with Resident 73, Resident 73 stated she was seen by the dentist one month ago because of her toothache. Resident 73 stated no facility staff have told her about the plan of the dentist. Resident 73 stated she wants the dentist to remove her tooth that causes discomfort. During a concurrent interview and record review on 7/23/2025 at 2:46 p.m., with the Social Service Director (SSD), Resident 73's clinical records were reviewed. The SSD stated she was aware of the dental treatment recommendation for tooth extraction for Resident 73. The SSD stated she informed Resident 73 about the dental treatment recommendation but did not document it. The SSD stated if it's not documented then it was not done. The SSD stated it is a violation of resident's rights by not informing the resident about the dental treatment recommendation. The SSD stated each resident has the right to be informed of any changes on their plan of care. During an interview on 7/25/2025 at 10:01 a.m., with the Director of Nursing (DON), the DON stated resident has the right to be involved in their plan of care. The DON stated any procedure or changes on resident's treatment plan should be discussed during the IDT meeting care conference. During a review of the facility's policy and procedure (P&P), titled Resident Rights, dated 2/2021, the P&P indicated, Federal and State laws guarantee certain basic rights to all residents of this facility that includes the right to be notified of his or her medical condition and be informed and participate in her care planning and treatment.

Based on observation, interview, and record review, the facility failed to ensure residents on tube feeding received treatment and care in accordance with professional standards of practice by failing to:1. Elevate the head of the bed while receiving formula through the gastrostomy tube ([GT] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of three sampled residents (Resident 40). This deficient practice had the potential to cause aspiration (inhalation of foreign materials) that could lead to pneumonia (lung infection) for Resident 40. Findings:During an observation on 7/22/2025 at 10:13 a.m. in Resident 40's room, Resident 40's was in bed lying flat on her back while the TF was running.During a review of Resident 40's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 40 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included GT placement, chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures).During a review of Resident 40's History and Physical (H&P), dated 1/29/2025, the H&P indicated, Resident 40 did not have the capacity to understand and make decisions.During a review of Resident 40's Minimum Data Set ([MDS] - a resident assessment tool), dated 6/19/2025, the MDS indicated, Resident 40's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). ). The MDS indicated, Resident 40 was totally dependent (helper does all of the effort) from staff with oral hygiene, lower and upper body dressing, and personal hygiene. The MDS indicated, Resident 40 was on tube feeding. During a review of Resident 40's Order Summary Report (a document containing active orders), dated 7/24/2025, the Order Summary Report indicated Resident 40 had tube feeding order of Peptamen (type of tube feeding formula) 1.5 kilocalorie ([kcal] - unit of measurement) at 50 cubic centimeters ([cc] - unit of volume) per hour for 20 hours to provide 1000cc/1500 kcal per day. The Order Summary Report indicated to observe aspiration precaution and elevate head of bed at 30 to 45 degrees (a unit of measurement for angles) at all times during GT feeding. During a concurrent observation and interview on 7/22/2025 at 10:23 a.m., with Licensed Vocational Nurse 3 (LVN 3), in Resident 40's room, Resident 40 was observed receiving GT feeding of Peptamen 1.5 at 50 cc/hour. LVN 3 stated Resident 40's head of bed was only 10 degrees. LVN 3 stated as standard of practice the head of bed should be elevated at 30 to 45 degrees while tube feeding is running. LVN 3 stated by not elevating the head of bed at least 30 degrees, Resident 40 is at risk for aspiration pneumonia that would likely require hospitalization. During a review of the facility's policy and procedure (P&P), titled Enteral Feedings - Safety Precautions, dated 11/2018, the P&P indicated, The facility will remain current and follow accepted best practices in enteral nutrition. The P&P also indicated to prevent aspiration, elevate the head of bed at least 30 degrees during tube feeding and at least 1 hour after feeding.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 2), had monitoring for complications related to Xarelto (an anticoagulant medication used to treat and prevent harmful blood clots) a medication that may increase the risk of bleeding. This deficient practice placed Resident 2 at risk of bleeding a possible side effect of anticoagulant medication. Findings: During a review of Resident 2's admission Record dated 3/17/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Atrial-Fibrillation (an irregular heartbeat, or arrhythmia that can lead to blood clots, stroke, heart failure and other heart-related complications). During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 2's cognition (thought process) was moderately impaired. The MDS indicated Resident 2 required substantial/maximal assistance partial (helper does more than half the effort) from staff for activities of daily living (ADL's - routine tasks/activities such as bathing, dressing, toileting a person performs daily to care for themselves). During a review of Resident 2's medication administration record (MAR) for the month of 7/1/2025, the MAR indicated Resident 2 has been receiving Xarelto 20 milligrams since 6/25/2025. During a concurrent record review and interview on 7/24/2025, 11:10 a.m. with Licensed Vocational Nurse 5 (LVN 5), stated Resident 2 did not have monitoring for adverse consequences and potential risk associated with medication and LVN 5 stated should have been started when medication was initiated because Xarelto can cause bruising and bleeding. During a review of the facility's policy and procedure (P&P) title, Anticoagulant/Antiplatelet with administration of Xarelto Resident 2 should have been monitored daily for signs and symptoms of bleeding.

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 60) received appropriate services, did not acquire a decline (reduction) in range of motion (ROM, full movement potential of a joint) and did not develop a contracture (chronic loss of joint motion associated with deformity and joint stiffness) to both hands and both wrists. The facility failed to: 1. Provide appropriate monitoring of Resident 60's ROM on a quarterly basis to determine any changes in ROM in accordance with the facility's policy titled Joint Mobility Assessment, ([JMS] a brief assessment of a resident's ROM in both arms and both legs) which indicated, all residents shall be assessed for joint mobility limitations upon admission and reviewed every three months thereafter. 2. Ensure Restorative Nursing Assistant ([RNA 1] certified nursing aide program that helps residents to maintain their function and joint mobility) reported Resident 60's decline in ROM during restorative program ( nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible ) sessions to the charge nurse (a licensed nurses in charge) in accordance with the facility's job description titled, Restorative Nursing Assistant. 3. Provide Resident 60 with passive range of motion ([PROM] a movement of a joint through the ROM with no effort from resident) exercises to both arms daily from March 2023 to October 2023 per physician's order and in accordance with the Occupational Therapy ([OT], profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) discharge recommendation made on 3/3/2023. 4. Ensure RNA 1 did not modify Resident 60's splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to both hands without notifying OT. These deficient practices resulted in Resident 60 developing contractures to both hands and both wrists, causing pain and placing Resident 60 at risk for physical, emotional, and psychosocial decline. Resident 60 was placed at risk to have a decline in ROM, improper fitting splints, ineffective interventions to maintain ROM, pain, and skin breakdown. Findings: During a review of Resident 60's Admission Record, the Admission Record indicated Resident 60 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and traumatic brain injury (damage to the brain from an external force that can cause temporary or permanent changes in brain function). During a review of Resident 60's OT's Joint Mobility Screening ([OT JMS, a brief joint mobility assessment of a resident's ROM in both arms and both legs completed by an OT), dated 1/5/2023, the OT JMS indicated Resident 60 had full PROM in both wrists, hands, fingers, and elbows and had moderate (26-50 percent [%] ROM loss) ROM limitations in both shoulders. During a review of Resident 60's OT's Evaluation and Plan of Treatment (OT Eval), dated 1/8/2023, the OT Eval indicated Resident 60's ROM in both elbows, forearms, wrists, and hands were within functional limits ([WFL]a sufficient movement without limitation). The OT Eval indicated Resident 60 had no contractures in both arms and was at risk for contracture development. During review of OT's Discharge Summary dated 3/3/2023, the OT's Discharge Summary indicated the OT recommended for Resident 60 to have RNA to provide PROM exercises to both arms and apply splints to both elbows, four to six hours daily or as tolerated. During a review of Resident 60's Order Summary Report, the Order Summary Report indicated a physician's order, dated 3/3/2023, for RNA to provide PROM exercises to Resident 60's both arms and both legs and apply splints to both elbows, four to six hours daily or as tolerated. During a review of Resident 60's RNA Survey Report (record of nursing assistant tasks) for March 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X (resident was not seen for RNA treatment that day) on the following days: 3/4/2023, 3/5/2023, 3/11/2023, 3/12/2023, 3/18/2023, 3/19/2023, 3/25/2023, and 3/26/2023. During a review of Resident 60's RNA Survey Report for April 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023, and 4/30/2023. During a review of Resident 60's RNA Survey Report for May 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 5/6/2023, 5/7/2023, 5/13/2023, 5/14/2023, 5/20/2023, 5/21/2023, 5/27/2023, 5/28/2023. During a review of Resident 60's RNA Survey Report for June 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 6/3/2023, 6/4/2023, 6/10/2023, 6/11/2023, 6/17/2023, 6/18/2023, 6/24/2023, and 6/25/2023. During a review of Resident 60's RNA Documentation Survey Report for July 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 7/1/2023, 7/2/2023, 7/8/2023, 7/9/2023, 7/15/2023, 7/16/2023, 7/22/2023, 7/23/2023, 7/29/2023, and 7/30/2023. During a review of Resident 60's RNA Survey Report for August 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 8/5/2023, 8/6/2023, 8/12/2023, 8/13/2023, 8/19/2023, 8/20/2023, 8/26/2023, and 8/27/2023. During a review of Resident 60's RNA Survey Report for September 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 9/2/2023, 9/3/2023, 9/9/2023, 9/10/2023, 9/16/2023, 9/17/2023, 9/23/2023, 9/24/2023, and 9/30/2023. During a review of Resident 60's RNA Survey Report for October 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The square on the RNA Survey Report was blank on 10/2/2023. The squares on the RNA Survey Report had the letter X on the following days: 10/1/2023, 10/7/2023, 10/8/2023, 10/14/2023, 10/15/2023, 10/21/2023, 10/22/2023, 10/28/2023, and 10/29/2023. During a review of Resident 60's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 7/11/2024, the MDS indicated Resident 60 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 60 was dependent (full staff performance) on staff with eating, oral hygiene, toilet hygiene, bathing, dressing, rolling to both sides, and transfers (moving from one surface to another). The MDS indicated Resident 60 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During a review of Resident 60's Annual OT JMS, dated 1/28/2024, the OT JMS indicated Resident 60 had severe (greater than 50 % ROM loss) ROM limitations in both wrists, both hands, both fingers, and both shoulders. The OT JMS indicated Resident 60 had minimal (less than 25% ROM loss) ROM limitations in both elbows. The OT JMS indicated Resident 60 had a minimal to severe loss of PROM to both arms and recommended a skilled OT evaluation. During a review of Resident 60's OT Eval, dated 1/30/2024, the OT Eval indicated Resident 60 was referred to OT services due to a decline in ROM and strength of both arms. The OT Eval indicated Resident 60 had contractures in both arms which affected Resident 60's functional skills (basic or everyday skills necessary for daily living) and required skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant) to address the contractures. The OT Eval indicated Resident 60's ROM in the right arm was impaired at the shoulder, elbow, forearm, wrist, and hand. The OT Eval indicated Resident 60 had a right claw hand contracture (condition of the hand where the fingers of the hand are in a hyperextended position [the extension of a body part beyond it's normal limits] at the knuckle joints and bent at the fingertips) and had zero degrees of PROM (normal is 70 to 90 degrees ROM) at the right wrist in an upward position. The OT Eval indicated Resident 60's ROM in the left arm was impaired at the shoulder, wrist, and hand. The OT Eval indicated Resident 60 was unable to straighten the fingers of the left hand and indicated a two-inch gap between the fingertips of the left hand and crease in the palm of the hand. The OT Eval indicated Resident 60 had zero degrees of PROM at the left wrist into an upward position. The OT Eval indicated OT recommended Resident 60 wear splints to both hands. During a concurrent observation and interview on 8/20/2024 at 10:43 a.m., in Resident 60's room, Resident 60 was lying in bed. Resident 60's right arm was held out in front of her body at shoulder level with the elbow bent, wrist fully bent in a downward position, and fingers of the hand in a hyperextended (the extension of a body part beyond it's normal limits) position at the knuckles with the fingertips bent. Resident 60's left arm moved upwards to shoulder height, the elbow was slightly bent, and the hand was partially closed with the fingers bent at the knuckles and the fingertips. Resident 60 was observed shouting and asking for staff to assist in wrapping her right arm in a towel. Resident 60 stated she wanted her right arm wrapped in a towel because her arm was in pain, liked the warmth the towel provided to help with the pain, and needed the towel wrapped around the right forearm so she could use it to wipe her mouth since her both hands does not work. Licensed Vocational Nurse (LVN 5) was observed entering the room and wrapping Resident 60's right arm with a towel. LVN 5 stated Resident 60 constantly asked for her right arm to be wrapped in a towel and was unsure why. LVN 5 stated she thought Resident 60 liked her arm wrapped because the right arm was painful, and it helped her wipe her mouth since she could not bring her forearm to her mouth. LVN 5 stated Resident 60 was unable to use both hands for activities of daily living (ADLs, basic activities such as eating, bathing, and dressing) because they were contracted and required total care for mobility and ADLs. During an interview with RNA 1 on 8/20/2024 at 12:59 p.m., RNA 1 stated the Director of Nursing (DON), all available RNAs, and the Director of Rehabilitation (DOR) met monthly to discuss any concerns with residents receiving RNA services, including if any resident experienced a decline in ROM or mobility. RNA 1 stated any concerns or declines observed during RNA sessions should be immediately reported to charge nurse and the Rehabilitation Department (Rehab) for re-assessment. During an interview with the DOR on 8/20/2024 at 1:49 p.m., the DOR stated the facility monitored residents for changes and declines in ROM by JMS conducted upon admission and quarterly by the rehab department and quarterly by the MDS nurses along with report from staff of any observed changes or declines. The DOR stated the DOR, RNAs, Director of Staff Development (DSD), and the DON met monthly to discuss any concerns (in general) with residents receiving RNA services, including any declines, changes, or problems requiring re-assessment or intervention. During an observation of RNA session with Resident 60 in Resident 60's room on 8/21/2024 at 10:53 a.m., the resident was lying in bed with her right arm wrapped in a towel covering the hand, wrist, forearm, elbow, and lower half of the upper arm. Resident 60's right arm was held out in front of her body with the right elbow bent and the wrist bent downwards. Resident 60's left arm was resting at the side of her body with the elbow slightly bent, the wrist straight, and the fingers of the hand bent into a fist position. RNA 1 was observed attempted to assist Resident 60 with PROM exercises to the right arm, but Resident 60 reported increased pain and refused exercises. RNA 1 moved to the left side of the bed and provided PROM exercises to Resident 60's left shoulder, elbow, wrist, and hand. RNA 1 was unable to straighten all of Resident 60's fingers on the left hand and moved the left wrist in small motions