Every finding on record at Madera Post Acute Center

Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation was provided to three of three sampled residents (Residents 11, 86 and 96) by failing to: a & b. Ensure call lights were within reach for Residents 11 and 86.c. Ensure Resident 96 had footrests on the wheelchair to place both feet on. These failures had the potential for Residents 11, 86 and 96 not to receive necessary care or receive delayed services affecting the residents' quality of life. Findings: a. During a review of Resident 11's admission Record (AR), the admission Record indicated the resident was admitted on [DATE] and re admitted on [DATE], with the following but not limited to diagnoses of muscle weakness, abnormalities of gait (unnatural pattern or style of walking) and mobility (ability to move easily, freely, and safely) and anxiety (feeling of worry, nervousness, and fear about what might happen in the future). During a review of Resident 11's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated the Resident 11 is cognitively intact and requires supervision for using the bathroom, showering and putting on/taking off shoes. During a concurrent observation and interview on [DATE] at 9:32 a.m. with Certified Nursing Assistant (CNA) 6 in Resident 11's room, Resident 11 was lying in bed with their head elevated at a 15-degree angle. The call light was behind the resident, on the floor not within reach. The CNA 6 stated that the call light should always be within the resident's reach. During an interview on [DATE] at 11:12 a.m. with Interim Director of Nursing (IDON), the IDON stated call lights should be readily available within reach to all residents. The IDON also stated it is a safety concern if a resident cannot call for assistance and stated that all staff members are responsible for ensuring residents' call lights are within reach to help prevent falls. During an interview on [DATE] at 9:10 a.m. with Infection Prevention Nurse (IPN), the IPN stated it is the responsibility of all staff to ensure that residents' call lights are always within their reach. The IPN also stated this practice prevents situations where residents might attempt to get out of bed to call for assistance, thereby reducing the risk of accidental falls. During review of the facility's policy and procedure (P&P) titled, Call Light, dated 4/2026, the P&P indicated staff are required to ensure that the resident's call light is positioned within the resident's reach before exiting the resident's room. b. During a review of Resident 86's admission Record (AR), the AR indicated Resident 86 was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities, severe enough to interfere with daily life), malnutrition, and encounter for attention to gastrostomy (a routine clinical checkup, cleaning, maintenance, or minor adjustment of an existing surgical opening into the stomach (stoma) or its feeding tube). During a review of Resident 86's History and Physical (H&P) dated [DATE], the H&P indicated Resident 86 did not have the capacity to understand and make medical decisions. During a review of Resident 86's MDS dated [DATE], the MDS indicated Resident 86 was dependent (helper does all the effort) on staff for oral, toileting and personal hygiene, showers, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 86's Care Plan Report (CPR) dated [DATE], the CPR indicated Resident 86 was at risk for falls related to diagnosis of dementia, and impaired mobility. The interventions included for staff to keep Resident 86's call light within reach and encourage Resident 86 to use it to get assistance. During an observation and interview of Resident 86 on [DATE] at 9:38 AM, inside Resident 86's room, Resident 86 was resting in bed watching TV. Resident 86's call light was on the floor. Resident 86 stated Resident 86 did not know where the call light was. Resident 86 stated Resident 86 could not reach the call light on the floor and could not use it to call staff. During an observation and interview with CNA1 and CNA2 on [DATE] at 9:47 AM, inside Resident 86's room, CNA1 stated Resident 86's call light was on the floor. CNA1 stated the call light should not be on the floor because Resident 86 could not reach it and could not call for assistance if needed. CNA2 stated Resident 86 was on fall precaution and should have the resident's call light within reach in case Resident 86 needed to call staff for help. CNA2 stated if the resident could not call for help, then staff would not be available to prevent a fall or an injury to Resident 86. During an interview with the IDON on [DATE] at 8:43 AM, the IDON stated the call light should be within the resident's arms reach and should not be on the floor. The IDON stated if the call light was on the floor, the resident could not use it to call for assistance. The IDON stated Resident 86 should have the call light within reach at all times to prevent a fall and injury and for staff to help Resident 86 as needed. During a review of the facility's P&P titled, Call Light, dated 4/2026, the P&P indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff. c. During a review of Resident 96's AR, the AR indicated Resident 96 was readmitted to the facility on [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and altered mental status. During a review of Resident 96's History and Physical (H&P) dated [DATE], the H&P indicated Resident 96 had limited safety awareness requiring frequent redirection and close supervision and required skilled medical management for fall prevention. The H&P indicated Resident 96 did not have the capacity to understand and make decisions. During a review of Resident 96's MDS dated [DATE], the MDS indicated Resident 96 needed substantial/maximal assistance (helper does more than half the effort) to walk 10 feet and uses a walker and wheelchair for mobility (ability to move). During a review of Resident 96's Fall Risk Evaluation (FRE) dated [DATE], the FRE indicated Resident 96 had one to two falls in the past three months, was disoriented to person, place and time at all times, was chairbound, incontinent, and had poor vision (with or without glasses). During an observation on [DATE] at 11:07 am, Resident 96 was in a wheelchair being pushed by Certified Nurse Assistant 7 (CNA 7) from the dining room near station four into the hallway with Resident 96 not actively lifting both feet causing them to drag on the ground. During a concurrent observation and interview on [DATE] at 11:09 am with Licensed Vocational Nurse 6 (LVN 6), LVN 6 asked Resident 96 to lift both feet and Resident 96 did not respond. LVN 6 stated Resident 96 did not always follow instructions. LVN 6 stated, wheelchair footrests were necessary to prevent both feet from dragging and prevent injury to Resident 96's feet. During an interview with [DATE] at 12:12 pm with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 96 was confused and needed assistance to move around. LVN 3 stated Resident 96's eyes were usually closed, even when spoken to. During an interview on [DATE] at 11:48 am with the Interim Director of Nursing (IDON), the IDON stated Resident 96 needed the wheelchair footrests for safety, to prevent injury to Resident 96's feet or entanglement with the wheelchair wheels. The IDON stated it was important to accommodate a resident's needs because it was their right and part of providing quality care to the residents. During a review of the facility's P&P titled, Activities of Daily Living, revised 1/2026, the P&P indicated, it was the policy of the facility to provide necessary care and services to ensure a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The P&P indicated the facility would provide the appropriate treatment and services to maintain or improve his or her ability to carry out the ADLs, including mobility- transfer and ambulation.

