Every finding on record at Kei-Ai los Angeles Healthcare Center

Based on interviews and record review, the facility failed to ensure one of six sampled residents (Resident 1) had her right to personal privacy protected while taking a shower when Certified Nursing Assistant 1 (CNA1) used his personal cell phone for personal reasons while providing shower care. This failure resulted in Resident 1 reporting that she believed CNA1 had used the cell phone to record her while she was unclothed and receiving personal care. Although CNA1 denied recording Resident 1 and the facility's review of CNA1's cell phone did not identify a recording, CNA1 acknowledged using his personal cell phone to check a text message during the resident's shower and acknowledged that he should not have been using the phone for personal reasons while providing care.During a review of Resident 1's admission Record, dated 8/28/2026, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of vertebra fracture (a break, crack, or collapse in one of the 33 bones (vertebrae) that make up your spinal column), depression (common and serious illness that negatively affects how one feels, thinks and acts), and severe psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 8/9/2026, indicated Resident 1 had intact cognition (ability to think, remember and reason) the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decision making. The MDS indicated Resident 1 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for oral hygiene, roll left and right, sit to lying, lying to sitting on side of bed, maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to shower, upper body dressing, lower body dressing, putting on taking off footwear, sit to stand, chair/bed to chair transfer, and was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for toileting. During a phone interview on 8/28/2026 at 11 AM with Resident 1's Family Member (FM), FM stated that on 8/25/2026 at approximately 10 PM, facility staff contacted him to notify him that Resident 1 had made a report that CNA1 had recorder her with his phone while she was taking a shower in the shower room of the facility. FM stated he went to the facility the next day on 8/26/2026 and filed a report in writing regarding Resident 1's allegations. FM stated that sometimes Resident 1 says things that do not make sense, but he wanted this report to be fully investigated because Resident 1 had never made allegations of this nature. FM stated Resident 1 was at home upon his request due to the allegation made by Resident 1.During a phone interview on 8/28/2026 at 11:42 with Resident 1, Resident 1 stated that on 8/25/2026 at approximately 2:30 PM, she believed CNA1 had used his cell phone to record her while she was receiving shower care. Resident 1 stated she believed that upon CNA1 closing the shower curtain, he pulled out his phone and believed he was recording her. No witnesses were able to validate this allegation. Resident 1 also reported that CNA1 touched her inappropriately during the shower. No witness to the alleged inappropriate touching was identified. Resident 1 reported the alleged conduct approximately seven hours after the shower. Resident 1 was unable to provide clear details regarding the incident and stated that she had already talked to a lot of clinicians and detectives regarding the incident. During a phone interview on 8/28/2026 at 1:18 PM with CNA1, CNA1 stated he was assigned to care for Resident 1 on 8/25/2026 from 7AM to 3PM, and throughout his shift, he had stopped by Resident 1's room three times to change her adult brief but Resident 1 refused to get changed every single time. CNA1 stated that at approximately 2PM, he went to Resident 1's room to do a last check on Resident 1 and asked if she'd prefer to get changed at that time. Resident 1 refused. CNA1 reported the refusal to the Licensed Vocational Nurse 1 (LVN1) who was in charge for the day, and the LVN1 asked CNA1 to offer her a shower since she had not been showered on her regular day which was Monday 8/24/2026. CNA1 stated he asked Resident 1 in English if she'd prefer a shower on Tuesday 8/25/2026 and Resident 1 agreed. CNA1 stated he prepared the supplies and took Resident 1 to the shower room. CNA1 stated Resident 1 was able to independently bathe herself, he just handed her the wash cloth and soap. CNA1 stated he did not bathe Resident 1 at all during the bath. CNA1 stated after handing Resident 1 the washcloth, he closed the shower curtain and admitted to reaching for his personal phone to check his text messages, but denied ever recording Resident 1 or touching Resident 1 inappropriately. CNA1 stated after Resident 1 finished bathing herself, he helped dry her from above the knee down to her toes, and never touched her genitalia. CNA1 stated he was aware of facility policy which does not allow staff to check their personal phones during resident care or work hours. CNA1 stated he had failed to comply with facility policy and this allegation by Resident 1 could have been prevented if he had complied with facility policy. During an interview on 8/28/2026 at 2:43 PM with the Director of Nursing (DON), the DON stated staff are educated on facility policy regarding cell phone use, and new employees are provided an employee handbook which reviews facility policies, expected standards of practice, and philosophy of care. The DON stated upon learning of Resident 1's allegation, CNA1 was interviewed, his phone reviewed for inappropriate videos related to Resident 1's allegation, and suspended pending internal facility investigation. The DON stated that CNA1's use of the cell phone during Resident 1's shower created an unnecessary misunderstanding and concern regarding the resident's privacy that could have been avoided if CNA1 had not pulled out and used his personal cell phone. The DON stated that CNA1's cell phone was reviewed, and no recordings of Resident 1 were identified. During a review of the facility's Employee Handbook, dated 2026, indicated personal phones are only permitted for use during break times, away from patient and common areas of the facility. Employees may not use a handheld device in any manner that violates company policies. Personal cell phones may not be used while working, in resident care areas, and cameras of any kind are not permitted to protect the privacy of residents and employees.

Based on interview and record review, the facility failed to ensure residents were free from abuse and failed to report, investigate, and take action on allegations of abuse reported to facility staff on 3/11/2026, involving an outside contracted phlebotomist for two of three residents (Residents 1 and 2) reviewed for abuse concerns. This failure resulted in:Resident 1 reported that the phlebotomist was unprofessional, harsh, and rude during the procedure. Resident 1 stated that despite verbally telling the phlebotomist to stop, he continued inserting the needle, causing distress and discomfort.Resident 2 also reported the phlebotomist was rough and unprofessional. As a result of this experience, Resident 2 refused further services from the phlebotomist, which led to a delay in necessary lab work, treatment, and diagnosis.Other residents remained at risk of experiencing similar disrespect and potentially abusive care.During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of presence of left artificial knee joint following joint replacement surgery.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/11/2026, the MDS indicated Resident 1 had the cognitive skills to daily decision making. The MDS indicated Resident 1 required partial assistance to shower, ability to dress below waist, put on footwear, sit to stand, toilet transfer, and was independent to eat. The MDS indicated Resident 1 required supervision for oral hygiene, toileting, upper body dressing, sit to lying, roll left and right, and lying to sitting on side of bed. During a review of Resident 1's Nursing Progress Notes, dated 3/11/2026, the Nursing Progress Notes indicated staff was aware of Resident 1's complaints regarding the phlebotomist's conduct. The Nursing Progress Notes indicated Resident 1 asked the Phlebotomist to stop but continued what he was doing. The Nursing Progress Notes indicated staff explained to Resident 1 that the facility would report the Phlebotomist to the Core lab company Administrator. There was no documented evidence the facility took immediate action to ensure resident safety or prevent the phlebotomist from continuing to provide services to other residents.During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of Spinal Stenosis (is a chronic condition characterized by the narrowing of spaces within the spine, putting pressure on the nerves that travel through it). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had the cognitive skills to daily decision making. The MDS indicated Resident 2 required supervision to eat, partial assistance for oral hygiene, personal hygiene, roll left and right, maximal assistance for sit to lying, lying on side of bed, upper body dressing, and was dependent on staff for toileting, showering, lower body dressing and putting taking off footwear. During a review of Resident 2's Nursing Progress Notes, dated 3/11/2026, the Nursing Progress Notes indicated staff was aware of Resident 2's complaints regarding the phlebotomist conduct rude and harsh and Resident 2 refused blood to be withdrawn on 3/11/2026. The Nursing Progress Notes indicated the Charge Nurse tried to convince Resident 2 to get her blood drawn but Resident 2 adamantly refused. During a telephone interview on 3/24/2026 at 12 PM with Resident 1, Resident 1 stated she was still very upset at the incident that occurred on 3/11/2026 at the facility because the man who had tattoos who came to draw her blood was very rude as he did not introduce himself. Resident 1 stated she asked him for his name, and he did not respond to her with his name. Resident 1 stated the phlebotomist had no name badge or identification, he came in her room around 4 am and said he was going to draw her blood, she asked him why and who he was but he proceeded to insert the needle in her arm not using a tourniquet, and he was forceful almost in a stabbing manner and it caused her a lot of pain. She yelled at him to stop the procedure, but he continued to re-insert the needle to draw her blood. Resident 1 stated she felt her rights were violated and the incident caused her anguish and anxiety. This incident, along with other issues made her want to leave the facility against medical advice (AMA), so she called her husband to pick her up. Resident 1 stated the phlebotomist never provided her with his name, but her roommate (Resident 2) was a witness to the incident that happened on 3/11/2026.During an interview on 3/24/2026 at 1:19 PM with Resident 2, Resident 2 stated that on 3/11/2026 she heard the discussion between Resident 1 and the phlebotomist early in the morning around 4 AM. Resident 2 stated there was a male phlebotomist who was very rude, I heard when he came to draw her blood, I could hear her asking him for his name and asked him to stop poking her and she was screaming in pain, but she complained that he stabbed her with the needle anyway. She reported to this to the nurses when they came to talk to her later that morning. Resident 2 stated she had also experienced the same negative experience with the same phlebotomist on a previous date prior to 3/11/2026. In fact, after the first time he drew blood from her on 3/7/2026, her arm was bruised for a week. He came in my room didn't identify himself, said he was here to draw my blood, he was rough, I was trying to tell him I have small veins. He kept holding my arm down I told him it hurt and he told me to cool off. He came back again a week after on 3/11/2026 around 4 AM and once again he didn't acknowledge himself. He doesn't knock, just pulls the curtain open. I told him to get out. I was a certified phlebotomist for 25 years so I know his technique is not good at all. I reported to pinky next day. He left me bruises. He uses a stabbing technique. It hurt a lot. He came back a few minutes later with one of the male nurses that work night shift and the nurse asked me if I would let the phlebotomist draw my blood, I again told him no he's not touching me because he does not know how to properly draw blood and he inflicts pain despite me telling him that I have small veins and I already know I am a hard stick. The male nurse and the phlebotomist left the room and did not draw my blood. Resident 2 stated the interaction with the phlebotomist caused her distress.During an interview on 3/24/2026 at 1:41 PM with the Registered Nurse Supervisor (RNS), the RNS stated that on 3/11/26 the Charge Nurse informed her that Resident 1 was packing her bags stating she wanted to go home. The RNS stated she went to talk to Resident 1 who reported the incident with the phlebotomist, which the RNS then reported to the Case Manager and the Social Worker. The RNS stated Resident 2 also complained about the phlebotomist and tried to explain what she heard between Resident 1 and the phlebotomist. The RNS stated she attempted to call the core lab to identify the phlebotomist but was unsuccessful and also failed to document and follow up thoroughly, which placed residents at risk for continued harm. The RNS stated when a resident says I don't want this as it relates to services provided but staff continues to proceed with care or services, this could be identified as abuse and staff should have reported the issue to the Administrator to further investigate the concerns reported by Resident 1 and 2.During an interview on 3/24/2026 at 1:58 PM with the Case Manager (CM), the CM stated the morning of 3/11/2026, Resident 1 was adamant to leave the facility. Resident 1 expressed dissatisfaction with late medication, poor food quality, and reported that the phlebotomist did not introduce himself and caused pain during blood draw. The CM offered a grievance form, which Resident 1 declined. She refused to wait for the doctor, signed out AMA, and left with her husband. Resident 2 confirmed the phlebotomist was unprofessional and did not identify himself. The CM notified the Administrator about the resident leaving AMA and concerns about the phlebotomist on 3/12/26 but did not provide further incident details. No investigation into the phlebotomist's conduct had been conducted as of 3/24/2026. During an interview on 3/24/2026 at 2:08 PM with the Charge Nurse (CN), the CN stated that on 3/11/2026, while administering medications in the morning, she observed Resident 1 packing her belongings. The CN stated she informed the RN supervisor and Case Manager, who then went in to speak with Resident 1. The resident's husband was already present at the bedside. The CN stated regarding the phlebotomist, she is unfamiliar with his identity as they typically arrive before the start of the morning shift at 7:00 AM. The CN stated Resident 2 reported to her that a phlebotomist had been rough with her and she listened to her concerns; however, the CN did not report the incident or investigate further. During an interview on 3/24/2026 at 2:15 PM with the Director of Staff Development (DSD), the DSD stated that about two weeks ago, Resident 2 made a complaint regarding the phlebotomist after her roommate in bed B, Resident 1, considered leaving against medical advice (AMA). The RN supervisor and case manager were working to find a solution. Resident 2 explained that Resident 1 wanted to leave because of issues with the phlebotomist, describing him as having heavy hands. Resident 2 agreed, saying the phlebotomist was very harsh. In these situations, staff are required to notify the administration about concerns with an external company. Forcing a resident to do something without their consent violates their rights.There was no record of the facility initiating an investigation to identify the phlebotomist, investigate Resident 1 and 2 concerns, and notify the contracted laboratory company. As of 3/24/2026, no interventions were implemented to prevent further incidents.During an interview on 3/24/2026 at 3:50 PM with the Director of Nursing (DON), the DON stated he was unaware of any issues with the contracted phlebotomist but noted communication with the vendor could be improved by facility staff. The DON emphasized that professionalism is required, residents can refuse blood draws, and in such cases, the nurse and physician should be promptly informed. The DON stated the phlebotomist should better educate residents about procedures as lab tests are essential for timely diagnosis and treatment; poor service or delays in blood draws may risk delayed care.During a review of the facility's policy and procedures (P&P) titled Abuse and Neglect, dated 4/10/2025, indicated Abuse is defined as willful infliction of injury, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Neglect is defined as the failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The staff will investigate alleged abuse and neglect to clarify what happened and identify possible causes.

Based on interview and record review, the facility failed to ensure two of three residents (Residents 1 and 2) were treated with respect and dignity and failed to honor residents' right to refuse care from the outside contracted phlebotomist on 3/11/2026 at 4 AM during a blood draw procedure at resident's bedside.This failure resulted in:Resident 1 reported that the phlebotomist was unprofessional, harsh, and rude during the procedure. Resident 1 stated that despite verbally telling the phlebotomist to stop, he continued inserting the needle, causing distress and discomfort.Resident 2 reported the phlebotomist was rough and unprofessional. As a result of this experience, Resident 2 refused further services from the phlebotomist, which led to a delay in necessary lab work, treatment, and diagnosis.Other residents remained at risk of experiencing similar disrespect and potentially abusive care.During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of presence of left artificial knee joint following joint replacement surgery.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/11/2026, the MDS indicated Resident 1 had the cognitive skills to daily decision making. The MDS indicated Resident 1 required partial assistance to shower, ability to dress below waist, put on footwear, sit to stand, toilet transfer, and was independent to eat. The MDS indicated Resident 1 required supervision for oral hygiene, toileting, upper body dressing, sit to lying, roll left and right, and lying to sitting on side of bed. During a review of Resident 1's Nursing Progress Notes, dated 3/11/2026, the Nursing Progress Notes indicated staff was aware of Resident 1's complaints regarding the phlebotomist's conduct. The Nursing Progress Notes indicated Resident 1 asked the Phlebotomist to stop but continued what he was doing. The Nursing Progress Notes indicated staff explained to Resident 1 that the facility would report the Phlebotomist to the Core lab company Administrator. There was no documented evidence the facility took immediate action to ensure resident safety or prevent the phlebotomist from continuing to provide services to other residents.During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of Spinal Stenosis (is a chronic condition characterized by the narrowing of spaces within the spine, putting pressure on the nerves that travel through it).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the cognitive skills to daily decision making. The MDS indicated Resident 2 required supervision to eat, partial assistance for oral hygiene, personal hygiene, roll left and right, maximal assistance for sit to lying, lying on side of bed, upper body dressing, and was dependent on staff for toileting, showering, lower body dressing and putting taking off footwear. During a review of Resident 2's Nursing Progress Notes, dated 3/11/2026, the Nursing Progress Notes indicated staff was aware of Resident 2's complaints regarding the phlebotomist conduct rude and harsh and Resident 2 refused blood to be withdrawn on 3/11/2026. The Nursing Progress Notes indicated the Charge Nurse tried to convince Resident 2 to get her blood drawn but Resident 2 adamantly refused. During a telephone interview on 3/24/2026 at 12 PM with Resident 1, Resident 1 stated she was still very upset at the incident that occurred on 3/11/2026 at the facility because the man who had tattoos who came to draw her blood was very rude as he did not introduce himself. Resident 1 stated she asked him for his name, and he did not respond to her with his name. Resident 1 stated the phlebotomist had no name badge or identification, he came in her room around 4 am and said he was going to draw her blood, she asked him why and who he was but he proceeded to insert the needle in her arm not using a tourniquet, and he was forceful almost in a stabbing manner and it caused her a lot of pain. She yelled at him to stop the procedure, but he continued to re-insert the needle to draw her blood. Resident 1 stated she felt her rights were violated and the incident caused her anguish and anxiety. This incident, along with other issues made her want to leave the facility against medical advice (AMA), so she called her husband to pick her up. Resident 1 stated the phlebotomist never provided her with his name, but her roommate (Resident 2) was a witness to the incident that happened on 3/11/2026.During an interview on 3/24/2026 at 1:19 PM with Resident 2, Resident 2 stated that on 3/11/2026 she heard the discussion between Resident 1 and the phlebotomist early in the morning around 4 AM. Resident 2 stated there was a male phlebotomist who was very rude, I heard when he came to draw her blood, I could hear her asking him for his name and asked him to stop poking her and she was screaming in pain, but she complained that he stabbed her with the needle anyway. She reported to this to the nurses when they came to talk to her later that morning. Resident 2 stated she had also experienced the same negative experience with the same phlebotomist on a previous date prior to 3/11/2026. In fact, after the first time he drew blood from her on 3/7/2026, her arm was bruised for a week. He came in my room didn't identify himself, said he was here to draw my blood, he was rough, I was trying to tell him I have small veins. He kept holding my arm down I told him it hurt and he told me to cool off. He came back again a week after on 3/11/2026 around 4 AM and once again he didn't acknowledge himself. He doesn't knock, just pulls the curtain open. I told him to get out. I was a certified phlebotomist for 25 years so I know his technique is not good at all. I reported to pinky next day. He left me bruises. He uses a stabbing technique. It hurt a lot. He came back a few minutes later with one of the male nurses that work night shift and the nurse asked me if I would let the phlebotomist draw my blood, I again told him no he's not touching me because he does not know how to properly draw blood and he inflicts pain despite me telling him that I have small veins and I already know I am a hard stick. The male nurse and the phlebotomist left the room and did not draw my blood. Resident 2 stated the interaction with the phlebotomist caused her distress.During an interview on 3/24/2026 at 1:41 PM with the Registered Nurse Supervisor (RNS), the RNS stated that on 3/11/26 the Charge Nurse informed her that Resident 1 was packing her bags stating she wanted to go home. The RNS stated she went to talk to Resident 1 who reported the incident with the phlebotomist, which the RNS then reported to the Case Manager and the Social Worker. The RNS stated Resident 2 also complained about the phlebotomist and tried to explain what she heard between Resident 1 and the phlebotomist. The RNS stated she attempted to call the core lab to identify the phlebotomist but was unsuccessful and also failed to document and follow up thoroughly, which placed residents at risk for continued harm. The RNS stated when a resident says I don't want this as it relates to services provided but staff continues to proceed with care or services, this could be identified as abuse and staff should have reported the issue to the Administrator to further investigate the concerns reported by Resident 1 and 2.During an interview on 3/24/2026 at 1:58 PM with the Case Manager (CM), the CM stated the morning of 3/11/2026, Resident 1 was adamant to leave the facility. Resident 1 expressed dissatisfaction with late medication, poor food quality, and reported that the phlebotomist did not introduce himself and caused pain during blood draw. The CM offered a grievance form, which Resident 1 declined. She refused to wait for the doctor, signed out AMA, and left with her husband. Resident 2 confirmed the phlebotomist was unprofessional and did not identify himself. The CM notified the Administrator about the resident leaving AMA and concerns about the phlebotomist on 3/12/26 but did not provide further incident details. No investigation into the phlebotomist's conduct had been conducted as of 3/24/2026. During an interview on 3/24/2026 at 2:08 PM with the Charge Nurse (CN), the CN stated that on 3/11/2026, while administering medications in the morning, she observed Resident 1 packing her belongings. The CN stated she informed the RN supervisor and Case Manager, who then went in to speak with Resident 1. The resident's husband was already present at the bedside. The CN stated regarding the phlebotomist, she is unfamiliar with his identity as they typically arrive before the start of the morning shift at 7:00 AM. The CN stated Resident 2 reported to her that a phlebotomist had been rough with her and she listened to her concerns; however, the CN did not report the incident or investigate further. During an interview on 3/24/2026 at 2:15 PM with the Director of Staff Development (DSD), the DSD stated that about two weeks ago, Resident 2 made a complaint regarding the phlebotomist after her roommate in bed B, Resident 1, considered leaving against medical advice (AMA). The RN supervisor and case manager were working to find a solution. Resident 2 explained that Resident 1 wanted to leave because of issues with the phlebotomist, describing him as having heavy hands. Resident 2 agreed, saying the phlebotomist was very harsh. In these situations, staff are required to notify the administration about concerns with an external company. Forcing a resident to do something without their consent violates their rights.There was no record of the facility initiating an investigation to identify the phlebotomist, investigate Resident 1 and 2 concerns, and notify the contracted laboratory company. As of 3/24/2026, no interventions were implemented to prevent further incidents.During an interview on 3/24/2026 at 3:50 PM with the Director of Nursing (DON), the DON stated he was unaware of any issues with the contracted phlebotomist but noted communication with the vendor could be improved by facility staff. The DON emphasized that professionalism is required, residents can refuse blood draws, and in such cases, the nurse and physician should be promptly informed. The DON stated the phlebotomist should better educate residents about procedures as lab tests are essential for timely diagnosis and treatment; poor service or delays in blood draws may risk delayed care.During a review of the facility's policy and procedures (P&P) titled Resident Rights, dated 4/2025, the P&P indicated residents are to be treated with respect, kindness, and dignity, be free from abuse, neglect, and self-determination. Residents will be informed of, participate in care planning and treatment and have the facility respond to his or her grievances.During a review of the facility's P&P titled Requesting, Refusing and or discontinuing care or treatment, dated 4/2025, indicated residents will be informed of the type of caregiver or professional that will provide the care, risks and benefits of proposed treatment or care. If resident refuses care or treatment the Charge Nurse or DON will meet with the resident to determine why the resident is requesting refusing treatment, try to address resident's concerns and discuss alternative options. The resident will not be coerced, intimated, or manipulated for refusing care or treatment. The interdisciplinary team will assess the resident's needs and offer the resident alternative treatments.

Based on interview and record review, the facility failed to notify the physician as indicated in the interdisciplinary team (IDT, comprises professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) meeting documentation for one of three sampled residents (Resident 1) reviewed for notification requirements.This failure resulted in Resident 1 experiencing emotional distress, uncertainty, and Resident 1 remains without physician review or documented medical evaluation related to discharge appropriateness from 2/19/2026 to 3/1/2026. During a record review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should).During a record review of Resident 1's Minimum Data Set (MDS- resident assessment tool) , dated, indicated Resident 1 had capacity to make decisions. The MDS indicated Resident 1 required clean up assistance for eating, oral hygiene, and maximal assistance for toileting, showering, lower body dressing, putting on footwear. The MDS indicated Resident 1 required partial assistance for lying to sitting, chair transfer, and supervision assistance for upper body dressing and personal hygiene.During a record review of Resident 1's progress notes, dated 2/19/2026, the progress notes revealed documentation that an Interdisciplinary Team (IDT) meeting was held on 2/19/2026 to discuss Resident 1's desire to discharge home. The IDT stated Resident 1 will remain in the facility to support full recovery then discharge home once deemed appropriate safe by medical doctor (MD). The progress notes indicated Resident 1 had expressed a desire to go home since September 12, 2025.During a record review of Resident 1's Care Plan, dated 8/8/2025, the Care Plan indicated:Evaluate and discuss with the resident/family the prognosis for independent assisted living.Identify, discuss and address limitation, risks, and benefits and needs for maximum independence.Establish a pre-discharge plan with the resident/family and evaluate progress and revise plan.Make arrangements with required community resources to support independence post-discharge homes care, PT, OT, MD, Nurse.Monitor for and address episodes of anxiety, fear, distress.During an interview on 2/27/2026 at 1:50 PM with Resident 1, in Resident 1's room, Resident 1 sat down on his wheelchair and verbalized experiencing emotional distress related to the facility's failure to clearly communicate discharge goals, discharge planning, and delays in progressing toward discharge. Resident 1 stated he has resided at the facility since August 2025, and for six months he has been frustrated due to the lack of updates regarding discharge process and uncertainty about the steps needed to facilitate a safe return to the community. Resident reported feeling uninformed and expressed concern that the absence of clear communication and planning has prolonged his stay and impacted his emotional and financial well-being. Resident 1 stated he thinks the facility will not let him go home because they want to take advantage of receiving his Social Security Benefits allowance, and stated he feels captured in the facility. Resident 1 stated he had a meeting regarding his request to go home, but nothing was further done. Resident 1 stated he had not even seen a doctor since he arrived at the facility.During an interview on 2/27/2026 at 3 PM with Social Services (SS), the SS staff stated she is part of the IDT and stated that Resident 1 was not deemed safe to discharge. The SS failed to provided documentation outlining the specific clinical, functional, or safety factors that made discharge not feasible. The SS stated Resident 1 had decision-making capacity related to discharge, but had not updated Resident 1 on his discharge goals after the IDT meeting on 2/19/2026. The SS also stated she had not notified the physician as stated on the summary of the IDT meeting notes.During an interview on 2/27/2026 with the Director of Nursing (DON), the DON stated as of 2/27/2026, the resident remains in the facility without documented discharge goals or a documented rationale explaining why discharge home is not feasible. The DON stated some goals and planning to be discussed is to assess if modifications need to be made to the resident's home such as grab bars, wheelchair access, make sure they educate resident on risks and ensure home health as follow up care. The DON stated in Resident 1's case it may be necessary to notify Adult Protective Services to follow up on resident. DON stated he usually participates in the IDT meeting, but could not remember if he was part of the meeting with Resident 1, however, someone from the team should have notified the MD to evaluate Resident 1 to determine discharge goals. The DON stated failure to document discharge planning efforts and resident-centered goals resulted in Resident 1 remaining in the facility without a clear plan, explanation, or pathway toward discharge.Documentation from the IDT meeting dated 2/19/2026 stated that the physician would be notified regarding the resident's request for discharge and the team's determination that discharge was not deemed safe.Record review as of 2/27/2026 revealed:No documentation that the physician was notified.No physician progress note addressing discharge appropriateness.No physician order related to discharge planning or safety concerns.No follow-up documentation indicating consultation occurred.Staff interview confirmed that the physician had not yet been notified.During a review of the facility's policy and procedure titled Change of Condition Reporting dated 3/2025, indicated it is the policy of this facility that changes in resident condition will be communicated to the primary physician for proper management. Any sudden or serious change in a resident's condition manifested by a marked change in physical or psychological status of the resident will be communicated by the Licensed Nurse to the physician with a request for physician visit promptly and acute care evaluation.

Based on interview and record review the facility failed to develop and document discharge goals and failed to provide a documented rationale for determining discharge was not feasible for one of three sampled residents (Resident 1) reviewed for discharge planning.This failure resulted in Resident 1 verbalizing experiencing emotional distress due to the facility's failure to clearly communicate discharge goals, discharge planning, and delays in progressing toward discharge.During a record review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should).During a record review of Resident 1's Minimum Data Set (MDS- resident assessment tool) , dated, indicated Resident 1 had capacity to make decisions. The MDS indicated Resident 1 required clean up assistance for eating, oral hygiene, and maximal assistance for toileting, showering, lower body dressing, putting on footwear. The MDS indicated Resident 1 required partial assistance for lying to sitting, chair transfer, and supervision assistance for upper body dressing and personal hygiene.During a record review of Resident 1's progress notes, dated 2/19/2026, the progress notes revealed documentation that an Interdisciplinary Team (IDT) meeting was held on 2/19/2026 to discuss Resident 1's desire to discharge home. The IDT stated Resident 1 will remain in the facility to support full recovery then discharge home once deemed appropriate safe by medical doctor (MD). The progress notes indicated Resident 1 had expressed a desire to go home since September 12, 2025.During a record review of Resident 1's Care Plan, dated 8/8/2025, the Care Plan indicated:Evaluate and discuss with the resident/family the prognosis for independent assisted living.Identify, discuss and address limitation, risks, and benefits and needs for maximum independence.Establish a pre-discharge plan with the resident/family and evaluate progress and revise plan.Make arrangements with required community resources to support independence post-discharge homes care, PT, OT, MD, Nurse.Monitor for and address episodes of anxiety, fear, distress.During an interview on 2/27/2026 at 1:50 PM with Resident 1, in Resident 1's room, Resident 1 sat down on his wheelchair and verbalized experiencing emotional distress related to the facility's failure to clearly communicate discharge goals, discharge planning, and delays in progressing toward discharge. Resident 1 stated he has resided at the facility since August 2025, and for six months he has been frustrated due to the lack of updates regarding discharge process and uncertainty about the steps needed to facilitate a safe return to the community. Resident reported feeling uninformed and expressed concern that the absence of clear communication and planning has prolonged his stay and impacted his emotional and financial well-being. Resident 1 stated he thinks the facility will not let him go home because they want to take advantage of receiving his Social Security Benefits allowance, and stated he feels captured in the facility. Resident 1 stated he had a meeting regarding his request to go home, but nothing was further done. Resident 1 stated he had not even seen a doctor since he arrived at the facility.During an interview on 2/27/2026 at 3 PM with Social Services (SS), the SS staff stated she is part of the IDT and stated that Resident 1 was not deemed safe to discharge. The SS failed to provided documentation outlining the specific clinical, functional, or safety factors that made discharge not feasible. The SS stated Resident 1 had decision-making capacity related to discharge, but had not updated Resident 1 on his discharge goals after the IDT meeting on 2/19/2026.There were no documented discharge goals developed in collaboration with the resident.There was no documented assessment of the resident'sThere was no documentation of exploration of community supports, services, or alternative discharge options.The resident care plan did not reflect discharge planning interventions or measurable objectives.The record did not reflect ongoing communication with the resident regarding next steps.During an interview on 2/27/2026 with the Director of Nursing (DON), the DON stated as of 2/27/2026, the resident remains in the facility without documented discharge goals or a documented rationale explaining why discharge home is not feasible. The DON stated some goals and planning to be discussed is to assess if modifications need to be made to the resident's home such as grab bars, wheelchair access, make sure they educate resident on risks and ensure home health as follow up care. The DON stated in Resident 1's case it may be necessary to notify Adult Protective Services to follow up on resident. DON stated he usually participates in the IDT meeting, but could not remember if he was part of the meeting with Resident 1, however, someone from the team should have notified the MD to evaluate Resident 1 to determine discharge goals. The DON stated failure to document discharge planning efforts and resident-centered goals resulted in Resident 1 remaining in the facility without a clear plan, explanation, or pathway toward discharge.During a review of the facility's policy and procedures (P&P) titled Transfers, Bed holds, and Discharges out of the facility dated 4/2025, indicated The IDT will reevaluate the resident's potential for discharge on a weekly basis to identify changes that required modification of the discharge plan. The discharge plan will be updated and changes documented in the medical record. The SSD will updated the resident's comprehensive care plan to include the discharge plan. The physician will document the basis of the discharge when a resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.During a review of the facility's P&P titled Discharge Summary and Plan dated 4/2025, the P&P indicated the discharge summary will include a description of the resident's discharge potential (the expectation of discharging the resident from the facility within the next three months). If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. A copy of the following will be provided to the resident in the resident's medical records:An evaluation of the resident's discharge needsThe post discharge planDischarge summary.

Based on observation, interview, and record review, the facility failed to ensure four of seven residents (Resident 260, 129, 8, and 83) were free of a significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention). By failing to assess Resident 260, 129, 8, and 83's systolic blood pressure (SBP - the pressure in the arteries when the heart beats [bpm]) and/or heart rate in accordance with physician's orders, with a parameter [specific, measurable instructions or limits that define exactly how, when, and under what conditions a medication should be given] to check BP and/or the heart rate (HR - how fast the heart beats, measured by taking the pulse, which is the throbbing of the arteries as blood is pushed through them) as a condition to give or hold blood pressure medications, manufacturer's specification, and the facility's policy and procedures (P&P) titled, Administering Medications dated 4/2025. This deficient practice increased the risk that Residents 260, 129, 8, and 83 experience adverse reactions (negative effects from medication), that include hypotension (low blood pressure [BP]) and bradycardia (a slower than normal heart rate), that could lead to a decline in the residents' condition, harm, or hospitalization.Findings: 1. During a review of Resident 260's admission record, the admission record indicated Resident 260 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension (HTN, high blood pressure) and hyperlipidemia (high cholesterol in the blood). During a review of Resident 260's Minimum Data Set (MDS, a resident assessment tool) dated 1/16/2026, the MDS indicated Resident 260's cognitive skills (ability to think and reason) was moderately impaired.Review of Resident 260's Order Review History Report, printed on 02/17/2026 and electronically signed by the prescriber, included the following active medication orders for the resident:Labetalol (medication used to treat HTN) 100 milligrams (mg, unit of measurement by weight) tablet, instruction to give one tablet by mouth two times a day for HTN. Hold for SBP less than 110 millimeters of mercury (mmHg, a unit for measuring blood pressure, normal SBP range: 90-120 mmHg) or HR less than 60 bpm (normal HR range: 60-100 bpm), order date 7/28/2025.Lisinopril (medication used to treat HTN) 40 mg tablet, instruction to give one tablet by mouth one time a day for HTN. Hold for SBP less than 110, order date 7/28/2025. During a review of Resident 260's care plan initiated on10/21/2024, the Care Plan focus indicated Resident 260 was at risk for Cardiac Distress (a condition characterized by symptoms such as chest pain, shortness of breath, or irregular heartbeat; cardiac distress can increase the workload on the heart and may contribute to elevated blood pressure) related to hyperlipidemia and HTN. The care clan indicated Resident 260 would remain free from signs and symptoms of cardiac distress. The care plan interventions indicated to administer Labetalol and Lisinopril as ordered.monitor apical pulse (heartbeat heard at the chest with a stethoscope) and blood pressure (BP) as indicated in the medication parameter. During a medication pass observation on 2/17/2026 between 9:58 AM to 10:18 AM, with Licensed Vocational Nurse (LVN) 6, LVN 6 was observed preparing medications that included the following BP medications: Labetalol 100 milligrams (mg, unit of measurement), one tablet and Lisinopril 40 mg, one tablet. LVN 6 stated she prepared a total of seven medications, and then entered the resident's room, called the resident by name and administered the medications. LVN 6 was not observed checking Resident 260's blood pressure (BP) or heart rate (HR) prior to administering the two BP medications Ldabetalol and Lisinopril.During an interview on 2/17/2026, at 10:21 AM, LVN 6 stated the Certified Nurse Assistants (CNA) normally checked the residents' vitals (measurements of essential body functions, such as blood pressure, heart rate, temperature, and respiratory rate). LVN 6 provided a handwritten paper that included Resident 260's BP and HR and stated the vital sign readings were provided to LVN 6 by CNA 1. LVN 6 acknowledged the paper with residents' vital signs did not include the date or time the vital signs were taken. LVN 6 acknowledged the vital signs were taken two and one-half hours earlier by CNA 1, on 2/17/2026 between 7:30 AM to 7:45 AM. During an interview on 2/17/2026 at 10:28 AM with CNA 1, in the presence of LVN 6, CNA 1 stated Resident 260's vitals were taken between 7:30 AM to 7:45 AM on 2/17/2026. CNA 1stated he (CNA 1) checked the vital signs of eight residents, which included the vital signs for Residents 260, 129, 8, and 83 before breakfast and once done provided the results to LVN 6. During a review on 2/17/2026 at 10:30 AM, with CNA 1 and LVN 6, CNA 1 confirmed the handwritten paper was the vital signs he (CNA 1) had taken earlier that day, 2/27/2026 between 7:30 AM to 7:45 AM which included the following undated and untimed BP readings:Resident 260's BP was documented as 136/78 (mmHg) and HR as 80 (bpm). Resident 129's BP was documented as 151/87 (mmHg) and HR as 57 (bpm).Resident 8's BP was documented as 134/65 (mmHg) and HR as 79 (bpm).Resident 83's BP was documented as 132/68 (mmHg) and HR as 71 (bpm). During a follow up interview on 2/17/2026 at 10:31 AM, with LVN 6, LVN 6 stated she (LVN 6) usually relied on the vitals taken by the CNAs to determine to give or hold BP medications to the residents. LVN 6 stated she could not verify based on the undated and untimed form when the vitals, that included BP and HR were taken by CNA 1 on 2/17/2026. LVN 6 stated that it was important to recheck the residents BP and HR to make sure the BP and HR readings were accurate before administering BP medications with an ordered parameter. LVN 6 stated if BP medications were administered outside of the ordered parameters residents could experience symptoms that include low blood pressure, weakness, change in cognition and alertness, syncope (brief loss of consciousness), which could lead to hospitalization. 2. During a review of Resident 129's admission record, the admission record indicated Resident 129 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included HTN, hyperlipidemia (high cholesterol in the blood), and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to the brain) affecting left non-dominant side (left side of the body that is not primarily used). During a review of Resident 129's MDS, dated [DATE], the MDS indicated Resident 129's cognitive skills were moderately impaired. Review of Resident 129's Order Review History Report, printed on 02/17/2026 and electronically signed by the prescriber, the report included the following active medication orders for the Resident 129:Amlodipine (medication used to treat HTN) 10 mg tablet, instructions to give one tablet by mouth one time a day for HTN. Hold for SBP less than 110 or HR less than 60, order date 6/18/2023.Lisinopril 40 mg tablet, instruction to give one tablet by mouth one time a day for HTN. Hold for SBP less than 110, order date 10/23/2023. Metoprolol (medication used to treat HTN) 50 mg tablet, instruction to give one tablet by mouth two times a day for HTN. Hold for SBP less than 110 mmHg or HR less than 60 bpm. Give with food/snack, order date 2/18/2025During a review of Resident 129's Care Plan, initiated 7/2/2022, with next target date of 3/9/2026, the Care Plan focus indicated Resident 129 was at risk for Cardiac Distress related to atrial fibrillation (A-fib, an irregular and often rapid heartbeat) and cerebrovascular accident (CVA, stroke; sudden loss of blood flow to the brain), hyperlipidemia and HTN. Resident 129 Care Plan interventions indicated to, Administer prescribed medication.Monitor apical pulse and blood pressure as indicated in the medication parameter. During a concurrent interview and record review on 2/17/2026 at 10:38 AM, with LVN 6, Resident 129's Medication Administration Record (MAR, a document used to track and record the administration of medications to residents or patients) for 2/17/2026 was reviewed and documentation and licensed nurse initials indicated Resident 129 was administered the BP medications Amlodipine 10 mg, Lisinopril 40 mg, and Metoprolol 50 mg on 2/17/2026 at 9:36 AM, without reassessing the resident's BP and HR. LVN 6 acknowledged Resident 8' vital signs were checked about two hours earlier by CNA 1, on 2/17/2026 between 7:30 AM to 7:45 AM. 3. During a review of Resident 8's admission record, the admission record indicated Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included HTN, hyperlipidemia, and hyperlipidemia, and hemiparesis following cerebral infarction affecting left non-dominant side. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8's cognitive skills were moderately impaired. Review of Resident 8's Order Review History Report, printed on 02/17/2026 and electronically signed by the prescriber, included the following active medication orders for Resident 8: Lisinopril 20 mg tablet, instruction to give one tablet by mouth one time a day for HTN. Hold for SBP less than 110, order date 2/12/2026. During a review of Resident 8's Care Plan, initiated 1/3/2026, the Care Plan focus indicated Resident 8 was at risk for Cardiac Distress related to CVA with left sided weakness, A-fib, HTN, hyperlipidemia, and Coronary Artery Disease status post stent (CAD S/P stent - heart artery narrowing treated with a tube called a stent). Resident 8 Care Plan interventions indicated to administer Lisinopril Oral Tablet as ordered. Observe and notify MD for new onset of confusion, change in the level of consciousness, shortness of breath, coughing, congestion, puffy eyelids, edema (swelling from excess fluid in tissues), weakness and easy fatigability (getting tired more easily than usual) secondary to fluid overload (excess water in the body, which strains the heart and lungs). During a concurrent interview and record review on 2/17/2026 at 10:38 AM, with LVN 6, Resident 8's MAR for 2/17/2026 was reviewed and documentation and licensed nurse initials indicated Resident 8 was administered the BP medication Lisinopril 20 mg on 2/17/2026 at 9:52 AM, without reassessing the resident's BP. LVN 6 acknowledged Resident 8' vital signs were checked over two hours earlier by CNA 1, on 2/17/2026 between 7:30 AM to 7:45 AM. 4. During a review of Resident 83's admission record, the admission record indicated Resident 83 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included HTN and hyperlipidemia, peripheral vascular disease (poor blood flow in the legs and arms due to narrowed blood vessels), myocardial infarction type 2 (a type of heart attack caused by a lack of oxygen to the heart, not a blocked artery), and chronic kidney disease, stage 4 (serious loss of kidney function; kidneys are not working well). During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83's cognitive skills were severely impaired. Review of Resident 83's Order Review History Report, printed on 02/17/2026 and electronically signed by the prescriber, included the following active medication orders for the resident:Amlodipine 10 mg tablet, instruction to give one tablet by mouth one time a day for HTN. Hold for SBP less than 120, order date 7/12/2024 During a review of Resident 83's Care Plan, initiated 3/7/2024, the Care Plan focus indicated Resident 83 was at risk for Cardiac Distress related to, CAD, congestive heart failure (CHF, a condition where the heart cannot pump blood well), use of a diuretic (a medicine that helps the body get rid of extra fluid), hyperlipidemia, HTN, and myocardial infarction. Resident 83 Care Plan interventions indicated to administer Amlodipine as ordered. Observe and notify MD when resident is experiencing change in the level of consciousness, shortness of breath, chest pain, restlessness, cyanosis, weakness, palpitation, secondary to cardiac distress. Monitor apical pulse and blood pressure as indicated in the medication parameter. During a concurrent interview and record review on 2/17/2026 at 10:38 AM, with LVN 6, Resident 83's MAR for 2/17/2026 was reviewed and documentation and licensed nurse initials indicated Resident 83 was administered the BP medication Amlodipine 10 mg on 2/17/2026 at 9:39 AM, without reassessing the resident's BP. LVN 6 acknowledged Resident 8' vital signs were checked over two hours earlier by CNA 1, on 2/17/2026 between 7:30 AM to 7:45 AM. During an interview on 2/18/2026 at 5:09 PM with the Director of Nursing (DON), the DON stated residents' BP should have been checked prior to, and as close as possible to the medication administration time. The DON stated that if a resident's BP and heart rate (HR) were checked two hours before medication administration, the licensed nurse had to recheck the resident's BP and HR immediately prior to administering the BP medication when there were ordered parameters, in order to prevent a decline in the resident's condition. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2025, indicated, Medications are administered in accordance with prescriber orders.The following information is checked/verified for each resident prior to administering medications.b. Vital signs, if necessary. A review of the facility's undated P&P titled, Medication Administration Principles, indicated, Vital signs (blood pressure, pulse rate, respiration) or blood sugar levels required for medication orders with hold parameters are taken prior to the administration of the medication and recorded on the MAR. During a review of the Food and Drug Administration (FDA)- approved prescribing information (package insert), revised 8/2024, the package insert for Lisinopril indicated, Hypotension: Patients with other heart or renal diseases have increased risk, monitor blood pressure after initiation.Patients at risk of excessive hypotension include those with the following conditions or characteristics: heart failure with systolic blood pressure below 100 mmHg. During a review of the Food and Drug Administration (FDA)- approved prescribing information (package insert), revised 8/2024, the package insert indicated, Metoprolol tartrate tablets are contraindicated in severe bradycardia.systolic blood pressure less than 100.

