Every finding on record at Los Angeles Comm Hospital

Based on observation, interview, and record review, the facility failed to follow infection control and Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) protocols for two of six residents (Resident 23 and Resident 2), by not wearing the required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) during suctioning and not maintaining proper infection control practices during wound care.These deficient practices placed Residents 23 and 2 and other residents at increased risk for infection.Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 7/30/2025, the H&P indicated Resident 2's diagnoses included a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and an open wound. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills for daily decision-making (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 2 required substantial to maximal assistance from staff to roll left and right in bed and was dependent on staff for all other mobility while in and out of bed. The MDS indicated Resident 2 was dependent on staff for bathing, getting dressed, and toileting hygiene. The MDS indicated Resident 2 had an unhealed Stage 4 pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During an observation on 2/2/2026 at 10:13 a.m., at Resident 2's bedside, observed the Treatment Nurse (TN) preparing Resident 2 for wound care treatment. The TN took a box of gloves from the wall mount and placed them onto Resident 2's bed, along with multiple single-use wound dressings. During an observation on 2/2/2026 at 10:25 a.m., at Resident 2's bedside, observed the TN performing wound care treatment to Resident 2's pressure injury. The TN took new gloves from the box of gloves on Resident 2's bed between treatments. The box of gloves were in contact with the plastic bags the TN was using to collect the soiled wound dressings and supplies. During an observation on 2/2/2026 at 10:42 a.m., at Resident 2's bedside, observed the TN taking the box of gloves from Resident 2's bed and returning them back onto the wall mount. The TN was then observed taking an unopened dressing from Resident 2's bed and placing it back onto the treatment cart. During an interview on 2/2/2026 at 10:45 a.m., with the TN, the TN stated he should not have returned the box of gloves to the wall mount. The TN stated returning a box of gloves to the wall mount was an infection control concern because it had already been in contact with Resident 2 and was now contaminated. The TN stated it was okay to return the unused wound dressing to the treatment cart because it was not opened. During an interview on 2/6/2026 at 10:33 a.m., with the Infection Control Manager (ICM), the ICM stated the box of disposable gloves could not be disinfected between use, therefore should be considered contaminated once in contact with a resident. The ICM stated that once the gloves were brought to a resident's bedside it should stay with that resident and not be returned to the wall mount for use with other residents. The ICM stated the dressing should not have been returned to the treatment cart. The ICM stated that the packaging was considered contaminated and could not be disinfected between use. The ICM stated that the box of gloves and the wound dressing were cross-contamination risks and had the potential to spread infection among residents. 2. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE]. Resident 23's diagnoses included hypotension (HTN- low blood pressure), seizures (a chronic brain disorder causing recurring movements due to abnormal electrical activity among brain cells), and chronic renal failure (CKD - long-term, irreversible loss of kidney function where kidneys fail to filter waste from the blood). During a review of Resident 23's History and Physical (H&P), dated 6/16/2025, the H&P indicated Resident 23's was unable to give any information regarding his neurological state of health. During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 cognitive skills for daily decision making were severely impaired. During a record review of Resident 23's physician orders dated 1/12/2026, the physician orders indicated Respiratory Therapist assistance for mechanical ventilation (a life-support technique using a machine [ventilator] to assist or replace spontaneous breathing by delivering oxygen) and tracheostomy tube (a tube inserted through a surgical incision (stoma) into the windpipe (trachea) to create an alternative airway for patients who cannot breathe through their mouth/nose due to blockage, long-term ventilation needs, or secretion management) care. During an observation on 2/2/26 at 10:09 a.m., inside Resident 23's room, observed an infection prevention and control protocol sign placed at the entrance of Resident 23's room. Respiratory Therapist (RT) 1 was providing tracheal suctioning to Resident 23 via the resident's tracheostomy tube. RT 1 was not wearing a gown. During an interview on 2/5/2026 at 1:10 p.m., with RT 1, RT 1 stated she forgot to put on a gown before initiating the suctioning care for Resident 23. RT 1 stated Resident 23 was on EBP and that PPE, including a gown, was required per the facility's infection prevention and control policies. RT 1 indicated that by not wearing the required PPE she did not follow established EBP and PPE protocols intended to reduce the transmission of MDROs and other infectious agents. RT 1 stated that suctioning through a tracheostomy involves direct access to the resident's airway and mechanical ventilation system. RT 1 stated failure to wear appropriate PPE increased the risk for contamination of the airway, cross-contamination, and transmission of respiratory infections. RT 1 stated there was a potential for infection-related complications for Resident 23, including respiratory infection and ventilator-associated complications. During a review of the facility's policy and procedure (P&P) titled Enhanced Barrier Precautions in the Long Term Setting dated 3/2025, the P&P indicated to implement Enhanced Barrier Precautions (EBP) to prevent the transmission of multidrug-resistant organisms (MDROs) and other healthcare-associated infections among residents. The P&P indicated EBP are an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP expands upon standard precautions by requiring the use of gowns and gloves during specific high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). During a review of the facility's P&P titled Standard Precautions, dated 6/2025, the P&P indicated standard precautions were the primary strategy for control of hospital-acquired infections. The P&P indicated precautions were designed to prevent the spread of microorganisms. The P&P indicated staff were to prevent infection transmission resulting from indirect contact of a susceptible resident with contaminated objects.

Based on observation, interview, and record review, the facility failed to ensure the Foley catheter (a flexible indwelling tube inserted through the urethra [a hollow tube that lets urine leave the body] into the bladder to drain urine into a collection bag) drained properly into the collection bag preventing the backflow of urine (when urine flows backward from the bladder to one or both ureters and sometimes to the kidneys) for one of two residents (Resident 20).This deficient practice placed Resident 20 at an increased risk for potential infection, discomfort, obstruction, and decline in health status.Findings:During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE]. Resident 20's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), enlarged prostate (increased in the size of the prostate [a small gland in the male reproductive system]), and seizures (a chronic brain disorder causing recurring movements due to abnormal electrical activity among brain cells).During a record review of Resident 20's History and Physical (H&P), dated 6/17/2025, the H&P indicated Resident 20 was not oriented, non verbal, his and eyes did not visually track (when the eyes focus on an object as it moves across the field of vision).During a record review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated 12/30/2025, the MDS indicated Resident 20 was comatose (deep unconsciousness for a prolonged or indefinite as a result of sever injury or illness). The MDS indicated Resident 20 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a concurrent observation and interview on 02/5/2026 at 1:47 p.m., with Registered Nurse (RN) 1, Resident 20's indwelling Foley catheter was observed hanging from the middle of the bed with a dependent loop (is a formed by excess drainage tubing in a urine drainage system where urine or liquid can accumulate). The Foley catheter was full with urine. RN 1 stated Resident 20's urine was backing up into the resident's bladder and not draining properly because of the dependent loop. RN 1 stated that urine should be able to flow down easily from the Foley catheter tube into the urine collection bag. RN 1 stated that backflow of urine can increase the chances of infection and/or discomfort. RN 1 stated that the Foley catheter should be maintained straight without any dependent loops.During a review of the facility's policy and procedure (P&P) titled Care of the Indwelling Catheter dated 03/2025, the P&P indicated the facility would provide patient comfort and proper urine drainage.

Based on interview and record review, the facility failed to ensure orders for hydrocodone-acetaminophen 5-325 (brand name Norco, an opioid medication used to reduce moderate to severe pain) did not exceed seven (7) days for one of twelve sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for complications related to administration of opioid medications, such as constipation, nausea, vomiting, sedation, dizziness, respiratory depression, physical dependence, addiction, and overdose.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 7/30/2025, the H&P indicated Resident 2's diagnoses included a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and open wound. During a review of Resident 2's physician orders for the months of October 2025, November 2025, December 2025, and January 2026, the orders indicated to administer Hydrocodone-acetaminophen (Norco) 5-325 milligram (mg, a unit of dose measurement), every 6 hours as needed for severe pain. The orders as follows exceeded the seven (7) day order limit: a. Norco 5-325mg, every 6 hours as needed for severe pain, dated 10/26/25 to 11/25/25b. Norco 5-325mg, every 6 hours as needed for severe pain, dated 11/25/25 to 12/24/25c. Norco 5-325mg, every 6 hours as needed for severe pain, dated 12/25/25 to 1/24/26d. Norco 5-325mg, every 6 hours as needed for severe pain, dated 1/24/26 to 2/23/26 During a concurrent interview and record review on 2/6/2026 at 11:42 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Preparation and Administration of Medications, dated 4/2025 was reviewed. The P&P indicated that all opioid medication orders were to be renewed every 7 days with a new order. The DON stated the purpose of re-evaluating opioid medication for order renewal was to prevent opioid dependency and to prevent the risk for unwanted side effects. The DON stated the facility's P&P was not followed.