side to side. Resident 60 stated she had pain with PROM exercises to the left wrist and hand with exercises. RNA 1 was observed attempted to place a hand splint (splint secured from the hand to the forearm to position the hand and wrist in a functional position) onto Resident 60's left arm but Resident 60 refused and stated the splint hurt. RNA 1 observed to bend the left-hand splint at the wrist and removed a cylindrical portion of the splint that supported the fingers of the hand. Resident 60 agreed to wear left hand splint after it was modified by RNA 1. RNA 1 placed the modified hand splint on Resident 60's left arm by securing the splint with straps around the wrist and forearm. The left-hand splint was observed not straightening or supporting the fingers of the hand. RNA 1 observed moved to the right side of the bed and tried to place a hand splint on Resident 60's right arm. Resident 60 refused and stated she wanted the cylindrical piece of the splint that supported the fingers removed because it hurt her hand. RNA 1 removed the cylindrical piece of the right-hand splint and placed it onto Resident 60's right arm by securing the splint with straps around the wrist and forearm. Observed the right-hand splint not straightening or supporting the fingers of the right hand. During an interview on 8/21/2024 at 11:15 a.m. RNA 1 stated Resident 60 had been occasionally complaining of pain in both hands and wrists during exercises and when trying to place splints on both hands for a long time but did not recall when it started. RNA 1 stated he modified both hand splints by bending the wrist portion of the left-hand splint and removing the cylindrical portion of both splints that stretched the fingers because Resident 60 was unable to tolerate the stretch the splints provided due to tightness and pain in both hands and wrists. RNA 1 stated he had been providing exercises to Resident 60's both arms since last year and noticed both hands and wrists were intermittently (irregular intervals) getting tighter and more painful with exercises. RNA 1 stated he did not report the changes in Resident 60's ROM to a charge nurse. RNA 1 stated he should have informed the charge nurse and DOR and should have discussed the decline in Resident 60's ROM of both hands and both wrists in the RNA monthly meetings but did not. RNA 1 stated he thought he told the DOR at some point but was unsure and stated he had no documented evidence to indicate the charge nurse or DOR was informed of Resident 60's ROM changes. RNA 1 stated he should not have modified the splints without notifying the DOR. RNA 1 stated he should have stopped trying to put the splints on Resident 60's both hands when they did not fit properly and Resident 60 complained of pain, notified the Rehab Department (Rehab), and waited for the OT to reassess the resident to check for any changes and modify the splints if needed. RNA 1 stated if RNAs modified splints without notifying the licensed therapist (OT), the resident could potentially be harmed since RNAs did not have the proper training and qualifications to modify splints and determine the type of splint a resident need. During an interview on 8/21/2024 at 11:50 a.m., the DOR who, was an OT, confirmed OT fitted and issued a hand-splints to Resident 60. The DOR stated the purpose of splints was for contracture management and to increase ROM. The DOR stated Rehab issued splints to residents in the facility. The DOR stated the licensed therapist assessed the resident to determine the appropriate type of splint, set goals to determine if a resident tolerated the splint, established the splint wear schedule (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits), and eventually transitioned the resident to the RNA program. The DOR stated if the splints prescribed by the therapist were no longer fitting appropriately or no longer tolerated by the resident due to issues such as pain, the RNA should inform Rehab department, and charge nurse for OT to re-assess the resident splint. The DOR stated licensed therapists were the only staff members who should modify splints. The DOR stated she was unaware Resident 60 had a decline in ROM in both wrists and hands and was not informed by RNA Resident 60's hand splints were not fitting appropriately. The DOR stated if RNAs modified splints without notifying Rehab, the splint may not fit appropriately, and the splinting intervention may not be effective. During an interview on 8/21/2024 at 12:04 p.m. the Director of Staff Development (DSD) stated the facility monitor residents for changes in ROM by the JMS's conducted by Rehab and nursing, communication with the RNAs in the monthly RNA meetings, and reports from any staff of any noticeable changes or declines in function. The DSD stated RNAs must notify the charge nurse of any changes in a resident's function such as increased pain, decrease in ROM, or if a splint was not fitting correctly to ensure the proper protocol was followed to ensure the resident received the appropriate treatment. The DSD stated RNAs were not allowed to modify splints because RNAs did not have the qualifications or training to determine the type of splint the residents needed. The DSD stated if a splint was not fitting correctly, it could indicate an area of concern that may require re-assessment. The DSD stated if RNAs modified splints without notifying Rehab department, it could cause skin breakdown and decline in ROM leading to further contracture development. The DSD stated once the charge nurse was notified, the charge nurse will complete a Change of Condition ([COC] a major decline or improvement in a resident's status that will not resolve itself without intervention) evaluation and notify the physician and licensed therapist for re-assessment. During a concurrent interview and record review of Resident 60's clinical record with the DOR on 8/21/2024 at 2:59 p.m., the DOR stated Resident 60 was admitted to the facility on [DATE] with no ROM limitations and no contractures to both wrists, hands, and fingers. The DOR reviewed Resident 60's Admission OT JMS, dated 1/5/2023, and confirmed Resident 60 had full ROM of both wrists, hands, and fingers. The DOR reviewed Resident 60's OT Eval, dated 1/8/2023, and confirmed Resident 60 had WFL ROM on both elbows, wrists, and hands which meant Resident 60 had sufficient ROM to perform ADLs. The DOR reviewed Resident 60's OT Discharge Summary, dated 3/3/3023, and stated Resident 60 was discharged from OT services with recommendations for an RNA program for PROM to both arms and application of splints to both elbows for four to six hours, daily. The DOR stated daily meant seven times a week. The DOR stated she recommended elbow splints to both arms at the time of discharge from OT services because Resident 60 had tightness from increased muscle tone (amount of tension in the muscles) in both elbows. The DOR stated any additional splinting to both arms were unnecessary because Resident 60 had no ROM limitations to both wrists and both hands at the time. The DOR reviewed Resident 60's Annual OT JMS, dated 1/28/2024, and confirmed Resident 60 had severe ROM limitations in both wrists and both hands and recommended an OT evaluation for skilled therapy services. The DOR reviewed Resident 60's OT evaluation, dated 1/30/2024, and confirmed Resident 60 had contractures to both hands and both wrists and recommended resting hand splints to both hands for contracture management. The DOR stated Resident 60 had a decline in ROM and developed contractures to both hands and both wrists while in the facility. The DOR stated she was never notified by RNA or nursing staff of any declines in Resident 60's ROM of both arms. The DOR stated Resident 60's contractures to both hands and both wrists could have been prevented if nursing staff or RNA notified Rehab once they noticed a decline in Resident 60's ROM and if there were more frequent JMSs conducted to detect declines in ROM since Rehab only performed JMSs upon admission and annually. During a concurrent interview and record review of Resident 60's clinical record with the DSD on 8/22/2024 at 2:03 p.m., the DSD stated the purpose of RNA services was to maintain a resident's current functional ability and prevent any declines in ADLs, mobility, and ROM. The DSD reviewed Resident 60's physician's orders and RNA Survey Reports for the months of March 2023 to October 2023. The DSD confirmed Resident 60 had physician's orders for RNA to provide PROM exercises to both arms and apply splints to both elbows, four to six hours daily, from March 2023 to October 2023. The DSD stated daily meant seven times a week. The DSD stated a blank square and the letter X on the RNA Survey Report indicated the resident was not seen for RNA treatment that day. The DSD confirmed Resident 60 missed the following number of scheduled RNA services for the following months: 1. Nine days for the month of March 2023. 2. Ten days for the month of April 2023. 3.Eight days for the month of May 2023, 4. Eight days for the month of June 2023. 5. Ten days for month of July 2023. 6. Eight days for the month of August 2023, 7. Nine days for the month of September 2023. 8. Ten days for the month of October 2023. The DSD stated Resident 60 did not receive RNA treatments as ordered by the physician for unknown reasons. The DSD stated it was important for RNA to provide services as prescribed by the physician because missed treatments could place residents at risk for a functional decline and contractures. During a concurrent interview and record review on 8/23/2024 at 10:39 a.m., with the Minimum Data Set Nurse (MDSN) on 8/23/2024 at 10:39 a.m., Resident 60's clinical record was reviewed. The MDSN stated the facility monitor for changes in joint ROM through JMSs performed by nursing and Rehab. The MDSN stated Rehab performed a detailed JMS of a resident's arms and legs upon admission and annually. The MDSN stated the MDSN and Minimum Data Set Assistant performed quarterly JMSs to assess a resident's general ROM in both arms and both legs to check for declines and checked the effectiveness of the services the resident was receiving such as RNA or skilled therapy. The MDSN stated any declines in ROM found in the nursing quarterly JMS were reported to Rehab for further assessment and a COC process would be initiated. The MDSN reviewed Resident 60's clinical record and confirmed no nursing quarterly JMS to monitor for ROM declines were conducted for Resident 60 between Resident 60's admission on 1/4/2023, on OT JMS, dated 1/4/2024, and the annual OT JMS, dated 1/28/2024. The MDSN stated Resident 60 should have had nursing quarterly JMSs to check Resident 60's ROM declines and completed in the months of 4/2023, 7/2023, and 10/2023 but did not. The MDSN stated the only JMSs Resident 60 received in the year of 2023 was by the Rehab upon admission (1/4/2023) and was not monitored quarterly throughout the year per facility policy. The MDSN stated the facility had three opportunities in 2023 when the nursing quarterly JMSs were due to detect a decline in Resident 60's arms and check if the current RNA program was effective but did not because the quarterly nursing JMSs were not done. The MDSN stated it was important to complete JMSs upon admission, quarterly, and annually to monitor for any declines in ROM and to ensure the facility could identify and provide the appropriate services the resident needs. The MDSN stated if joint ROM was not monitored routinely, the resident could have a functional decline and develop contractures. During a concurrent interview and record review on 8/23/2024 at 1:11 p.m., the DON stated the facility monitor for changes in ROM by multiple JMSs performed by nursing or Rehab upon admission, quarterly, and annually and by staff observation and report of any declines to the appropriate staff. The DON stated any change of condition noticed during routine nursing care or during RNA sessions such as a decline in ROM must be reported to the charge nurse who then completed a COC evaluation and notified the physician and licensed therapist for re-assessment. The DON reviewed Resident 60's Admission OT JMSs, dated 1/5/2023, and confirmed Resident 60 had full ROM of both wrists, hands, and fingers upon admission to the facility. The DON reviewed Resident 60's OT Evaluation, dated 1/8/2024, and confirmed Resident 60 had WFL ROM in both elbows, wrists, and hands upon admission to the facility. The DON reviewed Resident 60's OT Discharge Summary, dated 3/3/3023, and confirmed Resident 60 was discharged from OT services with recommendations for an RNA program for PROM to both arms and application of splints to both elbows for four to six hours, daily. The DON stated daily meant Resident 60 should be receiving RNA services seven times a week. The DON reviewed Resident 60's RNA Survey Reports from March 2023 to October 2023 and confirmed Resident 60 did not receive RNA services 7 days a week as ordered from March 2023 to October 2023. The DON reviewed Resident 60's Annual OT JMS, dated 1/28/2024, and confirmed Resident 60 had severe ROM limitations in both wrists and both hands and a skilled OT evaluation was recommended. The DON reviewed Resident 60's OT Eval, dated 1/30/2024, and confirmed Resident 60 had contractures to both hands and both wrists and OT recommended hand splints to both hands for contracture management. The DON reviewed Resident 60's clinical record and confirmed no quarterly JMSs were completed by nursing or the Rehab to monitor for ROM declines between the admission, OT JMS, dated 1/4/2024, and the annual OT JMS, dated 1/28/2024. The DON stated Resident 60 had a decline in ROM and developed contractures to both hands and wrists while in the facility. The DON stated she was never notified by RNA or nursing of any declines in Resident 60's ROM of both arms. The DON stated RNA should have notified the change nurse or discussed Resident 60's decline in ROM in the monthly RNA meetings to ensure a COC was completed, the physician was notified, and OT re-assessed Resident 60 to ensure the proper interventions were provided to prevent the contractures. The DON stated the quarterly JMSs should have been done every three months after admission to monitor for declines in ROM and ensure the appropriate services were provided to prevent contractures but were not done. The DON stated the facility could have caught the decline in ROM of Resident 60's both hands and both wrists earlier if quarterly JMSs were done and could have prevented the contractures. The DON stated the development of Resident 60's both wrists and both hands contractures was avoidable. The DON stated Resident 60's contractures could have been prevented if RNA reported the decline in Resident 60's ROM to both hands and both wrists to the charge nurse, if the quarterly JMSs were completed to monitor for ROM declines, and if RNA provided RNA services for PROM and splinting seven times a week as ordered by the physician. During an interview on 8/23/2024 at 1:11 p.m., the DON stated Rehab assessed and issued splints to the residents in the facility. The DON stated Rehab was the only staff in the facility who should modify splints since it was their expertise. The DON stated Rehab assessed splints specific to each resident and determined the appropriateness of the splint, resident's tolerance to the splint, and made any adjustments as necessary. The DON stated RNAs cannot modify splints because they did not have the knowledge and qualifications to determine what residents need. The DON stated if splints were not fitting correctly and required modification, the RNA should notify Rehab and charge nurse, a Change of Condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) evaluation would be completed, the physician would be notified, and Rehab would re-assess the resident and modify the splint as needed. During a review of the facility's Policy and Procedure (P&P) undated, titled, Joint Mobility Assessment, the P&P indicated the purpose of the Joint Mobility Assessment was to determine a resident's ROM for all major joints and to implement plans of care to increase, maintain, or reduce a decline in joint mobility. The P&P indicated all residents shall be assessed for joint mobility limitations upon admission and reviewed every three months thereafter. The P&P indicated limitations in the joint mobility shall be defined in the following terms: WNL describes full ROM, no limitations, resident has access to 100% normal ROM .and severe which represented limitations in joint mobility greater than 75% to approximately 100% of the normal ROM. The P&P indicated the licensed nurse shall assess the program's effectiveness and the resident response to treatment on a weekly basis in the licensed weekly summary. The P&P indicated therapy evaluations may be requested if programs provide ineffective or complications occur requiring therapy expertise. During a review of the facility's undated P&P titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents would not experience an avoidable reduction in ROM and residents with limited ROM would receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated nursing would identify the resident's current ROM of his or her joints and limitations in movement as part of the comprehensive assessment and develop a plan of care to include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve ROM. During a review of the facility's job description titled, Restorative Nursing Assistant, dated 1/27/2022, the job description indicated RNA assisted residents in reaching their maximal potential in collaboration with the Therapy Department and under the supervision of the Charge Nurse. The RNA job description indicated the RNA's essential duties and responsibilities included reporting and charting significant changes in a resident's condition and notifying the OT and Physical Therapy of any referrals and reassessment needs. During a review of the facility's undated Policy and Procedure (P&P) titled, S [TRUNCATED]