Based on observations, interviews, and record reviews, the facility failed to: 1. Notify Resident 262's physician when Spironolactone (a blood pressure medication prescribed for congestive heart failure, or CHF-a condition in which the heart cannot pump blood effectively) was unavailable on 02/16/2026.2. Positively identify Residents 260 and 262 before giving medications, increasing the risk of medication errors and harm.3. Maintain accurate emergency medication kit (Ekit, a secured, organized container holding essential, often pre-packaged, drugs and supplies designed for rapid access to treat specific health conditions, emergencies, or, in hospice settings, to provide immediate comfort care) usage records for all residents, putting residents at risk of not receiving needed medications during emergencies.4. Ensure both incoming and outgoing nurses counted and signed for controlled drugs (medications regulated by the Controlled Substances Act [CS] due to their potential for abuse, addiction, or diversion [Schedules II-V]. Requiring strict, secure storage, precise, ongoing inventory counts, and documented administration by licensed staff) together during shift change, increasing the risk of drug loss or misuse. These failures could lead to residents, including Residents 260 and 262 or any resident needing Ekit medications, receiving the wrong medication, missing doses, or experiencing adverse health outcomes such as hospitalization, serious injury, or misuse of controlled drugs.Findings: 1. During a review of Resident 262's admission record, the admission record indicated that Resident 262 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Hypertensive heart disease (heart problems caused by long-term high blood pressure). During a review of Resident 262's Minimum Data Set (MDS, a resident assessment tool) dated 11/28/2025, the MDS indicated that Resident 262's cognitive skills (ability to think and reason) were intact. During a review of Resident 262's History and Physical (H&P) dated 12/19/2025, the H&P indicated the resident did not have the capacity to make healthcare decisions. During a review of Resident 262's current Order Review History Report, printed on 02/17/2026 and electronically signed by the prescriber, the report included an active medication order for Spironolactone 50 milligram (mg, unit of measure by weight) Oral Tablet, instructions indicated to give one tablet by mouth one time a day for CHF, order date 1/30/2026 During a review of Resident 262's Medication Administration Record (MAR, a document used to track the administration of prescribed medications to residents) for the month of 2/2026, the MAR indicated that Resident 262's Spironolactone ordered dose on 2/16/2026 scheduled for the 9:00 AM medication administration was initialed by a licensed nurse and was marked with 4, and according to the MAR legend, 4 indicated the medication was held/other reason/ or see progress notes. During a medication pass observation, interview, and record review on 2/17/2026 at 9:00 AM, with a Licensed Vocational Nurse (LVN) 3, LVN 3 was preparing morning medications for Resident 262, at Station D-Wing, MedCart B. LVN 3 after searching MedCart B stated the Spironolactone for Resident 262 was not available. LVN 3 reviewed Resident 262's MAR for 2/16/2026 and confirmed that Resident 262's Spironolactone was also not available the day prior, 2/16/2026. During an interview on 2/17/2026 at 9:04 AM with LVN 3, LVN 3 stated she did not notify the pharmacy on 2/16/2026 regarding Resident 262 being out of Spironolactone, resulting in the resident missing a dose. During a concurrent interview and record review on 2/17/2026 at 2:26 PM, with LVN 3, Resident 262's MAR and nursing progress notes for the month of 2/2026 were reviewed. The nursing progress note dated 2/16/2026, timed at 9:13 AM, indicated that Spironolactone was Not available. LVN 3 stated that she did not notify the prescriber or document that Resident 262 missed a dose of Spironolactone on 2/16/2026. During a concurrent interview and record review on 2/19/2026 with the Director of Nursing (DON), Resident 262's physician order, nursing progress notes, and MAR for the month of 2/2026 were reviewed. The DON stated Resident 262's MAR for 2/16/2026, regarding the scheduled 9:00 AM dose of Spironolactone, was marked with the code 4, indicating that the medication was held. After reviewing Resident 262's nursing progress notes for 2/16/2026 and 2/17/2026, the DON stated there were no notes documented to indicate the reason Spironolactone was held on 2/16/2026, and there was no documentation that the physician was notified that the resident did not receive the medication. The DON stated the physician should have been notified. A review of the facility's undated policy and procedures (P&P) titled, Medication Ordering and Receiving, indicated, Note: Communication between nursing and pharmacy is crucial to ensure resident does not experience a missed dose. A review of the facility's P&P titled, Administering Medications, dated 4/2025, indicated, Medications are administered in accordance with prescriber orders, including any required time frame. 2a. During a review of Resident 262's admission record, the admission record indicated that Resident 262 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Hypertensive heart disease (heart problems caused by long-term high blood pressure). During a concurrent medication pass observations and interview on 2/17/2026 at 9:04 AM, with LVN 3, on Station D-Wing, MedCart B, LVN 3 prepared morning medications for Resident 262. LVN 3 stated she prepared three medications for Resident 262. LVN 3 entered Resident 262's room, stated the resident's name and administered the medications. LVN 3 was not observed verifying the resident's identity before administering the following medications: Apixaban (an oral anticoagulant used to prevent blood clots) 5 mg, one tablet. Escitalopram (a medication used to treat depression and anxiety) 10 mg, one tablet. Benztropine (a medicine that helps control shaking or stiffness from Parkinson's disease or certain mental health medicines) 1 mg, one tablet. During an interview on 2/17/2026 at 9:10 AM with LVN 3, LVN 3 stated that she already knew the resident. LVN 3 stated she asked Resident 262 her name, but the resident could not hear LVN 3. LVN 3 stated she did not know that Resident 262 had a hearing problem, and that Resident 262 was complaining that she could not hear.2b. During a review of Resident 260's admission record, the admission record indicated Resident 260 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included HTN and hyperlipidemia (high cholesterol in the blood). During a concurrent medication pass observations and interview on 2/17/2026 at 10:15 AM, with LVN 6, on Station 2, MedCart B, LVN 6 prepared morning medications for Resident 260. LVN 6 stated she prepared a total of seven medications, then entered the resident's room, stated the resident's name and administered the medications. LVN 6 was not observed verifying the resident's identity before administering the following medications:Labetalol (treat high blood pressure) 100 mg one tablet. Lisinopril (treat high blood pressure) 40 mg, one tablet. Vitamin C (vitamin supplement) 250 mg, one tablet. Cranberry (supplement to treat or prevent urinary tract infections) 450 mg, one tablet. Vitamin B12 (vitamin supplement) 1 mg, one tablet. Magnesium Oxide (used to help prevent and treat low levels of magnesium in the body) 400 mg, one tablet. Ferrous Gluconate (used to treat iron deficiency) 240 mg, one tablet. During an interview on 2/17/2026 at 10:21 AM with LVN 6, LVN 6 stated she should have checked Resident 260's identification name band before administering the medications to the resident. LVN 6 stated facility nurses were supposed to check resident identification prior to giving medications to be sure the correct resident was receiving the correct medication. A review of the facility's P&P dated 4/2025, titled, Administering Medications, the P&P indicated, The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band;b. checking photograph attached to medical record; andc. if necessary, verifying resident identification with other facility personnel. 3. During a medication storage area inspection and interview on 2/18/2026 at 11:36 AM, with a Registered Nurse (RN) 1, of Station 3 Medication Room and the Ekit usage was reviewed. RN 1 stated the facility did not keep a copy of the Ekit usage log. RN 1 stated the Ekit usage log was faxed to the pharmacy and then the form was put back inside of the Ekit and sent with the Ekit to the pharmacy. RN 1 stated the facility did not keep a copy of the Ekit usage which included both controlled Ekits, Injectable Ekits, and non-controlled Ekits, such as oral and antibiotic medications. During an interview on 2/18/2026 at 4:49 PM with the DON, the DON stated the facility did not have a process to monitor or track Ekit usage in the facility. A review of the facility's undated P&P titled, Emergency Medication Supply Procedures, indicated Medications will be available for administration to residents in emergency situations and situations requiring immediate administration of a medication 24 hours/ day, 7 days/week.Separate kits may be maintained according to routes of administration or storage needs.The nurse removing the medication from the emergency kit also enters a record of the medication withdrawn in the emergency medication administration record (log book) that is kept in the vicinity of the emergency kit. The record shall include the name and dose of each medication being used, the name of the resident to whom the medication is being administered, the time and date of medication administration, and the signature of the person who administers the medication. This emergency medication administration record must be retained as a permanent record .The pharmacist consultant monthly inspects the kits for expiration dating and integrity. Discrepancies are reported to the director of nursing services. 4a. During a concurrent medication storage area inspection and interview on 2/18/2026 at 3:39 PM of Station 1 MedCart B with LVN 4, a form titled, Controlled Drugs Inventory, was reviewed, and the spaces for nurses' signature In and Out for the 3 PM to 11 PM shift on 3/18/2026 was blank. LVN 4 stated that she was the incoming nurse and that she counted the controlled medications in the medication cart with the outgoing nurse for Station 1 MedCart B, but they both forgot to sign and the outgoing nurse had already left for the day. LVN 4 stated it was important to sign the Controlled Drugs Inventory form with two nurses to ensure the controlled count was correct, complete, and to prevent diversion (misuse) of controlled medications. 4b. During a concurrent medication storage area inspection and interview on 2/18/2028 at 4:10 PM of Station 1 MedCart A with LVN 5, a form titled Controlled Drugs Inventory,' was reviewed, and the space for nurses' signature Out for the 11 PM to 7 AM shift on 2/18/2026 was initialed/signed. LVN 5 stated that she accidentally signed the shift change (Controlled Drugs Inventory) form ahead of time before the end of the shift and before the next nurse arrived. LVN 5 stated it was important to sign together with the incoming nurse to prevent medication discrepancies especially for controlled medications. During a concurrent interview and review of the Controlled Drugs Inventory for Station 1, MedCart A, and Station 1, MedCart B on 2/18/2026 at 4:22 PM with the Assistant Director of Nursing (ADON), the ADON stated that when the next shift nurse arrives for Station 1 MedCart A, both the incoming and outgoing nurses were required to count the controlled medications together. The ADON stated that after counting, both nurses were required to sign the Controlled Drugs Inventory form together. The ADON stated that signing the Controlled Drugs Inventory form confirmed the controlled count was accurate and that the outgoing nurse was endorsing (formally handing over responsibility for) the medication cart to the incoming nurse. The ADON stated that failing to sign the form together could result in uncertainty about the accuracy of the controlled medications and could delay the discovery of any missing controlled medications. A review of the facility's P&P titled, Controlled Substances, dated 11/2025, indicated, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.The nurse coming on duty and nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage practices when: 1. Seven packages of turkey breast exceeding storage period (the amount of time a food product remains safe to eat and keeps its best quality) were stored in the facility's Walk-in refrigerator. 2. The temperature of the resident refrigerator located next to the nurse's station on the first floor was not maintained in a safe temperature range and was not monitored for unsafe refrigerator temperatures. These deficient practices had the potential to result in harmful bacteria growth that could lead to foodborne illness in 275 out of 283 residents who received food from the facility and including residents who had food stored in the resident refrigerator.Findings: During a concurrent observation in the refrigerator storage area located outside of the kitchen and interview on 2/17/2026 at 9:30 AM, Seven packages of previously frozen, turkey breast were stored in the walk-in refrigerator marked with dates 2/8/2026-2/9/2026. The Turkey breast was removed from original box, and the individual packages of turkey did not have any marking or manufactures use by date (a safety marker indicating the last date recommended for consuming a product while it is at its peak quality). The turkey breasts were stored inside a large plastic container that was labeled by the facility 2/8/2026 -2/9/2026. The Dietary Supervisor (DS) and Dietary Lead (DL), DL stated they would discard the turkey because it was removed from freezer to thaw on 2/8/2026 and staff did not label and date correctly. The DL stated everything was thawed for 3 days and then cooked or used. The DL stated the turkey breast were previously frozen products, staff removed them from the freezer and the portion that was not used should have been discarded. During a concurrent observation and interview with the DS and the DL on 2/17/2026 at 9:40AM, the DS was observed removing the turkey remove the turkey from storage to discard. The DS stated the packages of turkey were not labeled correctly and could have been a potential for residents to get sick. During a review of facility policy and procedures titled Food Receiving and Storage with a revised date of 10/2017, the policy indicated All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). During a review of the 2022 U.S. Food and Drug administration Food Code 3-501.18 titled Ready-to-Eat, time/temperature control for safety food, disposition. Indicated, A food specified in code 3-501.17 (A) or (B) shall be discarded if it: 2) is in a container or package that does not bear a date or day; 3) is inappropriately marked with a date or date that exceeds a temperature and time combination During a review of 2022 U.S. Food and Drug administration Food Code 3-501.17 titled Ready-to-Eat, Time/Temperature Control for safety Food, Date marking indicated B) Ready to eat time/temperature control for safety food prepared and packaged by food processing plant shall be clearly marked at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations and 1)the day or date marked by the food establishment may not exceed a manufacturer's use by date if the manufacturer determined the use by date based on food safety. 2. During an observation of the resident refrigerator located next to the nurse's station on the first floor on 2/18/2026 at 10:30AM, the thermometer inside the refrigerator unit registered at 45 degrees Fahrenheit (F). During the same observation there was one facility prepared lunch sandwich, snacks for a resident (unidentified), juices, and high calorie nutrition shakes were also observed in the refrigerator. During a concurrent observation and interview with Nurse Supervisor (RN4) on 2/18/2026 at 10:30AM, RN4 stated the refrigerator temperature was checked by the dietary staff. RN4 stated the normal temperature for food refrigerator was 41 degrees (F) and below. RN4 stated the perishable sandwich and snacks for the residents and juices had to be discarded because they were not stored at the right temperature. During a review of the temperature monitoring log dated February 2026, the temperature of the refrigerator was above 41 degrees (F) eight times on:2/1/2026: 42degrees F2/3/2026: 42degreesF2/10/2026: 42degrees F2/11/2026: 42 degrees F2/12/2026: 46 degrees F2/13/2026: 48 degrees F2/14/2026: 46 degrees F2/18/2026: 42 degrees FDuring the same review of the temperature monitoring log dated February 2026, no corrective actions for the out-of-range temperature were documented. During an interview with the Dietary Lead (DL) and the Registered Dietitian (RD1) on 2/18/2026 at 12:00PM, the DL stated dietary staff were responsible for checking the temperature of the resident refrigerators. The DL stated there were several out-of-range temperatures in February 2026 that were not brought to the DL's attention. The DL stated food was not stored in safe temperatures and residents could get sick. During an interview with the Director of Nursing (DON) on 2/18/2026 at 12:40PM, the DON stated the refrigerator was not working and would be replaced immediately. The DON stated that when the refrigerator temperature was not in range staff had to notify the maintenance supervisor. A review of the temperature log titled HACCP Refrigerator temperature Log-One Form Per Month for refrigerator Location: Nursing Station 1st Floor, dated 2/2026, indicated Maintain refrigerator temperature at 40F or below during stable times; complete corrective action column if temperature are not in proper ranges. A review of facility policy and procedure titled Food receiving and Storage with a revised date of 2017, the policy and procedure indicated, Food items and snacks kept on the nursing units must be maintained as indicated below: All food items to be kept below 41 degrees F must be placed in the refrigerator located at the nurses station and labeled with a use by date; Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines.

Based on observation, interview, and record review the facility failed to update and revise the range of motion (ROM - uses guided exercises to help joints move properly, reducing stiffness and increasing flexibility after injury, surgery, or illness) care plan for one out of one sampled resident (Resident 12). This deficient practice had the potential to prevent Resident 12 from receiving care to address their specific needs, which could lead to a decline in emotional and physical health. Findings: During a review of Resident 12's admission Record, the admission record indicated the facility admitted Resident 12 on 1/24/2022 with diagnoses that include bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), acquired absence of right leg above the knee (leg removed surgically or lost due to an injury at a point above the knee joint), unspecified dementia (a progressive state of decline in mental abilities) and neuralgia and neuritis unspecified (nerve pain and irritation of unknown cause). During a review of Resident 12 Baseline Admission Screen (an initial health check done when entering a skilled nursing facility to establish your normal status) note dated 2/3/2022, the note indicated Resident 12 had a left lower extremity contracture (stiffening/shortening of the left leg joint, that reduces the joint's range of motion). During a review of Resident 12's history and physical (H&P) dated 11/17/2025, the H&P indicated Resident 12 did not have the mental capacity (ability) to understand or make decisions. The H&P indicated resident 12 had a lower extremity (lower leg - did not specify which leg) contracture. During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool) dated 1/27/2026, the MDS indicated Resident 12 sometimes had the ability to make himself (Resident 12) understood and sometimes had the ability to understand others. During an interview on 2/19/2025 with Restorative Nurse Assistant 1 (RNA1, a specialized caregiver, often a certified nursing assistant [CNA], who helps patients regain or maintain their physical strength and independence after an illness or injury), RNA 1 stated she (RNA 1) only performed range of motion exercises on Resident 12's upper extremities (arm) because Resident 12 did not allow RNA 1 to touch the lower extremities (legs). During a concurrent interview and record review on 2/19/2025 with Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 3 (RN 3), Resident 12's Order Review History Report dated 2/19/2025 was reviewed. The Order review History Report indicated a physician order dated 2/19/2026 for active range of motion (ROM) of both upper extremities with RNA three times a week as tolerated. RN 3 stated there was only a physician order for an RNA (in general) to perform ROM on Resident 12's upper extremities. LVN 1 stated Resident 12 did not allow any staff to touch the left lower extremity. During a concurrent interview and record review on 2/19/2025 with Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 3 (RN 3), Resident 12's care plan titled High risk for further decline in range of motion related to impaired mobility and decreased strength for: Both Upper Extremities and Both Lower Extremities, dated 11/23/2022 was reviewed. The care plan indicated interventions to observe and document response to range of motion exercise for both upper and lower extremities. The care plan also had an intervention to observe for change in ROM of both upper and lower extremities. LVN 1 stated the facility's staff should have reviewed Resident 12's care plan quarterly (every three months) and as needed. RN 3 and LVN 1 stated if the RNAs (in general) were no longer providing ROM to Resident 12's left lower extremity, the facility should have revised Resident 12's care plan for the care plan to be person-centered (focusing on the whole person-their unique needs, choices, and strengths). RN 3 and LVN 1 stated Resident 12's care plan should have been accurate for the facility to be able to properly care for Resident 12. During a concurrent interview and record review on 2/19/2026 at 2:05 PM with Physical Therapist 1 (PT 1), Resident 12's progress note dated 10/10/2023 were reviewed. The PT note indicated Resident 12 had been refusing to participate with RNA for LLE (left lower extremities) with a recommendation to discontinue (stop) the RNA for LLE. The progress note indicated Resident 12's Nurse Practitioner was contacted, agreed to the recommendation, and discontinued the RNA for LLE. PT 1 stated Resident 12 had been refusing lower extremity therapy since 10/10/2023 and the therapy was discontinued in 2023 per Resident 12's request. During a concurrent observation and interview on 2/19/2026 at 3:00 PM with the Director of Nursing (DON), Resident 12's care plan High risk for further decline in range of motion related to impaired mobility and decreased strength for: Both Upper Extremities and Both Lower Extremities, dated 11/23/2022 was reviewed. The DON confirmed by stating the facility did not update Resident 12's care plan. The DON stated if Resident 12 was refusing to do lower extremity exercises, Resident 12's care plan should have been revised and updated. The DON stated the current care plan in place was no longer pertinent to Resident 12. During a review the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive (complete) Person-Centered, dated 3/2025, the P&P 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 P&P indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The P&P indicated 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; andd. at least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set - a resident assessment tool) assessment.The P&P indicated The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on interviews and record reviews the facility failed to renew psychotropic medications (drugs that alter brain chemistry) consents for one of two residents (Resident 13), As evidenced by: 1. Failing to renew Resident 13's Lamotrigine (medication used to stabilize moods to manage bipolar disorder [a mental health condition that causes extreme mood swings]) consent from 1/31/2023.2. Failing to renew Resident 13's Trazadone (medication used to improve mood and sleep).3. Failing to renew Resident 13's aripiprazole (medication used to treat mental health conditions like schizophrenia [a serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior] and bipolar disorder) consent from 12/10/2024. These failures had the potential for Resident 13 to be denied the opportunity to give informed consent, participate in the resident's own plan of care, and be informed of the medications.Findings: During a review of Resident 13's admission Record, the admission record indicated the facility admitted the resident on 10/5/2022 with diagnoses that included schizophrenia and bipolar disorder. During a review of Resident 13's Verification of Informed Consent for Psychotropic Medication dated 1/31/2023 for lamotrigine, the consent indicated the resident was provided information and the risks were discussed and reviewed. The consent had not been renewed since 2023. During a review of Resident 13's Verification of Informed Consent for Psychotropic Medication dated 2/21/2024 for trazadone, the consent indicated the resident was provided information and the risks were discussed and reviewed. During a review of Resident 13's Verification of Informed Consent for Psychotropic Medication dated 12/10/2024 for aripiprazole, the consent indicated the resident was provided information and the risks were discussed and reviewed. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool) dated 1/9/2026, the MDS indicated Resident 13 was alert and oriented with good recall. The MDS indicated Resident 13 had bipolar disorder and schizophrenia. During a concurrent interview and record review on 2/19/2026 at 2:42 PM with Licensed Vocational Nurse (LVN) 8, Resident 13's consent for lamotrigine was reviewed. LVN 8 reviewed Resident 13's electronic chart for consent for lamotrigine but could not locate the document in the chart. LVN 8 stated consents were needed and the risk to Resident 13 would be the resident would not be informed of the risks and benefits of the medication. LVN 8 reviewed the consents for Trazadone and Aripiprazole and noted the consents had not been renewed. LVN 8 stated she (LVN 8) was unsure when consents needed to be renewed. During an interview on 2/19/2026 at 2:54 PM, with the Assistant Director of Nursing (ADON), the ADON stated that consents need to be renewed every six months. The ADON was not sure if the facility's policy indicated if consents needed to be renewed every six months. During an interview on 2/19/2026 at 3:45 PM with the Director of Nursing (DON), the DON stated that consents for psychotropic medications were a requirement and the resident and or their representative (unspecified) needed to be informed of the risks and benefits of the psychotropic medication. The DON stated that consents needed to be updated every six months. The DON stated Resident 13 could have been deprived of the opportunity to give consent and participate in the plan of care and be informed of the medications. A review of the facility's policy and procedures (P&P) titled, Informed Consent Policy, dated 4/2025, the P&P indicated no mention of the time frame when the psychotropic consent should be renewed. A review of the facility's policy and procedures (P&P) titled, Psychotropic Medication Use, dated 4/2025, the P&P indicated no mention of the time frame when the psychotropic consent should be renewed. A review of the All Facilities Letter (AFL, an official bulletin or memo sent by a government agency [most commonly the California Department of Public Health (CDPH)] to keep healthcare facilities informed about new rules, safety alerts, or changes in the law) dated 2/3/2026, the AFL indicated Facilities had to renew the Informed Consent form every six months during which the resident received a psychotherapeutic drug (used to manage mood, behavior, and thoughts).

Based on observation, interview, and record review the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs for one of three sampled residents (Resident 193), by failing to create and implement a care plan for Resident 193's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). These deficient practices had the potential for Resident 193 to receive inadequate care and/or supervision which could affect the residents' quality of care and cause the resident harm.Findings: During a review of Resident 193's admission Record, the admission Record indicated the facility initially admitted the resident on 9/8/2000, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) type 2 with other circulatory (the body's primary transport network) complications, age-related osteoporosis(weak and brittle bones due to lack of calcium and Vitamin D) without current pathological fracture ( a broken bone caused by an underlying disease that weakens the bone structure), unspecified osteoarthritis(a progressive disorder of the joints, caused by a gradual loss of cartilage), unspecified site, muscle weakness(generalized),dysphagia (difficulty swallowing), monoplegia(the paralysis or severe weakness of a single limb[one arm or one leg]) of upper limb following nontraumatic subarachnoid hemorrhage ( a life-threatening, sudden bleeding in the space between the brain and its surrounding membrane, not caused by a head injury) affecting left non-dominant (less used) side. During a review of Resident 193's Physician Progress Note dated 9/12/2025, the Physician Progress Note indicated Resident 193 was wheelchair and bedbound, and weakness prevented ambulation (walking or moving from place to place). The Physician Progress Note indicated Resident 193 had dementia (a progressive state of decline in mental abilities). During a review of Resident 193's Minimum Data Set (MDS, a resident assessment tool) dated 12/5/2025, the MDS indicated the resident had severe cognitive impairment (impaired ability to think, understand, and reason). The MDS indicated Resident 193 was dependent on the staff (helper does all of the effort) for toileting hygiene, lower body dressing, lying to sitting on the side of the bed, and chair/bed to chair transfer. The MDS indicated Resident 193 was at risk of developing pressure ulcers/injuries (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). The MDS indicated Resident 193 utilized a pressure reducing device for bed. During a concurrent interview and record review on 2/19/2026 at 1:31 PM, with Licensed Vocational Nurse (LVN) 7, Resident 193's Order Summary Report and complete Care Plan Report were reviewed. LVN 7 confirmed there were no orders and no care plan for Resident 193's low air loss mattress. LVN 7 stated a care plan had focused goals and specific care interventions Resident 193 needed and should have been in place in the care plan. LVN 7 stated the use of a LALM mattress would have been part of a personalized care plan for Resident 193. LVN 7 stated Resident 193's LALM used to prevent skin breakdown since the resident's skin was fragile due to age. LVN 7 stated if there was no care plan there would be no guide on how to take care of Resident 193. LVN 7 stated the facility would not know where to start. LVN 7 stated the facility should have had a care plan for Resident 193's LALM and orders for her LALM for specific indication and settings. During a concurrent interview and record review on 2/19/2026 at 2:34 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Support Surface Guidelines dated 4/2025, was reviewed. The DON stated Resident 193 should have had a care plan for the use of a LALM. The DON stated the care plan documented the particular plan of care for a resident and had to be person centered and individualized. The DON stated a care plan had personalized interventions that had to be documented with goals to have mitigated (lessoned) problems to improve quality of care. The DON stated resident 193 should have had orders for her LALM to specify indications for the use of the LALM such as weight. During a review of the facility's policy and procedure (P&P) titled, Support Surface Guidelines dated 4/2025, the P&P indicated Review the resident's care plan to assess for any special needs of the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 4/10/2025, the P&P 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 P&P indicated The comprehensive, person-centered care plan will incorporate risk factors associated with identified problems, reflect treatment goals, timetables and objectives in measurable outcomes. The P&P indicated The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). The P&P indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, interviews, and record reviews, the facility failed to maintain infection control measures necessary to prevent the spread of infections for two out of nine sampled residents (Resident 262 and Resident 292), by failing to: Ensure Licensed Vocational Nurse 3 (LVN 3) performed hand hygiene (cleaning your hands to remove dirt, viruses, and bacteria, primarily through washing with soap and water or using alcohol-based sanitizer) before administering medications and coming in direct contact (physically touching someone or interacting face-to-face, allowing for the potential for immediate transfer of germs) with Resident 262.Ensure Certified Nurse Assistant 2 (CNA 2) wore full personal protective equipment (PPE-mask, gown, eye protection, gloves) per facility policy and procedures (P&P) titled Enhanced Barrier Precautions (EBP) with an last reviewed date of 1/8/2026 before providing care and treatment to Resident 292, who required enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes). This deficient practice had the potential to result in the spread of disease and infection to all 289 residents, visitors, and staff.Findings: 1.During a review of Resident 262's admission record, the admission record indicated Resident 262 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included diabetes mellitus (DM—a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid schizophrenia (a mental illness that causes someone to hear or see things that are not real and believe others want to harm them), hypertension (HTN—high blood pressure), hyperlipidemia (high cholesterol), and bed confinement status (unable to get out of bed without assistance). During a review of Resident 262's Minimum Data Set (MDS—a resident assessment tool) dated 11/28/2025, the MDS indicated Resident 262's cognitive skills (ability to think and reason) were intact. The MDS indicated Resident 262 required setup or clean-up assistance for eating and oral hygiene, as well as substantial staff assistance for upper body dressing. The MDS indicated Resident 262 was dependent on facility staff and required physical assistance from two or more staff members for toileting, showering/bathing, lower body dressing, and personal hygiene. During a review of Resident 262's History and Physical (H&P) dated 12/19/2025, the H&P indicated the resident did not have the capacity to make healthcare decisions. During a concurrent medication pass observation on Station D at Medication Cart B and interview, on 2/17/2026 between 8:52 AM through 9:08 AM, with LVN 3, LVN 3 stated she had prepared a total of three morning medications for Resident 262 and placed the medications into a medication cup, the medications were: Apixaban (a medicine that helps prevent blood clots) 5 milligrams (mg, measurement by weight) one tablet. Benztropine Mesylate (a medicine that helps with tremors and stiffness) 1 mg, one tablet. Escitalopram (to treat depression, feeling sad, and anxiety, feeling anxious) 10 mg, one tablet. On 2/17/2025 at 9:06 AM, before entering Resident 262's room, LVN 3 was not observed performing hand hygiene prior to entering Resident 262's room. LVN 3 proceeded to enter the resident's room and was observed administering medications to the resident, by mouth. During a follow up interview on 2/17/2026 at 9:10 AM with LVN 3, LVN 3 confirmed by stating she did not wash or sanitize her hands before entering Resident 262's room to administer the medications. LVN 3 acknowledged that she should have sanitized her hands before entering Resident 262's room to prevent the transmission of infections. During an interview on 2/17/2026 at 9:52 AM with LVN 11, LVN 11 stated that hand hygiene was important for infection control because hand hygiene prevented germs from being passed along to residents or staff, as hands were the dirtiest. During an interview on 2/18/2026 at 5:11 PM, the Director of Nursing (DON) stated that nurses were expected to perform hand hygiene as follows: - Before preparing medications - Before entering the resident's room to administer medications, and - After administering medications and before going to the next resident. During a review of the facility's policy and procedure (P&P), titled Infection Control Guidelines for All Nursing Procedures, revised 4/2025, the P&P indicated All employees must wash their hands for at least twenty seconds using antimicrobial soap and water under the following conditions . Before and after direct contact with residents.In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60 – 95 % ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents; b. Before donning sterile gloves; c. Before performing any non-surgical invasive procedures; d. Before preparing or handling medications. 2. During a review of Resident 292's H&P dated 1/12/2026, the H&P indicated the resident had the capacity to make healthcare decisions. During a review of Resident 292's care plan titled, At risk for infection initiated 2/16/2026, the care plan interventions included to implement Enhanced Barrier Precaution (EBP). During an observation outside of Resident 292's room on 2/17/202 at 11 AM, a sticker labeled EBP was observed next to Resident 292's name. During an observation in Resident 292's room on 2/18/2026 at 4:25 PM, CNA 2 was observed performing an incontinent brief change on Resident 292 wearing gloves, a mask, and no gown on. During an interview on 2/18/2026 at 4:28 PM with CNA 2 outside of Resident 292's room, CNA 2 stated the sticker labeled EBP next to the resident's name indicated the resident was on EBP. CNA 2 stated staff were required to wear PPE which included masks, gloves and gowns, when providing care to residents on EBP. CNA 2 stated wearing PPE helped protect residents from infection and prevented the spread of infection. CNA2 confirmed by stating she was not wearing a gown during the incontinent brief change of Resident 292. CNA2 stated she should have worn a gown. CNA 2 stated she failed to follow the infection control process and potentially could have spread infection. During an interview on 2/20/2026 at 10:55 AM with LVN 12, LVN stated the safe infection control practice of EBP was to check the label next to the resident's name and use PPE when providing care. LVN 12 stated Resident 292's safety was important. LVN 12 stated all staff had to wear PPE when residents were placed on EBP. During a concurrent interview and record review on 2/20/2026 at 2:21 PM with the Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 1/8/2026, was reviewed. The IP stated residents with EBP were at high risk of infection. The IP stated PPE including gowns and gloves were worn during high contact care. The IP stated the P&P indicated facility staff would wear a gown and gloves when performing high-contact resident care activities. The IP stated an incontinent brief change was considered a high contact care activity. The IP stated CNA 2 had potential contact with resident's soiled brief and CNA 2 should have worn the gown as indicated on the P&P. During a concurrent interview and record review on 2/20/2026 at 2:25 PM with the facility Administrator (ADM), the facility's P&P titled, Enhanced Barrier Precautions, dated 1/8/2026, was reviewed. The ADM stated the facility's priority was to practice and monitor infection control. The ADM stated the EBP P&P indicated to wear PPE for high-contact resident care activities. The ADM stated CNA 2 failed to wear the appropriate PPE and should have worn a gown when changing Resident 292's brief. The ADM stated there was a potential risk of spreading infection. During a review of the facility's P&P, titled Hand Hygiene, revised 10/2025, the P&P indicated To maintain the highest standards of infection prevention and control through hand hygiene adherence.Hand hygiene shall be performed under the conditions listed in, but not limited to, the attached hand hygiene reference table.before and after direct contact, after contact with surfaces or objects in immediate vicinity of patient. During a review of the facility's P&P, titled Administering Medications, dated 4/2025, the P&P indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During a review of Resident 292's admission Record, the admission Record indicated the facility originally admitted Resident 292 on 12/31/2025 and re-admitted on [DATE] with diagnoses the included chronic left foot ulcer (an open, painful, crater-like sore that develops on the skin) and anemia ( a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a review of the facility's P&P titled Enhanced Barrier Precaution, last reviewed on 1/8/2026, the P&P indicated EBP was used in with standard precautions and expanded the use of PPE to putting on a gown and gloves during high contact resident care activities. The P&P indicated facility staff were to perform hand hygiene and would put on a gown and gloves before performing the following high-contact resident care activities: Changing briefs or assisting with toileting.

Based on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or the he non-hardened, flexible area beneath your skin usually over a bony area) settings for two of six sampled residents (Resident 42 and Resident 193). This failure had the potential to increase the risk of skin breakdown (damage to the skin and underlying tissue, ranging from red, irritated skin to deep, open wounds/bedsores) and development of pressure ulcers/injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for Resident 42 and Resident 193.Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility originally admitted Resident 42 on 8/3/2021 and readmitted Resident 42 on 4/11/2022 with diagnoses that included rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), bilateral primary osteoarthritis of hip (he protective cushioning in both hip joints has worn away, causing the bones to rub together, resulting in pain, stiffness, and decreased mobility in both sides), peripheral vascular disease unspecified (common condition in which narrowed arteries reduce blood flow to the arms or legs), other specified disorders of bone density and structure, unspecified site (where bones become weak, brittle, misshapen, or soft due to faulty rebuilding, genetic issues, or metabolic problems that can cause an increased risk of fracture and bone pain), muscle weakness, unsteadiness on feet, congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), repeated falls, dementia (a progressive state of decline in mental abilities), and neuralgia and neuritis (nerve pain and inflammation of a nerve). During a review of Resident 42's History and Physical (H&P) dated 5/2/2025, the H&P indicated Resident 42 could make her (Resident 42) needs known but could not make medical decisions. During a review of Resident 42's Minimum Data Set (MDS – a resident assessment tool) dated 1/30/2026, the MDS indicated Resident 42 sometimes had the ability to make herself (Resident 42) understood and sometimes had the ability to understand others. The MDS indicated Resident 42 needed substantial/maximal assistance (helper does more than half the effort) for toileting, upper/lower body dressing, personal hygiene (comb hair, washing/drying hands and face), moving from lying on back to sitting on the side of the bed, moving from sitting to lying flat on the bed, and transferring from bed to chair or wheelchair. The MDS indicated Resident 42 was dependent (helper does all the work) on facility staff for getting in and out of a tub/shower and for showering/bathing. During a review of Resident 42's Situation, Background, Assessment, Recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) dated 2/11/2026, the SBAR indicated Resident 42's weight on 2/1/2026 was 79 pounds. During a review of Resident 42's care plan titled, Low Air Loss Mattress for pressure redistribution (spreading out) and skin Management dated 2/14/2026 indicated a goal for Resident 42 not to have skin breakdown. During a review of Resident 42's Pressure Ulcer Risk Evaluation dated 2/17/2026, the Pressure Ulcer Risk Evaluation indicated Resident 42's sensory perception (the process of using your senses—sight, sound, smell, taste, and touch—to gather information from the world and make sense of it in your brain) was slightly limited. The Pressure Ulcer Risk Evaluation indicated Resident 42's was constantly moist, likely had inadequate nutrition and had a problem with friction (the surface burn caused by rubbing, like sliding on sheets), and shear (happens when skin stays put while deeper tissue shifts downward, like sliding down in a bed, causing internal tissue damage). The Pressure Ulcer Risk Evaluation indicated Resident 42's Braden score was 12 (scores patients from 6 to 23, a score of 12 indicated high risk for developing bedsores). During a review of Resident 42's nurses notes dated 2/18/2026, the nurses notes indicated Resident 42 had left buttocks (butt) scar tissue, right ischium (the lower, back part of your hip bone) with excoriation (a surface-level scrape, scratch, or abrasion where the top layer of skin has been removed), and left buttocks with MASD (moisture-associated skin damage is defined as the erosion [wearing away] and/or inflammation [the body's natural response to protect itself against harm] of the skin due to extended exposure to moisture as well as its content such as mucus [a clear, slippery, gel-like substance that's part of your immune system], sweat, saliva, poop, and urine). During a review of Resident 42's Order Review History Report dated 2/19/2026, the Order Review History Report did not indicate there was a physician order for a LALM. The Order Review History Report indicated a physician order for zinc oxide (white, powdery, natural mineral commonly used in skin products for sun protection and healing) to Resident 42's right ischium daily. During a concurrent observation and interview on 2/17/2026 at 11:32 AM with the Wound Care Nurse (WCN), Resident 42's LALM was observed set for a weight of 250 pounds. The WCN stated Resident 42's LALM should have been set according to Resident 42's weight of 79 pounds. The WCN stated the LALM could cause the resident's wound on her ischium and buttocks to worsen. During a concurrent interview and record review on 2/17/2026 at 11:46 AM with Registered Nurse 2 (RN 2), Resident 42's vital sign weight dated 2/1/2026 on Resident 42's electronic medical record (EMR - a digital, computer-based version of a patient's paper chart) was reviewed. The vital sign weight indicated Resident 42 weight 79 pounds. RN 2 stated setting Resident 42's LALM to 250 pounds was too high and could cause Resident 42's wounds to get worse. RN 2 stated Resident 42's LALM should have been set according to Resident 42's weight. During an interview on 2/17/2026 at 12:09 PM with the Director of Nursing (DON), the DON stated if Resident 42's LALM was set to 250 pounds and Resident 42 weighed 79 pounds, the LALM was set too high and Resident 42 would not get the therapeutic benefit of the LALM. The DON stated the LALM should have been set based on Resident 42's weight. During a review of Resident 193's admission Record, the admission Record indicated the facility initially admitted the resident on 9/8/2000, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) type 2 with other circulatory (the body's primary transport network) complications, age-related osteoporosis(weak and brittle bones due to lack of calcium and Vitamin D) without current pathological fracture ( a broken bone caused by an underlying disease that weakens the bone structure), unspecified osteoarthritis(a progressive disorder of the joints, caused by a gradual loss of cartilage), unspecified site, muscle weakness (generalized),dysphagia (difficulty swallowing), monoplegia (the paralysis or severe weakness of a single limb[one arm or one leg]) of upper limb following nontraumatic subarachnoid hemorrhage ( a life-threatening, sudden bleeding in the space between the brain and its surrounding membrane, not caused by a head injury) affecting left non-dominant(less used) side. During a review of Resident 193's Physician Progress Note dated 9/12/2025, the Physician Progress Note indicated Resident 193 was wheelchair and bedbound; weakness prevented ambulation (walking or moving from place to place). The Physician Progress Note indicated Resident 193 has dementia (a progressive state of decline in mental abilities). During a review of Resident 193's Minimum Data Set (MDS, a resident assessment tool) dated 12/5/2025, the MDS indicated the resident had severe cognitive impairment (impaired ability to think, understand, and reason). The MDS indicated Resident 193 was dependent on the staff (helper does all of the effort) for toileting hygiene, lower body dressing, lying to sitting on the side of the bed, and chair/bed to chair transfer. The MDS indicated Resident 193 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 193 utilized a pressure reducing device for bed. During a review of Resident 193's Weights and Vitals Summary, the Weights and Vitals Summary indicated the resident weighed 118 pounds (lbs., a unit of weight) on 2/17/2026. During a concurrent observation and interview on 2/17/2026 at 12:08 PM, with Licensed Vocational Nurse (LVN)1, in Resident 193's room, Resident 193 was observed on a Drive LALM with settings set between 320 and 350 lbs. LVN 1 confirmed Resident 193's LALM settings were set at 320 to 350 lbs. LVN 1 stated the LALM settings were based on the Resident 146's weight. LVN 4 stated Resident 146's LALM settings at 350 lbs. were incorrect. LVN 1 verified Resident 193' weight in the medical record and stated Resident 193 current weight was 118 lbs. and stated the resident could have developed a pressure injury due to the mattress having been too hard for the resident. During an interview on 2/18/2026 at 11:45 PM, with the Director of Nursing (DON), the DON stated LALMs were set up based on a resident's weight to provide appropriate pressure. The DON stated if the LALM was too firm or too soft it could have been uncomfortable for the residents. The DON stated residents that had potential for pressure injuries with a LALM set at the incorrect weight, and would impact the benefit of having a LALM in place. During a review of the facility's policy and procedure (P&P) titled, Support Surface Guidelines dated 4/2025, the P&P indicated Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. During a review of the user manual titled Med-Aire Assure 5 Air +3 Foam Base Alternating Pressure and Low Air Loss Mattress System dated 3/22/2021, the user manual indicated .intended to help reduce the incidence of pressure ulcers while optimizing patient comfort. The user manual indicated Turn the pressure adjust knob to set a comfortable pressure level using the weight scale as a guide.

Based on observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of one sampled residents (Resident 120), by failing to ensure Resident 120's oxygen nasal cannula tubing (a lightweight, flexible plastic tube with two small prongs that sit just inside your nostrils to deliver supplemental oxygen) was not resting on the floor while Resident 120 was using the oxygen nasal cannula. This failure had the potential for Resident 120 to experience respiratory infections (infections of parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean in a way that could endanger health) oxygen nasal cannula tubing.Findings: During a review of Resident 120's admission Record, the admission Record indicated the facility originally admitted Resident 120 on 8/2/2021 and readmitted Resident 120 on 3/7/2022 with diagnoses that included personal history of COVID-19 (a contagious respiratory illness caused by the SARS-CoV-2 virus), dementia (a progressive state of decline in mental abilities), unspecified injury of head, dysphagia (difficulty swallowing), muscle weakness, and repeated falls. During a review of Resident 120's Minimum Data Set (MDS - a resident assessment tool) dated 12/10/2025, the MDS indicated Resident 120 rarely/never had the ability to make herself (Resident 120) understood and rarely/never had the ability to understand others. During a review of Resident 120's History and Physical (H&P) dated 10/17/2025, the H&P indicated Resident 120 was only oriented to person (means that a person knows who they are) due to dementia. During a review of Resident 120's care plan dated 1/18/2026, the care plan indicated Resident 120 had impaired (decrease in ability) respiratory function r/t (related to) desaturation (drop in your blood oxygen levels below normal), tachycardia (an abnormally fast resting heart rate, generally defined as exceeding 100 beats per minute), fever pneumonia per x-ray result. The care plan had an intervention to change tubing and oxygen humidifier bottle (small, reusable container filled with distilled water that attaches to an oxygen machine to prevent dry air from causing nosebleeds, throat irritation, and dry nasal passage) when in use per facility protocol (standardized set of rules, procedures, or instructions that dictate how communication, actions, or tasks are carried out, ensuring consistency and safety). During a review of Resident 120's Nurses Notes dated 2/3/2026, the Nurses notes indicated Resident 120 was S/P (status post - after or following) antibiotic for pneumonia (an infection/inflammation in the lungs). During a review of Resident 120's Order Review History Report dated 2/20/2026, the Order Review History Report indicated a physician order written on 1/18/2026 to change Resident 120's oxygen cannula tubing every 2 weeks on Sundays and as needed for soilage (the act of making something dirty, stained, or contaminated). During a concurrent observation in Resident 120's room and interview on 2/17/2026 at 2:47 PM with Licensed Vocational Nurse 6 (LVN 6) and Certified Nursing Assistant 1 (CNA 1), Resident 120's oxygen nasal cannula tubing was observed touching the floor while Resident 120 was using the oxygen nasal cannula. CNA 1 stated the oxygen nasal cannula tubing on the floor could cause a tripping hazard. LVN 6 stated Resident 120 could get an infection from the oxygen nasal cannula tubing touching the floor and Resident 120's oxygen nasal cannula tubing would need to be changed right away. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, dated 1/2026, the P&P: indicated the facility would change oxygen tubing every 2 weeks or as needed. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated 4/2025, the P&P indicated the facility would provide residents (in general) with a clean, sanitary (free from germs), and orderly environment. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 3/27/2025, the P&P indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections (when germs are spread from one person to another). The P&P indicated the facility would educate staff on adhering (sticking) to proper infection prevention techniques and procedures. The P&P indicated the facility would institute (put into place) prevention of infection measures to avoid complications and dissemination (spread).

