Every finding on record at Longwood Manor Conv.Hospital

Based on observation, interview, and record review, the facility failed to safeguard a resident's personal property during a resident's transfer to the general acute care hospital (GACH) and subsequent discharge from the facility for one of one sampled residents (Resident 1) by not ensuring: 1. Resident 1's inventory lists dated 1/4/2026, 3/10/2026, 3/18/2026, 4/27/2026, and 5/6/2026 were accurately completed. 2. Resident 1's belongings, including an inventoried corkboard which contained personal and sentimental cards and notes, were gathered, inventoried, secured, and accounted for following Resident 1's hospital transfer to the GACH on 5/6/2026 and subsequent discharge. 3. Resident 1's radio was properly labeled and identified. These deficient practices resulted in the facility being unable to account for Resident 1's inventoried corkboard and verify ownership of the radio located after discharge, and created the potential for loss or mishandling of other personal possessions. Findings: During a review of Resident 1' s admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), diabetes (poor blood sugar control), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's History and Physical (H&P), dated 3/18/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a phone interview on 8/17/2026 at 12:40 p.m. with Resident 1's Responsible Party (RP), RP 1, RP 1 stated she was dissatisfied with the facility's management of Resident 1's personal belongings following his discharge. RP 1 stated that prior to Resident 1's discharge on [DATE], she provided Resident 1 with a corkboard for the display of sentimental cards, a radio, and t-shirts. RP 1 stated, shortly after Resident 1's discharge on [DATE], she reached out to the facility to retrieve his belongings but did not receive a response. RP 1 stated, on 7/24/2026, due to continued lack of communication via email and phone, RP 1 visited the facility in person to collect Resident 1's belongings. RP 1 stated the facility presented a different cork board, without the attached letters and notes, and produced a radio that did not match the serial number recorded in the inventory list. RP 1 stated, additionally, facility staff offered a package of t-shirts as a replacement; however, they were not of equivalent quality. RP 1 stated the Social Services Director (SSD) and Social Services Assistant (SSA) requested she submit information electronically about the missing corkboard. The SSD and SSA stated that they would continue searching for the missing items. RP 1 stated she was particularly concerned over the loss of personal and sentimental cards attached to the corkboard, noting they could not be replaced. a. During a review of Resident 1's Inventory List, dated 4/27/2026, the Inventory List, dated 4/27/2026, indicated Resident 1 had one radio, six t-shirts, and one 17-inch by 23-inch corkboard. The inventory list had one facility staff representative signature; however, it lacked the resident or responsible party signature. During a review of Resident 1's Change of Condition (COC) Note and Resident Transfer Record, both dated 5/6/2026, the COC note and the Resident Transfer Record indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) for a leaking nephrostomy tube (a thin, flexible plastic tube put through the skin in your back and into your kidney to drain urine). The records did not indicate Resident 1's belongings were secured. During a review of Resident 1's Progress Notes, dated 5/6/2026 through 8/17/2026, the progress notes did not indicate the facility secured Resident 1's belongings following the transfer to the GACH on 5/6/2026, checked Resident 1's rooms for remaining belongings, or notified RP 1 regarding belongings available for retrieval. During a review of the Census List, dated 8/18/2026, the list indicated the following:1. Resident 1 was readmitted to the facility on [DATE].2. Resident 1 was transferred to the GACH on 3/10/2026 and discharged from the facility on 3/17/2026.3. Resident 1 was readmitted to the facility on [DATE].4. Resident 1 was transferred to the GACH on 5/6/2026 and subsequently discharged from the facility on 5/13/2026. During an interview on 8/18/2026 at 10:20 a.m. with the Medical Records Director (MRD), the MRD stated there were only two inventory lists that existed in Resident 1's medical record for 2026. During a concurrent record review and interview on 8/18/2026 at 11:30 a.m. with the Assistant Director of Nursing (ADON), Resident 1's Progress Notes, dated 4/2026 through 8/18/2026, Inventory Lists, dated 1/4/2026 and 4/27/2026, and Resident 1's Census List, dated 8/18/2026, were reviewed. The Inventory List from 1/4/2026 indicated no belongings for Resident 1 and had one facility staff representative signature; however, it lacked the resident or responsible party signatures. The Inventory List, dated 4/27/2026, indicated Resident 1 had one radio, six t-shirts, and one 17-inch by 23-inch corkboard. The inventory list had one facility staff representative signature; however, it lacked the resident or responsible party signatures. The ADON stated inventory lists were required to be completed upon discharge, transfer to another facility, admission, readmission, and whenever new personal items were added. The ADON stated the inventory lists for Resident 1's discharge on [DATE], readmission on [DATE], and discharge on [DATE] were missing. The ADON stated Inventory Lists must be completed and signed by either the resident or the responsible party to ensure accountability and facilitate accurate verification. The ADON stated the inventory lists, dated 1/4/2026 and 4/27/2026, lacked resident or responsible party signatures. The ADON further stated incomplete or missing inventory sheets present a risk of Resident 1's belongings becoming lost or unaccounted for due to the lack of proper signatures. During an interview on 8/18/2026 at 12:10 p.m. with Social Services Director (SSD), the SSD stated that it was important to ensure both signatures (the RP and the facility representative) were on the inventory lists so that both parties could verify the belongings and uphold accountability. The SSD indicated that incomplete inventory sheets may increase the risk of misplaced items. b. During a review of RP 1's email, dated 6/9/2026, addressed to the SSD, the email indicated RP 1 would contact the facility to pick up Resident 1's belongings. During a review of Resident 1's Progress Notes, dated 7/24/2026 through 8/17/2026, the progress note, dated 7/24/2026, indicated RP 1 visited the facility and requested Resident 1's belongings. The note indicated Social Services Assistant (SSA) explained to RP 1 that the facility would look for the requested items. There were no other progress notes to indicate SSA or SSD had followed up with RP 1 regarding the belongings. During a review of RP 1's email, dated 7/29/2026, addressed to the SSA and SSD, the email indicated RP 1 notified the facility that Resident 1's belongings remained missing and unaccounted for, including a multi-colored pack of t-shirt, a bedside radio, a cork bulletin board with all of the letters, index cards, and notes written by family. During an interview and record review on 8/17/2026 at 2:38 p.m. with the SSD, RP 1's email to the SSD dated 7/29/2026, was reviewed. The SSD confirmed receipt of RP 1's email and stated that did she did not provide a response. There was no other documentation demonstrating the facility located or accounted for Resident 1's missing corkboard and other personal items. During an interview on 8/18/2026 at 12:10 p.m. with the SSD, the SSD stated the normal process for securing personal belongings after a resident discharge was that the discharging certified nursing assistant (CNA) would gather all resident belongings into a bag, complete an inventory sheet, and place it in the SSD office. The SSD stated she did not receive any bagged belongings after Resident 1's discharge. The SSD stated herself, or anyone from the Social Services Department should have checked Resident 1's room for any existing items after Resident 1 was discharged . The SSD stated that it was important to secure the belongings because it was the resident's right to possess belongings and keep belongings accountable for. During an interview on 8/18/2026 at 1:19 p.m. with RN 1, RN 1 stated she was the RN Supervisor on 5/6/2026. RN 1 stated that the normal process after a resident's discharge or transfer to the hospital was to secure the resident's belongings either in the resident closet or the social worker's office and to complete an inventory sheet. RN 1 stated that she could not recall if the assigned CNA secured Resident 1's items after discharge. RN 1 stated that it was important to ensure or verify that Resident 1's items were secured because it was their right to maintain his or her valuables. RN 1 stated she recalled seeing Resident 1's corkboard with attached notes. 3. During a concurrent observation and interview on 8/18/2026 at 12:36 p.m., a radio was observed. The SSD stated the radio belonged to Resident 1. There was no label on the radio to identify it as belonging to Resident 1 and there was no serial number. During a concurrent record review and interview on 8/18/2026 at 1:51 p.m. with the SSD, the facility's policy and procedure (P&P) titled, Personal Property (undated), was reviewed. The P&P indicated the resident's personal belongings would be identified, inventoried and protected. The P&P indicated Social Services would be responsible for assuring television and radios were properly marked. The SSD acknowledged that the radio was not appropriately marked to indicate ownership, and the facility did not adhere to the stated policy. During a review of the facility's Policy and Procedure (P&P) titled, Personal Property (undated), the P&P indicated if a resident left the facility due to an unplanned discharge, Social Services would be responsible with the help of nursing personnel to inventory and pack the personal property of the resident and place in a secure location to prevent loss of personal property during absence of undetermined length. During a review of the facility's P&P titled, Inventory of Resident's Personal Valuables and Property (undated), the P&P indicated clothing and other valuable would be marked to identify ownership. The P&P indicated the date and signature of the resident or responsible party as well as the CNA or facility representative taking the inventory would be provided on the Inventory form on the At Admission portion of the inventory list. The P&P indicated upon discharge, the resident and a facility representative would document clothing or possessions present and both [would] acknowledge on the at discharge portion of the inventory list. During a review of the facility's P&P, titled, Theft and Loss of Resident Personal Property, dated 7/2026, indicated the facility was to make reasonable efforts to protect the personal property of residents in a manner that would comply with regulatory requirements and protect the facility from liability. The P&P indicated resident personal property would be identified with the resident's names by family and nursing staff to the extent feasible and include tagging radios, television, etc.

Based on interview and record review, the facility failed to ensure a discharged resident's representative (RP 1) was provided all requested medical records for one of one sampled residents (Resident 1). This deficient practice had the potential to interfere with RP 1's ability to exercise Resident 1's rights by preventing timely access to complete medical information regarding Resident 1's care and treatment. Findings: During a phone interview on 8/17/2026 at 12:40 p.m. with Resident 1's Responsible Party (RP), RP 1, RP 1 stated she was dissatisfied with the facility's lack of communication and lack of provision of medical records. RP 1 stated she provided the facility with an emailed medical records request on 7/29/2026. RP 1 stated Medical Records Director (MRD) provided a response more than a week later confirming receipt of her request. RP 1 stated she was told MRD was on vacation and had not received the medical records she requested. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), diabetes (poor blood sugar control), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 2/25/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's History and Physical (H&P), dated 3/18/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a record review of the facility's Log of Request for Access to Protected Health Information, dated 7/2026, the log indicated RP 1 requested Resident 1's medical record on 7/29/2026 and the facility responded on 8/13/2026. During a review of RP 1's email to the facility, dated 7/24/2026, the email indicated RP 1 provided a facility representative with a copy of the court order noting conservatorship (a court-ordered arrangement where a judge appoints a responsible person or agency [the conservator] to manage the personal care, finances, or both, of an adult [the conservatee] who is unable to handle their own daily needs or financial affairs) for Resident 1. The email indicated RP 1 attached the same provided documents to the email. During a review of an email provided by the facility, dated 7/29/2026 and timed at 6:00 a.m., the email indicated it was from RP 1 sent to the facility. The email indicated RP 1 requested for electronic copies of Resident 1's medical records from Resident 1's stay at the facility from 2021 through 5/6/2026, benefit notices, insurance correspondence, and personal matters. The email indicated attachments that proved legal conservatorship of Resident 1 were provided to the facility. During a review of an email provided by the facility, dated 7/29/2026 and timed at 11:31 a.m., Medical Records Director (MRD) received confirmation from the facility's legal counsel to honor the legal conservatorship paperwork provided by RP 1. During a review of RP 1's email, dated 8/18/2026 and timed at 10:24 a.m., RP 1 stated she did not receive any medical records from the facility. During an interview on 8/17/2026 at 2:17 p.m. with (MRD), the MRD stated the normal process of completing medical record requests for discharge residents was to ensure the responsible party or the resident received copies of the medical records within 48 hours of his or her request. MRD stated she recalled she read an email regarding RP 1's request for Resident 1's medical records on 7/30/2026. MRD stated she questioned the validity of the conservatorship paperwork and asked the facility's legal counsel to confirm paperwork (could not recall the exact date). MRD stated and received confirmation to honor the conservatorship paperwork (could not recall the exact date). MRD stated she emailed RP 1 medical records on 8/13/2026. During an interview on 8/18/2026 at 12:03 p.m. with the MRD, the MRD stated that she did not fulfil RP 1's medical record request timely and the request should have been started as soon as possible or as soon as the request was received. During a review of the facility's policy and procedure (P&P) titled, Request for Access to PHI, dated 6/11/2022, the P&P indicated requests for access of medical records could be made in writing or verbally. The P&P indicated if the discharged resident or resident representative requested a copy of the personal health information (PHI), legal counsel or a facility-based designee would provide the resident or the resident representative with a copy of the PHI, upon 15 days of receiving the written request.

Based interview and record review, facility did not meet professional standards of quality, by failing to ensure administered medications were documented timely for one of three residents (Resident 3). This deficient practice had the potential to lead to medication errors, like double medication administration, affecting resident's health.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included hypertension (high blood pressure), dementia (loss of memory, thinking, and reasoning skills), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side. During a review of Resident 3's History and Physical (H&P) dated 8/18/2025, the H&P indicated Resident 3 was able to make decisions for activities of daily living. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 5/21/2026, the MDS indicated Resident 3 was rarely/never understood and sometimes understood others. Resident 3 was dependent (helper does all the effort) for oral hygiene, toileting hygiene, shower/bathe self, upper/lower dressing, putting on/taking off footwear, personal hygiene, with rolling from left to right, for chair/bed to chair transfer, and tub/shower transfer. During a review of Resident 3's care plan titled, Resident is at risk for cardiac distress related to hypertension, hyperlipidemia (high cholesterol), coronary (heart) artery (blood vessels) disease with cerebrovascular accident (CVA, stroke), initiated 7/22/2019, the care plan interventions indicated to administer medications as ordered. During a review of Resident 3's care plan titled, Dementia behavioral or psychological symptoms of dementia, initiated 7/22/2019, the care plan intervention indicated to administer medication as ordered. During a review of Resident 3's care plan titled, Resident has potential for alteration in comfort/pain related to polyneuropathy (pian in hands and feet) initiated 7/22/2019, the care plan intervention indicated to administer medication as ordered. During a review of Resident 3's Order Summary Report dated 8/8/2025, the orders indicated the following: 1. Amlodipine besylate oral tablet 5 milligram (mg, unit of measurement), one (1) tablet via gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), one time a day, hold if systolic blood pressure (top number in blood pressure reading) is less than 100. 2. Gabapentin oral capsule 100 mg, 1 capsule via G-Tube three times a day for neuropathic (nerve) pain.3. Namenda oral tablet 10 mg, 1 tablet via G-Tube two times a day for dementia.4. Plavix oral tablet 75 mg, 1 tablet via G-Tube, one time a day for CVA prophylaxis (preventive treatment). During an interview on 7/28/2026 at 3:49 p.m., with LVN 1, LVN 1 stated on 7/28/2026, she arrived for work at the facility at 8:00 a.m., instead of 7:00 a.m. LVN 1 stated the covering nurse (not identified) did not give the residents' morning medications. During a concurrent interview and record review on 7/29/2026 at 1:43 p.m., with LVN 1, Resident 3's Medication Admin Audit Report, dated 7/28/2026 was reviewed. The audit report for 7/28/2026 indicated the following:Amlodipine besylate scheduled for 9:00 a.m. - was administered at 8:52 a.m., documented at 11:53 a.m. Plavix scheduled for 9:00 a.m. - was administered at 9:53 a.m.- documented at 11:53 a.m.Namenda scheduled for 9:00 a.m.- was administered at 9:53 a.m.- documented at 11:54 a.m.Gabapentin scheduled for 9:00 a.m. - was administered at 9:53 a.m.- documented at 11:54 a.m. LVN 1 stated the medication documentations when administered were late and should have been documented right after it was given to prevent medication errors, such as forgetting to document which medications were given, omitting the medication or giving the medication twice. During a review of the facility's Policy and Procedures (P&P) titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated the individual who administered the medication, records the administration on the resident's Medication Administration Record (MAR) directly after the medication is given.

Based on interview and record review, the facility failed to inform and provide the Notice of Medicare Non-Coverage (NOMNC, a notice that indicates when your care is set to end from a skilled nursing facility) form 48 hours prior to the end of skilled nursing services to resident representatives for three of three sampled residents (Residents 128, 136, and 164).This deficient practice had the potential to result in the resident representative not being able to exercise their right to file an appeal.Findings:1. During a review of Resident 128's Face Sheet, the Face Sheet indicated Resident 128 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 128's diagnoses included urinary tract infection (UTI, an infection in the bladder/urinary tract), acute respiratory failure (a life-threatening medical emergency where your lungs suddenly stop working properly), and dysphagia (difficulty of swallowing).During a review of Resident 128's Minimum Data Set (MDS, a resident assessment tool), dated 4/23/2026, the MDS indicated Resident 128's cognition (ability to think and process) was intact. The MDS indicated Resident 128 required moderate assistance (helper does less than half the effort) from staff with oral hygiene and personal hygiene.During a review of Resident 128's History and Physical (H&P), dated 6/3/2026, the H&P indicated Resident 128 was able to make decisions for activities of daily living.During a concurrent interview and record review on 6/26/2026 at 9:43 a.m. with the Business Office Manager Assistant (BOMA), Resident 128's NOMNC form, was reviewed. The BOMA stated Resident 128's last covered day for skilled services ended on 2/19/2026 with 8 days of skilled services remaining. The BOMA stated Resident 128's NOMNC was given to Resident 128's representative on 4/2/2026. The BOMA stated Resident 128's representative should have been notified 72 hours prior to end of skilled services. The BOMA stated Resident 128's representative was denied her rights to make an appeal because the NOMNC was given approximately 42 days after Resident 128 was discontinued from skilled services.2. During a review of Resident 136's Face Sheet, the Face Sheet indicated Resident 136 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 136's diagnoses included UTI, acute kidney failure (a sudden decline in kidney function), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 136's H&P, dated 4/12/2026, the H&P indicated Resident 136 was able to make decisions for activities of daily living.During a review of Resident 136's MDS, dated [DATE], the MDS indicated Resident 136's cognition was intact. The MDS indicated Resident 136 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, lower body dressing, and personal hygiene.During a concurrent interview and record review on 6/26/2026 at 9:39 a.m., with BOMA, Resident 136's NOMNC form, was reviewed. The BOMA stated Resident 136's last covered day for skilled services ended on 6/15/2026 with 33 days of skilled services remaining. The BOMA stated Resident 136's NOMNC was given and signed by Resident 136 on 4/12/2026. The BOMA stated Resident 136's NOMNC should have been given at least 72 hours before the end of skilled services on 6/15/2026.3. During a review of Resident 164's Face Sheet, the Face Sheet indicated Resident 164 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 164's diagnoses included hypertension (HTN, high blood pressure), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and DM.During a review of Resident 164s H&P, dated 1/3/2026, the H&P indicated Resident 164 did not have the capacity to understand and make decisions.During a review of Resident 164's MDS, dated [DATE], the MDS indicated Resident 164 was able to understand and be understood by others. The MDS indicated Resident 164 required substantial assistance from staff with oral hygiene, toileting hygiene, and upper body dressing.During a concurrent interview and record review on 6/26/2026 at 10:18 a.m., with BOMA, Resident 164's NOMNC form, was reviewed. The BOMA stated Resident 164's last covered day for skilled services ended on 6/8/2026 with 9 days of skilled services remaining. The BOMA stated Resident 164's NOMNC was given to Resident 164's representative on 6/7/2026. The BOMA stated the facility did not follow the Medicare guidelines to inform Resident 164's representative at least 72 hours before the last day of skilled coverage.During a review of the facility's policy and procedure (P&P) titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated 9/2022, the P&P indicated if the resident's Medicare Covered Part A stay was ending, a Notice of Medicare Non-Coverage (CMS form 10123) was issued to the resident at least two calendar days before the benefits end.