Based on interview and record review, the facility failed to ensure a resident, who had a diagnosis of dementia (progressive loss of memory), did not go missing from the facility unnoticed for almost 24 hours for one of two sampled residents (Resident A). The facility failed to: Ensure the facility had a system to alert staff when the door to the entrance of the facility was opened after 5 p.m., to ensure no resident left the facility unnoticed. Resident A, who was diagnosed with dementia (a brain disease marked by memory disorders, personality changes and impaired reasoning), other medical conditions, and a heart pacemaker (a device that generates electrical impulses to the heart to contract), eloped from the facility ' s front entrance on 3/14/2022 at 8:29 p.m. On 3/15/2022, the day after Resident A eloped from the facility, Resident A was found unresponsive in a parking lot approximately 12 miles away from the facility and was transported to a general acute care hospital (GACH) for evaluation, care, and treatment. This deficient practice resulted in Resident A eloping from the facility, becoming unresponsive and requiring treatment at a General Acute Care Hospital (GACH) for a drug overdose and placed Resident A at risk of remaining missing, exposure to harsh environmental conditions, including excessive heat and/or cold, hypothermia (occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature), harm, and/or death due to his medical conditions, use of illicit drugs (illegal use), and possible motor vehicle accident and death. Findings: During a review of Resident A ' s Admission Records (face sheet), the face sheet indicated Resident A was originally admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses included diabetes mellitus ([DM] a chronic condition associated with abnormally high levels of sugar in the blood), encephalopathy (brain disease, damage, or malfunction), hypertension ([HTN] high blood pressure, a condition in which the force of the blood against the artery walls was too high), glaucoma (a group of eye conditions that damage the nerve in the eye often leading to blindness), hearing loss, anxiety disorder (extreme worry or fear), and dementia. The face sheet indicated Resident A ' s primary decision maker was a family member. During a review of Resident A ' s history and physical (H/P), dated 5/27/2021, the H/P indicated Resident A could make his needs known but could not make medical decisions. During a review of Resident A ' s Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/7/2022, the MDS indicated Resident A ' s cognitive skills (thought process) for daily decision-making were moderately impaired. According to the MDS, Resident A required an extensive one-person physical assistance to complete his activities of daily living ([ADL] tasks such as eating, bathing, dressing, grooming and toileting) and was occasionally incontinent (involuntary voiding of urine and stool) of bowel and bladder functions. During a review of Resident A ' s Physician ' s Orders, dated 5/27/2021, the Physician ' s Order indicated Resident A did not have the capacity to understand and actively participate in decision making. The physician orders indicated Resident A ' s medications included the following: 1. Regular Insulin 2 to 8 units (an indication of measurement [dose] for insulin [a medications that lowers the level of blood sugar]) on a sliding scale (Insulin dose varies based on a patient ' s blood glucose level) for diabetes mellitus to cover elevated glucose levels twice a day. 2. Metoprolol 25 milligram ([mg] unit of measurement) every 12 hours for hypertension. 3. Norvasc 5 mg every day for hypertension. During a record review of Resident A ' s medication administration record (MAR) dated 3/14/2022 at 9:00 p.m. until 3/15/2022, (the 24 hours the resident was missing from the facility) Resident A did not receive any of the above medications to control his blood pressure and blood sugar levels. During a review of the facility ' s Investigation/Accident Known/Unknown Origin Form, dated 3/14/2022, the form indicated at 9 p.m., on 3/14/2022, Resident A was not in his bed. According to the Investigation Form, the facility ' s staff searched inside and outside of the facility for Resident A, which included staff driving around the facility ' s area and contacting local hospitals, but Resident A was not found. During a review of the GACH ' s Emergency Department (ED) notes, dated 3/15/2022 and timed at 5:06 p.m., the ED notes indicated Resident A presented for evaluation of a suspected drug overdose. Per EMS ([emergency medical services/ambulance or paramedic services] used to provide urgent pre-hospital treatment and stabilization for serious illness and injuries), Resident A was found unresponsive in a parking lot and was given Narcan (a medicine that rapidly reverses the effects of an opioid [a substance used to treat moderate to severe pain] overdose in an emergency) prior to arrival to the ED. During a review of Resident A ' s GACH laboratory results obtained on 3/15/2022 at 8:39 p.m., the laboratory results indicated Resident A tested positive for opiates in his urine. According to the ED note, Resident A was discharged to another skilled nursing facility on 3/16/2022. During a review of Resident A ' s care plans (CPs), there was no indication of a plan of care in place with interventions to address Resident A ' s confusion and forgetfulness and to ensure Resident A was kept safe and supervised. During an interview on 3/16/2022 at 3 p.m., the Director of Nursing (DON) stated Resident A was alert and oriented to his name, place, and time but had episodes of forgetfulness. The DON stated Resident A could make his needs known but could not make medical decisions. The DON confirmed that should have been but there was no plan of care developed with intervention to address Resident A ' s forgetfulness and confusion to ensure Resident A ' s safety. During an interview on 3/16/2022 at 3:14 p.m., the Administrator (ADM) stated on 3/14/2022 at approximately 9 p.m. a certified nursing assistant (CNA 1) was assisting another resident. When CNA 1 finished with that resident, she went to Resident A ' s room but did not find him there. The ADM stated it was reported, Resident A was last seen at the nursing station socializing with other residents at approximately 8 p.m. The ADM stated CNA 1 looked around the facility and when she could not find Resident A she reported it to the licensed vocational nurse (LVN 2) who was the charge nurse. The ADM stated a search was conducted in all the residents ' rooms, bathrooms, dining room, rehabilitation room, the break room, and the facility ' s parking lot but they could not locate Resident A. The ADM stated staff got in their personal cars and searched the surrounding cities but did not find Resident A. The ADM stated they reviewed the facility ' s camera footage and they saw Resident A leave the facility through the facility ' s front entrance at 8:29 p.m., on 3/14/2022. The ADM stated the receptionist was at the front desk until 5 p.m., and then locks the front entrance when she leaves. The ADM stated the front door only has a wander guard (a system that sounds alarms when an at-risk wanderer approaches a monitored door) and Resident A was not assessed at risk for wandering so he did not have a wander guard device in place. The ADM stated the front door was locked to prevent unauthorized persons from entering the facility after 5 p.m., but there was no alarm on the front door to alert staff the door was being opened from inside the facility. During an interview on 3/16/2022 at 4:21 p.m., CNA 1 stated Resident A was independent but had some confusion and forgetfulness. CNA 1 stated on the night Resident A eloped from the facility (3/14/2022) she went to Resident A ' s room at approximately 8:45 p.m., to check on Resident A ' s roommate (Resident B), and Resident A was not there. CNA 1 stated after she completed care with Resident B she went to look for Resident A but could not find him and reported to LVN 2, the charge nurse. CNA 1 stated they looked inside and outside of the building and could not find Resident A. CNA 1 stated Resident A did not have a behavior of going outside the facility. CNA 1 stated Resident A would usually talk to the other residents and then go back to his room. During an interview on 6/17/2022 at 2:10 p.m., the DON stated the only doors in the facility that alarms when opened from the inside were the facility ' s emergency doors. The DON stated the front door has a wander guard alarm on it and would only activate the alarm if a resident with a wander guard device activated it. The DON stated when the receptionist leaves at 6 p.m., the front door was locked from the outside only and there was no alarm to alert staff the door was being opened from the inside. DON was not able to provide a policy and procedure (P/P) regarding supervision of residents with dementia and forgetfulness. During an interview on 6/21/2022 at 5:23 p.m., LVN 2 stated Resident A was alert to his name and surroundings but had periods of confusion and forgetfulness. LVN 2 stated Resident A usually sat at or near the nursing station talking to other residents, conversing in a confused manner. LVN 2 stated on his shift, 3 p.m. to 11 p.m., Resident A did not have a behavior of attempting to leave the facility.

Based on interview and record review, the facility failed to ensure its policy, physician's orders and a resident's plan of care were followed for the care and treatment for [REDACTED]. Resident 1, who was admitted to the facility with a Stage IV pressure ulcer (full thickness of skin lost with exposed muscles, tendons and bones) on the sacrococcyx (tailbone area and a triangular bone at the base of the spine), did not receive the necessary care and services to promote healing, prevent pressure ulcer from developing, and prevent infection, including: 1. Failure to measure the pressure sores with complete description and measurement weekly. 2. Failure to measure the deep tissue injury (DTI) that developed on the resident's perineum area. 3. Failure to notify the physician promptly when there was a marked difference in the resident's skin condition. 4. Failure to follow the treatment recommendations by the wound specialist timely on 3/16/18. 5. Failure to maintain adequate protein levels to promote healing. This deficient practice resulted in the resident's wounds not being assessed, the physician not notified timely and a treatment order obtained; the treatment plan for the Stage IV sacrococcyx pressure ulcer not carried out for 13 days. Resident 1 required a transfer to a general acute care hospital (GACH) due to fever (elevated body temperature) and was diagnosed with [REDACTED]. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/19/18 indicated the resident's cognition (ability to reason and think) was intact. Resident 1 required total assistance of a two-person physical assist for bed mobility (how the resident moves in bed), toilet use, and required total assistance by one person assist for eating and personal hygiene. A review of an Admission Assessment, dated 3/12/18, indicated Resident 1 had a Stage IV sacrococcyx pressure ulcer (PU) that measured 7.0 centimeters (cm) in length by 6.8 cm in width by 1.0 cm in depth. A review of a care plan, dated 3/13/18, titled Altered Skin Integritt manifested by Stage IV PU, indicated the staff's approach included administering treatment as per the physician's orders, keep the physician aware of the progress and response to the treatment plan/ monitor baseline laboratory work and monitor the PU weekly and record. A review of a Wound Risk Assessment indicated Resident 1 scored high with a risk for development of pressure ulcers on 3/13/18, 3/20/18, 3/27/18, and 4/3/18. A review of Resident 1's Skin Progress Report form indicated the following: On 3/13/18, the Stage IV sacrococcyx PU measured 7 cm by 6.8 cm by 2 cm, with 50% granulation tissue (new tissue that forms on the surface of a wound), 50% slough (yellow stringy dead tissue that should be surgically removed to allow healing on the wound), and moderate amount of serous drainage (clear discharge from a wound). A review of a Physician Order, dated 3/13/18, indicated a treatment order for the Stage IV sacrococcyx pressure ulcer as follow: Clean with normal saline, pat dry, apply Santyl ointment (an ointment that breaks down damaged tissue and helps healthy tissue grow to help wounds heal faster), cover with dry dressing daily and as needed when soiled or pulled out for 30 days. A review of a Trunk Wound Assessment done by a Physician's Assistant (PA), a Wound Specialist, (specialized in the treatment and management of the care of wounds) dated 3/16/18, indicated a treatment plan to discontinue the above treatment with a new treatment order as follow: Apply Santyl loosely pack with Dakin's solution (a solution used to prevent and treat skin and tissue infections of pressure ulcers) of 25% impregnated gauze (mesh fabric material used as a dressing cover for a wound) with alginate (dressing used on wounds with drainage) daily for 30 days. A review of a wound assessment form, dated 3/16/18, indicated Resident 1's Stage IV sacrococcyx pressure ulcer (PU) had a deep tissue injury ((DTI) a type of pressure ulcer with skin intact and injury to underlying tissue below the skin's surface that results from prolonged pressure) to the perineum area, which measured 7.5 cm by 7.5 cm by 2 cm; 15% granulation tissue; 85% slough; moderate amount of serosanguinous (blood tinged) drainage; and undermining (tunneling in the wound that covers a wider area beneath the wound opening) on 1, 2, 3 o'clock (a method to measure depth and direction of undermining using the face of a clock). A review of a Physician's Order, dated 3/29/18, indicated the PA's wound care treatment orders were not relayed to the physician and ordered until 3/29/18, 13 days later. A review of Resident 1's Stage IV Wound Assessment Form indicated the following: a. On 3/23/18, the Stage IV PU with DTI with dimensions had increased in size and worsen with necrotic tissue (dead tissue) to 7.8 cm by 7.5 cm by 3 cm; 20% granulation tissue; 80% slough; moderate serous drainage; wound with black necrosis on the wound edge at 9 o'clock to 3 o'clock; string slough observed; and dusky red peri-wound (skin around the wound). b. On 3/30/18, the Stage IV PU measured 7.8 cm by 7.5 cm by 3.6 cm; 25% granulation tissue; 60% slough; 15% bone; moderate serous drainage; stringy slough present; undermining at 12, 2, and 5 o'clock; dusky purple noted on peri-wound. c. On 4/6/18, the Stage IV with dimensions of 7.8 cm by 7.8 cm by 3.8 cm; 25% granulation tissue; 60% slough; 15% bone; moderate serous drainage; stringy slough; undermining at 12, 2, and 5 o'clock; dusk purple on peri-wound with fragile newly epithelized tissue (healing tissue) on wound edges. A review of the Wound Specialist documentation's indicated Resident 1's PU was last evaluated on 3/30/18. There was no further documentation by the wound specialist between 3/31/18 and 4/11/18. A review of Resident 1's laboratory results dated [DATE] indicated the resident's [MEDICATION NAME] level was 2.9 gram/deciliter (gm/dl-the reference range was 3.5 to 5.7 gm/dl), 2.6 gm/dl on 3/21/18, 2.2 gm/dl on 3/23/18, and 2.1 gm/dl on 3/30/18. On 6/11/18 at 11:19 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 2 stated she took care of Resident 1 from the hours of 3 p.m. to 11 p.m. LVN 2 stated she did not perform routine skin assessment for the resident and the treatment nurse (LVN 1) was responsible for conducting routine skin assessment and assessment for pressure ulcer for the resident. On 6/11/18 at 2:30 p.m., a review of Resident 1's health record and a concurrent telephone interview, LVN 1 stated the wound specialist would make weekly visits every Friday and the wound specialist did not evaluate Resident 1 on 4/6/18. LVN 1 stated if Resident 1's pressure ulcer had a change of condition then she should have notified the Wound Specialist to obtain new orders. On 6/21/18 at 1:07 p.m., a review of Resident 1's Skin Progress Report initiated on 3/13/18 and a concurrent telephone interview, LVN 1 stated on 3/16/18 the resident had a Stage IV sacrococcyx PU and a DTI to the perineum area. LVN 1 stated the size of the wound bed of the Stage IV PU was 7.5 cm by 7.5 cm by 2 cm and it did not include the size and assessment of the DTI. LVN 1 stated on 3/23/18 Resident 1 had a stage IV pressure ulcer with DTI. LVN 1 stated the size of the wound bed of the stage IV pressure ulcer was 7.8 cm x 7.5 cm x 3 cm and it did not include the size of the DTI. LVN 1 stated she did not measure the size of Resident 1's DTI. LVN 1 stated it was important to assess the DTI because it was a deep tissue injury, a type of pressure ulcer. LVN 1 stated the DTI pressure ulcer should have been assessed for size, tissue involvement, presence of drainage, and color. LVN 1 stated if the PU had a change of condition, such as an increase in size and/or signs of infection then she should have notified the physician and the Wound Specialist for consultation on how to proceed with the care and obtain orders. LVN 1 stated there was a potential for the pressure ulcer to deteriorate. On 6/21/18 at 1:07 p.m., during a review of Resident 1's Trunk Wound Assessment (by the Wound specialist dated 3/16/18) and a concurrent telephone interview, LVN 1 stated the Wound Specialist recommendations were not carried out and an order obtained until 13 days later on 3/29/17. LVN 1 stated when the wound specialist made treatment recommendations they should be discussed with the physician immediately. LVN 1 stated since the wound specialist's recommendations were not implemented immediately there was a delay in wound healing for the resident's PU. LVN 1 also stated there were no documentation Resident 1's sacrococcyx PU was assessed upon transfer to the GACH on 4/11/18. A review of GACH's admission record indicated Resident 1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the GACH laboratory results, dated 4/11/18 and timed at 11:45 p.m., indicated Resident 1's [MEDICATION NAME] level remained low at 1.8 gm/dl. A review of an online article titled, NPUAP Pressure Injury Stages, by The National Pressure Ulcer Advisory Panel - NPUAP, dated 8/28/12, indicated the importance of maintaining nutrition, especially protein levels in the prevention of pressure ulcers development. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ A review of a computerized tomography ((CT scan), a series of x-ray images that provided detailed information of the bones, blood vessels, and soft tissues inside the body) of the lumbar spine (lower back) from the GACH, dated 4/12/18 and timed at 3:42 a.m., indicated Resident 1's sacral PU had undermining subcutaneous (tissue underneath the skin that contains fat) abscess (localized collection of fluid or drainage that was yellow color and was located at the site of infection) covering that was 15.5 cm by 1.8 cm by 7 cm, osteo[DIAGNOSES REDACTED] (infection of the bone) involving distal sacrum and coccyx posterior cortex, and a sacrococcygeal diastasis (dislocation or separation) with extension of [MEDICAL CONDITION] tissue (body's response to damage to tissue) into the presacral fat (space located in front of the coccyx and sacrum that contains a pocket of fat). A review of Resident 1's GACH records indicated a physician order, dated 4/16/18, for a Wound Vac (a therapeutic device placed on the wound and it decreases air pressure to the wound to help the wound heal) to the coccyx. A review of a Discharge Summary from the GACH, dated 4/24/18, indicated Resident 1's [DIAGNOSES REDACTED]. A review of facility's undated policy and procedure titled, Pressure Sore Management, indicated a complete description of the pressure sore(s) should be written in the comprehensive nursing assessment. A review of facility's undated policy and procedure titled, Measuring Pressure Sores, indicated all pressure sores should be measured upon admission and on a weekly basis. The policy indicated the length, width, and depth of pressure sores are to be measured in centimeters (cm). A review of facility's undated policy and procedure titled, Staging Pressure Sores, indicated a deep tissue injury (DTI) may have additional deep tissue loss. A review of facility's undated policy and procedure titled, Change of Condition (C[NAME]), indicated a change of condition was a sudden or marked difference in resident's open or red areas and skin condition. The policy indicated all changes of condition in a resident should be handled promptly and the physician should be called promptly. The policy indicated documentation of change of condition should be performed by the Licensed Nurse: documentation at least 72 hours, or longer; daily charting; vital signs each shift; reassess resident condition as needed; and C[NAME] would be completed.

Based on observation, interview, and record review, the facility failed to ensure that one of four sampled residents, who had history of [MEDICAL CONDITION] and was ventilator (machine that provides oxygen exchange) dependent received the necessary care and services in accordance with the facility's policy (Resident 1). Resident 1 was weaned (gradually taken off) off the ventilator and placed on a [MEDICAL CONDITION] mask ((T-mask), also known as T-collar mask placed over a surgically created hole through the front of the neck and into the breathing tube that leads to the lungs) including but not limited to: Failure to implement the facility's policy for ventilator weaning protocol (weaning criteria assessment), which included performing arterial blood gases ((ABG), a blood test that measured the pH, a scale that tells how acidic or alkaline a substance was, of the blood and the amount of oxygen and carbon [MEDICATION NAME] to evaluate lung function), close monitoring and ensuring the pulse oximeter machine (measures oxygen saturation and heart rate) was operable and parameter settings activated for Resident 1. This deficient practice resulted in Resident 1 not being closely monitored and was found unresponsive and cyanotic (blue color due to low levels of oxygen in the blood). Resident 1 was transferred to a general acute care hospital (GACH) for [MEDICAL CONDITION] (an emergency in which the heart and breathing stops) on [DATE], and died that day at 4 a.m. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. of the heart). The Admission Record also indicated Resident 1 had a [MEDICAL CONDITION] and a gastrostomy tube (([DEVICE]), a tube inserted through the abdomen that delivers nutrition and medication directly to the stomach). A review of Resident 1's History and Physical dated [DATE] indicated the resident had a medical history of [REDACTED]. A review of Resident 1's Minimum Data Set (MDS- standardized assessment and care screening tool), dated [DATE], indicated the resident had short and long-term memory problems. Resident 1 was totally dependent on the staff for dressing, eating, toilet use, and personal hygiene. A review of Resident 1's care plan titled, Respiratory and initiated on [DATE], indicated the resident was at risk for respiratory distress/SOB (shortness of breath) related to [MEDICAL CONDITION] and [MEDICAL CONDITION] ([MEDICAL CONDITION] was a condition in which the heart does not pump blood as well as it should). The staff interventions included to assess for SOB, irregular respiration, wheezing (breathe with a rattling sound in the chest), crackles (breathe with popping lung sounds), rhonchi (continuous rattling lung sounds from secretions in airways), coughing, weakness, chest pain, activity intolerance and excessive secretions and to inform the physician promptly. A review of a care plan titled, Anti-anxiety and initiated on [DATE], indicated Resident 1 was receiving [MEDICATION NAME] for anxiety, manifested by recurrent restlessness leading to shortness of breath. The care plan indicated [MEDICATION NAME] had adverse side effects that included sedation and confusion. The care plan indicated to use [MEDICATION NAME] with caution when combined with other sedatives or hypnotic agents (medications that induce sleep). The staff interventions included to observe for side effects and document occurrence of side effects and notify the physician. A review of a care plan titled, Sedative/Hypnotic and initiated on [DATE], indicated Resident 1 was [MEDICATION NAME] alteration in sleep patterns related to [MEDICAL CONDITION] and sleeplessness. The care plan [MEDICATION NAME] adverse side effects that included drowsiness and confusion and to [MEDICATION NAME] caution when combined with other sedatives or hypnotic agents, or with alcohol. The staff interventions included to observe for side effects and document occurrence of side effects. A review of Resident 1's Physician order [REDACTED]. On [DATE][MEDICATION NAME] milligram (mg), through the [DEVICE] at night (QHS) as needed (PRN) for [MEDICAL CONDITION] (inability to sleep). On [DATE] [MEDICATION NAME] (antianxiety) 0.5 mg via [DEVICE], every 6 hours (Q6) PRN for anxiety manifested by recurrent restlessness leading to shortness of breath (SOB). A review of Resident 1's Physician Order, dated [DATE] and timed at 6:45 a.m., indicated the following respiratory orders: 1. Monitor every six hours (Q6) and as needed (PRN) 2. Fraction of inspired oxygen ((FIO2), the amount of air breathed that actually contains oxygen) of 2 liters per minute of oxygen (LPM) through a T-bar (T-shaped tubing connected to [MEDICAL CONDITION] and used to deliver oxygen therapy) or [MEDICAL CONDITION] collar trials as tolerated. 3. (MONTH) place the resident on the ventilator with settings: a. Synchronized intermittent mechanical ventilation ((SIMV), a ventilator setting that guarantees synchronized mechanical breaths), b. Set respiration rate at 6 breaths per minute (bpm), c. Tidal volume ((VT), volume of air that a resident to receive each breath) of 450, d. Positive end-expiratory pressure ((PEEP), the pressure in the lungs at the end of a breath) of 5, pressure support ((PS), ventilator support delivered for every breath) of 10, e. FIO2 of 2 LPM as needed for shortness of breath (SOB) or respiratory distress (difficulty breathing). A review of Resident 1's Continuous Ventilator Flow Sheet (CVFS), dated [DATE] to [DATE], indicated the resident had rhonchi (lung sounds that sound like snoring and are caused by secretions or obstruction in the airways). A review of Resident 1's CVFS, dated [DATE], indicated at 7:10 a.m., the resident was placed on a T-bar with oxygen delivered at 2 LPM. The resident's O2 sat decreased to 88 percent (%) to 92% (normal therapeutic range (NRR) 92% to 100%), heart rate 98 beats per minute (bpm) (NRR 60 to 100 bpm), and respiratory rate increased to 26 to 28 bpm (NRR 12 to 20 breaths per minute). The CVFS indicated Resident 1 was complaining of having a hard time breathing and the resident was placed back on the ventilator. There was no documentation the physician was notified of Resident 1 having difficulties in breathing while on the T-bar. A review of laboratory results, with date of collection on [DATE], indicated Resident 1's red blood cells ((RBC) cells that carry oxygen from the lungs to the body) were low at 3.59 ul (NRR 4.63 to 6.08 million cells/milliliters (ul)), hemoglobin ((HGB), protein in the RBC that carries oxygen) was low at 10.8 g/dl (NRR 13.7 to 17.5 grams per deciliters (g/dl)), and hematocrit ((HCT), ratio of the volume of RBC to the total volume of blood) was low at 34.8% (NRR 40.1 to 51%). A review of the CVFS, dated [DATE], indicated Resident 1 was back on the ventilator, but was taken off on [DATE] at 11:15 a.m. The CVFS indicated on [DATE] at 11:15 a.m. Resident 1 was taken off the ventilator and placed on T-mask again to attempt to wean, but there was documentation that an ABG was done for Resident 1, as per policy. The CVFS indicated on the night shift at 12:25 a.m., early morning of [DATE], over 12 hours later, Resident 1 was observed to be non-responsive and required cardiopulmonary resuscitation ((CPR), a lifesaving technique used in medical emergencies for breathing and chest compression). A review of a physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of an article titled, [MEDICAL CONDITION], by the National Heart, Lung, and Blood Institute (NHLBI), indicated signs and symptoms of [MEDICAL CONDITION] may include shortness of breath, air hunger (feeling like you can't breathe enough air), bluish color on the skin, and confusion. The NHLBI indicated the main goals of treating [MEDICAL CONDITION] was to get oxygen to the lungs and organs; remove carbon [MEDICATION NAME] from the body, and to treat the underlying cause of the condition https://www.nhlbi.nih.gov/health-topics/respiratory-failure. A review of Resident 1's health record indicated there was no documented evidence that an ABG was being done during the 12 hours of being on the T-mask for the resident. A review of a Discharge Summary, dated [DATE], indicated the resident was discharge to a general acute care hospital for being unresponsive, and for not being able to obtain the resident's oxygen saturation ((O2 sat), measures the percentage of oxygen in the blood and normal levels were 92% to 100%) levels by using a portable pulse oximetry machine (a device that monitors oxygen saturation when it was connected to a resident) and vital signs (clinical measurements of the body's heart rate (normal heart rate was 60 to 100), temperature (normal temperature was 97 to 99 Fahrenheit), blood pressure (normal blood pressure ,[DATE] to ,[DATE]), respiration rate (normal respiration rate was 12 to 20), and oxygen saturation (normal oxygen saturation was 92 to 100%). A review of the paramedic's Prehospital Care Report Summary, dated [DATE], indicated they were called at 12:02 a.m. on [DATE], and arrived at the facility at 12:10 a.m. The summary indicated Resident 1 was unresponsive and apneic (absence of breathing), and chest compressions was started. A review of GACH's Emergency Department (ED) record indicated Resident 1 presented in cardiac and respiratory arrest with no pulse upon the paramedic arrival to the facility and was non-responsive and in [MEDICAL CONDITION]. The ED note indicated Resident 1 was placed on 100% of oxygen with oxygen saturation at 92% The ED note indicated a chest x-ray was done on [DATE] and timed at 1:10 a.m., which indicated Resident 1 had bilateral (both sides) diffuse (spread out over a wide area) infiltrates (pus, blood, or protein that lingers in the lungs). The ED note indicated Resident 1's laboratory results collected on [DATE] at 1:25 a.m. were as follows: RBC 2.21 m/ul, HGB 6.5 g/dl, and HCT 21.6% The ED note indicated Resident 1 went into [MEDICAL CONDITION] (heart function and breathing stops) and expired on [DATE]. A review of Resident 1's Certificate of Death indicated the resident's date of death was [DATE] at 4 a.m., with the immediate cause of death listed as cardiopulmonary arrest. On [DATE] at 12 p.m., during an interview, Respiratory Therapist 1 ((RT 1) a specialized healthcare practitioner trained to work with individuals with lung conditions) stated on [DATE], Resident 1 was on the ventilator and then was placed on a T-mask at 11:15 a.m. RT 1 stated she placed Resident 1 on a continuous pulse oximetry to monitor the resident's oxygen saturation and heart rate, but stated she did not check the alarm settings (alarms parameters for the heart rate and O2 sat that should be adjusted by the healthcare provider to alert for clinical problems) on the continuous pulse oximetry monitor. RT 1 stated Resident 1 had thick, white secretions and the resident had rhonchi on the right and left lung fields. On [DATE] at 3:10 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated she was assigned to take care of Resident 1 on [DATE] on the 3 p.m.-11 p.m. shift. LVN 3 stated Resident 1 was confused at times but was on a T-mask. LVN 1 stated on [DATE] she had administered [MEDICATION NAME] due to Resident 1's anxiety at 3:15 p.m. [MEDICATION NAME] 9:10 p.m. for [MEDICAL CONDITION]. LVN 3 stated at 10 p.m. to 11 p.m. on [DATE] she observed Resident 1 sleeping while on the T- mask. On [DATE] at 7:45 a.m., during a telephone interview, RT 3 stated on [DATE] at 10:35 p.m. Resident 1 was off the ventilator, on a T-mask , the resident was asleep but had rhonchi. RT 3 stated Resident 1 was on a continuous pulse oximetry monitor, but stated he did not check the alarm settings of the continuous pulse oximetry monitor, but should have and he did not know what the alarm settings were. RT 3 stated he did not hear an alarm when Certified Nurse Assistant 1 (CNA 1) reported to him that she did not see numbers (recordings of the heart rate and oxygen saturation levels) on Resident 1's continuous pulse oximetry monitor. RT 3 stated upon his arrival to Resident 1's bedside the resident was cyanotic (bluish discoloration of the skin or tissues from low oxygen saturation) with a faint pulse and pulse oximetry monitor was not registering numbers for the resident's oxygen saturation and/or heart rate levels. RT 3 stated he used a portable pulse oximetry on Resident 1, but it did not register an oxygen saturation level. RT 3 stated CPR was started and 911 (emergency services) was called. RT 3 stated when there was an alarm sound from the continuous pulse oximetry monitor, then a resident should be assessed immediately for possible changes of condition. RT 3 stated the continuous pulse oximetry monitor should have been checked to ensure it was plugged into an emergency outlet and to ensure an accurate placement of the probe to ensure accuracy reading and alarm parameters set for Resident 1. RT 3 stated the continuous pulse oximetry monitor would alarm when the resident became disconnected or when the resident was not within the alarm parameter setting of the oxygen saturation and/or heart rate. RT 3 stated the continuous pulse oximetry monitor needed to be set on a particular setting for the alarm to sound. On [DATE] at 9:51 a.m., during a telephone interview, Registered Nurse 1 (RN 1) stated she did not hear Resident 1's continuous pulse oximetry alarm on the night of [DATE]. On [DATE] at 7:50 a.m., during a review of Resident 1's health record and a concurrent interview, LVN 4 stated she was assigned to Resident 1 on [DATE] on the 11 p.m. to 7 a.m. shift. LVN 4 stated she did not document an assessment and interventions for the resident. On [DATE] at 9:23 a.m., during a telephone interview, Certified