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 79) identified as at risk for falls was free from risks of falling, by failing to ensure the resident's bed was placed in the lowest position. This deficient practice placed Resident 79 at increased risk for falls and complications related to fall injuries such as fractures, cuts, and internal bleeding.Findings: During a review of Resident 79's admission Record, the admission Record indicated the facility admitted Resident 79 on 6/28/2024 with diagnoses that included vascular dementia (a progressive state of decline in mental abilities), pain in right hip, pain in left hip, collapsed vertebra thoracolumbar region (one of the bones in the spine, located where the middle back meets the lower back, has broken and flattened, becoming shorter in height), malignant neoplasm of prostate (prostate cancer, a disease where cells in the walnut-sized male gland below the bladder grow uncontrollably and can spread), and pain in unspecified ankle and joints of unspecified foot. During a review of Resident 79's care plan titled, High risk for falls and injury related to perceived self as independent and will not call for assistance, history of falls, use of psychotropic medications (prescription drugs that change brain chemistry to affect mood, thoughts, behavior, or perception), hard of hearing, recent fall dated 6/24/2024, the care plan indicated a goal for Resident 79 to be able to follow safe technique when performing functional mobility (your ability to move around independently and safely in your daily life) and ADL (activities of daily living - the basic, everyday self-care tasks people do to live independently without assistance, such as bathing, dressing, eating, and moving around) to prevent falls and injury. The care plan indicated an intervention for Resident 79 to have a yellow nameplate on the door and to have a fall risk arm band that identified Resident 79 as a fall risk. During a review of Resident 79's History and Physical (H&P) dated 10/24/2025, the H&P indicated Resident 79 was mostly wheelchair and bedbound (a person is unable to leave their bed for most or all of the day due to severe illness, injury, or physical weakness). The H&P indicated Resident 79 had weakness and gait instability (an unsteady, unbalanced, or irregular walking pattern that makes you feel shaky on your feet and increases fall risk) that prevented safe ambulation (walking or moving from place to place). During a review of Resident 79's Interdisciplinary Team Meeting - Fall (a collaborative gathering of different specialists-such as doctors, nurses, therapists, and social workers-who meet to create a unified, whole-person care plan for a resident) dated 11/26/2025, the Interdisciplinary Team Meeting - Fall indicated Resident 79 had a fall while at the VA (Veterans Administration - a federal agency that provides lifelong support to military veterans, their families, and survivors) for an audiology (the healthcare science of hearing and balance, focusing on diagnosing, managing, and treating hearing loss) appointment. The Interdisciplinary Team Meeting - Fall indicated Resident 79 was a high risk for falls. During a review of Resident 79's Minimum Data Set (MDS - a resident assessment tool) dated 1/5/2026, the MDS indicated Resident 79 could make himself (Resident 79) understood and had the ability to understand others. During a review of Resident 79's Morse Fall Risk Screen (checklist used by facility staff to predict a resident's likelihood of falling) dated 1/5/2026, the Morse Fall Risk Screen indicated Resident 79 had a history of falling and had a fall risk score of 55 indicating Resident 79 was a high risk for falls.During a review of Resident 79's care plan titled, difficulty with bed mobility, unable to stand for transfer and gait, impaired balance with weakness BLE (bilateral lower extremities, both lower extremities) dated 1/13/2026 indicated an intervention for skilled physical therapy five times a week for neuromuscular reeducation (a specialized physical therapy technique that re-teaches your brain and muscles to communicate, restoring normal movement, balance, and coordination) and gait training (a form of physical therapy designed to improve how you walk, stand, and balance, helping you move more safely) due to Resident 79 being unsteady on feet. During a review of Resident 79's Nurses Weekly Progress Notes dated 2/7/2026, the Nurses Weekly Progress Notes indicated Resident 70 was forgetful and confused. The Nurses Weekly Progress Notes indicated Resident 79 required 2-person transfer assistance (a safety technique where two trained caregivers move a person who cannot stand or move safely on their own). During a review of Resident 79's Order Review History Report dated 2/19/2026, the Order Review History Report indicated a physician order for Wander guard (a wearable electronic device, usually a bracelet, designed for seniors or people with memory loss to prevent them from wandering away from safe areas ) placement on resident's (Resident 79) wheelchair secondary to: wandering, exit-seeking behavior. The Order Review History Report indicated to monitor for placement every shift. The Order Review History Report indicated a physician order to check for orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from a sitting or lying position that can cause dizziness, lightheadedness, fainting) every dayshift. During an observation in Resident 79's room and interview on 2/17/2026 at 12:43 PM with Certified Nurse Assistant 5 (CNA 5), Resident 79's bed was observed to be in a high position. CNA 5 stated Resident 79's bed was in a high position and Resident 79 could fall out of bed. During an interview on 2/172026 at 12:47 PM with Licensed Vocational Nurse 11 (LVN 11), LVN 11 stated if Resident 79's bed position was set too high, Resident 79 could be at risk for fall. During an interview on 2/17/2026 at 12:57 PM with Registered Nurse 2 (RN 2), RN 2 stated if Resident 79's bed was not in a low position, Resident 79 could fall and have an injury. RN 2 stated staff should have placed Resident 79's bed in a low position. During an interview on 2/19/2026 at 2:39 PM with the Director of Nursing (DON), the DON stated if Resident 79's bed was not in the low position, Resident 79 could fall and have an injury. The DON stated Resident 79's bed should have been positioned to the lowest position. During a review of the facility's policy and procedure (P&P) titled Falls - Clinical Protocol, dated 12/2025, the P&P indicated the facility would identify pertinent (relevant) interventions to try to prevent subsequent (following or additional) falls. During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, dated 4/2025, the P&P indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. The P&P indicated risk factors included bed safety. During a review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, dated 4/2025, the P&P indicated staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated incorrect bed height, delirium (a sudden, temporary state of severe confusion and rapid mental decline ) and other cognitive impairment (having trouble with thinking, memory, focus, or decision-making that is more noticeable than normal aging), lower extremity weakness, and balance and gait disorders as a factors that could contribute to a resident's (in general) risk for fall. The P&P indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on observation, interview, and record review, the facility failed to ensure the facility's medication error rate (the percentage of errors observed during medication administration) was less than five percent (%). Two medication errors out of a total of twenty-six opportunities contributed to an overall medication error rate of seven-point six nine percent (7.69 %), affecting one of four sampled residents (Resident 260) who was observed during medication administration (med pass). The facility failure to assess Resident 260's systolic blood pressure (SBP - the pressure in the arteries when the heart beats [bpm]) and/or heart rate (HR - the number of times the heart beats per minute) prior to administering Labetalol and Lisinopril (medications used to treat hypertension [HTN - high blood pressure]) to the resident as ordered. The failure placed Resident 260 at risk for bradycardia (HR that is too slow) and/or hypotension (low blood pressure [BP]), which could lead to other complications and hospitalization.Findings:During a review of Resident 260's admission record, the admission record indicated Resident 260 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension (HTN, high blood pressure) and hyperlipidemia (high cholesterol in the blood). During a review of Resident 260's Minimum Data Set (MDS, a resident assessment tool) dated 1/16/2026, the MDS indicated Resident 260's cognitive skills (ability to think and reason) was moderately impaired. During a review of Resident 260's Order Review History Report, printed on 02/17/2026 and electronically signed by the prescriber, included the following active medication orders for Resident 260:Labetalol (medication used to treat HTN) 100 milligrams (mg, unit of measurement by weight) tablet, instruction to give one tablet by mouth two times a day for HTN. Hold for SBP less than 110 millimeters of mercury (mmHg, a unit for measuring blood pressure, normal SBP range: 90-120 mmHg) or HR less than 60 bpm (normal HR range: 60-100 bpm), order date 7/28/2025.Lisinopril (medication used to treat HTN) 40 mg tablet, instruction to give one tablet by mouth one time a day for HTN. Hold for SBP less than 110, order date 7/28/2025. During a review of Resident 260's care plan initiated on10/21/2024, the Care Plan focus indicated Resident 260 was at risk for Cardiac Distress (a condition characterized by symptoms such as chest pain, shortness of breath, or irregular heartbeat; cardiac distress can increase the workload on the heart and may contribute to elevated blood pressure) related to hyperlipidemia and HTN. The care clan indicated Resident 260 would remain free from signs and symptoms of cardiac distress. The care plan interventions indicated to administer Labetalol and Lisinopril as ordered.monitor apical pulse (heartbeat heard at the chest with a stethoscope) and blood pressure (BP) as indicated in the medication parameter. During a medication pass observation on 2/17/2026 between 9:58 AM to 10:18 AM, with Licensed Vocational Nurse (LVN) 6, LVN 6 was observed preparing the following medications: Labetalol 100 milligrams (mg, unit of measurement), one tablet.Lisinopril 40 mg, one tablet. Vitamin C (vitamin supplement) 250 mg, one tablet. Cranberry (supplement to treat or prevent urinary tract infections) 450 mg, one tablet. Vitamin B12 (vitamin supplement) 1 mg, one tablet. Magnesium Oxide (used to help prevent and treat low levels of magnesium in the body) 400 mg, one tablet. Ferrous Gluconate (use to treat iron deficiency) 240 mg, one tablet. During a concurrent med pass observation and interview on 2/17/2026 at 10:15 AM, LVN 6 stated she prepared a total of seven medications, entered the resident's room, called the resident by name and administered the medications. LVN 6 was not observed checking Resident 260's blood pressure (BP) or heart rate (HR) prior to administering the two BP medications Labetalol and Lisinopril. During an interview on 2/17/2026, at 10:21 AM, LVN 6 stated the Certified Nurse Assistants (CNA) normally checked the residents' vitals (measurements of essential body functions, such as blood pressure, heart rate, temperature, and respiratory rate). LVN 6 provided a handwritten paper that included Resident 260's BP and HR and stated the vital sign readings were provided to LVN 6 by CNA 1. LVN 6 acknowledged the paper with residents' vital signs did not include the date or time the vital signs were taken. LVN 6 acknowledged the vital signs were taken two and one-half hours earlier by CNA 1, on 2/17/2026 between 7:30 AM to 7:45 AM. During an interview on 2/17/2026 at 10:28 AM with CNA 1, in the presence of LVN 6, CNA 1 stated Resident 260's vitals were taken between 7:30 AM to 7:45 AM on 2/17/2026. CNA 1stated he (CNA 1) checked the vital signs of eight residents, which included the vital signs for Residents 260, 129, 8, and 83 before breakfast and once done provided the results to LVN 6. During a follow up interview on 2/17/2026 at 10:31 AM, with LVN 6, LVN 6 stated she (LVN 6) usually relied on the vitals taken by the CNAs to determine to give or hold BP medications to the residents. LVN 6 stated she could not verify based on the undated and untimed form when the vitals, that included BP and HR were taken by CNA 1 on 2/17/2026. LVN 6 stated that it was important to recheck the residents BP and HR to make sure the BP and HR readings were accurate before administering BP medications with an ordered parameter. LVN 6 stated if BP medications were administered outside of the ordered parameters residents could experience symptoms that include low blood pressure, weakness, change in cognition and alertness, syncope (brief loss of consciousness), which could lead to hospitalization. During an interview on 2/18/2026 at 5:09 PM with the Director of Nursing (DON), the DON stated residents' BP should have been checked prior to, and as close as possible to the medication administration time. The DON stated that if a resident's BP and heart rate (HR) were checked two hours before medication administration, the licensed nurse had to recheck the resident's BP and HR immediately prior to administering the BP medication when there were ordered parameters, in order to prevent a decline in the resident's condition. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2025, indicated, Medications are administered in accordance with prescriber orders.The following information is checked/verified for each resident prior to administering medications.b. Vital signs, if necessary. A review of the facility's undated policy and procedure titled, Medication Administration Principles, indicated, Vital signs (blood pressure, pulse rate, respiration) or blood sugar levels required for medication orders with hold parameters are taken prior to the administration of the medication and recorded on the MAR. During a review of the Food and Drug Administration (FDA)- approved prescribing information (package insert), revised 8/2024, the package insert for Lisinopril indicated, Hypotension: Patients with other heart or renal diseases have increased risk, monitor blood pressure after initiation.Patients at risk of excessive hypotension include those with the following conditions or characteristics: heart failure with systolic blood pressure below 100 mmHg.

Based on observation, interview, and record review, the facility failed to ensure proper storage, labeling, and/or disposal of medications, by failing to ensure an open box of Advair Diskus (a medication that contains both an anti-inflammatory medicine (fluticasone propionate) and a long-acting bronchodilator (salmeterol) with a shorten expiration date (the medicine will become less effective or unsafe sooner than the date originally printed on the bottle) once opened, had an open date (the date the medication was first opened) for one of four sampled residents (Resident 334), as per the manufacturer's label for Advair Diskus dated 6/2023. The deficient practice increased the risks associated with Resident 334 chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) could have received expired or ineffective medications which could result in health complications, difficulty breathing, or hospitalization.During a review of Resident 334's admission record, the admission record indicated Resident 334 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included COPD. During a review of Resident 334's Minimum Data Set (MDS, a resident assessment tool), dated 11/5/2025, the MDS indicated Resident 334's cognitive skills (ability to think and reason) were intact. During a review of Resident 334's History and Physical (H&P) dated 2/16/2026, the H&P indicated the resident did not have the capacity to make healthcare decisions. During a review of Resident 334's Order Summary Report dated 2/18/2026, the Order Summary Report included an order for Advair Diskus (a medication that contains both an anti-inflammatory medicine (fluticasone propionate) and a long-acting bronchodilator (salmeterol), used to treat asthma and COPD) 250 micrograms ([mcg] - unit of measure of weight)/ 50 mcg, instructions indicated one inhalation orally two times a day for COPD, rinse mouth after each use, order date 2/13/2026. During a concurrent observation and interview on 1/18/2026 at 12:10 PM with a Licensed Vocational Nurse (LVN) 3 on Nursing Station 3, MedCart C was inspected, and one oral inhaler was observed inside of the MedCart open without an open date for Advair (used to treat breathing difficulty) 250-50 mcg. LVN 3 stated there was no open date on the Advair labeled for Resident 334. LVN 3 stated without an open date the nurses would not accurately know when the medication was due to expire, and if administered after expiration the efficacy (effectiveness) might not have been as effective and the resident could have had an adverse reaction that included shortness of breath or respiratory symptoms (breathing problems such as coughing, wheezing, or chest tightness). LVN 3 stated she (LVN 3) administered a dose of Advair 250-50 mcg to Resident 334 on the date of interview, 2/18/2026. During a concurrent interview and record review on 2/18/2026 at 12:31 PM with a Registered Nurse Supervisor (RN) 1, Resident 334's physician order dated 2/18/2026 and prescription label and packaging for Advair were reviewed. RN 1 stated there should have been an open date to know when the medication was first opened and used. RN 1 reviewed the manufacturer's labeling for Advair and stated, the medication expired one month after opening the foil pouch or when the counter read zero whichever comes first. During a review of the manufacturer's labeling for Advair Diskus, dated 6/2023, indicated, Safely throw away ADVAIR DISKUS in the trash 1 month after you open the foil pouch or when the counter reads 0, whichever comes first.Write the date you opened the foil pouch in the first blank line on the label.Write the use by date in the second blank line on the label.That date is 1 (one) month after the date you wrote in the first line.

Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) for two out of five sampled residents (Resident 49 and Resident 308) were accurate, by failing to: 1. Document a diagnosis of bipolar disorder (a mental health condition that causes extreme mood swings) on Resident 49's MDS dated [DATE].2. Ensuring Resident 308's MDS dated [DATE] accurately reflected Resident 308's discharge status. These deficient practice resulted in an inaccurate MDS assessments and had the potential to negatively impact Resident 49's plan of care and delivery of services as well as the submission of incorrect regulatory and reimbursement (the act of paying someone back money) data for Resident 308.Findings: During a review of Resident 49's admission Record, the admission record indicated the facility originally admitted Resident 49 on 10/31/2024 and readmitted Resident 49 on 1/21/2026 with diagnoses that included bipolar disorder, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and aftercare following joint replacement surgery. During a review of Resident 49's History and Physical (H&P) dated 1/22/2026, the H&P indicated Resident 29 had the capacity (ability) to make healthcare decisions. During a review of Resident 49's MDS dated [DATE], the MDS indicated Resident 49 had the ability to understand others and had the ability to make herself (Resident 49) understood. During a concurrent interview and record review on 2/19/2026 at 3:45 PM with the MDSRN, Resident 49's current admission Record progress note dated 11/25/2024 was reviewed. The progress note indicated Resident 49 had a medical history of bipolar disorder. During a concurrent interview and record review on 2/19/2026 at 3:45 PM with the Minimum Data Set Registered Nurse (MDSRN) and Minimum Data Set Licensed Vocational Nurse (MDSLVN), Resident 49's MDS dated [DATE] was reviewed. Resident 49's MDS indicated the box for bipolar disorder in Section I – Active Diagnoses was not checked. The MDSRN stated that the MDS was not accurate. The MDSLVN stated the MDS had to be accurate because the information was sent to CMS (Centers for Medicare and Medicaid Services - a federal agency within the U.S. Department of Health and Human Services that manages major government healthcare programs, including Medicare and Medicaid that ensures quality healthcare by setting safety standards for facilities and ensures they meet quality standards). During a concurrent interview and record review on 2/19/2026 at 3:50 PM with the Director of Nursing (DON), Resident 49's MDS dated [DATE] was reviewed. The MDS indicated the box for bipolar disorder in Section I – Active Diagnoses was not checked. The DON stated the MDS had to accurately represent the resident because the information was sent to CMS and it also affected the facility's reimbursement. The DON stated the MDS had to be accurate. During a review of Resident 308's admission Record, the admission Record indicated the facility originally admitted the resident on 10/7/2017 and readmitted the resident on 11/12/2025 with diagnoses that included dysphagia (difficulty swallowing), acute gastric ulcer (a sudden , open sore in the stomach lining caused when stomach acid damages the tissue faster than it can repair itself), and iron deficiency anemia (a common condition where a lack of iron prevents the body from making enough hemoglobin[red blood cells that carries oxygen]). During a review of Resident 308's History and Physical (H&P), dated 11/17/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 308's Order Summary Report dated 1/2/2026, the Order [NAME] report indicated to discharge Resident 308 to home on 1/2/2026 with family. During a review of Resident 308's Discharge Instructions dated 1/2/2026 at 1:41 PM, the Discharge Instruction indicated Resident 308 was discharged to home with medical equipment arrangements for a hospital bed with Low Air Loss mattress (a specialized therapeutic mattress used in healthcare to prevent and treat pressure ulcers), wheelchair, walker and bathroom handrails. During a review of Resident 308's nurses' notes dated 1/2/2026 at 5:23 p.m., the notes indicated Resident 308 was discharged home by Gurney (a wheeled cot, stretcher, used in hospitals and ambulances to transport patients who are unable to walk) and explained discharge instructions. During a concurrent interview and record review on 2/19/2026 at 2:25 p.m. with Minimum Data Set Licensed Vocational Nurse (MDSLVN), Resident 308's order summary report was reviewed. The MDSLVN stated the order dated 1/2/2026 indicated Resident 308's discharge orders were to home with family. Resident 308's nurses' notes dated 1/2/2026 were reviewed. The notes indicated Resident 308 was discharged home. The MDSLVN stated that Resident 308's daughter was given discharge instructions. The MDSLVN reviewed Resident 308's MDS and stated the MDS indicated Resident 308 was discharged to Short-Term General hospital (a medical center that specializes in the short-term medical treatment of patients). The MDSLVN confirmed by stating the discharge status of Resident 308 was incorrectly documented on the MDS. The MDSLVN stated the MDS should have indicated discharged to home instead of discharged to Short-Term General Hospital. The MDSLVN stated that MDS assessment had to be accurate. The MDSLVN stated it was an incorrect assessment and reimbursement submission. During an interview on 2/29/2026 at 3:13 p.m. with the Administrator (ADM), the ADM stated the MDS was an assessment process to determine the clinical picture of residents. The ADM stated the MDS needed to be accurate. The ADM stated the MDS reflected the quality of care and clinical status of Residents. During a concurrent interview and record review on 2/19/2026 at 3:18 p.m. with the ADM, Resident 308's MDS dated [DATE] and nurses' notes dated 1/2/2026 were reviewed. The ADM stated the MDS discharge status indicated that the resident was discharged to a short-term General Hospital. The ADM stated Resident 308 was discharged home on 1/2/2026. The ADM Stated the MDS did not reflect accurate discharge status of Resident 308. The ADM stated the inaccuracy potentially affected financial reimbursement and accurate assessment of Resident 308. During a review the facility's policy and procedure (P&P) titled, Certify Accuracy of the Resident Assessment, dated 4/2025, 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. The P&P indicated The information captured on the assessment reflects the status of the resident during the observation period (the specific timeframe during which staff review a resident's care, treatments, and behavior to fill out their assessment accurately to identify the resident's usual condition and to guide care planning and reimbursement) for the assessment.

Based on interview and record review, the facility failed to develop and implement an appropriate discharge plan for one of the four sampled residents (Resident 1) who was transferred to General Acute Care Hospital (GACH) on 7/29/2025 for further psychiatric evaluation and was not permitted to return to the facility per their policy. This deficient practice resulted in Resident 1 to unnecessary remain in GACH four months after he was cleared for discharge.A review of Resident 1's admission record indicated the facility initially admitted the resident on 7/22/2025, with diagnosis that included encephalopathy (a broad term for any disease, damage, or dysfunction of the brain that changes its function or structure, often showing up as an altered mental state like confusion, memory loss, or personality changes, caused by issues like infection, toxins, trauma, or lack of oxygen), epilepsy (a chronic brain disorder characterized by two or more unprovoked, recurring seizures, caused by sudden, abnormal electrical discharges in nerve cells), and dysphagia (difficulty swallowing) following cerebral infarction (cerebrovascular accident-CVA - stroke, loss of blood flow to a part of the brain). The same record did not indicate a psychiatric diagnosis. During a review of Resident 1's history and physical (H&P) dated 7/22/2025 indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's physician orders dated 7/22/2025 indicated, Quetiapine Fumarate (atypical antipsychotic medication primarily used to treat schizophrenia, bipolar disorder (mania and depression), and as an add-on treatment for major depressive disorder) Tablet 25 MG Giva 0.5 tablet Phone Active by mouth every 12 hours as needed for agitation. During a review of Resident 1's care plan (a written personalized document that outlines an individual's health conditions, specific care needs, goals, and the actions required to manage them) with a focus, The resident wishes to return [and] be discharged home, initiated 7/23/2025 included goals indicating Resident 1 will demonstrate correct administration. The interventions included:Encourage the resident to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress.Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan During a review of Resident 1's Interdisciplinary conference meeting dated 7/23/2025 (IDT - a collaborative group of professionals including physicians, nurses, social workers, and therapists, who work together to manage a resident's comprehensive care) indicated, DC [discharge] plan is to DC home with family when able. Writer informed [Resident 1's representative - RP] that we [facility] can assist with HH [home health services] and DME [durable medical equipment] arrangement when MD [medical doctor] clears DC. Writer also informed [RP] we [facility] have a DCP [discharge plan] that can assist with placement option if they are looking to place the resident. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/28/2025, indicated, the resident had severe cognitive impairment (a significant, advanced decline in mental abilities such as memory, reasoning, and decision-making which makes it impossible for a person to live independently). The same MDS indicated Resident 1 was mostly dependent on staff for activities of daily living (ADLs) such as toileting hygiene, Shower/bathe, lower body dressing, and putting on/taking off footwear. During a review of the GACH Case Manager (CM) treatment team communication notes dated 10/9/2025 at 3:38 pm., indicated a review of case notes indicated Resident 1 had been decannulated (permanent removal of a breathing tube (tracheostomy tube) from a person's neck, typically performed when they can breathe safely on their own again) and that a referral packet had been faxed to the facility for readmission. During a review of the GACH CM treatment team communication notes dated 11/3/2025 at 3:20 pm., indicated, the CM had faxed referrals to the facility as well as other Skilled Nursing Facilities (SNF) for placement.During a review of the GACH CM treatment team communication notes dated 12/16/2025 at 5:33 pm., indicated, the CM had faxed referrals to the facility as well as other Skilled Nursing Facilities (SNF) for placement. During a review of the GACH CM treatment team communication notes dated 1/19/2026 at 1:29 pm., indicated, the CM had faxed referrals to the facility as well as other Skilled Nursing Facilities (SNF) for placement. During a review of the GACH CM treatment team communication notes dated 1/26/2026 at 4:25 pm., indicated, the CM had faxed referrals to the facility as well as 20 other Skilled Nursing Facilities (SNF) for placement. During a review of the GACH CM treatment team communication notes dated 2/4/2026 at 4:25 pm., indicated, the CM placed a call to the facility and spoke with the admissions coordinator (AC) to confirm if they (Facility) had received the updated notes that had been faxed on 2/3/2026. The AC confirmed receipt of the referral and stated that Resident 1 was not appropriate for admission to the facility due to him (Resident 1) previously being transferred on 5150 (an involuntary 72 hour hold for individuals with mental health challenges to the hospital or approved facilities). The same notes indicated that the CM informed AC that Resident 1 did not require a sitter, was not on restraints, and that he was calm. During an interview with CM on 1/30/2026 at 9:05 am, CM stated that Resident 1 had been ready for discharge for at least three months. CM stated that he (CM) had first sent out a referral to the facility on [DATE] of which he had followed up with numerous calls that went unanswered. CM stated that he finally spoke with AC when she (AC) had called regarding a different resident for admission to their facility. CM stated that AC stated that per the DON, the facility will not be accepting Resident 1 because they had been transferred to GACH on a 5150. CM asked if he could speak directly with the DON but was kept on hold for extended periods before the line got disconnected. CM informed AC that Resident 1 was calm and did not require close supervision. CM stated that he had invited the facility staff to assess Resident 1 for themselves. During an interview with AC on 1/30/2026 at10:29 am, AC stated that when there is a referral to the facility, the information which included clinicals which shows the health status is provided to the DON. The DON then informs her if the resident is cleared or not based on the information reviewed. AC confirmed that she had received the referral on 12/17/2025 which she stated she had followed the procedure and gave it to the DON. AC was unable to verify other referrals as she had been out on leave and returned towards the end of November 2025. During an interview with the Director of Nursing (DON), on 2/2/2026 at 2:59 pm, the DON stated that discharge planning involved having an IDT along with the RP to discuss options. During IDT, the discharge goals are reviewed, and DME (Durable medical equipment such i.e. shower chair, wheelchair walker etc.) and other resources are discussed and arranged. The physician orders are obtained to ensure DME is provided to ensure an appropriate and safe discharge. DON stated that Resident 1 was admitted to the facility on [DATE] for physical and Occupational therapies to regain strength for possible to discharge back home with RP. DON stated that Resident 1 initially participated in physical therapy but became physically combative with the staff which required him to be placed on a 1:1 (one staff monitoring on resident) because Resident 1 was kicking, punching and disrobing and continued to progress until which led to the physician ordering to transfer to GACH on a 5150. The DON stated that he was only aware of one referral between 12/17/2025 and 12/18/2025 which he stated indicated that Resident 1 was still restrained and mind you this was a resident who was only here for 9 days. The DON stated that Resident 1 was discharged on a 5150 due to the change in condition which was an escalation and felt it was a proper discharge. The DON was unable to respond if being transferred to GACH was an appropriate long-term disposition for residents. The DON confirmed that he had reviewed the referral from December and had not spoken with someone at GACH to confirm the current status of the resident and maintained that the facility will not be readmitting Resident 1. During a review of the facility's policy and procedures (P&P) titled, readmission to the Facility, reviewed 1/8/2026 indicated, Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. The same P&P indicated, A Medi-Cal (custodial) resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed if the resident, and Residents who are not receiving Medi-Cal (custodial) benefits will be readmitted to the facility upon the first availability of a bed if the resident. During a review of the facility's P&P titled, TRANSFERS / BEDHOLDS AND DISCHARGES - OUT OF FACILITY, reviewed 1/8/2026, indicated, It is the policy of the facility to ensure that it is in compliance with all State and Federal Regulations and residents' rights when transferring/discharging a resident within or out of the facility. The same P&P indicated, The facility will develop a discharge planning procedure for each resident that focuses on the resident's discharge goals, the preparation of the residents to be active partners and effectively transition them to post-discharge care in order to reduce factors leading to preventable readmissions.

Based on interview, and record review the facility failed to make prompt efforts to resolve grievance for one of four sampled residents (Resident 1). The facility failed to address Resident 1's complaints regarding inadequate assistance from staff and nursing care.This deficient practice violated the residents' right to have his grievances addressed promptly.During a review of the admission Record indicated the facility admitted Resident 1 on 7/18/25 with diagnoses including esophagitis (inflammation of the lining of the esophagus [muscular tube that connects the throat to the stomach], duodenal ulcer (sores on the lining of the stomach) and generalized muscle weakness.During a review of the Minimum Data Set (MDS, resident assessment tool) dated 10/22/25 indicated Resident 1 was cognitively intact. Resident 1 used the walker and wheelchair for mobility. Resident 1 was independent with eating, oral hygiene, upper body dressing, putting on/taking off footwear. Resident 1 needed clean-up assistance with toileting hygiene and substantial assistance (helper does more than half the effort) with shower/bathe self.During a review of the History and Physical (H&P, comprehensive assessment of the resident) dated 12/5/26 at 11:45 a.m., indicated Resident 1 had the capacity to understand and make medical decisions. The same H&P indicated Resident 1 .expressed dissatisfaction with the staff and the facility, reporting inadequate assistance and communication issues.During an interview on 1/6/25 at 11:04 a.m., using the translation hotline, Resident 1 stated he has diarrhea, and he does not understand why the medications he was given are not working. Resident 1 further added the certified nursing assistants (CNA), housekeeping and licensed nurses were not giving him the assistance he needed.During an interview on 1/6/26 at 1:07 p.m., licensed vocational nurse (LVN 1) stated Resident 1 had a lot of complaints about the charge nurses, the housekeeping and the certified nursing assistants. LVN 1 further added, Resident 1 keeps repeating his complaints.During an interview on 1/12/26 at 12:30 p.m., the assistant director of nursing (ADON 1) stated Resident 1 had many complaints and Resident 1 would discuss his complaints repeatedly. ADON 1 stated the last interdisciplinary team (IDT) meeting with Resident 1 was held on 11/11/25. ADON stated IDT is done to discuss the plan of care and discuss any concerns Resident 1 may have. During an interview on 1/12/26 at 12:56 p.m., the social worker (SW 1) stated there was no grievance filed for Resident 1. SW 1 stated Resident 1's multiple complaints were addressed immediately. However, there were no supporting documents provided to support that the facility addressed Resident 1's complaints.During a review of the facility's policy and procedures (P&P) titled Resident and Family Grievances revised on 10/25 the P&P indicated it is the policy of the facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The same Policy indicated a resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents and other concerns regarding facility stay. The same policy indicated the staff member receiving the grievance will record the nature and specifics of the grievance on designated grievance form or assist resident or family member to complete the form. The grievance official will take steps to resolve grievance, log general nature of grievance and record information about grievance including actions taken on grievance form. The grievance official or designee will keep the resident appropriately apprised of progress towards resolution of grievance.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls, was cognitively impaired (had impairment in the ability to think, understand, and reason), had poor safety awareness, and required assistance with transferring and toileting was provided with the necessary care and services necessary to prevent falls. By failing to: 1. Follow the Physician's Order dated 11/27/2024 for Resident 1 to receive visual checks every 30 minutes for fall management after Resident 1 had an unwitnessed fall on 11/25/2024. 2. Review and update the High Risk for Falls Care Plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) after a second fall and change in condition on 12/6/2024. 3. Develop and implement new and/or additional interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent recurring falls and promote safety for Resident 1 during an Interdisciplinary Team Meeting (IDT, a gathering of healthcare professionals to review and update a resident's care plan) on 12/6/2024. As a result, on 2/3/2025 Resident 1 fell (third fall in 2 months 9 days) while in the bathroom, was transferred to General Acute Care Hospital (GACH) 1 and sustained a hematoma (a pool of blood that forms under the skin or in between tissues) to the head and left nondisplaced acromial fracture laterally (a broken left shoulder blade). Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility readmitted the resident on 6/13/2024 with diagnoses that included non-ST elevation myocardial infarction (a type of heart attack that occurs when a coronary artery is partially blocked), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney damage), dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), muscle weakness, psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dependence on renal dialysis (hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed), and hemiplegia (total paralysis of the arm, leg, and truck on the same side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (CVA, stroke, loss of blood flow to part of the brain). During a review of Resident 1's History and Physical (H&P) dated 6/17/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 11/25/2024, the MDS indicated the resident had severe cognitive impairment (impairment in the ability to think, understand, and reason). The MDS indicated Resident 1 required partial/moderate assistance from staff with toileting hygiene and supervision or touching assistance with personal hygiene, rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing, chair/bed to chair transfers, and toilet transfers. The MDS indicated the resident required partial/moderate assistance from staff for walking 10 feet. The MDS indicated Resident 1 did not have any falls with a major injury since admission to the facility (6/13/2024). During a review of Resident 1's Change in Condition documentation dated 11/25/2024 at 5:45 PM, the documentation indicated Resident 1 had an unwitnessed fall. The documentation indicated Resident 1's physician was notified and recommended to discontinue metoprolol (medication used to treat high blood pressure) and for Resident 1 to wear anti-slip socks only to prevent falls. During a review of Resident 1's Physician Order dated 11/25/2024, the physician order indicated Resident 1 was to wear anti-slip socks only to prevent a fall every shift. During a review of Resident 1's Interdisciplinary Team Meeting - Fall document dated 11/27/2024 at 4:10 PM, the document indicated the resident was found on the floor laying on his back with the back of his head on top of the left footrest of the wheelchair. The document indicated Resident 1 stated he was reaching for crackers then fell on the floor, slid from the wheelchair and hit his head. The document indicated Resident 1 fell while trying to pick up crackers without assistance. The document indicated the IDT recommended new interventions for Resident 1 to continue toileting every 2 hours, to monitor the resident with visual checks every 30 minutes for fall management, and for the resident was to only wear anti-slip socks to prevent falls. The document indicated an intervention for Resident 1 to be screened by Physical Therapy (PT) after the fall. During a review of Resident 1's Physician Order dated 11/27/2024, the physician order indicated to perform visuals checks every 30 minutes every shift for fall management. During a review of Resident 1's Rehab: Post Fall assessment dated [DATE] at 6:43 PM, the assessment indicated Resident 1 did not have any changes in safety awareness, range of motion, strength, transfers or gait. The assessment indicated Resident 1 did not have any complaints of pain or discomfort and recommended to continue with Restorative Nursing Assistant (RNA) treatment and to continue to monitor the resident for any changes. During a review of Resident 1's Change in Condition documentation dated 12/6/2024 at 7:05 AM, the documentation indicated the resident had a fall. The documentation indicated Resident 1 was found lying on the floor between the bed and the wheelchair. The documentation indicated Resident 1 was found with a skin tear on his right ear with swelling. The documentation indicated Resident 1's physician was notified and recommended to start neuro checks (assess the function of the neuorlogica/nervous system) and treatment to the resident's right ear. During a review of Resident 1's Rehab: Post Fall assessment dated [DATE] at 12:48 PM, the assessment indicated Resident 1 fell in his room. The assessment indicated Resident 1 had a change in safety awareness. The assessment indicated Resident 1 did not have any change in range of motion, strength, transfers, or gait. The assessment further indicated this was Resident 1's second fall in 2 weeks. The assessment indicated Resident 1 would benefit from skilled physical therapy service to include safety awareness and improve functional mobility. During a review of Resident 1's Morse Fall Risk Screen (a fall risk assessment tool that predicts the likelihood a resident will fall) dated 12/6/2024, the fall risk screen indicated the resident was at high risk for falling with a score of 65 (a score of 45 or higher indicated a resident was at high risk for potential falls). The fall risk screen indicated Resident 1 had a history of falling, more than one diagnosis on the chart, did not use any ambulatory aids (was either on bedrest, utilized a wheelchair, or required nurse assistance), exhibited weak gait (stooped but able to lift head without losing balance, steps are short, and resident may shuffle), and overestimated or forgot their limits (to act without considering personal boundaries or capabilities). The fall risk screen indicated Resident 1 was referred to the IDT. During a review of Resident 1's Interdisciplinary Team Meeting-Fall document dated 12/6/2024 at 4:26 PM, the document indicated the resident was lying on the floor of the right side of his bed and his wheelchair noted with a skin tear on his right ear with swelling. The note indicated Resident 1 was wearing shoes at the time of the fall. The document indicated Resident 1 stated he was trying to transfer himself from his bed to the wheelchair. The document indicated Resident 1 had poor judgement, poor safety awareness, CVA with right hemiparesis, and dementia. The document indicated Resident 1 perceived himself as independent and would not call for assistance. The document indicated new intervention recommendations from the IDT for Resident 1 to be screened by physical therapy for transferring from the wheelchair to bed and to continue 30-minute visual checks. During a review of Resident 1's Change of Condition documentation dated 2/3/2025 at 1:47 AM, the documentation indicated the resident had a fall. The documentation indicated Resident 1 was found lying on the floor in the restroom between the toilet and wall. The documentation indicated Resident 1 obtained a skin tear to his left forearm and knee with bleeding noted. The documentation indicated Resident 1's physician was notified and recommended to start neurochecks and treatment to the resident's left forearm and knee. During a review of Resident 1 Q (every) 30 minutes visual checks document dated 2/3/2025, the document indicated on 2/3/2025 at 2:00 AM there was documentation of N/A (not applicable) for Resident 1's location and behavior. During a review of Resident 1's Nurses Notes dated 2/3/2025 at 10:05 AM, the note indicated the resident was picked up by transportation via gurney for dialysis. The note indicated Resident 1 was complaining of pain on his left shoulder. The note further indicated Resident 1 was given 50 milligrams (mg) of Tramadol (a medication used for the short-term relief of moderate to severe pain) by mouth as ordered for the resident's pain. During a review of Resident 1's Nurses Notes dated 2/3/2025 at 11:40 AM, the note indicated a phone call was received from the dialysis center that Resident 1 was transferred to GACH 1 from the dialysis center for further evaluation due to a hematoma (a localized collection of blood outside of a blood vessel, usually caused by an injury that damages the vessel wall, resulting in a pool of blood that can appear as a bruise or swelling under the skin) to the left side of the head and increased pain to the left shoulder. The note indicated Resident 1's physician and responsible party were notified. During a review of Resident 1's Dialysis Form documentation dated 2/3/2025, the noted indicated that no dialysis treatment was initiated because Resident 1 was sent to the emergency room (ER). During a review of Resident 1's left shoulder x-ray report from GACH 1 dated 2/3/2025 at 2:36 PM, the report suggested the resident had a nondisplaced acromial fracture laterally (a broken left shoulder blade). During a review of Resident 1's Nursing Note dated 2/3/2025 at 10:37 PM, the note indicated the resident returned to the facility at 9:16 PM from GACH 1. The note indicated Resident 1 had a left shoulder x-ray that suggested a non-displaced acromial fracture laterally. The note indicated that per report from GACH 1's emergency department Resident 1 was to keep the left upper extremity (left arm) non-weight bearing (NWB, a restriction that requires a patient to avoid putting weight on an affected limb), follow up with orthopedics (a physician that specializes in the treatment of injuries to bones), and receive Tylenol (acetaminophen, a medication used to treat pain) 650 mg by mouth every 6 hours. During a review of Resident 1's Interdisciplinary Team Meeting - Fall document dated 2/4/2025 at 10:45 am, indicated staff responded to Resident 1 yelling from his room at approximately 1:45 AM. The document indicated Resident 1 was found lying on the floor in the restroom between the toilet and the wall. The document indicated Resident 1 was noted with a skin tear on his left forearm and knee with bleeding. The document indicated Resident 1 stated he did not know how he fell and may have tripped over his foot. The document indicated Resident 1's physician ordered for neurochecks monitoring. The document indicated Resident 1 proceeded to go to dialysis and left the facility at 10:05 AM. The document indicated at 11:30 AM, a call was received from the hemodialysis staff stating Resident 1 was transferred to the GACH from dialysis for further evaluation due to a hematoma to his left head and increased pain to his left shoulder. The documented indicated at 9:16 PM Resident 1 returned to the facility from the GACH with findings that included left shoulder nondisplaced acromial fracture laterally (broken left shoulder blade). The document indicated Resident 1 had poor judgment, poor safety awareness, CVA with right hemiparesis, gait/balance problems, non-compliant behavior, and dementia. The document indicated Resident 1 perceived himself as independent and would not call for assistance. The document did not indicate any new interventions to prevent future falls. During a review of Resident 1's Care Plan revised 2/5/2025, the care plan indicated the resident was at high risk for falls and injury related to limitation of mobility, history falls, use of psychotropic medication (medication used to treat mental health disorders), ascites (a condition where excess fluid accumulates in the abdominal cavity), dementia, ESRD on hemodialysis, hepatic encephalopathy (brain dysfunction caused by liver dysfunction), hyperlipidemia, seizure disorder (a neurological condition characterized by recurrent, unprovoked episodes of abnormal brain electrical activity), type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, hypertension (high blood pressure), psychosis, anxiety disorder (excessive and persistent worry, fear, and nervousness that can interfere with daily life), depression, Congestive Heart Failure (CHF, a condition where the heart muscle is weakened and cannot pump blood efficiently throughout the body), and a recent fall. The care plan indicated goals of managing Resident 1 were to minimize fall and injury, managing risk factors to minimize falls and injury, and for the resident to follow safe technique when performing functional mobility and Activities of Daily Living (ADL, basic self-care tasks that individuals perform on a daily basis) to prevent falls and injury. The care plan indicated interventions that included Resident 1 wearing anti-slip socks only, 30-minute visual monitoring for fall management, and providing the resident with assistance as needed with transfers and ambulation. The care plan indicated the interventions were updated after Resident 1 fell on [DATE] and 2/3/2025. The care plan did not indicate the interventions were updated after Resident 1's fall on 12/6/2024. During a telephone interview with Resident 1's Responsible Party (RP) on 2/19/2025 at 11:42 AM, the RP stated the facility called the RP to let her know Resident 1 fell on [DATE]. The RP stated she was told Resident 1 fell in the bathroom. The RP stated Resident 1 needed a lot of help. The RP stated Resident 1 would get confused because the resident had a stroke and had dementia. The RP stated half of Resident 1's body did not work because of the stroke. The RP stated Resident 1 thought he could do things on his own but did not realize he needs help especially when going to the bathroom. During a telephone interview on 2/19/2025 at 1:09 PM with Certified Nursing Assistant (CNA) 1, CNA 1 was the assigned to Resident 1 when he fell on [DATE]. CNA 1 stated Resident 1 fell around 1:40 AM to 2:00 AM. CNA 1 stated she did not witness Resident 1 fall because she was on break at the time. CNA 1 stated prior to taking her break she notified the registry (staffing agency) CNA that she was going to take her break. CNA 1 stated when she came back from her 10-minute break, Resident 1 was already back in bed. CNA 1 stated the charge nurse informed her Resident 1 fell . CNA 1 stated Resident 1 was a major fall risk. CNA 1 stated Resident 1 would get out of bed frequently. CNA 1 stated Resident 1 needed assistance with transferring from the bed to the wheelchair and to the bathroom. CNA 1 stated Resident 1 was not stable when out of bed and walking. CNA 1 stated Resident 1 was on visual checks every 30 minutes because he was not safe to get out of bed on his own. During a telephone interview on 2/19/2025 at 1:20 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to take care of Resident 1 when the resident fell on [DATE]. LVN 1 stated she did not remember what time Resident 1 fell . LVN 1 stated she remembered hearing Resident 1 yell out, and when she went to the resident's room, found the resident in the bathroom face down between the toilet and wall. LVN 1 stated she and another CNA helped the resident back to bed. LVN 1 stated Resident 1 had a skin tear on his left arm from the fall. LVN 1 stated she notified Resident 1's physician of the resident's fall, and the physician ordered neurochecks and treatment for the resident's skin tear. LVN 1 stated Resident 1 did not have a stable gait when walking. LVN 1 stated Resident 1 needed one-person assistance when going to the bathroom. LVN 1 stated Resident 1 was non-compliant, did not call for help, and would get up by himself. LVN 1 stated this made Resident 1 a high fall risk and was why the resident was on visual checks every 30 minutes. LVN 1 further stated Resident 1 had orders for anti-slip socks but was not wearing them when the resident fell on [DATE]. LVN 1 stated Resident 1 was wearing shoes. During a concurrent interview and record review on 2/19/2025 at 3:11 PM, Resident 1's IDT meetings dated 11/27/2024 and 12/6/2024 were reviewed with Registered Nurse Supervisor (RNS) 1. RNS 1 stated she was familiar with Resident 1. RNS 1 stated she was part of the IDT meetings that took place on 11/27/2024, 12/6/2024, and 2/4/2025 regarding Resident 1's falls. RNS 1 stated Resident 1 fell on [DATE], 12/6/2024, and 2/3/2024. RNS 1 stated the IDT would meet after each fall, during the IDT meetings the IDT reviewed the fall incident and discusses what interventions could be put into place to prevent future falls. RNS 1 stated because Resident 1 had a history of falls the interventions the IDT recommended during the IDT meetings should have been different than the previous interventions recommended in previous IDT meetings. RNS 1 stated after Resident 1's fall on 11/25/2024 the IDT recommended to continue toileting every 2 hours, to monitor the resident with visual checks every 30 minutes for fall management, for the resident was to only wear anti-slip socks to prevent falls, neuro checks, and for Resident 1 to be screened by PT after the fall. RNS 1 stated after Resident 1's fall on 12/6/20254, the IDT recommended interventions for Resident 1 to be screened by PT for transferring from the wheelchair to bed and continuing 30-minute visual checks. RNS 1 stated the IDT did not recommend additional and new interventions after Resident 1's second fall on 12/6/2024. RNS 1 stated a physical therapy screening and continuing 30-minute visual checks were also the interventions recommended on the IDT meeting on 11/27/2024. RNS 1 stated after each IDT meeting the recommendations should have been reflected on Resident 1's high risk for falls care plan. RNS 1 stated the high risk for falls care plan should have been updated after each fall. RNS 1 stated Resident 1's high risk for fall care plan was not updated after Resident 1's fall on 12/6/2024. RNS 1 stated the care plan was developed to inform staff about the care the resident needs. RNS 1 stated the care plan was a way for the IDT to inform staff about the updated recommendations and interventions. RNS 1 stated not updating the care plan could result in the resident not getting the care needed. RNS 1 stated Resident 1 had recurring falls. RNS 1 stated updating Resident 1's high risk for fall care plan and recommending new interventions after each fall could have helped prevent Resident 1 from falling. During a concurrent observation and interview on 2/19/2024 at 4:07 PM, in Resident 1's room, Resident 1 was observed sitting on the side of the bed. Resident 1 was observed grimacing, crying and holding his left shoulder. Resident 1 stated he was having pain to his left shoulder. Resident 1 stated he fell in the bathroom but could not remember when he fell . Resident 1 stated his arm started to hurt after he fell . During a concurrent interview and record review on 2/20/2025 at 11:01 AM Resident 1's Rehab: Post Fall Assessments dated 11/27/2024 and 12/6/2024, and IDT Meetings dated 11/27/2025 and 12/6/2024 were reviewed with the Director of Rehabilitation (DOR). The DOR stated a physical therapy screening was done after a resident had a fall and the findings were documented on the Rehab: Post Fall Assessment. The DOR stated a physical therapy screening after a fall assessed the resident for any changes in their mobility, ability to transfer, and functioning. The DOR stated she was a part of the IDT meetings on 11/27/2024, 12/6/2024, and 2/4/2025 regarding Resident 1's falls. The DOR stated the recommendations from the IDT on 11/27/2024 and 12/6/2024 were the same. The DOR stated both IDT meetings on 11/27/2024 and 12/6/2024 both indicate a recommendation for a PT screening and 30-minute visual checks. The DOR stated no new recommendations were developed or initiated for Resident 1's falls during the IDT meeting on 12/6/2024; The DOR further stated, It looks as if the recommendations were just continued. During a concurrent record review and telephone interview on 2/20/2025 at 11:51 AM, Resident 1's Q30 minutes visual checks dated 2/2/2025 to 2/3/2025 was reviewed with CNA 1. CNA 1 stated during the 11 PM to 7 AM shift, N/A was documented for Resident 1's location and behavior at 2 AM on 2/3/2025 because she wasn't there at the time to check on Resident 1. CNA 1 stated that was the time she went on break. CNA 1 stated she told the registry CNA she was going on break. CNA 1 stated when she went on break the registry CNA was covering for her. During a telephone interview on 2/20/2025 at 12:33 PM with CNA 2, CNA 2 stated she was the only registry CNA on the unit during the 11:00 PM to 7:00 AM shift when Resident 1 fell on [DATE]. CNA 2 stated LVN 1 called her into Resident 1's room to help pick up the Resident 1 when he fell at around 2:00 AM. CNA 2 stated the CNA assigned to take care of Resident 1 could not be found when Resident 1 fell . CNA 2 stated CNA 1 did not tell her to watch Resident 1 while CNA 1 went on break. CNA 2 stated we're supposed to tell another CNA when we go on our breaks, and we're supposed to tell them which residents were on visual checks. CNA 2 stated CNA 1 did not tell her she was taking her break or that Resident 1 was on visual checks. During a concurrent interview and record review on 2/20/2025 at 1:41 PM, Resident 1's high risk for falls care plan and IDT meeting dated 11/27/2024 and 12/6/2024 were reviewed with the Director of Nursing (DON). The DON confirmed that Resident 1's recommended interventions for a physical therapy screening and 30-minute visual checks by the IDT to prevent falls on 11/27/2024 and 12/6/2024 were the same. The DON reviewed Resident 1's high risk for falls care plan and confirmed the care plan was not updated after the resident's fall on 12/6/2024. The DON stated visual checks every 30 minutes were done because Resident 1 was a high risk for falls. The DON confirmed that on the Q 30-minute visual check there was documentation of N/A for Resident 1 location and behavior on 2/3/2025 at 2:00 AM. The DON stated the N/A was because CNA 1 indicated she was on break the time the Resident 1 fell on [DATE]. The DON stated it was important to make sure the facility had a progressive approach with care planning and reviewing previous interventions during the IDT meetings. The DON stated given Resident 1 had a history of falls prior to his fall on 2/3/2025. The DON stated it was important to ensure visual checks were completed every 30 minute. The DON stated it was important to update the high risk for falls care plan timely, and new and creative interventions needed to be developed to help prevent Resident 1 from falling again. The DON stated it was important to provide Resident 1 with a safe environment to ensure the resident was free from harm. During a review of the facility's policy and procedure titled Care Planning (IDT) Policy reviewed 10/10/2024, the policy indicated Care plans are revised per RAI [Resident Assessment Instrument: a standardized assessment tool used in long-term care settings to evaluate the health, functional status, and needs of resident] schedules and as changes in the resident's condition dictates or in preparation for discharge. During a review of the facility's policy and procedure titled Fall Risk Assessment reviewed 10/10/2024, the policy indicated The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information .The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. During a review of the facility's policy and procedure titled Falling Star Program, reviewed 10/10/2024, the policy indicated Residents identified as high risk and moderate risk for falls and those with recurrent falls of 3 and more in a month will be placed in the Falling Star Program .Residents placed on a falling star program will have the following in place: .Any resident with multiple falls of 3 or more in a month will be monitored visually every 30 minutes .IDT team will update the residents' plan of care to include appropriate interventions. During a review of the facility's policy and procedure titled Falls - Clinical Protocol reviewed 10/10/2024, the policy indicated If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and all reconsider the current interventions. During a review of the facility's policy and procedure titled Falls and Fall Risk, Managing reviewed 10/10/2024, the policy indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Environmental factors that contribute to the risk of falls include: wet floors; poor lighting; incorrect bed height or width; obstacles in the footpath; improperly fitted or maintained wheelchairs; and foot wear that is unsafe or absent .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnosis of vascular dementia (a type of dementia that occurs when the brain's blood supply has been damaged, causing a lack of oxygen and nutrients to brain cells and marked by memory disorder, personality changes, and impaired reasoning), history of falls, and a high fall risk, was provided with the necessary care needs and services. The facility failed to: -Develop an appropriate care plan for Resident 1's Dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety. -Provide for Resident 1, 2:1 staff supervision (ratio of 2 residents and 1 one certified nursing staff) due to impulsive behavior, per the care plan interventions. As a result, on 8/20/2024, Resident 1 had a fall with pain and facial grimacing in the facility Day Room. On 8/24/2024, Resident 1 had right leg pain with swelling (which was not previously assessed), was transferred to General Acute Care Hospital (GACH) 2 on 8/25/2024. At GACH 2, Resident 1 was diagnosed with a dislocation of the right hip and was placed under general anesthesia for a closed reduction right total hip arthroplasty (surgical procedure where the orthopedic surgeon removed the diseased parts of the hip joints and replaced with new, artificial parts). Findings: A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including left pubis fracture (bone that forms the lower front part of the hip bone), vascular dementia, and history of falling. A review of Resident 1's Morse Fall Risk Screen dated 5/13/2024, indicated the resident had a history of falling, had more than one diagnosis, and overestimates or forgets limits. The Fall Risk Screen indicated Resident 1 was a high risk for falls with a score of 55 (a score of 45 or more indicated a resident was a high risk for falling). A review of Resident 1's Care Plan regarding the resident crawled out of bed with poor judgement, poor safety awareness, dementia, and recent falls in the last 30 days, dated 5/13/2024 indicated the interventions were to provide Resident 1 a 2:1 sitter due to impulsive behavior, crawling / getting out of bed unassisted. A review of Resident 1's IDT Meeting dated 5/16/2024 indicated the resident had a diagnosis of a previous right total hip arthroplasty (a surgical procedure in which an orthopaedic surgeon removes the diseased parts of the hip joint and replaces them with new, artificial parts) from the past, indicated the resident had diagnosis of dementia at home, and the IDT discussed with Family Member regarding Resident 1's prior level of function and mentation at home. According to a review of Resident 1's History and Physical (H&P) dated 7/20/2024, the resident did not have capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/19/2024, indicated the resident had a prior fall in the last month and a fracture related to a fall in the last 6 months. The MDS dated [DATE], indicated the resident was dependent on staff for toileting, personal and oral hygiene and was severely impaired in cognitive skill for daily decision making. The MDS under active diagnoses indicated a musculoskeletal other fracture (non descriptive), an active diagnoses including age - related osteoporosis without current pathological fracture, and the resident had Non-Alzheimer's Dementia. A review of the Physician's Order dated 7/30/2024, indicated Resident 1 received Donepezil Hydrochloride (medication treats mild, moderate and severe dementia) 10 mg tablet by mouth every evening for dementia. A review of Resident 1's Change of Condition form (COC) dated 8/20/2024 at 6:45 PM, indicated the resident sustained a fall on 8/20/2024 at night. The COC indicated the resident was in the wheelchair with the footrest on and was sitting with other residents in the Day Room watching television. The COC indicated Certified Nursing Assistant (CNA) 1 was checking on the charting and when she raised her head up, Resident 1 was on the floor in front of the wheelchair. The COC indicated CNA 2 was by the Day Room door talking to another resident when she heard a noise and saw Resident 1 on the floor. The COC indicated Resident 1 sustained a bump on the left back side of the head, 911 was called and Resident 1's physician was notified. The physician gave orders to apply an ice pack to resident's head, as the resident had pain with facial grimacing, and ordered to transfer Resident 1 to a hospital. A review of Resident 1's GACH 1 Emergency Documentation (ED) dated 8/20/2024, indicated the resident was brought in for evaluation of a ground level fall with a left sided parietal scalp hematoma (bump on the head caused by damage to the skin and muscle on the outside of the skull). The ED indicated the resident's Computed Tomography scan (CT - an imaging procedure that uses special x-ray equipment to create detailed pictures or scans of areas inside the body) of the head, maxillofacial (face), and spine were without evidence of traumatic injuries. The ED indicated the resident was discharged to the skilled nursing home on 8/21/24. According to a review of Resident 1's GACH 2 Emergency Documentation dated 8/25/2024, the resident was brought in from a nursing home after a recent fall and right hip dislocation. A pelvic x-ray dated 8/25/2024 indicated a status post total right hip arthroplasty with dislocation of the femoral and acetabular component (parts of the hip joint, which is a ball-and-socket joint where the thigh bone [femur] meets the pelvis [acetabulum]). The GACH 2 operative note dated 8/27/2024 indicated Resident 1 had a closed reduction under general anesthesia right total hip arthroplasty dislocation (procedure that involves manually moving the hip back into place). Resident 1 was discharged from GACH 2 on 8/27/2024. During a concurrent interview and record review on 9/11/2024 at 11:04 AM, with the Director of Staff Development (DSD), Resident 1's care plans dated 5/13 and 5/26/2024 were reviewed. The DSD stated the care plan was developed for Resident 1 to prevent falls and a 2:1 meant one certified nurse assistant would supervise two residents, preferably in one room. The DSD stated and confirmed this intervention was to be implemented on the day of Resident 1's fall on 8/20/2024. After review of the Nursing Staff assignment and Sign-In Sheet for 8/20/2024 3 PM to 11 PM shift, the DSD stated Resident 1 did not have a 2:1 CNA assigned on 8/20/2024 and that the supervising nurse was responsible in assigning the CNA who would monitor residents 2:1. On 9/11/2024 at 12:15 PM, after review of the Huddle Report Form / Daily Clinical Meeting Report for 8/20/2024, the DSD stated and confirmed there was no report of Resident 1's care plan intervention for a 2:1 sitter. The DSD stated it was important to follow the care plan interventions to ensure Resident 1's safety and not following the care plan could lead to a fall with possible injury or death. During a phone interview on 9/11/2024 at 12:59 PM, CNA 2 stated she was assigned to a group of residents and could not recall how many. CNA 2 stated she was assigned to Resident 1 and the resident was not assigned as a 2:1. CNA 2 stated after dinner, Resident 1 was in the day room watching television with about 10 other residents and two CNA's (CNA 1 and CNA 2). CNA 2 stated she was standing by the door, turned her head from the residents in day room, and talked to a resident in the hallway. CNA 2 stated she recalled hearing Resident 1 state pain and when she turned to Resident 1, she observed the resident on the floor. During an interview on 9/11/2024 at 3:23 PM, CNA 1 stated Resident 1's fall occurred in the day room and recalled about nine residents in the room. CNA 1 stated she was watching all the residents in the day room and was not assigned to watch a specific resident. CNA 1 stated she did not witness the fall. CNA 1 stated she was sitting inside the day room charting for about five minutes when she heard Resident 1 scream, when she turned to Resident 1, she observed the resident sitting on the floor. During an interview on 9/11/2024 at 4:01 PM, CNA 3 stated Resident 1 had a fall in August 2024, was confused, active, and moved in the bed. CNA3 stated the resident needed supervision because she was a high fall risk. On 9/12/2024 at 11:27 AM, during a concurrent interview and record review with the Assistant Director of Nursing (ADON), Resident 1's care plans were reviewed. The ADON stated and confirmed Resident 1 had dementia but did not have a dementia care plan with individualized interventions. The ADON stated the resident should have had 2:1 supervision (ratio of 2 residents and 1 one certified nursing staff). The ADON stated the resident was in the day room with two staff members and cannot say for certain if the fall could have been prevented. The ADON stated it was important to have a dementia care plan with goals and interventions to address the resident's behavior and ensure the resident was safe. The ADON stated there was a risk that the resident was not receiving care that was specific to her diagnoses of dementia. A review of the facility's policy and procedure (P&P) titled, Dementia-Clinical Protocol, revised 11/2023, indicated for the individual with confirmed dementia, the Interdisciplinary Team (IDT) would identify a resident-centered care plan to maximize remaining function and quality of life. The policy indicated direct care staff would support the resident in initiating and completing activities and tasks of daily living: bathing dressing, mealtimes, and therapeutic and recreational activities would be supervised and supported throughout the day as needed. A review of the facility's P&P titled, Falling Star Program, effective 8/2024, indicated residents identified as high risk for falls and those with recurrent falls would be placed in the Falling Star Program. If resident scored a total of 45 points to 125 points on the Morse Fall Assessment, the resident would be checked visually by nursing staff every hour.