Based on interview and record review, the facility failed to:Ensure medication was administered within the required timeframe as ordered by the physician for one of 28 sampled residents (Resident 164).Ensure two licensed nurses conducted and signed as witnesses in the destruction of non-controlled discontinued medications for five out of five sampled residents (Residents 3, 43, 99, 134, and 152).This deficient practice had the potential for Resident 164's prescribed medication to be ineffective and had the potential of misuse of discontinued medications and drug diversion. Findings:1. During a review of Resident 164's Face Sheet, the Face Sheet indicated Resident 164 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 164's diagnoses included hypertension (HTN, high blood pressure), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 164's History and Physical (H&P), dated 3/12/2026, the H&P indicated Resident 164 had a power of attorney but could make needs known.During a review of Resident 164's physician order, dated 3/10/2026, the physician order indicated to administer diltiazem hydrochloride (HCL) (medication for treatment of HTN) 90 milligrams (mg, unit of measurement) one tablet before meals and at nighttime for HTN, hold if systolic blood pressure (SBP, top number in a blood pressure reading) less than 110 or heart rate less than 70.During a review of Resident 164's Minimum Data Set (MDS, a resident assessment tool), dated 3/23/2026, the MDS indicated Resident 164 was able to understand and be understood by others. The MDS indicated Resident 164 required substantial assistance (helper does more than half the effort) from staff with oral hygiene, toileting hygiene, and upper body dressing.During a review of Resident 164's Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 6/1/2026 to 6/23/2026, the MAR indicated Resident 164's diltiazem HCL 90 mg was administered at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m.During a concurrent medication observation and interview on 6/24/2026 at 9:57 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 was about to administer Resident 164's diltiazem HCL. LVN 3 stated Resident 164's diltiazem HCL should have been administered at 6:30 a.m. which is 30 minutes before meals as per physician's order. LVN 3 stated Resident 164 already ate her breakfast meal. LVN 3 stated diltiazem HCL should be given before meals for better absorption.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame.2. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included sepsis (a life-threatening blood infection), chronic respiratory failure (a serious condition that makes it difficult to breathe on your own), and dysphagia (difficulty swallowing).During a review of Resident 3's H&P, dated 9/1/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 3 was dependent (helper does all of the effort) on staff for oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 43's Face Sheet, the Face Sheet indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 43's diagnoses included generalized anxiety disorder (disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness), chronic respiratory failure, and dysphagia.During a review of Resident 43's H&P, dated 3/20/2025, the H&P indicated Resident 43 did not have the capacity to understand and make decisions.During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43's cognition was severely impaired. The MDS indicated Resident 43 was dependent on staff for oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 99's Face Sheet, the Face Sheet indicated Resident 99 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 99's diagnoses included hyperlipidemia (high amounts of fats in the blood), respiratory failure, and dysphagia.During a review of Resident 99's H&P, dated 8/8/2025, the H&P indicated Resident 99 did not have the capacity to understand and make decisions.During a review of Resident 99's MDS, dated [DATE], the MDS indicated Resident 99's cognition was severely impaired. The MDS indicated Resident 99 was dependent on staff for oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 134's Face Sheet, the Face Sheet indicated Resident 134 was admitted to the facility on [DATE]. Resident 134's diagnoses included bacteremia (presence of bacteremia in the bloodstream), dysphagia, and aphasia (a disorder that makes it difficult to speak).During a review of Resident 134's H&P, dated 12/22/2025, the H&P indicated Resident 134 did not have the capacity to understand and make decisions.During a review of Resident 134's MDS, dated [DATE], the MDS indicated Resident 134's cognition was severely impaired. The MDS indicated Resident 134 was dependent on staff for oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 152's Face Sheet, the Face Sheet indicated Resident 152 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 152's diagnoses included HTN, respiratory failure, and dysphagia.During a review of Resident 152's MDS, dated [DATE], the MDS indicated Resident 152's cognition was severely impaired. The MDS indicated Resident 152 was dependent on staff for oral hygiene, toileting hygiene, and upper and lower body dressing.During a concurrent interview and record review on 6/24/2026 at 11:56 a.m., with Registered Nurse 2 (RN 2), the Medication Disposition Records, dated 3/3/2026, 3/10/2026, 4/14/2026, 5/26/2026, 6/2/2026, and 6/26/2026, were reviewed. RN 2 stated on 3/3/2026, Resident 43's Medication Disposition Record indicated there were 10 tablets of Buspar (medication to treat anxiety disorder) 10 mg that were destroyed but it was missing a signature of a licensed nurse as a witness. RN 2 stated on 3/10/2026, Resident 152's Medication Disposition Record indicated there were 6 tablets of labetalol (medication to treat HTN) 100 mg and 13 tablets of hydralazine HCL (medication to treat HTN) 25 mg that were destroyed but it was missing a signature of a licensed nurse as a witness. RN 2 stated on 4/14/2026, Resident 152's Medication Disposition Record indicated there were 4 tablets of hydralazine HCL 25 mg that were destroyed but it was missing a signature of a licensed nurse as a witness. RN 2 stated on 5/26/2026, Resident 134's Medication Disposition Record indicated there were 6 tablets of levofloxacin 750 mg (antibiotic to treat infection) that were destroyed but it was missing a signature of a licensed nurse as a witness. RN 2 stated on 6/2/2026, Resident 99's Medication Disposition Record indicated there were 17 tablets of Gemfibrozil 600 mg (medication to treat hyperlipidemia) that were destroyed but it was missing a signature of a licensed nurse as a witness. RN 2 stated on 6/26/2026, Resident 134's Medication Disposition Record indicated there were 9 tablets of ondansetron HCL 4 mg (medication to treat and prevent nausea and vomiting) that were destroyed but it was missing a signature of a licensed nurse as a witness. RN 2 stated there should be two signatures by licensed nurses (disposed by and a witness) when disposing or destroying non-controlled medications. RN 2 stated it was important to have 2 licensed nurses signing the Medication Disposition Record when destroying non-controlled medications to validate the total number of medications destroyed.During an interview on 6/24/2026 at 12:42 p.m., with the Director of Nursing (DON), the DON stated the facility's process when destroying non-controlled medication required the signatures of 2 licensed nurses. The DON stated there was a risk for theft and drug diversion if the Medication Disposition Record was not completed accurately.During a review of the facility's policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, dated 1/2025, the P&P indicated non-controlled medication destruction would occur in the presence of two licensed nurses.During a review of the facility's P&P titled Discarding and Destroying Medications, dated 3/2023, the P&P indicated medications would be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.

Based on observation, interview and record review, the facility failed to ensure:Food items were labeled and not expired in the kitchen.Food items were labeled and dated in one out of one sampled resident (Resident 20)'s room.This deficient practice had the potential to place residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 6/23/2026 at 8:49 a.m. with the Dietary Services Supervisor (DSS) in the walk-in refrigerator during the initial kitchen tour, one pitcher of cranberry juice and one gallon of hamburger dill slices were not labeled and a 32 ounce of minced garlic had an expiration date of 5/15/2026. The DSS stated not labeling food items could result in staff not being able to identify the food items or not knowing if they were expired. The DSS stated not discarding expired food items could result in foodborne illnesses for the residents if used. During a concurrent observation and interview on 6/23/2026 at 8:55 a.m. with the DSS in the walk-in freezer during the initial kitchen tour, an opened bag of chicken patties did not have a label. The DSS stated not labeling food items could result in staff not being able to identify the food item and not knowing if the food item was expired. During a concurrent observation and interview on 6/23/2026 at 9:14 a.m., with the DSS during the initial kitchen tour, one pound of an opened ground ginger bottle and a 16-ounce lemon juice bottle were not labeled on the spice rack. The DSS stated not labeling food items could result in the food items being expired. During a review of the facility's policy and procedures (P&P), titled Dating and Labeling, undated, the P&P indicated all items should be properly covered, dated and labeled and to remove any food item that was expired or beyond the best buy date. 2. During a review of Resident 20's Face Sheet, the Face Sheet indicated Resident 20 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 20's diagnosis included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), emphysema (a lung disease, causing difficulty in breathing), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 20's History and Physical (H&P), dated 6/15/2026 the H&P indicated Resident 20 had the capacity to understand and make medical decisions. During a review of Resident 20's Minimum Data Sheet (MDS, a resident assessment tool), dated 5/16/2026, the MDS indicated Resident 20's cognition (ability to think and process) was intact. The MDS indicated Resident 20 required supervision (helper provides verbal cues to complete activities) from staff for personal hygiene, showers, and dressing. During an observation on 6/24/2026 at 9:16 a.m., in Resident 20's room, Resident 20 had an opened jar of peanut butter and mayonnaise that were not dated and labeled. During a review of Residents 20's Interdisciplinary Team (IDT, a group of health care professionals from different disciplines collaborating) note, dated 5/1/2026, the IDT note indicated Resident 20 was hoarding food items in drawers and on beside table. During a concurrent interview and record review on 6/25/2026 at 10:10 a.m., with MDS Nurse (MDSN 2), a picture of Resident 20's bedside table with an opened jar of peanut butter and mayonnaise that was not dated and labeled was reviewed. MDSN 2 stated the food items should have been labeled and dated. MDSN 2 stated the opened food items in Resident 20's room had the potential to become contaminated and cause food borne illness. MDSN 2 stated the food items should be refrigerated to prevent vermin (small, common animals or insects) from entering Resident 20's room. During an interview on 6/25/2026 at 11:42 a.m. with the Assistant Director of Nursing (ADON), the ADON stated it was the responsibility of the staff to date and label the food items in Resident 20's room. The ADON stated if the staff does not keep track of the food items in the room it could put Resident 20 at risk to develop a food illness. During a review of the facility's policy and procedure (P&P) titled, Food from Outside Sources, unknown date, the P&P indicated food brought to the facility by visitors and family was permitted. The P&P indicated facility staff would assist residents with food brought in to ensure safe and sanitary storage of outside food. The P&P indicated all outside foods would be properly dated and labeled. The P&P indicated the nursing staff would discard perishable food on or before the used by date (the final date recommended by the manufacturer for the consumer to use a perishable product).

Based on interview and record review, the facility failed to ensure Gabapentin (a medication used to relieve nerve pain) and Duloxetine (a medication used to treat various forms of chronic pain) prescriptions were refilled in a timely manner for one of seven sampled residents (Resident 97).This deficient practice had the potential to cause unnecessary pain for Resident 97.Findings:During a review of Resident 97's Face Sheet, the Face Sheet indicated Resident 97 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 97's diagnoses included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), left and right knee contractures (a permanent tightening or shortening of muscles, tendons, skin, or other soft tissues that causes joints to become stiff and restricts normal movement), muscle weakness, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 97's History and Physical (H&P) form, dated 11/24/2025, the H&P indicated Resident 97 had the capacity to understand and make decisions.During a review of Resident 97's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 4/2/2026, the MDS indicated Resident 97's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 97 was dependent (helper does all of the effort) on staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an interview on 6/23/2026 at 12:08 p.m. with Resident 97, Resident 97 stated she had pain in both of her legs. Resident 97 stated she was prescribed Gabapentin for neuropathy, which was very painful. Resident 97 stated her pain level at that time was 9/10. Resident 97 stated she had not received her morning dose of both medications that morning of 6/23/2026.During a record review on 6/25/2026 at 8:29 a.m., Resident 97's Medication Administration Record indicated on 6/23/2026, Resident 97's morning dose of Duloxetine and Gabapentin were not administered due to the medications not being available.During a concurrent interview and record review on 6/25/2026 at 10:36 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the protocol for refilling medication was to refill the resident's medication a week prior to the medication running out. LVN 1 stated the pharmacy would be notified when a resident had one week left of medication and the medication needed to be refilled. LVN 1 stated Duloxetine and Gabapentin medications were used for diabetic neuropathy. LVN 1 stated Resident 97's morning dose for Duloxetine and Gabapentin were not administered because the medication was not available and had not been delivered by the pharmacy. LVN 1 stated Resident 97 should not have run out of medication. LVN 1 stated the risk of not refilling medication for pain in a timely manner could result in causing a resident prolonged pain, which would affect the resident's daily activities and cause unmanaged pain.During a review of the facility's policy and procedures (P&P), titled Pain Assessment and Management, undated, the P&P indicated to review the medication administration record to determine how often the individual requested and received pain medication, and to what extent the administered medications relieve the resident's pain.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of four sampled residents (Resident 83).This deficient practice had the potential for Resident 83 not to be able to call for assistance when needed.Findings:During a review of Resident 83's Face Sheet, the Face Sheet indicated Resident 83 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 83's diagnosis included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and muscle weakness (a reduction in a patient's ability to generate normal muscle force).During a review of Resident 83's History and Physical (H&P), dated 2/12/2025, the H&P indicated Resident 83 was able to make decisions for activities of daily living.During a review of Resident 83's Minimum Data Sheet (MDS, a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 83's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 83's was dependent (helper does all of the effort) on staff for all activities of daily living (ADL, activities such as bathing, dressing, and toileting a person performs daily) and mobility. During a record review of Resident 83's care plan titled, Resident had self-care deficits and was dependent with ADL's., revised on 7/3/2025, the care plan intervention indicated to place the call light within reach and attend needs promptly.During a concurrent observation and interview on 6/24/2026 at 9:24 a.m. with Resident 83 in Resident 83's room, Resident 83's right arm and hand were contracted (the permanent or severe tightening and shortening of muscles, tendons, ligaments, or skin). The call light was on the right side of Resident 83's body. Resident 83 stated he could not reach the call light when he needed to be assisted.During a concurrent observation and interview on 6/24/2026 at 9:27 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 83's room, CNA 1 stated the call light was on Resident 83's contracted side of his body and not within reach. CNA 1 stated the call light should be on Resident 83's left side. CNA 1 stated it was important to place the call light within reach to make it easier for Resident 83 to call for assistance.During an interview on 6/24/2026 at 11:21 a.m. with Minimum Data Set Nurse (MDS) 2, MDS 2 stated Resident 83 had contractures to the right side of his body. MDS 2 Nurse stated the call light had to be on Resident 83's left side and within reach. MDS Nurse 2 stated if the call light was not within reach for Resident 83, then the staff could not attend to him right away.During a review of the facility's undated policy and procedure (P&P) titled, Answering the Call Light, the P&P indicated the call light was to be accessible to the resident when in bed.

Based on interview and record review, the facility failed to update the care plan for one of eight sampled residents (Resident 4). This failure had the potential to result in Resident 4 not receiving current and relevant care. Findings:During a review of Resident 4's Face Sheet, the Face Sheet indicated that Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnosis included respiratory failure (a condition where there's not enough oxygen in the body), cerebral infarction (death of brain tissue), and Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 4's History & Physical (H&P), dated 6/27/2025, the H&P indicated Resident 4 did not have the capacity to make decisions.During a review of Resident 4's physician order, dated 6/15/2026, physician order indicated to clean the diabetic ulcer with normal saline solution, pat dry, apply betadine (povidone-iodine, an antiseptic) swab, cover with dry dressing, and secure with kerlix (a highly absorbent gauze bandage) every day for 21 days.During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 3/16/2026, the MDS indicated that Resident 4 was dependent on staff to roll left and right.During a review of Resident 4's Care Plan Report, titled Diabetic Ulcer, initiated on 9/19/2025, the Care Plan report did not indicate a revised date.During a concurrent interview and record review on 6/26/2026 at 2:07 p.m. with Minimum Data Set Nurse (MDSN 2), Resident 4's Care Plan report titled, Diabetic Ulcer was reviewed. MDSN 2 stated the care plan did not have a revision date. MDSN 2 stated without the revision date, the facility could not determine whether the diabetic wound care plan interventions were effective and if the wound was healing.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plans, undated, the P&P indicated the interdisciplinary team (a group of health care professionals who work together toward the goals of their patients) would review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment.During a review of the facility's P&P titled, Interdisciplinary Team Care Planning, undated, the P&P indicated the revision of care planning was done quarterly or as needed when patient's condition or needs change.

Based on observation, interview, and record review, the facility failed to ensure:a. a pack of cigarettes was safely stored for one of four sampled residents (Resident 20).b. Resident 65 who requires supervision (the helper provides verbal cues or touching/steadying as resident completes activity) during feeding was properly assisted for one of four sample residents (Resident 65). These failures had the potential to increase Resident 65's the risk of aspiration (inhalation of food, liquid, saliva, vomit, or other foreign material into the airway or lungs) and at risk for injury for Resident 20. Findings: During a review of Resident 20's Face Sheet, the Face Sheet indicated Resident 20 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 20's diagnosis included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), emphysema (a lung disease, causing difficulty in breathing), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 20's History and Physical (H&P), dated 6/15/2026, the H&P indicated Resident 20 had the capacity to understand and make medical decisions. During a review of Resident 20's Minimum Data Sheet (MDS, a resident assessment tool), dated 5/16/2026, the MDS indicated Resident 20's cognition (ability to think and process) was intact. The MDS indicated Resident 20 required supervision (helper provides verbal cues to complete activities) from staff for personal hygiene, showers, and dressing. The MDS indicated Resident 20 received oxygen therapy (a medical treatment that provides supplemental oxygen to individuals who cannot get enough naturally). During an observation on 6/24/2026 at 11:39 a.m. in Resident 20's room, there was a pack of cigarettes and a single cigarette (out of the pack) on Resident 20's bedside table. During a review of Resident 20's Interdisciplinary Team (IDT, a group of health care professionals from different disciplines collaborating) note, dated 5/6/2026, the IDT note indicated Resident 20 had unsafe behavior of smoking inside his room while on continuous oxygen therapy. The IDT indicated the interventions would include staff monitoring Resident 20 closely for possession and use of smoking materials in prohibited areas. During a review of Resident 20's Smoking and Safety assessment, dated 6/15/2026, the smoking and safety assessment indicated Resident 20 used tobacco products. The smoking and safety indicated Resident 20 were to follow the facility's policy on location and time of smoking. During a concurrent interview and record review on 6/25/2026 at 10:00 a.m., with MDS Nurse 1 (MDSN 1), Resident 20's IDT note, dated 5/6/2026, was reviewed. MDSN 1 stated the staff did room rounds daily before stand-up meetings (a brief, daily check-in where teams meet to align daily goals). MDSN 1 stated during rounds, the staff should monitor for cigarettes in the room. During a concurrent interview and record review on 6/25/2026 at 10:05 a.m. with Assistant Director of Nursing (ADON), a picture of Resident 20's room with a pack of cigarettes and a single cigarette (out of the pack) on his bedside table, dated 6/24/2026 was reviewed. The ADON stated cigarettes were not allowed in the residents' rooms. The ADON stated it was dangerous to have any smoking materials in Resident 20's room because he smoked and used oxygen. The ADON stated it was a fire hazard and placed Resident 20 at risk of starting a fire due to the oxygen in the room. During a review of the facility's policy and procedure (P&P) titled, Smoking, undated, the P&P indicated the facility was required to ensure the safety of all residents. The P&P indicated the facility recognized the resident's right to smoke but would comply with local state and federal smoking regulations to ensure the safety of residents. The P&P indicated there would be no smoking in any room or where oxygen was in use or stored. During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 65's diagnoses included traumatic subdural hemorrhage (bleeding between layers the brain caused by a head injury), metabolic encephalopathy (a brain dysfunction caused by an underlying chemical processes problem), major depressive disorder (a mental health condition characterized by a persistent low mood, loss of interest, and significant impairment in daily functioning). During a review of Resident 65's H&P form, dated 6/22/25, the H&P indicated Resident 65 has a history of aspiration pneumonia (lung infection that occurs when food, liquid, saliva, vomit, or stomach contents are inhaled into the lungs) and does not have the capacity to understand and make decisions. During a review of Resident 65's MDS, dated [DATE], the MDS indicated Resident 65 required supervision or touching assistance (helper provides verbal cues or touching or contact guard assistance as resident completes activity) from staff while eating. During a review of Resident 65's aspiration care plan (an individualized plan of care developed for residents who are at risk for aspiration), dated 6/11/2026, the care plan indicated, Resident is at risk for aspiration of food and liquids secondary to dysphagia (difficulty swallowing). The care plan interventions indicated, Speech therapy (ST, health professional who evaluates, diagnoses, and treats communication and swallowing disorders) evaluation and treatment as order. Monitor for sign and symptom of aspiration. Monitor tolerance of diet and fluids. During a review of Resident 65's progress notes titled, Speech Therapy Note, dated 7/17/2025, the therapy notes indicated, Resident 65 requires a feeder to monitor during meals and prompt to utilize safe swallow strategies. Strategies for feeding posted on the wall at bedside. Feeder at bedside with patient for breakfast, lunch, and dinner. During the review of Resident 65's Order Summary Report (a document containing active physician orders), dated 6/25/2026, the Order Summary Report indicated, every day shift every Mon, Tue, Wed, Thu, Fri, Sat, Sun Resident 65 requires close supervision during meal d/t high aspiration risk. Resident 65cannot recall any safe swallow strategies. During a concurrent observation and interview on 6/23/2026 1:40 p.m., with Resident 65, Resident 65 had a meal tray on the bedside table, and no staff members were present in the room. Resident 65 stated not sure if lunch had arrived and he was feeling hungry. During an interview on 6/23/2026 at 2:19 p.m., with Certified Nursing Assistant (CNA ) 2,. CNA 2 stated Resident 65 can eat meals independently. CNA 2 stated Resident 65 lunch was delivered to at approximately 1:00 p.m., and no staff were in the room during lunch to assist or monitor because Resident 65 does not require supervision or assistance. During an observation on 6/25/2026 12:56 p.m., in Resident 65's room, CNA 2 placed the meal tray on Resident 65 bedside table and then left the room. During an observation on 6/25/2026 12:58 p.m., in the hallway, Resident 65 yelling and stating, Hey, hello! no staff went inside Resident 65 to help. During a concurrent observation and interview on 6/25/2026 1:14 p.m., with Resident 65, Resident 65 sat at the bedside with meal tray placed on the side table. Resident 65 stated he tried the food and did not like it, and he had been calling and no one came. During a concurrent interview and record review on 6/25/2026 at 1:16 p.m., with Registered Nurse (RN) 4, RN 4 stated a prior speech therapy assessment determined Resident 65 could not safely eat without supervision due to cognitive impairment and swallowing difficulties. RN 4 stated that Resident 65 sometimes forgets to swallow or may fall asleep with food in the mouth. RN 4 stated that no staff supervised Resident 65 during lunch today 6/25/2026. A review of Resident 65's physician order indicated the resident requires supervision for all meals, and the aspiration care plan directs staff to monitor diet tolerance. RN 4 stated the facility did not follow the physician order or the resident's care plan, and noted that failing to do so increases the risk of aspiration. During a review of the facility's P&P titled Assistance with Meals, dated 7/2017, the P&P indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident.