Based on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 147 and 3) Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment by failing to: a. Ensure Resident 147, who was discharged to home under the care of home health (wide range of health care services that could be given at home) service was coded accurately in the MDS assessment dated [DATE].b. Ensure Resident 3's MDS assessment dated [DATE] reflected Resident 3 was receiving oxygen therapy. These deficient practices resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and work with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Residents 147 and 3 not receiving interventions to address specific care concerns. Findings: a. During a review of Resident 147's Face Sheet (FS), the FS indicated the facility admitted Resident 147 on 6/4/2026 with diagnoses including abnormal posture, hypertension (high blood pressure) and history of falling. During a review of Resident 147's Order Summary Report (OSR) dated 6/16/2026, the OSR indicated to discharge Resident 147 per sister's request under home health for nursing, Physical Therapy (PT)/Occupational Therapy (OT) Evaluation and treatment and provide durable medical equipment (DME, medically necessary devices prescribed by a doctor) of a hospital bed. During a review of Resident 147's Discharge Summary and Post Discharge Plan of Care, dated 6/30/2026, the Discharge Summary and Post Discharge Plan of Care indicated the facility had arranged community resources to assist Resident 147's transition to Resident 147's new living environment such as home health services for Nursing and Therapy. During a review of Resident 147's MDS dated [DATE], the MDS indicated Resident 147 was discharged to home/community. During an interview on 7/29/2026 at 11:22 am with the Interim Director of Nursing (IDON), the IDON stated Resident 147 was discharged to home under home health on 6/30/2026 and should have been coded in the MDS as discharged to home under care of organized home health service organization. The IDON stated MDS assessment needed to be coded correctly to give accurate information to CMS. During a concurrent interview on 7/30/2026 at 10:59 am with the facility's Minimum Data Set Nurse (MDSN), Resident 147's medical record (PointClickCare - PCC, a cloud-based software used in charting) was reviewed. The MDSN stated Resident 147 was discharged to home on 6/30/2026 under home health for nursing, PT/OT evaluation and treatment. The MDSN stated Resident 147's MDS assessment dated [DATE] indicated Resident 147 was discharged to home/community. The MDSN stated Resident 147's MDS should have been coded as discharged to home under care of organized home health service organization. During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessment and Associated Processes, revised 1/2026, the P&P indicated, An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals life history and preferences, using the RAI (Resident Assessment Instrument). b. During a review of Resident 3's Face Sheet (FS), the FS indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including emphysema (a lung condition that causes shortness of breath from lung damage), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with exacerbation (sudden worsening) and pulmonary hypertension (high blood pressure in the arteries of the lungs). During a review of Resident 3's Order Summary Report (OSR) dated 7/31/2026, the OSR indicated Resident 3 had an active order for oxygen to be administered at two (2) lpm via nasal cannula to keep oxygen saturation (measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) above 92% as needed for shortness of breath or wheezing related to COPD, ordered on 3/24/2026. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 6/5/2026, the MDS indicated Resident 3 was cognitively intact (ability to think) and was not receiving oxygen therapy. During a review of Resident 3s untitled Care Plan (CP) revised on 6/30/2026, the CP indicated Resident 3 had oxygen therapy to keep Resident 3's oxygen saturation above 92% with an intervention for oxygen setting as needed at two lpm via NC to keep oxygen saturation above 92%, During a review of Resident 3's Weights and Vitals Summary- Oxygen Saturation (O2 sats) dated 6/1/2026 to 6/31/2026, the O2 sats indicated Resident 3 used oxygen via NC on 6/1/2026, 6/4/2026, and 6/5/2026. During a concurrent observation and interview on 7/28/2026 at 9:45 am with Resident 3 in Resident 3's room, Resident 3 was receiving oxygen via NC while in bed. Resident 3 stated, Resident 3 used oxygen as needed and was occasionally short of breath. During a concurrent observation and interview on 7/29/2026 at 9:29 am with Licensed Vocational Nurse 5 (LVN 5) in Resident 3's room, Resident 3 was in bed receiving oxygen via NC and the oxygen level was close to three (3) lpm. LVN 5 stated Resident 3 received oxygen for shortness of breath for COPD. LVN 5 stated Resident 3 had an active order for oxygen at 2 lpm During a concurrent interview and record review on 7/30/2026 at 3:26 pm with Minimum Data Set Nurse (MDSN), Resident 3's MDS dated [DATE] was reviewed. The MDS indicated Resident 3 was not receiving oxygen therapy. The MDSN stated the MDS was submitted to CMS to provide information on the services and treatments provided to the residents and should be coded accurately. The MDSN stated Resident 3's MDS should have been coded 'Yes' for oxygen therapy. During an interview on 7/31/2026 at 10:07 am with the Interim Director of Nursing (IDON), IDON stated it was important for the MDSN to code the MDS assessment accurately to give a true picture of the resident assessment and an accurate submission to CMS. During a review of the facility's P&P titled, Resident Assessment and Associated Processes- Resident Assessments, revised 1/2026, the P&P indicated, An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals life history and preferences, using the RAI (Resident Assessment Instrument). The P&P further indicated each individual who completed a portion of the assessment would electronically sign and certify the accuracy of that portion of the assessment, as well as the date the data was obtained.

Based on observation, interview, and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans (CP) to meet the residents' needs for three of three sampled residents (Residents 15, 82, and 106) by failing to: a. Develop and implement an individualized CP to address Resident 15's refusal on influenza (a contagious respiratory virus that caused fever, aches, and cough) vaccine. b. Follow the CP to use caution during transferring for Resident 82 when Resident 82 sustained a skin tear (traumatic wounds caused by friction when the upper layer of the skin becomes torn from the underlying layers).c. Develop an individualized CP to address Resident 106's diagnosis of seborrheic dermatitis (a chronic skin condition that caused red, scaly, greasy patches on oily areas of the body like the scalp and face). These failures resulted in the residents not receiving individualized care to maintain the residents' highest practicable physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 15's admission Record, the admission Record indicated that Resident 15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to pancytopenia (a condition where there are low counts of all three blood cell types: red blood cells, white blood cells, and platelets), unspecified viral hepatitis without hepatic coma (an infection caused by viruses that cause swelling and damage to the liver), and unspecified protein-calorie malnutrition (a serious health condition caused by not getting enough protein and calories). During a review of Resident 15's Minimum Data Set (MDS – a resident assessment tool) dated [DATE], the MDS indicated Resident 15 had intact cognitive skills (a person's brain functions, such as memory, attention, reasoning and problem-solving work well) for daily decision making. The MDS indicated that Resident 15 was dependent (helper does all the effort) for toileting hygiene and putting on/taking off footwear and needed substantial/maximum assistance (helper does more than half the effort) for showering/bathing and lower body dressing. The MDS indicated that Resident 15 was independent with eating. During a concurrent interview and record review of Resident 15's care plan report on [DATE] at 10:28 a.m. with Infection Prevention Nurse (IPN), IPN stated care plan should have been initiated if Resident 15 refused vaccination or if there is immunization refusal in the chart. Care plans are to provide risk factors, monitoring and interventions. IPN stated she could not locate where the care plan for refusal of vaccination for Resident 15. During a review of the facility's Policy and Procedure (P/P) titled, Comprehensive Person-Centered Care Planning, the resident has the right to refuse treatment. In the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's (interdisciplinary team's) effort to educate the resident and resident representatives and any alternate means to address risk. b. During a review of Resident 82's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of abnormal gait (irregular way of walking) and mobility (the ability to move freely and easily), need for assistance with personal care (help with daily physical tasks like bathing, dressing, and eating) and atrial fibrillation (a heart condition where the upper