Based on observation, interview, and record review, the nursing staff failed to ensure one of two sampled residents (Resident 1), who had a history of falls and was assessed as a high risk for falls, received the care and services necessary to prevent accidents and falls by failing to: 1. Monitoring for effectiveness and modifying plan of care interventions for fall based on the identified risk of the resident. 2. Ensure not to leave Resident 1 unattended after a fall on 7/22/2024 at 8:49 PM. As a result, on 7/22/2024, Resident 1 had two consecutive (one after another) falls. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 where Resident 1 was diagnosed with a fracture (crack or break) of the right hip. Findings: During a review of Resident 1's GACH 1 History and Physical (H&P) dated 4/17/2021 at 9 AM, it indicated the resident was brought in for evaluation of a mechanical fall and pelvic pain. The H&P indicated the resident has a history of unsteady gait and generalized weakness that could have contributed to the fall. During a review of Resident 1's Admission Record indicated the resident was admitted on [DATE] from GACH 1 with diagnoses including pelvic fracture, Alzheimer's disease (A brain disorder that affects memory and thinking skills), dementia (Impaired ability to remember, think, or make decisions that interferes with doing everyday activities), right ear hearing loss, and history of falling. During a review of Resident 1's High Risk for Recurrent Falls and Injury Care Plan related to dementia, hearing loss, glaucoma (Eye condition that can cause blindness), history of falls, impaired physical mobility, impaired vision, and impaired hearing was initiated on 1/16/2023. The care plan indicated a goal was to have no injuries related to falls for Resident 1 through appropriate interventions. The care plan interventions included assisting Resident 1 with their activities of daily living (ADL's) and use of a sensor pad alarm when Resident 1 was in bed to alert the staff when the resident was attempting to get out of bed unattended. During a review of Resident 1's annual Fall Risk Assessment titled dated 6/21/2024 at 10:51 AM, it indicated the resident was a high risk for falls with a score of 65 (A score of 45 or more indicated a resident was a high risk for falling). The Fall Risk Assessment indicated Resident 1 had a history of falling, had more than one diagnosis, had a weak gait (stooped [having the head and shoulders bent forward] but able to lift head without losing balance, steps were short, resident may shuffle [to walk pulling your feet slowly along the ground rather than lifting them]; and overestimates or forgets limits. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/21/2024, it indicated the resident had severely impaired cognition (Reduced ability to think, understand, and reason). The MDS indicated Resident 1 required partial/moderate assistance (Helper does less than half the effort) with toileting hygiene, toilet transfers, and substantial/maximum assistance (Helper does more than half the effort) with walking 50 feet with two turns. The MDS indicated Resident 1 was continent of urine and bowel. The MDS further indicated Resident 1 has fallen at least one time since admission. During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique that provides a framework for communication between members of the health care team about a patient's condition) Form and Progress Note dated 7/23/2024 at 10:19 AM, it indicated that resident sustained two witnessed falls. The note indicated that on 7/22/2024 at 8:49 PM, Resident 1 got up from the chair, lost balance and fell to the floor landing on her right thigh. Resident complained of pain on their right thigh and two tablets of Tylenol (pain medication) 325 milligrams (mg- unit of measurement) was administered by mouth. Shortly after Resident 1's first fall, the resident threw herself on the floor and hit the back of her head on a treatment cart. The note further indicated that Resident 1's physician was notified and gave orders to transfer the resident to GACH 1 for further evaluation for pain in right hip and right leg. The note indicated that the resident would be picked via ambulance at 2 AM on 7/23/2024. During a review of Resident 1's Physician's Order dated 7/22/2024, it indicated to transfer to GACH 1 for further evaluation related to status post fall and pain on right hip and right leg. During a review of Resident 1's GACH 1's H&P dated 7/23/2024, it indicated the resident had an x-ray (A medical test that takes pictures of bones and soft tissues) of the right pelvis on 7/23/2024, it indicated a right femoral intertrochanteric fracture (Hip fracture) likely secondary to mechanical falls. During a review of Resident 1's Post Fall Interdisciplinary Team (IDT) note dated 7/23/2024, it indicated on 7/22/2024 the resident had a witnessed fall in the hallway during the 3-11 PM shift. Three to five minutes after the fall the resident threw herself on the floor. The Post Fall IDT noted indicated Resident 1 was receiving hourly monitoring and using a front wheel walker when ambulating. The IDT note further indicated that Resident 1's behavior highly contributed to the recent fall. During an interview on 7/31/2024 at 10:15 AM with Registered Nurse (RN 1), she stated that Resident 1 can easily get upset and agitated because of their dementia. RN 1 stated that residents with dementia need constant supervision as they are more at risk for falls and can act out irrationally. RN 1 stated she believes Resident 1 was receiving one-to-one supervision which means that someone was constantly watching Resident 1 and that it should be in the resident's orders and care plan. RN 1 was unable to provide documented evidence that resident was receiving one-to-one supervision prior to Resident 1's fall on 7/22/2024. During a telephone interview on 7/31/2024 at 11:48 AM with Certified Nursing Assistant (CNA 2), CNA 2 stated they were assigned to Resident 1 on the 3-11 PM shift. CNA 2 stated she was not present when the resident fell the first time, but it was witnessed by the Licensed Vocational Nurse (LVN 2). CNA 2 stated the resident was talking to herself and more agitated than usual. After Resident 1 had the first fall, LVN 2 assessed Resident 1 for injuries and sat the resident in a chair in the hallway. LVN 2 asked CNA 2 to watch Resident 1 while she called the resident's physician. CNA 2 stated left Resident 1's side to get the resident juice to calm her down because she was agitated (severe restlessness). While CNA 2 was getting Resident 1's juice, CNA 2's back was turned away from Resident 1 and the resident threw herself to the floor. CNA 2 stated it happened so quick that there was no way to get to the resident in time to prevent them from falling. During an interview on 7/31/2024 at 12:46 PM with the Director of Nursing (DON), DON stated Resident 1 has a history of impulsive (doing things suddenly without thought) behaviors. If the resident does not get what they want right away, such as a juice or snack, the resident will become agitated. DON stated that according to the report from LVN 2, LVN 2 stated that Resident 1 was sitting in a chair in the hallway and LVN 2 witnessed resident get up and fall to the floor. LVN 2 instructed CNA 2 to supervise Resident 1 while LVN 2 notified the resident's physician of the fall. CNA 2 left Resident 1 sitting in a chair in the hallway to get the resident a drink. While CNA 2 was away from Resident 1, the resident then threw herself to the floor. DON stated that according to the Fall Risk assessment dated on 6/21/2024 it indicated that Resident 1 was a high risk for falls. The DON stated that residents who have a history of falls and are identified as a high fall risk are put on hourly visual checks. During an interview on 7/31/2024 at 2:23 PM with the Administrator (ADM), ADM stated close supervision is based on the needs of the resident. If a resident has had a history of falls, identified as a high fall risk, or a resident is a harm to themselves it would be recommended for one-to-one supervision. Per ADM Resident 1 should have probably been closely monitored and no one should have left the resident's side. ADM stated that Resident 1's care plan could have been adjusted to suite her needs and potentially prevent the resident from falling. During a telephone interview on 8/5/2024 at 3:56 PM with LVN 2, LVN 2 stated that she was the charge nurse during the 3-11 PM shift. LVN 2 stated that around 9 PM on 7/22/2024 she was at the medication cart and noticed Resident 1 standing in the hallway and making incoherent noises. LVN 2 stated she asked Resident 1 what she needed when Resident 1 continued walking and tripped and fell on her right side. LVN 2 assessed resident and assisted the resident with two other CNA's. LVN 2 then asked CNA 2 to take Resident 1's vital signs. CNA 2 then informed LVN 2 that Resident 1 was refusing to have her vitals taken and LVN 2 suggested for CNA 2 to get her juice to calm Resident 1 down. LVN 2 then stated CNA 2 yelled for LVN 2 because the resident threw herself on the ground. LVN 2 stated that if she did not ask CNA 2 to get the resident juice, she probably would not have fallen a second time because someone would have been watching the resident. During a review of the facility's Policy & Procedure (P&P) revised November 2023 and titled Falls and Fall Risk Managing, it indicated if falling recurs despite initial interventions, staff will implement additional or different interventions. It further indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.

Based on interview, and record review, the facility failed to provide supervision for one of three sampled residents (Resident 458), who had dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychosis (a mental disorder characterized by a disconnection from reality), Alzheimer's Disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), and history of falls, with a history of hip fracture, status post hemiarthroplasty (partial hip replacement) on 11/27/2023, received care, treatment, and services in accordance with professional standards of practice by failing to: -Provide a 1:1 sitter as ordered, and care planned. -Develop a care plan for Resident 458's non-compliance with the abduction pillow (a pillow placed between the legs that helps prevent the hip from turning in or away from the body. It keeps the hip straight while in bed and while asleep. The abduction pillow holds the hip in one position to help it heal). As a result, on 12/5/2023 (eight days after original surgery) it was observed Resident 458's left foot was pointing inward. On 12/6/2023, the resident was transferred to the General Acute Care Hospital (GACH), for further evaluation and management of the left lower extremity abnormal position. Resident 458 developed a second dislocation of the left hip and required a closed reduction left hip surgery under anesthesia. On 12/27/2023 at 9:51 AM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM) and Director of Nursing (DON), Operation Resource regarding the facility's failure to provide supervision for Resident 458, who had a diagnosis of dementia, required a 1:1 sitter as ordered, and care planned; and failed to develop a care plan for Resident 458's non-compliance with the abduction pillow. On 12/28/2023 at 3 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and DON, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: -Clinical Resource Nurse(s) / Director of Staff Development/ Designee/Certified Physical Therapist conducted a series of in-service/training and re-education on 12/27/2023 to Nursing staff, Admission and Case Management Department about purpose and importance of provision of 1:1 sitter to resident(s) and any status post-surgery precautions pertaining to any devices, weight bearing status and any special precautions during care and transfers, as prescribed by the physician. -Clinical Resource Nurse(s) / Director of Staff Development/ Licensed Designee/Certified Physical Therapist conducted a series of in-service/training and re-education on 12/27/2023 to Licensed Nurses (RNs/LVNs - Registered Nurses / Licensed Vocational Nurses) and Certified Nursing Assistants (CNAs) about purpose and importance of reviewing any status post-surgery precautions pertaining to any devices, weight bearing status and any special precautions during care and transfers, as prescribed by the physician on admission to ensure that interventions are implemented and addressed in the care plan. This in-service/ training and reeducation will continue until current 71 licensed nurses (RNs and LVNs) and 132 CNAs are captured. At this time, the Facility has completed the in-service for 54 licensed nurses and 114 CNAs which is 86 percent. -Director of Nursing/ Licensed Designee/ Clinical Resource Nurses checked/ reviewed current residents identified with diagnosis of any post-surgery care admitted in the facility in the last 30 days to see, if there was an order for 1:1 sitter and if any specific post-surgery intervention(s), if any, was/ were implemented. -No other Residents were found affected by this deficient finding for 1:1 sitter. 6 Residents were identified who were admitted with status post-surgery. -A clinical review meeting 5x/week (Monday-Friday), excluding observed holidays, will be conducted by the Director of Nurses/ Designee with MDS Nurse(s) and other interdisciplinary team members, which comprises of Nursing staff and Social Service Designee, Case Manager to review new admission' clinical records, change-of-condition in the last 24-72H including but not limited to resident(s) with diagnosis of hemiarthroplasty status-post surgery to see if there was an order for 1: 1 sitter and/ or other precautionary measures/ intervention prescribed by the physician to ensure that prescribed 1:1 sitter and/ or specific intervention(s) is/are implemented and addressed in the care plan. -Initial provision of 1:1 supervision/ sitter and the reason for the service shall be documented on the resident's clinical records. Resident's clinical records will be reviewed by the Interdisciplinary Team (IDT) which comprises of Director of Nursing / Designee, Case Managers, Social Service Designee, MDS Nurse(s), with Resident and/ or responsible party, within 24-72H after the 1:1 sitter was ordered to review the need of 1:1 sitter request while considering the resident's needs and medical condition, as well as to discuss the appropriate intervention(s) to prevent injury post-surgery. The approval or denial of the request or order of 1:1 sitter will be based on resident's rights, quality of life criteria and accepted standards of practice. -If it was determined that 1:1 sitter was necessary for the resident, the assigned sitter completes the continuous visual and behavioral monitoring form every 30 minutes to 60 minutes for the duration of the 1:1 sitter order. -During the Shift-to-Shift Huddle, the RN Supervisor or Designee will populate the residents with 1:1 sitter orders and discussed the residents and check the staff assignment sheet records to verify that scheduled sitters were in place for the shift and any status surgery precautions pertaining to any devices, weight bearing status, treatments, and any special precautions during care and transfers, as prescribed by the physician. -In the event of non-compliance behavior with the devices on preventing a dislocation or fracture, the Primary Medical Doctor (MD) will be notified of such behavior and a Change of Condition will be initiated by the Licensed Nurse. -Medical Records Designee/ Licensed Nursing Designee will audit prescribed provision of 1:1 sitter to see if the intervention was implemented and Change of Condition for non-compliance behavior with MD notifications, as prescribed and addressed in the care plan within 72 hours then weekly x 4 weeks then 2x/week x 4 weeks then weekly thereafter. Findings: A review of Resident 458's Admission Record indicated the facility admitted the resident on 11/30/2023 with diagnoses including fracture of the left femur (broken hip joint), repeated falls, lack of coordination, unsteadiness on the feet, Alzheimer's dementia, anxiety, and psychosis. A review of Resident 458's Physician's Order dated 11/30/2023, indicated to apply abductor pillow while in bed every shift. The Physician's Order indicated Resident 458 was to have no flexing post 90 degrees and no internal rotation. A review of Resident 458's Nurses Notes dated 12/1/2023, indicated the resident was non-compliant with safety measures, tried to get out of bed unassisted, and refused to be assisted during ambulation. The note indicated redirection was ineffective, and that Resident 458 was reminded to use the call light but was unable to put it to use due to her condition. The nurses note indicated Resident 458 removed the abductor pillow three times while in bed during the 7 AM to 3 PM shift. The nurses note indicated Resident 458 was explained the risk and benefits multiple times but continued to refuse. A review of Resident's 458's Orders-Administration Note dated 12/2/2023 indicated the resident was non-compliant with the abductor pillow and the risk and benefits were explained. According to a review of Resident 458's Skilled Services Documentation dated 12/2/2023, the resident was noted trying to get up from bed unassisted, safety reminders and frequent visual checks were provided to Resident 458. A review of Resident 458's Nurses Notes dated 12/2/2023 at 7:41 PM, indicated the resident had a 1:1 sitter noted at bedside. The note indicated Resident 458 was non-compliant with the use of the abductor pillow, the risk and benefits were explained, but Resident 458 continued to remove it. A review of Resident 458's Nurses Notes dated 12/2/2023 at 8:25 PM, indicated the resident got up from bed unassisted three times at the start of the PM shift, was non-compliant with safety measures and indicated the redirection was ineffective. The nurses note indicated Resident 458 was being monitored, was reminded to use the call light, but the resident was unable to put it to use due to her condition. The note further indicated Resident 458 was non-compliant to keep the abductor pillow on. A review of Resident 458's Orders-Administration Note dated 12/3/2023 at 2:59 AM, indicated the resident was trying to get out of bed without assistance. A review of Resident 458's Nurses Notes dated 12/3/2023 at 7:15 AM, indicated there was a 1:1 sitter at the resident's bedside, resident was non-compliant with the use of the abductor pillow and the risk and benefits were explained. According to a review of Resident 458's Skilled Services Documentation dated 12/3/2023 at 5:28 PM, the resident was trying to get up from bed unassisted, and safety reminders and visual checks were provided. A review of Resident 458's Case Manager Note dated 12/4/2023 at 11:20 PM, indicated an urgent request was sent to the resident's insurance for a 1:1 sitter. The note indicated the sitter was to be provided by Resident 458's insurance for diagnoses including Alzheimer's disease, dementia, psychotic disturbance, anxiety disorder, psychosis not due to a substance or known physiological condition. A review of Resident 458's Physician's Order dated 12/4/2023, indicated for a 1:1 sitter to be provided by the resident's insurance for diagnoses including Alzheimer's disease, dementia, psychotic disturbance, anxiety disorder, psychosis not due to a substance or known physiological condition. A review of the facility's Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/4/2023 for the 7 AM- 3 PM shift, indicated Certified Nursing Assistant (CNA) 8 was assigned to be 1:1 sitter for Resident 458. A review of Resident 458's Altered Thought Care Plan initiated and revised on 12/4/2023, indicated this was related to Alzheimer's disease and dementia as evidenced by a short term and long-term memory problem, the resident could not recall after five minutes or of long past; unable to make decisions, a problem understanding others, and a problem making needs known. The care plan indicated interventions included to provide a 1:1 sitter as ordered, to anticipate and meet needs, observe/report change in cognitive status, increasing confusion, increased forgetfulness, and a change in communication skills. The care plan interventions further indicated to provide reality orientation, provide calm, therapeutic environment and structured routine, establish and maintain a consistent, routine, environment, use simple language, and to allow resident ample time to absorb and respond to information. According to a review of Resident 458's Care Plans there was no care plan developed for the resident's non-compliance to use the abductor pillow or for the resident's attempts to get out of bed without assistance. A review of the facility's Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/4/2023 for the 3 PM- 11 PM shift, indicated CNA 8 was again assigned to be the 1:1 sitter for Resident 458, and the 11 PM- 7 AM shift, indicated Resident 458 was assigned a sitter. A review of the facility's Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 7 AM - 3 PM shift, did not indicate there was a 1:1 sitter for Resident 458. The Sign-In Sheet indicated Resident 458 was one of six residents assigned to CNA 6 that shift. A review of the facility's Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 3 PM - 11 PM shift, did not indicate there was a 1:1 sitter for Resident 458. The Sign-In Sheet indicated Resident 458 was one of the six residents assigned to CNA 9 that shift. During a concurrent interview and record review on 12/5/2023 at 11:50 AM, the Nursing Staffing Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 7 AM - 3 PM shift and Resident 458's care plan was reviewed with the Director of Nursing (DON). The DON stated Resident 458 had orders for a 1:1 sitter dated 12/4/2023 and indicated the resident's altered thought process care plan indicated interventions to provide a 1:1 sitter as ordered. The DON stated the Nursing Staff Schedule for C-Wing on 12/5/2023 for the 7 AM to 3 PM shift did not indicate there was a sitter for Resident 458 on that day and shift. The DON further stated Residents 458's non-compliance to use the abductor pillow was not care planned prior to the resident's change of condition on 12/5/2023. The DON stated the care plan for non-compliance should have been initiated when Resident 458 first started having these behaviors. The DON stated not providing a 1:1 sitter as ordered and not care planning for non-compliance behaviors could lead to the resident dislocating or fracturing the hip. A review of Resident 458's Change of Condition (COC) Evaluation form dated 12/5/2023 at 9:13 PM, indicated the resident had an abnormal appearance of the left leg that started on 12/5/2023 at night. The COC form indicated Resident 458's family visited and informed the charge nurse that the resident's leg looked different. The COC form indicated the charge nurse and Registered Nurse (RN) assessed the resident and noted the resident's the left foot was pointing inward. The COC form indicated Resident 458 had previous behavior of non-compliance and trying to get out of bed. The COC form indicated the wedge was in place, the primary care clinician was notified. According to a review of Resident 458's Physician's Order dated 12/5/2023, a STAT (immediate) x-ray (an imaging study that creates pictures of the inside of the body using radiation) of the left hip, knee, and ankle. A review of Resident 458's Nurses Notes dated 12/6/2023 at 1:58 PM, indicated radiology was checked to follow-up with the resident's x-ray, and indicated a tech was not yet assigned. A review of Resident 458's Nurses Notes dated 12/6/2023 at 4:30 PM, indicated a phone call was received from Medical Doctor (MD) 1 from the GACH. The note indicated MD 1 ordered to transfer Resident 458 to the GACH for further evaluation and management of the left lower extremity abnormal position / appearance related to status post left hip arthroplasty (hip replacement, a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis) per Family Member (FM) 1's request. A review of Resident 458's Emergency Department Physician's Notes from GACH dated 12/6/2023 at 8:43 PM, indicated the resident was brought in by ambulance complaining of the left foot turn inwards. The History and Physical indicated Resident 458 denied pain on arrival. A review of Resident 458's Imaging Report of the left hip dated 12/6/2023 at 10:39 PM, indicated the resident had posterior superior acetabular component dislocation (dislocated left hip). A review of the History and Physical Update from GACH dated 12/7/2023, indicated MD 1 was informed by FM 1 that Resident was noted to be without abduction pillow and the leg was noted to be shortened when she visited the resident on 12/5/2023. The H and P update further indicated the x-ray imaging showed dislocation of a left hemiarthroplasty and no evidence of a fracture. The H and P update indicated Resident 458 would need closed reduction under anesthesia that same day. According to a review of the Surgery and Procedure Reports from GACH dated 12/7/2023 at 5:06 PM, Resident 458 had an operation under anesthesia. The Surgery and Procedure Report indicated Resident 458 had a left hip closed reduction of dislocated hip prosthesis. During a telephone interview on 12/13/2023 at 10:40 AM, FM 1 stated she did not like the care the facility was giving Resident 458. FM 1 stated she went to visit Resident 458 on 12/5/2023 in the evening and found the resident's left leg twisted. FM 1 stated she then informed the nurse what she had seen. FM 1 stated Resident 458 had a 1:1 sitter at the GACH and she spoke to MD 1 from the GACH who stated the resident's leg did not look good. FM 1 stated MD 1 informed her that Resident 458 must have fell or got the injury when the resident was changed. FM 1 stated MD 1 told her Resident 458's leg got dislocated so he was going to try and snap the leg back in. FM 1 stated MD 1 informed her Resident 458 lost a lot of tissue from the injury. FM 1 stated facility staff said they couldn't be watching Resident 458, couldn't have a 1:1 sitter during the day to watch the resident. FM 1 stated the facility staff told her sorry and that they were going to try to do their best. During a concurrent interview and record review on 12/13/2023 at 1:47 PM, the Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 7 AM - 3 PM shift was reviewed with Registered Nurse (RN) 4. RN 4 stated she was working on the C-wing on 12/5/2023 on the 7 AM to 3 PM shift. RN 4 stated Resident 458 was non-compliant with the abductor pillow and indicated the resident removed it and tried to get up out of bed. RN 4 stated Resident 458 required a 1:1 sitter and there were no reports from staff regarding abnormalities of the left leg that shift. RN 4 stated there were no reports that Resident 458 fell on that shift. RN 4 stated that the Sign In Sheet had no indication there was a sitter for Resident 458 on 12/5/2023 during the 7 AM to 3 PM shift. During an interview on 12/13/2023 at 2:34 PM, CNA 6 stated she was taking care of Resident 458 on 12/5/2023 during the 7 AM to 3 PM shift. CNA 6 stated on that shift Resident 458 would try to stand up and would throw away her abductor pillow. CNA 6 stated Resident 458 did not have a sitter on 12/5/2023 during her shift. CNA 6 stated she fed the resident breakfast and lunch, and indicated she had to stay with the resident a while because the resident would try to get out of bed. CNA 6 stated she went in and out of the room to see and help Resident 458. CNA 6 stated Resident 458 was confused and on occasions would see Resident 458 with her legs hanging off the side of the bed. On 12/13/2023 at 4:10 PM, during an interview, CNA 9 stated she was working 12/5/2023 on the 3 PM to 11 PM shift and was assigned to take care of Resident 458. CNA 9 stated Resident 458 would try to stand up and try to remove the pillow between her legs. CNA 9 stated Resident 458 did not have a sitter at the change of the shift and indicated she told the charge nurse the resident needed a 1:1 sitter. CNA 9 stated FM 1 came to sit with the resident that night sometime after 4 PM. CNA 9 stated FM 1 saw how Resident 548's leg looked different and told the charge nurse. During a telephone interview on 12/14/2023 at 10:34 AM, MD 2 stated she saw Resident 458 on 12/4/2023. MD 2 stated she was not informed Resident 458 was declining the abductor pillow. MD 2 stated Resident 458 needed to use the abductor pillow at all times after her left hip surgery on 11/27/2023. MD 2 stated if Resident 458 was not compliant with the abductor pillow the left hip could get dislocated. During an interview on 12/14/2023 at 1:42 PM, Resident 458's care plans were reviewed with RN 4. RN 4 stated Resident 458 was confused and was non-compliant with the abductor pillow. RN 4 stated Resident 458 started refusing and removing the abductor pillow on 12/1/2023 and would regularly try to get out of bed. RN 4 stated Resident 458 did not have a care plan developed for the resident's non-compliance of the abductor pillow prior to the residents change of condition on 12/5/2023. RN 4 stated a care plan assisted in communication to staff and to identify concerns that needed attention. RN 4 stated not care planning for Resident 458's non-compliance could cause staff to not be aware of the resident's needs and affect the resident quality of care. On 12/15/2023 at 12:05 PM, during an interview, the Administrator stated the Nursing Staff Assignment and Sign-In Sheet dated 12/5/2023 did not indicate Resident 458 had a sitter on that day and shift. The Administrator stated he reviewed some video footage that indicated there was no sitter for Resident 458 between the hours of 7 AM and 10 AM on 12/5/2023. During a telephone interview on 12/20/2023 at 12:21 PM, MD 2 stated she first saw Resident 458 on 12/4/2023. MD 2 stated a physician should see a resident within 48 hours of being admitted to the facility. MD 2 stated the initial visit was to see the overall status of the resident and their needs, and to reconcile the resident's medication. MD 2 stated not seeing the resident within 48 hours of admission to the facility could affect their over-all well-being. During a telephone interview on 12/20/2023 at 2:25 PM, the DON stated a physician should see the resident within 72 hours of being admitted . The DON stated Resident 458 was admitted on [DATE] and indicated MD 2 first saw the resident on 12/4/2023. The DON stated that MD 2 saw Resident 458 after 72 hours. During a telephone interview on 12/20/2023 at 3:05 PM, the Medical Director (MED) stated physicians were required to see the residents within 72 hours from admission. The MED stated this was done to make sure and confirm the safety of the resident. The MED stated a physician visit done after 72 hours from the time of admission could cause complications from orders not being carried out, infection, bleeding, and inadequate pain control. A review of the facility's policy and procedure titled, Care Planning (IDT) Policy, effective 11/16/2023, indicated all residents will have a comprehensive care plan to meet their individual needs that is prepared by the Interdisciplinary Team (IDT) within seven days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments. Licensed Nurses and other IDT members would develop a care plan to meet the resident's immediate care needs at the time of admission. Preliminary care plans were used until the comprehensive care plan was completed. Care planning shall include review of clinical issues, discharge planning, coordination of care and management of resources. A review of the facility's policy and procedure titled, Safety and Supervision of Residents Policy, effective 11/16/2023, indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risk for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented; and documenting interventions. Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual risk factors, and then adjusts interventions accordingly. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs. A review of the facility's policy and procedure titled, Supervision/Sitter, released 11/2023, indicated the purpose of the policy and procedure was to assist residents who need additional supervision and/or companionship in obtaining sitters or companion care. The facility would assist residents and families in obtaining sitters for residents. Sitters may be appropriate when the resident would like or needs to have additional services outside of the services provided by the facility. 1:1 sitter providing supervision may be employed by the facility provide specific task indicated on their scheduled shift. Resident and/or legal representative may request for a sitter and the specific task to be performed by them. The need for sitters shall be documented on the resident's medical records as part nursing intervention. Initial provision of 1:1 supervision/sitter and the reason for service shall be documented on the resident's clinical records. The IDT would revise the resident's care plan to include specific care modalities which would be provided by the sitter. A sitter's responsibility was to provide companionship and/or supervision to a resident including, but not limited to: sitting at bedside, conversating with resident and/or supervising to resident's needs, setting up food trays Accompanying the resident to the bathroom, notify facility's staff of any resident's needs. Sitters must agree to comply with the facility sitter 1:1 supervision policy approved by the facility. Sitters who are CNAs may assist with feeding. The sitter will notify the facility staff when taking a break or when the sitter will be away from the resident during his/her work shift. Sitters must report to nurse supervision/charge nurse when coming on and going off duty. Sitters must report changes in a resident's condition to nurse supervisor/charge nurse immediately. Sitters may not serve for more than 12 hours during a 24H period.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a gastrostomy tube (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food and medication) and was at risk for infection per the care plan, received care, treatment, and services in accordance with the professional standards of practice and the facility's policies and procedures by failing to: -Implement the Physician's Order to clean and treat Resident 1's G-tube site, every day (QD) on 7/2, 7/16 and 7/24/2023, and as needed. -Develop and implement an effective comprehensive person-centered ostomy (surgery to create an opening [stoma] from an area inside the body to the outside) care plan for Resident 1, including to cleanse the G-tube site per Physician's Order to prevent risk of infection. -Review and Revise Resident 1's ostomy care plan when there was a change in condition (COC) on 8/5/2023, per the facility policy titled, Care plans, Comprehensive Person Centered, as the resident had redness and a foul smell at the G-tube site. -Identify and monitor Resident 1's modifiable risks and complications, as the culture and sensitivity laboratory screening tests (a test to find bacteria, virus, or a fungus [different types of germs] that can cause an infection) were not ordered until after the antibiotic was completed. Per the facility's policy and procedure titled, Antibiotic Stewardship Program, the Infection Preventionist will track, collect, and review data such as whether appropriate cultures were obtained before ordering the antibiotic. And failed to ensure administration of enteral feeding (delivers nutrition directly to the stomach through a tube) was provided to Resident 1 per Physician's Order. These deficient practices caused Resident 1 to develop redness and a foul smell at the G-tube site on 8/5/2023 requiring antibiotic treatment, and increased the risk for further G-tube complications. Findings: a. A review of Resident 1's Admission Record indicated the facility admitted the resident on 1/21/2023 with diagnoses including Type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), quadriplegia (paralysis of all four limbs), and encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of the Physician's Order, dated 3/22/2023, indicated to cleanse the gastrostomy tube (G-tube) site with normal saline (mixture of salt and water used to clean wounds), pat dry and cover with T-drain dry dressing (a sterile pad applied to a wound to promote healing and protect the wound from further harm) every day (QD) and as needed (PRN) if dressing was soiled or dislodged every shift. A review of Resident 1's Care Plan for at risk for ostomy site infection initiated 3/22/2023, indicated the resident required a feeding tube related to dysphagia (difficulty swallowing). The goal was for the G-tube site to be free from signs and symptoms of redness, excoriation (scratch or wear off the skin resulting in an abrasion), and drainage through the next review date. The interventions included change feeding syringe every 24 hours, change tubing every 24 hours, administer prescribed treatment as ordered, and observe and notify medical doctor (MD) for signs and symptoms of infection on insertion site, and surrounding skin area: redness, excoriation, pain, drainage, local fever, swelling, tenderness. According to a review of the Treatment Administration Record (TAR) for G-tube site, Resident 1 did not receive treatment to the G-tube site on 7/2, 7/16, or 7/24/2023. A review of the nursing assignment sheet for 7/2, 7/16, and 7/24/2023, indicated there was no treatment nurse assigned for these days. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 7/15/2023 indicated Resident 1 was cognitively (process to think, learn or remember) severely impaired (never/rarely made decisions) with total dependence on staff with one person assist for eating. The MDS indicated Resident 1 had malnutrition, difficulty swallowing, with active diagnoses of encounter for attention to gastrostomy. A review of Resident 1's Care Plan for at risk for ostomy site infection indicated a revision on 8/1/2023, but there were no changes or additions noted on the care plan to prevent ostomy site infection. A review of the change of condition (COC) form dated 8/5/2023, indicated Resident 1 developed redness and a foul smell at the G-tube site. A review of Resident 1's Care Plan for at risk for ostomy site infection dated 8/1/2023 indicated there was no revision or update to the care plan after Resident 1's COC on 8/5/2023 for development of redness and a foul odor, per the facility's policy and procedure titled, Care plans, Comprehensive Person Centered. A review of the Physician's Order, dated 8/7/2023, indicated Resident 1 received Bactrim DS (a type of antibiotic) 800-160 milligram (mg - a unit of measure) one tablet via G-tube every 12 hours for G-tube site infection for seven days. During an observation on 8/10/2023 at 1:28 PM, in Resident 1's room, the G-tube site was observed with a clean dressing, no foul smell or redness noted. During an interview on 8/10/2023 at 1:35 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had an infection on the G-tube site with redness and foul smell on 8/5/2023. LVN 1 stated Resident 1 was currently receiving Bactrim antibiotics for the infection, that the infection was improving and currently had no foul smell or discoloration. A review of Resident 1's Physician's Orders dated 8/14/2023, indicated Resident 1 was to receive a wound culture for G-tube site infection, which was after the antibiotic treatment was completed. During a record review and concurrent interview on 8/14/2023 at 3:05 PM, with Registered Nurse 2 (RN 2), the nurse staffing assignment and Resident 1's medical record were reviewed. RN 2 stated she has done treatments before, because there was no treatment nurse on some days. RN 2 stated there was no treatment nurse signed in for 7/2, 7/16, and 7/24/2023 on the staff assignment sheet and no treatment was provided to Resident 1. She stated there was a high-risk of infection for residents with G-tube and failing to provide G-tube treatment per physician's order may increase the risk of Resident 1 getting an infection. RN 2 stated according to Resident 1's change of condition dated 8/5/2023, the resident was observed with redness and foul smell at G-tube opening. During an interview on 8/15/2023 at 9:15 AM, the Infection Control Preventionist (ICP) stated she conducted the antibiotic stewardship and assessed Resident 1's infection as it had redness and a foul smell at G-tube site on 8/5/2023. The ICP stated she did not conduct a culture and sensitivity; she did not communicate with Resident 1's physician for culture and sensitivity and did not communicate with the medical director regarding a wound culture for Resident 1. The ICP stated the antibiotic stewardship protocol was to conduct culture and sensitivity for infections and inform the physician of the result to ensure the appropriate antibiotic was used for the specific type of germ of the infection and prevent antibiotic resistance. During an interview on 8/15/2023 at 12:05 PM, RN 2 stated Resident 1 had a G-tube infection on 8/5/2023 and the culture and sensitivity were not ordered and conducted until 8/14/2023. RN 2 stated the culture and sensitivity should be conducted when the antibiotic was ordered on 8/7/2023 due to a risk of antibiotic resistance and potential ineffective treatment for Resident 1's infection. RN 2 stated the facility did not revise Resident 1's Care Plan for at risk for ostomy site infection to include a new intervention for the prevention of G-tube infection on 8/1/2023. On 8/15/2023 at 1:40 PM, during an interview, the Medical Director (MD) stated it was not necessary to order a culture for all wounds, depending on the type of wound and location. The MD stated for a wound with a foul smell and/or purulent exudate (thick fluid may be white, yellow, or pink or green tinged caused by infection), she would normally order a culture but cannot recall if she ordered the culture or not for Resident 1. The MD stated ordering the culture at the time of treatment of a resident's infection for more effective antibiotic treatment, and to prevent spread of the infection to other residents, would be best practice. She stated she was not sure why a culture and sensitivity would be ordered for Resident 1 on 8/14/2023 after the antibiotic treatment was completed. During an interview on 8/15/2023 at 3:07 PM, the Director of Nursing (DON) stated Resident 1's care plan for at risk for ostomy infection initiation 3/22/2023 indicated a revision on 8/1/2023 but there were no changes in the care plan. The DON stated the care plan was not effective and should have been revised. She stated according to the nursing staffing assignment and sign in sheet, there was no treatment nurse assigned for Resident 1 on 7/2, 7/16 or 7/24/2023. The DON stated the TAR indicated Resident 1 did not receive G-tube care per Physician's Orders on 7/2, 7/16, or 7/24/2023. During an interview on 8/28/2023 at 9:05 AM, Family Member 1 (FM 1) stated she spoke with someone at the facility regarding Resident 1's G-tube infection and the facility staff informed her the infection can be from not cleaning the G-tube properly. FM 1 stated the facility staff indicated there were no treatment nurses on some weekends and missed the G-tube cleaning. FM 1 stated she did not believe the facility staff provided good quality cleaning to prevent the infection at the G-tube site for Resident 1 and that the infection could have been prevented if the facility properly cleaned the G-tube. A review of the facility's policy and procedure (P&P) titled, Enteral Feedings-Safety Precautions, revised January 2023, indicated keep the skin around the exit site clean, dry, and lubricated (as necessary). A review of the facility's P&P titled, Gastrostomy / Jejunostomy Site Care, revised January 2023, indicated the purpose of this procedure was to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown, and infection. The policy indicated to verify that there was a physician's order for this procedure. According to a review of the facility's P&P titled, Prevention and Screening - Clinical Protocol, revised 1/2023, the physician will order lab screening tests that are relevant to monitoring the individual's treatment regimen or identifying modifiable risks and complications. A review of the facility's P&P titled, Antibiotic Stewardship Program, revised 1/2023, indicated the infection Preventionist will track, collect, and review data such as whether appropriate cultures were obtained before ordering antibiotic. A review of the facility's P&P titled, Care plans, Comprehensive Person Centered, reviewed January 2023, indicated assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met. b. A review of Resident 1's care plan for at risk for tube feeding intolerance, initiated 3/22/2023, indicated to administer tube feeding as ordered. A review of the Physician's Order, dated 7/1/2023, indicated Resident 1 was to receive Jevity 1.5 (high-protein, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) at 60 milliliters/hour (ml/hr - unit of measure) x 20 hours, via enteral pump from 12 PM to 8 AM or until dose limit was met. According to a review of Resident 1's MDS dated [DATE] indicated the resident was cognitively severely impaired and required total dependence with one person assist for eating, personal hygiene, and two people assist for toilet use. A review of Resident 1's August medication administration record (MAR), indicated the resident's enteral feeding was administered on 8/10/2023. During an observation on 8/10/2023 at 1:28 PM, in Resident 1's room, the Jevity 1.5 enteral feeding was observed hung and dated 8/9/2023. The enteral feeding was turned off with 550 ml remaining in the bottle. During an interview on 8/10/2023 at 1:35 PM, in Resident 1's room, LVN 1 stated Resident 1's enteral feeding of Jevity 1.5 was dated 8/9/2023 with about 550 ml remaining and was turned off. She stated the enteral feeding was supposed to be on at 12 PM and not turned off at this time. During an interview on 8/10/2023 at 1:50 PM, in Resident 1's room, RN 1 stated the enteral feeding for Resident 1 was Jevity 1.5 calories dated 8/9/2023. RN 1 stated the enteral feeding for Resident 1 was turned off at this time. She stated the enteral feeding was supposed to be on at 12 PM according to the Physician's Orders. RN 1 stated Resident 1 gets his nutrition through enteral feeding and there was a risk resident would not get sufficient nutrition if his enteral feeding was not provided. During an interview on 8/15/2023 at 3:07 PM, the DON stated facility staff were required to provide enteral feeding per the Physician's Order and if staff did not turn on enteral feeding there was a chance the resident would not receive sufficient nutrition and develop complications of enteral feeding. A review of the facility's P&P titled, Enteral Nutrition, revised 1/2023, indicated adequate nutritional support through enteral nutrition was provided to residents as ordered.