Based on interview and record review, the facility failed to ensure two of eight sampled residents (Resident 13 and Resident 24) had informed consent prior to the placement of hand and wrist restraints. This deficient practice resulted in Resident 13 and Resident 24 being placed in restraints without consent from their responsible party. Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE]. During a review of Resident 13's electronic medical records, the electronic medical records indicated Resident 13's diagnoses included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 13's History and Physical (H&P), dated 3/4/2025, the H&P indicated Resident 13 was unable to convey any concerns or complaints due to mental status and tracheostomy (trach, an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) status. During a review of Resident 13's Minimum Data Set ([MDS], a resident assessment tool), dated 12/20/2025, the MDS indicated Resident 13's cognitive skills for daily decision making was severely impaired (ability to think and reason). The MDS indicated Resident 13 required maximal assistance (helper does more than half the effort) for upper body dressing. The MDS indicated Resident 13 was dependent 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). The MDS indicated Resident 13 required oxygen therapy (treatment that provides supplemental oxygen to help people who can't get enough from normal breathing) and tracheostomy care (cleaning and maintenance of a breathing tube (tracheostomy tube) and the surrounding neck skin (stoma) to prevent infection, ensure clear airways, and manage secretions). The MDS indicated Resident 13 used limb restraints daily while in bed. During a review of Resident 13's care plan titled Bilateral Soft Wrist Restraints dated 6/14/2025, the care plan indicted Resident 13 would not pull out his tracheostomy tube. The interventions indicated to explain the risks and benefits of using restraints to the resident and family.During a review of Resident 13's Patient Orders, dated 2/5/2026, the order indicated bilateral (both) soft wrist restraints to support and promote physical healing, avoid treatment interruptions, and enable active interventions. During a concurrent interview and record review on 2/5/2026 at 10:38 a.m. with the Director of Nursing (DON), Resident 13's Consent for Bilateral Soft Wrist Restraints, dated 6/14/2025, was reviewed. The consent did not indicate consent was obtained prior to applying the soft wrist restraints to Resident 13. The DON stated the name of the person who consented to the application of the soft wrist restraints was required on the consent form. The DON stated it was important to indicate the name of the person that gave consent because it proved the facility received the permission to place the restraints. The DON stated the consent form was incomplete and restraints were placed on Resident 13 without consent. 2. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 24's electronic medical records, the electronic medical records indicated Resident 24's diagnoses included chronic respiratory failure and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 24's H&P, dated 12/1/2025, the H&P indicated Resident 24 had neurologic (involves the brain, spine, and nerves) and functional limitations. During a review of Resident 24's MDS dated [DATE], the MDS indicated Resident 24's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 24 was dependent on staff for all ADLs. The MDS indicated Resident 24 required oxygen therapy and tracheostomy care. The MDS indicated Resident 24 used limb restraints daily while in bed. During a review of Resident 24's care plan titled Bilateral Soft Wrist Restraints dated 1/2/2025, the care plan indicated Resident 24 would be not pull out the trach and tube. The interventions indicated to explain the risks and benefits of using restraints to the resident and their family. During a review of Resident 24's Patient Orders, dated 2/5/2026, the orders indicated right hand mitten restraint to avoid treatment interruptions and enable active interventions. During a concurrent interview and record review on 2/5/2026 at 10:56 a.m. with the DON, Resident 24's Consent for Right Hand Mitten Restraint, dated 1/2/2024, was reviewed. The consent indicated Resident 24 was to have a right hand mitten restraint. The consent form did not indicate consent was obtained prior to the application of the right hand mitten restraint. The person's name who gave consent for the placement of the restraint was not indicated. The DON stated the consent form required the name of the person who gave consent to apply the restraints to Resident 24. The DON stated if the consent did not have a name, it meant the facility did not receive consent to apply restraints to Resident 24. During an interview on 2/6/2026 at 10:42 a.m. with Registered Nurse (RN) 2, RN 2 stated for consent to be complete it must have two RN signatures, the name of the doctor ordering the restraints, and the name of the person giving permission to apply the restraints. RN 2 stated it was negligent to apply restraints on residents without consent. During a review of the facility's Policy and Procedure (P&P) titled Consent/Informed Consent, dated 5/2025, the P&P indicated an informed consent was the process which a patient learns about and understands the purpose, benefits, and potential risks of a medical or surgical intervention, and then agrees to receive the treatment. The P&P indicated a physician was responsible for providing information that was necessary to allow an informed decision to be made.

Based on interview and record review, the facility failed to ensure staff documented and properly assessed bilateral hand edema (swelling caused by an abnormal accumulation of excess fluid trapped in the body's tissues) and documented the scab above a resident's lip for two resident of eight sampled residents (Resident 7 and 14).These deficient practices delayed care for Resident 7 and 14 and placed the residents at risk for complications due to not receiving the necessary care.Findings:a. During an observation on 2/2/2026 at 10:18 a.m. in Resident 7's room, observed Resident 7 lying in bed. Resident 7 had bilateral hand edema. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE]. During a review of Resident 7's electronic medical record, the electronic medical record indicated Resident 7 had diagnoses that included respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 7's History and Physical (H&P) dated 1/29/2026, the H&P indicated Resident 7 had an anoxic brain injury (brain injury caused by a complete lack of oxygen flowing to the brain) and was nonresponsive.During a review of Resident 7's Minimum Data Set ([MDS], a resident assessment tool) dated 11/12/2025, the MDS indicated Resident 7's cognitive skills for daily decision making was severely impaired (ability to think and reason). The MDS indicated Resident 7 was dependent on staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 7 required oxygen therapy (treatment that provides supplemental oxygen to help people who can't get enough from normal breathing) and tracheostomy care (cleaning and maintenance of a breathing tube [tracheostomy tube] and the surrounding neck skin [stoma] to prevent infection, ensure clear airways, and manage secretions). During a review of Resident 7's electronic medical record, the electronic medical record did not indicate any documentation addressing the resident's bilateral hand edema.During a concurrent interview and record review on 2/5/2026 at 1:30 p.m. with the Director of Nursing (DON), Resident 7's electronic medical record was reviewed. The electronic medical record did not indicate any documentation addressing Resident 7's bilateral hand edema. The DON stated there were no nursing progress notes indicating nursing staff documented the observation of Resident 7's bilateral hand edema. The DON stated nursing staff must document all changes of conditions (COC). The DON stated if the COC was not documented it meant nothing was done to make that change of condition better. The DON stated she expected nursing staff to document all change of conditions, assess residents, inform the family, inform the doctor and carry out the doctor orders. During an interview on 2/6/2026 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she worked with Resident 7 on 2/2/2026, 2/3/2026 and 2/6/2026 and did not notice the bilateral hand edema. LVN 2 stated she noticed Resident 7's right arm was swollen but did not document or report the swelling because she was busy. LVN 2 stated she was required to assess her residents every day and document any new findings. LVN 2 stated swollen hands were a change of condition and needed to be documented. LVN 2 stated all findings must be documented and reported to the physician because Resident 7 might need a higher level of care.b. During an observation on 2/2/2026 at 10:35 a.m. in Resident 14's room, observed Resident 14 lying in bed. There was a scab above Resident 14's lip.During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE].During a review of Resident 14's electronic medical record, the electronic medical record indicated diagnoses that included (chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and coronary artery disease (artery disease that is caused by plaque buildup in the wall of the arteries that supply blood to the heart, causes coronary arteries to narrow, limiting blood flow to the heart).During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 14 was dependent on staff for all ADLs. The MDS indicated Resident 24 required oxygen therapy and tracheostomy care.During a concurrent interview and record review on 2/5/2026 at 11:39 a.m. with the Director of Nursing (DON), Resident 14's electronic medical record was reviewed. The electronic medical record did not indicate documentation addressing Resident 14's scab above her lip. The DON stated documenting changes of conditions was a way of communicating with all staff. The DON stated if changes of conditions were not documented, nursing staff would be unaware of resident changes.During a concurrent interview and record review on 2/5/2026 at 11:46 a.m. with the DON, the DON stated Resident 14 did not receive any care for the scab. The DON stated she did not know how or when Resident 14 developed the scab because it was not documented.During an interview on 2/6/2026 at 11: 58 a.m. with LVN 2, LVN 2 stated she noticed the scab over Resident 14's lip one month prior. LVN 2 stated she did not notify the physician of Resident 14's scab and she did not document the finding. LVN 2 stated on 2/3/2026, she did not document the finding because the scab began lifting up and she thought it was going to fall off. LVN 2 stated she should have notified her charge nurse. LVN 2 stated Resident 14 did not receive any care or treatment for the scab because Resident 14's physician was not notified. LVN 2 stated she was supposed to document her assessment and monitor Resident 14's scab. LVN 2 stated Resident 14 had the scab for over one month and no one knew how Resident 14 got the scab or what treatment to provide to Resident 14.During a review of the facility's Job Description for LVN dated 2/5/2026, the Job Description indicated LVN's would recognize changes in patient conditions, take appropriate action and document interventions. The Job description indicated an LVN would effectively collaborate with the health care team to intervene, and advocate for the safety of the patient.During a review of the facility's Policy and Procedure (P&P) titled Care of Unconscious Resident dated 4/2025, the P&P indicated the facility would provide the unconscious resident with care that maintained safety, comfort, and minimized complications. The P&P indicated staff would report any changes or unusual observations to the physician. The P&P indicated staff would document significant observations in the nursing narrative notes.