Based on observation, interview, and record review, the facility failed to ensure the nasal cannula (NC, a flexible device used to deliver supplemental oxygen to people who have difficulty breathing) tubing was changed weekly per policy for one of four sampled residents (Resident 128).This deficient practice had the potential for Resident 128 to develop a respiratory infection (an infectious disease of the upper or lower respiratory tract).Findings:During a review of Resident 128's Face Sheet, the Face Sheet indicated Resident 128 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 128's diagnosis included emphysema (a lung disease, causing difficulty in breathing), respiratory failure (a critical condition where the respiratory system fails in its primary function of gas exchange), and asthma (a chronic lung disease where the airways become inflamed, swollen, and narrow, making it difficult to breathe).During a review of Resident 128's History and Physical (H&P), dated 6/3/2026, the H&P indicated Resident 128 was able to make decisions for activities of daily living.During a review of Resident 128's Minimum Data Sheet (MDS, a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 128's cognition (ability to think and process) was intact. The MDS indicated Resident 128's was dependent (helper does all of the effort and the resident does none of the effort to complete the activity) on staff for toileting hygiene, showers, and dressing. During a review of Resident 128's physician order, dated 6/2/2026, the physician order indicated changing the nasal cannula every night shift on Sundays.During an observation on 6/25/2026 at 10:08 a.m., in Resident 128's room, Resident 128 was using an NC dated 6/17/2026. The NC was attached to an oxygen concentrator (a type of medical device used to deliver oxygen to individuals with breathing-related disorders) infusing at five liters ([L]-a metric unit of volume used to measure liquids and gases).During a concurrent interview and record review on 6/26/2026 at 11:28 a.m. with Minimum Data Set Nurse (MDSN) 2, Resident 128's picture of the NC attached to an oxygen concentrator, dated 6/17/2026 was reviewed. MDSN 2 stated the NC tubing was dated 6/17/2026. MDSN 2 stated the NC had to be changed every Sunday. MDS 2 Nurse stated the NC was to be changed weekly per policy to prevent bacteria accumulation and not changing the NC weekly could potentially cause a respiratory infection.During a review of facility's policy and procedure (P&P) titled, Changing Disposable Equipment, dated 3/2019, the P&P indicated to change nasal cannula on Saturdays and as needed.

Based on observation, interview, and record review, the facility failed to ensure:1. Staff food was not stored in medication storage 2 refrigerator.2. Discontinued ondansetron hydrochloride (medication that prevents and treat nausea and vomiting) was removed from medication cart one for one out of one sampled resident (Resident 141).3. Aerosol nebulizers (a liquid prescription converted into a breathable mist to treat respiratory conditions) were properly stored for one out of one sampled resident (Resident 20).These deficient practices had the potential to result in cross contamination (transfer of harmful bacteria from one place to another) that could compromise the efficacy of the medications, prolonged use of the discontinued medication for Resident 141, and Resident 20 using the medication unsafely.Findings: 1. During a concurrent observation and interview on 6/24/2026 at 11:29 a.m., with Licensed Vocational Nurse 5 (LVN 5) in medication storage 2, one yellow banana was stored inside the medication refrigerator. LVN 5 stated staff food should not be stored in the medication refrigerator. LVN 5 stated storing staff food inside the medication refrigerator could cause cross contamination with the refrigerated medications. 2. During a review of Resident 141's Face Sheet, the Face Sheet indicated Resident 141 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), urinary tract infection (UTI, an infection in the bladder/urinary tract), and hypertension (HTN, high blood pressure). During a review of Resident 141's History and Physical (H&P), dated 11/25/2025, the H&P indicated, Resident 141 could understand and make own medical decisions. During a review of Resident 141's physician order, dated 5/9/2026, the physician order indicated to administer ondansetron hydrochloride 4 milligrams (mg, metric unit of measurement) one tablet every 6 hours as needed for nausea and vomiting for 14 days. During a review of Resident 141's Minimum Data Set (MDS, a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 141's cognition (ability to think and process) was intact. The MDS indicated Resident 141 required substantial assistance (helper does more than half the effort) from staff with upper body dressing and personal hygiene. During a concurrent observation and interview on 6/24/2026 at 12:28 p.m. with LVN 7 of medication cart one, there was one bubble pack (blister pack, organizes pills into individual, sealed compartments according to the exact day and time they need to be taken) with 8 remaining medications of ondansetron hydrochloride 4 mg for Resident 141. LVN 7 stated Resident 141's ondansetron hydrochloride 4 mg should have been removed from medication cart one on 5/23/2026, which was 14 days after it was ordered by the physician. LVN 7 stated resident's discontinued medication should be stored in a bin located at the nursing office for destruction. LVN 7 stated there was a risk the discontinued medication would be given to Resident 141 because it was not removed from medication cart one. 3. During a review of Resident 20's Face Sheet, the Face Sheet indicated Resident 20 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 20's diagnosis included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), emphysema (a lung disease, causing difficulty in breathing), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 20's H&P, dated 6/15/2026, the H&P indicated Resident 20 had the capacity to understand and make medical decisions. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20's cognition was intact. The MDS indicated Resident 20 required supervision (helper provides verbal cues to complete activities) from staff for personal hygiene, showers, and dressing. The MDS indicated Resident 20 received oxygen therapy a (medical treatment that provides supplemental oxygen to individuals who cannot get enough naturally). During a review of Resident 20's assessment titled, Self-Administration of Medication, dated 5/30/2026, the assessment indicated it was unsafe for Resident 20 to self-administer medications and may not keep medications at the bedside. During an observation on 6/24/2026 at 11:39 a.m. in Resident 20's room, Resident 20 had three vials of aerosol nebulizers on his bedside table. During a concurrent interview and record review on 6/25/2026 at 10:29 a.m., with MDS Nurse 2 (MDSN 2), a picture of Resident 20's bedside table, dated 6/24/2026, was reviewed. MDSN 2 stated Resident 20 had aerosol nebulizers on his bedside table. During a concurrent interview and record review on 6/25/2026 at 10:33 a.m., with MDSN 2, Resident 20's assessment titled, Self-Administration of Medication, dated 5/30/2026 was reviewed. The assessment indicated it was unsafe for Resident 20 to self-administer medications and may not keep medications at the bedside. MDSN 2 stated Resident 20 was not to have medication at the bedside. MDSN 2 stated the medication was to be stored in the medication cart. MDSN 2 stated leaving the mediation at the bedside placed Resident 20 at risk for improperly using the medication and another resident could get access to the medication. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 4/2019, the P&P indicated medications are stored separately from food and labeled accordingly. During a review of the facility's P&P titled, Discontinued Medications, dated 3/2023, the P&P indicated staff shall destroy discontinued medications or return them to the dispensing pharmacy in accordance with facility policy. During a review of the facility's P&P titled, Storage of Medication, undated, the P&P indicated the facility stored all drugs and biologicals in a safe, secure, and orderly manner. The P&P indicated drugs and biologicals used in the facility were stored in locked compartments.

Based on interview and record review, the facility failed to implement the physician's orders to draw laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for one of one sampled resident (Resident 2).This deficient practice had the potential to result in the delay of the identification of medical concerns, which could delay the care and services necessary for Resident 2.Findings:During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included bipolar disorder (sometimes called manic depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 2's H&P, dated 3/23/2026, the H&P indicated Resident 2 was able to make decisions for activities of daily living.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 4/9/2026, the MDS indicated Resident 2's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 2 was dependent (helper does all of the effort) on staff for eating, oral hygiene, and toileting hygiene.During a review of Resident 2's physician order, dated 4/14/2026, the physician order indicated Resident 2 had orders for Complete Blood Count (CBC, a blood test that checks the overall health of the blood by measuring the number and types of cells), Thyroid Stimulating Hormone (TSH, a blood test that measures this hormone), basic metabolic panel (BMP, a routine blood test that measures eight key substances to evaluate your body's fluid balance, kidney function, and blood sugar), Free Thyroxine (FT4, a blood test that measures the active, unbound T4 hormone in your bloodstream), pre-albumin (it measures the level of protein in your blood), iron panel (blood test that measures your body's total iron levels, how much iron is stored, and how iron moves through your bloodstream), and Depakote level (blood test to measure the amount of valproic acid level in the blood).During a concurrent interview and record review on 6/24/2026 at 3:40 p.m., with Registered Nurse 3 (RN 3), Resident 2's laboratory results, were reviewed. RN 3 stated Resident 2's order for CBC, TSH, BMP, FT4, pre-albumin, and Depakote level were not completed and results were not available. RN 3 stated there was no documentation that Resident 2 refused the blood test. RN 3 stated there was no documentation that the licensed nurse staff made a follow-up call to the laboratory provider to find out what happened with the laboratory results. RN 3 stated it was important to complete the laboratory test as ordered by the physician to know and identify the medical condition of the resident especially if there was a deviation from resident's baseline and to give appropriate treatment immediately without delay. RN 3 stated she would obtain a new order for CBC, TSH, BMP, FT4, pre-albumin, and Depakote level from Resident 2's physician since the previous laboratory tests orders were not completed.During a review of the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results-Clinical Protocol, dated 11/2018, the P&P indicated the physician would identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs and the staff would process test requisitions and arrange for tests.Cross Reference: F842

Based on interview, and record review, the facility failed to ensure:1. The notes for ordering the laboratory tests (a medical analysis of a body sample [blood, urine, tissue] to check health, diagnose diseases and monitor chronic conditions) were documented in the progress notes for one of one sampled resident (Resident 2).2. The out on pass (OOP, temporary permission to leave a confined facility) log was complete for one of one sampled resident (Resident 20).This deficient practice had the potential to place Resident 2 at risk of not receiving appropriate care and delay in communication among staff due to incomplete medical records and placed Resident 20 at risk for medical complications while OOP. Findings: 1. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included bipolar disorder (sometimes called manic depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 2's History and Physical (H&P), dated 3/23/2026, the H&P indicated Resident 2 was able to make decisions for activities of daily living. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 4/9/2026, the MDS indicated Resident 2's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 2 was dependent (helper does all of the effort) on staff for eating, oral hygiene, and toileting hygiene. During a review of Resident 2's physician order, dated 4/14/2026, the physician order indicated Resident 2 had orders for Complete Blood Count (CBC, a blood test that checks the overall health of the blood by measuring the number and types of cells), Thyroid Stimulating Hormone (TSH, a blood test that measures this hormone), basic metabolic panel (BMP, a routine blood test that measures eight key substances to evaluate your body's fluid balance, kidney function, and blood sugar), Free Thyroxine (FT4, a blood test that measures the active, unbound T4 hormone in your bloodstream), pre-albumin (it measures the level of protein in your blood), iron panel (blood test that measures your body's total iron levels, how much iron is stored, and how iron moves through your bloodstream), and Depakote level (blood test to measure the amount of valproic acid in the blood). During a concurrent interview and record review on 6/24/2026 at 3:16 p.m., with Registered Nurse 3 (RN 3), Resident 2's Progress Notes, were reviewed. RN 3 stated Resident 2's medical records were incomplete due to missing a note by the licensed nurse regarding the physician order for laboratory test on 4/14/2026. RN 3 stated the licensed nurse should document in the Progress Notes when receiving an order from the physician. RN 3 stated she does not know the reason why the physician of Resident 2 ordered a laboratory test since there was no documentation in the Progress Notes. RN 3 stated it was important to have complete documentation to prevent communication breakdown and for collaboration of care among facility staff. During an interview on 6/26/2026 at 9:11 a.m., with the Director of Nursing (DON), the DON stated any laboratory test order should be documented in the resident's Progress Notes. The DON stated the resident's medical records should be complete to provide continuity of care. 2. During a review of Resident 20's Face Sheet, the Face Sheet indicated Resident 20 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 20's diagnosis included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), emphysema (a lung disease, causing difficulty in breathing), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 20's H&P, dated 6/15/2026 the H&P indicated Resident 20 had the capacity to understand and make medical decisions. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20's cognition was intact. The MDS indicated Resident 20 required supervision (helper provides verbal cues to complete activities) from staff for personal hygiene, showers, and dressing. The MDS indicated Resident 20 received oxygen therapy (a medical treatment that provides supplemental oxygen to individuals who cannot get enough naturally). During a review of Resident 20's Progress Note, dated 4/20/2026, the progress note indicated Resident 20 went OOP. During a review of Resident 20's Weights and Vitals Summary, dated 4/20/2026, the weights and vitals summary indicated there were no vitals taken prior to Resident 20 leaving the facility for OOP. During a concurrent interview and record review on 6/25/2026 at 1:35 p.m., with Assistant Director of Nursing (ADON), facility's OOP log titled, Release of Responsibility for Out On Pass and/or Therapeutic Home Visits, date not legible, the OOP log indicated Resident 20 had left the facility, and the date was not legible with no time. The OOP log indicated Resident 20 had returned to the facility at 11:12 (a.m. or p.m.) unknown with no date of return. The ADON indicated the date was unclear and there was no time when Resident 20 had left the facility. The ADON indicated there was no date on the OOP log when Resident 20 had returned and the time did not indicate if it was in the morning or afternoon. The ADON stated the staff had to make sure Resident 20 properly filled out the OOP log so staff could keep track of the date and time when Resident 20 was OOP and returned to make sure he did not develop any complications while OOP. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical records. The P&P indicated documentation of procedures and treatments will include care-specific details including whether the resident refused the procedure or treatment. During a review of the facility's P&P titled, Signing Residents Out, dated 8/2006, the P&P indicated all residents leaving the premises must be signed out. The P&P indicated registers must indicate the resident's expected time of return. The P&P indicated residents must be signed in upon return to the facility.

Based on observation and interview, the facility failed to ensure a foam pool noodle (used for swimming) was not used as a siderail for one of 7 sampled residents (Resident 85).This deficient practice had the potential to result in contamination due to a porous (a material or surface containing tiny holes, spaces, or gaps) foam pool noodle being used as a siderail, which can hold bacteria and viruses.Findings:During a review of Resident 85's Face Sheet, the Face Sheet indicated Resident 85 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 85's diagnoses included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), schizoaffective disorder- bipolar type, (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), hypertension (high blood pressure), and chronic obstructive pulmonary disorder (COPD, a chronic lung disease causing difficulty in breathing).During a review of Resident 85's History and Physical (H&P), dated 2/5/2025, the H&P indicated Resident 85 had the capacity to understand and make decisions.During a review of Resident 85's Minimum Data Set (MDS, a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 85's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 85 required partial assistance (helper does less than half the effort) from staff for oral hygiene, personal hygiene, and sitting to standing.During an observation on 6/23/2026 at 12:46 p.m. in Resident 85's room, of Resident 85's bed, Resident 85's upper bed siderails had foam padded siderails.During a concurrent observation and interview, on 6/25/2026 at 11:55, with Infection Prevention Nurse 1 (IPN 1), Resident 85's upper bed siderails had foam padded siderails. IPN 1 stated foam siderails were used for residents who had diagnoses of seizures and falls. IPN 1 stated Resident 85 was a fall risk. IPN 1 stated foam siderails were porous and could hold bacteria and viruses. IPN 1 stated the risk of having foam siderails could result in a source of infection and harbor bacteria.During a review of the facility's policy and procedures (P&P), titled Policies and Procedures- Infection Prevention and Control, undated, the P&P indicated to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on interview and record review, the facility failed to obtain and document informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of four sampled residents (Resident 144) prior to administering treatment with psychotherapeutic medications (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior).This deficient practice violated Resident 144's and their responsible party (RP)'s right to make an informed decision regarding the use of psychotherapeutic medications. Findings:During a review of Resident 144's Face Sheet, the Face Sheet indicated Resident 144 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (a condition in which the heart muscle could not pump blood as well as it should), presence of a cardiac pacemaker (a device that prevents the heart from beating too slowly), and dementia (a progressive state of decline in mental abilities).During a review of Resident 144's History & Physical (H&P) dated 10/22/2025, the H&P indicated Resident 144 did not have the capacity to understand and make decisions. During a review of Resident 144's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2026, the MDS indicated Resident 144's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 144 required substantial assistance (helper does more than half the effort) from staff for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear.During a review of Resident 144's physician order, dated 3/26/2026, the physician order indicated to administer Rexulti (medication used for agitation associated with dementia) 1 milligram (mg, a unit of measurement) oral tablet by mouth in the morning for Alzheimer disease (a disease characterized by a progressive decline in mental abilities) for agitation associated with dementia.During a review of Resident 144's Social Service Note, dated 5/14/2026, the note indicated the coroner's office called the facility regarding Resident 144's son, who passed on 1/25/2026.During a review of Resident 144's Medication Administration Record (MAR) dated 6/1/2026 through 6/30/2026, the MAR indicated Rexulti 1 mg tablet was administered daily as ordered.During a concurrent interview and record review on 6/26/2026 at 11:18 a.m. with Licensed Vocational Nurse (LVN) 8, Resident 144's Psychotherapeutic Drug Informed Consent Form for Rexulti, dated 3/25/2026, was reviewed. The form indicated Resident 144's son was Resident 144's representative. The form indicated Resident 144's son was notified and understood and gave consent to the treatment via phone call with Nurse Practitioner (NP) 1 on 3/25/2026. LVN 8 stated it was NP 1's responsibility to explain to the residents, or their responsible party, the benefits, side effects, and right to refuse treatment. LVN 8 stated her signature on the form indicated confirmation that Resident 144's son gave consent for the drug Rexulti to NP 1. LVN 8 stated she was unable to confirm if the prescriber spoke to Resident 144's son because she left a message to the son and he did not return the call. LVN 8 stated she was not aware Resident 144's son's passed away on 1/26/2026. LVN 8 stated the medication should not be given if the consent was not verified.During a review of the facility's policy and procedure (P&P) titled Psychotherapeutic Drug Informed Consent revised 1/2026, the P&P indicated residents and/or their representatives would be fully informed of the benefits, risks, frequency/duration, possible side effects and alternative approaches before initiating the administration of psychotherapeutic drugs.