chambers of the heart beat fast in an irregular way). During a review of Resident 82's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 82 is cognitively intact, needs assistance for toileting, showering, putting on and taking off shoes and clothes below your waist. During a review of Resident 82's physician order dated [DATE], the physician order indicated Resident 82 is to be monitored for signs and symptoms of skin breakdown. During a review of Resident 82's Care Plan Report (CPR), (undated), the CPR indicated Resident 82 has potential/actual impairment of skin integrity and caregivers are to be educated to causative factors and measure to prevent skin injury during transfer and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces with an initiated date of [DATE]. During an interview on [DATE] at 9:35 a.m. with Resident 82, Resident 82 stated Certified Nursing Assistants (CNAs) are too aggressive while changing her positions in bed and while assisting her with getting dressed. Resident 82 also stated that she feels upset about frequently being rushed and reported recently sustaining an injury to their right lower leg when a CNA hurried while assisting with putting on their shoes. During an interview on [DATE] at 1:11 p.m. with Wound Treatment Nurse (WTN), the WTN stated they are aware Resident 82 has a new skin tear on their right shin, but are unaware of how it was obtained, as there is no indication of the cause documented in the resident's chart. The WTN also stated that understanding how the skin tear was acquired is crucial to prevent similar incidents in the future. During an interview on [DATE] at11:24 a.m. with Interim Director of Nursing (IDON), the IDON stated that it is unacceptable for staff providing direct patient care not to know how Resident 82 acquired the skin tears, as lack of knowledge regarding the cause could lead to repeated injuries. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2016 with revised 1/2026, the P&P indicated care plans are to be developed and implemented for each resident, including resident goals and interventions. The P&P also indicated that staff who are to be informed of such care plans include, but are not limited to, Nurse Aides responsible for the resident and other appropriate staff or professionals from relevant disciplines, as determined by the resident's needs. c. During a review of Resident 106's admission Record (AR), the AR indicated the facility admitted Resident 106 on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (brain tissue death) affecting left non-dominant side and seborrheic dermatitis. During a review of Resident 106's History and Physical (H&P) dated [DATE], the H&P indicated Resident 106 had the capacity to understand and make decisions. During a review of Resident 106's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 106 had intact cognition (ability to understand and process information). The MDS indicated Resident 106 required setup assistance from staff with eating. The MDS indicated Resident 106 required maximal assistance (helper did more than half the effort) from staff with oral and personal hygiene. The MDS indicated Resident 106 was dependent (helper did all the effort) on staff with toileting hygiene, showering/bathing, and bed-to-chair transferring. During an observation on [DATE] at 11:20 am at Resident 106's bedside, Resident 106 had white scaly skin on the face. During a concurrent record review and interview with Registered Nurse Supervisor 1 (RN 1) on [DATE] at 9:11 am, Resident 106's entire care plans were reviewed. RN 1 stated there was no CP developed to address Resident 106's diagnosis of seborrheic dermatitis. RN 1 stated a CP should have been developed to address Resident 106's seborrheic dermatitis. RN 1 stated the licensed nurse should initiate and develop the CP. RN 1 stated the CP should be specific and resident centered so that staff would know the resident's condition and how to treat and prevent worsening of the resident's condition. During an interview with the Interim Director of Nursing (IDON) on [DATE] at 10:45 am, the IDON stated the facility should have specific and resident centered CP to address the resident's diagnosis/condition. The IDON stated the CP was the plan of care for the nurses to follow and meet the resident's needs. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 1/2026, the P&P indicated the facility should develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated the facility should develop and implement a comprehensive person-centered care plan for each resident within seven days of completion of the resident MDS.

Based on observation, interview, and record review, the facility failed to revise the care plans (CP) for two of two sampled residents (Residents 7 and 148) when: a. Resident 7's nephrostomy (a small opening made in the back so a tube could drain urine directly from the kidney when it could not flow normally) bag was removed. b. Resident 148 had a second fall on 7/28/2026. These deficient practices had the potential for Residents 7 and 148 to not receive appropriate care, treatment, and/or services. Findings: a. During a review of Resident 7's Face Sheet (FS), the FS indicated the facility admitted Resident 7 on 1/22/2020 and readmitted on [DATE] with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract) and chronic kidney disease (CKD, kidney damage and could not filter blood or remove waste and extra fluid). During a review of Resident 7's History and Physical (H&P) dated 6/12/2026, the H&P indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool) dated 6/17/2026, the MDS indicated Resident 7 had intact cognition (ability to understand and process information). The MDS indicated Resident 7 required moderate assistance (helper did less than half the effort) from staff with eating. The MDS indicated Resident 7 required maximal assistance (helper did more than half the effort) from staff with oral hygiene and personal hygiene. The MDS indicated Resident 7 was dependent (helper does all the effort) on staff with toileting hygiene, showering/ bathing, and bed-to-chair transferring. During a review of Resident 7's CP related to nephrostomy dated 6/18/2026, the CP indicated nursing interventions included to position the catheter bag below the level of the bladder and change the catheter bag and tubing as ordered. During an observation and interview with Resident 7 on 7/28/2026 at 1:17 pm, at Resident 7's bedside, Resident 7 did not have a nephrostomy bag. Resident 7 stated she did not remember when the nephrostomy bag was removed. During a concurrent record review and interview with Registered Nurse Supervisor 1 (RN 1) on 7/30/2026 at 10:12 am, Resident 7's CP for nephrostomy dated 6/18/2026 was reviewed. RN 1 stated the CP indicated Resident 7 had a catheter bag and it should be revised because Resident 7 did not have catheter bag. RN 1 stated the CP should be revised by the licensed nurses when there were any changes with the residents. During an interview with the Interim Director of Nursing (IDON) on 7/30/2026 at 10:50 AM, the IDON stated Resident 7 did not have a catheter bag. The IDON stated Resident 7's CP for nephrostomy should be revised. The IDON stated resident's CP should be specific and resident centered so staff would know how to take care of residents' needs. b. During a review of Resident 148's FS, the FS indicated the facility admitted Resident 148 on 7/25/2026 with diagnoses including legal blindness and generalized anxiety disorder (a condition where a person worried too much about everyday things). During a review of Resident 148's Clinical admission (CA) assessment dated [DATE], the CA assessment indicated Resident 148 was alert with forgetfulness. The CA assessment indicated Resident 148 had impairment on all extremities' range of motion. During a review of Resident 148's H&P dated 7/28/2025, the H&P indicated Resident 148 did not have the capacity to understand and make decisions. During a review of Resident 148's Change in Condition Evaluation (CICE) dated 7/28/2026 at 7:00 am, the CICE indicated Resident 148 had a fall on 7/28/2026 at 7 am. During a review of Resident 148's CICE dated 7/28/2026 at 9:30 am, the CICE indicated Resident 148 slid off the bed on 7/28/2026 at 8:40 am. During an observation on 7/28/2026 at 8:40 am at Resident 148's bedside, Resident 148 slid off the bed. During a concurrent record review and interview with RN 1 on 7/30/2026 at 8:31 am, Resident 148's fall CP dated 7/28/2026 was reviewed. RN 1 stated RN 1 did not revise Resident 148's fall CP after the fall on 7/28/2026 at 8:40 am and should have revised it. RN 1 stated the licensed nurse should revise the resident's CP right after a resident's fall incident. RN 1 stated staff should know the CP goal and intervention to prevent a fall. RN 1 stated the probability of fall was increased when the resident's CP was not revised right after the fall. RN 1 stated it was important to revise CP timely to prevent further falls. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 1/2026, the P&P indicated the facility should review and/or revise the resident's comprehensive plan of care after each assessment, including both the comprehensive and quarterly review assessments. During a review of the facility's P&P titled, Fall Management System, revised 1/2026, the P&P indicated the facility should update the resident's care plan after a fall.