Based on observation, interview, and record review, the facility failed to ensure the pulse oximetry (device called placed on a finger or earlobe used to measure the oxygen level of the blood) was applied in order to effectively monitor the oxygen saturation level ([O2 sat], a measurement of how much oxygen the blood is carrying as a percentage) for one of eight sampled residents (Resident 24) receiving respiratory services (treatment, management and care of the patient's breathing). This deficient practice placed Resident 24 at high risk of failing to detect hypoxemia (low blood oxygen), and delayed treatment that can rapidly progress to life-threatening complications. Findings: During observations on 2/2/2026 at 10:22 a.m., and 2/4/2026 at 3:40 p.m., in Resident 24's room, observed Resident 24 was not wearing a pulse oximetry probe. The cord of the pulse oximetry was hanging off the bed. During an observation on 2/5/2026 at 11:00 a.m. in Resident 24's room, observed Resident 24 was not wearing a pulse oximetry probe. The cord of the pulse oximetry cord was unplugged on top of the bed. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 24's electronic medical records, the electronic medical records indicated Resident 24's diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 24's History and Physical (H&P), dated 12/1/2025, the H&P indicated Resident 24 had neurologic (pertaining to the brain, spine, and nerves) and functional limitations. During a review of Resident 24's Minimum Data Set ([MDS], a resident assessment tool) dated 12/23/2025, the MDS indicated Resident 24's cognitive skills for daily decision making was severely impaired (ability to think and reason). The MDS indicated Resident 24 was dependent on staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 24 required oxygen therapy (treatment that provides supplemental oxygen to help people who can't get enough from normal breathing). During a review of Resident 24's care plan titled Impaired Gas Exchange (process by which oxygen and carbon dioxide move across the air-blood barrier in the lungs, involving ventilation, perfusion, and diffusion) dated 10/1/2021, the care plan indicated Resident 24 was to have an effective gas exchange as evidenced by the pulse oximetry being within normal range. The care plan intervention's indicated to assess and record signs of hypoxia (low tissue oxygen). During a review of Resident 24's Patient Orders, dated 11/17/2025, the orders indicated for oxygen therapy and to maintain oxygen saturation level at 95 percent (%). During a review of Resident 24's Parameter History for Oxygen Saturations, dated 2/2/2026 - 2/5/2026, the Parameter History indicated Resident 24's oxygen saturation was monitored daily. During a concurrent observation and interview on 2/4/2026 at 11:45 a.m. with the Director of Nursing (DON), in Resident 24's room, observed Resident 24 did not have an oximetry probe on her finger. The DON stated she did not know why the pulse oximetry probe was not attached to Resident 24. The DON stated the pulse oximetry probe had to be attached to Resident 24 to monitor the resident's oxygen saturation. During a concurrent observation and interview on 2/4/2026 at 11:58 a.m. with Respiratory Therapist (RT) 2, in Resident 24's room, RT 2 stated Resident 24 should have a pulse oximetry to monitor her oxygen saturation. RT 2 stated he provided respiratory care for Resident 24 that morning (2/4/2026) and she had on the pulse oximetry. RT 2 stated he did not know why it was off. RT 2 stated someone must have taken it off for an unknown reason. RT 2 stated it was important to have the pulse oximetry probe to monitor Resident 24's oxygen level and heart rate and to know if she was hypoxic. During a review of the facility's Job Description for Therapist Respiratory Care Practitioner (RCP), dated 9/18/2024, the job description indicated the RCP was responsible for assessing, planning, implementing, and evaluating the needs of the patient. The job description indicated the RCP would evaluate all clinical data to determine the appropriateness of the prescribed respiratory care. During a review of the facility's Policy and Procedure (P&P) titled Pulse Oximetry dated 1/2025, the P&P indicated pulse oximetry would be implemented to monitor oxygen saturation. The P&P indicated spot checks for pulse oximetry would be implemented on each shift when ordered by the physician, residents requiring supplemental oxygen and residents under respiratory care services as part of a routine assessment.

Based on interview and record review, the facility failed to ensure as needed (PRN) orders for lorazepam (Ativan, a medication to treat anxiety [feeling of unease]), did not exceed a 14-day administration period for two of 12 sampled residents (Resident 2 and Resident 19). This deficient practice had the potential to result in prolonged administration of lorazepam placing the resident at risk for serious complications such as dependence on the medication, sedation, and withdrawal from prolonged use (the physical and mental symptoms that a person has when they suddenly stop or cut back the use of an addictive substance).Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 7/30/2025, the H&P indicated Resident 2's diagnoses included anxiety disorder (excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 2 had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 2 required substantial to maximal assistance from staff to roll left and right in bed and was dependent on staff for all other mobility while in and out of bed. The MDS indicated Resident 2 was dependent on staff for bathing, getting dressed, and toileting hygiene. During a review of Resident 2's physician order, dated 10/28/2025, the physician order indicated Resident 2 was to receive lorazepam 0.5 milligrams (mg, a unit of dose measurement) every 24 hours PRN for anxiety. During an observation on 2/5/2026 at 1:02 p.m., at Resident 2's bedside, Resident 2 was observed lying in bed. Resident 2's breathing appeared unlabored, even, and he appeared calm when spoken to. Resident 2 was not restless, agitated, or displaying any behavior or mood concerns. During an interview on 2/5/2026 at 1:06 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 was usually very relaxed and used his call light if/when he needed something. CNA 1 stated he had not observed Resident 2 display restlessness or agitation. During an interview with 2/5/2026 at 1:10 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 was typically calm but would often get restless and complain of pain to his sacrum (triangular bone in the lower back). LVN 1 stated that aside from restlessness due to pain, Resident 2 did not display agitation or restless behavior. During an interview on 2/5/2026 at 3:03 p.m., with the Director of Nursing (DON), the DON stated that psychotropics ordered for as needed (PRN) administration were to be limited to a 14-day administration period. The DON stated Resident 2's current lorazepam order was ordered for one (1) year. The DON stated the order should have been limited to 14 days and re-ordered if still indicated, but the order duration should not be for one year. The DON stated the purpose of keeping the 14-day duration of administration was to prevent unnecessary use of psychotropic medications. 2. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE]. During a review of Resident 19's H&P, dated 1/9/2026, the H&P indicated Resident 19's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar affective 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 19's MDS, dated [DATE], the MDS indicated Resident 19 had severe cognitive impairment. The MDS indicated Resident 19 was sometimes understood by others and usually understood others. The MDS indicated Resident 19 required substantial to maximal assistance from staff to roll left and right in bed and was dependent on staff for all other mobility while in and out of bed. The MDS indicated Resident 19 was dependent on staff for all hygiene activities. During a review of Resident 19's physician order, dated 1/22/2026, the physician order indicated Resident 19 was to receive lorazepam 1 mg every six (6) hours as needed for anxiety/agitation. During an interview on 2/5/2026 at 1:14 p.m., with LVN 1, LVN 1 stated Resident 19 was typically confused, requiring reorientation to reality. LVN 1 stated that re-orientation was typically effective in stopping any restlessness or agitation. During an interview on 2/5/2026 at 3:13 p.m., with the DON, the DON stated Resident 19 had an order for lorazepam with a duration of 30 days. The DON stated the order should have been limited to 14 days and reordered if still needed. The DON stated there was no documentation in the record indicating that a duration beyond 14 days was required. During a review of the facility's policy and procedure (P&P) titled Psychoactive Medication, dated 10/2022, the P&P indicated psychoactive (psychotropic, a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications were to be used in the lowest possible dose and discontinued when no longer required. The P&P indicated that when medications were ordered outside of the Unnecessary Drug Guidelines, the physician was to document the reason why the medication was appropriate.