Nurse Assistant 1 (CNA 1) stated there was no staff in Resident 1's room when she entered and saw the resident asleep, but making noises. CNA 1 stated Resident 1's continuous pulse oximetry monitor did not have numbers for the heart rate and oxygen saturation levels and stated she notified RT 3. At 1:24 p.m. on [DATE], during review of Resident 1's health record and concurrent interview, the Director of Nursing (DON) stated there was no documentation that the resident was placed on a continuous pulse oximetry monitor and if it was checked for proper functioning and alarm parameter settings were set. On [DATE] at 11 a.m., during an observation of the respiratory therapist equipment room and a concurrent interview accompanied with RT 2, RT 2 stated there was a continuous pulse oximetry monitor with a sensor cable and piece of paper that indicated cleaned [DATE] in a clear plastic bag. RT 2 stated there was not a probe in the bag. RT 2 stated when he plugged the continuous pulse oximetry monitor into an outlet and plugged the sensor cable into the continuous pulse oximetry, then the continuous pulse oximetry screen indicated in red color bad and yellow color SEN and the alarm button had a continuous orange color light on to indicate silence alarm. RT 2 stated the sensor cable was not functioning properly because the continuous pulse oximetry monitor indicated bad sensor and the continuous pulse oximetry would not produce an alarm sound. RT 2 stated he was not able to check the volume of the alarm on the continuous pulse oximetry monitor and the sensor cable should have been labelled to alert staff that the sensor cable needed to be fixed and should not be used on residents. RT 2 stated a continuous pulse oximetry monitor was used to alert staff that the resident had a change of condition, especially residents who were not stable, such as Resident 1 who was taken off the ventilator. RT 2 stated when a continuous pulse oximetry monitor was not functioning properly then the resident was not being continuously monitored and there was a risk for [MEDICAL CONDITION]. At 1:40 p.m., on [DATE], during an interview, the lead RT 4 (LRT 4) stated all subacute residents are assessed every two hours and PRN (whenever necessary) for the need for suctioning and all subacute residents assessed for heart rate and oxygen saturation every 6 hours (Q6) and PRN. LRT 4 stated she did not keep track of when continuous pulse oximetry monitors, sensor cables, and probes were serviced and calibrated. LRT 4 stated she would check the functioning of the continuous pulse oximetry every two years by using it on herself and whenever it was used on a resident. LRT 4 stated the continuous pulse oximetry monitors were scheduled for a check on [DATE]. During a review of Resident 1's health record and concurrent interview, LRT 4 stated she could not determine that the resident was placed on the continuous pulse oximetry monitor that was checked and properly functioning to register the alarm settings of the resident's oxygen saturation and heart rate. On [DATE] at 4:45 p.m., during review of Resident 1's health record and concurrent interview, the Director of Nursing (DON) stated the physician was not notified that the resident had rhonchi, and DON stated the physician should have been informed of the resident's rhonchi because it was a change of condition and that the physician could provide orders for the resident and necessary interventions were rendered to the resident. DON stated when the physician was not notified of the rhonchi then the resident's condition would be left untreated and it could worsen. At 3:07 p.m., on [DATE], during an interview, RT 4 stated when Resident 1 had a hard time breathing on the T-mask then it was a change of condition and the physician should have been notified to obtain orders. On [DATE] at 3:15 p.m., during a review of Resident 1's health record and concurrent interview, the DON stated the resident was not assessed and monitored for how the resident exhibited anxiety and restlessness, and the resident's respiratory status should have been observed. The DON stated Resident 1 was administered [MEDICATION NAME] for anxiety and restlessness. The DON stated when [MEDICATION NAME] used in combination then there was a potential for sedation and decreased respiratory rate. A review of the facility's undated policy and procedure titled, Ventilator Weaning/ Quarter Weaning Evaluation, indicated all ventilator dependent residents would be assessed for weaning potential. The policy indicated the facility was responsible for assessing the ventilator dependent resident utilizing the criteria outlined on the Weaning Criteria Assessment Sheet and to total the scores as indicated on the form and discussing the resident score with the physician and the Interdisciplinary Team ((IDT), a group of healthcare professionals from diverse fields who collaborate together for the resident's care). The policy indicated the facility was responsible for documenting the individual resident information related to the assessment and the treatment plan on the Subacute Resident Ventilator Weaning Log. The policy included an algorithm care plan on the weaning protocol that indicated for a fast wean to T-collar: 1.Start T/C trials by four hours on and four hours off during the day. 2.Next day, increase T/C trial to 12 hours. Rest at night PSV 10. 3.Third day, increase T/C trial to 24 hours 4.Obtain every four hours exhaled volumes and ABG after 24 hours. If ABG was acceptable then discontinue ventilation. If ABG was not acceptable, then assess for cause and return back. A review of the facility's policy and procedure titled, Ventilator Weaning Guidelines, indicated factors to be consider and improved prior to weaning from the mechanical ventilator: acid/base abnormalities - especially metabolic alkalemia (a condition in which the pH of tissue is elevated beyond the normal range (normal pH 7.35 to 7.45)); [MEDICAL CONDITION]; infection; excessive secretions; and drug therapy (medications that decrease respiratory drive or decrease muscle strength). The policy indicated factors that weaning from the mechanical ventilation is feasible: negative inspiratory force ((NIF), measurement to assess for respiratory muscle strength on inhalation) greater than -20 centimeter of water (cm H2O); PaO2 > 80; PaCO2 < 55; and tidal volume (VT) 3 to 4 ml/lb. ideal body weight. A review of the facility's policy and procedure titled, Continuous Monitoring and Spot Check Assessments, dated [DATE], indicated the facility was responsible for continuous monitoring Spo2 during any time period or clinical situation when the resident's oxygenation status may be susceptible to acute change. The policy indicated the continuous monitors should be checked and documented at least every shift with ventilator checks, and with changes in resident status or to document response to therapies and procedures. The policy indicated all non-disposable probes, probes sights would be changed at least every shift to prevent tissue damage.

Based on interview and record review, the facility failed to follow its policy and procedures and resident plan of care to ensure residents were not neglected and care/services were provided for one of three sampled residents (Resident 1). Resident 1, who had end stage [MEDICAL CONDITION] (([MEDICAL CONDITION]) a medical condition in which the kidneys no longer function and waste builds up in the body) and was dependent on [MEDICAL TREATMENT] (a method for removing waste products), was missing for three hours, after being picked up by the wrong transportation company. The resident was transported to an unknown residential location instead of back to the facility. These deficient practices resulted in Resident 1 being left unsupervised and neglected with mental anguish, emotional and psychological distress, with the resident expressing fear in returning to [MEDICAL TREATMENT]. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on (MONTH) 23, (YEAR), and was last readmitted on (MONTH) 30, (YEAR). The resident's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated (MONTH) 28, (YEAR), indicated a Brief Interview for Mental Status (BIMS) score of 7 (0-7 severe impairment), which indicated that Resident 1 had severe problems with memory and cognition (thought process). The MDS indicated Resident 1 used a wheelchair for mobility and was totally dependent on the facility's staff for locomotion outside of the facility. A review of Resident 1's [MEDICAL TREATMENT] Care Plan, dated (MONTH) 24, (YEAR), indicated the resident was receiving [MEDICAL TREATMENT] treatment, and would be transported to and from the [MEDICAL TREATMENT] center via a transportation company (TC) for [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday at p.m. The staff's interventions included arranging transportation on time; checking post [MEDICAL TREATMENT] special instructions from the [MEDICAL TREATMENT] clinic, post [MEDICAL TREATMENT] resident observations and documenting the resident's condition upon return from [MEDICAL TREATMENT]. A review of Resident 1's Activities of Daily Living (ADL) Functioning Care Plan, dated (MONTH) 24, (YEAR), indicated the resident had a self-care deficit related to poor safety awareness and would have minimized risk decline in the next 90 days. The staff's interventions included providing Resident 1 with a safe environment. A review of Resident 1's Cognitive Loss/Communication Care Plan, dated (MONTH) 24, (YEAR), indicated the resident had a short-term memory problems and would have all her needs anticipated and met in the next 90 days. The staff's interventions included avoiding placing Resident 1 in unfamiliar situations and notifying the medical doctor of any significant changes. A review of the [MEDICAL TREATMENT] Center's (DC) Documentation, dated (MONTH) 14, (YEAR), indicated the following: 1. Resident 1's [MEDICAL TREATMENT] treatment began at 1:40 p.m. and ended at 5:25 p.m. 2. Resident 1 was picked up by the wrong transportation company and was later returned to the DC at 7:25 p.m. Resident 1's family member (FM 1) then went to the [MEDICAL TREATMENT] center and transported the resident back to the facility. A review of Resident 1's (MONTH) [MEDICAL TREATMENT] Communication Record indicated the resident's post [MEDICAL TREATMENT] assessment was completed by the facility's nurse on the following dates and times: (MONTH) 12, (YEAR) at 5:30 p.m., (MONTH) 14, (YEAR) at 9:05 p.m., and on (MONTH) 17, (YEAR) at 6 p.m. A review of the facility's Nurse Progress Notes, dated (MONTH) 14, (YEAR), indicated the following for Resident 1: 1. At 1 p.m., the resident was picked up by the transportation company (TC) to be transported to the DC. 2. At 7:05 p.m., the facility was notified that the driver would be arriving to bring Resident 1 back the facility within 10 minutes. 3. At 7:30 p.m., the TC notified the facility that there was a computer error and Resident 1 was currently being picked up from the DC. 4. At 7:45 p.m., Resident 1's family member (FM 1) called the facility and stated the TC took Resident 1 to the wrong facility. The note indicated FM 1 was upset. 5. At 7:50 p.m., the facility was notified by the TC that Resident 1 had been taken to the wrong address. The TC was trying to contact the driver to find the resident's whereabouts. 6. At 8:30 p.m., the TC was unable to contact the driver or locate his whereabouts. 7. At 9:05 p.m., FM 1 arrived to the facility with the resident. The note indicated FM 1 was upset and was notified there would be a follow-up with the TC regarding the miscommunication on the following Monday (two days later). A review of the facility's Interview Record, dated (MONTH) 7, (YEAR), and untimed, indicated a complaint was placed with the TC and the facility's Social Services Director (SSD) requested a Spanish-speaking driver for Resident 1. A review of Resident 1's Interdisciplinary Team ((IDT) a group of different disciplines working together towards a common goal for the resident) Conference record, dated (MONTH) 14, (YEAR), indicated the conference was conducted to discuss Resident 1's safety and security. The resident was encouraged to immediately report any suspicious activities or persons to the local authorities or [MEDICAL TREATMENT] center staff and to trust her instincts and find a trustworthy adult if someone made the resident feel unsafe. On (MONTH) 8, (YEAR), at 8:50 a.m., during an interview, FM 1 stated Resident 1 was picked up by the TC and taken to a residence in another city approximately 25 miles by mistake. FM 1 had to drive to pick the resident up. Upon arrival at the residence, FM 1 stated that Resident 1 was crying, had a soiled diaper and the owner of the home was upset that the resident had been left at an incorrect location. FM 1 stated when they transported Resident 1 back to the facility, the facility was still unaware of the resident's location. FM 1 stated she told that the facility was not responsible for transportation. On (MONTH) 8, (YEAR) at 11:10 a.m., during an interview, Registered Nurse 1 (RN 1) stated there was a recent incident where Resident 1 was taken to another location by the TC. RN 1 stated the resident was missing and after calling the TC and DC, she was unable to determine Resident 1's location. RN 1 did not know the facility's policy regarding missing residents and she did not notify law enforcement and/or the Department of Public Health (DPH) of the incident. On (MONTH) 13, (YEAR) at 10 a.m., during an interview, the SSD stated if there was a problem with the TC, the insurance company and TC should be called to file a complaint. The SSD stated if there were previous problems with the TC, for resident safety, the same transportation company should not continue to pick the resident up. On (MONTH) 13, (YEAR) at 11:45 a.m., during an interview, TC Representative 1 stated they did not receive any complaints from the facility and were not aware of an incident involving Resident 1 being transported to an incorrect location. TC Representative 1 continued to transport Resident 1 to and from the [MEDICAL TREATMENT] center and stated they would investigate the incident. On (MONTH) 13, (YEAR) at 12:40 p.m., during an interview, Resident 1 was tearful and stated she was scared to go to [MEDICAL TREATMENT] because the TC previously took her to a house instead of the facility. Resident 1 stated she felt frustrated and scared and told the TC it was the wrong home but she was still left at the location. On (MONTH) 13, (YEAR) at 2:15 p.m., during an interview, the SSD stated after the incident with Resident 1, the TC was called to request a Spanish speaking driver. The SSD stated the TC was not notified of Resident 1 being left at an incorrect location. On (MONTH) 13, (YEAR) at 2:30 p.m., during an interview, the administrator (ADM) stated the resident was missing and the incident was not reported to DPH or the ombudsman because he did not think it met criteria for reporting. The ADM stated law enforcement was not notified after of the incident. The ADM stated, What were we supposed to tell them? We knew (Resident 1) was at the wrong address, but we didn't know where? The ADM was unable to locate an agreement with the transportation company and could not locate the facility's investigation of the incident. On (MONTH) 14, (YEAR) at 4:15 p.m., during a telephone interview, the Director of Nursing (DON) stated when a resident was missing, the facility's nurse was to notify law enforcement, DPH, the resident's family or responsible party, and doctor and call local hospitals in an attempt to locate the resident. The nurse was to document the notifications in the nurse's notes. On (MONTH) 20, (YEAR) at 3:20 p.m., during a telephone interview, the DC stated Resident 1 was picked up by the wrong transportation company and taken to an incorrect location. On (MONTH) 21, (YEAR) at 2:54 p.m., during a telephone interview, the DON was unable to locate the [MEDICAL TREATMENT] contract that was in effect at the time of the incident (October 14, (YEAR)). The DON stated the facility was supposed to have a copy. A review of the facility's undated policy and procedure titled, Missing Resident, indicated to reduce the possibility of resident injury or death, the facility would notify police if a missing resident wasn't located within an hour. The policy also stipulated the DPH was to be notified of the incident within 24 hours. A review of the facility's undated policy and procedure, titled Unusual Occurrences, indicated unusual occurrences included missing residents and were to be immediately reported to the DPH. The policy indicated a complete investigation of the incident was to be completed within five days. A review of the facility's undated policy and procedure, titled Reporting of Accidents/Incidents, indicated the facility would investigate and report all accidents or incidents involving residents residing at the facility. The facility would document the conclusions of the investigation and the steps taken to prevent recurrence of the incident within five days. A review of the facility's undated policy and procedure, titled Abuse Allegation Reporting, indicated the facility would report incidents of suspected abuse or neglect to local law enforcement, the ombudsman and the DPH within 24 hours. Conclusions of the abuse investigation were to be reported to DPH and the ombudsman within five working days. A review of the facility's undated policy and procedure, titled Abuse and Mistreatment of [REDACTED].