Based on interview and record review, the facility failed to ensure two of six sampled residents (Resident 7 and 144) had completed Advance Healthcare Directive Acknowledgement (AHCD, a legal document indicating resident preference on end-of-life treatment decisions) by failing to:Inform and offer Resident 7's representative the right to formulate an AHCD. Maintain a current copy of Resident 144's AHCD in his clinical records.This deficient practice had the potential to cause conflict with resident's wishes that could delay treatment or life sustaining procedures in the event of an emergency for Residents 7 and 144.Findings: 1. During a review of Resident 7's Face Sheet, the Face Sheet indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), osteoarthritis of knee (a progressive disorder of the joints, caused by a gradual loss of cartilage), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 7's History and Physical (H&P), dated [DATE], the H&P indicated Resident 7 could not make decisions. During a review of Resident 7's Psychosocial Assessment Form, dated [DATE], the Psychosocial Assessment Form indicated Resident 7 did not have an advance directive. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 7 was able to understand and be understood by others. The MDS indicated Resident 7's cognition (ability to think and process) was intact. The MDS indicated Resident 7 was dependent (helper does all of the effort) on staff for activities of daily living such as oral hygiene, toileting hygiene, and upper and lower body dressing. During a concurrent interview and record review on [DATE] at 2:24 p.m., with the Social Service Director (SSD), Resident 7's AHCD Acknowledgement Form, dated [DATE], was reviewed. The AHCD Acknowledgement Form did not indicate whether Resident 7's representative was given written materials about the right to accept or refuse treatments. The form did not indicate whether Resident 7's representative was informed of the rights to formulate an AHCD. The form indicated there was no signature for Resident 7's representative. The AHCD Acknowledgement Form indicated Resident 7 was not capable of making decisions. The SSD stated she was responsible for offering and following up on the AHCD with the resident's representative. The SSD stated she called and spoke with Resident 7's representative on [DATE] but did not inform nor offer the right to formulate an AHCD. The SSD stated it was important to have resident's AHCD so the facility staff would know the resident's healthcare wishes during an emergency. The SSD stated by not offering an AHCD, it was a violation of the resident's rights because the resident's representative was not given a choice regarding medical decision making and interventions during end-of-life care. During an interview on [DATE] at 9:19 a.m. with the Director of Nursing (DON), the DON stated an AHCD was a written instruction or wishes of resident on what the facility staff would do in case of resident's change of condition or life-threatening situation. 2. During a review of Resident 144's Face Sheet, the Face Sheet indicated Resident 144 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (a condition in which the heart muscle could not pump blood as well as it should), presence of a cardiac pacemaker (a device that prevents the heart from beating too slowly), and dementia (a progressive state of decline in mental abilities). During a review of Resident 144's H&P, dated [DATE], the H&P indicated Resident 144 did not have the capacity to understand and make decisions. During a review of Resident 144's AHDA, dated [DATE], the AHDA indicated Resident 144 was not capable of making decisions. The AHDA indicated the facility did not document Resident 144's decision regarding advance directives. During a review of Resident 144's MDS, dated [DATE], the MDS indicated Resident 144's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 144 required substantial assistance (helper does more than half the effort) from staff for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. During a concurrent interview and record review on [DATE] at 10:36 a.m. with the SSD, Resident 144's AHDA was reviewed. The SSD stated Resident 144's son usually made decisions for him. The SSD stated the facility was informed that Resident 144's son died on [DATE]. The SSD stated the facility was waiting for Resident 144's doctor to sign the form and the document needed to be completed to be legitimate. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 12/2016, the P&P indicated if the resident was incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. The P&P indicated information about whether or not the resident has executed an advance directive would be available in the medical record.

Based on interview and record review, the facility failed to ensure a change of condition (COC, any new, worsening, or significant deviation from a patient's normal baseline health status) was completed for one of four sampled residents (Resident 20).This deficient practice had the potential for information regarding Resident 20's change in condition to not be accurate.Findings:During a review of Resident 20's Face Sheet, the Face Sheet indicated Resident 20 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 20's diagnosis included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), emphysema (a lung disease, causing difficulty in breathing), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 20's History and Physical (H&P), dated 6/15/2026, the H&P indicated Resident 20 had the capacity to understand and make medical decisions.During a review of Resident 20's Minimum Data Sheet (MDS, a resident assessment tool), dated 5/16/2026, the MDS indicated Resident 20's cognition (ability to think and process) was intact. The MDS indicated Resident 20 required supervision (helper provides verbal cues to complete activities) from staff for personal hygiene, showers, and dressing. During a review of Resident 20's discharged Summary Report, dated 1/23/2026, the discharge summary report indicated Resident 20 complained of chest pain and 911 (a universal three-digit telephone number used to reach emergency services) was called.During a concurrent interview and record review on 6/24/2026 at 3:40 p.m. with Registered Nurse (RN) 1, Resident 20's discharged Summary Report, dated 1/23/2026 was reviewed. The discharge summary report indicated Resident 20 complained of chest pain and 911 was called. RN 1 stated when Resident 20 had a change of condition, a COC was to be completed even after 911 was called. RN 1 stated the COC for Resident 20 was not done. RN 1 stated the COC would include an assessment of the change and the notification of the physician and family. RN 1 stated completion of the COC documentation was important to ensure staff had accurate information regarding Resident 14's change in his medical condition.During a facility's review of policy and procedures (P&P) titled, Change in a Resident's Condition or Status, dated 3/2023, the P&P indicated prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant information prompted by the Situation Background Assessment and Recommendation (SBAR) communication form. The P&P indicated notifications will be made within twenty-four hours of a change occurring in the resident medical condition or status.

Based on interview and record review, the facility failed to ensure a written Notice of Proposed Transfer and Discharge Form was provided to the resident representative and sent to local ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one of six sampled residents (Resident 164).This deficient practice had the potential to compromise Resident 164's due process rights related to transfer.Findings:During a review of Resident 164's Face Sheet, the Face Sheet indicated Resident 164 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 164's diagnoses included hypertension (HTN, high blood pressure), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 164's History and Physical (H&P), dated 1/3/2026, the H&P indicated, Resident 164 did not have the capacity to understand and make decisions.During a review of Resident 164's Situation, Background, Assessment and Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/1/2026, the SBAR indicated Resident 164 was transferred to the General Acute Care Hospital (GACH) for swelling of the right upper extremity.During a review of Resident 164's Minimum Data Set (MDS, a resident assessment tool), dated 3/23/2026, the MDS indicated Resident 164 was able to understand and be understood by others. The MDS indicated Resident 164 required substantial assistance (helper does more than half the effort) from staff with oral hygiene, toileting hygiene, and upper body dressing.During a concurrent interview and record review on 6/25/2026 at 11:45 a.m., with Registered Nurse 3 (RN 3), Resident 164's Notice of Proposed Transfer and Discharge Form, dated 3/1/2026, was reviewed. RN 3 stated there was no evidence the facility provided a written Notice of Proposed Transfer and Discharge to Resident 164's representative nor faxed the notice to the local ombudsman office. RN 3 stated it was not the facility's practice to provide a written copy of the Notice of Proposed Transfer and Discharge to the resident or resident's representative. RN 3 stated Resident 164's representative was not informed about the appeal process when Resident 164 was transferred to the GACH on 3/1/2026. RN 3 stated it was important to notify and fax the Notice of Proposed Transfer and Discharge to the local ombudsman so they would know that the resident was no longer under the care of the facility and for transparency.During an interview on 6/25/2026 at 12:24 p.m. with the Social Service Director (SSD), the SSD stated it was important to notify the local ombudsman if the resident was transferred to an acute hospital or discharged to lower level of care to ensure resident's rights were protected. The SSD stated it was important to provide a written copy of the Notice of Proposed Transfer and Discharge to the resident or resident's representative so they would be aware of their right to make an appeal if they feel that the resident was not safe for discharge.During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, dated 3/2025, the P&P indicated upon transfer or discharge, the resident would be provided with a statement of his or her right to appeal the transfer or discharge which includes the name, address, email, and telephone number of the entity who received that request and the information about how to obtain, complete and submit an appeal form.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a structured, personalized roadmap that outlines an individual's health conditions, care needs, and specific goals) for two of 36 sampled residents (Resident 8 and 14) by failing to ensure a care plan was created for:Resident 8's diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).Resident 14's diagnosis of dementia (a progressive state of decline in mental abilities).This failure had the potential to result in a lack of meeting necessary care and addressing medical needs for Resident 8 and had the potential for Resident 14 to not receive monitoring of dementia behavior symptoms and medication management. Findings: 1. During a review of Resident 8's Face Sheet, the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 8's diagnoses included bipolar disorder, epilepsy (a chronic brain disorder characterized by repeated, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 8's History and Physical (H&P), dated 5/22/2025, the H&P indicated Resident 8 had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 4/8/2026, the MDS indicated Resident 8's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 8 was dependent (helper does all of the effort) from staff with toileting hygiene, lower body dressing, and personal hygiene. The MDS indicated Resident 8 had an active bipolar disorder diagnosis. During a concurrent interview and record review on 6/25/2026 at 9:18 a.m., with Minimum Data Set Nurse 2 (MDSN 2), Resident 8's care plans were reviewed. MDSN 2 stated there were no bipolar disorder care plans for Resident 8. MDSN 2 stated all resident's information triggered in the MDS should have an individualized comprehensive care plan. MDSN 2 stated it was important to develop individualized comprehensive care plans for residents to address their health statuses and meet the needs of the residents. MDSN 2 stated a care plan was a communication tool among facility staff and the interdisciplinary team (IDT, team members from different disciplines who come together to discuss resident care). MDSN 2 stated the facility did not have interventions in place to address and manage Resident 8's bipolar disorder since there was no care place developed. 2. During a review of Resident 14's Face Sheet, the Face Sheet indicated Resident 14 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 14's diagnosis included encephalopathy (an umbrella term for any disease, damage, or malfunction that affects the brain's structure or function), dementia, and mood disturbances (mental health conditions that cause intense, persistent emotional states). Resident 14 was diagnosed with dementia on 6/6/2026. During a review of Resident 14's H&P, dated 6/6/2026, the H&P indicated Resident 14 had the capacity to make needs known. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14's cognition was intact. The MDS indicated Resident 14 required set-up or clean-up assistance (helper sets up or cleans up and residents completes activity) from staff for toileting hygiene, showers, and dressing. During a review of Resident 14's physician orders, dated 6/6/2026, the physician orders indicated to administer Aricept (to treat the symptoms for dementia) and memantine (to treat moderate to severe dementia). During a review of Resident 14's physician orders, dated 6/16/2026, the physician orders indicated to administer Zunveyl (to treat mild to moderate dementia) to treat dementia. During a concurrent interview and record review on 6/26/2026 at 11:22 a.m., with Assistant Director of Nursing (ADON), Resident 14's Face Sheet was reviewed. The Face Sheet indicated Resident 14 was diagnosed with dementia on 6/6/2026. The ADON could not locate a care plan for Resident 14's diagnosis of dementia. The ADON stated a care plan should include the diagnosis so the staff could monitor Resident 14's behavior. During a concurrent interview and record review on 6/26/2026 at 11:30 a.m., with MDS Nurse 2, Resident 14's physician orders were reviewed. The physician orders indicated Resident 14 resident was on medications Aricept, memantine, and Zunveyl to treat dementia. MDS Nurse 2 stated there was no care plan created for these medications for dementia. MDS Nurse 2 stated there should be a care plan for these medications. MDS Nurse 2 stated the care plan was used as a guideline to manage and monitor Resident 14's behavior. During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, undated, the P&P indicated comprehensive person-centered care plans were based on resident assessments and developed by an interdisciplinary team. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, undated, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives, needs were developed and implemented for each resident. The P&P indicated which professional services are responsible for each element of care. The P&P indicated to include resident's stated goals, desired outcomes, and reflects currently recognized standards of practice for problem areas and conditions. During a review of the facility's P&P titled, Safety and Supervision of Residents, undated, the P&P indicated the care team shall target interventions to reduce individuals risk related to hazards in the environment including adequate supervision.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Abuse and Mistreatment of Residents, which indicated residents will be free from verbal, sexual, and mental abuse, corporal punishment, involuntary seclusion for two of three sampled residents (Resident 1 and Resident 2) by a License Vocational Nurse (LVN 1). LVN 1 cursed, yelled and pushed Resident 1 on to his bed. LVN 1 was rude and yelled at Resident 2. This deficient practice resulted in Resident 1 crying and feeling fearful. It also resulted in Resident 2 feeling inhuman, withdrawn and anxious (feeling uneasy). Findings: 1.A review of Resident 1 ' s admission record (Face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis that included diabetes (abnormal blood sugar), dementia (impairment of memory and judgement) with behavioral disturbance, and encephalopathy (disturbance of the brain function). A review of Resident 1 ' s history of physical (H&P) dated 7/20/2023, indicated Resident 1 was able to make decisions for activities of daily living. A review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 10/24/2023, indicated Resident 1 ' s cognitive skills (thought process) was moderately impaired and was sometimes understood by others. The MDS indicated Resident 1 required extensive assistance of one to two people assist with activities such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). The MDS indicated Resident 1 was always of bowel and bladder incontinent (inability to control bladder and bowel function). A review of Resident 1 ' s care plan titled Resident with episodes of uncontrollable mood swings, easily gets agitated and prefers to be alone, dated 11/13/2023, indicated interventions including to approach resident in a calm and friendly manner, if the resident became hostile during care, stopped, and resume back when resident had calm down. A review of Resident 1 ' s change in condition (COC) form dated 11/20/2023 at 3:05 a.m., indicated Certified Nurse Assistant (CNA) reported that Resident 1 was standing at the door of his room and was unable to be re-directed to his bed. The COC indicated LVN 1 assigned to Resident 1 assisted the CNA ' s in re-directing Resident 1 back to his bed. The COC indicated Resident 1 became aggressive and was swinging his arms uncontrollably. The COC indicated LVN 1 was unable to control Resident 1 ' s movements and LVN 1 became agitated and pushed Resident 1 onto his bed. A review of Resident 1 ' s interdisciplinary team ([IDT]- team members from difference disciplines working together to meet residents ' needs) dated 11/20/2023, indicated the IDT a meeting was held due to staff mishandling Resident 1. The IDT notes indicated Resident 1 became aggressive when staff asked him to return to his bed. The IDT notes indicated LVN 1 became agitated with Resident 1 and pushed the resident on to his bed. The notes indicated Resident was alert and oriented by name, but confused and unable to recall incident. b. A review of Resident 2 ' s face sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis including muscular dystrophy (loss of muscle), quadriplegia (condition in which both arms and legs are paralyzed), and depression (a mental health disorder affecting how a person thinks, feels and behaves). A review of Resident 2 ' s H&P dated 10/3/2023, indicated Resident 2 had the capacity to understand and make medical decisions. A review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 was able to understand and be understood by other. The MDS indicated Resident 2 required max assistance of two person assist for activities such as dressing, toilet use, personal hygiene, transfer, and bed mobility. The MDS indicated Resident 2 was always incontinent of bowel and bladder. A review of Resident 2 ' s IDT meeting notes, dated 12/12/2023, was held due to Resident 2 ' s allegations of verbal threats by LVN 1. The IDT notes indicated Resident 2 ' s alleged LVN 1 threatened him by stating don ' t you ever disrespect me. The IDT notes indicated Resident 2 felt frightened. A review of Resident 2 ' s physician psychiatric notes dated 12/13/2023, indicated Resident 2 was withdrawn during the interview and reported LVN 1 cursed at him when Resident 2 asked for his medication. The psychiatric notes indicated Resident 2 admitted to experiencing anxiety. During an interview on 12/11/2023 at 5:09 p.m. with CNA 1, CNA 1 stated Resident 1 was standing outside of his room [ROOM NUMBER]/202/2023 and even though he was not assigned to her (CNA 1), she was concerned that the resident would fall. CNA 1 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 1 stated LVN 1 walked over to Resident 1 and LVN 1 and CNA 1 grabbed Resident 1 by the arms and walked the resident back to his bed. CNA 1 stated LVN 1 was rushing Resident 1 back to his bed and Resident 1 became agitated and said, slow down I cannot walk that fast, I feel like I am going to fall. CNA 1 stated while at the edge of Resident 1 ' s bed, LVN 1 became agitated and pushed Resident 1 on the bed practically slamming the resident ' s body. CNA 1 stated LVN 1 proceeded to yell and curse at Resident 1 stating do not disrespect me. You will respect me and my nurses. CNA stated she observed LVN 1 place his right fist on Resident 1 ' s chest and the left fist inside Resident 1 ' s mouth as he continued to curse and yell at Resident 1. CNA 1 stated Resident 1 looked frightened and started crying stating please do not let that nurse hurt me. CNA 1 stated as soon as Resident 1 calmed down, she and CNA 2 reported the incident to the Registered Nurse (RN) Supervisor. CNA 1 stated this was not the first time she observed LVN 1 speaking harshly to Resident 1. CNA 1 stated Resident 2 also had encountered harsh treatments from LVN 1. CNA 1 stated Resident 2 had reported to her that LVN 1 had yelled at him stating you should be grateful that I am here. I could be at home with my family. During an interview on 12/11/2023 at 5:28 p.m. with CNA 2, CNA 2 stated she was walking towards the elevator to get linens with CNA 1 and noticed Resident 1 standing outside his room. CNA 2 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 2 stated LVN 1 and CNA 1 proceeded to re-direct Resident 1 back to his bed. CNA 2 stated when she walked into the room, she observed LVN 1 ' s right fist on Resident 1 ' s chest and his left fist on the resident ' s mouth yelling and cursing at Resident 1. CNA 2 stated LVN 1 was muzzling (preventing one from speaking freely) Resident 1 with his left fist. CNA 2 stated she pushed LVN 1 off of Resident 1 and told LVN 1 that he was not allowed to treat the residents is such manner. CNA 2 stated she observed Resident 1 crying and saying, please do not let that man hurt me. CNA 2 stated she and CNA 1 reported the incident to the RN Supervisor. CNA 2 stated at an unknown date and time, she observed Resident 2 crying after he was informed that LVN 1 was assigned to him. During an interview on 12/12/2023 at 1:45 p.m. with Resident 2, Resident 2 stated he experienced mistreatment from LVN 1 before. Resident 2 stated whenever he asked LVN 1 for assistance he would ignore him and when he yelled louder for LVN 1 to assist him, LVN 1 would tell him You should be grateful that I am helping you. LVN 1 stated Resident 2 reported LVN 1 made degrading remarks to him and would curse and yell at him. Resident 2 stated LVN 1 never hit him, but he would get in front of his face multiple times to the point where he felt afraid that one day, he would be physically hit by LVN 1. Resident 2 stated LVN 1 made him feel inhuman and his anxiety worsen whenever LVN 1 was assigned to him. Resident 2 stated he had expressed his concerns to various nurses at the facility including CNA 1 and CNA 2. During a concurrent interview the Administrator (Admin), and Assistant Director of Nursing (ADON) on 12/12/2023 at 2:25 p.m., the Admin stated it was difficult to substantiate the allegations against LVN 1 because the interviews with the CNAs were incongruent. The Admin and the ADON stated the facility was not aware Resident 2 experienced harsh treatment from LVN 1. The Admin stated LVN 1 was dismissed from the facility, and the facility will follow up and monitor Residents 1 and 2. A review of the facility ' s undated policy and procedure (P&P) titled Abuse and Mistreatment of Residents, indicated the facility will uphold the residents right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. The P&P indicated abuse was the willful infliction of injury, unreasonable conferment, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being.