Based on observation, interview, and record review, the facility failed to follow its infection prevention control policy to prevent the spread of infection: a. When the facility's Water Management Program (WMP - written guidelines to ensure the building's water system is safe and clean) did not implement testing for cold water as written.b. When the facility failed to place the order for Enhanced Barrier Precautions (EBP - infection control guidelines to stop the spread of infection) timely, for one of one sampled resident (Resident 148) who was admitted with multiple wounds.c. When the facility failed to ensure the Personal Protective Equipment (PPE- worn to protect a person from hazards) bin had adequate PPE supply available for one of one sampled resident on EBP (Resident 148). The failure of not implementing the water management plan placed the building's water system at risk for growth of waterborne pathogens (harmful bacteria that spread through contaminated water)The failure to put the order for EBP timely upon admission and not ensuring PPE was available for Resident 148 while on EBP had the potential to spread infection in the facility. Findings: a. During a concurrent interview and record review on 7/31/26 at 11:39 a.m. with Maintenance Supervisor (MS), the WMP binder was reviewed. The WMP has logs for checking the hot water, faucet, shower, cooler, Air Conditioning and swamp cooler once a month. MS stated he does not check the cold water in the facility as indicated in the plan. The MS stated that the administration did not discuss that this is necessary, so he is not aware. During a review of the facility's Policy and Procedure (P/P) titled, Water Safety Management Program (Legionella) originally dated 12/2016 was reviewed. The P/P indicated the inclusion of cold-water distribution and mentions cold-water storage tanks as an example of an internal source where Legionella can grow and spread. b. During a review of Resident 148's Face Sheet, the face sheet indicated Resident 148 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of breast (cancerous tumor), type 2 diabetes mellitus (the body's inability to process sugar), unspecified severe protein-calorie malnutrition (serious medical condition caused by a major lack of food, calories and protein) and unspecified open wound of left great toe. During a review of the History and Physical dated 7/28/2026, it indicated that Resident 148 does not have the capacity to understand and make decisions. Resident 148's general appearance is described as very thin and confused, with a history of multiple falls at the facility. During a concurrent interview and record review on 7/31/26 at 9:32 a.m. with Infection Prevention Nurse (IPN), the physician's orders for Resident 148 were reviewed. ENHANCED BARRIER PRECAUTIONS: PPE (personal protective equipment) required for high resident contact care activities. Indication: Wound was ordered on 7/27/26, two days after admission. IPN stated that Resident 148 was on EBP (use of gown and gloves during high-contact resident care activities) because Resident 148 has wounds. IPN stated that residents with wounds automatically get put on enhanced barrier precautions due to risk for MDROs (multi-drug-resistant organisms). During a review of the facility's Policy and Procedure (P/P) titled, IPCP Standard and Transmission-Based Precautions, the P/P indicated that enhanced barrier precautions are used during activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to resident. Residents with wounds.are at especially high risk of both acquisition of and colonization with MDROs. c. During a review of Resident 148's FS, the FS indicated Resident 148 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm (a cancerous tumor) of the breast and open wound of the left great toe area. During a review of Resident 148's History and Physical (H&P) dated 7/28/2026, the H&P indicated Resident 148 did not have the capacity to understand and make decisions. During a review of Resident 148's Order Summary Report (OSR) dated 7/27/2026, the OSR indicated to place Resident 148 on Enhance Barrier Precautions (EBP): PPE required for high resident contact care activities. Indication: Wound. During a review of Resident 148's untitled Care Plan Report (CPR) dated 7/27/2026, the CPR indicated Resident 148 was at risk for serious infections related to open wound and undergoing wound care. The CP interventions included for nursing staff to implement EBP during the provision of close contact care, to wear gowns and gloves during high-contact resident care activities and to follow proper infection control practices as indicated. During an observation of Resident 148 on 7/28/2026 at 8:36 AM, Resident 148 was observed sliding off the bed. Surveyor 1 called out for help/assistance from facility staff at Station 3. The Restorative Nurse Assistant (RNA) took the last gown from the PPE bin and walked into Resident 148's room to assist Resident 148. The PPE bin outside of Resident 148's room was empty and did not have gowns. During an interview with the RNA on 7/28/2026 at 8:39 AM, the RNA stated Resident 148 was on EBP and staff needed to wear PPE to assist Resident 148 with transfers and close contact care. The RNA stated the PPE bin outside Resident 148's room was empty and should always be full of PPE for staff to use to assist Resident 148 in a timely manner. During an interview with the Infection Preventionist (IP) on 7/28/2026 at 8:44 AM, the IP stated the PPE bin should be full at all times. The IP stated if there were no reusable gowns, the bin should be refilled with disposable gowns so that staff could assist the resident. The IP stated the PPE bin should always have PPE available for staff to use. The IP stated it would be an infection control issue if there were no PPEs available. During an interview with the IDON on 7/30/2026 at 3:21 PM, the IDON stated the PPE bin should have PPE if a resident is on isolation or EBP. The IDON stated staff needed PPE supplies because they were constantly going inside to provide care to the resident. The IDON stated if the PPE bin was empty or running low on PPE supplies, it should be replenished immediately. During a review of the facility's P&P titled, IPCP Standard and Transmission Based Precautions, dated 1/2026, the P&P indicated, It is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions.