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to treat an ongoing rash (over a month) for one of 16 sampled residents (Resident 1) and to follow the physician's orders [REDACTED]. Resident 1 had an ongoing body rash with darken [MEDICAL CONDITION] over the body, resulting in constant itching and scratching and multiple linear (in a straight line) scratches over the body. Resident 1's rash was diagnosed as a psychogenic (a psychological (mental) origin, rather than a physical one) pruritus (severe itching of the skin), and was treated with a black box warning (a type of warning that appears on prescription drugs that may cause serious adverse effects with potential to be fatal) antipsychotic medication, [MEDICATION NAME] without any improvement (Cross referenced to F329). These failures resulted in Resident 1 having an ongoing rash with constant itching and multiple scratches all over the body, which put Resident 1 at risk for secondary infections and unnecessary drug ([MEDICATION NAME]) that had a black box warning (strictest warning label on a drug that is potentially fatal), which put Resident 1 at risk for drug side effects and possibly death. Resident 24, who had weight loss and had a physician's orders [REDACTED]. This deficient practice had the potential of the medication being less effective on a full stomach. Findings: a.On 7/18/16 at 1:45 p.m., during the facility's initial tour, Resident 1 was observed lying in bed and was observed with red spots on his lower and upper extremities. Resident 1 was grimacing and frowning, while scratching himself on the chest, elbow, and extremity areas, constantly thrashing in bed moving linen off his body. A review of Resident 1's Admission Face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 7/4/16, indicated Resident 1's cognitive skills for daily decision-making were severely impaired and the resident was non-ambulatory and totally dependent on staff for all care with a one-person physical assist. According to the MDS, Resident 1 had functional limitation in range of motion of one side (right). The MDS indicated Resident 1 was non-English speaking and unable to communicate needs verbally. A review of Resident 1's physician's orders [REDACTED]. Another physician's orders [REDACTED]. A review of Resident 1's care plan, dated 7/4/16, with a focus; Resident had episodes of psychogenic pruritus, manifested by scratching until he bleeds. The care plan indicated [MEDICATION NAME] 12.5 mg via GT every night was started with the resident being at risk for side effects of [MEDICATION NAME]. The goal was for Resident 1's episodes of scratching to be minimized through appropriate interventions daily. The staff's interventions included assessing Resident 1's pain and discomfort and observe for side effects of [MEDICATION NAME], which included agitation, headache, nausea, [MEDICAL CONDITION], dizziness and constipation. A review of Resident 1's care plan, dated 7/13/16, and timed at 7:30 p.m., titled, Resident has depression, manifested by itchiness, give Trazadone 25 mg via GT every night. It indicated the resident was at risk for side effects of the medication and the goal was for the resident to have less episodes of depression (sic). The staff's interventions included administering the medication as ordered and observe side effects and document. A review of the Medication Administration Record [REDACTED]. At 8:15 a.m., on 7/19/16, during a medication pass observation, Resident 1 was observed lying in bed, moving his head from side to side, as though he was scratching his head. Resident 1 was scratching his body constantly during the medication pass observation for approximately 40 minutes. Resident 1 had reddened spots visible on the front of the chest, abdomen, and right thigh with linear scratches while he was removing the linen off his body. The medication nurse, a licensed vocational nurse (LVN 4) stated, He (Resident 1) scratches himself secondary to being hot. On 7/19/16 at 12:22 p.m., during an interview, a certified nursing assistant (CNA 1) stated she first noticed Resident 1's rash a month or so ago. CNA 1 stated Resident 1's rash starting on the back of the neck, across the chest, arms and down to the legs. CNA 1 stated the treatment nurse (LVN 6), and the other licensed vocational nurses were informed about the resident's rash and was currently treating Resident 1's rash. CNA1 stated there had not been a change in the rash. On 7/19/16 at 12:32 p.m., during an interview, LVN 6 stated Resident 1 had been seen by the dermatologist before. When asked for the physician's consultation note, LVN 6 was unable to produce one. LVN 6 looked in Resident 1's medical record, as well as the over flow and was not able to produce the physician's consultation note. On 7/19/16 at 12:35 p.m., during an interview, LVN 4 stated Resident 1 had been scratching for the past month and was prescribed a [MEDICAL CONDITION] medication (any medication capable of affecting the mind, emotions, and behavior) to stop the itching. LVN 4 stated the nurses were monitoring Resident 1's itching episodes, but not the side effects of the [MEDICAL CONDITION] medications as per Resident 1's plan of care. On 7/19/16 at 2:10 p.m., while at Resident 1's bedside, observing Resident 1's skin with a certified nurses assistant (CNA1), a dermatologist (a physician who specializes in treatment of [REDACTED]. At 2:50 p.m., on 7/19/16, Physician 1 stated he was called in after the survey team raised concerns about Resident 1's rash. Physician 1 was asked if he had heard of [MEDICATION NAME] being used to treat skin rashes, Physician 1 was in disbelief and was shown Resident 1's physician's orders [REDACTED]. A review of Physician 1's consult report, dated 7/19/16, indicated Resident 1 was seen due to severe itching over body and receiving an antipsychotic for behavioral psychogenic as the cause for the itching. The dermatologist documented Resident 1 had multiple excoriation plagues (traumatized or abraded skin caused by scratching or rubbing) over his body in various stages of healing and hyperpigmentation (patches of skin become darker in color than the normal surrounding skin) on the left back. Physician 1's documented plan indicated to keep Resident 1's nails short, apply a daily moisturizer (nourishment for dry skin), and follow-up on Resident 1's abnormal lab related to kidney impairment, which could be the cause of the chronic itching. A review of Resident 1's physician's telephone order (Physician 2), dated 7/19/16, and timed at 12:10 p.m., indicated to apply [MEDICATION NAME] lotion (anti-itching treatment) to Resident 1's self-inflicted scratch marks on the right upper extremity, front chest, abdomen, right thigh twice a day for 14 days for itching. Another physician's orders [REDACTED]. On 7/19/16 at 3:20 p.m., Physician 1 stated he understood our concern about Resident 1's rash. Physician 1 stated he had scraped (skin testing) for scabies (a condition of very itchy skin caused by tiny mites that burrow into your skin. The itching is caused by an allergic reaction to the mites), but it was negative. Physician 1 stated he would consider treating Resident 1 empirically (provided by physicians based on their observations and experience prior to a definitive [DIAGNOSES REDACTED]. for approval. A review of Physician 2's progress note, dated 7/19/16, and timed at 6 p.m., deciphered by the director of nurses (DON), indicated Resident 1 was still itching, generalized; but skin much improved. Physician 2 document the plan was to continue Trazadone (antidepressant medication) for the itching. On 7/20/16 at 10 a.m., during an interview, Resident 1's family member (FM1) stated that she had been trying to get a dermatologist consult for Resident 1, but was unable to do so. FM1 stated she had asked the facility if she could transfer Resident 1 to the dermatologist clinic to remedy the itching and scratching. FM1 stated Resident 1's primary physician (Physician 2), indicated Resident 1's itching and scratching was just in Resident 1's mind. FM1 stated she was told that [MEDICATION NAME] will treat Resident 1's itching and scratching behavior. At 10:30 a.m., on 7/20/16, during Resident 1's skin and wound care observation with LVN 6, Resident 1 was observed to have many scratches on his upper chest with redden round spots on the abdomen, upper extremities, arms, lower extremities, and right thigh. At 8 a.m., on 7/21/16, Resident 1 was observed lying in bed, comfortable, no restless behaviors, no agitation, no facial grimacing or frowning. Resident 1 was relaxed and calm. On 7/21/16 at 9:20 a.m., LVN 5 stated Resident 1 looked better, less scratching and itching, and looked more comfortable after having [MEDICATION NAME] lotion added to the treatment plan for Resident 1's itching episodes. On 7/21/16 at 10 a.m., while at Resident 1's bedside, Resident 1 was observed resting quietly with no scratching observed. CNA 2, Resident 1's primary care nurse for the day, stated Resident 1 had less itching and scratching episodes that morning. CNA 2 stated Resident 1 looked more calm and comfortable. On 7/21/16 at 1:55 p.m., during a telephone interview, Resident 1's primary care physician, Physician 2, stated he was aware that [MEDICATION NAME] had a black box warning. Physician 2 stated, A fell ow physician told me I should try [MEDICATION NAME] for the resident's (Resident 1) rash, since I had tried other thing, but was not successful. Physician 2 stated he had not ordered a psychiatric evaluation (mental health assessment) prior to prescribing the antipsychotic medications for Resident 1. A review of Resident 1's July 2016 MARs indicated prior to Resident 1 receiving [MEDICATION NAME] lotion and antibiotic ointment on 7/19/16, he had many episodes of itching documented. The MAR indicated [REDACTED]0 itching episodes documented by LVN 5. b. On 7/20/16 at 7:58 a.m., during a medication administration observation, Resident 24 was observed eating breakfast. A licensed vocational nurse (LVN1) interrupted Resident 24's breakfast to administer one capsule of [MEDICATION NAME] 5 milligram (mg). A review of Resident 24's Admission Face Sheet indicated Resident 24 was admitted to the facility on [DATE]. Resident 24's [DIAGNOSES REDACTED]. breath). A review of Resident 24's annual Minimum Data Set (MDS), a resident assessment and care screening tool, dated 6/15/16, indicated Resident 24 had some memory problems, mild impairment with decision-making, but was able to make needs known and understand others. According to the MDS, Resident 24 was assessed as being dependent with bed mobility, transferring, and locomotion on and off the unit, and required supervision with eating and limited assistance with personal hygiene. A review of Resident 24's care plan, initiated on 6/22/15 and 7/3/16 identified a problem with nutritional status secondary to poor oral intake related to anorexia (a lack of appetite for food). Resident 24's goals were to minimize the resident's risk of weight loss and any unplanned weight changes daily. The staff interventions included to provide diet as ordered, offer food substitutes (if resident refused meal tray or poor intake), and give [MEDICATION NAME] 5 mg three times a day (TID) before meals, as an appetite stimulant at 7 a.m., 12 p.m., and 5 p.m. A review of a Medication Regimen Review (MRR), completed by the pharmacist consultant, dated 3/7/16, indicated Resident 24 continued on [MEDICATION NAME] 2.5 mg by mouth two times a day (BID) at 12 noon and 5 p.m. for an appetite stimulant since 8/12/15. The MRR indicated Resident 24's weight was as follow: On 8/6/15 and 9/4/15; it was 127 lbs. On 10/8/15; it was 125 lbs. On 11/5/15 and 12/5/15: it was 123 lbs. On 1/7/16, it was 125 lbs. On 2/8/16; it was 123 lbs. On 3/5/16; it was 121 lbs., for an overall weight loss of six lbs. in seven months. The pharmacist consultant suggested the physician to review the weight patterns to reassess the effectiveness of the ongoing [MEDICATION NAME] therapy. A physician's telephone order, dated 3/17/16, and timed at 5:30 p.m., indicated to discontinue the [MEDICATION NAME] 2.5 mg and increase the dosage to [MEDICATION NAME] 5 mg one capsule by mouth, TID, before meals (AC) at 7 a.m., 12 p.m., and 5 p.m., as an appetite stimulant. On 7/21/16 at 8:55 a.m., LVN1 was asked about the purpose of [MEDICATION NAME] and when it should be administered. LVN 1 stated, It is supposed to stimulate his (Resident 24) appetite, and I gave it later than I was supposed to. On 7/21/16 at 2:33p.m., during a phone interview, Resident 24's physician stated, Yes, [MEDICATION NAME] is to be given prior to meals, three times a day, so that the resident will put on weight. If given during a meal the medication is not effective. According to DailyMed (an online medication resource), [MEDICATION NAME] is a drug used as an appetite stimulant and the drug is most effective when administered prior to meals (<https://dailymed.nlm.nih.gov>). The facility's undated policy and procedure titled, Med Pass for Duration of Med Pass, Section B, indicated Special- time meds are to be given as close to the time as possible. Special time meds may include: AC (before meals), PC (after meals), meds to be given with meals, meds to be given at a specific time according to order.