Based on interviews and record review, the facility failed to provide the necessary care and treatment for one of five sampled residents (Resident 1), who suffered from constipation (a condition in which stool becomes hard, dry, and difficult to pass, and bowel movements do not happen very often). The facility failed to: 1. Assess Resident 1 for constipation on 4/5/2023 before giving milk of magnesia (MOM, over-the-counter laxative [a type of medicine that loosen stools and increase bowel movements or BM]) at 9 p.m., as per Resident 1's plan of care for constipation. 2. Monitor and document the effectiveness of the MOM after it was given to Resident 1 on 4/5/2023 at 9 p.m., as per Resident 1's plan of care for constipation. 3. Implement the physician's orders to administer Resident 1 Lactulose (laxative to treat constipation) and if not effective, give MOM, as per Resident 1's plan of care for constipation. As a result, on 4/6/2023, when Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) Emergency Department (ED) for a neurology consult (medical specialty that deals with the disorders of the nervous system [tissues that record and distribute information within a person by electrical and chemical means]), Resident 1 complained of bloating, abdominal pain, and constipation during assessment. Resident 1 was found with stool bulging out of the rectum and needed manual disimpaction (a lubricated, gloved index finger is inserted into the rectum and the hardened stool is manually removed). Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 1/11/2023 with diagnoses including Guillain-Barre Syndrome (GBS, a person's own immune system [body's defense against infections] harms the body's nerves [fibers that transmit messages between the brain and other parts of the body] sometimes progressing to complete paralysis [inability to move all or part of the body]), generalized muscle weakness, and constipation. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/15/2023 indicated Resident 1 was able to understand, remember, and make decisions. Resident 1 was totally dependent on staff for bed mobility, transfers, eating, dressing, personal hygiene, and toilet use. Resident 1 was unable to walk and was always incontinent (inability to voluntarily control) of bowel and bladder (organ that collect and store urine until excreted by urination) functions. A review of Resident 1's Care Plan initiated on 1/16/2023 indicated the resident was at risk for constipation related to decreased mobility, and history of constipation. The care plan goal was for Resident 1 to have soft bowel movements at least every three days. The interventions included monitoring / recording BM every shift and report hard, dry, and bloody stools; if no BM for more than three days check for constipation, abdominal distention, and notify the physician as needed; give medication as ordered, monitor and report effectiveness. A review of the Physician's Telephone Orders for Resident 1, dated 2/21/2023, indicated: 1. Docusate Sodium Capsule 100 milligrams (mg), give one capsule by mouth twice a day for bowel movements, hold for loose stools. 2. Senokot oral tablet 8.6 mg, give one tablet by mouth at bedtime for constipation, hold for loose stools. 3. Lactulose oral solution, give 30 milliliters (ml) by mouth as needed for constipation daily. 4. MOM Suspension 1200 mg/ml, give 30 ml by mouth every 24 hours as needed for constipation if lactulose is ineffective. 5. Dulcolax suppository 10 mg insert one suppository rectally (by the anus) every 24 hours as needed for constipation if MOM is ineffective. 6. Fleet enema 7-19 grams (gm)/118 ml insert one dose rectally every 24 hours as needed for constipation if Dulcolax is ineffective. 7. May have prune juice as needed for constipation. A review of Resident 1's Bowel Elimination from 4/2/2023 to 4/6/2023 indicated: - On 4/2/2023, Resident 1 did not have BM during the day (7 a.m. to 3 p.m.) and evening shifts (3 p.m. to 11 p.m.) and had one small normal formed BM during the night shift (11 p.m. to 7 a.m.). - On 4/3/2023, Resident 1 did not have BM. - On 4/4/2023, Resident 1 did not have BM during the day and evening shifts but had a medium putty-like (pale) BM during the night shift. - On 4/5/2023 Resident 1 had one small hard BM on the day shift and did not have BM during evening and night shifts. - On 4/6/2023, Resident 1 did not have BM during the day and evening shift. A review of Resident 1's Medication Administration Record (MAR) indicated Resident 1 was given MOM on 4/5/2023 at 9 p.m. A review of Resident 1's Nursing Notes, dated 4/6/2023 and timed at 4:01 p.m., indicated the nurses set an appointment a neurology consultation for 5/15/2023 via telehealth (through the telephone), but Family Member 1 (FM 1) refused and wanted instead for the attending physician to send Resident 1 to a hospital for evaluation. A review of Resident 1's Nursing Notes, dated 4/6/2023 and timed at 6:54 p.m., indicated Resident 1's attending physician (Physician 1) ordered to transfer Resident 1 to GACH 1 for a neurology evaluation related to exacerbation (worsening) of GBS. A review of Resident 1's Nursing Notes, dated 4/6/2023 and timed at 8:30 p.m., indicated the facility transferred Resident 1 to GACH 1 ED by ambulance. A review of Resident 1's GACH 1 ED Treatment Record dated 4/6/2023 timed at 11:14 p.m., indicated Resident 1 complained of abdominal pain and constipation. A review of Resident 1 GACH 1 Computed Tomography (CT - a series of X-ray images and a computer to obtain detailed internal images of the body), dated 4/7/2023 timed at 3:29 a.m. indicated Resident 1 had large rectal stool consistent with stercoral colitis (fecal matter [BM] collects and causes swelling within the colon [large intestine]). A review of Resident 1 GACH 1 Gastroenterology (branch of medicine that deals with diagnosis and treatment of diseases of the stomach, intestines, and associated organs) Consultation note, dated 4/7/2023 timed at 10:53 a.m., indicated Resident 1 had stool bulging out of rectum on exam and had manual disimpaction performed. A review of Resident 1 GACH 1 Discharge Summary indicated on 4/21/2023, the discharge of Resident 1 to another Skilled Nursing Facility (SNF). On 6/14/2023 at 1:50 p.m., during an interview, the interim (temporary) Director of Nursing (DON) and concurrent review of Resident 1's clinical record, the DON stated the licensed nurse gave MOM on 4/5/2023 at 9 p.m. because the resident did not have a BM for two days. The DON stated she was unable to find documentation that Resident 1 was assessed before and after giving Resident 1 MOM and if the MOM was effective The DON stated the assessment would include checking Resident 1 for abdominal pain and vomiting. The DON stated the physician's order was to give Resident 1 lactulose first and if not effective give MOM, but the licensed nurses did not follow the physician's order and Resident 1's plan of care for constipation. On 6/15/2023 at 11:52 a.m., during a telephone interview, Physician 1 stated Resident 1's constipation may contribute to Resident 1's decline due to the accumulation of toxins in the body. During an interview on 6/28/2023 at 11:49 a.m., Resident 1 stated that while she was at the facility, she informed the staff she was constipated, and the MOM had no effect. Resident 1 stated, I was in a lot of pain in my pelvic area and in my bottom. Resident 1 stated she felt stuffed up and had no BM. On 7/5/2023 at 12:50 p.m., during an interview with the DON and concurrent review of Resident 1's clinical record, the DON was unable to find documentation for the reason the licensed nurse gave MOM to Resident 1 on 4/5/2023 at 9 p.m. The DON stated Resident 1 may have verbalized that she was constipated. The DON stated that before giving Resident 1 MOM, the nurses should have assessed Resident 1 for abdominal pain and distention, ask the resident when she had last BM and if she had difficulty passing stool, and review the bowel elimination record. The DON further stated the MOM might not work immediately and the licensed nurses needed to monitor Resident 1 for discomfort and effectiveness of the MOM. If Resident 1 continued to complain of discomfort, Resident 1's physician should have been notified for further orders. The DON stated the licensed nurses should have followed the sequence of the physician's order to give Lactulose first, then the MOM. If not effective the give the suppository and last give the fleet as ordered by the physician. A review of the facility's policy titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, revised 9/2017 indicated the staff and physician will monitor the individual's response to interventions and overall progress, for example overall degree of comfort or distress, frequency, and consistency of bowel movements. A review of the facility's policy titled, Medication Administration (General), reviewed on 1/2023 indicated medications shall be administered in accordance with the orders, including any required timeframe. The same policy indicated as required or indicated for a medication, the individual administering the medication will record in the resident's medical record which included any complaints of symptoms for which the drug was administered, and any results achieved and when those results were observed. A review of the facility's policy titled, Charting and Documentation, reviewed on 1/2023, indicated the following information is to be documented in the resident medical record which included: a. Objective observations. b. Medication administered. c. Treatments of services performed. d. Changes in the resident's condition. e. Events, incidents, or accidents involving the resident. The same policy indicated the documentation of procedures and treatments will include care-specific details including: a. The date and time the procedure/treatment was provided. b. The assessment data and/or any unusual findings obtained during the procedure/treatment. c. How the resident tolerated the procedure/treatment.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) who received dialysis (the process of filtering the blood when the kidneys are not able to cleanse it) treatment received care in accordance with standards of practice, by failing to: 1. Review the Dialysis Communication Form post (after) dialysis for any identified concerns, missed treatment/medications documented by staff at the dialysis center. 2. Implement and follow up on the physician's order to administer intravenous (IV- inside a vein) vancomycin (antibiotic medication used to treat serious infections for which other medicines may not work) during dialysis for Resident 2 on 2/28/2023, 3/2/2023, 3/4/2023, and 3/7/2023. 3. Document and perform post dialysis assessment for Resident 2 on 3/4/2023 and 3/14/2023. As a result of these deficient practices, on 3/14/2023, Resident 2 was transferred to general acute hospital (GACH) 2 and was admitted to the Intensive Care Unit (ICU) due to septic shock (a life-threatening condition caused by a severe localized or system-wide infection causing organ failure and dangerously low blood pressure that requires immediate medical attention). Findings: A review of GACH 1's Microbiology report (involve culturing of patient samples for disease forming micro-organisms) for Resident 2 dated 2/12/2023, indicated Resident 2 tested for positive for enterococcus faecalis (bacteria) which was sensitive (effective against a bacteria) to vancomycin. A review of GACH 1 Discharge Summary notes for Resident 2 dated 2/23/2023, indicated GACH 1 admitted Resident 2 on 2/12/2023. GACH 1 discharged Resident 2 on 2/23/2023 with a physician's orders to continue IV vancomycin (dose and frequency not specified) for six weeks with dialysis. A review of Resident 2's Progress Notes from GACH 1, dated 2/26/2023, indicated Resident 2 had a wound infection from a left hip open reduction and internal fixation (ORIF, a type of surgery that puts pieces of a broken bone into place using screws, plates, sutures, or rods) and needed six weeks of vancomycin. A review of Resident 2's admission record indicated the facility admitted the resident on 2/27/2023 with diagnoses including end stage renal disease (ESRD - loss of kidney function in which the kidneys no long work to meet the body's needs), dependence on renal dialysis and sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage). According to a review of Resident 2's Admission Note, dated 2/27/2023, the resident was admitted to the facility from GACH 1 with diagnoses of sepsis and ESRD on hemodialysis (HD - the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so). It also indicated the orders were verified with the physician and carried out. A review of Resident 2's Physician's Order, dated 2/28/2023 timed at 11:38 AM indicated vancomycin to be administered at dialysis center times six weeks every Tuesday, Thursday, and Saturday for sepsis. A review of the facility's Progress Notes for Resident 2 dated 2/28/2023, timed at 11:39 AM., indicated, Order for vancomycin communicated and faxed to . dialysis for dosing and frequency. Patient [Resident 2] to complete treatment (Vancomycin) times four weeks. A review of the fax confirmation sheet indicated the facility faxed the order regarding vancomycin to the dialysis center on 2/28/2023 at 11:49 AM. A review of the Physician's History and Physical (H&P) for Resident 2, dated 2/28/2023, indicated Resident 2 was alert and oriented, was diagnosed with ESRD, was on hemodialysis and was to receive IV vancomycin with dialysis. A review of Resident 2's Impaired Renal function Care Plan, initiated 2/28/2023, indicated Resident 2 was on hemodialysis. The interventions included to properly relay medications to the dialysis clinic and to monitor vital signs pre and post dialysis. It also indicated Resident 2 was at risk for worsening condition due to dialysis clinic not administering IV Vancomycin as ordered. According to a review of Resident 2's Nurses Note, dated 2/28/2023, the resident was to be given IV vancomycin at the dialysis center. A review of Resident 2's Administration Note, dated 2/28/2023 indicated vancomycin to be given during dialysis. A review of the facility's Dialysis Communication Form indicated it was a three-section form. The first section was the pre-dialysis assessment to be completed by the facility. The second section was for the dialysis unit to fill out. The third section was the post dialysis assessment to be completed by the facility when the resident returned from dialysis. A review of Resident 2's Dialysis Communication form, the second section for the dialysis unit to fill out, dated 2/28/202, indicated no entry for the area Medication Given. A review of Resident 2's Dialysis Center Post Treatment Note, section Medications and Axillaries Administered, dated 2/28/2023, indicated the vancomycin 1000 milligrams (mg) was not given. According to a review of Resident 2's Dialysis Communication form, the second section for the dialysis unit to fill out, dated 3/2/2023, indicated no entry for the area Medication Given. A review of Resident 2's Dialysis Center Post Treatment Note dated 3/2/2023, did not indicate Resident 2 received vancomycin at the dialysis center. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 3/3/2023, indicated Resident 2 had modified independence in cognition (some difficulty in new situations only). The MDS indicated Resident 2 required extensive assistance with one-person assist in bed mobility, locomotion on and off unit, dressing and personal hygiene and the resident was totally dependent and required one-person physical assist with transferring and toileting. The MDS indicated Resident 2 was receiving dialysis treatment. A review of the facility's Order Note for Resident 2, dated 3/4/2023, indicated Vancomycin was administered at dialysis center earlier today (3/4/2023) per physician's order. A review of Resident 2's Dialysis Center Post Treatment Note dated 3/4/2023, did not indicate Resident 2 received vancomycin at the dialysis center. The facility was unable to provide the Dialysis Communication Form for the date 3/4/2023, when requested. A review of Resident 2's Nurses Note, dated 3/4/2023 timed at 1:44 PM, indicated Resident 2, Returned back from dialysis in stable condition. Alert and verbally responsive. However, the nurses' notes did not indicate if the facility assessed Resident 2's vital signs (blood pressure, temperature, pulse, respirations, or pain level) or if the HD access site on the left upper arm (LUA) was dry and intact, and had no redness, pain, bleeding, or bruising. The nurses' notes did not indicate if the facility checked/assessed the HD access site on the LUA for the presence or absence of a thrill (a vibration felt on the skin over a blood vessel) and bruit (the sound created by turbulent [erratic motion] blood flow in an artery) and there was no documentation of the resident's lung sounds as indicated by the post dialysis assessment form. According to a review of the facility's Nurses Notes for Resident 2, dated 3/7/2023, timed at 2:46 PM., Resident 2 went for dialysis in AM. A review of Resident 2's Dialysis Communication form, the second section for the dialysis unit to fill out, dated 3/7/2023, indicated no entry in the area of Medication Given. A review of Resident 2's Dialysis Center Post Treatment Note dated 3/7/2023, the section Medications and Axillaries Administered, did not indicate the dialysis center administered vancomycin to Resident 2 on 3/7/2023. A review of the facility's Administration Note, dated 3/7/2023, indicated Registered Nurse 1 (RN 1) contacted the dialysis center and the dialysis center told RN 1 that Resident 2 did not receive any doses of vancomycin because the facility did not have laboratory (blood tests) results for Resident 2. The Administration Note also indicated the facility (SNF) would start administering the vancomycin to Resident 2. A review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR - A tool used to facilitate prompt and appropriate communication between different disciplines caring for a resident), dated 3/8/2023, indicated vancomycin was not administered at the dialysis center. The SBAR indicated a nurse contacted the dialysis center and was told by a dialysis staff that the dialysis center previously received a message from the nursing facility not to administer vancomycin to Resident 2. The SBAR indicated the dialysis center staff could not provide the name of the facility's nursing staff he [Dialysis staff] communicated with. The SBAR also indicated a physician ordered to restart IV Vancomycin 900 mg on 3/8/2023 every Tuesday, Thursday, Saturday for six weeks for Resident 2. According to a review of the Dialysis Center Post Treatment Note, dated 3/14/2023, Resident 2's dialysis treatment started at 9:17 AM and ended at 12:13 PM. A review of all Resident 2's Nurses Notes, dated 3/14/2023, indicated there was no mention of when the resident left for dialysis, when she returned, or any post dialysis assessment done upon return. A review of Resident 2's Nurses Note, dated 3/14/2023 timed at 3:13 PM, indicated the facility (SNF) called the dialysis center due to Resident 2's altered mental status and unstable vital signs. A review of Resident 2's Nurses Note, dated 3/14/2023 timed at 4:20 PM, indicated the resident was transferred to GACH 2 for further evaluation via emergency services. A review of Resident 2's SBAR form, dated 3/14/2023 timed at 4:22 PM, indicated Resident 2 had altered mental status (AMS - a change in mental function) and an irregular pulse. A review of GACH 2's Emergency Physician Note, dated 3/14/2023, indicated the resident was brought in from the nursing home with AMS. It also indicated the resident's blood pressure was 90/50 millimeter of mercury (mmHg - Normal range is less than 120/80 mm Hg), heart rate 120 (Normal range is 60 to 100 beats per minute), respiration rate of 22 breaths per minute (Normal range is 12 to 16 breaths per minute), temperature of 101.2 degrees Fahrenheit ( F - normal range is 97 degrees F to 99 degrees F). The resident was started on Levophed (a medication used to treat life-threatening low blood pressure) to maintain the resident's blood pressure. According to a review of Resident 2's Nurses Note, dated 3/15/2023, Licensed Vocational Nurse (LVN) 1 called the dialysis center to follow up on the communication report for yesterday's treatment and the dialysis center did not have it. A review of GACH 2's Discharge Summary Narrative Report, signed 3/31/2023, indicated Resident 2 was transferred to the hospital for altered mental status and fever. Resident 2 was found to have septic shock and was admitted to the Intensive Care Unit (ICU). During an interview on 4/7/2023 at 10:42 AM, Registered Nurse (RN) 1 stated Resident 2 was initially admitted on [DATE] from GACH 1 with diagnoses of sepsis, and ESRD with dialysis. RN 1 further stated Resident 2 had her dialysis schedule on Tuesday, Thursday, and Saturday. RN 1 stated the purpose of the Dialysis Communication form was to communicate important information between the facility and dialysis center. RN 1 stated on 3/7/2023, she happened to review the dialysis form and called the dialysis center to make sure the vancomycin was given that day. RN 1 stated, We needed to make sure that they were giving it. She further stated the dialysis center reported they were not able to give the vancomycin. I was worried because there was an infection and if it wasn't given the infection may have gotten worse and something could happen to the patient. On 4/7/2023 at 11:57 AM, Resident 2's Dialysis Communication Forms for 2/28/2023, 3/2/2023 and 3/7/2023 were reviewed. During a concurrent interview, Licensed Vocational Nurse (LVN) 1 stated there was no indication that vancomycin was given. LVN 1 stated, If they did, they would put it on the note. He further stated, I should have followed up on the vancomycin not being given. If I had followed up, I would have let my supervisor know so that there could have been a remedy. LVN 1 stated, The purpose of the form is to communicate between our facility and the dialysis center. It's important to know the situation of the patient and whatever the dialysis does with the patient. So, we know what is done. A possible outcome of Resident 2 not receiving vancomycin was her infection not getting better. During a phone interview on 4/7/2023 at 12:37 PM, the dialysis center's Facility Administrator (DFA) stated, During the initial administration on 2/28/2023 we received a call from the nursing home not to give it (vancomycin). He was not able to say who called from the facility and stated there was no documentation of the call. The DFA further stated the dialysis nurse noted the vancomycin was not given and did not indicate on the Dialysis Communication Form that it was given or not given. During an interview on 4/7/2023 at 12:40 PM, the Medical Records Assistant (MRA) stated there were no Dialysis Communication Forms for 3/4/2023 and 3/14/2023. During an interview on 4/7/2023 at 3:08 PM, the Director of Nursing (DON) stated that for 3/4/2023 and 3/14/2023 the dialysis company did not return the patient with the communication form. She further stated a post dialysis assessment should be done even if the form was not returned. The assessment form was completed to make sure that there were no complications and to receive needed instructions from the dialysis center regarding the patient's care. The purpose of the form was for communication with the dialysis company and to report any changes from here to the dialysis center. There should be some communication from the dialysis company. The DON further stated, It's the charge nurses' responsibility to check the (Dialysis Communication) form. If the nurse knows that the medication was supposed to be given, it was their responsibility to follow up and make sure it was provided. The DON stated infection and sepsis which can lead to death was a possible outcome. On 4/7/2023 at 3:47 PM, Resident 2's Administration Note for 2/28/2023 and 3/4/2023 were reviewed. During a concurrent interview, RN 2 stated the charge nurse fills out the post dialysis assessment section and Resident 2 was to receive vancomycin during her dialysis on Tuesday, Thursday, and Saturday. RN 2 stated, I just assumed during that time that the medication was given so I could sign my e-MAR (electronic Medication Administration Record) because the medication was on the e-MAR, I had to make a note. All the while we were thinking it was being given at dialysis center. Another nurse found out because she refused to sign the e-MAR without being sure the medication was given. RN 2 stated a possible result from Resident 2 not receiving the antibiotic was a resistant infection or Resident 2's condition could get worse. A review of the facility's policy and procedure titled, Hemodialysis Access Care, revised 1/2010, indicated the general medical nurse should document in the resident's medical record any part of report from dialysis nurse post-dialysis being given. A review of the facility's policy and procedure titled, Hemodialysis, Care of a Resident, reviewed 1/2023, indicated its purpose was to prevent complications pre and post dialysis treatment and to provide a safe environment. It also indicated staff were to notify dialysis center of any special precautions or medication to be administered in the dialysis center, review the Dialysis Communication Form for any pertinent information regarding the patient's care post dialysis, record post-dialysis assessment on Dialysis Communication Form and all physician's orders such as lab work and administration of medications were to be followed as indicated by the physician.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 111), who had a medical history of an epidural abscess (an infection inside or near the spine that requires immediate treatment) received care, treatment, and services in accordance with professional standards of practice by failing to: -Ensure discharge orders from the hospital were verified with a Medical Doctor (MD), which includes Bactrim (a medication consisting of a combination of two antibiotics, used to treat bacterial infections, one of the few antibiotics that are available to treat Methicillin-Resistant Staphylococcus Aureus [MRSA - an infection that is difficult to treat because of resistance to some antibiotics]). -Ensure Resident 111 was seen by a physician within 72 hours of admission (on [DATE]) for the initial visit and evaluation, per facility policy. -Ensure Resident 111 was evaluated by a physician at least once every 30 days for the first 90 days after admission ([DATE] - [DATE]). -Ensure Resident 111 received Rifampin (antibiotic to treat bacterial infection) on ,d+[DATE], ,d+[DATE] and [DATE]. -Ensure Resident 111 had transportation to the Infectious Disease (ID - a doctor that specializes in the treatment of infections) appointment on [DATE] and assist in re-scheduling a follow up appointment. These deficient practices caused an increased risk for Resident 111 to develop bilateral (affecting both sides) lower extremity flaccid paralysis (extreme muscle weakness), with new discitis (infection between the discs of the spine) / osteomyelitis (inflammation and swelling of the bone) at the T5-T7 (thoracic spine- upper and middle part of the back) on [DATE] and the resident expired at general acute care hospital (GACH 1) on [DATE] at 2:40 AM. On [DATE], at 12:25 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM), the Director of Nursing (DON) and the Administrator in Training, regarding the facility's failure to enter (and administer) antibiotic medications from the GACH discharge medication orders for Resident 111, who had a spinal abscess, upon admission to the facility, on [DATE]. The facility also failed to ensure transportation for Infectious Disease specialist appointment on [DATE], per GACH discharge instructions for Resident 111. On [DATE] at 5:18 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and Director Staff Development (DSD), after the ADM and DON submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview and record review. The acceptable removal plan was as follows: -Clinical Research Nurse, DSD / Designee conducted a series of in-service, trainings and re-education on [DATE] to staff regarding the purpose and importance of making advance arrangements of transportation to meet resident's appointments and purpose and the importance of reviewing hospital discharge instructions are entered and carried out. This training will continue until all responsible staff are captured. -Resident clinical records will be reviewed by the Interdisciplinary Team (IDT - a team of professionals who plan, coordinate, and deliver personalized health care) and the Medical Records Designee will audit resident admission records to ensure interfacility transfer reports, including facility admission orders 24 hours after resident admission daily five times a week, audit report will be presented to the clinical meeting for follow up. -Medical Records will print the appointment records daily from the last ,d+[DATE] hours to be reviewed at the clinical meeting. Licensed Nurse / designee will attempt to reschedule missed appointments and re-evaluate resident for urgent medical needs. The IDT will follow up any missed clinical appointments and will remain on the IDT clinical meeting agenda until resolved. -Assistant Director of Nursing will randomly audit the clinical records of residents admitted within the seven-day period for completeness of reconciliation of admission orders. -Medical and ancillary appointments ordered on admission or newly prescribed resident appointments will be inputted and transmitted electronically into the facility's Smart Sheet system to ensure that appointments will be coordinated to other departments responsible. Once confirmed, the scheduled appointment and transportation will send an automatic reminder to designated staff or department at least five days prior, so the scheduled appointment will not be missed. Licensed Nurse / Designee with document the communication process in the resident's clinical record. -In the event that a medical appointment is missed, the facility has vans and multiple vendor partners that will be used to fulfill transportation requests. Facility will use its own vans to complete the trip as soon as possible. -Administration / Designee will randomly track the appointment records inputted in the Smart Sheet system three times a week for three weeks, then randomly two times per week thereafter. This will be adopted as a performance measure and discussed during regularly scheduled Quality Assurance and Performance Improvement (QAPI) meetings. Findings: A review of Resident 111's Discharge Documentation from GACH 1, dated [DATE], signed by the Internal Medicine doctor (MD 4) indicated the resident was discharged from GACH 1 to the facility and the discharge action plan included: -Continuing antibiotics for an epidural infection and follow-up with Infectious Disease for the treatment course. -New prescription antibiotic medications of Rifampin (used to treat bacterial infections) 300 milligrams (mg), two capsules orally once a day before a meal; and Bactrim DS two tablets orally every eight hours. -A Follow-up appointment with Infectious Disease on [DATE] at 1 PM. A review of Resident 111's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) following a cerebral infarction (also known as a stroke which occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type II diabetes (when the body doesn't use insulin properly leading to usually high levels of blood sugar), scoliosis (curvature of the spine), extradural and subdural abscess (serious infection that develops in the space between the bones of the spine), hypertension (high blood pressure), and resistance to multiple antibiotics. The Admission Record further indicated Resident 111 was self-responsible. A review of Resident 111's Progress Note dated [DATE] at 3 PM, indicated the resident was able to verbalize her needs in English, and was alert and oriented to self, date, and place at the time of admission despite her underlying diagnoses. A review of the Physician's Order Summary Report dated [DATE] to [DATE], indicated Resident 111 was to receive: -Infectious Disease appointment on [DATE] at 1 PM. -Rifampin Oral Capsule 300 mg, give two capsules by mouth one time a day for epidural abscess. The Physician's Order Summary Report indicated there was no order for the antibiotic Bactrim and that the orders were signed and dated by Nurse Practitioner (NP 1) on [DATE] (the day of admission), not the MD. A review of Resident 111's Medication Administration Record (MAR) dated [DATE] to [DATE], indicated there was no documentation that the resident received Bactrim. A review of Resident 111's MAR dated [DATE], indicated Resident 111 did not receive Rifampin on ,d+[DATE], ,d+[DATE] or [DATE]. The MAR indicated Resident 111 received her first and only dose of Rifampin on [DATE]. A review of Resident 111's Interdisciplinary Team (IDT) Discussion - Infection document dated [DATE], indicated Resident 111 was admitted on Rifampin 300 mg two capsules daily for epidural abscess without any adverse reaction noted. Further review of the IDT document indicated the Bactrim antibiotic was not mentioned. A review of Resident 111's Care Plan initiated on [DATE], indicated the resident had an epidural abscess, with a care plan goal of no signs and symptoms of active infection. The care plan interventions included Rifampin two capsules by mouth one time a day (Bactrim was not indicated), offering and encouraging the intake of fluids, administering medications as ordered, vital signs every shift until antibiotic/anti-infectives were completed, monitoring for side-effects from antibiotic therapy such as nausea, vomiting, diarrhea, and notifying the physician. The interventions also indicated to report to the physician any worsening signs and symptoms of infection or lack of improvement from treatment, encouraging good clean hygiene techniques to avoid cross-contamination. A review of Resident 111's Progress Note dated [DATE] at 5:13 PM, indicated the resident had a physical medicine rehabilitation consult for mobility, activities of daily living (ADL) impairment, weakness, and debility (physical weakness) secondary to bacteremia (presence of bacteria in the blood stream) and epidural abscess/discitis now with generalized weakness and total dependence for ADLs. The note further indicated Resident 111 had pain in her back and down her right leg and had difficulty moving her right leg. A review of Resident 111's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated [DATE], indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required), required extensive assistance and two-person physical assistance for bed mobility, and required extensive assistance and one-person physical assistance for dressing, eating, toilet use, and personal hygiene. A review of Resident 111's Medication Administration Record (MAR) dated from [DATE] to [DATE], indicated the resident did not receive any as needed doses of Tylenol (medication used to relieve mild pain). A review of Resident 111's Medication Administration Record dated [DATE] to [DATE], indicated there was no documentation that the resident received Bactrim. A review of Resident 111 IDT Discussion - Care Meeting document dated [DATE], indicated the resident's medication regime was reviewed and all admission orders were followed and carried out, as needed with the pharmacy consultant and nursing. The IDT Discussion Care meeting document indicated nursing staff would notify the Medical Doctor (MD 1) for any change in condition (COC) and that it was signed by NP 1 on [DATE], The IDT Discussion - Care Meeting document did not include Bactrim antibiotic. A review of Resident 111's Medical Progress Notes dated [DATE], indicated the resident had no recent events or change in condition, and indicated it was signed by NP 1, not the MD. A review of Resident 111's Progress Note dated [DATE] at 1:46 PM, indicated the resident did not go to her infectious disease (ID) appointment due to transportation and the desk nurse was working on rescheduling the appointment. No additional information was documented. A review of Resident 111's Physician's Telephone Orders dated [DATE] at 2 PM, indicated a telephone order from NP 1 was received indicating the MD was notified of the resident's missed ID appointment and the MD ordered to re-schedule the ID appointment on or before [DATE]. A review of Resident 111's MAR dated from [DATE] to [DATE], indicated the resident received Percocet (medication used to relieve moderate to severe pain) ,d+[DATE] mg twice a day in addition to 16 doses of Percocet ,d+[DATE] mg and 27 doses of Percocet ,d+[DATE] mg as needed for pain. A review of Resident 111's Medical Progress Notes dated [DATE], indicated it was signed by NP 1, not the MD. The medical progress note was illegible and unable to determine Resident 111's current health status. A review of Resident 111's medical record indicated there were no other medical progress notes documented in the resident's medical record. A review of Resident 111's Progress Note dated [DATE] at 12:43 PM, indicated the resident reported numbness in both of her legs and the inability to move both her legs which was associated with feeling nauseous and lethargic (drowsy). The Progress Note indicated the resident's right sided back pain remained and recommendations from MD 2 (Rehabilitation Physician) was to discuss with the primary team about transferring Resident 111 back to the hospital for evaluation given new acute onset weakness and numbness in bilateral lower extremities, lethargy, and prior history of lumbar epidural abscess on Magnetic Resonance Imaging (MRI- a procedure that uses radio waves, a powerful magnet, and a computer to make a series of detailed pictures of areas inside the body) of left spine during last admission. A review of Resident 111's MAR dated from [DATE] to [DATE], indicated the resident had a pain management consult due to increased radiating pain to the right thoracic back, and received Percocet ,d+[DATE] mg twice a day, Baclofen (medication used to treat muscle spasms) 5 mg for lower back muscle spasms, two as needed doses of Percocet ,d+[DATE] mg and one as needed dose of Percocet ,d+[DATE] mg. A review of Resident 111's Situation, Background, Assessment, Recommendation (SBAR - a tool used to gather information and communicate with a healthcare professional) Communication Form dated [DATE], indicated the facility received a call from NP 1 indicating MD 2 noticed Resident 111 more weaker than usual. The recommendations from NP 1 were to transfer Resident 111 to GACH 1 for further revaluation due to an increase in bilateral lower extremity weakness. A review of Resident 111's GACH 1 Emergency Documentation dated [DATE] at 8:20 PM, indicated the resident was readmitted to GACH 1. A review of Resident 111's GACH 1 Consultation Note dated [DATE] indicated the resident reported the inability to move her legs accompanied by decreased sensation (ability to feel) below her waist since waking up on [DATE]. The Consultation Note further indicated that per Resident 111, she had been intermittently compliant with her antibiotics due to not receiving them every day at the facility. The note indicated Resident 111 had informed the facility about her new leg weakness that started on [DATE], but the facility decided to bring her to GACH 1 on [DATE]. A review of Resident 111's GACH 1 History and Physical Report dated [DATE] at 10:42 PM, indicated Resident 111 reported receiving antibiotics inconsistently since residing at the facility, The report indicated Resident 111 was discharged on oral Bactrim and Rifampin, but with questionable adherence at the facility. The History and Physical further indicated Resident 111 had bilateral lower extremity flaccid paralysis (extreme muscle weakness), with the MRI showing new discitis / osteomyelitis (inflammation and swelling of the bone) at T5-T7 (thoracic spine- upper and middle part of the back) with epidural phlegmon extension resulting in cord compression and suspected cord edema (spinal cord swelling). A review of Resident 111's GACH 1 Consultation Note dated [DATE] at 11:22 AM, indicated Resident 111 had a previous admission to GACH 1 on [DATE] to [DATE], was found to have persistent MRSA bacteremia and lumbar epidural abscess. The Consultation Note further indicated Resident 111 was discharged on oral Bactrim and Rifampin to the facility. During an interview on [DATE] at 3:42 PM, RNS 7 stated he was working on [DATE] on the 3 PM to 11 PM shift. RNS 7 stated the Discharge Documentation from GACH 1 indicated Resident 111 should have been receiving both Bactrim and Rifampin while at the facility. RNS 7 stated Resident 111 did not have any orders for Bactrim in their medical record, and further stated the MAR for ,d+[DATE], ,d+[DATE], and ,d+[DATE] also did not indicate Resident 111 received Bactrim during the resident's time at the facility. RNS 7 stated the medication list from GACH 1 should be checked and verified with the MD on admission. RNS 7 stated maybe he missed or failed to put the order in the system, and that he should be double checking. RNS 7 stated Resident 111 not receiving Bactrim could cause possible harm because the resident had sepsis (a body's response to an infection, which can be life threatening). A review of Resident 111's Death Summary from GACH 1 dated [DATE] indicated on [DATE] the resident was noted to have hypotension (low blood pressure) that was not responsive to intravenous fluid (special formulated fluid injected into a vein to help keep blood pressure in normal range), noted to have a decrease in her mentation, and elevated lactate level of 6.8 (normal range 0XXX,d+[DATE], can be caused by septic shock, a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) and white blood cell (WBC - help the body fight infection and disease, normal levels 4.5 to 11) count of 43. The death summary indicated after discussion with Resident 111's friend, the resident was changed to a code status of Do not Resuscitate (DNR) and was moved to the Medical Intensive Care Unit (MICU - a unit in the hospital for patients who need critically intensive care) due to likely septic shock. Overnight Resident 111, became more hypotensive and it was determined that the risks of surgery outweighed the benefits, posing unreasonable discomfort to the resident without being able to address the underlying bacteremia or source control; ultimately causing unnecessary and prolonged suffering. The decision was made to transition Resident 111 to comfort measures only (medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort). Resident 111 passed on comfort care at 2:40 AM on [DATE]. During a telephone interview on [DATE] at 10:13 AM, Licensed Vocational Nurse (LVN) 15 stated that she was working at the facility on [DATE] (missed ID appt) during the 7 AM to 3 PM shift. LVN 15 stated transportation did not show up to the facility to take Resident 111 to her follow up appointment. LVN 15 stated she then asked the desk nurse to work on rescheduling the resident's ID appointment. LVN 15 stated she did not remember who the desk nurse was at the time but stated she did not receive an update regarding the rescheduling of Resident 111's appointment. During an interview on [DATE] at 10:49 AM, Registered Nurse Supervisor (RNS) 3 stated there was no documentation in Resident 111's medical record indicating the ID appointment was rescheduled (after almost one month). During a telephone interview on [DATE] at 11:40 AM, Charge Registered Nurse (CRN) 1 stated she worked for Infectious Disease at GACH 1 and that Resident 111 did not show up for her appointment on [DATE] at 1 PM, and the appointment was not rescheduled. During an interview on [DATE] at 12:35 PM, NP 2 (who directly worked with the facility Medical Director) stated for newly admitted residents, the policy was the physician would perform the initial visit and would review and reconcile the resident's medications. NP 2 stated the NP would perform the follow-up visits and if a resident was coming from a GACH with antibiotics, the antibiotics would be continued at the facility, because you would not want the infection to become worse. NP 2 stated the only time antibiotics from the hospital would be discontinued was if the resident has an allergy. During a telephone interview on [DATE] at 1:13 PM, a call was made to MD 1's office. MD 1 was unable to be reached. The office receptionist indicated that NP 1 was to be contacted for information and could not provide any additional contact information for MD 1. During a telephone interview on [DATE] at 2:09 PM, NP 1 stated she saw Resident 111 on admission when the resident was admitted to the facility on [DATE]. NP 1 stated she told staff to continue all of Resident 111's medications from the hospital especially antibiotics because the resident was a special case. NP 1 stated she informed staff to continue all medications from GACH 1 until Resident 111 was seen and followed up with the ID physician. During an interview on [DATE] at 3:31 PM, MD 3 stated she was the Medical Director for the facility and that when a resident was admitted to the facility the nurses call her and go over the resident's discharge summary, history and physical, and medications. MD 3 stated physicians reconcile resident's medication because how can a nurse decide to start or stop something. MDs were always the one to give admission orders, and stated she did not think consulting an NP for continuing orders from GACH was appropriate, but she was not aware of what occurred in this case. MD 3 stated Resident 111's Discharge Documentation indicated the resident was to continue Bactrim and Rifampin at the facility and it did not look like Resident 111 received Bactrim at the facility only Rifampin. MD 3 stated if a resident were to miss a month and a half of Bactrim, it was possible the resident's condition could worsen. During an interview on [DATE] at 5:16 PM, with the Director of Nursing (DON), Resident 111's medical record was reviewed. The DON stated and confirmed NP 1's signature was documented on the resident's History and Physical, Order Summary Report dated [DATE] to [DATE], the IDT Discussion - Care Meeting, and the Medical Progress Notes dated [DATE], and [DATE]. The DON confirmed there were no other medical progress notes in the resident's medical record. The DON stated, according to the documentation MD 1 did not see the resident; NP 1 did. The DON stated NP 1 saw and verified Resident 111's orders on admission. The DON stated it had always been the facility's practice to verify orders with the physician. The DON stated the facility failed to have a physician see Resident 111 timely after admission, and the facility failed to verify admission orders with MD. The DON stated, if there was difficulty reaching the MD, staff should have gone up the chain of command and notified the Medical Director. A review of the facility's policy and procedure titled, Administrative Manual, Physician Services, revised ,d+[DATE], indicated a physician will personally approve in writing a recommendation that an individual be admitted to a facility. Physicians were expected to comply with all the state and federal regulations and accepted tenets of professional practice, facility policies and practices including state and federal requirements for documentation related to supervision and management of care and to support reimbursement. For the initial physician visit the attending physician will: be notified by the facility immediately upon the arrival of his resident at the facility; personally approve in writing a recommendation that an individual be admitted to a facility, verify orders upon admission with the licensed nursing personnel, state the diagnoses, prescribe medications, treatments, rehabilitative services, diet, special procedures, diagnostic tests, restraints, and any other orders for care as specified by the physician, inform the resident of his/her medical condition, treatments/medications, risks/benefits, and alternatives, and indicate resident capacity for decision-making; including a written report of a history and physical examination within seventy-two (72) hours after admission or within five (5) days prior to admission. The residents in a skilled nursing facility must be seen by a physician within 72 hours of admission for the initial visit and evaluation and at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter, unless the resident's condition requires more frequent visits, or an alternate schedule of visits is deemed appropriate. A review of the facility policy and procedure titled, Physician Visits, reviewed ,d+[DATE], indicated the attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Policy and Procedure titled, Telephone Orders, reviewed ,d+[DATE], indicated Verbal telephone orders may only be received by licensed personnel. Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. The entry must contain instructions from the physician, date, time, and the signature and title of the person transcribing the information. Telephone orders must be countersigned by the physician during his or her next visit. A review of the facility's Policy and Procedure titled, Admission Assessment and Follow-up: Role of the Nurse, revised ,d+[DATE] indicated reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. A review of the facility's policy and procedure titled, Transportation, revised [DATE], indicated the facility shall help arrange transportation for residents as needed. Social Services and/or nursing services will help the resident as needed to obtain transportation.