Based on observation, interview, and record review, the facility failed to develop a care plan for three of 12 sampled residents (Resident 2, Resident 7, and Resident 14). This deficient practice placed Residents 2, 7, and 14 at risk of not receiving resident-centered interventions.Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 7/30/2025, the H&P indicated Resident 2's diagnoses included a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and an open wound. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 2 had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 2 required substantial to maximal assistance from staff to roll left and right in bed and was dependent on staff for all other mobility while in and out of bed. The MDS indicated Resident 2 was dependent on staff for bathing, getting dressed, and toileting hygiene. During a review of Resident 2's physician order, dated 1/24/2026, the order indicated Resident 2 was to receive hydrocodone-acetaminophen (narcotic combination used to treat moderate to severe pain) 5-325 milligrams (mg, unit of measurement) every 6 hours as needed for severe pain (score of 7-10 on a pain scale, with 0= no pain, 10= worst pain). During an observation on 2/2/2026 at 10:05 a.m., at Resident 2's bedside, Resident 2 was observed with a sacral (tailbone) wound, measuring 10 centimeters (cm, a unit of measurement) long, 4.3 cm wide, and 1.1 cm deep. During an interview with 2/5/2026 at 1:10 p.m., with Licensed Vocational Nurse (LVN) 1, stated Resident 2 had complaints of pain to his sacrum. LVN 2 stated Resident 2 received hydrocodone-acetaminophen to treat his pain which was usually effective. During an interview on 2/5/2026 at 3:07 p.m., with the Director of Nursing (DON), the DON stated Resident 2 did not have a care plan to address his pain or for the administration of hydrocodone-acetaminophen. The DON stated the care plan for hydrocodone-acetaminophen 5-325 mg should include instructions for monitoring including possible side effects such as sedation or dependency. The DON stated the care plan should include interventions for the administration of hydrocodone-acetaminophen 5-325 mg and non-pharmacological interventions. The DON stated the care plan would ensure staff conducted ongoing monitoring of the effectiveness of the interventions being provided to address Resident 2's pain. 2. During observations on 2/2/2026 at 10:18 a.m., and 2/4/2026 at 11:55 a.m., in Resident 7's room, observed Resident 7's hands. Both hands were swollen. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE]. During a review of Resident 7's electronic medical records, the electronic medical records indicated Resident 7's diagnoses included respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 7's H&P dated 1/29/2026, the H&P indicated Resident 7 was nonresponsive and had anoxic brain injury (brain injury caused by a complete lack of oxygen flowing to the brain). During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 7 was dependent on staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 7 required oxygen therapy (treatment that provides supplemental oxygen to help people who can't get enough from normal breathing) and tracheostomy care (cleaning and maintenance of a breathing tube [tracheostomy tube] and the surrounding neck skin [stoma] to prevent infection, ensure clear airways, and manage secretions). The MDS indicated Resident 7 had a Foley catheter (a flexible, indwelling tube inserted through the urethra into the bladder to drain urine). During a review of Resident 7's Patient Orders, dated 12/23/2025, the Patient Order indicated Resident 7 had an order for an indwelling urinary catheter. During a concurrent interview and record review on 2/5/2026 at 1:30 p.m. with the DON, Resident 7's electronic medical records were reviewed. The electronic medical records did not indicate a care plan addressing the resident's Foley catheter or bilateral hand edema (swelling). The DON stated Resident 7 needed a care plan addressing the resident's use of a Foley catheter. The DON stated a care plan would address interventions to prevent infections and provide guidance on how to care for the Foley catheter. The DON stated the risk of not having a care plan was that staff would not know how to care for residents with a Foley catheter. The DON stated Resident 7 also needed a care plan addressing his bilateral hand edema. The DON stated a care plan served as a communication tool to inform staff of the health status of a resident and provided interventions to implement for better resident outcomes. The DON stated without a care plan, staff was not aware of Resident 7's swollen hands. 3. During observations on 2/2/2026 at 10:35 a.m., and 2/4/2026 at 11:22 a.m., in Resident 14's room, Resident 14 was observed with a scab (a dry blood clot on the surface of the skin) above the left side of the upper lip. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE]. During a review of Resident 14's electronic medical records, the electronic medical records indicated Resident 14 had diagnoses that included (chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and coronary artery disease (artery disease that is caused by plaque buildup in the wall of the arteries that supply blood to the heart, causes coronary arteries to narrow, limiting blood flow to the heart). During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 14 was dependent on staff for all ADLs. The MDS indicated Resident 14 required oxygen therapy and tracheostomy care. During a concurrent interview and record review on 2/5/2026 at 11:39 a.m. with the DON, Resident 14's electronic medical records, the electronic medical records did not indicate a care plan addressing Resident 14's left upper lip scab. The DON stated Resident 14 should have a care plan. The DON stated Resident 14's left upper lip scab should be treated and initiated in the care plan. The DON stated without a care plan, Resident 14 did not receive the appropriate treatment for his let upper lip scab. During a review of the facility's policy and procedure (P&P) titled Care Planning, dated 4/2025, the P&P indicated staff were to ensure a coordinated and comprehensive written plan was developed, based on the resident assessment instrument and on the individual needs of the resident.

Based on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident in one room with multiple residents.This deficient practice had the potential to compromise resident privacy and could potentially affect residents' health and safety.Findings:During a review of the facility's Client accommodations Analysis Form, dated 2/2/2026, the form indicated one room did not meet the 80 square (sq.) foot (ft.) per resident requirement.During a review of the facility's Room Waiver Request Letter, dated 10/10/2025, the letter indicated room [ROOM NUMBER] did not meet the 80 sq. ft. of space per resident requirement. The letter indicated the facility would ensure not to admit ventilator dependent residents (resident who cannot breathe adequately on their own and require long-term, daily, or continuous mechanical support to assist or control their breathing) in that room. The letter indicated if a resident in the room had a change of condition and would need a ventilator (a machine or device used medically to support or replace the breathing of a person), that resident would be moved out of that room. The letter indicated the charge nurse would monitor compliance daily and report any changes to the Subacute Director. The letter indicated the Subacute Director would be responsible for monitoring compliance and would report variations to the environment of care committee on a monthly basis.During observations made throughout the course of the survey, from 2/2/2026 to 2/6/2026, there were no adverse effects that pertained to the residents' care provided by facility staff, residents' privacy, health, and safety related to the provided living space of less than 80 sq. ft. per resident. Residents in room [ROOM NUMBER] were not ventilator dependent.During a concurrent interview and record review on 2/5/2026 at 10:10 a.m. with the Director of Nursing (DON), the facility's Room Waiver Request letter, dated 10/10/2025, was reviewed. The Room Waiver Request letter indicated residents on a ventilator would not be admitted to room [ROOM NUMBER]. The DON stated the two residents in room [ROOM NUMBER] were not ventilator dependent and the facility would ensure the residents' health and safety was not adversely affected.

Based on observation, interview, and record review the facility failed to: 1. Ensure Resident 19's peripheral line (a small flexible tube inserted into a vein near the skin surface to administer fluids and medications) to his right forearm dressing was changed every 72 hours (three days) per policy and procedure. 2. Ensure Resident 17's peripheral line to his right-hand dressing was changed every 72 hours per policy and procedure. 3. Ensure the Medication Cart (Cart 1) was cleaned after a sticky liquid medication had spilled onto other medications. These deficient practices of not changing the peripheral lines dressing placed Resident 19 and 17 at risk for infection at the insertion site. In addition, the sticky liquid medication spill had the potential to result in cross-contamination with other medications. Findings: a. During an observation on 11/23/2024 at 9:46 a.m. in Resident 19 room, Resident 19 had a right forearm peripheral line with a dressing dated 11/16/2024. During a review of Resident 19's Admission Record (Face Sheet), the Face Sheet indicated Resident 19 was admitted to the facility on [DATE]. Resident 19's diagnoses included were ventilator dependent (a patient is unable to breathe independently) and respiratory distress (a patient is having difficulty breathing). During a review of Resident 19's History and Physical (H&P), dated 4/26/2024, the H&P indicated, Resident 19's diagnose tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe to help with breathing). The H&P indicated Resident 19 opens eyes only responsive to painful stimuli. During a review of Resident 19's Minimum Data Set ([MDS] a resident assessment tool), dated 10/23/2024, the MDS indicated Resident 19's cognition (ability to learn, reason, remember, understand, and make decisions) persistent vegetative state (when a person has severe brain damage and is in a state of partial arousal, and not aware of their surrounds)/no discernible(something that can be seen, smelled, and tasted) consciousness severely impaired and never/rarely made decisions. The MDS indicated Resident 19 was dependent for eating, oral hygiene, showering, and personal hygiene. During an interview on 11/24/2024 at 8:17 a.m. with Director of Nursing (DON), the DON stated the peripheral lines dressings should be changed every 96 hours (every 4 days). The DON stated it was important to change the peripheral lines every 4 days to decrease the risk of infection to the insertion sites. b. During an observation on 11/23/2024 at 10:03 a.m. in Resident 17 room, Resident 17 had a right-hand peripheral line with a dressing dated 11/17/2024. During a review of Resident 17's Admission Record (Face Sheet), the Face Sheet indicated Resident 17 was admitted to the facility on [DATE]. Resident 17's diagnose was respiratory failure (a serious condition that occurs when the lungs can't get enough oxygen into the bloodstream and can't remove enough carbon dioxide). During a review of Resident 17's History and Physical (H&P), dated 2/9/2024, the H&P indicated, Resident 17's diagnose tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe to help with breathing. During a review of Resident 17's Minimum Data Set ([MDS] a resident assessment tool), dated 11/21/2024, the MDS indicated Resident 17's cognition (ability to learn, reason, remember, understand, and make decisions) persistent vegetative state (when a person has severe brain damage and is in a state of partial arousal, and not aware of their surrounds)/no discernible(something that can be seen, smelled, and tasted) consciousness severely impaired and never/rarely made decisions. The MDS indicated Resident 17 was dependent for eating, oral hygiene, showering, and personal hygiene. During an interview on 11/24/2024 at 8:30 a.m. with Registered Nurse (RN) 1, RN 1 stated the dressing for peripheral lines should be changed every 4 days. RN 1 stated when the dressing is removed the staff is to check for infiltration (leakage of intravenous fluids into surrounding tissues), redness, and swelling around the insertion site. RN 1 stated the dressing change is to prevent infection. During a review of the facility's policy and procedure (P&P) titled, Intravenous (IV) Policies, General, dated 9/2022, the P&P indicated to provide and maintain standard, and safety related to IV therapy. The P&P indicated responsibility of nurse on unit was IV sites are to be dressed with dry sterile dressing on insertion, dressings to be changed every 72 hours and documented. The P&P indicated the indwelling cannula should not be left in place longer than 72 hours. C. During a concurrent observation and interview, on 11/23/2024, at 1:32 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 observed a red sticky substance (Ketoconazole shampoo- an antifungal medication that treats yeast and fungal infections of the skin and scalp) had spilled in Medication Cart 1 onto other medications. LVN 1 stated the protocol was to keep medication carts free of spills. LVN 1 stated the risk of the medication cart being soiled could result in cross-contamination and ineffectiveness of medications. During a review of the policy and procedures, titled Medication Storage, dated 8/2023, the policy and procedures indicated, Drugs shall be stored under the proper conditions of sanitation, temperature, light, moisture, ventilation, organization, segregation and security.