Based on observation, interview and record review, the facility failed to provide treatment and services to ensure Resident 1 who entered the facility without a pressure sore did not develop pressure sores to the right and left heels. After the pressure sores developed, the facility failed to ensure the necessary treatment and services were provided to promote healing of the left heel pressure sore. The resident was not provided with a pressure relieving surface in bed ordered by the physician on admission. A left heel discoloration was not promptly assessed, the left heel was not kept off pressure, the registered dietitian (RD) was not consulted for nutritional recommendations, and the RD did not ensure the resident's nutritional needs were met after the insertion of a gastrostomy tube (GT - placement of a tube into the stomach to provide nutrition and medications).The resident's oral intake of supplemental nourishment was not accurately monitored and the oral administration of the supplemental nourishment was not re-evaluated. Resident 1's left heel pressure sore evolved affecting skin, fascia, fat, muscle, and bone, required sharp serial debridement, incision, and draining, and the wound bed was 100 percent covered with eschar (a dry necrotic tissue). Findings: On 1/31/11 at 9:05 a.m., an unannounced visit was made to the facility to investigate a complaint related to quality of care. According to the admission record, the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial nursing admission assessment record on 12/10/10 and the reassessment record dated 12/11/10 indicated the resident had no pressure sores, but multiple discolorations and a necrotic left fourth toenail. There were no discolorations to the heels documented. A Wound Risk Assessment form dated 12/11/10 indicated the resident total score was 5, moderate risk for skin breakdown. On 1/31/11, a review of the physician's orders [REDACTED]. Physical therapy (PT) and occupational therapy (OT) evaluation and treatment, and the use of an alternating pressure pulse mattress (a pad/overlay mattress divided into chambers which are filled with air alternately from an electric pump) for skin management. On 12/13/10 the physician ordered speech therapy (ST) evaluation. The ST recommended and obtained an order, on 12/13/10, to change the diet to a mechanical soft diet with thick liquid (no consistency stated). The physician ordered ST treatment five times a week for four weeks. The ST weekly progress note dated 1/31/11 indicated the resident had poor intake and made little progress with the therapy. According to the Nutritional Assessment form, the RD first evaluated the resident on 12/16/10 and indicated the resident's weight on admission was 134 lbs, the ideal body weight ranged from 108 to 132 lbs, the resident's daily calorie requirement was 1300 kilocalories (kcal), the protein requirement was 75 to 90 grams, and the fluid requirement was 1800 cc. The RD indicated that the [MEDICATION NAME] level dated 12/14/10 was 2.3 g/dl, moderately depleted. The RD documented the resident had variable intake 30 to 75 percent of oral intake, recommended oral multivitamins with minerals daily (ordered on [DATE]) and high protein nourishment 4 ounces twice a day between meals to add 400 kcal and 12 grams of proteins (ordered on [DATE]). The RD assessed the resident at high nutritional risk. According to the weekly weighs recorded since admission, the resident's weight on 12/17/10 was 126 (a weight loss of 8 lbs in one week), on 12/24/10 the weight was 122 (4 lbs weight loss in one week), on 12/31/10 and 1/11/11, the weight was 119 (a loss of 3 lbs in one week which totaled 25 lbs in one month). There was no documented evidence the RD was notified on 12/17/10 of the resident's weight loss of 8 lbs in one week. According to the initial MDS (Minimum Data Set - standardized assessment and care plan tool) dated 12/17/10, the resident rarely or never understood others or made herself understood, had short and long-term memory problem, was severely impaired for daily decision-making, and was totally dependent of staff for all ADLs including bed mobility, transfers, and eating. The resident had no pressure sores, the weight was 126 lbs, and had a 5 percent or more weight loss in the last month. The Care Area Assessment (CAA) Summary from the MDS dated [DATE], indicated the assessment triggered the care areas of nutritional status and pressure sores and these care areas were addressed in a care plan. The plan of care developed on admission for the resident's risk for skin breakdown included in the approaches to have RD consults as needed, provide diet and supplements as ordered, monitor the resident's skin every shift, and provide pressure relieving devices as ordered. The plan of care developed on admission for the resident's alteration in nutrition included in the approaches to provide diet and supplements as ordered, RD consults as indicated, monitor food intake, monitor weights, and report any weight gain/loss of 5 lbs or more to the physician. A review of the physician's progress note dated 12/19/10 indicated the resident had 8 lbs weight loss and ordered [MEDICATION NAME] 40 mg twice a day as appetite stimulant, Restorative Nursing Assistant (RNA) feeding program three times a day, and Ensure (a high calorie nutritional supplement) one can (eight ounces) orally three times a day with meals. The dose for [MEDICATION NAME] was changed on 12/29/10 to 200 mg orally twice a day. The RNA feeding program was changed on 12/23/10 to twice a day as requested by the family. The Ensure order was increased to four times a day on 1/4/11 due to a laboratory test result showing an [MEDICATION NAME] level of 2.4 gm/dl (below the reference value ranging from 3.4 to 4.8). The protein level was 4.8 gm/dl (below the reference value ranging from 6.4 to 8.3). [MEDICATION NAME] is the most abundant protein in blood serum. Decreased level of [MEDICATION NAME] may indicate severe [MEDICAL CONDITION]. Total protein level measures all major blood proteins and decreased levels may indicate [MEDICAL CONDITION] (Lippincott William & Wilkins, Diagnostic Tests Made Incredibly Easy!-2nd edition, 2009, Pages 44-47) The Restorative Dining Program Daily Notes from 12/20/10 to 1/9/11 indicated the resident refused breakfast and lunch from 12/27/10 to 1/2/11, on 1/8/11, and 1/9/11. The other days the resident consumed between 10 to 80 percent and refused at least one meal on three days. The resident received intravenous antibiotic for urinary tract infection for five days from 12/30/10 to 1/3/11, and again on 1/6/11 for one day. On 1/5/11 the physician referred the resident for a GT insertion that was scheduled on 1/10/11. The GT feeding formula ordered on [DATE] indicated [MEDICATION NAME] 1.2 at 40 cc per hour for 20 hours per day. The order for oral administration of Ensure and high protein nourishment was not changed. The oral diet was changed on 1/12/11 to a puree diet for oral gratification. According to the undated facility's policy and procedure on Resident Weight Losses and Gains, all residents who exhibit a significant weight gain or loss will be evaluated by the consultant RD for dietary interventions. Although the resident had poor oral intake, significant weight loss, and abnormal laboratory test results suggesting [MEDICAL CONDITION], there was no referral to the RD after 12/16/10. The second RD evaluation was conducted on 1/10/11, the same day the resident had the GT inserted. Although the RD noted that the GT feeding formula only met 50 percent of the resident's nutritional needs (960 kcal instead of the 1300 kcal required, 44 grams of protein instead of the 75-90 the resident required, and 800 cc of fluids instead of the 1800 cc required), the RD documented the rest of the needs would be met with the oral diet. There was no further RD documentation; the RD did not re-evaluate the resident's oral intake to ensure adequate nutrition. On 1/31/11, a review of the Certified Nursing Assistant ADL (activities of daily living) Sheet dated 1/5/11, Certified Nursing Assistant 2 (CNA 2) documented that the resident was noted to have a black and blue area on the left heel which was reported to the charge nurse. The undated facility's policy on Skin Care (Body Check), indicated to look for color changes, redness, blueness, graying, blackening, and white spots. Inspect the resident's skin often, and complete the daily body check log, note any changes in the skin, and notify the charge nurse. A review of the 3-11 Shift Daily Body Check Log revealed CNA 2 documented on 1/5/11, 1/6/11, 1/7/11, 1/8/11, and 1/9/11 the resident had a black and blue discoloration on the left heel. On 1/31/11 at 3:30 p.m., during an interview, CNA 2 confirmed that on 1/5/11, she noticed a black and blue area on the resident's left heel and reported it to the charge nurse. A review of the licensed nurses' notes during the same period of time revealed the licensed nurses did not address the black and blue area to the left heel documented by CNA 2. It was not until 1/10/11 at 7 a.m., (five days later) that Treatment Nurse 1 documented that staff reported to her that Resident 1 had a black wound on the left heel, but the resident left the facility to have the GT insertion. At 3 p.m., after the resident returned to the facility with the GT in place, Treatment Nurse 1 documented a left heel black deep tissue injury (DTI). DTI is defined as a purple or maroon localized area of discolored intact skin or blood -filled blister due to damage of underlying soft tissue from pressure and/or shear. (Fleck, Cynthia, Wound Care Canada, Volume 5, Number 2, 2007, Page 10). The left heel wound measurement was 6 cm in length by 5 cm in width, with undetermined depth secondary to the dark/purple hard area. The site was tender to touch. Treatment Nurse 1 also documented the resident had a suspected DTI in the right heel, described as red, non-blanchable (persistent redness that does not disappear when pressure is relieved), and tender to touch. The wound measured 4.3 cm in length by 4 cm in width with an undetermined depth due to the non-blanchable area. The physician was notified and obtained treatment orders and consultation with a physician wound specialist. On the same day, 1/10/11, the physician ordered daily liquid protein 30 cc, by the GT, to help with the wound healing. On 1/11/11 a laboratory test result indicated the Pre-[MEDICATION NAME] level was 10.8 mg/dl (below the reference value ranging from 18.0 to 45.0). [MEDICATION NAME] is a protein produced primarily in the liver. It has a short half-life (2 days), which makes it a good indicator of nutritional status. (Lippincott William & Wilkins, Diagnostic Tests Made Incredibly Easy!-2nd edition, 2009, Pages 44-45) The [MEDICATION NAME] was 2.4 gm/dl (below the reference value ranging from 3.4 to 4.8).The total protein level was 4.9 gm/dl (below the reference value ranging from 6.4 to 8.3). There was no documented evidence the RD was informed of the abnormal tests suggesting [MEDICAL CONDITION]. According to the assessment of the physician wound specialist dated 1/11/11, both heel [MEDICAL CONDITION] were suspected DTI and probably developed secondary to immobilization. The left heel was assessed as measuring 2.5 cm in length by 4 cm in width with an undetermined depth. The wound bed was covered 100 percent with eschar and the tissue involvement was unknown. The consulting physician documented performing sharp debridement (removal of dead tissue), incision and drainage of skin and fascia (a fibrous tissue between muscles). The treatment plan included serial debridement, local wound care with Santyl ointment (a [MEDICATION NAME] agent), and off loading with ankle bolster (a device to eliminate friction or provide support). The consulting physician assessed the right heel as having slight [DIAGNOSES REDACTED] (redness). The follow-up visit by the consulting physician was dated 1/20/11 and indicated the right heel had no wound. The left heel was assessed as measuring 2.1 cm in length by 1.8 cm in width with an undetermined depth. The wound bed was covered 100 percent with eschar and the tissues involved were skin and fascia. The consulting physician documented performed sharp debridement of skin and slough/eschar (a dry slough). The treatment plan included serial debridement, continue treatment with Santyl ointment, and off loading with ankle bolster. Another follow-up visit by the consulting physician was dated 1/28/11 and indicated the right heel lesion was resolved. The left heel was assessed as measuring 2.2 cm in length by 2.1 cm in width with an undetermined depth. The wound bed was covered 100 percent with eschar and the tissues involved were skin, fascia, fat, muscle, and bone. The consulting physician documented performing sharp debridement of skin and slough/eschar. The treatment plan was serial debridement, continue current treatment with Santyl ointment, and off loading with ankle bolster and multipodus boot (boot commonly used to decrease pressure or friction on the heel, and to prevent of foot/ankle contractures). On 1/31/11, at 9:55 a.m., Resident 1 was observed lying in bed, on her back, and had a GT for feeding. The resident was unable to communicate her needs and her eyes remained closed. The mattress noted on the bed was not a pressure relieving mattress and there was no pressure relieving surface over the mattress. The resident's heels had heel protectors and the feet rested in direct contact with the mattress. The heels did not have any device to keep pressure off the heels and/or feet. Treatment Nurse 1, who was present at the time of the observation, stated the resident should have the heels off pressure, on a floating position. Treatment Nurse 1 stated she did not know if the resident should have a pressure relieving mattress. At 10:20 a.m., the left heel was observed with Treatment Nurse 1 and the director of nursing. The left heel wound was noted black in color with irregular edges and the resident had facial grimacing at the start of the treatment. Treatment Nurse 1 measured the left heel wound revealing a length of 2.3 cm, the width was 2.5 cm and the depth was undetermined due to the black tissue. A follow up observation of the resident was conducted on 2/2/11 at 8:55 a.m., with the director of nursing. The resident was lying in bed, on her back, on a regular mattress. There was no pressure relieving surface in the bed. On 2/2/11 at 1:35 p.m., an interview with the director of nursing and Treatment Nurse 1 revealed they were not aware of the physician's orders [REDACTED]. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, the percentage consumed by the resident was not documented. According to the Certified Nursing Assistant ADL Sheet, since 1/10/11, the CNAs were documenting in the section for snack and meals that the resident had a GT. The CNAs did not document giving the resident any food by mouth. On 2/2/11, at 10 a.m., an interview with CNA 3 (routinely assigned to the resident during the day shift) revealed the resident does not get nourishment. CNA 3 stated the resident is served meals for oral gratification but eats little. On 2/3/11, at 8:45 a.m. an interview was conducted with LVN 3 (Licensed Vocational Nurse - routine charge nurse), and was followed by a written declaration. LVN 3 stated the licensed nurses give the Ensure to the resident and the CNAs give the high protein nourishment which is supplied by the kitchen staff. LVN 3 stated he did not get reports from CNAs that the resident was not taking the nourishment and did not know how much the resident was taking each time. On 2/3/11, at 12:30 p.m., the dietary service supervisor confirmed the nourishment is supplied by the kitchen for the CNAs to give to the residents. The dietary department had a list of residents who had order for nourishment and Resident 1 was in the list. There was no documented evidence the nursing staff was providing Resident 1 with the diet and supplements as ordered and there was no accurate monitoring the resident's oral intake as stated in the plan of care. Although the RD evaluated Resident 1 on 1/10/11, the same day the pressure sores on both heels were identified by Treatment Nurse 1, the RD did not address the presence of skin problems to the heels and made no recommendations to promote healing. There was no further referral for RD evaluation as stated in the plan of care. There was no revision of the oral administration of the Ensure and the high protein nourishment after the resident was placed on the GT. On 2/2/11, at 2:40 p.m., during an interview, the RD stated she was never informed of the resident's development of wounds to the heels. The RD also stated that if the resident's oral intake was not enough, the GT feeding formula should have been increased to meet the resident's nutritional needs. On 2/3/11, at 12:30 p.m., during an interview, the dietary service supervisor stated she did not notify the RD of the pressure sores because the treatment nurse did not provide her with the weekly skin report. On 2/3/11 at 3:40 p.m., during a telephone interview, Resident 1's responsible party stated that she visits the resident 1 to 3 times per week and finds her lying in bed, on her back, with the feet resting against the mattress.