Based on interview and record review, the facility failed to ensure an antibiotic stewardship program was implemented during antibiotic use to monitor true infection for two of 2 sampled residents (Resident 126 and Resident 29).This failure had to potential to increased the risk of Residents 126 and Resident 129 developing antibiotic-resistant organisms.Findings:During a review of Resident 126's Face Sheet, the Face Sheet indicated that Resident 126 was admitted to the facility on [DATE] with diagnoses including nondisplaced intertrochanteric fracture of right femur (stable right hip break), chronic kidney disease (a condition where kidneys are damaged and cannot filter blood well), type 2 diabetes mellitus (the body's inability to process sugar), malignant neoplasm of brain (cancerous tumor that harms healthy brain tissue), and acute upper respiratory infection (short-term illness affecting the sinuses, nose or throat).During a review of Resident 126's Minimum Data Set (MDS - a resident assessment tool) dated 7/13/26, the MDS indicated Resident 126 was dependent (helper does all of the effort and resident does none of the effort to complete the activity) on staff with toileting hygiene, upper and lower body dressing, and putting on and taking off footwear.During a record review of Resident 126's physician's order dated 7/25/26, Levofloxacin Tablet (antibiotic for acute upper respiratory infection) 750 milligram (mg- unit of measurement) started on 7/25/26 for five days, and Metronidazole Tablet (an antibiotic with the indication for aspiration pneumonia) 500 mg ordered on 7/27/26 for five days. Resident 126 was not recorded to be showing any further signs and symptoms of infection at this time.During a review of Resident 29's Face Sheet, the Face Sheet indicated that Resident 29 was admitted to the facility on [DATE] with diagnoses including bilateral primary osteoarthritis of hip (joint disease causing bones to rub together), type 2 diabetes mellitus (the body's inability to process sugar), and unspecified dementia (condition that affects memory, thinking and the ability to perform daily activities).During a review of Resident 29's MDS dated [DATE], the MDS indicated that Resident 29 needed partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathing, and personal hygiene.During a record review of Resident 29's physician's order dated 5/20/26, Cephalexin Tablet(antibiotic prescribed for bacterial infections of the skin) 500 mg was started on 5/20/26 for 7 days.During a review of Resident 29's Mc Geer's Infection Surveillance (standardized definitions and guidelines used for tracking infections), resident met criteria for true infection due to presence of pus in a wound on her mid-back. Antibiotics were ordered but wound culture was never done.During a concurrent interview and record review on 7/31/26 at 9:32 a.m. with Infection Prevention Nurse (IPN), Resident 126's Mc Geer's Infection Surveillance and Progress Notes were reviewed. IPN stated that if residents do not meet criteria to receive antibiotics and Medical Doctor (MD) continues to order the antibiotic then it is discussed in the QAPI (Quality Assurance and Performance Improvement) meeting. QAPI is to discuss all the concerns that we have in the facility so that way we are able to resolve issues and follow guidelines. IPN stated the surveillance indicated that Resident 126 did not meet Mc Geer's guidelines for true infection. IPN stated that this case was not addressed in the QAPI meeting. IPN stated that Resident 126 is not supposed to have these antibiotics if not needed because it creates resistance. IPN stated that Resident 29 did not have any wound culture despite the Wound MD performing an incision and drainage (a minor surgery used to treat a skin abscess or boil) to see what antibiotic can be used.During a review of the facility's Policy and Procedure (P/P) titled, Antibiotic Stewardship, the P/P states the facility will promote the appropriate use of antibiotics and may consider time-out practices (stop order) of an antibiotic when symptoms of resident do not support the diagnosis of infection. IP and/or other members of the ASP (Antibiotic Stewardship Program) team will review and report findings to facility staff and to QAPI committee, who will then provide feedback to facility staff.

Based on interview and record review, the facility failed to maintain documentation related to staff COVID-19 (respiratory illness caused by the SARS-COV 2 virus) vaccination ( treatment with a vaccine to produce immunity to a particular infectious disease or pathogen) for Wound Doctor, Registered Dietician(RD) and Medical Director (MD). This failure has the potential to increase risk of acquiring Covid-19 infection with staff, residents and visitors in the facilityFindings:During a review of the facility's employee COVID 19 immunization ( the action of making a person resistant to a particular infectious disease) records, there was no documentation showing that the Wound Doctor, RD, or MD received or declined the required COVID 19 vaccination, or any documentation that they were provided information on the benefits and potential risks of the COVID 19 vaccination. During a concurrent interview and record review on 7/31/26 at 9:32 a.m. with Infection Prevention Nurse (IPN), the facility's Policy and Procedure (P/P) titled, Immunizations-Staff was reviewed. IPN stated staff are required to have immunizations because they can transmit contagious disease to staff, residents and family members that visit. IPN stated that the wound doctor goes inside resident rooms to do assessment and measures the wounds of the resident with open wounds but does not have immunization record in Vaccination / Immunizations staff binder. IPN stated there is no record for Medical Director or Registered Dietician either. During a record review of the facility's P/P dated 9/2020, the P/P mentions COVID-19 guidelines including maintaining the consent and record of vaccination in the employee medical record. If an employee declines the vaccine for reasons other than medical contraindication, this shall be documented on the Consent for COVID-19 Vaccination.

Based on interview and record review, the facility failed to follow its policy and procedure to call 911 (the standard emergency telephone number used to reach police, fire, and medical services) in a timely manner for Resident 146 on [DATE]. This deficient practice had the potential to result in the delay of the emergency system first responders arriving quickly to aid in the resuscitation efforts for Resident 146. Findings: During a review of Resident 146's Face Sheet (FS), the FS indicated Resident 146 was admitted to the facility on [DATE] with diagnoses including encephalopathy (any disease, damage, or malfunction of the brain), hypovolemic shock (a life-threatening medical emergency caused by a sudden, severe loss of blood or body fluids) and severe sepsis with septic shock (a life-threatening medical emergency where an infection causes an extreme immune response, leading to dangerous organ dysfunction and critically low blood pressure ). During a review of Resident 146's History and Physical (H&P) dated [DATE], the H&P indicated Resident 146 did not have the capacity to understand and make decisions. During a review of Resident 146's Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their residents) meeting conference note dated [DATE], the IDT note indicated the resident's Physician Orders for Life Sustaining Treatment (POLST) was reviewed with the resident's daughter and the code status was Do Not Resuscitate (DNR) with selective treatment of long-term artificial means of nutrition. During a review of Resident 146's Minimum Data Set (MDS-resident assessment tool) dated [DATE], the MDS indicated Resident 146's cognition (ability to understand) was severely impaired. The MDS indicated Resident 146 was dependent (helper does all the effort) on staff for toileting, showers, upper and lower body dressing and putting on/taking off footwear. The MDS indicated Resident 146 required substantial/maximal assistance (helper does more than half the effort) from staff for oral and personal hygiene. During a review of Resident 146's Progress Notes (PN) dated [DATE] at 1:03 am, the PN indicated that around 1:00 AM, Certified Nurse Assistant (CNA5) found Resident 146 not moving. CNA5 called License Vocational Nurse 4 (LVN4) and Registered Nurse (RN2) to Resident 146's bedside. During a concurrent review of Resident 146's PN dated [DATE] at 1:03 AM, the PN indicated that on [DATE] at 1:03 AM, RN2 (witnessed by LVN4) spoke (over