Based observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse and misappropriation of property (deliberate misplacement, exploitation, wrongful, temporary, or permanent use of a resident's belongings without the resident's consent) by Resident 1 for two of three sampled residents (Resident 2 and Resident 3). Resident 1 hit Resident 3 with a cane, and Resident 1 took Resident 2 and Resident 3's personal property for his own use and without permission. As a result, on 1/5/2023, Resident 1 was transferred to the general acute hospital (GACH 1) for a psychiatric evaluation (medical doctor that specializes in the diagnosis and treatment of mental illness). Resident 3 developed a bruise in the inner bicep (large muscle of the arm) measuring eight centimeters (cm) by four cm. Resident 3 stated he felt scared and had severe pain in both arms and shoulder requiring Tylenol (pain medication). Resident 2 stated he felt anxious and upset when he saw Resident 1 with his personal property. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy (brain disorder caused by exposure to toxic substances) and muscle weakness. A review of the History and Physical dated 11/1/2022 indicated Resident 1 could make needs known but could not make medical decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/5/2022 indicated Resident 1 was oriented to year, month, and day. Resident 1 needed set up help (performs activity once the materials are provided) with eating and one-person physical assistance with bed mobility, transfer, dressing, toilet use, personal, hygiene, and bathing. The MDS indicated Resident 1 had no behavioral symptoms (hitting, scratching, or threatening). A review of the Care Plan initiated on 12/2/2022 indicated Resident 1 spoke another language other than English. The Care Plan indicated the language barrier may appear to limit effective communication that may result in decline of psychosocial (the interrelation of social factors and individual thought and behavior) well-being under the new environment. The Care Plan goal indicated Resident 1 would maintain stable mood and behavior. The interventions included to observe Resident 1 for any changes in mood, behavior, and psychosocial well-being. According to a review of the Nurses Notes dated 1/5/2023, at 5:25 a.m., Resident 1 and Resident 3 had an altercation (a noisy argument or disagreement). The Nurses Notes indicated Resident 1 used his cane and hit Resident 3. The Notes indicated during an assessment Resident 1 had no injury, was anxious and continuously talking. Resident 1 calmed down and gave up his cane without resistance. Resident 1 refused to talk about the incident and was moved to another unit. A review of the Nurses Notes dated 1/5/2023 at 7:55 a.m., indicated Resident 3 verbalized he was hit on his back and both hands many times, by Resident 1 while Resident 3 was trying to get the food that Resident 1 took from him. The Nurses Notes indicated Resident 3 did not have open wound, skin tears or discolorations. Resident 3 complained of pain on his arms rated at five out of 10 (using the pain scale, one to three for mild pain, four to six, moderate pain and seven to 10 severe pain) and was given Tylenol (pain medication). Resident 1's primary physician and Nurse Practitioner (NP) was notified. A review of the Interdisciplinary Team Meeting (IDT, team of health professionals from different disciplines who work together to address resident's needs) notes dated 1/5/2023 at 11:34 a.m., indicated Resident 1 took Resident 3's food. Resident 1 used his cane and hit Resident 3 when Resident 3 tried to take his food back. Resident 1 was alert and oriented. The IDT Notes indicated the police department and Resident 1's primary physician was notified. The primary physician gave an order to transfer Resident 1 to the general acute hospital (GACH 1) for psychiatric (medical doctor that specializes in the diagnosis and treatment of mental illness) evaluation. A review of the IDT notes dated 1/5/2023 at 12:20 p.m., indicated Resident 3's physician gave an order to continue to monitor Resident 3 for side effects to the arms and back for 72 hours and to notify the physician if there were any changes. According to a review of the Admission Record, Resident 3 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and generalized muscle weakness. A review of the MDS dated [DATE] indicated Resident 3 was oriented to year and month. Resident 3 needed set up help with bed mobility, transfer, dressing, eating, toilet use and one-person physical assistance with personal hygiene and bathing. A review of the Physician Progress Notes dated 1/13/2023, indicated skin assessments after the altercation between Resident 1 and Resident 3 did not record any bruising or discoloration. The Progress Notes indicated Resident 3's bruise may have been deeper initially and surfaced over time. The Physician Progress Notes indicated, However, given the altercation and size of the bruise, will order x-ray to confirm no damage to bone. During an observation on 1/13/2023 at 9:15 a.m., Resident 3's right inner bicep (arm) had a bruise. During a concurrent interview, Resident 3 stated on 1/5/2023 at around 5 a.m., while he was sleeping, his roommate, Resident 1 stole his snacks, peanuts and fruits. Resident 3 stated when he woke up, he saw his food on Resident 1's bed. Resident 3 stated he went to get his food and Resident 1 became angry and hit him on the arms, shoulder, back and his head with the cane. Resident 3 stated after Resident 1 hit him he was in so much pain, and staff gave him Tylenol which helped ease the pain. Resident 3 stated the bruise in the inner bicep was due to Resident 1 hitting him with the cane. Resident 3 stated he felt better and safe when Resident 1 was moved to another room right after the incident. During an interview on 1/13/2023 at 9:30 a.m., Resident 2 stated on 12/31/2022 during the morning, his bathrobe was missing from his closet. Resident 2 stated when he looked across the room, he saw Resident 1, his roommate, wearing his bathrobe. Resident 2 further stated Resident 1 came to his bedside, looked through his belongings and took his box of tissue paper without his permission. Resident 2 stated he informed Certified Nursing Assistant (CNA) 1 that Resident 1 was bothering him and wearing his bathrobe. Resident 2 stated he felt upset and anxious. A review of the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including depression and low back pain. A review of the History and Physical, dated 10/5/2022 indicated Resident 2 had the capacity to understand and make decisions. A review of the MDS dated [DATE] indicated Resident 2 was oriented to year, month, and day. During an interview on 1/13/2023 at 10:21 a.m., CNA 1 stated Resident 2 did inform her that Resident 1 took his bathrobe. CNA 1 stated she asked Resident 1 for the bathrobe and gave it back to Resident 2. CNA 1 further stated Resident 1 would go from one bed to the other when his roommates were not in the room. CNA 1 stated she saw items like a comb in Resident 1's closet that did not belong to him. CNA 1 stated she re-directed Resident 1, informed Registered Nurse Supervisor (RNS) 2 and the licensed vocational nurse (LVN 1). During an interview on 1/13/2023 at 11:09 a.m., RNS 1 stated Resident 3 was assessed every shift after the altercation. RNS 1 stated this morning during breakfast, CNA 1 reported that Resident 3 had a bruise in the right inner bicep. During an interview on 1/13/2023 at 11:59 a.m., LVN 1 stated she was not aware that Resident 1 was taking belongings from his roommates. LVN 1 stated if she had known she would notify the physician and redirect Resident 1. On 1/13/2023 at 12:46 p.m., during an interview, RNS 2 stated she was not aware that Resident 1 was going through the belongings of his roommates and if she had known they would do a room change, notify the physician and focus on the resident's behavior. During an interview on 1/13/2023 at 2:42 p.m., LVN 2 stated CNA 1 informed him about Resident 3's right inner bicep bruise this morning. LVN 2 stated Resident 3's bruise measured eight cm by four cm. During an interview on 1/13/2023, at 2:57 p.m., the director of nursing (DON) stated she was not aware Resident 1 took Resident 2's bathrobe or that Resident 1 took personal property from his roommates. The DON stated if she had known, Resident 1 would need to be redirected and monitor his whereabouts. The DON stated if Resident 1 was getting personal belongings from other roommates, an altercation could happen. A review of the facility policy titled, Resident Rights, revised on 8/2022, indicated residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. The policy indicated residents have the right to retain and use personal possessions to the maximum extent that space and safety permit. The policy indicated the residents will be supported by the facility in exercising his or her rights. A review of the facility policy titled, Abuse Prevention Program, dated 12/1/2022, indicated the policy was to promote an environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnosis of dysphagia (difficulty swallowing) was provided speech therapy services (treatment of impairments and disorders of speech, voice, communication and swallowing) timely and was provided extensive assistance and one-person physical assist while eating, per the comprehensive assessment. The facility failed to: -Develop and implement Resident 1's person-centered care plan with interventions to address the resident's dysphagia and pocketing of food (keeping food in the cheeks or mouth instead of swallowing). -Implement interventions of extensive assist and one-person physical assist while eating, per the comprehensive assessment, including to monitor and assess for episodes of Resident 1 pocketing food. -Follow the Physician's Order dated [DATE], to provide Resident 1 with a Speech Therapy Evaluation in a timely manner (within 48 hours), on [DATE]. -Adequately assess Resident 1 for emergency services (911) on [DATE] at 5:30 pm, as Resident 1 was weak, unarousable, and had a low blood pressure of ,d+[DATE] millimeters of mercury (mm/hg, normal range ,d+[DATE] mm/hg - ,d+[DATE] mm/hg). As a result, on [DATE], at around 9:30 pm, Resident 1 had a change of condition and was found with food residue lodged on the left inside of his cheek. Resident 1 was transferred by paramedics to the General Acute Care Hospital (GACH) where Resident 1 had a chest x-ray indicating Right Lower Lobe (RLL) infiltrates (abnormal substance that accumulates gradually in the cells of the lungs) likely secondary to aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). Resident 1 was admitted to the GACH. On [DATE], the results of the GACH Diagnostic Radiology report indicated Resident 1 had new airspace disease (when air in the lungs is replaced by blood, fluid, pus, or other material) within the right lower lung. On [DATE] Resident 1 had died and was discharged from GACH with diagnosis of septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) secondary to aspiration pneumonia. Findings: A review of Resident 1's Admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by chemical imbalances that can lead to personality changes), Type II diabetes (an impairment in the way the body regulates and uses sugar as fuel), generalized epilepsy and epileptic syndromes (having seizures [uncontrolled electrical disturbance in the brain] that come from the entire brain at once with typically no warning), dysphagia (difficulty swallowing) and dementia (loss of memory, thinking and reasoning). A review of Resident 1's Speech Therapy Encounter Note dated [DATE] indicated, per the resident's chart the resident had a tendency to pocket with fine chopped textures; and due to the severity of his dementia, Resident 1 was not able to follow 1-step command to clear. A review of Resident 1's Physical Medicine & Rehabilitation Consult dated [DATE] indicated recommendations for the resident to receive a speech language pathology evaluation and treatment as appropriate to assess for dysphagia, speech language disorder, higher cognitive function, and to improve safety awareness. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated [DATE], indicated Resident 1 had severely impaired cognition (never/rarely made decisions) and fluctuating inattention. The MDS indicated Resident 1 required extensive assistance and two-person physical assistance for bed mobility and transferring; and required extensive assistance and one-person physical assistance for eating and personal hygiene. The MDS further indicated Resident 1 had complaints of difficulty or pain with swallowing; and indicated he would hold food in his mouth or cheeks after meals (pocketing food). The MDS indicated Resident 1 was on a mechanically altered therapeutic diet (food that has been altered for those who have difficulty chewing or swallowing). According to a review of Resident 1's Speech Therapy Treatment Encounter Note dated [DATE], Resident 1 had occasional pocketing and holding boluses (small rounded ball of food) in his buccal (cheek) cavity. A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendations- a framework for communication between members of the health care team about a resident's condition) Summary for Providers dated [DATE] indicated Resident 1 had a habit of pocketing food. A review of Resident 1's Progress Note dated [DATE] at 4:53 p.m., indicated Resident 1 was noted not swallowing medications after receiving directions. The note indicated it took Resident 1 a long time to swallow and indicated Resident 1 was given a lot of direction. A review of Resident 1's Physician's Order dated [DATE], indicated the resident was to receive therapy evaluation and treatment as indicated for physical therapy (PT), speech therapy (ST), and occupational therapy (OT) one time only for three days. According to a review of Resident 1's Progress Note dated [DATE], Resident 1's medications needed to be crushed, because the resident had difficulty in swallowing. A review of Resident 1's Physician's Order dated [DATE], indicated there was a clarification order for Speech Therapy (ST) for oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or throat) every day three times a week for four weeks to include a least restrictive diet, diet modification, safe swallowing strategies and precaution, and patient and caregiver education. A review of the Physician's Order dated [DATE] at 5:05 p.m., indicated to monitor and document Resident 1's episodes of pocketing food. Further review of the Physician's Orders indicated there were no physician orders to monitor and document Resident 1's episodes of pocketing food prior to [DATE]. According to a review of Resident 1's Medication Administration Record dated [DATE] to [DATE] Resident 1's episodes of pocketing food were not documented. A review of Resident 1's progress notes dated [DATE] at 5:15 p.m., indicated Resident 1 was arousable and the Nurse Practioner ordered to transfer Resident 1 to the hospital for evaluation and possible Gastrostomy Tube (g-tube, a tube inserted directly through the belly for direct nutrition to the stomach) insertion. The note further indicated Resident 1 was able to open his eyes when aroused. Ambulance Service 1 was called, and Resident 1's family was made aware. A review of Resident 1's SBAR dated [DATE] at 5:30 p.m., indicated Resident 1 was very weak, was noted pocketing food, and was very high risk of aspiration. The ST recommended for Resident 1 to be NPO (nothing by mouth), the resident's physician was notified, and orders were received for the resident to be transferred to the hospital for evaluation and possible GT insertion. The SBAR indicated Resident 1's blood pressure was ,d+[DATE] millimeters of mercury (mm/hg, normal range ,d+[DATE] mm/hg - ,d+[DATE] mm/hg). A review of Resident 1's progress note dated [DATE] at 9:15 p.m., indicated Ambulance Service 1 came to transport the resident, but did not because Resident 1 was very weak and unable to be aroused. The note indicated the Ambulance Service 1 then called 911 prior to notifying the facility they were not transporting the resident. The note indicated Resident 1's family were at bedside and were aware of the situation. According to a review of Resident 1's progress note dated [DATE] at 9:30 p.m., the paramedics came to the facility and Resident 1 was now totally awake and the paramedics were made aware Resident 1 needed extra tactile stimuli due to severe weakness (possible dehydration) and due to pocketing food. The facility had to transfer for possible GT placement if the resident's family agreed. A review of the General Acute Care Hospital (GACH) Emergency Documentation dated [DATE] at 10:17 p.m., indicated Resident 1 was being transferred from the facility to the emergency department for the concern of by mouth (PO) intolerance and possible need for GT placement. A review of Resident 1's GACH Diagnostic Radiology report dated [DATE] at 10:51 p.m., indicated Resident 1 had a chest x-ray (a type of imaging that uses radiation to take pictures of the inside of the body) for dysphagia and hypotension (low blood pressure). The results of the chest x-ray indicated Resident 1 had airspace disease (when air in the lungs is replaced by blood, fluid, pus, or other material) developing in the right lung base, concerning for multifocal (affecting more than one area) infection or aspiration. A review of Resident 1's Speech Therapy Treatment Encounter Note dated [DATE] at 1:46 p.m., indicated on [DATE] during a limited oral mechanical examination, the ST observed oral trace residue. The note indicated the ST successfully removed the remaining food material from Resident 1's oral cavity via a gloved finger. The note further indicated Resident 1 presented non-responsive to varied multi-sensory stimuli (e.g., auditory, thermal, verbal, and visual). The note indicated the ST attempted multiples times for approximately 15 minutes to re-alert Resident 1, however, the resident was unable to sustain alertness (e.g., eyes opened for 4 seconds). The note further indicated Resident 1 was not safe for PO (by mouth) intake. FM 1 and FM 2 verbalized request to transfer Resident 1 to the hospital. The note indicated the ST alerted the charge nurse, and the charge nurse endorsed plan to start Intravenous Fluid (IVF) and to notify Resident 1's physician. The note indicated Resident 1 was not alert, however, no increased work of breathing was noted and the resident's oral cavity clear at the end of treatment. According to a review of Resident 1's Medical Record the resident did not have a care plan for the resident's pocketing of food or dysphagia prior to [DATE]. A review of Resident 1's GACH Discharge Documentation dated [DATE] indicated Resident 1 was deceased and discharged from GACH on [DATE]. The Discharge Documentation indicated Resident 1 was admitted to GACH for altered mental status concerning for aspiration pneumonia and the resident's primary discharge diagnosis was septic shock secondary (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) to aspiration pneumonia. The discharge documentation indicated on [DATE] at 6 p.m. Resident 1 became hypotensive with blood pressure in the 70's/30's and became hypoxic to the 50's. The documentation indicated rapid response (Medical Emergency Team that responds to immediate critical conditions) was called, the resident's blood pressure improved with intravenous fluid [IVF] and Sp02 (oxygen) improved with a nasal cannula [a device that delivers oxygen through the nose] at 6 liters (amount of oxygen delivered through the nasal cannula). The documentation further indicated Resident 1 was transferred to the Medical Intensive Care Unit and from there Resident 1 was downgraded to the Progressive Care Unit and then back to the floor where the resident's respiratory status progressively worsened, and the resident expired on [DATE]. A review of Resident 1's Autopsy Report dated [DATE] at 9:30 a.m., indicated on [DATE] Resident 1 was brought via ambulance from the facility to GACH after being found unresponsive with unchewed food in his mouth and hypotensive in the 80s systolic. Resident 1 was alert, but not oriented (at baseline, oriented to self), and was noted to have decreased breath sounds at the bilateral lung bases, right more than left. The patient received intravenous fluid resuscitation (maintain organ perfusion (hemodynamics) and substrate (oxygen, electrolytes, among others) delivery through the administration of fluid and electrolytes) and initial doses of IV vancomycin (antibiotic medication to treat infection) and cefepime (antibiotic medication to treat infection), and the resident was admitted to the general medicine service on [DATE]. The Report indicated on admission, a nasogastric tube (a tube placed through the nose to the stomach) was placed for Resident 1's nutrition and medication administration and the antibiotic regimen was changed to IV ceftriaxone (antibiotic medication to treat infection) and metronidazole (antibiotic medication to treat infection) given high concern for aspiration pneumonia. On the evening of the first day of admission, ([DATE]), a rapid response was called for hypoxia with oxygen saturation 59% and hypotension (,d+[DATE], low blood pressure), at which time the resident was also hypothermic to 35 degrees Celsius (95 degrees Fahrenheit). The resident was noted to have a possible aspiration event on the evening of [DATE] after which nasogastric tube feeds were held for a time before being restarted at a trickle rate. The resident was transferred back to the medicine floor on [DATE]. On [DATE] the resident experienced a desaturation (a decrease in the level of oxygen in a resident's blood) event which was not improved despite maximal supplemental oxygen. Resident 1's family was notified of the change in clinical status and the resident was given intravenous lorazepam (medication to treat anxiety) for comfort. Resident 1 expired at 6:18 a.m. on [DATE]. The clinical cause of death was related to aspiration with dementia, diabetes and epilepsy contributing factors. The report indicated the autopsy cause of death was respiratory failure due to pneumonia of the resident's right lung with conditions that included aspiration. The report further indicated final anatomic diagnosis of acute pneumonia of the right lower lobe and aspiration of foreign material in the bilateral lungs. A review of the Certificate of Death dated [DATE] indicated Resident 1's cause of death was respiratory failure and right lung pneumonia. During an interview on [DATE] at 1 p.m., Family Member (FM) 2 stated on [DATE] he went to visit Resident 1 at the facility and Resident 1 was non-responsive with his eyes fluttering back. FM 2 stated he knew Resident 1's baseline because he is the resident's caregiver and he knew there was something wrong. FM 2 stated staff indicated Resident 1 was tired. FM 2 stated he found the resident had a big wad of food in his mouth. FM 2 stated this was not the first time this happened and asked staff previously to make sure someone was feeding the resident and not leaving him with food in his mouth. FM 2 stated he pulled out the wad of food in Resident 1's mouth and asked the nurse to please call someone but was brushed off. FM 2 stated he told the nurse the resident needed to go to the hospital, but the nurse told him she doesn't think it's necessary. FM 2 stated around 9:14 p.m. an ambulance came to pick up the resident but stated they would call 911 instead. FM 2 stated the resident was transferred to GACH and never recovered. FM 2 stated when an autopsy was done pieces of food were found in Resident 1's lungs. On [DATE] at 3:51 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated when an order for speech therapy evaluation was received from the physician, the order was good for three days and the speech therapist should see the resident the next day, but no later than three days. LVN 1 stated if the resident had difficulty swallowing an order should be obtained from the physician to down grade the resident's diet until the swallow evaluation was done. During an interview on [DATE] at 4:06 p.m., ST 1 stated he remembered Resident 1. ST 1 stated FM 2 stated Resident 1 was found lying flat with food in his mouth. ST 1 stated FM 2 was cursing at the DON and holding food in his hand that he pulled from Resident 1's mouth. ST 1 stated FM 2 indicated Resident 1 had food lodged in his left cheek and had pictures of it in his cellphone. ST 1 stated he had just finished reading Resident 1's medical record on [DATE] and was about to do an evaluation. ST 1 stated Resident 1 was not alert and had residue on the inside cheek of the left side of his mouth, and it matched the food material FM 2 was holding in a napkin. ST 1 stated he sat the resident up, and he removed the remaining food in the resident's mouth. ST 1 stated the resident was so lethargic he was not efficient enough to take a diet by mouth. ST 1 stated he turned to the charge nurse and informed her to alert the resident's physician and the charge nurse indicated she could start IV fluid. ST 1 stated the resident was not alert enough and unable to sustain alertness ST 1 informed FM 1 and FM 2 that Resident 1 was deemed not safe to eat and expressed concerns to the resident's family and the charge nurse that the resident currently had no means to eat. ST 1 stated the charge nurse would notify the doctor. ST 1 stated when a resident receives an order for a ST evaluation, the speech therapists receive a schedule and residents are usually seen the same day. A review of the National Foundation of Swallowing Disorders document titled, Caregiver's guide to Dysphagia in Dementia, dated [DATE], indicated among the many problems seen in individuals with dementia, there is growing evidence and concern regarding the presence of eating and swallowing disorders in this population, also known as dysphagia. The presence of dysphagia in individuals with dementia can lead to serious consequences such as weight loss, malnutrition and dehydration; all of which can lead to other serious medical complications in older adults. It can also lead to lung-related complications such as aspiration pneumonia, which may cause the person to be hospitalized and even become life-threatening. In individuals with Alzheimer's disease (dementia), pneumonia accounts for nearly 70% of the causes of death. During an interview and concurrent record review on [DATE] at 11:51 a.m. with Registered Nurse (RN) 1, Resident 1's medical record was reviewed. RN 1 stated and confirmed Resident 1 had difficulty swallowing and would pocket food. RN 1 stated Resident 1 should have been monitored for pocketing food after each meal and the difficulty swallowing and pocketing food should have been care planned. RN 1 reviewed Resident 1's medical record and stated the speech therapist initiated a care plan for dysphagia on [DATE] (after the SBAR on [DATE]). RN 1 stated there was no documentation that indicated Resident 1 was monitored for pocketing of food prior to [DATE]. RN 1 stated the care plan was the guide and intervention necessary for how the resident needs to be cared for. RN 1 stated if a resident has difficulty swallowing and pockets food, and there was no care plan for the difficulty swallowing or pocketing of food, this could possibly harm the resident and put the resident at risk for choking and aspiration. During an interview and concurrent record review on [DATE] at 12:29 p.m., with the Director of Rehab (DOR), Resident 1's medical record was reviewed. The DOR stated Resident 1 had orders for a speech therapy evaluation dated [DATE] and was seen for evaluation on [DATE]. The DOR stated Resident 1 should have been seen earlier, on [DATE] or [DATE], and that there was a delay in Resident 1 receiving a speech therapy evaluation. The DOR stated a delay in a speech therapy evaluation could put the resident at risk for harm given the medical conditions. The DOR stated an evaluation would determine if the resident had a skilled need for an intervention, proper diet, or assistance. On [DATE] at 1:16 p.m., during an interview and concurrent record review with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated and confirmed that for Resident 1, both the difficulty swallowing, and the pocketing of food should have been care planned. The DON stated she did not see any care plan for Resident 1's difficulty swallowing or pocketing of food. The DON stated the care plan was the foundation in providing and meeting the needs of the resident. The DON stated Resident 1 should have been monitored for episodes of pocketing of food when the physician orders were received on [DATE]. The DON stated if a resident was pocketing food the resident should have been monitored after every meal because they were at a risk for choking and aspiration. The DON further stated Resident 1 had a delay in treatment for his speech therapy evaluation and the physician's orders for a speech therapy evaluation were received on [DATE], the resident should have been seen sooner than [DATE]. During an interview on [DATE], at 12 pm, when asked why the facility staff called the ambulance vs. calling 911, the Director of Staff Development had no answer, then stated the resident was transferred via 911. During an interview on [DATE], at 12:20 pm, when asked should the facility staff have called 911 vs. the ambulance, the DON stated, Absolutely, based on the resident's needs. A review of the facility's policy and procedure titled, Care Planning Policy, dated [DATE], indicated all residents will have a comprehensive care plan to meet their individual needs that is prepared by the Interdisciplinary Team (IDT) within 7 days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments. Preliminary care plans are used until the comprehensive care plan has been completed. A review of the facility's policy and procedure titled, Specialized Rehab Services, dated [DATE], indicated it was the policy of the facility to ensure specialized rehab services, including physical, occupational, speech-language pathology, and respiratory therapy were provided, as required, based upon the resident's comprehensive plan of care. A review of the facility policy titled, Supporting Activities of Daily Living (ADLs), revised on ,d+[DATE] indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care) b. mobility (transfer and ambulation, including walking) c. elimination (toileting) d. dining (meals and snacks) e. communication (speech, language and any functional communication systems). The policy indicated interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate.

Based on observation, interview, and record review, the facility failed to identify and ensure one of three sampled residents (Resident 34), who had a dehisced abdominal wound (a partial or total separation of previously approximated wound edges), received care, treatment, and services in accordance with professional standards of practice and the comprehensive assessment by failing to: -Develop and implement Resident 34's person-centered comprehensive care plan with interventions to address the effectiveness of the wound care treatment. -Follow the Physician's Order to clean and treat Resident 34's abdominal wound every day shift and as needed. -Assess and re-evaluate Resident 34's pain on 10/24/2022 and 10/29/2022. As a result, Resident 34 had increased pain due to the abdominal wound dressing was not changed and caused feelings of embarrassment from the smell produced by the increased drainage on the dressing. Findings: A review of the admission record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified ovary (a cancerous tumor involving the ovary), encounter for other specified surgery after care, and depression. A review of the care plan for alteration in comfort due to pain initiated on 9/29/2022, indicated the interventions were to monitor for side effects of pain medications, evaluate pain for effectiveness, document pain characteristics using pain management scale, observe and report any signs and symptoms of non-verbal pain. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/2/2022 indicated Resident 34 had a surgical wound, required application of ointments / medication, was cognitively intact (able to make decisions), and required extensive assistance from staff for activities of daily living such as bed mobility, transfers, personal hygiene, toilet use and dressing. A review of the Physician's Order dated 10/19/2022, indicated to irrigate Resident 34's abdominal wound with normal saline (salt water and electrolytes used to help clean wounds) and pat dry. Apply Medihoney (dressings aids and supports debridement and a moist wound healing environment in acute and chronic wounds) on all parts of the wound and undermining wound bed, and then apply Calcium Alginate (used on moderate to heavily exudative wounds during the transition from debridement to repair phase of wound healing) Pack with a roll of gauze, cover with an abdominal pad and a dry dressing, then secure with tape every day shift and as needed. According to a review of the medical record, Resident 34 did not have a care plan for the abdominal wound. A review of the Medical Administration Record (MAR) dated 10/24/2022 at 12 PM, indicated Resident 34 received Tramadol 100 milligram (mg, unit of measurement) medication (an opioid pain medication used to treat pain) for moderate to severe pain. The MAR indicated Resident 34 was not assessed for pain including the description or location of the pain and was not re-evaluated for pain after the Tramadol was administered on 10/24/2022. A review of the nursing assignment for 10/29/2022, indicated there was no treatment nurse assigned for the morning or evening shift, to ensure Resident 34's abdominal wound was cleaned and treated every day. According to a review of the Treatment Administration Record (TAR) dated 10/29/2022 (Saturday), Resident 34's abdominal wound treatment was not completed every day, per the physician's order. A review of the MAR dated 10/29/2022 indicated Resident 34 was not assessed for pain including the description or location of the pain on 10/29/2022. During an interview on 11/1/2022 at 3:17 p.m., the medical records assistant (MRA) stated and confirmed Resident 34's abdominal wound treatment was not signed or completed for 10/29/2022, per the physician's order. On 11/1/2022 at 3:30 p.m., during an observation in Resident 34's room and concurrent interview, Resident 34 had a dressing located to her mid abdomen. Resident 34 stated she did not receive wound care treatments on Saturday (10/24/2022). Whenever she asked the staff why she did not receive wound treatments, the response was there was no available staff. Resident 34 stated the drainage collected in the dressing and remained there for several hours causing a very bad odor and it caused an increase in pain. Resident 34 stated the pain would increase to a six out of 10 (using the scale 0-10, 10 being the most severe pain) and she also felt embarrassed due to the odor. During an observation in Resident 34's room, on 11/2/2022 at 10:30 a.m., Resident 34's abdominal wound care was performed by Licensed Vocational Nurse (LVN-2) and Medical Doctor (wound specialist [MD-WS]), the wound measured 18 centimeters (cm, unit of measurement) in length, 5.5 cm in width and 3 cm in depths and was noted to have about 50% slough (dead tissue separating from living tissue) and 50% granulation tissue (a new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process). During an interview with the Director of Nursing (DON) on 11/2/2022 at 3:45 p.m., the DON stated missing a wound treatment could negatively affect Resident 34 and cause infections while also causing psychosocial harm of negative feelings. During an interview on 11/3/2022 at 2 p.m., when asked about Resident 34's wound care plan, the Assistant Director of Nursing (ADON) stated that a wound care plan should have been developed for Resident 34 because it helped keep track of the provided treatments and the effectiveness. On 12/1/2022 at 4:30 p.m., during an interview, the ADON stated and admitted that treatments that were not documented were not done and that the risk of missing wound care for Resident 34 would result in worsening of the wound. During an interview with the ADON on 12/1/2022 at 4:32 p.m., when asked about Resident 34's lack of pain assessment, she stated that pain needs to be assessed and evaluated before pain medications were administered. The ADON further stated that not assessing pain before and after would not allow them to evaluate if the ordered treatments for pain were effective. A review of the facility policy titled, Care Plans, dated 2/5/2016 indicated care plans will be initiated upon resident's condition change, incident or identified problems. Care plans will include the identified problem, long-term and short-term goals which are measurable and with a timeframe. A review of the policy titled, Pain Assessment Management, revised 3/2015 indicated the purpose of this procedure was to develop interventions that are consistent with the resident's needs. The policy indicated a resident's pain and consequences of pain will be assessed, at least each shift, for the response to the interventions. The policy indicated when assessing for pain to gather the characteristics of pain such as intensity, descriptors, location and frequency.

Based on interview and record review, the facility failed to ensure licensed staff did not administer [MEDICATION(S)] (a medication used to treat constipation) to one of three sampled residents (Resident 1) who was experiencing diarrhea (loose stools, a side effect of [MEDICATION(S)]) from 7/4 - 7/18/2022. This deficient practice of administering medications in the presence of adverse effects (unwanted, dangerous side effects of medication therapy) caused Resident 1 to experience diarrhea leading to [CONDITION(S)] (low blood pressure), transfer to the general acute hospital (GACH 1) emergency room (ER), where Resident 1 was diagnosed with severe dehydration (a potentially life-threatening medical emergency, can cause serious damage to your kidneys, heart, and brain) due to prolonged diarrhea, an infected Stage II decubitus bed sore (skin appears as a shallow, crater-like wound or a blister containing a clear or yellow fluid) in the sacral area (lower back), an abrasion to the scrotum, and [CONDITION(S)] (life threatening illness caused by the body's response to an infection) due to the Stage II decubitus bed sore. Resident 1 resided in the GACH for 10 days. Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Physician's Order dated 6/29/2022 at 4:35 p.m., indicated to administer [MEDICATION(S)] 8.6 milligrams (mg.), two tablets by mouth at bedtime for constipation and to hold for loose stools. A review of the Care Plan created on 6/30/2022, indicated Resident 1 had dehydration or potential fluid deficit related to decreased fluid intake. The care plan goal indicated Resident 1 would be free from signs and symptoms of dehydration which included headache, dizziness, fatigue, and weakness. The listed interventions included to observe and notify the responsible party of signs and symptoms of persistent vomiting and diarrhea, notify the physician of the resident's change of condition, and consult with the registered dietitian (RD) for Resident 1's hydration needs. A review of the Change in Condition (COC) note dated 7/4/2022 at 1:08 p.m., indicated Resident 1 had three episodes of diarrhea in the morning. The physician was notified and gave an order to administer Loperamide 2 mg tablets by mouth every eight hours as needed for diarrhea and infuse Normal Saline (used for fluid or electrolyte [essential minerals in that are vital in the key functions in the body] replenishment) Intravenously (IV) two liters at 50 milliliters per hour (ml/hour). According to a review of the Care Plan dated 7/4/2022, Resident 1 had episodes of diarrhea and the goal indicated Resident 1's diarrhea will resolve within 72 hours without complications. The care plan interventions included to observe and report signs and symptoms of skin breakdown, provide good peri-care, administer Loperamide 2 mg. as ordered, and report adverse reaction from the medication. A review of the Bowel and Bladder Elimination (BBE) form dated 7/2022, indicated Resident 1 had episodes of diarrhea on the following dates: -7/4/2022 - three episodes. -7/10/2022 - one episode. -7/11/2022 - three episodes. -7/12/2022 - four episodes. -7/13/2022 - three episodes. -7/14/2022 - three episodes. -7/16/2022 - three episodes. -7/17/2022 - four episodes. -7/18/2022 - two episodes. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . two tablets by mouth at 9 p.m. on 7/4, 7/10, 7/11, 7/12, 7/13, 7/14 and 7/16/2022. A review of the MAR for 7/1 to 7/31/2022, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . tablets by mouth on 7/13/2022 at 2 a.m. (the same day he received the [MEDICATION(S)]) and on 7/17/2022 at 3:36 p.m. However, there was no documentation found that Resident 1 was administered loperamide every eight hours as needed, per physician's order when Resident 1 had episodes of diarrhea on 7/4, 7/10, 7/11, 7/12, 7/14, 7/16, and 7/18/2022. A review of Resident 1's Nurses Notes dated 7/12/2022 at 10:37 a.m., indicated the nurse practitioner (a registered nurse who has additional education and training in how to diagnose and treat diseases) was notified that .resident still with episodes of diarrhea. The Notes indicated the NP gave an order which included to continue to administer loperamide. The Bowel Bladder Elimination form indicated Resident 1 continued to receive the [MEDICATION(S)] for five days after this order. A review of the Situation, Background, Appearance, Review and Notify (SBAR) dated 7/18/2022 indicated Resident 1 had a blood pressure of 87/57 millimeter mercury (mm/Hg, a blood pressure of less than 90 is considered low blood pressure) and had two episodes of diarrhea. The nurse practitioner was notified and gave orders to transfer Resident 1 to GACH 1 by paramedics. According to a review of the Paramedics Patient Care Report dated 7/18/2022, at 11:49 a.m., Resident 1 had a chief complaint of general weakness with diarrhea of over two weeks. Resident 1's blood pressure was 94/56 at 12:05 p.m. A review of the GACH 1 Emergency Department (ED) Continuity of Care note dated 7/18/2022, at 8 p.m., indicated during assessment, Resident 1's lower back showed what .appears to be a decubitus bedsore . with mild surrounding [CONDITION(S)] (redness of the skin caused by injury or another inflammation causing condition). The ED note indicated Resident 1 stated that the area had become more painful and tender over the past several days. A review of the GACH 1 Photographic Documentation dated 7/18/2022, indicated Resident 1 had an abrasion in the scrotum and a Stage II pressure injury (bedsore) in the sacral area with serosanguineous drainage (thin, watery discharge that contains a small amount of blood). A review of the Nephrology Consultation Note dated 7/19/2022 indicated Resident 1 had acute kidney injury (AKI, kidneys [organ that remove waste and extra water from the body] suddenly stop working) from severe dehydration, acidosis (condition in which the body's fluids are more acidic than normal) due to severe diarrhea and [CONDITION(S)]. The consultation further noted Resident 1 was on IV fluids and antibiotics. According to a review of the GACH 1 Cardiology Consultation Note dated 7/19/2022, Resident 1 had [CONDITION(S)] secondary to fluid loss with diarrhea and early septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection). A review of the GACH 2 History and Physical (H and P) dated 7/20/2022 indicated GACH 2 admitted Resident 1 from GACH 1 for continuity of care, evaluation, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/28/2022, at 10:52 a.m., Certified Nursing Assistant (CNA 1) stated Resident 1 had diarrhea and redness on both buttocks and the scrotal area. CNA 1 stated she would clean Resident 1 after each episode of diarrhea. During a telephone interview on 8/18/2022, at 1:28 p.m., the Resident 1's MAR for the [MEDICATION(S)] for 7/2022 and the COC dated 7/4/2022 were reviewed with the registered nurse supervisor (RNS 1). RNS 1 stated when Resident 1 had diarrhea, the [MEDICATION(S)] should have been stopped because the physician's order indicated to hold for loose stools. On 8/23/2022 at 9:47 a.m., during an interview, the Director of Nursing (DON) stated when Resident 1 had episodes of diarrhea, the [MEDICATION(S)] should have been stopped and the loperamide should have been given as ordered by the physician. The DON further stated episodes of diarrhea would make the Moisture Associated Skin Damage (MASD - caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, [MEDICATION(S)], saliva, and their contents / decubitus bed sore) worse. During an interview on 8/23/2022, at 10:32 a.m., the Registered Dietician (RD) stated the facility should have notified the RD when Resident 1 was having diarrhea. The RD stated the diarrhea can make Resident 1 at risk for fluid deficit (dehydration) and electrolyte imbalance. The RD stated one of the interventions would be to review Resident 1's medications and recommend holding stool softeners to find out if the stool softeners were causing the diarrhea. On 8/23/2022 at 11 a.m., during an interview, CNA 1 stated Resident 1 had diarrhea and every time Resident 1 turned, Resident 1 would have loose bowel movement come out. CNA 1 stated Resident 1 had a skin tear in the scrotal area. During a telephone interview on 8/25/2022 at 1:33 p.m., the NP stated the facility should not have given the [MEDICATION(S)] when Resident 1 was having diarrhea, because Resident 1 would continue to have diarrhea. The NP stated diarrhea can lead to [CONDITION(S)] and dehydration. A review of the facility policy titled, Medication Administration - General Guidelines, dated 2/23/2015, indicated medications were administered in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy indicated medications were administered in accordance with written orders of the attending physician.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to: -Implement care plan interventions of stand by assist for Resident 1 during self-feeding. -Develop a care plan with appropriate interventions to address Resident 1's behavior of eating rapidly, per the Speech Therapist assessment on 10/18/2021. -Assess Resident 1 for dysphagia (difficulty in swallowing) as recommended on 10/19/2021, per the Physical Medicine and Rehabilitation Medical Consultant's Initial Evaluation. As a result, on 11/6/2021 at 9:10 a.m., during breakfast, Resident 1 choked on his food, became unresponsive and needed the [MEDICATION(S)] maneuver (emergency procedure for removing foreign object lodged in the airway that is preventing a person from breathing). Resident 1 was transferred to the general acute hospital (GACH) by paramedics where Resident 1 was intubated (medical procedure in which a tube is placed into the windpipe through the mouth or nose), admitted to the Intensive Care Unit (ICU) for acute [CONDITION(S)] (ARDS, life threatening condition where the lungs [a group of organs and tissues for breathing] cannot provide the body with enough oxygen) and septic shock (serious condition when an infection causes extremely severe low blood pressure and organ failure). Findings: A review of the Admission Record indicated the facility readmitted Resident 1 on 10/13/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan initiated on 10/14/2021 indicated Resident 1 had self- care deficit as evidenced by requiring assistance with: Transfers - moderate assistance (requires more help than touching) Gait - moderate assistance Self- feeding - standby assistance (presence of another person within reach) Toileting - moderate assistance. The Care Plan interventions indicated to provide verbal, visual and physical cues as indicated, instruct resident on the use of adaptive equipment when eating, personal hygiene and dressing, avoid rushing resident and give rest periods to conserve energy. A review of the Speech Therapy Evaluation and Plan of Treatment dated 10/18/2021 indicated Resident 1 had impaired memory, confusion, lack of insight and awareness causing problem solving and safety awareness concerns. The evaluation indicated Resident 1 needed speech therapy services which included to enhance cognitive skills (able to receive, interpret and understand messages), promote safety awareness and facilitate immediate memory in order to enhance quality of life by improving ability to participate in meaningful interactions and increase participation with ADLs. A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 10/19/2021 indicated Resident 1 was disoriented to year, month and day, needed supervision (oversight encouragement or cuing) while eating, and limited assistance (resident highly involved with activity staff provide guided maneuvering of limbs or other non-weight bearing assistance) with walking. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene. According to a review of the Physical Medicine and Rehabilitation Medical Consultant's Initial Evaluation dated 10/19/2021, at 7:01 p.m., Resident 1 had some weakness in the left and lower extremities and had mild right side facial droop (facial weakness that may cause one corner of the mouth to droop). The Physician's Initial Evaluation indicated recommendations that included speech language pathology (study of the cause and effects of a disease or injury) and evaluation, and treat as appropriate to assess for dysphagia, speech language disorder, higher cognitive function and to improve safety awareness. A review of the Speech Therapy Discharge Summary with dates of service 10/18 - 10/29/2021, indicated Resident 1 was often confused, forgetful and impulsive. The Summary indicated Resident 1 did not make much progress due to status of cognitive skills with frequent forgetfulness, confusion and anxious behavior/tendencies. The discharge recommendation indicated for frequent monitoring and observation of Resident 1 due to tendencies to escape and wander, resulting in falls, somewhat impulsive behaviors. (The discharge recommendation did not indicate Resident 1 needed cuing and reminders to eat slowly to prevent choking). A review of the Care Plan revised on 10/29/2021 by speech therapy, indicated Resident 1 had impaired cognition secondary to memory, orientation, problem solving/safety awareness deficits. The goal indicated Resident 1 will enhance cognitive skills and prevent further decline in function. The Care Plan interventions indicated Resident 1 to receive speech therapy three times a week for 60 days for cognition-memory, safety awareness, problem solving and orientation. (No other intervention addressing Resident 1's identified behavior of eating rapidly, needs cuing to slow down when eating to prevent choking). A review of the Situation, Background, Appearance, Review and Notify (SBAR) Communication Form, dated 11/6/2021, no time, indicated Resident 1 was eating breakfast when Resident 1 became unresponsive to verbal and touch stimuli. Resident 1 was noted to have food and fluids inside his mouth. The SBAR indicated Resident 1's mouth was emptied of its contents and [MEDICATION(S)] maneuver was performed. Food and liquid were ejected from the mouth and Resident 1 began breathing and gasping. Resident 1 was taken to his room and smaller particles of food and fluids were suctioned. Resident 1 was administered oxygen. The SBAR indicated the paramedics arrived and took over Resident 1's care. A review of the Prehospital Care Report Summary dated 11/6/2021 indicated Resident 1 choked during breakfast, aspirated and became short of breath. The Care Report indicated Resident 1 had audible wheezes (the shrill whistle or coarse rattle heard when the airway is partially blocked) and audible rhonchi (harsh, rattling sounds that resemble snoring) with oxygen saturation of 50% (amount of oxygen in the blood, normal range is 95% to 100%). The paramedics administered [MEDICATION(S)] (medicine to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing and chest tightness) by nebulizer (machine that turns liquid medication into a mist for breathing) with no effect. The Care Report indicated Resident 1 was placed on continuous positive airway pressure ([CONDITION(S)], breathing therapy device that delivers air to a mask worn over the nose and/or mouth to help consistent breathing) and given [MEDICATION(S)] and the oxygen saturation increased to 97%. Resident 1 was transported to GACH 1. According to a review of GACH 1 Emergency (ER) Documentation dated 11/6/2021 at 9:56 a.m., Resident 1 was noted eating breakfast and began to choke. The ER Documentation indicated Resident 1 arrived in respiratory distress (having trouble breathing), diaphoretic (profuse perspiration) and tachypneic (breathing rapidly). Resident 1 was intubated (medical procedure where a tube is placed into the windpipe through the nose or mouth and connected to a breathing machine to help with breathing) and noted to have some debris in airway during intubation. A review of the Cardiology Consult dated 11/10/2021 at 10:35 p.m., indicated Resident 1 was admitted to the intensive care unit (ICU) for acute [CONDITION(S)] (ARDS, life-threatening condition where the lungs [a group of organs and tissues that work together to help a person breathe] cannot provide the body's vital organs with enough oxygen) and septic shock (life threatening condition when the blood pressure drops to a dangerously low level). Resident 1 was placed on four pressors (medication to increase the blood pressure) and started on antibiotics for septic shock due to aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed. During an interview on 7/29/2022, at 9:06 a.m., the Speech Therapist (ST) stated she did not assess or evaluate Resident 1 for dysphagia on 10/18/2021 because she observed right away that Resident 1 did not have swallowing problems and was on regular diet. The ST stated she concentrated on assessing Resident 1's cognitive skills, as Resident 1 was forgetful, eats quickly, needed cuing to eat slowly and at appropriate intervals to prevent choking. The ST stated Resident 1 needed reminders to eat slowly because Resident 1 stuffs his mouth with food and tends to eat rapidly. The ST stated there was no documentation that she communicated her assessment to the care team. During an interview on 7/29/2022 at 9:10 a.m., CNA 1 stated she was feeding another resident when Resident 1 choked while eating breakfast. CNA 1 stated Resident 1 was seated at another table, and she was not within reach of Resident 1. CNA 1 stated her back was towards Resident 1. Resident 1 was eating independently, and no one informed her that Resident 1 needed to have someone beside him while eating. During a telephone interview on 8/2/2022 at 2:25 p.m., CNA 2 stated she was in the dining room (not within reach of Resident 1) feeding another resident when Resident 1 choked. CNA 2 stated she thinks that the potatoes were too big. On 8/5/2022, at 1:03 p.m., during a telephone interview, the physician assistant (PA) stated when the Medical Rehabilitation Consultant Physician (MD Consultant) had a recommendation for dysphagia assessment the therapist has to follow the recommendation. During a telephone interview on 8/11/2022, at 2:16 p.m., the Medical Rehabilitation Consultant Physician (MD Consultant) stated he made the recommendation to evaluate Resident 1 for dysphagia because Resident 1 had history of [CONDITION(S)], subdural hematoma (type of bleed inside the head) and had facial droop. The MD Consultant stated the nursing staff informed him that Resident 1 had occasional cough while eating and he had a concern that Resident 1 had a risk for aspiration. The MD Consultant stated Resident 1's next of kin informed him about the aspiration concern and when he made recommendations, he expected the facility to follow his recommendations. The MD Consultant further stated the facility did not inform him that Resident 1 choked on his food on 11/6/2021. During a telephone interview on 8/12/2022 at 2:28 p.m., the Director of Nursing (DON) stated the dysphagia assessment was important to find out if the resident had difficulty swallowing and if not done in a timely manner the resident was at risk for choking and aspiration. During a telephone interview on 8/15/2022, at 2:29 p.m., the DON stated she was unable to find documentation that Resident 1 tended to eat rapidly and required cuing to eat slowly. The DON stated there should be communication between the rehabilitation department and nursing, and that Resident 1 needed to be monitored and supervised while eating. On 8/16/2022, at 3:48 p.m., during a telephone interview, Resident 1's Next of Kin (NOK) stated when Resident 1 was discharged from the GACH it was difficult for her to watch Resident 1 because Resident 1 used to walk, talk and eat by himself. The NOK stated after Resident 1 choked, he did not talk anymore, did not move and was being fed through a gastrostomy tube (GT, tube inserted through the abdomen directly into the stomach used to give food and medicines). During a telephone interview on 8/17/2022 at 9:46 a.m., the facility's Director of Rehabilitation stated the MD Consultant was notified on 10/29/2021 about Resident 1's behavior of eating rapidly, but no order was given. The Rehab Director stated Resident 1 needed cuing to slow down when eating. During a telephone interview on 8/23/2022 at 2:26 p.m., the MD Consultant stated he was the consultant physician that made the recommendation to evaluate Resident 1 for dysphagia. The MD Consultant stated the facility was supposed to notify the primary physician that Resident 1 needed a dysphagia evaluation based on his evaluation of Resident 1. A review of the facility policy titled, Rehabilitation Services, dated 1/1/2017 indicated Speech Language Therapy shall be provided in an agreement with qualified contracted resources. There shall be written administrative and resident care policies and procedures developed for each rehabilitation services provided. The policy and procedure shall cover consultation, the responsibility of the attending physicians, coordination of services, reporting mechanism to communicate with attending physicians. A review of the facility policy titled, Care Planning, with an effective date of 10/1/2017 indicated licensed nurses and other Interdisciplinary Team (IDT) members will develop preliminary plan to meet the resident's immediate care needs at the time of admission. The IDT shall complete a comprehensive care plan within seven days of completion of the MDS. The IDT members include but not necessarily limited to attending physician, MDS coordinator, licensed nurses who was responsible for the resident and therapists as applicable. Care planning shall include review of clinical issues, discharge planning, coordination of care and management of resources. Care Plans are revised during Resident Assessment Instrument (RAI, resident comprehensive assessment) schedules and as changes in the resident's condition dictates or in preparation for discharge. A review of the facility policy titled, Supporting Activities of Daily Living (ADLs), revised on 3/2018 indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care) b. mobility (transfer and ambulation, including walking) c. elimination (toileting) d. dining (meals and snacks) e. communication (speech, language and any functional communication systems). The policy indicated interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate.