Based on interview and record review, the facility failed to: 1. Ensure there were consistent indication and behavior was specifically identified and non-pharmacological interventions were attempted to support the use of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) for one of five sampled residents (Resident 8). This deficient practice had the potential to develop an undesired effect due to unnecessary psychotropic drug use for Resident 8. Findings: During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 8 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person to breathe) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problem). During a review of Resident 8's Patient Orders (a document containing active physician order), dated 11/23/2024, the Patient Order indicated, Resident 8 has an active order of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) 50 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) every 12 hours (9 a.m. and 9 p.m.) for psychosis manifested by pulling out tubes. During a review of Resident 8's MDS, dated [DATE], the MDS indicated, Resident 8's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 8 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. During a concurrent interview and record review on 11/23/2024 at 6:16 p.m., with the Director of Nursing (DON), Resident 8's Psychiatric Progress Notes, dated 9/24/2024, 10/29/2024, and 11/19/2024, were reviewed. The DON stated, Resident 8's Psychiatric Progress Notes, did not indicate Resident 8's had a diagnosis of mental illness of psychosis and receiving Quetiapine. The DON stated Resident 8's Quetiapine was ordered on 9/4/2024. The DON stated the facility had no documentation of Resident 8's behavior of pulling out tubes and attempted behavioral interventions 72 hours prior to initiating Quetiapine. The DON stated Resident 8 had no pattern of pulling out tubes behavior that would necessitate the use of Quetiapine. During an interview on 11/23/2024 at 6:30 p.m., with the Director of Staff Development (DSD), the DSD stated pulling out of tubes was not a specific behavior of a resident with psychotic feature. The DSD stated facility's psychiatrist attended monthly meeting to discuss all residents receiving psychotropic medications. The DSD stated he could not explain why the psychiatrist did not identify Resident 8's diagnosis of psychosis. The DSD stated Resident 8's Quetiapine was considered as unnecessary medication. The DSD stated use of psychotropic medications could affect or alter resident's behavior, chemical imbalance (occurs when there is to much or too little of a substance that helps the body function normally), and cardiac complications that would likely result in resident's hospitalization . During an interview on 11/24/2024 at 1:19 p.m., with the Associate Chief Nursing Officer (ACON), the ACON stated the facility should have utilized least restrictive measures such as hand mittens (type of glove that covers the hand and wrist), redirection of behavior, and providing a staff as one on one sitter to closely monitor Resident 8's behavior of pulling out tubes before he was started on Quetiapine. The ACON stated psychotropic medication has sedating effect to the resident that would put their safety at risk. During a review of facility's policy and procedure (P&P) titled, Psychoactive Medications, dated 10/2022, the P&P indicated, When psychoactive medications are ordered, the assessment process will be utilized to assure alternative interventions/behavior management programs have been attempted prior to the use of psychoactive medications. The P&P also indicated when psychoactive medications are initiated on the unit, the resident's medical record will contain completed assessments, documented interventions, before the drug is administered.

Based on observation, interview, and record review the facility failed to: 1. Ensure one out six sampled residents (Resident 11) hair was shampooed twice a week. The deficient practice had the potential for Resident feeling unkept and not clean. Findings: During a review of Resident 11's Admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnose was chronic respiratory failure (a serious condition that occurs when the lungs can't get enough oxygen into the bloodstream and can't remove enough carbon dioxide). During a review of Resident 11's History and Physical (H&P), dated 1/7/2024, the H&P indicated, Resident 11's diagnoses included sepsis (a life-threatening blood infection), tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe to help with breathing), and encephalopathy (a group of conditions that cause brain dysfunction). The H&P indicated Resident 11 was unable to give any information regarding her state of health. During a review of Resident 11's Minimum Data Set ([MDS] a resident assessment tool), dated 10/5/2024, the MDS indicated Resident 11's cognition (ability to learn, reason, remember, understand, and make decisions) persistent vegetative state (when a person has severe brain damage and is in a state of partial arousal, and not aware of their surrounds)/no discernible(something that can be seen, smelled, and tasted) consciousness severely impaired and never/rarely made decisions. The MDS indicated Resident 11 was dependent for eating, oral hygiene, showering, and personal hygiene. During an observation on 11/23/2024 at 10:30 a.m. in Resident 11's room, Resident 11 hair was matted and had an abundance amount of dandruff (flakes of skin to fall off the scalp) throughout her hair. During a review of Resident 11's Care Plan, titled Resident 11 requires total assist in all Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) secondary to medical condition, dated 3/2023, the Care Plan indicated provide total care in all ADLs. The Care Plan indicated to bath and shampoo as scheduled and as ordered. During a concurrent observation and interview on 11/23/2024 at 6:10 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 11's room, Resident 11's hair was matted and had an abundance amount of dandruff through her hair. CNA 1 stated hair care is provided on the residents' shower day which would be twice a week. CNA 1 stated Resident 11's hair looked dirty. CNA 1 stated it was important to wash the resident hair to avoid dryness and dandruff to the hair. CNA 1 stated after the hair is washed its important to comb the hair out to avoid the hair from tangling up. During a concurrent observation and interview on 11/23/2024 at 6:22 p.m. with Associate Chief Nursing Officer (ACNO), the ACNO stated Resident 11's hair is part of the ADLs, and her hair should have been shampooed on her shower days. The ACNO stated the CNAs were to provide hair care by softening the hair to prevent the matting and loosen the knots in the hair. The ACNO stated the hair care is a part of Resident 11's hygiene. The ACNO stated clean hair would help to keep Resident 11 comfortable and to prevent infection on her scalp. During a review of the facility's policy and procedure (P&P) titled, Hair and Scalp, Care, dated unknown, the P&P indicated to provide comfort, increase circulation, maintain cleanliness, provide an attractive appearance, and improve resident's self-image. The P&P indicated shampoo of the hair shall be performed as part of a resident's bathing program. The P&P indicated to observe the condition of hair and scalp. The P&P indicated if hair is tangled cream rinse may be sued to assist with removal.

Based on interview and record review, the facility failed to: 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASRR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of two sampled residents (Resident 8) who had a new diagnosis of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) to the appropriate state-designated authority for PASRR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 8 not receiving specialized services for mental illness. Cross Reference F641. Findings: During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 8 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person to breathe) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problem). During a review of Resident 8's Patient Orders (a document containing active physician order), dated 11/23/2024, the Patient Order indicated, Resident 8 has an active order of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) 50 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) every 12 hours (9 a.m. and 9 p.m.) for psychosis manifested by pulling out tubes. During a review of Resident 8's MDS, dated [DATE], the MDS indicated, Resident 8's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 8 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. During a concurrent interview and record review on 11/23/2024 at 6:16 p.m., with the Director of Nursing (DON), Resident 8's PASRR level I Screening completed 4/21/2023, was reviewed. The PASRR Level I screening indicated, Resident 8 had no serious mental illness diagnosis and not receiving psychotropic medications. The PASRR level I screening also indicated, Resident 8's case was closed and, and a PASRR level II mental health evaluation was not required. The DON stated she was responsible for completing and submitting PASRR. The DON stated Resident 8 was receiving Quetiapine 50mg every 12 hours for psychosis manifested by pulling out tubes as ordered by the physician on 9/5/2024. The DON stated she should have submitted a new PASRR level I for Resident 8 since he had a new diagnosis of psychosis. The DON stated once the PASRR level 1 was submitted, then the state mental health agency would decide if level II evaluation was necessary. The DON stated it was important for Resident 8 to be referred to PASRR state mental health agency so she could avail additional resources, support, and services for treatment of his psychosis. During a review of PASRR reference manual, dated 2/2023, the PASRR reference manual indicated, An additional requirement has been added for NF's to promptly notify the state mental health and/or intellectual or developmental disability authority, as applicable, if there is a significant change in the physical or mental condition of an individual who is mentally ill or has an intellectual or developmental disability. This would warrant a re-evaluation to determine if NF is still the most appropriate setting and/or if the individual could benefit from specialized services for his/her mental illness or intellectual disability.

Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 12 sampled residents (Resident 8) by failing to: 1. Ensure Resident 8's Psychiatric/Mood Disorder under section I (Active Diagnoses) diagnosis of Psychotic Disorder (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) was encoded correctly. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect Resident 8's plan of care. Findings: During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 8 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person to breathe) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problem). During a review of Resident 8's MDS, dated [DATE], the MDS indicated, Resident 8's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 8 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 8's Patient Orders (a document containing active physician order), dated 11/23/2024, the Patient Order indicated, Resident 8 has an active order of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) 50 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) every 12 hours (9 a.m. and 9 p.m.) for psychosis manifested by pulling out tubes. During a concurrent interview and record review on 11/23/2024 at 6:30 p.m., with the Minimum Data Set Nurse (MDS Nurse), Resident 8's MDS assessment, dated 10/31/2024, was reviewed. The MDS Nurse stated Resident 8's MDS assessment was completed inaccurately. The MDS Nurse stated there was a wrong entry on the MDS assessment under Section I. The MDS Nurse stated there should be a checked mark on MDS assessment under Section I5950 for psychotic disorder since Resident 8 was receiving Quetiapine for psychosis. The MDS Nurse stated accuracy of MDS assessment was important for facility reimbursement and for proper care of resident . During an interview on 11/24/2024 at 1:19 p.m., with the Associate Chief Nursing Officer (ACON), the ACON stated accuracy of MDS assessment was essential because it reflects the care provided by facility staff to resident. The ACON stated Resident 8's MDS assessment should be corrected and modified immediately to reflect his diagnosis of psychotic disorder. During a review of facility's undated policy and procedure titled, Assessment and Care Planning, the P&P indicated, The assessment is certified for accuracy by means of a signature of individuals who complete any portion of the assessment.

Based on observation, interview, and record review, the facility failed to: 1. Post the report of complaint investigation results by California Department of Public Health ([CDPH] state licensing and certification agency) during the three preceding years in the areas of the facility that are prominent and accessible to the residents, visitors, family members, or resident representative. This deficient practice placed the residents, visitors, family members, or resident representative at risk of not knowing the status of the facility non-compliance outcome results and past performance history. Findings: During a concurrent observation and interview on 11/23/2024 at 1:09 p.m., with the Director of Nursing (DON) at odd nursing station hallway, the DON stated the survey binder posted on the wall included only the last recertification survey conducted by the CDPH last year. The DON stated the facility was visited by the CDPH for a complaint visit last year and this year. The DON stated the complaint investigation results by the CDPH in the past 2 years were not included in the survey binder. The DON stated all survey results should be posted and accessible to residents, visitors and family members for them to know the findings identified by the CDPH and facility's plan of correction. The DON stated it was a violation of resident's rights by not posting the complaint investigation results by CDPH. During an interview on 11/24/2024 at 1:19 p.m., with the Associate Chief of Nursing (ACON), the ACON stated posting of survey and complaint investigation results are federal requirements. The ACON stated it was the responsibility of the DON to post the survey and complaint investigation results. The ACON stated it was important to post the survey and complaint investigation results so the resident, resident representative and facility staff could review the facility's plan of action so the deficient practice would not happen again. During a review of the facility's admission packet, titled Attachment F Resident [NAME] of Rights, dated 5/2011, the form indicated A resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents and must post a notice of their availability.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the corrugated (a flexible tube that delivers oxygen to a patient from an oxygen source, such as a tank or concentrator) oxygen (air) was labeled with a date of change for one of five sampled residents (Resident 183). This deficient practice had the potential to cause respiratory infection for Resident 183. Findings: During a review of Resident 183's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 183 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person to breathe) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problem). During a review of Resident 183's Admission Nursing Note, dated 11/2/2024, the Admission Nursing Note indicated, Resident 183's current functional level was totally dependent on staff with bathing, dressing, and eating. During a review of Resident 183's Patient Orders (a document containing active physician order), dated 11/22/2024, the Patient Order indicated, Resident 183 had an active order of oxygen therapy via cool aerosol (a mist of sterile water that is delivered to the upper airways) at Fraction of Inspired Oxygen ([Fio2] percentage of oxygen in the gas mixture a person inhales) at 28 percent [%] unit of measurement) daily. During a concurrent observation and interview on 11/23/2024 at 9:51 a.m., with Respiratory Therapist 1 (RT 1) in Resident 183's room, Resident 183 was observed in bed asleep with tracheostomy and on oxygen therapy continuously. RT 1 stated the corrugated oxygen tubing of Resident 183 was not dated. RT 1 stated it was her first day to work with Resident 183. RT 1 stated it was unknown when Resident 183's corrugated oxygen tubing was changed because it was not dated and labeled. RT 1 stated it was important to label and put the date it was changed the corrugated oxygen tubing for infection control purposes. During an interview on 11/23/2024 at 6:04 p.m., with the Director of Nursing (DON), the DON stated it is facility's policy to label with a date of change all respiratory equipment. The DON stated a clogged oxygen tubing would not deliver the right amount of oxygen concentration that could likely result in shortness of breath of resident. During an interview on 11/24/2024 at 1:19 p.m., with the Associate Chief Nursing Officer (ACNO), the ACNO stated all oxygen tubing should be changed and dated at the same time once a week or as needed to prevent further infection that can develop in the oxygen tubing. During a review of the facility's P&P titled, Routine Responsibilities and Equipment Schedule, dated 4/1/2014, the P&P indicated, all equipment will be changed as needed or when visibly dirty and dated.

Based on interview and record review, the facility failed to: 1. Ensure a pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation to review and provide justification for restarting of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) for one of out of five sampled residents (Resident 8) was acknowledged and acted upon. This deficient practice for failing to respond to recommendation from the pharmacy consultant placed Resident 8 at risk for unnecessary medication administration. Cross Reference F758. Findings: During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 8 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person to breathe) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problem). During a review of Resident 8's Patient Orders (a document containing active physician order), dated 11/23/2024, the Patient Order indicated, Resident 8 has an active order of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) 50 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) every 12 hours (9 a.m. and 9 p.m.) for psychosis manifested by pulling out tubes. During a review of Resident 8's MDS, dated [DATE], the MDS indicated, Resident 8's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 8 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 8's Psychiatric Progress Notes, dated 9/24/2024, 10/29/2024, and 11/19/2024, the Psychiatric Progress notes, did not indicate, Resident 8 had a diagnosis of mental illness of psychosis and receiving Quetiapine. During a concurrent interview and record review on 11/24/2024 at 11:15 a.m., with the Director of Nursing (DON), Resident 8's Consultant Pharmacist Medication Regime Review (MRR), dated 9/30/2024, was reviewed. The MRR report indicated, Resident 8 was started back on Quetiapine on 9/2024 but documentation could not be found in the resident's record as to why it was re-started. Also, the psych progress notes from 9/24/2024 did not include the use of Quetiapine or diagnosis. Please review and make sure justification is provided for restarting this medication. The DON stated she was responsible for following up all pharmacy consultant recommendation to resident's physician. The DON stated the timeline to follow-up pharmacy consultant recommendation is 1 month before the next scheduled visit of the pharmacy consultant. The DON stated the facility did not follow-through the pharmacy consultant recommendation, dated 9/30/2024, to Resident 8's physician. The DON stated it was important to address all pharmacy consultant recommendations to be compliant with the regulations and to avoid residents receiving unnecessary medications. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review, dated 6/5/2024, the P&P indicated, The attending/prescriber should address the consultant pharmacist recommendation no later than their next scheduled visit to the facility to assess the resident, per facility policy and state or federal regulations. The P&P also indicated the attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any action has been taken to address it.