Based on interview, and record review, the facility failed to inspect residents' bedrails routinely per the bed manufacturer's recommendations to prevent one of three sampled residents (Resident 1), from falling from the bed to the floor during care. As a result, Certified Nursing Assistant (CNA) 2, while providing care to Resident 1, turned the resident toward her (CNA 2), the side rail broke, and Resident 1 fell to the floor and sustained a fracture (broken bone) to her left femur (long bone in the upper leg). Findings: During a review of Resident 1's Face sheet (Admission Record), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included obstructive pulmonary disease ([COPD] a disease that causes airflow blockage and breathing-related problems), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness) following cerebral infarction (brain injury caused by the interruption of blood flow to part of the brain) affecting left nondominant side, and osteoarthritis (a disorder that happens when the cartilage in the joints breaks down over time, causing pain during movement). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 9/22/2022, the MDS indicated Resident 1 was rarely able to understand or be understood by others. The MDS indicated Resident 1 required a one person assist with bed mobility, locomotion (movement between locations), dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 1 was a two person assist with transfers from bed to chair or chair to a standing position. During a review of Resident 1's Fall Risk assessment dated [DATE], the fall assessment indicated Resident 1 was at high risk for falls. During a review of Resident 1's History & Physical (H&P) dated 10/11/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Care Plan titled Resident is at risk for falls/injury dated 7/22/2019, the care plan intervention indicated the facility was to provide safety instructions to Resident 1 regarding transfers and activities of daily living when appropriate. During a review of Resident 1's Interdisciplinary team ([IDT], a team of clinicians from different disciplines, working together for the resident's benefit) notes dated 10/22/2022, at 4:01 p.m., the IDT indicated per Resident 1's doctor, Resident 1 was at risk for pathological (caused by disease) fracture related to demineralization of the bone (loss of minerals from a person's bones that makes them more prone to fracture) or possible inflammation (swelling) of the bone due to osteoarthritis. During a review of Resident 1's Radiology ([x-ray] series of tests that take pictures or images of parts of the body) Report dated 10/22/2022, the radiology report indicated Resident 1 had an acute left subcapital neck (fracture line that extends through the junction of the head and neck of femur) fracture. During a review of Resident 1's Change of Condition (COC), dated 10/22/2022 at 6:55 a.m., the COC indicated on 10/22/2022, at 5:55 a.m., CNA 2 was rendering care to Resident 1 when CNA 2 turned Resident 1 towards herself, Resident 1 slid from the bed. The COC indicated CNA 2 was unable to break the fall due to Resident 1's weight and the resident fell on her left side. During a review pf Resident 1's Incident Report dated 10/23/2022, the incident report indicated Resident 1 had a witnessed fall with injury. The incident report indicated CNA 2 provided care to Resident 1 when the accident occurred, and CNA 2 attempted to hold and prevent Resident 1 from falling but was unsuccessful. During a review of Resident 1's General Acute Care Hospital (GACH) consultation report, dated 10/24/2022, the GACH report indicated Resident 1 was not a candidate for surgical intervention for the fractured femur. The GACH report indicated Resident 1 was monitored for pain and referred to physical therapy (field of medicine that improves mobility, restores function, reduces pain, and prevents further injury by using a variety of methods, including exercises, and stretches) for evaluation and treatment. During a telephone interview on 12/28/2022 at 7:40 a.m., with a CNA 2, CNA 2 stated on 10/22/2022 at 5:55 a.m., during morning care, CNA 2 told Resident 1 to hold on to the bed rail for support and to turn to her right side towards the window and away from CNA 2. CNA 2 stated she (CNA 2) continued to clean Resident 1 and placed the chuck (bed pads that protected beds and other surfaces from bodily fluids) underneath Resident 1's buttock, the right-side bedrail went down and caused Resident 1 to roll off the bed to her left side. CNA 2 stated she observed the bedrail was broken. During a concurrent interview and record review on 12/29/2022 at 10:53 a.m., with the Maintenance Supervisor (MS), the facility's maintenance logs dated January 2022 to December 2022 were reviewed. The logs did not indicate residents bed rails were cleaned and checked. The MS stated he did not routinely check bedrails because bed rails were usually up. The MS stated bedrails were only checked if something was wrong with the bedrails. The MS stated he fixed Resident 1's bedrail after he was notified by CNA 2 the day Resident 1 fell approximately two months ago. The MS stated on 10/2022, after Resident 1's fall, CNA 2 notified him (MS) Resident 1's bed rail was not locking properly, and the bedrail would fall when pressure was put on the bed rail. The MS stated he observed the right side of Resident 1's bedrails was not locking because the black lock latch underneath the bedrail was not attached properly. The MS stated the bedrail latch was displaced and made the bedrail malfunction when a lot of pressure was placed on the bedrail. The MS stated he did not have the owner's manual for the bed or bedrails and did not know how often the bed rails should be checked. During an email correspondence from a representative (Rep) of the Resident 1's bed manufacturer dated 12/30/2022 at 8:53 a.m., the email indicated residents' bedrails were not designed to support residents with lifting themselves in bed or as a support to get in and out of bed. The bedrails could be used for slight adjustments or movements but never for the sole purpose of support or movement because it could cause the bedrails to break. The email indicated for residents requiring extra support, trapeze bars (a gymnastic or acrobatic apparatus consisting of a short horizontal bar suspended by two parallel ropes) should be used. The email also indicated bedrails were to keep residents from falling out of bed and the nuts, bolts and screws should be checked often to make sure everything was tight and secured. During a review of an undated manufacturer's manual for residents' beds, the manual indicated to check monthly that all screws were tight and not loosened and inspect monthly for signs of cracking, frame, or any deterioration. The manual indicated regular maintenance of bed and accessories were required to ensure proper operation. The manual also indicated casters (set of small wheels fixed to the legs or base of a heavy piece of furniture so that it could be moved easily) and axle bolts (screws) were to be checked for tightness. During a telephone interview on 2/8/2023 at 11:44 a.m., with the MS, the MS stated it was important to perform maintenance on residents' beds and accessories for safety and to prevent accidents. The MS stated he should have followed the manufacturer's manual for safety checks. The MS stated he only had basic knowledge on how to maintain residents' beds and accessories. During an interview on 2/8/2023 at 4:58 p.m., with the Director of Nursing (DON), the DON stated bedrails were considered an assistive device during incontinent care because a resident could hold on to the bedrail for support. The DON stated if the manufacturer's recommendations were not followed, it could cause residents to have accidents such as falls and fractures. The DON stated it was very important to perform maintenance on residents' beds including bedrails according to the manufacturer's manual for residents' safety. During a telephone interview on 2/9/2023 at 7:24 a.m., with the Director of Rehabilitation (DOR), the DOR stated before Resident 1's fracture she had full Range of Motion ([ROM] movement at a given joint in a specific direction) to her left and right hip that consisted of bending the hips more than 90 degrees (unit of measurement) and rotating her hips. The DOR stated after Resident 1's accident on 10/22/2022, Resident 1 did not have full ROM to the left hip compared to her right hip. The DOR stated he did not expect Resident 1 to have full ROM to her left hip anytime soon because the resident's left hip was broken and unstable. The DOR stated Resident 1 was at risk for loss of ROM and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to her left hip because Resident 1 was not ambulatory and not able to perform full ROM due to the fracture. The DOR stated the benefits of full ROM to joints was to prevent contractures. During a review of the facility's undated policy and procedures (P&P) titled Pathological/spontaneous Fractures- Reducing Risks, the P&P indicated a pathological fracture occurred when a bone breaks in an area weakened by another disease process. The P&P indicated reducing risks included two- people or lift transfer/re- positioning as needed. During a review of the facility's undated P&P titled Promoting Safety, Reducing Falls, the P&P indicated by simply focusing on fall preventions, caregivers can enhance the quality of life for residents, promote their independence, maintain their highest practical level of functioning. The P&P indicated the caregivers should inspect assistive devices routinely to make sure they are in good repair and working order with no missing or loose parts. During a review of the facility's undated P&P titled Equipment, the P&P indicated the facility will provide equipment for care of residents in the amount necessary to meet anticipated needs of the resident. The P&P indicated other equipment will be provided on a dedicated- patient basis. The P&P further indicated the equipment will be clean, maintained, and replaced as needed.

Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent elopement (when a resident who is not capable of protecting or caring for themselves leaves the facility without authorization or supervision) for one (1) of three (3) sampled residents (Resident 1), as indicated in the resident's Medication Administration Record (MAR). Resident 1 was found in a parking lot bloody, bruised, disheveled and wearing diapers, by the police. This deficient practice resulted in Resident 1 eloping from the facility, being found 8 hours later, by a Social Worker who then called Los Angeles Police Department (LAPD). Resident 1 was admitted to a general acute care hospital (GACH) and was noted to be bloody, bruised, and disheveled. Findings: During a review of an incident report dated 3/5/2022 from the Adult Protective Services (APS), the report indicated Resident 1 was found by police officers bloody, bruised, and disheveled, mumbling and unable to provide any information other than the name [NAME]. The report indicated Paramedics and the Police Department (PD) were called and the resident was placed on a 5150 hold and admitted to a general acute care hospital (GACH). The report also indicated, Resident 1's diagnosis included Alzheimer's and a history of wandering. According to the report, the resident wandered out of the facility on 3/5/2022. The report also indicated there were concerns the facility was accepting individuals with Alzheimer's and dementia but was not providing proper supervision to the residents. During a review of Resident 1's admission record, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included white matter disease (wearing of tissue in the largest and deepest part of the brain due to aging, which can result in memory loss, imbalance immobility in older age), [CONDITION(S)] (a disorder that affects a person's ability to think, feel, and behave), signs and symptoms involving cognitive functions and awareness (multiple mental abilities that include learning, thinking, reasoning, problem solving, decision making, memory, attention and language comprehension), and cognitive communication deficit (difficulty with thinking and how someone uses language which may occur after a stroke, tumor, brain injury, progressive [CONDITION(S)] brain disorder or other neurological damage). During a review of Resident 1's Minimum Data Set ([MDS]), a standardized assessment and care planning tool), dated 2/9/2022, the MDS indicated Resident 1 was severely impaired in cognitive skills (process of acquiring knowledge and understanding through thought, experience, and senses) for daily decision-making. The MDS indicated Resident 1 required supervision (oversight, encouragement or cueing from staff) with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor) and locomotion off unit (how resident moves to and returns from off-unit locations and moves to and from distant areas on the floor). During a review of Resident 1's Elopement Risk Evaluation dated 2/26/2022, the elopement risk evaluation indicated Resident was at risk for elopement. During a review of Resident 1's History and Physical (H&P) dated 2/28/2022, the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's Social Services' Progress Record dated 2/28/2022, at 9:15 a.m., the Social Services' Progress Record indicated Social Services Designee (SSD) observed Resident 1 going into other residents' restrooms and SSD redirected Resident 1 to use the designated restroom his (Resident 1's) room. During a review of Resident 1's Change of Condition (COC), dated 3/4/2022, the COC indicated on 3/4/2022, at 8:30 p.m., Resident 1 was not in his room and staff searched the facility and surrounding areas of the facility but could not find the resident. During a review of Resident 1's Emergency Department Triage Report, dated 3/5/2022 and timed at 1:14 p.m., the Emergency Department Triage Report indicated Resident 1 was disoriented to person, confused, lacks cognitive ability to make relevant decisions, had a new superficial laceration on his left cheek, dirt on his face, and superficial lacerations (shallow and is in the outer layer of the body affecting only the skin) to his extremities. During a review of Resident 1's GACH Wound Care Initial Assessment, dated 3/6/2022 and timed at 10:42 a.m., the Wound Care Initial Assessment indicated Resident 1 had a wound care consult for abrasions on the face, arms, and legs. During a review of Resident 1's GACH History and Physical (H&P), dated 3/6/2022 and timed at 7:27 p.m., the H&P indicated Resident 1 was noted with multiple scabs on bilateral cheeks, and both upper and lower extremities. The H&P also indicated Resident 1 appeared disheveled (untidy), confused, and disoriented. The H&P also indicated Resident 1 was admitted to the medical floor for an altered mental status. During an interview on 3/11/2022, at 2:35 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 3/4/2022, Resident 1 was not wearing a wander guard (bracelet worn by residents who are at risk for wandering or eloping that triggers alarms and can lock monitored doors to prevent the residents leaving unattended). LVN 1 stated Resident 1 did not have an order for a wander guard and that the resident should have had a wander guard because Resident 1 had a hist9ory of elopement and wandering, to prevent the resident from leaving the facility unsupervised. During an interview on 3/11/2022, at 3:18 p.m., with SSD, SSD stated, Resident 1 used to remove his cloths, wander around the nurses' station frequently, and required frequent redirection. SSD stated Resident 1 attempted to leave the facility one time and as soon as the resident pushed the front door open, the alarm went off, and Resident 1 just stood in the doorway. During an interview on 3/11/2022, at 4:22 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 1 always tried to escape (leave) and had left the yellow zone (designated area for residents suspected to have the corona virus) station CNA 1 stated in the evening of 3/4/2022, around 7 p.m., she saw Resident 1 walking around the yellow zone, and the moment she could not see the resident, she heard the door alarm go off in the sub-acute area and that's when she realized Resident 1 had exited the facility. CNA 1 stated she notified an unidentified nurse and ran after Resident 1 but couldn't find the resident. During a concurrent interview and record review of Resident 1's Medication Administration Record (MAR), on 4/12/2022 at 10:42 a.m., with Assistant Director of Nursing (ADON), ADON stated the MAR indicated, on 3/5/2022, at 9 a.m., Resident 1 did not receive the following medications as ordered by his physician: [MEDICATION(S)] (blood pressure medicine) 10 milligram ([mg] unit of measurement), [MEDICATION(S)] (softener stool) 100mg, Multivitamin with Mineral (vitamin supplement) 1 tablet, and [MEDICATION(S)] (medicine for mental health disorders) 100 mg. ADON also stated not taking his medications as ordered could lead to a decline in Resident 1's health. ADON stated staff was supposed to monitor Resident 1's whereabouts every two (2) hours but the staff did not. During a concurrent interview and record review, on 4/18/2022, at 1:44 p.m., with ADON, of Resident 1's Order Summary Report, dated 3/1/2022, ADON stated the Order Summary Report indicated there was no order to monitoring Resident 1's whereabout. ADON stated there was no care plan to address Resident 1's wandering behaviors. During a review of the facility's Policy and Procedure (P/P) titled, Care of Wandering Residents, undated, the P/P indicated the purpose of the policy was to protect wandering residents from injury, continuously reorienting resident to room, and monitoring the resident's location with visual checks as needed.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was discharged from the facility and readmitted to the facility with a pressure ulcer of the sacrum /coccyx (tail bone) and did not receive wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] This deficient practice resulted in Resident 1 developing a Stage 3 (the sore has gone through all layers of skin into the fat tissue, exposing the patient to infections) pressure ulcer to the sacrum and deep tissue injury ([DTI] persistent deep red, maroon or purple discoloration to intact or non-intact skin revealing a dark wound bed or blood filled blister) to both the left and right buttocks and thighs. Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated the resident was initially admitted to the facility on [DATE] and recently readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's revised care plan dated on 9/23/2020 and titled Pressure Sore, At risk to develop pressure sore and other skin problems related to aging process, [CONDITION(S)] (low blood level), DM, deep venous [CONDITION(S)] ([DVT] blood clots from in the large veins of the leg), [CONDITION(S)] (brittle or fragile bones) and reduced mobility. The interventions indicated for staff to assess Resident 1's skin by using the wound risk assessment on admission, quarterly and as needed, and assess the resident's skin condition daily during care and with weekly body checks. During a review of Resident 1's history and physical (H/P), dated 11/20/2020, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of the facility's weekly body check log for the month of 12/2020, the log indicated Resident 1's skin was clear. During a review of Resident 1's Licensed Nurse Record Weekly Summary, dated on 12/7/2020, 12/14/2020 and 12/21/2020, the Weekly Summary indicated Resident 1 had no signs and symptoms of dehydration, had good skin turgor with intact and clear skin. There was no documented evidence on the weekly summaries that indicated Resident 1 had any pressure ulcers/pressure injury ([PU/PI] areas of damaged skin caused by staying in one position for too long). During a review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 12/21/2020, the MDS indicated Resident 1's cognition (ability to reason and think) was moderately impaired, required extensive assistance with one-person physical assist with transfers, toileting and personal hygiene. The MDS indicated Resident 1 was at risk for developing PU/PI and skin injuries and did not indicate Resident 1 had any ulcers, wounds, and skin problems. During a review of Resident 1's Wound Risk Assessment, dated on 12/21/2020 and timed at 2:44 p.m., the assessment indicated Resident 1 was assessed as a high wound risk with a score of 11. According to the wound risk assessment, a score of 8 or more is considered a high risk for skin breakdown. During a review of the general acute care hospital (GACH) Wound Assessment, dated 12/26/2020 and timed at 5:40 p.m., the assessment indicated Resident 1 had redness, peeling and rashes to the perineum and the buttocks and a PI to the coccyx. During a review of Resident 1's Admission Assessment, dated 12/27/2020, the assessment indicated Resident 1 did not have any pressure ulcer/pressure injury (PU/PI). The Admission Assessment indicated for the staff to describe existing ulcers and each skin conditions including the location, length, width, depth, undermining (wider area of tissue) , tunneling (occurs in one direction) , [MEDICATION(S)] tract (narrow opening or passageway extending from a wound underneath the skin in any direction through soft tissue and results in dead space), and drainage as applicable. Upon further review of the Admission Assessment, there was no documented evidence of a description of Resident 1's skin condition. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Emergency Department's H/P, dated 1/2/2021, the H/P indicated Resident 1 had a stage 3 sacral and buttock ulcers with full thickness skin loss. The H/P indicated based on Resident 1's lab results and clinical appearance, there was a likelihood that Resident 1 had been lying in bed and not fed or moved. During a review of the GACH's Wound Consultation note, dated 1/4/2021 and timed at 9:32 a.m., the note indicated Resident 1 had a large deep tissue injury across the entire sacrum, bilateral (both) buttocks and bilateral posterior thighs with intermittent open areas of full thickness stage 3 skin loss. to the sacrum and the right ischium. The H/P indicated Resident 1's wounds were from limited movement and prolonged pressure in supine (lying flat on back, face upward)) or seated position. During a concurrent interview and record review on 4/16/2021 at 12:35 p.m. with the Registered Nurse Supervisor (RNS), Resident 1's Admission Assessment, dated 12/27/2020 and timed at 8 p.m., was reviewed. The admission assessment, under the skin condition section indicated a description of bruises, discolorations and/or pressure ulcers, was blank and did not indicate a description of Resident 1's skin condition. The admission assessment indicated Resident 1's skin was clear and intact with no skin break down The RNS stated he conducted Resident 1's admission assessment. RNS was asked if Resident 1 had any skin PI/PU at the time of admission on 12/27/2020, RNS stated he was not sure. The RNS stated he did not conduct a complete assessment only a quick assessment by only assessing Resident 1's front side of his body and did not turn Resident 1 over onto his back to inspect his skin because Resident 1 was housed in the COVID-19 (a mild to severe respiratory illness) unit. The RNS stated on that day (12/27), he was not assigned to the COVID unit, but as the RNS it was his responsibility to conduct an assessment. During a review of the facility's undated policy and procedure (P/P), titled, Pressure Sore Management, indicated the all available measures shall be taken to reduce breakdown and pressure sores. The P/P indicated the licensed nurse was to complete an initial admission assessment which includes a thorough body check of the resident. The P/P indicated for residents admitted with an existing pressure sore(s) a complete description of the pressure sore shall be written on the in the comprehensive nursing assessment. A photograph of the pressure sore(s) shall be taken at admission only and kept per facility policy. All photographs will be placed in the resident's chart with the following information: resident's name, date and time photograph was taken, location of pressure sore(s), measurement of the pressure sore(s), state of ulcer and the signature and title of professional who took the photograph. The P/P indicated if the resident has no treatment orders for the pressure sore(s), an order is to be made, the resident's name and the presence of the pressure sore shall be noted on the Weekly Body Checklist and the resident should be re-positioned as scheduled. During an interview on 4/16/2021 at 1:15 p.m., the Director of Nursing (DON) stated treatment nurses would usually obtain a photograph of residents with skin issues and place the pictures in a binder. The DON was asked if there were any pictures obtained for Resident 1's skin, the DON stated, No. The DON stated Resident 1 did not have any skin breakdown while in the facility. The DON was asked why did the Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1, who had a COC and was experiencing confusion, respiratory distress (shortness of breath [SOB]), had an elevated body temperature of 101 degrees Fahrenheit ([F]) (Normal Reference Rate [NRR] is ,d+[DATE] F), had no current V/S documented during the COC and physician was not notified. This deficient practice resulted in a four-hour delay in diagnosis, care and services for Resident 1, who required a transfer to the general acute care hospital (GACH) after the resident became unresponsive (not verbally responding) and unarousable (unable to waken), on [DATE] by emergency transport services via 911 call (an emergency service). Resident 1 had an altered mental status ([AMS] general changes in brain function, such as confusion, amnesia (memory loss), loss of alertness, and/or disorientation). Resident 1 was diagnosed in the GACH with severe [CONDITION(S)] (infection in the blood), [CONDITION(S)] (bacterial [dangerous germs] infection involving the inner layers of the skin) of left abdominal wall, pneumonia (infection of the lungs) of both lungs, and required multiple intravenous ([IV] into the vein) antibiotics (medications to treat an infection in the blood). The History and Physical (H/P) indicated Resident 1 was hospitalized and expired 47 days later. Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's history and physical (H/P), dated [DATE], the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Admission Assessment, dated [DATE], the admission assessment indicated Resident 1 was dysphasic (unable to speak/talk) with a neck [CONDITION(S)], and her skin was clean and without any documented evidence of skin breakdown. During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment tool and care screening tool, dated [DATE], the MDS indicated Resident 1's cognitive (thought process) status was not assessed. According to the MDS, Resident 1 required an extensive assistance of a two- person physical assist with bed mobility and a one-person assist with transfers. During a review of Resident 1's revised care plan, dated [DATE] and titled,Risk for infection: High risk for infection secondary to ARF, [CONDITION(S)] and vent dependent, the staff's interventions included to do labs if physician order, medication as ordered, urinary tract infection ([UTI] an infection of the urinary bladder) stat (immediately), cranberry probiotics (safe germs that lives in the stomach), monitor for signs and symptoms of infection, notify the physician if any sign and symptoms of infection. During a review of Resident 1's revised care plan, dated [DATE] and titled, At risk for shortness of breath, chest pain, irregular pulse, dizziness, [CONDITION(S)] (swelling), elevated blood pressure (BP), [CONDITION(S)] (low blood pressure), altered mental status (AMS) and headache, the staff's intervention included to observe Resident 1 for headache, chest pain, irregular pulse, [CONDITION(S)], shortness of breath, elevated BP, dizziness, [CONDITION(S)], fatigue (feeling tired), weakness, diaphoresis (sweating) and AMS, report to the physician promptly, give medication as ordered, monitor pulse rate, blood pressure as ordered and monitor the effect of medication and inform the physician if the medication is ineffective. During a review of Resident 1's recapitulated (a summary) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. A pressure relieving mattress for skin management. 2. Staff to monitor for cognitive impairment and tally (total) with hashmarks (a method of counting) 0= absence, 1= presence every shift. 3. Administer Tylenol (medication to relieve pain and reduce a body temperature) 325 milligrams ([mg] a unit of measurement), 2 tablets via G-tube every four (4) hours as needed for temperature of 101 degrees Fahrenheit (F). During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident 1 did not receive Tylenol 325 milligram ([mg] a unit of measurement) or a temperature of 101degree F. According to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Resident 1's records, the resident was not transported to the GACH after 8 p.m. During a review of Resident 1's pulmonologist (a medical doctor that treats disease and conditions of the lungs) progress note (PPN), dated [DATE] and timed at 3:59 p.m., the progress note indicated Resident 1 did not have any acute changes in her neurological status. During a review of Resident 1's Continuous Ventilator Flow Sheets (CVFS) , dated [DATE] timed at 12:37 a.m. and on [DATE] timed at 6:22 a.m., the CVFS indicated Resident 1 had an extra- large (XLT) [CONDITION(S)] tube size 8 and was in respiratory distress (shortness of breath [SOB]) and placed on ventilator ([vent] a machine that helps you breathe or breathes for you) settings. During a review of Resident 1's V/S summary, dated [DATE] indicated the following: Temperature Summary At 1:57 a.m. - 98.4 F, Normal Reference Rate ([NRR]= 97.,d+[DATE].0 F) At 7:59 a.m. - 97.8 F, there was no documented evidence of Resident 1's temperature on the V/S summary after 7:59 a.m. Pulse Summary At 8:52 a.m. -75 beats per minute (bpm) (NRR= ,d+[DATE] bpm), there was no documented evidence of Resident 1's pulse rate was assessed on the V/S summary after 8:52 a.m. Blood Pressure Summary At 8:52 a.m. -,d+[DATE] millimeters of mercury [mmHg], (NRR = ,d+[DATE]- ,d+[DATE] mm/hg) At 8:53 a.m. - ,d+[DATE] mm/hg, there was no documented evidence Resident 1's blood pressure was checked after 8:53 a.m. Respiratory Summary At 7:59 a.m. - respirations 18 ([bpm] breaths per minute) (NRR is ,d+[DATE] breaths per min), there was no documented evidence of Resident 1's respiratory rate being checked after 7:59 a.m. During a review of Resident 1's CVFS, dated [DATE] and timed at 6:03 p.m., the CVFS indicated Resident 1 tolerated treatments well and the resident's [CONDITION(S)] tube was secured. The CVFS indicated at 7:15 p.m., Resident 1 was found unresponsive, had an O2 saturation ([sat] amount of oxygen in the blood) of 99% with an irregular and fluctuating heartbeat. The CVFS indicated 911 was called and Resident 1 was transported to the GACH. During a review of Resident 1's PPN, dated [DATE] and timed at 7:15 p.m., the PPN indicated Resident 1's V/S were as follow: B/P of ,d+[DATE], HR (pulse) of 75 bpm, RR of 18 bpm, temperature of 97.8 F and O2 sat of 99%. The PPN indicated Resident 1 had a change in level of consciousness and an arterial blood gas ([ABG] a test that measures the amount of oxygen [air] and [MEDICATION(S)] [(CO2) a waste gas] in the lungs) high CO2 levels with confusion. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the Change of Condition (COC) note, dated [DATE] and timed at 8 p.m. the COC indicated at 3 p.m., Resident 1 was awake with periods of confusion and shortness of breath (SOB). The COC note indicated at 7 p.m., the Nurse Practitioner was made aware of Resident 1's condition including a high CO2 and provided written orders for Resident 1. The COC note indicated at 7:45 p.m. Resident 1 was unarousable with episodes of SOB, 911 (emergency services) was called, the paramedics arrived at the facility at 8 p.m. and transported Resident 1 to the GACH. The COC note indicated at 8 p.m. Resident 1's primary physician was notified. The COC note indicated Resident 1 had an untimed body temperature of 101 degrees F. During a review of the COC note, dated [DATE] and timed at 8 p.m., the COC note indicated Resident 1's most recent V/S were as follow: At 8:53 a.m.-blood pressure: ,d+[DATE] mm/Hg At 8:52 a.m. -pulse: 75 bpm At 7:59 a.m. - respirations: 18 bpm At 5:36 p.m.O2 sat: 99% on a vent During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's GACH face sheet, the face sheet indicated Resident 1 arrived to the Emergency department (ED) on [DATE] at 8:37 p.m. During a review of Resident 1's GACH ED H/P, dated [DATE] and timed at 8:46 p.m., the H/P indicated Resident 1 arrived to the ED with altered mental status, non-verbal, unresponsive to pain, [CONDITION(S)] (heart rate greater than 100 bpm) with a heart rate of 169 bpm (NRR= ,d+[DATE] bpm), febrile with a temperature of 101 degrees F and a blood pressure of ,d+[DATE] mmHg. According to the H/P, Resident 1 was reportedly at her baseline two (2) hours prior to arriving at the GACH and the SNF nursing staff indicated Resident 1 had decreased responsiveness from normal. During a review of Resident 1's Emergency Department's (ED) H/P timed at 9:57 p.m., the H/P indicated Resident 1 had weeping (oozing) wounds through her mid torso and lower abdomen and had a stage II pressure ulcer on the buttocks and sacral area. The H/P indicated Resident 1 had an elevated white blood count (WBC) of 11.28 per microliter (uL) (NRR =levels 4.00 -11.00). According to the H/P, Resident 1 received Tylenol 975 mg rectally, [MEDICATION(S)] (medication used to treat an infection) 1,000 mg per intravenously ([IV] into the vein), [MEDICATION(S)] (medication used to treat an infection) 3.375 mg IV, [MEDICATION(S)] (medication used to treat an infection) 1,250 mg and [MEDICATION(S)] (salt water) 0.9% continuous IV fluids. The H/P indicated Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The H/P indicated Resident 1 expired on [DATE]. During an interview on [DATE] at 12:50 p.m., the facility's Treatment Nurse stated Resident 1 was alert was able to communicate in Spanish, required a two-person assistance with transfers, turning and repositioning. During an interview on [DATE] at 1:07 p.m., the facility's Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was alert, talkative and tolerated showers and bed baths. CNA 1 stated during Resident 1's showers, the RT would stand by the door for assistance with the ventilator equipment. During a telephone interview on [DATE] at 2:10 p.m. the facility's Registered Nurse Supervisor 1 (RNS 1) stated on [DATE], Resident 1 was unarousable, and she completed a change of condition (COC) note on Resident 1. RNS 1 was asked did she obtained Resident 1's V/S on the COC note and did she conduct an assessment on Resident 1 during the resident's COC, RNS 1 stated she could not recall which staff obtain the V/S and she completed a COC assessment on Resident 1. RNS 1 stated she completed the COC note and stated she probably forgot to include Resident 1's most current V/S. RNS 1 was asked if Resident 1 had confusion, RNS 1 stated Resident 1's confusion was a significant COC. RNS 1 stated on [DATE] from 3 p.m. through 7 p.m., she monitored Resident 1 by assessing the resident's cognition. RNS 1 stated she did not notify Resident 1's physician after 3 p.m. RNS 1 stated Resident 1's Nurse Practitioner arrived at the facility at 7 p.m. and was made aware of Resident 1's condition. RNS 1 was asked why there was a 4 -hour delay notifying Resident 1's primary physician, RNS 1 did not respond. RNS 1 was asked if obtaining V/S was included in an assessment, RNS 1 stated obtaining V/S was included in an assessment. During an interview on [DATE] at 2:33 p.m., CNA 1 stated Resident 1 was confused in the am of [DATE] and Resident 1 was repeatedly saying Mama. CNA 1 stated Resident 1 only spoke Spanish and would normally state her needs. CNA 1 stated on [DATE], she informed the RNS Resident 1 was confused, but could not recall which RNS she notified. CNA 1 stated Resident 1 had been confused for a couple of days prior to [DATE]. A review of the facility's undated policy and procedure (P/P) titled, Change of Condition, the P/P indicated for the facility to ensure residents had a proper assessment and follow through with a COC assessment. The P/P indicated when a resident's condition change for any reason, the facility would ensure proper care and follow-up by using a monitoring system using a nursing 24 hour repost form and when the resident's condition changed, the physician would be called promptly. The P/P indicated a COC is of any sudden or marked change in the resident's V/S, behavior (lethargic, agitated, anxiety, refusing care and non-responsive), congestion, shortness of breath, change in level of consciousness and change in level of functioning. The P/P indicated the licensed nurses would ensure proper assessment and documentation of the resident's COC by timely notification of the physician, V/S documented each shift, and all condition changes should be handled promptly.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of sexual abuse. Resident 1, who had a severely decreased mental capacity and a history of self-masturbating (self-stimulation of one's own genitals) while exposing herself and moaning sexual sounds out loud, was not monitored closely to prevent male residents (Residents 3 and 4) from entering her room. Residents 3 and 4 sexually abused Resident 1. This deficient practice resulted in Residents 3 and 4 sexually abusing Resident 1 and had the potential to result in Resident 1 contracting sexually transmitted diseases ([STD] an infection transmitted through sexual contact). Resident 1 required a transfer to a general acute care hospital (GACH) for an evaluation and prophylactic (action used to prevent disease) treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: a. During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/18/2021, the MDS indicated Resident 1's cognition (ability to reason and make decisions) was severely impaired. The MDS indicated Resident 1 required an extensive assist to being totally dependent with activities of daily living ([ADLs] daily care activities such as toileting, grooming, etc.). Resident 1 required a two-person physical assist for transferring and a one-person assist for bed mobility, dressing, hygiene and eating. During a review of Resident 1's History and Physical (H/P), dated 3/13/2021, the H/P indicated Resident 1 does not have the capacity to understand and make decisions. b. During a review of Resident 2's Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact, and she had the ability to understand and be understood and a good memory recall. According to the MDS, Resident 2 required set-up only and was totally independent (self-sufficient) with ADLs. During a review of Resident 2's H/P, dated 8/9/2020, the H/P indicated Resident 2 have the capacity to understand and make decisions. c. During a review of Resident 3's Admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was impaired. The MDS indicated Resident 3 required prompting for memory recall. According to the MDS, Resident 3 required set-up and supervision only and was totally independent with ADLs. During a review of Resident 3's H/P, dated 2/18/2021, the H/P indicated Resident 3 was able to make decisions for activities of daily living. During a review of Resident 3's care plan titled, History of indecent (improper; indiscreet) exposure to female residents, dated 2/16/2021, the care plan indicated for the staff to provide one to one monitoring, with frequent visual checks by staff for safety. d. During a review of Resident 4's Admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was not documented. According to the MDS, Resident 4 required supervision and set-up only for ambulation and eating and limited assistance with ADLs. During a review of Resident 4's H/P, dated 2/13/2021, the H/P indicated Resident 4 has the capacity understand and make decisions. During an interview on 3/31/2021 at 10:15 a.m., Resident 2 (Resident 1's roommate) stated, I witnessed a rape (unlawful sexual activity) two times the other night in my room! Resident 2 stated, My roommate (Resident 1) yells and moans all day and night and says filthy words that makes no sense and it attracts men to our room. Resident 2 stated she witnessed Resident 3 come into the room the night of 3/28/2021, put his penis by Resident 1's face until Resident 2 yelled for him to get out of the room and called for certified nursing assistant (CNA 1). Resident 2 stated later that night she woke up (3/29/2021) when she heard noises and saw another male resident (Resident 4) in the room on top of Resident 1 with his pants down having sex with Resident 1. Resident 2 stated she started yelling and went out to notify the nurse (CNA 2). Resident 2 stated eventually a licensed vocational nurse (LVN 1), came in and told Resident 4, You can't do that, and pulled him off Resident 1. Resident 2 stated she did not see any staff monitoring her room after the first sexual incident of Resident 3 entering her room. Resident 2 stated CNA 3 sat outside of her room door and guarded the room all night after the second incident of Resident 4 entering the room at night and having sex with Resident 1. Resident 2 stated she thanked CNA 3 for watching her room. During a review of Resident 1's Licensed Nurse Record, dated 3/29/2021 the record indicated Resident 1 was assessed and moved to Station 1, closer to the nursing station for visual monitoring. The physician was notified of Resident 1 being touched by a male resident and an order was received to transfer Resident 1 to the hospital for evaluation. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Interdisciplinary Team Conference Record ([IDT] coordinated group of experts from different fields who work together toward a common goal for the resident), dated 3/29/2021 and titled, Attempted Sexual Interaction by a Male Resident, the IDT note indicated on 3/28/2021 at 8 p.m., a male resident (Resident 3) was seen in the room with Resident 1 and the charge nurse immediately re-directed the male resident out of Resident 1's room. On 3/29/2021 at 12:20 a.m., Resident 2 informed the staff that a male resident (Resident 4) had sex with Resident 1. The IDT record indicated the goal was to conduct a thorough investigation and notify the police. During an interview, on 4/1/2021 at 1:20 p.m., CNA 1 stated approximately 8 p.m. on 3/28/2021 she was making rounds and was notified by Resident 2 that Resident 3 was in her room standing over Resident 1. CNA 1 stated she immediately went to notify LVN 2. CNA 1 stated she was not assigned to sit or closely monitor Resident 1's room that night but she continued to do her usual rounds. CNA 1 stated she was not sure if Resident 1 and Resident 3 were to be monitored after the incident. During an interview, on 4/5/2021 at 11:49 a.m., LVN 1 stated he was notified by CNA 1 of Resident 3 being in Resident 1's room. LVN 1 stated he told Resident 3 he was not allowed to go into female resident's rooms. LVN 1 stated he did not document the sexual incident or pass it on to the oncoming charge nurse. LVN 1 stated, It was a common occurrence for residents to wander or go into other resident's rooms in the facility. LVN 1 stated he did not assign any staff to closely monitor Resident 1's room or Resident 3 whereabouts during the shift (3 p.m.-11 p.m.). LVN 1 stated he was not aware Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 4/6/2021 at 3:15 p.m., LVN 2 stated he was notified by staff on 3/29/2021 that Resident 4 was in Resident 1's room and when he entered the room he observed Resident 4 with his pants down and on top of Resident 1. LVN 2 stated he assisted Resident 4 off Resident 1. LVN 2 stated he was not made aware of any previous incident regarding Resident 1. LVN 2 stated he assigned a staff to sit at the door of Resident 1's room for 1:1 observation of Resident 1 for the remainder of the shift. During an interview, on 4/6/2021 at 4:45 p.m., Resident 1's family member (FM 1), stated she was very upset about Resident 1 being sexually assaulted in the facility where she (Resident 1) was placed to receive help for a traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head). FM 1 stated Resident 1 babbles and was not able to communicate or give sexual consent due to her mental status. FM 1 stated after she was notified of the alleged incidents, she accompanied Resident 1 to the hospital where she received a rape kit (a package of items used by medical personnel for gathering and preserving physical evidence following an allegation of sexual assault) and an evaluation was performed. FM 1 stated she was not given any status of the test for STD because it takes up to two weeks for results to come back. FM 1 stated Resident 1 was given prophylactic medication (antibiotics) to prevent STDs. FM 1 stated she was in the process of finding another nursing facility for Resident 1 to be transferred. During a review of Resident 1's GACH sexual assault aftercare instruction, dated 3/29/2021, the aftercare instructions indicated Resident 1 had a sexual assault examination, collection of evidence, and preventative treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 1. If bleeding or discharge from the vagina or rectum, fever, nausea, vomiting, diarrhea, pain, or any other symptoms or injuries, to seek immediate medical attention. 2. Please give medication via g-tube: [MEDICATION(S)] (an antibiotic) 250 milligram ([mg] unit of measurement), [MEDICATION(S)] (an antibiotic) 1 gram (for chlamydia [a common sexually transmitted disease; caused by bacteria] prevention), and [MEDICATION(S)] (antibiotic that is used to treat a wide variety of infections) 2 grams (for prevention of trichomonas [a common sexually transmitted disease (STD); an infection caused by a parasite] and bacterial vaginosis [too much of certain bacteria in the vagina]). 3. [CONDITION(S)] antibody (looks for [CONDITION(S)] [([CONDITION(S)]) a virus that attacks the body's immune system] antibodies in the blood or saliva) and syphilis serology test (used to screen for and diagnose syphilis [a bacterial infection spread by sexual contact]) to be completed in 6 weeks, 3 months, and 6 months. During an interview, on 4/6/2021 at 4:25 p.m., the facility's director of nursing (DON) stated Resident 3 had history of psychiatric (mental illness) problems and was sent out to a GACH the same day of the sexual incident for a psychiatric evaluation (an evaluation designed to diagnose emotional, behavioral, or developmental conditions or disorders). The DON stated Resident 3 was still in the hospital receiving treatment and Resident 4 left the facility AMA (against medical advice). The DON stated the facility have hired an outside permanent sitter to monitor Resident 1 for safety because she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated although the first sexual incident was a quick one and nothing happened, it was unfortunate that the second sexual incident occurred. During a review of the facility's undated policy and procedure (P/P) titled, Resident Abuse, indicated upon report of any allegation or violation, the administrator or his/her designated representative will thoroughly investigate the situation. The P/P indicated the investigation of allegations of abuse will identify events that may constitute abuse and then the Administrator/Abuse Coordinator will determine the direction of investigation.