Based on interview and record review, the facility failed to identify and ensure one of two sampled residents (Resident 1), who was diagnosed with an ileus (muscles of the intestines do not allow food to pass through, resulting in a blocked intestine), after complaining of severe abdominal pain, and a distended abdomen (abnormally swollen stomach outward) with loose green stools received care, treatment, and services in accordance with the physician ' s order and policy and procedure by failing to: -Assess and monitor Resident 1 for abdominal distention, abdominal pain, and diarrhea for 72 hours, in accordance with the facility ' s policy. -Develop a care plan to address Resident 1 ' s identified problems of abdominal distention, abdominal pain, diarrhea and ileus. -Immediately notify the physician when Resident 1 had a low oxygen saturation level of 91% on 5/13 and 88% on 5/14/2022 (normal range between 95% to 100%, Oxygen saturations below 90% is very concerning and indicates an emergency). -Follow the physician ' s order to titrate (maintain saturations within a prescribed target range) Resident 1 ' s oxygen saturation (amount oxygen carried in the blood) level to greater than 92% every shift. As a result, on 5/14/2022 at 8:45 a.m., Resident 1 complained of pain rated at 10 out of 10 (the most severe pain), with an oxygen saturation rate below normal at 85%. Resident 1 was transferred to the General Acute Care Hospital (GACH), underwent emergency surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician ' s Order dated 2/7/2022 and May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s care plan for risk of difficulty breathing and pain initiated on 2/8/2022, indicated Resident 1 was at risk for difficulty in breathing related to asthma (airways become narrow and swell making it hard to breathe). The care plan interventions indicated to observe for signs and symptoms of respiratory distress, report to the physician, as needed, increased respirations and decreased pulse oximetry, check oxygen saturation as ordered and administer oxygen as ordered. According to a review of the care plan for pain initiated on 2/8/2022, Resident 1 had a potential for an alteration in comfort related to altered mental status and weakness. The interventions included to observe and assess pain location, duration, frequency, and strength, determine cause of pain and activity that aggravates pain, notify physician if the interventions were unsuccessful or if current complaint was a significant change from resident ' s experience of pain. A review of the quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 5/12/2022 indicated Resident 1 was disoriented to year, month, and day, required supervision (oversight, encouragement, or cuing) when eating and extensive assistance (resident involved in activity, staff provide weight bearing support) with activities of daily living (ADLs). The MDS indicated Resident 1 was not steady moving on and off toilet, was frequently incontinent of bowel and bladder, with an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Situation Background Assessment Response (SBAR) dated 5/12/2022 at 11:30 a.m., indicated Resident 1 had a distended abdomen with a complaint of severe pain when her abdomen was touched, a poor appetite, and had three episodes of loose green stool (bowel movement). The nurse practitioner (NP 1) was notified and gave orders to: -Keep Resident 1 nothing by mouth (NPO) except for medications. -Obtain a stool specimen (fecal sample) for [CONDITION(S)] dificile (C. diff). -Blood tests. -Urinalysis (urine test to diagnose and monitor various illness) and Kidney Ureter Bladder (KUB) test stat (immediately). -Administer 5% Dextrose and 0.45% Sodium Chloride intravenously (IV, a therapy that delivers fluid into veins in the body) at 60 milliliters every hour (ml/hr.) every shift for dehydration for three days. A review of the Radiology Result Report dated 5/12/2022 at 1:38 p.m., indicated Resident 1 had mild to moderate ileus (a temporary and often painful lack of movement in the intestines, a serious condition, if left untreated it can cut off blood supply to the intestines and cause tissue death) with mild increased feces in the colon (long, tube-like organ that carries waste to be expelled from the body). A review of the Progress Notes dated 5/12/2022 at 5:04 p.m., indicated the nurse practitioner (NP 1- registered nurse with advanced training and education to diagnose and prescribe medications) was notified of the KUB result and gave an order to administer Resident 1 a Dulcolax (medicine for constipation) suppository rectally followed by a fleets enema (medicine for constipation) after 45 minutes even if Resident 1 had a bowel movement due to the Dulcolax suppository. The NP also ordered to repeat the KUB on 5/13/2022. According to a review of the progress notes dated 5/12/2022 at 9:59 p.m., Resident 1 ' s abdomen remained distended with discomfort when palpated. The notes indicated Resident 1 was given the Dulcolax suppository and a fleets enema and had loose green stool throughout the shift. A review of the Pain Monitoring sheet dated 5/12/2022 indicated Resident 1 had mild pain during the evening and the night shift. A review of the nurse ' s notes dated 5/13/2022 at 2:07 a.m., indicated Resident 1 denied pain or discomfort. However, there was no documentation that the licensed nurse assessed or monitored Resident 1 ' s abdomen for distention, bowel sounds (sounds made by moving food, fluid and gasses in the intestines heard by using the stethoscope [device used to listen sounds produced within the body]) and tenderness. A review of the nurse ' s notes dated 5/13/2022 at 7:31 a.m. indicated Resident 1 had a pain score of 0. However, there was no documentation the licensed nurse assessed or monitored Resident 1 ' s abdomen for distention, bowel sounds, and tenderness. A review of the progress notes dated 5/13/2022 at 1:47 p.m. indicated Resident 1 had no complaints of pain and had no episodes of diarrhea. However, there was no documentation that the licensed nurse assessed or monitored Resident 1 ' s abdomen for distention, listened for bowel sounds, or palpitated for abdominal tenderness during the afternoon and night shift. A review of the Radiology Results Report dated 5/13/2022 at 1:51 p.m., indicated Resident 1 had prominent nonspecific gas-filled loops of bowel. (This will fall in between the normal bowel and grossly abnormal blocked bowel). A review of the Weights and Vitals Summary indicated on 5/13/2022 at 7:59 p.m. Resident 1 had an oxygen saturation of 91% while on oxygen via nasal cannula (rate of oxygen was not documented). There was no documented evidence the physician was notified or consulted with or that Resident 1 ' s oxygen level was titrated as ordered by the physician. According to a review of the SBAR dated 5/14/2022 at 8:25 a.m., Resident 1 complained of abdominal distention with pain to touch. Resident 1 ' s pain score was rated as 10 out of 10 (most severe pain) and her oxygen saturation level was 84% to 85% on five liters of oxygen via face mask. Resident 1 stated she wanted to go to the hospital. NP 2 was notified and gave an order to transfer Resident 1 to GACH 1. A review of the Prehospital Care Report dated 5/14/2022 indicated Resident 1 had abdominal pain and a distended and rigid abdomen making it difficult to breath and a low oxygen saturation level. A review of the GACH 1 emergency room documentation dated 5/14/2022 at 11:49 a.m., indicated Resident 1 ' s chief complaint was abdominal pain for three days with reports of shortness of breath. On examination, Resident 1 had a distended abdomen, with tenderness and guarding. A review of the GACH 1 Surgical Consultation dated 5/14/2022 at 4:13 p.m., indicated Resident 1 had small liquid bile (yellow-green fluid produced in the liver that helps digest fat) for stool and the Computed tomography (CT scan, a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) of the abdomen indicated a concern for mesenteric ischemia (decreased or blocked blood flow to the intestine). The GACH surgical consultation indicated Resident 1 was then taken to the operating room for emergency surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Surgical Documentation Operative Report dated 5/14/2022 at 11:20 p.m., indicated Resident 1 had an exploratory laparotomy, total colectomy and end [CONDITION(S)] (removal of colon). During an interview on 7/14/2022 at 12:21 p.m., the clinical record was reviewed with Registered Nurse 2 (RNS 2) and RNS 3. RNS 2 and RNS 3 were unable to find a care plan that would address Resident 1 ' s abdominal distention, abdominal pain, diarrhea, or ileus. RNS 2 stated when Resident 1 had a change of condition on 5/12/2022 of abdominal pain, abdominal distention, diarrhea, and ileus a care plan should have been created to help guide the plan of care for Resident 1. RNS 2 stated the care plan would include an alteration in comfort related to ileus. The goal may include Resident 1 would verbalize relief from pain and the interventions would include assess for pain, repositioning, administer Tylenol for pain, monitor for pain, reassess and to notify the physician if the pain was not relieved. During a telephone interview with NP 1 on 7/14/2022 at 4:02 p.m., NP 1 stated she was notified on 5/12/2022 that Resident 1 had KUB that indicated Resident 1 had a mild to moderate ileus with moderate feces in the colon. NP 1 stated she gave orders to administer IV fluid, to keep Resident 1 NPO, and blood tests. NP 1 stated Resident 1 ' s blood test results were acceptable and there was no indication for Resident 1 to go the GACH 1. NP 1 stated if Resident 1 continued to complain of abdominal pain she would have given an order to send Resident 1 to the GACH 1. On 7/18/2022 at 2:40 p.m., during a telephone interview with RNS 1, Resident 1 ' s SBAR dated 5/12/2022 was reviewed with the RNS 1. RNS 1 stated Resident 1 should have been monitored for 72 hours from 5/12/2022 for abdominal pain, abdominal distention, and loose green stool. RN 1 stated the 72- hour monitoring was done to monitor the progress or intervene if there were changes and to notify the physician for the changes. During a telephone interview on 7/18/2022 at 3:30 p.m., Resident 1 ' s clinical record was reviewed with the director of nursing (DON). The DON stated she was unable to find documentation that assessment or monitoring for Resident 1 ' s abdominal distention and abdominal pain for the afternoon and night shift was done on 5/13/2022. The DON stated Resident 1 had a change of condition on 5/12/2022 and Resident 1 should be monitored for 72 hours. The DON further stated when Resident 1 ' s oxygen saturation was 91% on 5/13/2022 at 7:59 p.m. and 88% on 5/14/2022 at 12:02 a.m., interventions should have been implemented, documented and if needed, notify the physician. A review of the facility ' s undated policy titled, Change of Condition Reporting, indicated it was the policy of the facility to identify changes in the resident ' s condition and the resident ' s condition will be communicated to the primary physician and / or / his / her designee for proper management. The policy further indicated: -For life threatening change, the licensed nurse will inform the primary physician and/or his/her designee (alternate physician, on-call physician, nurse practitioner, physician assistant or medical director) of the resident status as soon as possible before, during or after the change of condition. The resident observation and assessment information, nursing intervention, physician contacts and resident ' s responsible party notification will be documented under the progress note section. -For acute medical change, any sudden or serious change in a resident ' s condition manifested by a marked change in physical or psychological status of the resident will be communicated by the licensed nurse to the physician and/or his/her designee with a request for physician visit promptly and/or acute care evaluation. -For routine medical change, unusual signs and symptoms and any deviation from the resident ' s baseline condition will be communicated to the attending physician and or his/her designee promptly. Document resident change of condition and response in the nursing progress notes on 24- hour report and update resident care plan as indicated. The licensed nurse assigned to the resident will continue the observation, assessment, and documentation every shift for at least 72 hours or until condition has stabled. A review of the facility policy titled, Care Plans, dated 2/5/2016 indicated care plans will be initiated upon resident ' s condition change, incident or identified problems. Care plans will include the identified problem, long-term and short-term goals which are measurable and with a timeframe.

Based on observation, interview, and record review, the facility failed to maintain a system to prevent and control the transmission of COVID -19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) infection for three of five sampled residents (Resident 3, Resident 4, and Resident 5) by failing to: -Designate a break room for the staff working in the red zone (space designated for COVID-19 positive residents) away from the resident care area. -Ensure the doors to three resident rooms in the red zone remained closed. -Ensure Restorative Nurse Assistant 1 (RNA 1), Certified Nursing Assistant 1 was wearing eye protection and gown while inside a resident room in the yellow zone (space designated to be used and occupied by residents potentially exposed to COVID-19). As a result, on 6/20, 6/25 and 6/30/2022, Resident 3, 4 and 5 tested COVID-19 positive and on 7/6/2022 there were 16 residents and 11 staff positive for COVID-19, 30 residents moved to the yellow zone and all staff and residents in the facility were at risk of being infected and becoming seriously ill, possibly leading to hospitalization and/or death. Findings: A review of facility's census and color-coded map for the third floor indicated, on 6/3/2022 when the facility physically opened the red zone for the current COVID-19 outbreak, there was one resident in the red zone. Eight residents were in the yellow zone, who were newly admitted residents to the facility, and there were 59 residents in the green zone. A review of Resident 3's Admission Record indicated the facility admitted the resident to the green zone (space designated for residents not exposed to COVID-19) on 4/6/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 4/10/2022 indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required), and required extensive assistance with one person assist for personal hygiene, dressing, bed mobility, transfer, and toilet use. A review of the Situation Background Assessment and Response (SBAR) form dated 6/20/2022 indicated Resident 3 tested positive for COVID-19 and was transferred to the red zone. A review of the progress note dated 6/20/2022 at 11:11 PM indicated Resident 3 had a non-productive cough, chest congestion and fatigue. A review of progress note dated 6/24/2022 at 6:11 PM indicated Resident 3 stated she was feeling depressed because of her medical condition. Resident 3 expressed that she was having trouble falling asleep, felt tired or having little energy, had poor appetite and she was having trouble concentrating on things. The progress note indicated Resident 3 stated she was feeling restless because of her current situation being in the facility and being far from family. During a telephone interview on 7/20/2022 at 12:35 PM, Resident 3's family member (FM) stated he visited Resident 3 on 6/19/2022 and on 6/20/2022. The FM stated he started developing COVD-19 symptoms two days after his visit. A review of Resident 4's Admission Record indicated the facility admitted the resident to the green zone on 4/16/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE] indicated the resident had mildly impaired cognition (some difficulty in new situations only) and required extensive assistance with one person assist for dressing, bed mobility, transfer, and toilet use. A review of Resident 4's SBAR dated 6/25/2022 indicated Resident 4 tested positive for COVID-19 and was transferred to the red zone. A review of progress note dated 6/25/2022 indicated Resident 4 had a non-productive cough and sneezing. The progress note timed at 11:43 PM indicated Resident 4 was experiencing weakness and feeling cold. On 6/27/2022 at 5:11 AM the progress note indicated Resident 4 exhibited COVID-19 symptoms of fatigue, was weak during shift requiring more assistance during shift while using bathroom. A review of Resident 5's Admission Record indicated the facility admitted the resident on 6/19/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's MDS dated [DATE] indicated the resident had severely impaired cognition (never / rarely made decisions) and required extensive assistance with one person assist for toilet use, dressing, bed mobility and transfer. A review of facility's Line Listing (used for infection control surveillance purposes) dated 6/27/2022 indicated 10 in-house residents and seven staff members tested COVID-19 positive. On 6/28/2022 the Line Listing indicated the 11 residents and four additional staff members tested positive for COVID-19. During an observation of the facility's red zone on 6/27/2022, 6/28/2022 and 7/6/2022 at 11:19 AM, at the end of the red zone was an attempt to create a designated staff break room. This makeshift breakroom was deficient in that the barrier was not from floor to ceiling, had no door, and had an open walkway exposing the break room to the red zone. During an interview on 6/27/2022 at 2:45 PM, the facility's Infection Preventionist Nurse (IPN) stated for the facility's current outbreak which started on 6/1/2022, the facility did not designate a separate room as the red zone break room. The IPN stated, The facility separated the end of the third-floor hallway of the red zone with a divider and created a break area. As the number of positive COVID-19 residents increased, the facility increased the number of rooms in the red zone, however, did not make any modifications to the break room / area. A review of the Nurses Progress Note dated 6/28/2022 indicated Resident 5 was transferred to the yellow zone because she was exposed to a COVID-19 positive roommate. During an interview on 6/28/2022 at 1:15 PM, the IPN stated staff members remove their masks and face shields while in the break area and the facility was trying to designate a resident room in the red zone as a break area, so the nurses can take their breaks safely, and entirely separate from the red zone. The IPN stated the facility was in the process of planning to designate an additional room in the red zone as a break room. A review of Resident 5's SBAR dated 6/30/2022 indicated, the resident tested positive for COVID-19 and had fever and on 7/1/2022 Resident 5 was transferred to the red zone. A review of progress note dated 6/30/2022 at 6:40 PM indicated Resident 5 had a temperature of 101.7-degree Fahrenheit and was COVID-19 positive. Resident 5 was screaming and was verbally aggressive to the nurses. It was explained why he needed to be moved but still refused three times and screamed at the nurses. During an observation of the red zone on 7/6/2022 at 11:19 AM, the doors of the three resident rooms, including Resident 5's room, near the makeshift break room were wide open. During a concurrent observation Certified Nurse Assistant 3 (CNA3) was seated in the red zone break area without a mask while eating. The three open resident rooms were noted directly across and beside the makeshift red zone break area. During an interview on 7/6/2022 at 11:21 AM, CNA3 stated it was her first day working in the red zone and she was told to take her break in the designated break area at the end of the red zone hallway. During an interview in the red zone on 7/6/2022 at 11:24 AM, when asked whether an employee sitting in the break area without a mask on could be exposed to COVID-19, IPN 2 did not answer the question. IPN 2 stated the resident room doors in the red zone were required to always be closed to prevent transmission of COVID-19 virus throughout the facility. During an interview with Licensed Vocational Nurse 4 (LVN4) on 7/6/2022 at 11:32 AM, LVN 4 stated he was assigned to work in the red zone today and that he had worked in the yellow zone the day before on 7/5/2022. LVN 4 stated that taking breaks with no mask in the designated red zone break area was not safe when the resident room doors were open. LVN 4 stated resident room doors in the red zone were required to remain closed to prevent the spread of virus in the hallway and break area. During an observation and concurrent interview with RNA 1 on 7/6/2022 at 12:29 PM, RNA 1 was observed not wearing a gown or eye protection while entering a resident room in the yellow zone. RNA 1 was observed standing immediately next to a resident who was eating her lunch. RNA 1 stated it was required to wear a gown and face shield or goggles inside the resident room in the yellow zone. RNA 1 stated she forgot to wear her gown and goggles. During an interview on 7/6/2022 at 1:03 PM, the IPN stated staff were required to wear gown and face covering when entering resident room in the yellow zone. The IPN stated RNA 1 did not follow the facility's policy and procedure for COVID-19 and stated the potential outcome was the spread of infection to residents and staff. During an interview with the facility's Administrator (ADM) and Director of Nursing (DON) on 7/6/2022 at 2:23 PM, the DON stated on 6/28/2022 the facility was planning to designate a room in the red zone as the staff break room. However, an additional resident tested positive and was transferred to the room planned to serve as the break room. The ADM stated, The ideal situation for the red zone break room is a closed-door separate room so staff can safely take their masks off and have their breaks. The facility is trying to designate a room with closed door for the red zone break room if possible. The ADM stated resident room doors in the red zone were to be kept closed to act like a barrier for airborne transmission of the virus into hallways and break room. During a review of the facility Line Listing and a concurrent interview with the IPN on 7/6/2022, the facility had 17 COVID-19 positive residents, 38 residents in the yellow zone, and 11 COVID-19 positive staff. On 7/15/2022, at 11:43 AM., during an observation and interview, CNA 1A was observed on the second floor of the hallway without a face shield or a N95 respirator mask. CNA 1A stated she was in a hurry to clock in after returning from her break and did not put on a N95 respirator mask or a face shield. CNA 1A stated she was informed of the requirement to wear a N95 mask and face shield while in the facility and in resident care areas. CNA 1 confirmed and stated she failed to follow facility's personal protective equipment requirement for the use of N95 mask and face shield to protect herself, other staff and residents from the spread of COVID-19. During a telephone interview on 7/21/2022 at 1:26 PM, CNA5 stated she worked both in the red and the yellow zones on the third floor. CNA5 stated, At the beginning of the COVID-19 outbreak in the facility, staff assigned to the red zone did not have a room as their break area. The facility separated the end of the red zone hallway as a break area. We used to take off our masks and eat in that area. We did not even have a microwave to heat up our food and we had to go downstairs to use the first-floor bathroom. I voiced my complaints multiple times, but nothing happened. It was not safe at all to take our masks off to take a break, but we had no choice. We needed to provide financially for our families. Eventually no nurses wanted to work in the red zone anymore and the facility placed a microwave for us. CNA5 stated, A lot of nurses and residents tested positive. A review of the Nursing Staffing Assignment and Sign in sheet indicated CNA5 was assigned to the red zone on 6/1/2022. The staffing assignment sheet indicated CNA5 was assigned to Resident 4 on 6/8, 6/9, 6/10, 6/13, 6/14, 6/15, 6/21 and 6/22 in the green zone. CNA5 was assigned to the red zone on 6/25, 6/26, 6/27 and 6/29 after Resident 4 contracted COVID-19. On 7/29/2022, at 1:18 PM., during an observation and interview, Housekeeper (HK) 1 was observed in the yellow zone Room A without an isolation gown, gloves, or face shield. HK1 stated Room A was a droplet isolation room for COVID-19 and she was cleaning the room and throwing out the trash. HK1 stated she failed to wear the isolation gown, gloves, and face shield. On 7/29/2022, at 1:48 PM., during an interview, the IPN stated all facility staff were required to use a N95 respirator mask and face shield while in the facility and use isolation gown and gloves and face shield when entering droplet isolation rooms. The IPN stated CNA 1 and HK 1 failed to follow facility's policy and procedures for infection control and PPE by not using a N95 respirator mask and face shield while in the facility and isolation gown, gloves, and face shield while in the droplet isolation Room A. The IPN stated the potential outcome could lead to the spread of infection including COVID-19 to all residents and staff. During a telephone interview on 8/15/2022 at 10:17 AM, the IPN stated all residents in the red zone, except for COVID-19 positive admissions, acquired COVID -19 in the facility and at 10:30 AM, the IP stated the facility currently had 28 COVID-19 positive residents. The IPN stated facility staff who were working in the red zone, were also working in the yellow zone or green zone the following day and this pattern of shifts and working in various zones may be the reason for a staff member to transmit COVID -19 to another resident. The IPN stated, We try to avoid assigning staff to different zones and for staff who work double shifts, we try to assign the staff to the same zone in order to avoid exposing residents in other zones to COVID -19. An attempt to conduct an interview with the facility's Medical Director (MD) was made on 8/15/2022 at 9:58 AM to and 12:43 PM, to inquire if the MD was made aware of the outbreak and what was done. Another attempt was made on 8/16/2022 at 9:45 AM and 3:06 PM. The MD did not respond. A review of Center for Disease Control and Prevention guideline titled, Nursing Home COVID-19 Infection Control Assessment And Response (ICAR) Tool Facilitator Guide, indicated while it was generally safest to implement universal use of source control for everyone in a healthcare setting, the following allowances could be considered for individuals who are up to date with all recommended COVID-19 vaccine doses in healthcare facilities located in counties with low to moderate community transmission. Health Care Personnel (HCP) who are up to date with all recommended COVID-19 vaccine doses should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors). https://www.cdc.gov/infectioncontrol/pdf/icar/nursing-home-icar-facilitator-guide-2022-508.pdf A review of facility's policy and procedure titled, Infection Prevention and Control: Novel Coronavirus (COVID-19), revised on 10/30/2020 indicated in the yellow zone, staff were required to wear goggles/face shields when providing care within six feet of residents. In the yellow zone gowns should be worn with only single patient. COVID-19 positive residents (asymptomatic or symptomatic) will be placed in a separate area (building, unit, or wing) of the facility (Red Zone) and have dedicated staff who do not provide care for residents in other cohorts and should have separate break rooms and restrooms if possible. In the red zone, staff only respite area away from resident care area staff storage, breaks, etc. separate from other staff working in the yellow and green zones. A review of the facility's policy and procedures titled, COVID-19 Routine Diagnostics or Surveillance Testing and COVID-19 Response Testing Policy, revised 1/6/2022, indicated all staff, regardless of vaccination status, must wear a medical grade surgical/procedure mask or N95 respirator for universal source control at all times while they are in the facility, or in accordance with current federal, state, or local health department guidance. A review of the facility's policy and procedures titled, COVID-19 General Guidelines, dated 1/6/2022, indicated all staff members, must don (put on) and doff (remove) gowns each resident encounter with symptomatic residents and/or asymptomatic, recently exposed or in accordance with the current federal, state or local health department and guidance.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was a high fall risk, unsteady on feet, and required one-person physical assistance with walking, was provided a safe environment and supervision to prevent falls, as indicated in the resident's care plans and the comprehensive assessment. As a result: - On 7/20/2021, after Resident 1 was walking in the hallway without assistance, had an unwitnessed fall in her room, required transfer to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with a left knee fracture (break of a bone) and a laceration (cut) of the left eyelid. - On 12/10/2021, Resident 1 sustained a fall requiring transfer to GACH 2 where she was diagnosed with five rib fractures, a clavicle (bone between the ribcage and shoulder blade that connects the arm to the body) fracture, and pneumothorax (condition occurs when air leaks into the space between the lungs and chest wall). Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 12/1/2015 with last re-admitted d 2/15/2021. Resident 1's diagnoses included [CONDITION(S)] (a condition in which the bones become fragile, thin and breaks easily), unsteadiness on feet, and muscle weakness. A review of Resident 1's Care Plan developed on 4/22/2021 for the resident's high risk for recurrent falls and injury related to [CONDITION(S)], [CONDITION(S)] (condition that causes joints to become painful and stiff) as evidenced by impaired physical mobility, poor balance, unsteady gait (manner of walking), muscle weakness, cognition (ability to comprehend and reason) and communication deficit. The goal was for Resident 1 to be able to follow safe technique when performing functional mobility and activities of daily living (ADLs, such as eating, dressing, transferring, walking, bathing, and personal hygiene) to prevent falls and injury. The interventions included keeping room and common areas free from clutter, assisting the resident with transfer and walking. A review of Resident 1's Care Plan developed on 4/30/2021 for the resident's risk of joint swelling and pain, pathological fracture (a break of a bone that occurs without trauma and is caused by a preexistent bone condition) and spontaneous fracture (occur in seemingly normal bone with no apparent [MEDICATION(S)]-force trauma) related to [CONDITION(S)] and [CONDITION(S)] as evidenced by decreased bone density and impaired physical mobility. The goal was for Resident 1 to remain free of injuries or complications related to [CONDITION(S)]. The interventions included observing resident for falls, educating resident, family/caregivers on safety measures needed to reduce risk of falls (the specific safety measures were not included). A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-screening tool) dated 5/11/2021, indicated the resident had severely impaired cognition (unable to comprehend, make needs known, or make decision a very hard time remembering things, making decisions, concentrating, or learning). Resident 1 needed one-person physical assist with bed mobility, transfer, and ambulation (walking), dressing, toilet use, personal hygiene, and bathing. Resident 1 was not steady (balanced) and only able to stabilize with staff assistance when moving from seated to standing position, when walking with assistive device, when turning around and facing the opposite direction while walking, when moving on and off the toilet and transfer between bed and chair or wheelchair. According to a review of Resident 1's Fall Risk assessment dated [DATE], the resident was a high fall risk, had history of falls, used an ambulatory (walking) aid such as wheelchair or walker, exhibited impaired gait, and overestimated or forgot limits. A review of Resident 1's Physical Therapy (PT) Discharge Summary dated 6/1/2021 indicated Resident 1 was a high risk for fall and was discharged from PT because the resident had achieved her highest practical level. Resident 1 was able to walk 100 feet using her front wheeled walker (FWW) with contact guard assist (the assisting person has one or two hands on resident's body but provides no other assistance to perform the functional mobility). A review of Resident 1's Change of Condition (COC) form, dated 7/20/2021 timed at 3:30 p.m., indicated the resident tripped on her slipper and fell on her left side. Ice packs were applied to both knees, the laceration (cut) on the eyebrow was cleaned and covered and pain medicine was given. A review of Resident 1's nursing Progress Notes, dated 7/20/2021 timed at 3:40 p.m., indicated at 3 p.m. Resident 1 was in bed reading the newspaper. At 3:30 p.m., Resident 1 was seen walking in the hallway with her walker. At 3:40 p.m., Resident 1 was noted on the floor lying on her side. Resident 1 sustained a laceration on her left eyebrow and complained of pain on both knees. Resident 1's primary physician was notified and gave order to transfer the resident to GACH 1 for evaluation. A review of GACH 1 X-ray result of Resident 1's left knee dated 7/20/2021 indicated the resident had a fracture of the patella (a break of the bone located on the front of the knee joint) with moderate lipohemarthrosis (collection of fat and fluid [blood] within the joint usually following trauma). According to a review of GACH 1 Discharge Summary for Resident 1, dated 7/21/2021, at 1:55 a.m., the resident's left knee was placed in an immobilizer (used to prevent, restrict, or reduce normal movement in the body, a limb, or a joint) to help heal the patella. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 required extensive assistance with one-person physical assist with ambulation, was not steady for walking, only able to stabilize with staff assistance, and used a walker / wheelchair when walking with assistive device. A review of Resident 1's Post Fall Care Plan dated 8/19/2021 indicated the resident fell at 2:44 p.m. with no injury. The approaches included frequent visual monitoring, room change near the Nursing Station, involve family for 1:1 supervision (one staff with the resident at all times) with caregiver, apply clip alarm to alert staff, and remind resident not to get up unassisted. A review of Resident 1's Post Fall Care Plan dated 8/26/2021 indicated Resident 1 had an actual fall at 4:35 p.m. with no injury. The approaches included frequent visual monitoring, medication regimen review, clip alarm was changed to pad alarm (monitor activity of sitting resident and that emits an alarm when there is reduction of pressure). A review of Resident 1's Post Fall Care Plan dated 9/30/2021 indicated Resident 1 had actual fall at 7:40 p.m. with no injury, related to unsteady gait, noncompliance did not call for assistance, and perceived self as independent. A review of Resident 1's Post Fall Care Plan dated 10/10/2021 indicated Resident 1 had actual fall at 3:45 p.m. with no injury, related to poor safety judgment, cognitive impairment, does not remember how she ended up on the floor. A review of Resident 1's Post Fall Care Plan dated 10/20/2021 indicated Resident 1 had an actual fall at 4:45 p.m. with no injury, related to balance deficit/shuffling, noncompliance did not call for assistance/use call light, perceived self as independent, perceived self as able to perform task, and ambulated to the restroom. According to a review of Resident 1's Post Fall Care Plan dated of 11/5/2021, Resident 1 had an actual fall at 7:47 a.m. with no injury, related to noncompliance did not call for assistance, perceived self as independent. A review of Resident 1's nursing Progress Notes dated 12/10/2021 timed at 3:55 p.m., indicated a loud thump was heard from Resident 1's room. Resident 1 was found lying on her left side next to the bed and wheelchair. Resident 1 was noted with skin discoloration to left elbow and left temple (located on the side of the head behind the eye between the forehead and the ear), had limited range of motion to left shoulder and pain on left side of chest. The primary physician was notified and ordered STAT (immediately) X-ray of the upper chest and clavicle. A review of Resident 1's X-ray report dated 12/10/2021 indicated the clavicle and left shoulder show no fracture or dislocation. A review of Resident 1's nursing Progress Notes dated 12/11/2021 at 11:10 a.m. indicated Resident 1 complained of chest pain. The primary physician was notified and ordered to send Resident 1 to GACH 2 via paramedics (trained to give emergency medical care to people who are injured or ill). A review of GACH 2 History and Physical dated 12/11/2021 at 10:42 a.m. indicated Resident 1 had left eye hematoma (resulted from injury that caused the blood to collect and pool under the skin), left upper chest crepitus (air under the skin that produces unusual crackling sound as the gas is pushed through the tissue), left shoulder /lateral neck/scapular (relating to shoulder blade) ecchymosis (discoloration of the skin that resulted from bleeding underneath the skin) five centimeters (cm) by six cm, left elbow with abrasion (open wound caused by the skin rubbing against a rough surface) and ecchymosis, and left knee ecchymosis. A review of the Orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) Inpatient Progress Notes, dated 12/11/2021 indicated computed tomography scan (CT, combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images [slices]) included the following injuries: 1. Acute minimally displaced fracture of the left third, sixth and seventh ribs and left segmental rib fractures of the fourth and fifth ribs 2. left pulmonary contusion 3. left pneumothorax 4. left chest wall subcutaneous [CONDITION(S)] 2. Minimally displaced left distal clavicular fracture 6. likely hemothorax 7. chronic pelvic fractures A review of Resident 1's Admission/Readmission Screen indicated Resident 1 was readmitted to the facility on [DATE]. During a telephone interview on 1/26/2022 at 8:54 a.m., the Director of Nursing (DON) stated Resident 1 had multiple injuries due to previous falls and no surgical interventions were recommended because of the diagnosis of [CONDITION(S)]. The DON stated the facility tried everything: frequent monitoring, urinalysis, use of pad alarms for the wheelchair, bed and floor mat, and ran out of options to prevent Resident 1 from falling. During a telephone interview on 1/28/2022 at 4:07 p.m., the DON stated it would be good if Resident 1 had a 24-hour sitter so the sitter could catch Resident 1 right away before she falls. The DON stated Resident 1's family did not want to pay or share the cost of hiring a 1:1 sitter and the facility did not have enough staff to provide Resident 1 with a 1:1 sitter. During a telephone interview on 1/31/2021 at 1:16 p.m., Certified Nursing Assistant 1 (CNA 1) stated when she heard the alarm, she would go immediately to Resident 1's room. CNA 1 stated, CNA's have other residents to take care of and when the alarm is triggered, sometimes they can't hear the alarm, it is too late, and Resident 1 had already fallen. During a telephone interview on 1/31/2022, at 3:47 p.m., the Registered Nurse Supervisor (RNS) stated the facility could not provide 1:1 staff to Resident 1. The RNS stated, The alarm may work to prevent falls but sometimes when the pad/chair alarms are triggered by the time the nurse responds to the alarm the resident may already have fallen. During a telephone interview on 2/1/2022 at 5:09 p.m., Resident 1's next of kin (NOK) stated the staff informed the NOK that Resident 1 needed 1:1 supervision but they did not have staff to provide 1:1 supervision and asked for the family to visit to monitor Resident 1. On 2/10/2022, at 8:26 a.m., during an interview with the RNS and a concurrent review of Resident 1's nursing Progress Notes and MDS dated [DATE], the RNS stated and confirmed that on 7/20/2021 Resident 1 was seen by staff walking in the hallway with her FWW and without staff assist. Ten minutes later Resident 1 had an unwitnessed fall and was found on the floor in her room. The RNS stated the MDS indicated Resident 1 needed extensive assistance (resident involved in activity, staff provide weight-bearing support while walking in the room or corridor). On 2/10/2022 at 8:52 a.m., during an interview, the physical therapist stated Resident 1 had physical therapy from 4/23/2021 to 6/1/2021. Resident 1 was not supposed to walk without assistance. Someone was supposed to stay close to Resident 1 while walking in case Resident 1 lost her balance, staff was there to assist. A review of the facility policy titled, Safety and Supervision of Residents, revised on 7/2017 indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The facility's individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive device. The systems approach to safety included: -The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual risk factors and then adjusts interventions accordingly. -Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. -The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by a virus and transmitted from person to person) in accordance with the facility's policy and their Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for three residents (Resident 1, Resident 2, and Resident 3) out of a total of 110 residents in the yellow zone by failing to: a. Ensure a thorough screening process for staff and for visitors entering and exiting the facility, including asking for signs and symptoms of COVID-19, history of travel and any contact with positive COVID-19 persons. b.Ensure Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA1) wore an N95 mask (a particulate-filtering face piece, respirator that meets the U.S. National Institute for occupational safety and Health [NIOSH] and filters at least 95% of airborne particles), while in the yellow zone (space designated to be used and occupied by residents potentially exposed to COVID-19) for two of two facility staff. censure CNA 2 entered Resident 2`s room in the yellow zone (area with residents who are suspected of COVID-19) with a face shield or face protection. d. Ensure Housekeeper 1 (HK 1) started cleaning/disinfecting in the least contaminated area first before going to the most contaminated areas such as the red zone (where COVID-19 positive residents are placed). e. Ensure CNA 4 doffed (removed) required Personal Protective Equipment (PPE - protective clothing, goggles, head/shoe covers, mask, gown, gloves or other garments or equipment designed to protect the wearer's body from infection) upon exiting the red zone where seven COVID-19 residents were located. f.Ensure a designated break room for facility staff assigned to the red zone in the C-wing (another area of the facility designated for COVID-19 residents). These deficient practices had the potential to result in the spread of COVID-19, placing 286 residents in the facility and the staff at risk of infection with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 8/5/2021 at 1:23 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Director of Nursing (DON) and the Infection Preventionist (IP) for the facility's failure to implement measures to prevent the transmission of COVID-19 infection, which threatened the health and safety of the residents and staff. On 8/6/2021 at 1:45 p.m., the IJ was lifted after the facility submitted an acceptable Plan of Action (POA). The survey team verified and confirmed on-site the implementation of the POA through observation, interview, and record review. The IJ situation was removed in the presence of the Administrator, the DON, and the Infection Preventionist. The accepted POA included the following actions: a. The screening personnel was given a 1:1 (one to one) inservice / training and reeducation by director of staff development on 8/5/2021 regarding purpose and importance of inquiring visitors, staff, on possible exposure to persons. b. LVN 1 and CNA 1 were given 1:1 inservice / training reeducation by director of staff development on 8/5/2021 regarding purpose and importance wearing proper PPE's, emphasis on N95 mask when in yellow zone, and providing care in the yellow zone to prevent the spread of infection such as COVID-19. c. CNA 2 was given a 1:1 inservice / training and reeducation by director of staff development on 8/5/2021 regarding purpose and importance of removing contaminated PPE prior to exiting the yellow zone to prevent spread of infection associated with COVID-19. d. Housekeeper 1 (HK 1) was given a 1:1 inservice / training and reeducation by director of staff development on 8/5/2021 regarding purpose and process of cleaning / disinfecting area by cleaning the least contaminated area first then going to most contaminated area such as red zone. e. CNA 4 was given a 1:1 inservice / training and reeducation by director of staff development on 8/5/2021 regarding purpose and importance of removing contaminated PPE prior to exiting the red zone. f. A room in the C wing was designated as the dedicated break room for facility staff assigned to the red zone in the C-wing. Findings: A review of the facility`s census during onsite visits conducted on 8/5/2021 indicated the facility had 286 residents in-house, 110 residents in the yellow zone and 7 residents in the red zone. a. On 8/5/2021 at 9:39 a.m., during an observation, upon entrance to the facility, the Front Desk Receptionist (FDR) did not verbally ask the surveillance questions regarding COVID-19 signs and symptoms to the surveyor. Upon inquiry she pointed to the appropriate screening form for visitors to complete. During a concurrent observation, at 9:40 a.m., the FDR did not verbally ask the surveillance questions regarding COVID-19 signs and symptoms to a facility staff person entering the facility. During an interview on 8/10/2021 at 10:59 a.m., the FDR stated she was required to ask surveillance questions regarding COVID-19 signs and symptoms from each staff/visitor/vendor when they entered the facility. The FDR stated the consequence of not asking surveillance questions and allowing staff / visitors / vendors to complete the form would be potential for having false information. During an interview on 8/5/2021 at 11:50 a.m., the IP stated the Front Desk Receptionist was required to ask the surveillance questions regarding COVID-19 signs and symptoms from each staff, visitor, and vendors upon entry of the facility to reduce risk of infection. The IP stated there was a designated front desk receptionist available for all three shifts. IP stated if staff, visitors, and vendors complete the screening log there was a possibility to not tell the truth as opposed to being questioned by the receptionist directly. A review of facility's policy and procedures titled, Lobby-COVID-19 Temperature Check and Screening Duties, updated on 6/1/2021 indicated all staff, vendors, visitors, Emergency Medical Technicians and patients/residents should be screened twice a day (when arriving for the shift, and at the end of the shift) by: taking the temperature to be sure they do not have fever. The policy indicated the screener was to ask staff / vendor / visitor etc. the questions and complete the screening for questionnaire. According to a review of the facility's Mitigation Plan, revised 1/22/2021, it was policy for the facility to protect its residents, staff, and others who may be in the facility from harm during emergency events. The Mitigation Plan indicated the IP was responsible for overseeing the screening of all individuals entering the facility and will maintain records that all screening occurred in accordance with All Facilities Letter 20-22.4 b. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1 on 10/8/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 7/17/2021 indicated Resident 1 had severely impaired cognition and required extensive assistance with one person assist with activities of daily living (ADLs -personal hygiene, dressing, and toilet use) and two persons assist for transfer. On 8/5/2021 at 9:57 a.m., during an observation in the yellow zone (where Resident 1 was located), LVN 1 was observed wearing a surgical mask and a face shield in front of the medication cart in the hallway. During a concurrent interview, LVN 1 stated, the required PPE in the yellow zone was an N95 mask as opposed to a surgical mask. LVN 1 stated she forgot to donn (put on) the N95 mask. On 8/5/2021 at 10:03 a.m., during an observation in the yellow zone, CNA 1 was observed entering Resident 1's room, wearing a surgical mask and face shield. During a concurrent interview, CNA 1 stated she forgotten to wear her N95 mask. CNA 1 stated the required PPE in the yellow zone was an N95 mask. During an interview on 8/5/2021 at 10:05 a.m., the IP stated staff should always wear an N95 mask and face shield while in the yellow zone including hallways and, in the resident rooms. The IP stated LVN 1 and CNA1 did not follow the facility`s COVID-19 policy and procedure. The IP stated the potential outcome was the spread of infection to residents and staff. A review of the facility's Mitigation Plan dated 1/22/2021 indicated all staff were provided an N95 mask to wear while on their shift and performing direct care. c. A review of Resident 2`s Admission Record (Face Sheet) indicated the facility admitted Resident 2 on 4/3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE] indicated Resident 2 had moderately impaired cognition and required extensive assistance with one person assist with personal hygiene, dressing, and toilet use and two persons assist for bed mobility and transfer. On 8/5/2021 at 10:12 a.m., during an observation in the yellow zone, CNA 2 was observed entering Resident 2's room, wearing N95 mask but no face shield. During a concurrent interview, CNA 2 stated she was required to always wear face shield or goggles with the N95 mask in the yellow zone. During an interview on 8/5/2021 at 10:14 a.m., the IP stated staff should wear a face shield in the hallways and resident rooms in the yellow zone. The IP stated CNA 2 did not follow facility's COVID-19 policy and procedure and the potential outcome was the spread of infection to residents and staff. d. A review of Resident 3`s Admission Record (Face Sheet) indicated , the facility admitted Resident 3 on 5/18/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS dated [DATE] indicated Resident 3 had moderately impaired cognition and required supervision with ADLs. On 8/5/2021 at 10:40 a.m., during an observation in the yellow zone at the C-wing , Housekeeper (HK1) was observed cleaning Resident 3's room, a wearing N95 mask, face shield, gown, and gloves. On 8/5/2021 at 10:45 a.m., during an interview HK1 stated she started her cleaning/disinfecting in the red zone and then proceeded to clean/disinfect the yellow zone. Upon inquiry as to why HK1 began cleaning in the red zone and then the yellow zone, HK1 replied, They did not tell me anything as far as which zone to start first. During an interview on 8/5/2021 at 11 a.m., the Environmental Service Manager (EVSM), stated the housekeepers were required to start cleaning the clean area first before going to contaminated area(s) such as red zone. The EVSM stated HK1 did not follow the facility's policy and procedure on infection control and COVID-19 and that the potential outcome was the spread of infection to all residents and staff. On 8/5/2021 at 11:10 a.m., during an interview the IP stated and confirmed the cleaning process should start from the yellow zone and end in the red zone, and staff were required to exit the facility upon completion of cleaning the red zone. The IP further stated if any staff enters the red zone, they must then exit the facility. IP stated HK1's action can potentially result in the spread of infection that could lead to serious harm to residents and staff. On 8/5/2021 at 11:25 a.m., during an interview with HK1, the EVSM and the IP, HK 1 stated she made a mistake and acknowledged she should have cleaned the yellow zone first and then moved to cleaning the red zone. The EVSM stated to HK1 to change her clothes and go home for the remainder of the day. A review of facility`s policy and procedure titled, Cleaning Process-Resident's room, revised on 10/30/2020 indicated cleaning shall include the 7-step process: Proceed from Cleaner to Dirtier to avoid spreading dirt or microorganisms. e/f. During an observation on 8/5/2021 at 11:10 a.m., CNA 4 exited the red zone plastic barrier (where seven residents with COVID-19 were located) while donned in full PPE. CNA 4 was observed doffing in the yellow zone hallway and started drinking water. During a concurrent interview, CNA 4 stated, I forgot to doff prior to exit. CNA 4 acknowledged, she was required to doff prior to exiting the red zone. CNA 4 stated she did not follow the facility's policy and procedure regarding COVID-19 and that there was no breakroom for her to drink water in the red zone. CNA 4 stated for her lunch break she was instructed to go outside the facility to have lunch. On 8/5/2021 at 11:13 a.m., during an interview the IP stated staff were required to doff PPE prior to exiting the red zone. The IP stated the facility recently designated a yellow and red zone in the C wing and this may be why the staff was confused. The IP stated CNA 4 did not follow the facility`s COVID-19 policy and procedure and did not doff prior to exiting the red zone. The IP stated the potential outcome was the spread of infection to residents and staff. A review of facility`s policy and procedure revised on 10/30/2021 indicated while in the yellow zone, N95 respirators (masks) will be worn for the duration of shift and doffed when contaminated. The policy indicated goggles/face shields should be worn when providing care within 6 feet of a resident. A review of facility`s Mitigation Plan titled, Personal Protective Equipment, revised on 1/22/2021 indicated, all staff will wear recommended PPE while in the building per current California Department of Public Health (CDPH) PPE guidance.