Based on observation, interview and record review, the facility failed to: 1. Ensure the medication error rate was less than 5%. This deficient practice resulted in medication errors. Findings: During an observation of 27 medication administration opportunities, on 11/25/2024, at 8:15 a.m., 2 routine medications out of 27 were not administered at its scheduled time. During a concurrent medication administration observation and record review, on 11/25/2024, at 8:19 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated protocol for administering medication was one hour before and one hour after the scheduled time. LVN 1 stated a nebulizer (a device for producing a fine spray of liquid) medication, levalbuterol (a medication used to prevent or relieve the wheezing, shortness of breath, coughing, and chest tightness), was to be administered 7:00 a.m. by the respiratory therapist (a health professional who evaluates and treats patients with breathing or lung disorders) that morning for Resident 27. LVN 1 stated from observation of the Medication Administration Record (MAR- a report detailing the drugs administered to a patient by a healthcare professional), the medication was not administered nor documented as being administered at that time. LVN 1 stated the risk of not administering routine medications at a scheduled time could result in medication errors. During a concurrent medication administration observation and record review, on 11/25/2024, at 8:40 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 was observed administering medications to Resident 17. LVN 2 stated a nebulizer medication, albuterol/ipratropium (a medication used to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema), was to be administered 7:00 a.m. by the respiratory therapist. LVN 2 stated from observation of the MAR, the medication was not administered. LVN 2 stated the risk of not administering routine medication at a scheduled time could result in medication errors or overmedicating a resident. During a concurrent observation, interview, and record review, on 11/25/24, at 9:46 a.m., with the Director of Respiratory Therapy (DRT), the DRT stated if a medication had a red box on its scheduled time, it indicated the medication was not administered. The DRT observed a picture of Resident 27's and Resident 17's nebulizer medication respectively on each MAR and acknowledged the medications were not administered at the scheduled times. The DRT stated both medications were administered after their scheduled times. The DRT stated the risk of not administering medication at its scheduled time could result in a medication error, overmedicating the residents, and a lack of communication between staff. The DRT stated, I will speak to all the respiratory therapists about administering medications on time. During a review of the facility's policy and procedures, titled Medication Administration, dated 10/2022, indicated, Medications shall be charted immediately after being administered. and Documentation of medication doses administered shall be charted as soon as possible after administration to any individual resident.

Based on observation and interview, the facility failed to: 1.Ensure an intravenous (fluids given directly into the blood stream) medication, Amikacin (an antibiotic used to treat serious infections that are caused by bacteria), was refrigerated as labeled. This deficient practice had the potential to result in administering an ineffective medication. Findings: During a concurrent observation and interview, on [DATE], at 1:51 p.m., of the intravenous medication cart (IV cart- a medical cart used to store and transport IV supplies and equipment), with Registered Nurse 1 (RN 1), RN 1 stated intravenous medications were stored in the IV cart or refrigerator, if needed. RN 1 observed an IV medication, dextrose (a sterile solution used to provide your body with extra water and carbohydrates) 5% with Amikacin, had a refrigerate label. RN 1 stated the IV medication was scheduled to be given at 9:00 p.m. RN 1 stated the medication should had been refrigerated and not in the IV cart. RN 1 stated the risk of not refrigerating a medication could result in a medication being ineffective or expired. During a review of the policy and procedures, titled Medication Storage, dated ,d+[DATE], the policy and procedures indicated, Drugs shall be stored under the proper conditions of sanitation, temperature, light, moisture, ventilation, organization, segregation and security.

Based on observation, interview, and record review the facility failed to: 1. Ensure one of six sampled residents (Resident 25) had a revised care plan for interventions on the non-behavioral restraint (a device or method used to restrict a patient's movement preventing them from removing medical tubes or lines) flow sheet. This deficient practice of not having a revised care plan for the Non-Behavioral Restraint Flow Sheet had the potential to increase Resident 25's discomfort. Findings: During a review of Resident 25's Admission Record (Face Sheet), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE]. Resident 25's initial diagnose was respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 25's History and Physical (H&P), dated 1/7/2024, the H&P indicated, Resident 25's diagnoses included seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), pneumonia (an infection/inflammation in the lungs), and supplemental oxygen therapy (a medical treatment that provides extra oxygen to people who have difficulty breathing). During a review of Resident 25's Minimum Data Set ([MDS] a resident assessment tool), dated 10/6/2024, the MDS indicated Resident 25's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired and never/rarely made decisions. The MDS indicated Resident 25 was dependent for eating, oral hygiene, and showering. The MDS indicated Resident 25's limb restraints used in bed daily. During an observation on 11/23/2024 at 9:40 a.m. in Resident 25's room, Resident 25 had non-behavioral soft restraints attached to his right and left wrist. During a review of Resident 25's Sub-Acute Restraints Care Plan titled, Physical mobility impaired related to use of bilateral restraints, dated 11/1/2024, the Sub-Acute Restraints Care Plan Indicated Resident 25 will not pull tubes out. The staff interventions included to release restraints for 15 minutes every two hours, reposition the restraints every two hours under direct supervision for comfort, and check for circulation. During a review of Resident 25's blank restraint flow sheet, titled Non-Behavioral Restraint Order and Flow Sheet, dated 5/2015, the Non-Behavioral Restraint Order and Flow Sheet had no indication of how long to the release restraints and how often to reposition the restraints. During a concurrent interview and record review on 11/24/2024 at 9:27 a.m. with Minimum Data Set (MDS) Nurse, Resident 25's Sub-Acute Restraints Care Plan titled, Physical mobility impaired related to use of bilateral restraints, dated 11/1/2024, was reviewed. The Sub-Acute Restraints Care Plan Indicated Resident 25 will not pull tubes out. The staff interventions included to release restraints for 15 minutes every two hours, reposition the restraints every two hours under direct supervision for comfort, and check for circulation. In addition, Resident 25's Non-Behavioral Restraint Order and Flow Sheet, dated 5/2015, the Non-Behavioral Restraint Order and Flow Sheet had no indication of how long to release the restraints and how often to reposition the restraints. The MDS Nurse stated the Non-Behavioral Order and Restraint Flow Sheet should reflect the care plan approaches and interventions was reviewed. The MDS Nurse stated on the Non-Behavior Order and Restraint Flow Sheet did not indicate to release the restraints for 15 minutes and reposition the restraints every two hours in comparison to the care plan. The MDS Nurse stated not having the proper time on the Non-Behavior Order and Restraint Flow Sheet had the potential for the restraints to stay on longer than necessary. The MDS Nurse stated if the restraints were to stay on longer it had the potential to cause discomfort for Resident 25. During a concurrent interview and record review on 11/14/2024 at 9:53 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 25's Sub-Acute Restraints Care Plan titled, Physical mobility impaired related to use of bilateral restraints, dated 11/1/2024, was reviewed. The Sub-Acute Restraints Care Plan Indicated Resident 25 will not pull tubes out. The staff interventions included to release restraints for 15 minutes every two hours, reposition the restraints every two hours under direct supervision for comfort, and check for circulation. In addition, Resident 25's Non-Behavioral Restraint Order and Flow Sheet, dated 5/2015, the Non-Behavioral Restraint Order and Flow Sheet had no indication of how long to release the restraints and how often to reposition the restraints was reviewed. LVN 3 stated the Non-Behavioral Restraint Order and Flow Sheet does not give specific times when to release the restraints and when to reposition the restraints. LVN 3 stated having the time on the Non-Behavioral Restraint Order and Flow Sheet would help to keep track of how long it took before Resident 25 before he would pull on the tubing. LVN 3 stated the release of the restraints, the length of time would be documented, and would be a good indicator to notify the physician to discontinue the restraints to keep the resident comfortable. During a review of the facility's policy and procedure (P&P) titled, Assessment/Reassessment/Care Planning Documentation Instructions, dated 10/2022, the P&P indicated care planning document the maps the information from the care plan in real time. The P&P documentation of use of protective restraints and restraint monitoring. The P&P identification of goals, interventions, and evaluation of patient progress. During a review of the facility's policy and procedure (P&P) titled, Assessment and Care Planning, dated 10/2022, the P&P indicated the comprehensive care plan is prepared to meet the needs of the resident. The P&P indicated to update the resident care plan post admission and no less than three months thereafter.