Based on interview and record review, the facility failed to ensure the environment was hazard free and provide supervision to prevent aspiration (breathing in a foreign object (plastic medication cup) into the airway) of a resident who had a history of [REDACTED]. Resident 1, who had intellectual delay disabilities (below-average intelligence or mental ability and a lack of skills necessary for life skills) and severe dysphagia (difficulty in swallowing) due to a history of [MEDICAL CONDITION]'s disease (a genetic disorder that causes progressive breakdown of nerve cells in the brain and deteriorates a person's physical and mental abilities over time and can be fatal) with a habit of putting objects in her mouth was left unsupervised by the facility's staff. This deficient practice resulted in Resident 1 having access to a plastic medication cup and putting it in her mouth and aspirating. Resident 1 had low oxygen levels for an unknown amount of time and required a transfer to a general acute care hospital (GACH) on 5/10/2020. Resident 1 was intubated (a medical procedure in which a tube is placed into the windpipe (trachea) through the mouth in an emergency for ventilation) and placed on mechanical ventilation (a breathing machine) and was admitted to the intensive care unit ((ICU) higher level of care unit) for a total of 9 days. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 3/23/2020 indicated Resident 1 had impaired cognitive skills (ability to reason and think) for daily decision-making and rarely or never understood others. The MDS indicated Resident 1 required supervision and a one-person physical staff assist for eating, transferring, dressing, and bed mobility (how the resident moves). According to the MDS, under Section K 300 (Nutritional approaches) Resident 1 was receiving nutrition through a feeding tube. A review of Resident 1's care plan, initiated on 5/12/12 and last reviewed on 4/6/2020, identified a problem of cognitive and communication deficit due to short and long-term memory problem, problems making self-understood, and understanding others related to intellectual disability. The goal indicated Resident 1 would be able to maximize cognitive skills and decision-making capabilities daily. The staff's interventions included to speak clearly, slowly and maintain eye contact with Resident 1 and notify physician of any significant changes. A review of Resident 1's care plan, initiated on 8/2/15 and last reviewed on 4/6/2020, identified a problem for Resident 1's risk for aspiration related to dysphagia. The goal indicated Resident 1 would have no aspiration daily. The staff's interventions were to provide moderately thick liquids, a pureed diet (food that is soft, moist, and smooth in the texture, as of pudding), speech therapy (specially trained to improve communication techniques and treat swallowing disorders) evaluation and treatment as ordered and to monitor for signs and symptoms of aspiration such as shortness of breath and respiration changes. A review of Resident 1's care plan, initiated on 2/14/2020, identified a problem of Resident 1 being at risk for injuries/complication related to the resident's tendency to grab items/objects. The goal indicated Resident 1 would have no injury and will receive adequate care daily for 90 days. The staff's interventions included daily room visits, resident's room free from clutter, redirect resident as needed, and a psychiatric (a mental health assessment used to diagnose problems with thought processes and behaviors) evaluation. A review of a Situation, Background, Assessment and Recommendation ((SBAR) an internal communication form), dated 5/10/2020 and timed at 1:37 p.m. indicated the following: At 7 a.m., on 5/10/2020 the resident (Resident 1) was sleeping with even breathing (smooth equal breathing). No shortness of breath noted. At 9 a.m., all due medications administered and resident (Resident 1) tolerated well. At 11 a.m., the resident was noted with a low-grade fever (abnormal body temperature) and the physician made aware with new orders. Resident (Resident 1) received an x-ray; awaiting results, will continue to monitor throughout shift. A review of the radiology results report, dated 5/10/2020 and timed at 2:23 p.m., indicated Resident 1 had a chest x-ray due to having a fever. The x-ray results indicated Resident 1 had right lower lobe (RLL) pneumonia (an infection that inflames the air sacs of the lungs). A review of Resident 1's Licensed Nurse Record Change of Condition, dated 5/10/2020 and timed at 7:11 p.m. indicated the following: At 3 p.m., Resident 1 was received with a change of condition from the morning shift with an assessment done and had an elevated body temperature of 101.0 degrees Fahrenheit (F) (Normal Reference Range (NRR) 97.2-98.8) and Tylenol (([MEDICATION NAME]) fever reducing; pain reliever) 325 milligrams ((mg) unit of measurement) was given. Resident 1's vital signs (measurements of the body's essential basic functions) were as follow; blood pressure 128/68 (normal reference range (NRR) is 90/60- 139/89), respirations 18 (NRR 12-20 breaths per minute (bpm)), and heart rate at 82 (NRR 60-100 per minute). At 5 p.m., Resident 1 was administered all prescribed medications and tolerated it well. The chest x-ray showed Resident 1 had pneumonia and had generalized body weakness. Resident 1's physician was called, and an order received to transfer the resident to the hospital. At 6 p.m., Resident 1 was transferred to the hospital. A review of Resident 1's GACH Emergency Department (ED) report, dated 5/10/2020 and timed at 6:46 p.m. indicated Resident 1 arrived to the ED with an elevated heart rate of 145, increased respirations of 28, a low blood pressure of 79/46 and a pulse oximetry (measure the amount of [MEDICATION NAME] blood (Spo2) in the body) measuring a low oxygen saturation of 85 % (NRR 95-100%) while receiving five (5) liters (L) of oxygen with a nasal cannula (a small flexible plastic tube used to deliver oxygen into the nostrils). The ED report indicated Resident 1's physical assessment indicated the resident was awake, moving all extremities, non-verbal with tachypnea (abnormally rapid breathing) with an increased work to breathe, no cough, no audible wheezes (breathing with a [MEDICATION NAME] sound in the chest). The ED note indicated Resident 1 had to be advanced to a nonrebreather mask (a device used to delivery higher concentrations of oxygen) at 15 L with no significant improvement in oxygenation. The ED note indicated due Resident 1's extra work to breathe with persistent [MEDICAL CONDITION] (deprived of adequate oxygen) despite increased oxygen therapy a decision was made to intubate Resident 1 at 8:03 p.m. According to the note, during intubation, under direct visualization there was a plastic foreign body (medication cup) sitting over Resident 1's vocal cords. The medication cup was removed with an alligator clamp (surgical instrument used for grasping small objects or removing items from small cavities in the body). The note indicated Resident 1 was successfully intubated without complication. A review of Resident 1's ED note indicated Resident 1 was admitted to the intensive care unit (ICU) secondary to [DIAGNOSES REDACTED]. On 7/9/2020 at 2:50 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 received feedings via the gastrostomy tube and crushed pills given with water in small medication cups. According to LVN 1, at times Resident 1 would move her hands about and put her fingers in her mouth often. LVN 1 denies giving Resident 1 anything by mouth. On 7/23/2020 at 9:43 a.m., during a telephone interview, the Director of Nursing (DON) stated she received a call from an unknown GACH Risk management caseworker and was told a pill (sic) was found in Resident 1's throat. The DON stated she did not document the information received from the GACH in Resident 1's records and an investigation was started, but not completed. The DON stated an investigation was not necessary to report to the Department of Public Health because it was not abuse, neglect or mistreatment. The DON stated the nurses that administered Resident 1's medication only gave the medications through the [DEVICE]. On 7/23/2020 at 10:12 a.m., during a telephone interview, LVN 2 stated Resident 1 reaches for items at times, but during medication administration time the resident does not grab any medication or medication cups. LVN 2 stated Resident 1 had to be monitored due to the habit of putting her fingers in her mouth. LVN 2 stated she would observe Resident 1 putting her fingers in her mouth daily approximately perhaps three to four times during her rounds. LVN 2 stated Resident 1 had no gag reflex (a contraction of the back of the throat, evoked by touching the soft palate; helps prevent aspiration) and was unable to cough. According to LVN 2, Resident 1 was dysphagic and received medications through the [DEVICE]. On 7/23/2020 at 10:28 a.m., during a telephone interview, Certified Nursing Assistant (CNA 1) stated she was regularly assigned to Resident 1 during the day shift. CNA 1 stated Resident 1 does not speak and was unable to move around much, only her arms. CNA 1 stated she have seen Resident 1 put her fingers in her mouth in a child-like manner. CNA 1 stated Resident 1 does not eat food by mouth only through the [DEVICE]. According to CNA 1, she has observed medication cups left at the residents' bedside, including Resident 1's bedside, after the nurses gave the residents their medications. A review of the facility's undated policy and procedure (P/P) titled, Monitoring Residents indicated the purpose was to identify ways in which the facility monitors residents and resident care. The P/P indicated residents with special care needs and potential for neglect shall likewise be monitored in accordance with their plan of care, and at a minimum included in the regular monitoring of charge nurses during endorsements of care to nurse's aides. The facility's monitoring programs included daily rounds, medication pass, nourishment pass, and etc.

Based on interview and record review, the facility failed to follow the physician's orders and a resident's plan of care to ensure a resident who had a gastrostomy tube site (([DEVICE]) a surgical opening into the stomach to provide food, hydration and medications) received wound care to the site to keep the [DEVICE] site clean for one of three sampled residents (Resident 1). The physician ordered for Resident 1's [DEVICE] site to be cleaned and assessed daily but the facility had not cleansed the site for over 23 days (crossed referenced to F925). This deficient practice resulted in Resident 1 developing an infection at the [DEVICE] site and having maggots (the larvae of a fly) crawling around and in the [DEVICE] site. Resident 1 was transferred to a general acute care hospital (GACH) and received treatment for [REDACTED]. Findings: A review of the Resident 1's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. interferes with a person's daily life and activities). Resident 1 was recently diagnosed with [REDACTED]. A review of Resident 1's Order Summary Report, dated 7/29/2020, indicated a physician's order, dated 5/6/2020, to check Resident 1's [DEVICE] for placement, monitor patency and change the feeding syringe every shift. The physician ordered a treatment to the [DEVICE] site as follows; cleanse with normal saline (solution that has medical uses, including cleaning affected areas of the body), pat dry and cover with dry dressing every day. A review of Resident 1's Admission assessment, dated 5/6/2020 indicated Resident 1 was receiving [DEVICE] feeding and was incontinent (inability to control) of bowel and bladder and was dependent on staff for all care. A review of Resident 1's care plan, initiated 11/3/16 and last revised on 12/16/19 indicated Resident 1 was at risk for [DEVICE] site infection. The staff's interventions included to provide [DEVICE] site care daily and assess for redness, pain, swelling, increased body temperature and/or discharges from the site and report to physician promptly. A review of a change of condition ((COC)/Interact Assessment Form ((Situation, Background, Assessment, and Recommendation) internal communication document), dated 5/22/2020 indicated Resident 1 had maggots found around the [DEVICE] site. On 5/22/2020, during care, Certified Nurse Assistant 1 (CNA 1) observed maggots around Resident 1's [DEVICE] site and wound dressing. The COC form indicated Resident 1 was showered, soiled linen removed, and bed disinfected. The COC indicated the maggots continued to be seen and the physician gave an order to send Resident 1 to the GACH. A review of Resident 1's Treatment Administration Record (TAR) for the month of 5/2020 indicated there was no documented evidence Resident 1's [DEVICE] site received treatment as per the physician's order (5/6/2020), until 5/30/2020. A review of the facility's undated policy and procedure titled, Gastrostomy/Jejunostomy Care indicated the objective was to maintain the skin in good condition and to decrease irritation and risk of infection to promote residents' comfort. A review of Resident 1's GACH History and Physical (H/P), dated 5/22/2020 indicated the resident's [DEVICE] site had a pinkish color discharge and maggots at the site. The H/P assessment and plan indicated Resident 1 had abdominal [MEDICAL CONDITION] (bacterial skin infection) / infection ([DEVICE] site), malfunction at [DEVICE] site and will receive wound care and intravenous antibiotics. A review of the GACH's Wound Photographic Documentation, dated 5/22/2020 indicated Resident 1' [DEVICE] site at the middle upper abdomen area there was excoriation (a scratch or abrasion of the skin) with a skin description of weeping pink. On 6/11/2020 at 11:55 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 had two maggots seen outside the [DEVICE] site. The DON was asked who the treatment nurse was for the COVID-19 unit (unit Resident 1 resided on) and she stated she could not recall because the facility had been using registry's nurses to cover the COVID-19 unit. On 7/29/2020 at 2:48 p.m., during an interview, CNA 1 stated she was giving Resident 1 a bed bath and saw something moving on the resident's [DEVICE] site area and coming out of the opened wound. The [DEVICE] dressing was not secured, and the maggots were seen crawling from underneath the dressing. CNA 1 stated Station 3, where Resident 1 was housed, had flies due to the rooms being outside of the main building that lead into an opened patio area. CNA 1 stated there was nothing in place to prevent flies from entering the residents' rooms. On 7/29/2020 at 3 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated, Maggots came from not being cleaned. LVN 1 stated she sees flies in the building daily despite the fly lights in some of the resident's rooms. LVN 1 stated she recently noticed there were fly lights in the facility, but they are not working because flies are always in the building. On 7/30/2020 at 12:20 p.m., during a telephone interview, LVN 2 stated she was assigned to the COVID-19 unit to pass the medications. LVN 2 stated sometimes in 5/2020, CNA 1 notified her she saw maggots coming from Resident 1's [DEVICE] site. LVN 2 stated Resident 1's room was outside of the unit where there are flies all of the time and enter into the resident's rooms due to the door being opened. LVN 2 stated the staff's assignment was up in the air and they did not know who was going to be the treatment nurse but was told there would be a treatment nurse coming on the 3 p.m. -11 p.m. shift. LVN 2 stated the facility did not have supplies to do treatments for the residents. LVN 2 stated she had not done [DEVICE] treatments for Resident 1. LVN 2 stated the CNAs cleaned Resident 1 and the resident was transferred to the hospital due to having maggots in the [DEVICE] site. On 7/30/2020 at 2:30 p.m., during a telephone interview, Resident 1's physician (Physician 1) stated Resident 1's [DEVICE] site should have been routinely checked, cleaned and cared for. Physician 1 was asked if he had discontinued the [DEVICE] treatment order and he stated, there was no way I would have discontinued an order for [REDACTED]. A review of the facility's undated policy and procedure titled, Gastrostomy/Jejunostomy (surgical opening into the stomach) Care, indicated the objective of care was to maintain the skin in good condition, decrease irritation and risk of infection to promote resident comfort and inspect the site for leakage, redness, purulent (a milky texture and is gray, yellow, or green; a sign of an unhealthy wound) drainage, [MEDICAL CONDITION], tenderness, and/or any inflammation (a response triggered by damage to living tissues) and/or pain.

Based on observation, interview and record review, the facility failed to maintain a pest-free environment and an effective pest control program to ensure the facility was free of flies from laying eggs on one of three sampled resident's (Resident 1) gastrostomy tube site (([DEVICE]) a surgical opening into the stomach to provide food, hydration and medications) was provided. Resident 1's [DEVICE] had live maggots (the larvae of a fly) inside and outside of the wound site with pink drainage. This deficient practice resulted in Resident 1 having maggots crawling around and in the [DEVICE] site and being admitted to a general acute care hospital (GACH) for six days with [DIAGNOSES REDACTED]. Findings: A review of the Resident 1's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. with a person's daily life and activities). A review of Resident 1's Order Summary Report indicated a physician's orders [REDACTED]. The physician ordered a treatment to the [DEVICE] site as follow; cleanse with normal saline (salt water), pat dry and cover with dry dressing every day. A review of Resident 1's Admission assessment, dated 5/6/2020 indicated Resident 1 was receiving [DEVICE] feeding and was incontinent (inability to control) of bowel and bladder and was dependent on staff for all care. A review of Resident 1's care plan, initiated 11/3/16 and last revised on 12/16/19 indicated the resident was at risk for [DEVICE] site infection. The staff's interventions included to provide [DEVICE] site care daily and assess for redness, pain, swelling, increased body temperature and/or discharges from the site and report to physician promptly. A review of a change of condition ((COC)/Interact Assessment Form ((Situation Background Assessment Recommendation) internal communication document), dated 5/22/2020 indicated Resident 1 had maggots found around the [DEVICE] site. On 5/22/2020, during care, Certified Nurse Assistant 1 (CNA 1) observed maggots around Resident 1's [DEVICE] site and wound dressing. The COC form indicated Resident 1 was showered, soiled linen removed, and bed disinfected. The COC indicated the maggots continued to be seen and the physician gave an order to send Resident 1 to the GACH. A review of the facility's Pest Management Sanitation Report dated 5/5/2020 indicated new fly lights for the hallways were ordered with recommendations to keep the doors that leads to the patio closed. According to the report, the fly lights were delivered to the facility on [DATE]. There was no documented evidence of instillation or placement of the fly traps and or lights. A review of Resident 1's Treatment Administration Record (TAR) for the month of 5/2020 indicated there was no documented evidence Resident 1's [DEVICE] site received treatment as per the physician's orders [REDACTED]. A review of the facility's undated policy and procedure titled, Gastrostomy/Jejunostomy (surgical opening in the stomach and the small part of the intestine) Care indicated the objective was to maintain the skin in good condition and to decrease irritation and risk of infection to promote residents' comfort. A review of Resident 1's GACH History and Physical (H/P), dated 5/22/2020 indicated the resident's [DEVICE] site had a pinkish color discharge and maggots at the site. The H/P assessment and plan indicated Resident 1 had abdominal [MEDICAL CONDITION] (bacterial infection of the skin)/infection, malfunction at [DEVICE] site and will receive wound care and intravenous antibiotics. A review of the GACH's Wound Photographic Documentation, dated 5/22/2020 indicated Resident 1' [DEVICE] site at the middle upper abdomen area there was excoriation (a scratch or abrasion of the skin) with a skin description of weeping pink. On 6/11/2020 at 11:45 a.m., Resident 1 was observed in the room. Resident 1's room door led to an opened patio. On 6/11/2020 at 11:55 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 had two maggots seen outside the [DEVICE] site. On 7/29/2020 at 2:48 p.m., during an interview, CNA 1 stated she was giving Resident 1 a bed bath and saw something moving on the resident's [DEVICE] site area and coming out of the opened wound. The [DEVICE] dressing was not secured, and the maggots were seen crawling from underneath the dressing. CNA 1 stated Station 3, where Resident 1 was housed, had flies due to the rooms being outside of the main building that lead into an opened patio area. CNA 1 stated there was nothing in place to prevent flies from entering the residents' rooms. On 7/29/2020 at 3 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated, Maggots came from not being cleaned. LVN 1 stated she sees flies in the building daily despite fly lights in some of the resident's rooms. LVN 1 stated she recently noticed there were fly lights in the facility but they are not working because flies are always in the building. On 7/29/2020 at 3:10 p.m., during an interview, CNA 2 stated he was called to assist with cleaning Resident 1 and he too, saw 3-4 maggots crawling around the resident's [DEVICE] and dressing. CNA 2 stated there was nothing in place to keep the flies out of the residents' rooms. On 7/29/2020 at 3:20 p.m., during a brief observation tour of the facility, accompanied by the Director of Staff Development the following was observed: Station 3's door was opened leading to the outside. room [ROOM NUMBER]'s door was opened. Station 2's patio door that leads to the lunchroom was opened. Flies were seen in the resident's rooms. There was no blue/ fluorescent light in either of the resident's rooms, hallways or near rooms in Station 3 (outdoor patio area rooms). On 7/29/2020 at 3:34 p.m., during an interview, the Administrator stated she could not remember the date, but she put fluorescent and blue light in resident rooms on Station 3 and in room [ROOM NUMBER]. The administrator stated the Maintenance/Housekeeping Supervisor was on vacation and would be unavailable for interview for a month. On 7/29/2020 at 3:36 p.m., during an interview the Director of Nursing stated the flies come from outside and goes into the resident rooms. The facility had an anti- fly device a long time ago which became defective, they don't have anything to prevent flies from coming into the building now. On 7/30/2020 at 12:20 p.m., during a telephone interview, LVN 2 stated she was assigned to the COVID-19 (highly contagious virus) unit to pass the medications. LVN 2 stated sometime in 5/2020, CNA 1 notified her she saw maggots coming from Resident 1's [DEVICE] site. LVN 2 stated Resident 1's room was outside of the unit where there are flies all of the time and enter into the resident's rooms due to the door being opened. LVN 2 stated there was nothing in place to stop the flies from entering the residents' rooms. LVN 2 denied seeing any fly lights in Resident 1's room. LVN 2 stated the CNAs cleaned Resident 1 and the resident was transferred to the hospital. LVN 2 stated she did not provide wound care to Resident 1's [DEVICE] site. According to an online Orkin pest control, the common house female fly lays up to 150 eggs, which resembles individual grains of rice, into damp, dark surfaces or in decomposing (process of decaying) materials for over a period of a few days. Within one day, the female house fly egg hatch into larvae (maggots (white legless insects that feed from the egg-laying site for three to five days)) https://www.orkin.com/flies/house-fly/life-cycle-of-house-fly. A review of the facility's undated policy and procedure titled, Pest Control Program, indicated the facility had scheduled pest control visits by a qualified pest control agent that included eradication and containment of common household pest that included roaches, ants, mosquitoes, flies, mice and rats. The policy indicated the pest control program would be conducted in the main patient buildings, all outbuildings on the property and all grounds. The policy indicated the pest control agent would leave a Pest Management Sanitation Report at the end of each pest control visits.