the phone) with Fam1 who decided to change Resident 146's DNR status to resuscitate status. At 1:04 AM, CPR (Cardiopulmonary resuscitation- a lifesaving emergency procedure performed when someone's breathing or heartbeat has stopped) was started by RN2 assisted by team (facility staff[unidentified]) including LVN4. The team rotated to perform CPR and Ambu-bag (a hand-held tool used to push air into a person's lungs) tasks. At 1:05 AM, Resident 146 had no pulse and no respirations but the team continued CPR. At 1:17 AM, staff called the facility's Director of Nursing (DON) and continued CPR. At 1:19 AM, the Administrator (Admin) was called and staff continued CPR. At 1:19 AM, the Medical Director was called. At 1:23 AM, 911 was called and arrived at 1:30 AM. At 1:34 AM, Resident 146 was pronounced dead. During an interview with the Interim Director of Nursing (IDON) on [DATE] at 10:41 AM, the IDON stated that when a resident had DNR status and found unresponsive with no pulse or breathing the staff must begin CPR and call 911 before even checking the code status. The IDON stated that every second counts to keep the patient alive. The IDON stated that once it was determined that the resident was DNR then staff would stop doing CPR. The IDON stated, We have to honor the resident's medical directive. The IDON stated that if the family want to resuscitate, then staff would continue with the resuscitation efforts. During a concurrent interview with the IDON on [DATE] at 10:45 AM, the IDON stated that the moment the facility staff found a resident to be unresponsive, staff should call 911 because at that time, staff do not know the resident's code status until the staff review the resident's medical record. The IDON stated that the facility staff should not stop CPR until 911 staff arrived at the facility and hand over the resident to 911 staff. The IDON stated 911 should be called right away. The IDON stated that for Resident 146, waiting for 20 minutes to call 911 was not acceptable even if staff did CPR to Resident 146. The IDON stated staff should have called 911 when Fam1 said to change the status to resuscitate Resident 146. During a telephone interview with CNA5 on [DATE] at 3:01 PM, CNA5 stated CNA5 could not remember what time CNA5 found Resident 146 in bed unresponsive and not breathing. CNA5 stated CNA5 immediately called LVN4 and RN2 who initiated CPR. CNA5 stated 911 arrived at the facility around 1:30 AM. During an interview with LVN4 on [DATE] at 3:17 PM, LVN4 stated that on [DATE] at around 11:30 PM, LVN4 made rounds and saw Resident 146 sleeping. LVN4 stated Resident 146 responded to touch and LVN4 was able to see Resident 146's mouth movements. LVN4 stated the next time LVN4 saw Resident 146 was around 1:00 AM when CNA5 informed LVN4 that Resident 146 was unresponsive and not breathing. LVN4 stated that when CNA5 reported to LVN4 of Resident 146's status, LVN4 assessed Resident 146 who had no pulse, was still warm, and the chest was still rising. LVN4 stated LVN4 got the pulse oximeter (a machine that measures the oxygen) which was not registering. LVN4 stated LVN4 checked Resident 146's chart and saw Resident 146 was DNR. LVN4 stated LVN4 called RN2 who called Fam1. LVN4 stated Fam1 informed RN2 that Fam1 still wanted the staff to perform CPR on Resident 146. LVN4 stated staff continued CPR while RN2 called 911. LVN4 stated staff continued CPR until the ambulance arrived. During an interview with RN2 on [DATE] at 3:27 PM, RN2 stated that on [DATE], RN2 was the Charge Nurse (CN) in Station 4. RN2 stated that RN2 was notified that there was something wrong with Resident 146. RN2 stated RN2 went to assess Resident 146 and found that Resident 146 was unresponsive and had no pulse. RN2 stated RN2 checked Resident 146's code status in Resident 146's chart. RN2 stated Resident 146's code status was DNR. RN2 stated RN2 informed the doctor and called Fam 1 around 1:10 AM to inform Fam 1 of Resident 146's condition. During an interview with RN2 on [DATE] at 3:37 PM, RN2 stated that if a resident was full code, staff must call 911 immediately while staff were doing compressions. During a review of the facility's Policy and Procedure (P&P), titled, Change in Condition, revised 1/2026, the P&P indicated, It is the policy of the facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. During a review of the facility's P&P, titled, Cardiopulmonary Resuscitation-CPR), revised 1/2026, the P&P indicated, If unresponsive, not breathing (occasional gasps are not breathing) and no pulse: Page or yell loudly for Code Blue to the area. Activate the Emergency Medical Services (EMS} by calling 911.

Based on interview and record review, the facility failed to provide necessary care and services for a resident with indwelling catheter (also known as foley catheter {FC}, a tube that allows urine to drain from the bladder into a bag) in accordance with the physician's order and resident's care plan for one of four sampled residents (Resident 8). This failure had the potential for Resident 8 not to receive care or receive delayed care and placed the resident at risk for urinary tract infection (UTI, an infection in the bladder/urinary tract).Findings: During a review of Resident 8's Face Sheet (FS), the FS indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute kidney failure (a sudden decline in kidney function), UTI and benign prostatic hyperplasia (BPH-a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms. During a review of Resident 8's Order Summary Report (OSR) dated 12/20/2024, the OSR indicated Resident 8 had an order for indwelling catheter urine monitoring every shift for signs and symptoms of infection such as fever, hematuria (blood in the urine), sediments, (visible particles in the urine), change of urine color or foul smelling urine and notify Medical Doctor (physician) if any. During a review of Resident 8's OSR dated 1/22/2026, the OSR indicated Resident 8 had an order for licensed staff to insert an indwelling catheter French (a type of catheter) 18 (size of the catheter) per 10 milliliters (ml, unit of measurement) to closed drainage system (a sterile, self-contained urinary catheter attached to a collection bag) for neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems) and BPH. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 had intact cognition (ability to understand) for daily decision making. The MDS indicated Resident 8 needed maximum assistance (helper does more than half of the effort) from staff for putting on/off footwear. The MDS indicated Resident 8 needed moderate assistance (helper does less than half of the effort) from staff for showering. During a review of Resident 8's untitled Care Plan (CP) revised 7/13/2026, the CP indicated Resident 8 was at risk for serious infection related to indwelling catheter and history of Multidrug-Resistant Organism (MDRO - refers to bacteria or other germs that have developed resistance to antibiotics) infection. The CP interventions included nursing staff to observe for and notify the medical provider of fever, acute change in mental status, and local signs and symptoms of active infection. During an interview on 7/28/2026 at 11:42 am, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated residents on FC needed to be monitored every shift for signs and symptoms of UTI such as sediments, possible blood in the FC tubing or bag and pain at the FC site. LVN 2 stated signs and symptoms for UTI needed to be documented by Licensed Nurses (in general) in the resident's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). During an interview on 7/29/2026 at 11:00AM with the IDON, the IDON stated the facility did not have a Policy and Procedure (P&P) to monitor signs and symptoms of infection by the Licensed Nurse every shift for residents on FC. During a concurrent interview and record review on 7/29/2026 at 11:17 am with the Interim Director of Nursing (IDON) of Resident 8's medical records (PointClickCare - PCC, a cloud-based software used in charting) was reviewed. The IDON stated Licensed Nurses needed to monitor Resident 8's signs and symptoms of UTI every shift and should be documented in Resident 8's MAR to prevent early signs and symptoms of UTI. The IDON stated there was no clinical documentation that Resident 8's signs and symptoms of UTI was monitored by Licensed Nurses every shift as ordered by the doctor and as indicated in Resident 8's care plan. During a review of the facility's P&P titled, Indwelling Urinary Catheter Care, revised 1/2026, the P&P indicated, It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection.