Based on interview and record review, the facility failed to identify and ensure one of three sampled residents (Resident 1), who was at risk for cardiac (heart) distress related to [CONDITION(S)] (CHF, a chronic condition in which the heart does not pump blood as well as it should) and had diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), received care and services in accordance with professional standards of practice and the comprehensive person centered care plan by failing to: 1.Recognize and assess Resident 1's change of condition related to the resident's CHF when the resident's systolic blood pressure (top number of the blood pressure measurement and is the maximum pressure your heart exerts while beating) went below 110 millimeters of mercury (mm/hg, a unit of pressure) on [DATE] and [DATE] and had a loss of appetite by refusing meals on [DATE]. 2.Implement Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Implement Resident 1's care plan for at risk for cardiac distress related to CHF, dated [DATE], to notify the physician when the resident was experiencing shortness of breath. Licensed Vocational Nurse 2 (LVN 2) stated that the resident's oxygen saturation levels (amount of oxygen in the blood, normal oxygen saturation level 95 to 100 percent [%]) were going down around from 90% to 85% on [DATE]. 4. Implement Resident 1's care plan, for special care related to oxygen use to document the effectiveness of oxygen therapy. Resident 1 had CHF and required oxygen for shortness of breath. 5. Prevent delay of treatment by communicating to the physician of Resident 1's changes in condition related to the resident's showing signs and symptoms of exacerbating CHF, which are decreasing blood pressure, initiation of oxygen, and loss of appetite on [DATE] and [DATE] for proper management in accordance with the facility's policy and procedure, titled, Change of Condition Reporting. 6. Obtain Resident 1's blood sugar level when the resident was found unresponsive on [DATE] at 6:10 AM. As a result, on [DATE], Resident 1 was found with pale skin, oxygen at two liters via nasal canula, unresponsive to stimuli, not breathing, pulse not palpable, and unable to obtain vital signs. Resident 1 died at the skilled facility on [DATE] at 6:35 AM. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Special Care related to Oxygen Use care plan dated [DATE], indicated the goal for Resident 1 was to maintain a patent airway by observing Resident 1 for signs and symptoms of respiratory distress and report to the primary doctor (PMD) as needed. The care plan interventions indicated to administer oxygen as ordered, give medications as ordered by PMD, and to monitor and document side effects and effectiveness. According to a review of Resident 1's At Risk for Cardiac Distress related to chest pain and CHF care plan, dated [DATE], the goal for Resident 1 was to be free of signs and symptoms of cardiac distress. The care plan interventions indicated to observe and notify MD when resident was experiencing change in the level of consciousness, shortness of breath, chest pain, restlessness, weakness, monitor meal intake, administer prescribed oxygen and monitor blood pressure as indicated in the medication parameter. A review of Resident 1's care plan for At Risk for [CONDITION(S)] and [CONDITION(S)] related to diabetes dated [DATE], indicated interventions to observe/ report any signs and symptoms of [CONDITION(S)] such as faintness, headache, trembling, difficulty awakening, and to notify the primary doctor promptly; monitor oral intake; report any meal refusal, check blood sugar as ordered and notify MD if sugar was less than 70 or greater than 400. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a review of the Minimum Data Set (MDS-a standardized screening and care assessment tool), dated [DATE], Resident 1 was not receiving oxygen therapy as respiratory treatment. The MDS indicated Resident 1's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 also received insulin (a medication used to move the sugar from the blood into other body tissues where it is used for energy. Once the sugar moves into the cells of the body tissues, the blood sugar level should go back to normal) for six days since admission. A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Weights and Vitals summary form, dated [DATE] at 9:48 PM, indicated Resident 1 received oxygen via nasal cannula. Further review of the form indicated there was no documentation to indicate the amount or liters of oxygen per minute Resident 1 received, the oxygen saturation level, resident condition, any distress, or if oxygen was effective. According to a review of Resident 1's Weights and Vitals summary form, dated [DATE] at 8:01 PM and at 8:16 PM, Resident 1 received oxygen via nasal cannula. Further review of the form indicated there was no documentation to indicate the flow rate or liters of oxygen per minute Resident 1 received, the resident's oxygen saturation level, Resident 1's condition, any distress, or if oxygen administered was effective. A review of Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Weights and Vitals summary form, dated [DATE], indicated the following blood pressure: 7:32 AM, BP ,d+[DATE] 8:03 AM, BP ,d+[DATE] 3:15 PM, BP ,d+[DATE] 5:29 PM, BP ,d+[DATE] 8:15 PM, BP ,d+[DATE] According to a review of the facility's documentation survey report, dated [DATE], Resident 1 had episodes of meal refusals and had zero - 25 % meal intake throughout the day. There was no documentation regarding notifying the primary care physician of Resident 1's change in condition (meal refusal) or of the assigned certified nursing assistants reporting Resident 1's meal refusal to the charge nurse. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Progress Notes dated [DATE] at 11:30 PM, indicated Resident 1 was received by the incoming nurse with oxygen at 2 liters per minute via nasal cannula. There was no documentation regarding notifying the doctor of the resident's systolic blood pressure below 110 mg/hg on [DATE] or that the resident was started on oxygen, the resident's oxygen saturation level, if the resident was in respiratory distress, or if the oxygen administered was effective. A review of Resident 1's Progress Notes on [DATE] at 11:42 PM, indicated Resident 1 received oxygen at 2 liters with oxygen saturation at 97%. There was no documentation for notifying the doctor the resident was started on oxygen. A review of the Progress Notes dated [DATE] at 6:10 AM, indicated LVN 1 documented Resident 1 was pale with oxygen at 2 liters via nasal canula. The progress note indicated Resident 1 was unresponsive to stimuli, not breathing, pulse not palpable, and the staff was unable to obtain vital signs (body temperature, pulse rate, respiration rate, and blood pressure). A review of Resident 1's medical record, indicated there was no documentation a licensed nurse checked Resident 1's blood sugar when Resident 1 was found unresponsive on [DATE] at 6:10 AM. According to the article, dated [DATE] and titled, Low blood sugar, by [MEDICATION(S)] Plus, a service of the National Library of Medicine (NLM), the world's largest medical library, which is part of the National Institutes of Health (NIH), at https://medlineplus.gov/ency/article/ 6.htm, severe low blood sugar is a medical emergency. Severe low blood sugar that causes you to become unconscious is called hypoglycemic or insulin shock. A review of Resident 1's Death Certificate Worksheet, signed by the attending physician (MD), dated [DATE], indicated Resident 1 died on [DATE] at 6:35 AM, due to cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing and consciousness), [CONDITION(S)] and atherosclerosis (disease of blood vessels that hardens the arteries). During an interview with the night shift Licensed Vocational Nurse 1 (LVN1) on [DATE] at 6:54 AM, LVN 1 stated she was not aware of the reason Resident 1 had oxygen, since it was her first night back (on [DATE]), but it was endorsed by the outgoing nurse. LVN 1 stated He (Resident 1) was already on oxygen so we started the CPR (cardiopulmonary resuscitation-a lifesaving technique when breathing or heart beat has stopped) as soon as possible (on [DATE]) and the rest of the nursing staff assisted until the paramedics (a health care professional whose primary role is to provide advance emergency medical care) came in and took over. During an interview with the Licensed Vocational Nurse 2 (LVN2) on [DATE] at 10:58 AM, LVN 2 stated he administered the oxygen via nasal cannula to Resident 1 on [DATE] since the resident's oxygen saturation levels were going down around 90%-85%. LVN 2 stated he was supposed to document in the MAR (the oxygen saturation level and the initiation of the oxygen administration) and notify the MD regarding the administered oxygen to Resident 1, but he did not. During an interview with LVN 2, on [DATE] at 1:43 PM, LVN 2 stated Resident 1 had episodes of lowered blood pressure for the past days that he had worked, and added if there was no documentation, he must not have notified the doctor. During an interview on [DATE] at 5:58 PM Certified Nursing Assistant 2 (CNA2) stated that Resident 1 had an oxygen at 2 liters via nasal cannula during the whole morning shift of [DATE]. CNA2 stated that Resident 1 was not eating on [DATE] morning shift and, He seemed very weak. CNA 2 stated he notified someone but forgot who it was and did not document his report. On [DATE] at 2:18 PM, during an interview, LVN 3 stated that if a resident needed oxygen, or there were any airway or breathing issues with the resident, a licensed nurse should start a change of condition report and notify the resident's PMD of the change in condition as soon as possible. LVN 3 stated it was important to get notification from staff for any changes in condition such as poor oral intake or meal refusals, since he could have endorsed it to the evening shift nurse and a change of condition could have been started. During an interview on [DATE] at 10:45 AM, the Director of Nursing (DON) stated that changes in condition included changes in any vital signs of a resident and breathing or airway related issues, and these must be reported to the primary doctor so the facility would be able to take care and monitor the resident properly. The DON stated that it was important to notify the doctor and start a change in condition monitoring if a resident refused a meal or had not had any meal intake for the whole day. The DON stated that the nursing assistant should report to the licensed nurse for any changes in the resident's condition so the licensed nurse can check the resident and notify the doctor. During this interview with the DON, on [DATE] at 10:45 AM, the surveyor requested to speak with the primary physician, who declined the interview. During an interview with the DON on [DATE] at 5 PM, when asked about any documentation indicating the the physician was notified of Resident 1's low BP and oxygen administration (on [DATE] to [DATE]), the DON stated, There was no documentation seen regarding notification to the primary care physician. On [DATE] at 1:43 p.m., during an interview, CNA 1 stated that she reported to the evening nurse regarding Resident 1's blood pressure of ,d+[DATE] mm/hg taken on [DATE], since there was a blood pressure medication that needed to be given to Resident 1. CNA 1 stated that the previous nursing assistant did not endorse to her that Resident 1 was refusing to eat since the morning of [DATE]. During an interview with Resident 1's Nurse Practitioner (NP) on [DATE] at 1:05 PM., the NP stated that, If there's anything that would have prompted them to call the doctor such as shortness of breath, it would've triggered us that Resident 1 might need a visit and perhaps start a diuretic (a medication that treats CHF). When the NP was asked, if she was made aware regarding Resident 1's low blood pressure and use of oxygen on ,d+[DATE] and ,d+[DATE], the NP did not answer. A review of facility's policy titled, Resident Examination and Assessment, revised ,d+[DATE], indicated under reporting to notify the physician of any abnormalities such as, but not limited to: abnormal vital signs, labored breathing, breath sounds that are not clear, or cough, productive or nonproductive and to report other information in accordance with facility policy and professional standards of practice. A review of facility's policy titled, Oxygen Administration, revised on ,d+[DATE], indicated under documentation, that after completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: date and time, name and title of the individual, rate of oxygen flow, route and rationale, reason for as needed administration, all assessment data obtained before, during and after the procedure and how the resident tolerated the procedure. A review of facility's policy titled, Change of Condition Reporting, undated, indicated the facility would identify changes in resident's conditions and will be communicated to the primary physician and/ or his /her designee for proper management. The policy indicated to document the resident change of condition and response in nursing progress notes, on 24-hour report and update resident Care Plan, as indicated. A review of facility's policy titled, License Nurse's Notes, undated, indicated meaningful and informative notes shall be written by a licensed nurse to reflect the care and treatment, observations and assessments and other appropriate entries. The policy indicated entries were necessary for any changes in resident's condition that require a telephone call to the physician shall be well recorded by the nurse reporting and physician shall be notified promptly of the following event such as, any sudden and/or marked adverse changes in signs, symptoms or behavior exhibited by a resident. According to a review of the facility's Charge Nurse: Job Description, dated 2003, under Care Plan and Assessment Functions, to ensure that the CN's nurses' notes reflect that the care plan is being followed when administering nursing care or treatment; review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs; ensure that the assigned certified nursing assistants (CNAs) are aware of the resident care plans; and ensure that the CNAs refer to the resident's care plan prior to administering daily care to the resident. A review of facility's, Certified Nursing Assistant: Job Description, dated 2003, indicated under Administrative Functions that CNAs will record all entries on flow sheets, notes, charts, etc., in an informative and descriptive manner and report all changes in the resident's condition to the Nurse Supervisor/ Charge Nurse as soon as practical. The Job Description indicated under Care Plan Functions, that CNAs will inform the Nurse Supervisor/ Charge Nurse of any changes in the resident's condition so that the appropriate information can be entered on the resident's care plan and ensure that the notes reflect that the care plan is being followed. The Job Description indicated under Food Service Functions that CNAs will record the resident's food/fluid intake and report changes in the resident's eating habits.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 4), who had [DIAGNOSES REDACTED]. plan and facility policy. This deficient practice resulted in Resident 4 having complaints of moderate level abdominal pain, had a change in condition due to bladder distention (increased urine in bladder), was transferred to the General Acute Care Hospital (GACH) where over seven liters of urine was drained and diagnosed with [REDACTED]. Resident 4 was discharged home after one week and died three weeks later. Findings: A review of Resident 4's admission record indicated an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of Resident 4's Care Plan, dated [DATE], indicated an alteration in comfort due to pain related to recent fall and fracture, [MEDICAL CONDITION], and nerve pain. The care plan interventions indicated to determine cause of pain, observe / assess pain location, document characteristics of pain and to communicate any change in unusual activity. A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], indicated Resident 4 received opioid medication (used for pain relief) six out of seven days. A review of the Medication Administration Record [REDACTED] -[DATE] at 8:18 AM for pain level of 0, and 3:30 PM for pain level of 6, -[DATE] at 9:06 PM for pain level of 6, -[DATE] at 6:43 PM for pain level of 6, -[DATE] at 1:09 PM for pain level of 4, and 6:21 PM for pain level of 5, -[DATE] at 5:11 PM for pain level of 5. There was no documentation on the MAR indicated [REDACTED]. A review of the Input and Output Record dated ,[DATE]- [DATE] indicated Resident 4's average 24-hour intake was 537 ml (normal intake 2000 ml). In addition, there was no documentation the staff assessed the resident for abdominal pain when pain medication was given from [DATE]-[DATE]. A review of the Change of Condition form (COC), dated [DATE], at 10 AM indicated Resident 4 had bladder distention (increased urine volume in bladder) and was observed with increased confusion, lethargy (state of sleepiness or inactivity), and abdominal enlargement. The COC indicated the physician was notified, bladder scan was completed, foley (indwelling) catheter insertion was unsuccessful, and a physician's order was obtained to transfer Resident 4 to the hospital for further evaluation. A review of the history and physical examination [REDACTED]>1000 milliliters (ml), and that the foley catheter placement and in/out catheter were both unsuccessful. A review of the General Acute Care Hospital (GACH) Emergency Department (ED) Report, dated [DATE], indicated Resident 4 was brought by Emergency Medical Services (EMS) for abdominal distention / urinary catheter placement. The GACH ED Report indicated respiratory distress resolved after distention relieved. Per GACH ED report, Resident 4 arrived at hospital ED on [DATE] at 12:28 PM. Vital signs were BP ,[DATE], Pulse 98, Respiration 18, Temp 98.2, Pulse Oximetry 99% at room air. CT Brain and CT Abdomen/Pelvis were completed in the emergency room . Per Medical Director notes urinary catheter was placed immediately given concerns for bladder rupture and >7 L drained initially dark yellow then bloody urine. Resident 4's respiratory distress resolved after distention relieved, lab shows acute [MEDICAL CONDITION] with [MEDICAL CONDITION] but without any heart changes. Uremia (a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys) noted likely explains initial confusion. Other electrolytes stable. Resident was admitted with [DIAGNOSES REDACTED]. Instead of flowing from your kidneys to your bladder, urine flows backward, or refluxes, into your kidneys). A review of Resident 4's GACH H&P, dated [DATE], indicated Resident 4 presented to the emergency room from the skilled facility with ongoing abdominal pain, foley (indwelling) catheter placed. The GACH H&P indicated Resident 4, put out 5.2 liters of urine (5,200 milliliters), after several hours another 2.4 liters (2,400 milliliters) of urine was collected. A review of the GACH Discharge Summary indicated Nephrology consult = ARF (acute [MEDICAL CONDITION]) due to [MEDICAL CONDITION]. Renal replacement therapy was not recommended. Urology consult = gross hematuria due to rapid decompression of bladder retention. Continue present foley (indwelling catheter) x ,[DATE] weeks for [MEDICAL CONDITION] and be evaluated with voiding trials. Oncology consult = diffuse large B-cell [MEDICAL CONDITION] of the r-tibia status [REDACTED]. Resident was discharged home with home health PT on [DATE]. During an interview on [DATE] at 1:17 PM, the Director of Nursing (DON), stated and confirmed there was no documentation to indicate the location of Resident 4's pain for the eight times pain medication was administered from ,[DATE] - [DATE]. The DON stated the location of pain should have been documented for staff to follow-up and reevaluate the complaint of Resident 4's pain. The DON stated, follow-up and assessment of the pain location was important for evaluation of the effectiveness of the medication, to address the correct location and characteristics of the pain, and to evaluate if resident was experiencing acute pain (mild and last just a moment, or it might be severe and last for weeks or months) or chronic pain (ongoing and usually lasts longer than six months). During an interview with the DON on [DATE] at 1:35 PM and concurrent review of the Progress Notes from ,[DATE] to [DATE], the DON stated and confirmed there was no documentation to indicate the location of Resident 4's pain. The DON stated and confirmed with the various admission [DIAGNOSES REDACTED]. During an interview, on [DATE] at 1:40 PM, the DON stated, pain medication given for Resident 4 on [DATE] at 8:18 AM for pain level of 0 was not appropriate as this may result in adverse effects for Resident 4. A review of the facility policy titled, Pain Management, dated [DATE], indicated the licensed nurse shall review residents for pain when vital signs are taken including: origin of pain, location of pain, severity of pain, alleviating and exacerbating factors, and current treatment and response to treatment. The policy stated if pain is a new onset or change in nature, notify physician for a review of medications. A review of the facility policy titled, Assessment and Reassessment Policy, dated [DATE], indicated the resident will be re assessed and care plan shall be updated with each change in condition, new problem and/or resolution of problem. The policy indicated to assess the resident's pain including its origin, location, severity (using pain scale), alleviating and exacerbating factors and current treatment and response to treatment. A review of the facility policy titled, Change of Condition, dated ,[DATE], indicated the facility to identify changes in the resident's condition. Unusual signs and symptoms and any deviation from the resident's baseline condition will be communicated to the Attending Physician and/or his/her designee promptly.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent falls and minimize injuries for one of three sample residents (Resident 1), including: 1. Failure to ensure Resident 1, who was assessed as requiring two-person assist for bed mobility and personal hygiene, was provided with two staff assistance while turning in bed when providing personal hygiene. 2. Failure to indicate in the Care Plan Resident 1 needed two-staff assistance with bed mobility and personal hygiene as indicated in comprehensive assessment. 3. Failure to implement the facility's policy and procedure on Care of Residents by not providing Resident 1 with the support need during bed mobility and personal hygiene. 4. Failure to implement the facility's policy on Safety, Accidents and Supervision, by not preventing avoidable accidents due to lack of implementation of interventions consistent with Resident 1's needs, goals, plan of care, and current standards of practice. As a result, on 12/15/17, at 12:40 p.m. Resident 1 fell out of bed when Certified Nursing Assistant 1 (CNA 1) was alone turning Resident 1 in bed to provide incontinent care. Resident 1 sustained a fracture (break) of the right 10th rib and the right clavicle (collarbone). Findings: On 3/2/18 at 10:50 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. On 3/2/18 at 11:34 a.m., during observation of Resident 1's room, by the headboard, there was a form titled, Nursing Alerts. This form had several pictures including two people and a lift machine. On 3/2/18 at 12:18 p.m., during an interview, the Director of Staff Development (DSD) stated they use the Nursing Alerts to communicate important information of the residents. On 3/2/18 at 12:35 p.m., during an interview regarding the posted Nursing Alert, Licensed Vocational Nurse 1 (LVN 1) explained the picture of two people alerted the staff Resident 1 needed two-person assist and needed a mechanical lift for transfers. A review of the Admission Record indicated Resident 1 was originally admitted on [DATE], with a recent re-admitted d 7/19/17. Resident 1's [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the Side Rail Screening Tool dated 7/19/17 indicated Resident 1 required two-person assist with bed mobility. A review of the Care Plan developed on 7/19/17, for Resident 1's self-care deficit and requiring assistance with bed mobility, transfers and personal hygiene, included in the interventions to maintain the side rails of the bed up at all times use two-person assist during transfers. The plan of care did not address the support needed with bed mobility and personal hygiene. A review of the History and Physical exam dated 9/21/17 indicated progressive dementia and [MEDICAL CONDITION], which was worsening the dementia. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 10/3/17, indicated Resident 1 had impaired reasoning and memory; was alert and oriented to person (self) only; and had no mood or behavior symptoms. Resident 1 had severely impaired vision, was unable to walk, and needed extensive assistance and two or more person assist with bed mobility, dressing, toilet use, and transfers. Resident 1 was totally dependent on staff for personal hygiene with two or more person assist. Resident 1 was incontinent (unable to control) of bowel and bladder, had no history of falls, was 71-inch tall and weighed 208 pounds. A review of the nursing Progress Note dated 12/15/17, indicated Resident 1 had an assisted fall at 12:40 p.m., with no injury. A review of the SBAR form (Situation - Background - Assessment - Request) dated 12/15/17, indicated at 1:05 p.m. Resident 1's physician was notified. A review of the SBAR form dated 12/16/17 indicated Resident 1 was identified with bruising, swelling and pain to the right shoulder and bruising to the right upper arm and right rib cage area. Resident 1's physician was notified at 9:50 a.m., who ordered x-rays. A review of the nursing Progress Note dated 12/16/17, timed at 7 p.m., indicated the x-rays results showed fracture to Resident 1's lateral right 10th rib and fracture to the right distal (close to the shoulder joint) clavicle. A review of the Interdisciplinary Team (IDT) Notes Post Fall dated 12/18/17, indicated on 12/15/17 Certified Nursing Assistant 1 (CNA 1) was turning Resident 1 in bed to provide incontinent care and Resident 1 slipped from the bed onto the floor. The air loss mattress was overinflated forcing Resident 1 down to the floor when CNA 1 was turning Resident 1 to the left (towards CNA 1). CNA 1 was able to catch Resident 1's upper torso to prevent the head from hitting the floor. The following day, 12/16/17, Resident 1 was noted with multiple bruises to the right shoulder, rib area and upper arm and swelling to the right shoulder. Resident 1's physician when notified ordered x-rays. On the same day, 12/16/17, the x-ray results showed fractures. The IDT recommendations included to apply a floor mat, ensure providing two-person assist with cleaning, bathing, transfers, and treatments, and in-service on low-air low mattress settings. Resident 1 remained in the facility and did not require surgery or hospitalization due to the fractures. On 3/2/18 at 1:32 p.m., during an interview, LVN 2 stated, I told (CNA 1), whenever he needs to transfer or assist Resident 1, Resident 1 would need two-person assist. We have a Restorative Nurse Assistant (RNA 2) who offered to help (CNA 1), but (CNA 1) did not wait for (RNA 2). LVN 2 stated, Knowing that Resident 1 is big and heavy, around 200 lbs., he (CNA 1) should have waited for (RNA 2) or someone to assist. On 3/2/18 at 2:57 p.m., during an interview, RNA 2 stated, he offered CNA 1 help with Resident 1 but CNA 1 did not ask for help. CNA 1 told RNA 2 when he moved Resident 1, the mattress moved. On 3/7/18 at 11:50 a.m., during an interview, RNA 1 stated, Resident 1 normally needs two persons to assist him in and out of bed or even personal hygiene. Before the fall, he already needed two-person assist. Our indicator is on the wall by Resident 1's bed, it is called Nursing alert and two-person assist has always been highlighted for Resident 1. A review of the facility's policy dated 3/2010 titled, Care of Residents indicated it was the policy to provide support to residents needing assistance and those that are dependent on staff for activities of daily living (ADL). The procedures, indicated residents who are unable to carry out ADLs will receive necessary services to maintain the following from their assigned nursing staff; safety, grooming, personal and oral hygiene. A review of the facility's policy titled, Safety, Accidents and Supervision, with last revision date 3/5/18, defined accident as any unexpected or unintentional incident which may result in injury or illness to a resident. Avoidable accident is defined as an accident occurred because the facility failed to implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent altercations between residents and prevent injuries from the altercations for two of 38 randomly selected residents (RSR 37 and RSR 38). RSR 38 hit RSR 37's left and right forearms with a metal spoon after dinner as one of the four certified nursing assistants (CNAs) in the dining room were assisting two residents to finish their meals, three of the four CNAs were returning residents to their respective rooms, and the two charge nurses/licensed vocational nurses (LVN 12 and 13) were giving medications to some residents remaining in the dining room. The incident was not witnessed by a facility staff. This deficient practice resulted in RSR 37 sustaining seven skin tears to her left forearm and three skin tears with bruises on her right forearm, with moderate bleeding. RSR 37, who had a left-sided paralysis, had to undergo skin treatment for two weeks and was given Tylenol (a medication used to treat mild to moderate pain) 650 milligrams (mg) for complaints of mild pain. Findings: On 6/16/16 at 1:10 pm, an unannounced visit was made to the facility to investigate a complaint regarding a resident to resident altercation. A review of the Incident Report, dated 1/25/16, indicated RSR 37 was assessed as having seven skin tears to her left forearm, and three skin tears with bruising on her right forearm, with moderate bleeding, as a result of the altercation with RSR 38.The initial nursing observation, assessment, and treatment on the incident report indicated that after dinner at 5:45 pm, RSR 37 was noticed being stabbed and hit with a (metal) spoon by another resident (RSR 38). Both residents were separated right away. The incident report indicated an initial nursing intervention was provided to the mild to moderate bleeding; RSR 37 complained of mild pain; and Tylenol (a medication used to treat mild to moderate pain) 650mg was given to the resident . A review of RSR 38's admission record (Face Sheet) indicated the resident was readmitted to the facility on [DATE]. The resident's admission [DIAGNOSES REDACTED]. (a group of brain disorders that cause the loss of rational and social skills), and cataract (a clouding of the lens in the eye leading to a decrease in vision). A review of RSR 38's Minimum Data Set (MDS, an assessment and care screening tool), dated 2/10/16, indicated that RSR 38 was severely impaired in cognition, and was able to make her needs known and understand others. The MDS indicated that the resident did not exhibit physical behavioral symptoms directed towards others (e.g. hitting, pushing, and grabbing) and that the resident required supervision during meals. A review of RSR 38's care plan titled, Cognitive Loss, dated 2/11/15, indicated RSR 38 had cognitive loss related to dementia/Alzheimer. The interventions included providing the resident with cueing, directions and oversight frequently when interacting with the resident, passing in hallways, or in dining or activity rooms. A review of RSR 38's care plan titled, Dementia/Alzheimer's Disease, dated 5/11/15, indicated the resident had potential for injury related to inappropriate judgement manifested by aggressive outburst (verbal). The interventions included providing the resident with monitoring for unfavorable behaviors. A review of RSR 38's care plan titled, Mood and Behavior, dated 5/14/15, indicated that the resident had mood and behavior problems related to impulse control disorder manifested by angry outburst and refusing treatment. The interventions included reporting to the charge nurse if resident does not respond to a re-direction and to monitor the resident's behavior every shift. A review RSR 38's Care Conference Summary, dated 11/17/15, indicated the resident's mental status as forgetful and confused, and required cueing and supervision while eating. A review RSR 38's Nurses Progress Notes, dated 1/25/16 at 4:30 pm, indicated the resident was moved by a CNA to sit on the first table in the dining room near the television set, as requested by the resident, in order for the resident not to get angry. The progress notes indicated the resident was calm and quiet at this time, her medications were given as ordered, and she was very cooperative and was not exhibiting angry outburst. According to the licensed vocation nurse (LVN 12), during an interview, on 7/28/16 at 9:45 am, RSR 38 was seated on a table near the television set because the resident wanted to watch a show and the resident would calm down (would not get angry) when she was in front of the television set. The Nurses Progress Notes, dated 1/25/16 at 5:45 pm, indicated a charge nurse's medication cart was parked in front of the table where RSR 38 was seated. After dinner, the charge nurse/ licensed vocational nurse (LVN 12) noticed that RSR 38 was stabbing a resident (RSR 37) beside her. The two residents were separated right away and RSR 38 propelled herself back in the hallway. The social worker spoke with RSR 38 to remind the resident that hitting another resident was inappropriate. RSR 38's legal representative was informed about the incident and a psychiatric evaluation was requested. According to LVN 12, during an interview on 7/28/16 at 9:45 am, the medication cart was not blocking her view of the table where RSR 38 was seated. A review of RSR 38's Nurses Progress Notes, dated 1/25/16 at 11 pm, indicated that the resident was provided with close visual monitoring to prevent recurrence and to continue monitoring the resident since resident is not safe for other residents. On 6/16/16 at 1:10 pm., during an interview, Registered Nurse (RN) 6 stated dinner started at 5 pm. RN 6 stated that a facility staff was interviewed if RSR 38 showed any aggressive behavior prior to the incident, which happened between RSR 37 and 38 on 1/25/16 after dinner, and the answer was No. RN 6 stated that on 1/25/16, there were CNAs and charge nurses (CNs) in the dining room. During the interview, RN 6 stated that after dinner on 1/25/16, there had to be at least one or two CNAs or the charge nurse to remain in the dining room area to make sure the residents, who were waiting to be taken to their respective rooms, were safe. On 6/16/16 at 3:09 pm, during an interview, CNA 2 stated that she was in the dining room when the incident happened between RSR 37 and 38 on 1/25/16. CNA 2 stated she was at the back part of the dining room assisting two residents to eat. CNA 2 stated that she did not witness the incident. CNA 2 stated that if the CNAs started returning the residents in their respective room after dinner, one (1) CNA should be left behind in the dining room to supervise the residents waiting to be returned to their rooms. On 6/16/16 at 3:37 pm, during an interview, RN 6 stated there was no specific assignment for the CNAs during dinner. RN 6 stated, We just have a general guideline on meal time. RN 6 stated there were 50 residents (both residents who eat independently and who needed total assistance from staff to eat) with four CNAs in the dining room on 1/25/16 during dinner. On 6/16/16 at 3:40 pm, during an interview, LVN 12 stated that she went to the back of the dining area to give a medication to a resident and on her way out of the dining room, she saw RSR 37 with six slits on her left arm. The incident report, dated 1/25/16, indicated RSR 37 had seven skin tears on the left forearm. LVN 12 stated she did not see any CNAs supervising RSR 38 when she (LVN 2) walked into the dining room and on her way out of the dining room. During an interview, on 7/14/16 at 3:20 pm, LVN 12 stated that on 1/25/15, she observed RSR 37 and 38 sitting at the front table of the dining room. RSR 38 was sitting to the right side of RSR 37. When LVN 12 was exiting the dining room, LVN 12 stated she saw RSR 37's left forearm extended, resting on the table, and bleeding. LVN 12 observed RSR 38 with a metal spoon patting hard on RSR 37's right forearm. LVN 12 noted blanching and bruising to RSR 37's right forearm. LVN 12 stated there was no CNA supervising RSR 37 and 38 at their table. LVN 12 stated it was hard to supervise and pass medications at the same time. On 6/16/16 at 5:01 pm, during an interview, the director of staff development (DSD) stated that there were two charge nurses (LVN 12 and 13) in the dining room at that time of the incident between RSR 37 and 38 on 1/25/16 but nobody witnessed the incident. The DSD stated that after dinner, when residents were ready to go back to their respective rooms, nobody was assigned to them anymore. (LVN 13 was no longer employed at the facility). On 7/12/16 at 2:55 pm, during an observation in dining room of the nursing station, Station D, CNA 12 was monitoring 21 residents, who were sitting down, getting ready for dinner. CNA 12 stated, during a concurrent interview, that if she needed help, I can call people from the kitchen. On 7/14/16 at 10:40 am, during a telephone interview, the director of nursing (DON) stated that during meal times, either lunch or dinner, there are approximately eight (8) to 10 residents, who needed assistance in eating. The DON stated that all CNAs were required to go to the dining room during meal times, except if the residents stayed in their rooms, then one CNA would stay behind to pass trays and help the residents as needed. The DON stated, Typically, each CNA helps their own (assigned) resident to eat, but they (the CNAs) also help each other. On 7/14/16 at 2:45 pm, during an observation and interview, RN 6 held a metal teaspoon and described the edges of the teaspoon as hard, not smooth but not too sharp. RN 6 stated plastic utensils were given to RSR 38 for a period of time as prevention so not to hurt other residents. RN 6 stated RSR 38 was not physically aggressive. RN 6 stated, She (RSR 38) usually becomes loud and agitated when she doesn't agree with the nurses. On 7/14/16 at 2:47 pm, during an observation, RSR 37 was observed alert but confused, and sitting on her wheelchair while watching a television show. The skin of RSR 37's forearms was thin, intact, and clear. The resident denied pain in her forearms. On 7/14/16 at 2:50 pm, during an interview, LVN 13 stated the treatment for RSR 37's skin tears that resulted from the altercation between RSR 37 and 38 lasted a couple of weeks long. LVN 13 stated RSR 37 had multiple skin tears and bruises to both arms after the altercation. A review of RSR 37's admission record (Face Sheet) indicated RSR 37 was admitted to the facility on [DATE]. The resident's admission [DIAGNOSES REDACTED]. lens in the eye leading to a decrease in vision). A review of RSR 37's Minimum Data Set, dated dated [DATE], indicated the resident was severely impaired in cognition. The MDS indicated that the resident had minimal difficulty hearing, impaired vision, usually understood verbal content of others, and required corrective lenses. The MDS indicated that RSR 37 required extensive assistance (resident involved in activity staff provide with bearing support) from staff for transfers, eating, and personal hygiene. A review of RSR 37's care plan titled, Fragile Skin, dated 6/15/15, indicated the resident was at risk for skin tears and bruising related to history of skin tears, bruising, poor safety awareness, and use of Aspirin (a medication used to prevent blood clot formation, but it may increase risk of bleeding). The interventions included encouraging the resident to wear long sleeves or protective arm and leg covering, providing safety cueing and oversight, and handling with care to avoid skin tears and scraping of skin. According to RSR 37's ADL (activities of daily living) Function care plan, dated 6/15/15, the resident had limited function to perform eating. The interventions included providing the resident with assistance and cueing at meals. A review of the Nurses Progress Notes, dated 1/25/16, indicated RSR 37 sustained the following: a. Seven skin tears on the left forearm measuring from 0.7 centimeter (cm) to 1.2 cm. b. Skin discoloration on the right forearm measuring 14 cm in length by 8 cm in width. c. Two L-shaped skin tears on the right forearm, sizes 0.7cm in length 0.5 cm in width and 1.2 cm in length 0.9 cm in width. d. One skin tear on the right forearm measuring 0.7 cm with mild to moderate bleeding. According to the physician's orders [REDACTED]. The treatment order was to cleanse the skin tears with normal saline (salt) solution, apply triple antibiotics, cover the skin tears with a dry dressing and wrap with a roller gauze dressing daily for two (2) weeks. The physician also ordered to apply geri sleeves (a reusable, breathable cotton-blend fabric that protects against skin tears) to RSR 37's forearms. A review of the facility's undated policy and procedure titled, Guidelines for Dining Room Service, indicated that all staff will tend to the needs of residents during mealtime, and residents will also be supervised per Resident Supervision policy and procedure. A review of the facility's policy and procedure titled, Resident Supervision, dated on 6/10/16, indicated that in order to ensure the residents are provided supervision before, during and after meals, staff will rotate in 15 minute intervals to supervise the residents in either the day room or near the nurses' station according to the needs of the nursing unit.