Based on observation, interview, and record review, the facility failed to supervise residents with a history or had a potential for self-injurious behavior (the intentional act of causing physical injury to oneself) and ensure these residents did not keep objects, such as utensils, that could be used to self-inflict injury for three of nine sampled residents (Residents 1, 4, and 14). Resident 1, who had a recent history of cutting himself in the left side of his neck prior to his facility's admission, was able to cut himself on both sides of his neck on 11/11/19. The facility did not know what object he used to self-inflict his injuries. Resident 1 had an order to use plastic utensils, but his dietary tray card did not have a notation that he had to use plastic utensils. Resident 4, who had an order to use plastic utensils, kept at his bedside a plastic container with one metal knife, one metal spoon, one metal fork, and several plastic utensils. Resident 14 who had an order to use plastic utensils was observed, on 1/16/2020 at 1:09 p.m., taking food items from the meal tray cart and walking back to his room because Certified Nursing Assistant (CNA) 5 and 7 left the meal tray cart unattended in the hallway. The CNAs and the licensed nurses did not have a consistent knowledge of who were the residents with self-injurious behaviors and requiring supervision, and the reason the residents with self-injurious behaviors had orders to use plastic utensils during meals. The CNAs did not know that utensils need to be accounted for after each meal to prevent residents from keeping and using them to self-inflict injury. These deficient practices resulted in Resident 1 cutting himself in the left side of his neck with an unknown object on 11/11/19. Resident 1 required a transfer to a general acute care hospital (GACH) and then to a trauma (a serious injury to the body) acute care center (TACH). Resident 1 was admitted to the TACH and required suture repair of the self-inflicted laceration on both sides of his neck. Resident 1 was hospitalized on a 5150 hold (legal involuntary hold when one is a danger to themselves and others) at TACH. This deficient practice had the potential to result in harm to Resident 4 and 14, and the other eight (8) residents (Residents 2, 7, 8, 9, 10, 11, 12, 13) identified by the facility with self-injurious behavior. A pattern of the facility's system failure to ensure staff was aware of all residents with self-injurious behavior were provided the necessary supervision and an hazardous-free environment to prevent residents from self-inflicted injuries resulted in an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has cause, serious injury, harm, impairment, or death to a resident). On 1/16/2020 at 5:46 p.m., the Department declared an Immediate Jeopardy. The facility's Administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness noncompliance that threatened the residents' health and safety. On 1/17/2020 at 12:54 p.m., the ADM and DON provided a written acceptable plan of action (POA) as follows: 1. The facility identified eight other residents with history of self-harm (Residents 2, 7, 8, 9, 10, 11, 12, 13) on 1/17/2020. 2. For residents identified with risk of self-harm and suicide ideation, a blue dot was placed next to their names, by the door of their rooms, and on their medical records to identify these residents at risk for self-harm on 1/17/2020. 3. A binder with all the residents identified with risk of self-harm and suicide ideation was placed on five out of the five nursing stations in the facility on 1/17/2020. 4. The plan of care for residents identified with risk of self- harm and suicide ideation was updated by the interdisciplinary team ((IDT) a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) members on 1/17/2020. 5. Facility implemented a separate dietary cart that identified residents with risk of self-harm and suicide ideation. These residents were provided with plastic utensils on 1/17/2020. 6. The Director of Staff Development (DSD) assigned team leaders to observe all meal carts, while meal trays were passed out during meals on 1/17/2020. 7. For residents identified with risk of self-harm, the IDT implemented a behavior monitoring every shift by coordinating with the resident's primary care physician on 1/16/2020 and 1/17/2020. The signs and symptoms of suicide ideation would be monitored every shift, by the licensed nurses, who will document the findings on the residents Medication Administration Record [REDACTED]. 8. All the staff were in-serviced by the DSD, DON, and Administrator on 1/16/2020, 1/17/2020, and 1/18/2020 regarding the blue-dot identifier for residents with risk of self- harm. The facility reviewed the suicide policy with the staff. 9. Social Services (SS) would provide daily visits for residents identified with risk of self-harm and suicide ideation on 1/17/2020. 10. Weekly psychiatric visits would include review of residents who have been identified at risk for self-harm. 11. Quality Assurance and Performance Improvement Program ((QAPI) is the coordinated application of two mutually-reinforcing aspects of a quality management system) was initiated by IDT on 1/17/2020 to review residents with history of suicide ideation, which will be reviewed on a monthly-basis during QAPI meetings. 12. Facility implemented a QAPI suicide ideation committee to monitor trends and root cause analyses on a monthly-basis on 1/17/2020. 13. The DSD will train new employees on the blue-dot system for suicide prevention and awareness during new employee orientation; handout and documentation will be provided on 1/17/2020. 14. The DSD, ADM, DON, and all the IDT members were responsible to monitor for compliance on a monthly basis by monthly in-services, chart reviews, communication huddles, blue dot identification program, staff awareness and QAPI. Findings will be reported and followed up on the monthly quality assurance meeting on 1/17/2020. 15. The Minimum Data Set (MDS, a standardized assessment and care planning tool) Nurse (a nurse that coordinates the completion of the MDS) and the nursing supervisors reviewed the medical records of residents with history of self -harm, residents who had orders for the use of plastic utensils, and who had care plans for the use of plastic utensil on 1/16/2020 and 1/17/2020. After reviewing the medical records MDS Nurse and nursing supervisors communicated the findings to the physician and clarified the orders based on the doctors' recommendations. The resident's care plan and diet card were updated to reflect the physician order. 16. The needs of the residents identified with risk of self- harm and suicide ideation were reviewed by all IDT members, including their dietary needs, to ensure plastic utensils were appropriate and included in the care plan on 1/17/2020. 17. The facility discontinued the use of plastic utensils for residents who did not have a history of self-harm and suicide ideation on 1/17/2020. 18. The DON and the Registered Nurse (RN) supervisors implemented daily communication huddles every shift to ensure communication and suicide awareness was included on 1/17/2020. 19. Licensed nurses and RN supervisors were provided in-service on developing patient centered care plan for the use of plastic utensils on 1/16/2020 and 1/17/2020. 20. The dietary Supervisor (DS) in-serviced the dietary staff on 1/16/2020 and 1/17/2020 regarding the use of plastic utensils and the suicide ideation policy to ensure compliance. 21. The ADM, DON, DSD, SS, Medical Records (MR) staff, and DS were responsible to ensure compliance by in-services, observation, spot-checks, and chart review on 1/17/2020. On 1/18/2020 at 2:28 pm, after the Department conducted a facility visit and inspected that the POA was implemented, both the ADM and the DON were notified the IJ was lifted. Findings: A review of Resident 1's psychiatric hospital History and Physical (H/P), dated 9/4/19, prior to Resident 1's admission to the skilled nursing facility (SNF), indicated the psychiatric hospital admitted Resident 1 after he cut himself on the left side of the neck. The H/P indicated Resident 1 had a laceration (deep cut) repaired on the left side of the neck. A review of Resident 1's SNF Admission Record indicated the facility admitted Resident 1 on 9/10/19 with [DIAGNOSES REDACTED]. A review of Resident 1's Admission Assessment, dated 9/10/19, indicated Resident 1 had a [DIAGNOSES REDACTED]. The assessment indicated Resident 1 had an old scar to the left neck from a previous self-inflicted injury. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's Multidisciplinary Progress Record, dated 9/10/19, indicated the facility admitted Resident 1 with the primary [DIAGNOSES REDACTED]. A review of Resident 1's Care Plan, dated 9/10/19, indicated Resident 1 was at risk for suicidal ideation (thinking about or wanting to take your own life). The staff's interventions included to keep Resident 1 safe by using plastic utensils to eat with. A review of Resident 1's Care Plan, dated 9/10/19, indicated Resident 1 was at risk for harming self with the use of silver utensils. The staff's interventions included to keep Resident 1 safe and provide the resident with plastic utensils, one-on-one monitoring (one staff monitoring one resident) as needed and monitoring the resident every shift if needed. A review of Resident 1's Diet Communication, dated 9/10/19, indicated Resident 1 had orders to use plastic utensils. A review of Resident 1's MDS), dated [DATE], indicated Resident 1 felt down, depressed, or hopeless. The MDS indicated Resident 1 required supervision while eating and during meal set up. A review of Resident 1's Psychiatric Note, dated 10/23/19, indicated Resident 1 was sitting on a chair with episodes of aggressive behavior, anxiety and intermittently sadness. A review of Resident 1's undated dietary card indicated there was no notation that Resident 1 should be using plastic utensils. A review of a Situation, Background, Appearance, and Review Communication form ((SBAR) an internal communication tool) and Resident 1's Multidisciplinary Progress Record, both dated 11/11/19 and timed at 7:30 p.m., indicated Resident 1 had a small wound on the left side of his neck. A review of Resident 1's untimed Physician Telephone order, dated 11/11/19, indicated Resident 1 had orders to be transferred to the GACH. A review of Resident 1's untimed GACH record, the emergency room (ER) Report, dated 11/11/19, indicated Resident 1 was admitted to the GACH with a stab wound. The report indicated Resident 1 stated he was feeling ill and he stabbed himself to feel better. The report indicated the facility's nursing staff reported Resident 1 was found with stab wounds. The report indicated Resident 1 had multiple stab wounds with the most significant stab wound being on the left side of the neck. The report indicated Resident 1 had multiple smaller lacerations on the neck. The ER report indicated Resident 1 presentation was extremely concerning and Resident 1 met the trauma criteria and he was transferred to a TACH for a trauma surgery evaluation. A review of Resident 1's TACH record, the Acute Care Surgery Trauma H/P and Consultation, dated 11/11/19, indicated Resident 1 had self-inflicted slash (a cut with a violent sweeping movement) wounds to the neck. The wounds included a three-centimeter ((cm) unit of measurement) laceration and a two by one cm left neck laceration; one 0.5 cm left neck laceration and one abrasion (superficial cut) to right neck; and two abrasions to the left neck. The resident's [DIAGNOSES REDACTED]. The consultation indicated Resident 1's neck lacerations were repaired. A review of Resident 1's TACH records, the ER Note, dated 11/12/19, indicated Resident 1 had a complete neck laceration repair. The note indicated Resident 1 had attempted suicide in the past. The ER note indicated Resident 1 was responding to voices and Resident 1 stated he cut his neck with a razor and attempted the suicide on the morning of 11/11/19. The ER note indicated the lacerations were sutured (a stitch or row of stitches holding together the edges of a wound) by the trauma team, which included one 3 cm laceration on the right neck and two lacerations to the left neck (0.5 cm and 2 cm) for a total of 5.5 cm in length suture repair. The ER note indicated Resident 1 stated he had been feeling suicidal for a long time. A review of Resident 1's TACH records indicated a Psychiatric Consult (an evaluation by a physician who specializes in the [DIAGNOSES REDACTED]. On 11/25/19 at 10:30 a.m., during an interview, the DON stated the facility transferred Resident 1 to the GACH. The DON stated she thought Resident 1 had scratched the neck scar he had from his previous suicidal attempt. The DON stated Resident 1 was at risk for self-harm, because he had attempted to hurt himself before and he had [MEDICAL CONDITION]. The DON stated Resident 1 had a small wound to the left side of the neck (on 11/11/19). On 11/25/19 at 11:26 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated he was not aware Resident 1 had a history of [REDACTED]. LVN 1 stated the facility's protocol for new admissions included to endorse the resident's medical history of [REDACTED]. On 11/25/19 at 1:30 p.m., during an interview, the DON stated Resident 1 did not want to tell the facility's staff what happened to his neck. The DON stated the staff could not be with Resident 1 for 24 hours a day. The DON stated after the incident (attempt of suicide on 11/11/19) with Resident 1, the facility implemented a 30-day behavior monitoring for all residents with a history of self-harm. On 11/25/19 at 3:51 p.m., during an interview, Registered Nurse (RN) 1 stated LVN 3 notified her that Resident 1 had a small wound on the left side of the neck on 11/11/19. RN 1 describe the wound as small and deep, without bleeding, but RN 1 stated she did not measure the wound. RN 1 stated after the suicide attempt, Resident 1 did not want to be touched. RN 1 stated she did not find any sharp objects near Resident 1 that could have been used on his neck. On 12/5/19, at 11:45 a.m., during an interview, CNA 1, stated Resident 1 used plastic utensils. CNA 1 stated the reason Resident 1 used plastic utensils was because the facility wanted Resident 1 to have plastic utensils (sic). CNA 1 stated she distributed the food trays to the residents and returned later to the residents to pick up the trays. CNA 1 stated she was not notified about Resident 1's history of self-harm. On 12/5/19 at 11:51 a.m., during an interview, CNA 2 stated residents who used plastic utensils had mental issues and could hurt themselves. CNA 2 stated Resident 1's Roommate 1 used regular silver utensils. CNA 2 stated he delivered the food trays with plastic and metal utensils and he would return to pick up the trays after the residents were done eating. CNA 2 stated he only would check the amount of food left on the tray and he did not focus on counting or checking for the utensils. CNA 2 stated the facility did not always notify him of residents who were at risk to hurt themselves. On 12/5/19 at 12:15 p.m., during an interview, LVN 4 stated she received shift report at the beginning of the shift about the care of the residents. LVN 4 stated she would notify the CNAs of residents who were at risk for self- harm. LVN 4 stated residents at risk for self -harm used plastic utensils during meals and were checked for body harm. When LVN 4 was asked how the resident's utensils were monitored, LVN 4 stated she had to make sure the CNAs stayed with the residents until they were finished eating. On 12/5/19 at 12:42 p.m., during an interview, RN 2 stated residents who had a history of [REDACTED]. RN 2 stated the CNAs were supposed to supervise the residents who used plastic utensils during meals. RN 2 was unable to answer how the utensils were monitored for residents with history of self-harm. On 12/5/19 at 3:49 p.m., during an interview, LVN 3 stated on 11/11/19, at around 7 p.m. he noticed Resident 1 had a small wound on the left side of the neck and he became concerned. LVN 3 stated he asked Resident 1 what had happened and Resident 1 responded that he was okay. LVN 3 stated the CNAs were responsible to check the resident's meal trays and utensils after the residents eat. On 12/9/19 at 1:40 p.m., during an interview, CNA 3 stated the resident's food (dietary) card would specify which residents used plastic utensils. CNA 3 stated the nursing staff did not notify her of the reason residents used plastic utensils. CNA 3 stated she did not count the utensils on the resident's meal trays. CNA 3 stated she checked the meal trays for food and beverage consumed, not if the utensil were (still) on the trays. On 12/20/19 at 7:35 a.m., during an observation and interview, Resident 4 had a meal tray at the bedside with plastic utensils. There were no staff member seen in Resident 4's room. Resident 4 had a cup with multiple plastic utensils on the bedside table. Resident 4 stated he often hid the plastic spoons in his room to eat at a later time. Resident 4 stated the staff did not watch him eat during mealtime. On 1/16/2020 at 7:36 a.m., during an interview with CNA 6, she stated she knew the residents who were at risk for self-harm from working with them and because they were aggressive. CNA 6 stated Resident 4 was at risk for self-harm. CNA 6 stated when she picked up the meal tray for residents at risk for self-harm, she had to make sure to get all the utensils and not leave anything in the room. During a concurrent observation of Resident 4's bedside table, there was a plastic container with one metal knife, one metal spoon, one metal fork, and several plastic utensils. CNA 6 stated Resident 4 would become aggressive by yelling and cursing, if the staff attempted to remove the utensils from his room. CNA 6 stated Resident 4 was at risk to hurt himself and others by keeping the utensils on the bedside table. A review of Resident 4's Care Plan, dated 11/30/19, indicated Resident 4 was at risk for self- harm with use of silver utensil. The care plan indicated an intervention of providing plastic utensil to prevent self-harm. A review of Residents 4's Order Summary Report, dated 11/14/19, indicated an order for [REDACTED]. On 1/16/2020 at 8:04 a.m., during an interview, LVN 5 stated all residents who had a mental diagnosis, such as [MEDICAL CONDITION] and dementia (a progressive condition marked by memory impairment) were at risk for self-harm. LVN 5 stated she had a list of residents who used plastic utensils. LVN 5 stated residents who used plastic utensils during their meal were at risk for self-harm, but she did not know which residents had a history of [REDACTED]. On 1/16/2020 at 9 a.m., during an interview, the DON stated residents who had a history of [REDACTED]. The DON stated the LVNs and CNAs worked together to supervise residents who used plastic utensils. The DON stated residents who were not supervised could harm themselves and the CNAs had to visually monitor residents with plastic utensils and to ensure the meal trays had all the utensils when they were picked up. The DON stated Resident 1 had orders for plastic utensils to prevent self-harm. On 1/16/2020 at 10:24 a.m., during an interview and a concurrent record review, LVN 1 stated she was not aware of Resident 1's history of self-harm. LVN 1 stated residents who had a history of [REDACTED]. LVN 1 reviewed Resident 1's physician's orders [REDACTED]. On 1/16/2020 at 1:09 p.m., during an observation, the meal tray carts were left unattended in the hallway. CNA 7 was observed going in and out of residents' rooms. Resident 14 who had orders to use plastic utensils with meals, was observed taking food items from the meal tray cart and walking back to his room. On 1/16/2020 at 1:25 p.m., during an interview, CNA 5 stated two CNAs worked together passing the trays to ensure the meal cart was closely monitored. CNA 5 stated CNA 7 would let her know when he walked away from the meal tray cart. CNA 5 stated CNA 7 did not notify her that he had left the meal tray cart unattended. CNA 5 stated meal carts had to be monitored because the residents could get food and utensils from the meal tray cart. A review of the facility's undated policy and procedures titled, Suicidal Residents indicated the purpose of the policy and procedures was to manage the behavioral symptoms of the resident with [MEDICAL CONDITION]. For immediate threat/concern of resident self-inflicting harm resident should be placed on one-on-one monitoring and provided a quiet and safe environment. A review of the facility's undated policy and procedure titled, Monitoring residents indicated the purpose of the policy and procedures was to identify ways in which the facility monitored residents and resident care. The policy indicated residents that were identified to have behavioral symptoms potential for conflict and anger should be monitored in accordance with plans of care developed to address such problems. Monitoring of such residents should be the responsibility of, but not limited to, direct caregivers, charge nurses, nursing supervisors, and members of the interdisciplinary team. Residents with special care needs and potential for neglect shall likewise be monitored in accordance with their plans of care, and at a minimum, included in the regular monitoring of charge nurses during endorsements of care to nurses' aid. A review of the facility's undated policy titled, Avoidance of Environmental Hazards indicated items that would pose harm to residents, due to accessibility by vulnerable residents would be removed, including sharp objects and other items.