Based on observation, interview, and record review, the facility staff failed to elevate the resident's head of bed (HOB) for one of three sampled residents (Resident 4) while receiving feeding formula through a gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) in accordance with the resident's care plan and physician's order This deficient practice had the potential to result in aspiration (inhalation of foreign materials) and pneumonia (a lung infection) for Resident 4. Findings: During a review of Resident 4's Face Sheet (FS), the FS indicated the facility admitted Resident 4 on 3/5/2026 and readmitted on [DATE] with diagnoses including encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for medication/nutritional support), dysphagia (difficulty in swallowing) and muscle weakness. During a review of Resident 4's untitled Care Plan (CP) revised 5/5/2026, the CP indicated Resident 4 required tube feeding related to dysphagia. The care plan interventions included nursing staff to elevate Resident 4's HOB to 45 degrees during and thirty minutes after tube feeding and elevate HOB at least 30 to 45 degrees at all times during feeding. During a review of Resident 4's Order Summary Report (OSR) dated 6/15/2026, the OSR indicated for staff to elevate Resident 4's head of bed (HOB) at 30 to 45 degrees during and one hour after feeding. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 6/23/2026, the MDS indicated Resident 4 had severely impaired cognition (ability to understand) for daily decision making. The MDS indicated Resident 4 was dependent (helper did all the effort) on staff for oral hygiene, toileting, shower, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 4's OSR dated 7/14/2026, the OSR indicated Resident 4 required continuous GT feeding of Nepro 1.8 (formula) rate at 60 milliliter (ml, unit of measurement) per hour (hr.) for 16 hours to provide 960 cubic centimeters (cc, unit of measurement)/1728 calories (cal, unit of energy) in 24 hrs. via enteral feeding pump; turn on pump at 2 pm, pump off 6 am or until desired volume was reach. During an observation on 7/28/2026 at 2:14 pm inside Resident 4's room, Resident 4 was lying in bed with HOB elevated at 10 to 20 degrees and Resident 4 was connected to an ongoing GT feeding running at 60 ml/hr. During a concurrent observation and interview on 7/28/2026 at 2:19 pm, together with Licensed Vocational Nurse 3 (LVN 3), Resident 4 was awake, lying in bed in supine position with HOB almost flat in bed and connected to an ongoing GT feeding formula. LVN 3 stated Resident 4's HOB was below 30 degrees. LVN 3 stated Resident 4's HOB should have been elevated at least 30 degrees while receiving GT feeding to avoid choking and to prevent aspiration. During an interview on 7/29/2026 at 11 am with the Interim Director of Nursing (IDON), the IDON stated there was no policy and procedure related to elevating the resident's HOB while receiving GT feeding. During an interview on 7/29/2026 at 11:02 am with the IDON, the IDON stated Resident 4's HOB needed to be elevated at 30 to 45 degrees while receiving GT feeding to prevent aspiration and as ordered by the physician,

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 3) received two liters per minute (lpm) of oxygen via nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as ordered by the physician. This failure had the potential to cause complications associated with oxygen therapy for Resident 3.Findings: During a review of Resident 3's Face Sheet (FS), the FS indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including emphysema (a lung condition that causes shortness of breath from lung damage), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with exacerbation (sudden worsening) and pulmonary hypertension (high blood pressure in the arteries of the lungs). During a review of Resident 3's Order Summary Report (OSR) dated 7/31/2026, the OSR indicated Resident 3 had an active order for oxygen to be administered at two (2) lpm via nasal cannula to keep oxygen saturation (measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) above 92% as needed for shortness of breath or wheezing related to COPD, ordered on 3/24/2026. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 6/5/2026, the MDS indicated Resident 3 was cognitively intact (ability to think). During a review of Resident 3s untitled Care Plan (CP) revised on 6/30/2026, the CP indicated Resident 3 had oxygen therapy to keep Resident 3's oxygen saturation above 92% with an intervention for oxygen setting as needed at two lpm via NC to keep oxygen saturation above 92%, During a concurrent observation and interview on 7/28/2026 at 9:45 am with Resident 3 in Resident 3's room, Resident 3 was receiving oxygen via NC while in bed. Resident 3 stated, Resident 3 used oxygen as needed and was occasionally short of breath. Resident 3 stated Resident 3 told nursing staff (unidentified) to check the oxygen level and wanted nursing staff to check it more often. During a concurrent observation and interview on 7/29/2026 at 9:29 am with Licensed Vocational Nurse 5 (LVN 5) in Resident 3's room, Resident 3 was in bed receiving oxygen via NC and the oxygen level was close to three (3) lpm. LVN 5 stated Resident 3's oxygen level was at 2.5 lpm, closer to 3 lpm. LVN 5 stated Resident 3 received oxygen for shortness of breath for COPD. LVN 5 stated Resident 3 had an active order for oxygen at 2 lpm, and the order should be followed because Resident 3 had COPD and getting more oxygen than needed would be harmful to Resident 3. During an interview on 7/31/2026 at 10:07 am with the Interim Director of Nursing (IDON), the IDON stated it was important to follow the physician's order for residents with oxygen, especially for residents with COPD. The IDON stated administering inaccurate amount of oxygen could lead to desaturation or respiratory illnesses. During a review of the facility's Policy and Procedure (P&P) titled, Licensed Nurse Procedures: Oxygen Therapy, revised January 2026, the P&P indicated it was the policy of the facility to administer oxygen as prescribed by the physician, in a safe manner.