Based on interview and record review, the facility failed to provide the necessary care and services in accordance with the comprehensive assessment, physician's orders [REDACTED]. Resident 3, had a fall and sustained a head injury with a left ear bleeding on [DATE] at 10:10 p.m., and the resident was not promptly transferred to an emergency room resulting in complications from the head injury. The facility failed to immobilize the resident after the fall with injury occurred. The facility failed to monitor the resident's vital signs and neurological status. Resident 3 was evaluated at the emergency room 1 hour and 55 minutes after the head injury occurred, and was diagnosed with [REDACTED]. Resident 2, who was identified by a physical therapy staff on [DATE] to have developed pain to the left hip associated with movements and ambulation, was not assessed for pain, contributory factors, and there were no interventions developed to prevent complications. There was also no evidence of training on safe techniques to transfer the resident when in pain. On [DATE], after the resident sustained [REDACTED]. On [DATE], the resident was diagnosed with [REDACTED]. Findings: a. On [DATE] at 9:05 a.m., an unannounced visit was made to the facility to investigate a complaint related to quality of care. According to Resident 3's closed clinical record review, the Admission and Discharge Summary sheet (face sheet) indicated the resident was [AGE] years old, initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS (Minimum Data Set - a standardized assessment and care planning tool) dated [DATE] disclosed Resident 3 as moderately impaired for daily decision-making; sometimes was able to make himself understood and understand others. The resident required limited assistance from staff for bed mobility, transfers, and toilet use, and required extensive assistance with one person physical assist to walk. The resident had fallen in the past ,[DATE] days and was at risk for falls. On [DATE], a review of the nurses' notes revealed the resident sustained [REDACTED]. On [DATE] the physician ordered a low bed and a pad alarm while in bed. According to the nurse's notes dated [DATE], Licensed Vocational Nurse 1 (LVN 1) documented that at 10:10 p.m., Resident 3 was found on the floor, on his back, with blood coming out of his left ear, with redness on the back of the head, and was complaining of back pain. The resident was awake, alert, and able to move all extremities. At 10:15 p.m., LVN 1 informed the physician of the fall with bleeding from the left ear and received the order to transfer the resident to a specific acute care hospital emergency room . At 10:25 p.m., LVN 1 called the ambulance service and was given an estimated time of ,[DATE] minutes for the ambulance to pick up the resident. At 11:45 p.m., 1 hour and 10 minutes later, when the resident was picked up by the ambulance, he was still bleeding from the left ear. Between 10:25 p.m. and 11:45 p.m., there were no vital signs and neurological status evaluation documented. According to the undated facility's policy and procedures on Emergency Response to Fall/Fracture, the objective included to evaluate the total extent of the injury, administer emergency care, relieve pain, control bleeding, and prevent complications. The procedures included to leave the resident in position if injury had occurred, take vitals signs, and obtain assistance for transfer to an acute hospital as quickly as possible. According to the undated facility's policy and procedures on Falls, a neurological assessment (which includes level of consciousness, reflexes, changes in movement, sensation, and strength) will be conducted for 72 hours to evaluate any neurological deficits significant changes in the resident's level of consciousness. On [DATE], a review of the licensed nurse's notes dated [DATE], revealed that after the fall with head injury, the documentation did not include any vital signs values, and was limited to state the vital signs were stable. There was no documented evidence of a neurological evaluation to monitor the resident's level of consciousness and complications after the head injury had occurred and while waiting to be transported. A review of the Patient Care Report from the ambulance service revealed that on [DATE] at 11:37 p.m., the resident was found sitting in a wheelchair at the nursing station, and had been moved by the facility staff before the crew could evaluate if a C-spine (neck collar immobilizer) was needed. The ambulance crew assisted the resident with walking to the gurney and the vital signs were monitored. The resident was still bleeding from the left ear and also from the nose, when became less responsive, the resident was transported to a different hospital from the one specified by the physician. A review of the emergency room record revealed the resident arrived on [DATE] at 12:05 a.m., 1 hour and 55 minutes after the injury occurred, with bright red blood oozing from the left ear canal and dried blood on the nares. A computerized tomography (CT-a radiological diagnostic test) scan of the head performed on [DATE] at 1:20 a.m., reported an acute left subdural and subarachnoid hemorrhage and a non-displaced longitudinal left temporal bone fracture extending to the attic of the middle ear cavity. Resident 3's condition deteriorated and on [DATE] was discharged to the facility with orders for hospice care, and comfort measures only. According to the facility's nurse's note dated [DATE], Resident 3 expired at 2:15 a.m. On [DATE] at 10:35 a.m., during a telephone interview, the attending physician stated the nurse who called to report the resident's fall, did not report the resident had obvious trauma. The physician further stated that if the resident had obvious trauma and was bleeding from the nose and ear, 911 (paramedics) should have been called. On [DATE] at 3:30 p.m., during an interview, LVN 1 stated that when she called the attending physician to report the injury the resident was stable and she asked the physician if 911 should be called. However, the physician did not order to call 911 and a regular (non-emergency) transportation was called. LVN 1 also stated she was aware that the resident's bleeding from the ear was a sign of head injury. b. On [DATE], a review of Resident 2's Admission and Discharge Summary Sheet (face sheet) indicated the resident was an [AGE] years old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Pain Risk Assessment form dated on [DATE] indicated the resident had intermittent confusion and had no pain present. The admitting physician's orders [REDACTED]. The Pain Assessment/Management form indicated the pain rating scale used was from zero (no pain) to 10 (worst possible pain). The History and Physical signed by the attending physician on [DATE] indicated the resident was forgetful and did not have the capacity to understand and make decisions. On [DATE] the attending physician ordered physical therapy (PT) treatments five times a week for four weeks for balance, mobility, transfer training, therapeutic exercises, progressive balance/gait training, caregiver training, and group treatment. The Physical Therapy Initial Evaluation form signed and dated by the registered physical therapist (RPT) on [DATE], indicated the resident required maximum assistance with transfers from sitting to standing and from bed to wheelchair. The standing balance was poor, the gait was slow, unsteady, had full weight bearing, and required maximum assistance with gait and a front wheel walker. Both lower extremities had range of motion within functional level. The resident was assessed at risk for falls. A plan of care developed on [DATE] for Resident 2's potential for falls related to history of falls included an the approach to use one person assist with transfers, toilet transfers, standing, and walking. The plan of care developed on [DATE] for Resident 2's decreased functional mobility, strength, and gait, included an approach for skilled PT. There was no plan of care developed for pain management in the event Resident 2 developed pain. According to the Physical Therapy Treatment Record form, on [DATE], Physical Therapist Assistant 1 (PTA 1) documented that during the afternoon treatment (no time specified), Resident 2 complained of "shooting" pain to the left hip with movement of the left lower extremity rated ,[DATE] (moderate pain). PTA 1 indicated nursing was notified of the pain. On [DATE] PTA 1 documented the resident had minimal pain (no rating value stated) and increased soreness with left lower extremity mobility. There was no documented evidence nursing staff was notified of the pain. On [DATE] PTA 2 documented Resident 2 was seen in a group setting and had left hip pain rated ,[DATE]. There was no documented evidence nursing staff was notified of the pain. There was no documentation nursing administered the resident a pain medication. According to the attending physician's progress note, on [DATE], the resident complained of pain when ambulating and on the same day, [DATE], the physician ordered Tylenol 650 mg every 9 a.m. and 4 p.m. According to the undated facility's Change of Condition policy, a marked change in movement (pain upon movement) was a change of condition. The policy also indicated the licensed nurses will ensure proper assessment and documentation as evidenced with care planning and interdisciplinary team conference if indicated. The undated facility's policy and procedure on Pain Management indicated the pain management program is individualized according to the resident's needs and is updated as needed. Clear documentation of pain assessment and a plan of care shall be completed and maintained by the nursing staff. Non-pharmacological interventions shall be utilized as part of the pain management. Staff is to utilize the Pain Assessment Flow sheet for ongoing evaluation, documentation of interventions, and determining efficacy of pain control. It is recommended that documentation of pain management occur every shift unless it is determined that a different frequency of evaluation would be more appropriate. On [DATE], a review of the nurses' notes revealed there was no documentation addressing the resident's pain reported by PTA 1 on [DATE], and there was no evidence that the Tylenol ordered on admission as needed for pain was given until the physician ordered routine Tylenol on [DATE]. There was no documented assessment by the nursing staff of Resident 2's pain, effectiveness of the pain medication, contributory factors to the pain and non-pharmacological interventions attempted. There was no evidence of an interdisciplinary team conference with input from the RPT for recommendations to prevent complications from the pain associated with movements and walking. There was no evidence of caregiver training on safe techniques for transfers and walking Resident 2 when he complained of pain to the left hip. On [DATE] at 1:30 p.m., during an interview, the RPT acknowledged the resident's pain to the left hip should have been addressed. On [DATE] at 4 p.m., during another interview, RPT confirmed there was no caregiver training provided as stated in the plan of care. RPT explained that caregiver training is given when the resident is strong and is safe to be transferred by the caregiver, however, Resident 2 was not strong/stable enough. According to the nurses' notes, LVN 1 documented on [DATE] at 3 p.m., while Certified Nursing Assistant 1 (CNA 1) was assisting Resident 2 to the bathroom, the resident squatted, complained of pain rated ,[DATE] (worst pain possible) on his right femur (upper leg) and was assisted by CNA 1 to the floor. The physician was notified and ordered an x-ray and Tylenol #3 one tablet every six hours as needed for pain. Another nurse documented at 3:30 p.m. Resident 2 was in his room, sitting in a wheelchair, complaining of pain rated ,[DATE], had swelling to the right leg and was unable to move the leg. The resident was transferred to his bed with the assistance of two CNAs and was administered Tylenol #3 as ordered. The x-ray report at 6:30 p.m. indicated a fracture to the neck of the right femur with displacement. At 7 p.m., the physician ordered the resident to be transferred to an acute hospital. A written declaration by CNA 1 dated [DATE], indicated that on [DATE], after lunch (no specific time of the fall was given), when she was assisting Resident 2 to use the bathroom, the resident's leg bent and he could not stand up. CNA 1 helped the resident to the floor and he was complaining of pain in his upper leg. CNA 1 got help from CNA 2 and LVN 1 and sat the resident on the toilet. After using the toilet CNA 1 and LVN 1 transferred the resident to his wheelchair. The resident was still complaining of pain but wanted to sit in the wheelchair because he had visitors. The undated facility's policies and procedure on Transfer Belts and Gait Belts, indicated the purpose was to reduce incidents of employee and resident injury and to provide additional sense of security for the residents. All employees are to use transfer belts when transferring residents. The belt is securely applied around the resident's waist. However, on [DATE] at 9:45 a.m., an interview with CNA 1 revealed she did not use a gait belt while transferring Resident 2 to the toilet. CNA 1 acknowledged she was aware of the gait belt policy. According to the undated facility's policy and procedure on Emergency Response to Fall/Fracture, the objective included to evaluate the total extent of the injury, administer emergency care, relieve pain, control bleeding, and prevent complications. The sign and symptoms included pain, tenderness, [MEDICAL CONDITION], an inability to move the injured area. The procedures included to apply a splint if extremity is involved, leave the resident in position if injury had occurred, handle the injured area as little as possible, and obtain assistance for transfer to an acute hospital as quickly as possible. However, this policy and procedure was not implemented. According to the undated facility's policy and procedure on Falls, any affected limb will be immobilized as needed. However, there was no documented evidence the resident's limb was immobilized. Further record review revealed there was no documented evidence Resident 2's extent of the injury was evaluated, and there was no evidence the resident was immobilized after he was on the bathroom floor complaining of severe pain to the right leg and unable to move the leg. The resident was manually transferred by staff from the floor to sit on the toilet bowl, then to sit in a wheelchair, and then to lie in bed without any immobilizing device to prevent further injuries and complications. On [DATE] at 4:50 p.m., during an interview, the director of nurses stated that when an injury/fracture is suspected, immobilization is needed to avoid further injuries. According to the acute hospital records, on [DATE], Resident 2 underwent right hip hemiarthroplasty for a right hip subcapital fracture displacement. The resident was discharged from the acute hospital to another skilled nursing facility on [DATE] as requested by the resident's responsible party.