Based on observation, record review, and interviews, the facility failed to ensure that two of 10 sampled residents (Resident 4 and 6), who were placed on physical restraints, were assessed and evaluated for the use of restraints, as indicated by the facility's policy and procedure. For Resident 6, who was observed with bilateral soft wrist restraints, the resident's clinical record did not indicate an assessment and care planning for restraint use, least restrictive measures prior to use of restraint, and a physician order for [REDACTED]. For Resident 4, who had two fall incidents, was placed on bilateral soft wrist restraints. There was no documented evidence of least restrictive measures were attempted to prior to the use of the soft wrist restraints. These deficient practices violated the resident's right to be free from physical restraints and placed the residents at risk for complications due to impaired mobility. Findings: 1. During an initial tour of the sub acute unit on April 24, 2015, at 9:10 a.m., Resident 6 was observed lying in bed, and soft restraints were applied to both wrists. Resident' s hands were observed swollen. Resident 6 was also observed with a [MEDICAL CONDITION] (opening surgically created through the neck into the trachea), an indwelling catheter (a tube which is inserted into the bladder to drain urine from the bladder into a bag), and was receiving total parental nutrition (TPN- is a form of feeding in which all nutritional needs are met with a solution which is infused into the veins ) at 65 cubic centiliters (cc) per hour. During an interview on April 24, 2015, at 9:10 p.m., Registered Nurse (RN) 1 stated Resident 6's family member was requesting to apply restraints on Resident 6's wrists due to Resident 6's attempt to pull out tubes. On April 24, 2015, at 9:15 a.m., during an observation, Resident 6's family member (Family Member 2) was present in the resident's room and was seated on a cox besides Resident 6. During a concurrent interview, Family Member 2 (FM 2) stated she had a concern that there was no physician order for [REDACTED]. A review of the Face Sheet indicated Resident 6 was readmitted from the acute care unit of the hospital to the sub-acute unit of the hospital on April 18, 2015, with [DIAGNOSES REDACTED]. The facility document indicated Resident 6's original admission to the sub-acute unit was January 22, 2015. The full Minimum Data Set (MDS- an assessment and care plan tool) dated February 24, 2015, Section P - Restraints, indicated limb restraint used daily. The full MDS dated [DATE] indicated Resident 6 was severely impaired for daily decision making. She was totally dependent on the staff for activities of daily living in bed mobility, walking, dressing, eating, toileting, and bathing. Resident 6 had functional limitation in range of motion impairment to her bilateral upper and lower extremities. A review of the Assessment and Cares notes dated April 18, 2015, at 4:48 p.m., indicated Resident 6 was alert and oriented to time, place and person. The Activity Progress Notes dated April 20, 2015, indicated Resident 6 was able to verbalize her needs. The Assessment and Cares notes dated April 23, 2015, at 9:40 p.m., was entered by Licensed Vocational Nurse (LVN) 1 indicated Resident 6 was turned and repositioned every two hours for comfort to prevent skin breakdown. LVN 1 documented Resident 6's Neuro Assessment was WDL (within defined limits). There was no documented evidence the bilateral soft wrists restraints were applied on the resident's wrists and no documentation of the swelling on Resident 6's hands. There was no other documentation by the licensed nurses until April 24, 2015 at 8:30 a.m. A review of the Assessment and Care dated April 24, 2015, at 8:30 a.m., indicated while RN 1 was making rounds, she found Resident 6 with bilateral soft wrist restraints which were applied by Resident 6's family member (Family Member 2). The family member gave RN 1 a letter and ordered RN 1 to call the physician to get an order for [REDACTED]. The other family members also do not want Resident 6 to be placed in bilateral soft wrist restraints. The physician was notified. There was no documented evidence RN 1 had removed the bilateral soft wrist restraints upon discovery at 8:30 a.m. and an assessment for Resident 6's swollen hands. During an interview on April 24, 2015, at 11:45 a.m., Resident 6's family member (Family Member 1) stated Resident 6 was alert. Resident 6's family member told Resident 6 the surveyor wanted to know if she wanted to be restrained. Resident 6 opened her mouth and mouthed in Spanish, No, loca hija (the English translation means crazy daughter referring to Family Member 2). When asked again if she wanted the wrist restraints, Resident 6 shook her head side to side and said, No. Resident 6's family member stated the resident's hands became swollen when the restraints were not released for 3 to 4 hours. The surveyor observed Resident 6's hands were still swollen. During a review of Resident 6's electronic record for the re-admitted [DATE], and an interview with RN 1 on April 25, 2015, at 3:15 p.m., RN 1 stated Resident 6's family member, who visited the resident in the evening and slept in the resident's room, requested the restraints. RN 1 stated she informed Resident 6's physician about the family member's request. RN 1 further stated there was no documentation in the resident's record prior to April 24, 2015, Resident 6's family member had requested the restraints and the physician was informed. There was no documentation the resident was assessed for pulling out her tubes. There was no documented evidence of an assessment and care planning for restraint use, least restrictive measures prior to use of restraint, and a physician order for [REDACTED]. During an interview, on April 25, 2015, at 4 p.m., Employee 1 was asked what were the expectations when conducting rounds with the residents. Employee 1 stated the licensed nurses were expected to go into the room to conduct a head to toe assessment. The licensed nurses were to observe for residents' intravenous medications and tube feeding. When asked about the restraints, Employee 1 stated observe the resident for use of restraint and document their findings. On April 25, 2015, at 5:45 p.m., during an observation, Resident 6's family members were visiting Resident 6. During a concurrent interview, when asked about the restraints, Resident 6's family member (Family Member 3) opened the top drawer of Resident 6's night stand and pulled out soft wrist restraints. When asked who provided the bilateral restraints, Family Member 3 stated Resident 6 used soft restraints to prevent pulling out tubes when she was in the intensive care unit of the hospital and also when the resident was initially was admitted in sub acute unit. Family Member 3 further stated that Resident 6's hands became swollen when the soft wrist restraints were applied and not released for 3 to 4 hours. She further stated the restraints were applied by Family Member 2 when no one was in the room to watch the resident. Family Member 3 stated Family Member 2 visited the resident in the evening, stayed during the night in the resident's room, and applied the soft restraints on Resident 6's wrists at night. Family Member 3 stated Family Member 2 removed the soft restraints before the other family member arrived. During an interview on April 26, 2015, at 7:30 a.m., RN 1 stated she removed the bilateral soft restraints from the resident's room. On April 26, 2015, at 8:30 a.m., RN 1, Licensed Vocational Nurse (LVN) 2, verified a pair of bilateral soft wrist restraints were in Resident 6's top night stand drawer. RN 1 stated she did not know where the soft restraints came from as she removed the restraints on April 24, 2015. During a telephone interview on April 28, 2015, at 9:50 a.m., Resident 6's family member (Family Member 1) stated the restraints were only applied by the other family member (Family Member 2) who stayed in the resident's room overnight. Family Member 1 stated Family Member 2 arrived in the evening, between 9 p.m. to 10 p.m. Family Member 1 stated prior to re-admission on April 18, 2015, Resident 6 was in room [ROOM NUMBER] (sub acute unit) and had the soft wrist restraints. Family Member 1 stated Resident 6's hands were swollen. During a telephone interview, on April 28, 2015, at 12:07 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 6's family member, who comes in the facility in the evening, sleeps besides Resident 6 and applies the soft restraints on Resident 6's wrists. CNA 1 stated, Yes, I had seen Resident 6's family member applied the restraints. CNA 1 stated she reported the restraints to her charge nurse. CNA 1 stated she quickly provided care to Resident 6 before 9:30 p.m. because the family member (Family Member 2) arrived the facility, placed the restraints on Resident 6, closed the door, and she did not want to be disturbed. CNA 1 stated she returned to the resident's room, between 10:30 p.m. -11 p.m., with the licensed vocational nurse to make rounds and observed soft restraints were applied on Resident 6's wrists. During a telephone interview, on April 29, 2015, at 9:30 a.m., RN 3 stated Resident 6's family member stays overnight and the staff removed all the restraints. RN 3 stated that the CNA had informed her that Resident 6's family member had applied restraints to the resident. When asked had she assessed Resident 6 for attempting to pull out the tubes, RN 3 stated she was busy and informed the LVN to remove all restraints. RN3 further stated Resident 6's family member requested the restraints, and she endorsed to the day shift staff. When asked what shift does RN 3 work, RN 3 stated, 7 p.m. to 7:30 a.m. shift. A review of facility's policy and procedures titled, Non Behavioral Restraints Use, dated January 2013, included the leadership recognizes restraints have the potential to produce serious consequences such as physical or psychological harm, loss of dignity, and violation of patients rights. Non behavioral restraints shall be used only when alternative less restrictive measures were not sufficient to protect resident or others from injury. The policy was to ensure the proper and safe use of restraints when clinically warranted. The objective included to assure regulatory guidelines were followed and maintained for resident safety. The procedures included less restrictive measures used, nursing assessment, a physician order for [REDACTED]. 2. A review of the admission face sheet indicated Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (an assessment and care plan tool) dated February 8, 2015, indicated the resident was totally dependent on the staff for activities of daily living such as transferring, dressing, eating and personal hygiene. Resident 4 had functional limitations in range of motion in his bilateral upper and lower extremities. The care plan dated January 14, 2015, indicated the resident was at risk for falls, due to unsteady gait and limitation in range of motion. The Assessment and Cares Miscellaneous Note dated January 14, 2015, at 2 a.m., indicated the resident was found on the floor. No injury was noted. Resident 4 was assisted back to bed, the resident was assessed, placed bilateral side rails up, placed a call light within reach, and the bed was placed in low position. Encourage resident to ask for help. A review of the Assessment and Cares Miscellaneous Note dated January 14, 2015, at 12:12 p.m., indicated the resident was found on the floor at 11:40 a.m. by the CNA, assisted back to bed, cleaned up, and placed all 4 side rails up. Resident 4 sustained a small knee abrasion, treatment was given to the knee, an x-ray was ordered for bilateral knees, padded bilateral side rails, and applied bilateral soft wrist restraints. A review of a care plan titled, Resident requires use of Bilateral Soft Restraints due to attempting to get out of bed and frequent falls dated January 14, 2015, indicated the restraints were discontinued on January 22, 2015, and on the same date the resident's bed was placed in low bed with floor mat for safety precautions due to history of falls. There was no indication the facility's staff attempted alternative less restrictive measures prior to the use of bilateral soft wrist restraints.