Based on observation, interview and record review, the facility failed to complete one of three sampled employees (Licensed Vocation Nurse [LVN] 1)'s comprehensive clinical competency review annually, ensuring staff are qualified to deliver nursing and related services that safeguard resident safety.This failure had the potential to result in the residents receiving inadequate care.During an interview on 7/31/2026 at 11:06 a.m. with the Director of Staff Development (DSD), the DSD stated LVN's must undergo competency assessments and skills checks upon hire, annually, and whenever necessary. DSD also stated that these assessments are designed to evaluate proper technique, ensuring residents consistently receive appropriate care during daily routines.During a concurrent interview and record review on 7/31/2026 at 11:55 a.m. with the DSD, LVN 1's employee records were reviewed. The employee record indicated they were hired on 2/12/2004 and it did not indicate their 2023 comprehensive clinical competency review was completed. The DSD stated she was unable to locate the 2023 annual competency assessment and skills check for LVN 1 and stated that assistance from Human Resources (HR) was being sought to locate the documentation.During an interview on 7/31/2026 at 2:51 p.m. with HR, HR stated he was not able to locate the 2023 annual competencies and skills check for LVN 1 and explained employees are to complete comprehensive competency skills at the time of being hire and on an ongoing annual basis's. HR also stated that all employee documents including the annual competency checklist must be completed each year, kept readily accessible upon request, are never to be destroyed and are required to ensure residents receive accurate care.During an interview on 7/31/2026 at 2:44 p.m. with Interim Director of Nursing (IDON), IDON stated that staff members providing patient care, such as LVNs, are required to complete a competency checklist both at the time of hire and annually thereafter. IDON also stated competency checks serve to refresh employees' skills, keep them updated on new procedures, and ensure patient safety.During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated 7/2010, the P&P indicated performance evaluations should occur on, but are not limited to on the employee's annual date of hire anniversary.

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Foods Brought by Family or Visitor, by failing to label and properly store outside food for Resident 105. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 105 that could lead to serious medical complications and hospitalization.Findings: During a review of Resident 105's Face Sheet (FS), the FS indicated the facility admitted Resident 105 on 11/19/2024 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) and stage 2 chronic kidney disease (CKD, kidney damage and could not filter blood or remove waste and extra fluid). During a review of Resident 105's History and Physical (H&P) dated 11/6/2025, the H&P indicated Resident 105 had the capacity to understand and make decisions. During a review of Resident 105's Physician Orders (PO) dated 11/24/2025, the PO indicated Resident 105 had an active order for no added salt and easy to chew level 7 (regular) texture diet. During a review of Resident 105's Minimum Data Set (MDS, a resident assessment tool) dated 5/22/2026, the MDS indicated Resident 105 had intact cognition (ability to understand). The MDS indicated Resident 105 required setup assistance from staff with eating. The MDS indicated Resident 105 required supervision from staff with oral hygiene. The MDS indicated Resident 105 required moderate assistance (helper did less than half the effort) from staff with personal hygiene and bed-to-chair transferring. The MDS indicated Resident 105 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene and showering/ bathing. During a concurrent observation and interview on 7/28/2026 at 10:44 am in Resident 105's room, there was a clear and unlabeled container with a piece of cake at Resident 105's bedside. Resident 105 stated Resident 105's family brought the cake for Resident 105's birthday last night. During a concurrent picture review and interview with Certified Nurse Assistant 3 (CNA 3) on 7/30/2026 at 2:31 pm, the picture dated 7/28/2026 at 10:44 am was reviewed. CNA 3 stated the picture indicated the cake container did not have the resident's name or date labeled. CNA 3 stated the facility does not allow food at bedside for more than two hours for infection control. CNA 3 stated outside to be consumed by the resident at a later time should be placed in the resident's refrigerator. CNA 3 stated food left in the resident's room could spoil and attract flies. CNA 3 stated staff should label outside food with the resident's name and room number, so that staff would know whom the food belonged to. CNA 3 stated staff should label the food with a date so that staff would know how long the food was in the facility. During an interview with the Infection Preventionist Nurse (IPN) on 7/31/2026 at 3:33 pm, the IPN stated staff should label food at the resident's bedside with the date opened/received and resident's name. The IPN stated cake was perishable food (food that spoiled quickly because it needed to be kept cold) and mold could grow on the food. The IPN stated it was dangerous and harmful for residents to consume food with mold and could lead to food-borne illnesses. The IPN stated staff should ensure there was no food at residents' bedside. The IPN stated it was infection control to label bedside food. The IPN stated the facility should ensure a safe environment to protect the residents' health condition. During an interview with the Interim Director of Nursing (IDON) on 7/31/2026 at 4:20 pm, the IDON stated it was for residents' safety to label outside food with residents' names and date before storing in the residents' refrigerator. The IDON stated all staff should check for any food left at bedside and ensure it was labeled with resident's name and date. During a review of the facility's P&P titled, Foods Brought by Family or Visitors, dated 2/16/2026, the P&P indicated the facility should store resident food in resident refrigerator in Dinning room [ROOM NUMBER]. The P&P further indicated all food should be labeled with the resident name and date.

Based on interview and record review, the facility failed to ensure the afternoon (PM) shift staff documented/charted in the Treatment Administration Record (TAR) the monitoring of the low air loss mattress (LALM) and side rails on 7/25/26 as ordered, for one of one sampled resident (Resident 10). This deficient practice had the potential to negatively impact on the care and services provided to Resident 10.Findings: During a review of Resident 10's Face Sheet (FS), the FS indicated Resident 10 was readmitted to the facility on [DATE] with diagnoses including chronic kidney disease ( progressive loss of kidney function over time) and muscle wasting and atrophy (decrease in muscle size). During a review of Resident 10's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/12/2026, the MDS indicated Resident 10 was cognitively intact (ability to think). During a review of Resident 10's Order Summary Report (OSR) with active orders as of 7/31/26, the OSR indicated Resident 10 had active orders for staff to:1. Monitor placement of side rails, every shift, ordered on 6/24/2026.2. Check the motor settings and placement of the LALM per weight for tissue load management, ordered on 7/8/2026. During a review of Resident 10's TAR dated 7/1/2026 to 7/31/2026, the TAR indicated Resident 10 had missing documentation for the PM shift on 7/25/2026 for: 1. Low air loss mattress for tissue load management. Check motor setting per weight and placement. Every shift for wound management and per patient request.2. Monitor placement of side rails, every shift. During a review of Resident 10's untitled Care Plan (CP), the CP indicated:1. Resident 10 may have 1/4 bilateral padded siderails for positioning and ease in mobility as an enabler with a goal for Resident 10 to have safe use of bed and rails and sustain no entrapment. The CP was revised on 7/2/2026. 2. Resident 10 had the potential for pressure ulcer (PU- lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) development related to Resident 10's co-morbidities with CP intervention to check the motor setting and placement of the LALM for tissue load management. The CP was revised on 7/7/2026. During a concurrent interview and record review on 7/30/2026 at 3:03 pm with Licensed Vocational Nurse 3 (LVN 3), the TAR dated 7/1/2026 to 7/31/2026 was reviewed. The TAR indicated Resident 10 did not have charting/documentation by the PM shift on 7/25/2026 to check the motor settings of Resident 10's LALM and monitor the placement of Resident 10's siderails. LVN 3 stated the PM shift did not check the LALM settings and missed monitoring the side rails. LVN 3 stated it was important to check the LALM settings for wound healing and pain management. LVN 3 stated charting should be completed before the end of each shift. During an interview on 7/31/2026 at 10:08 am with the Interim Director of Nursing (IDON), the IDON stated Resident 10 had a PU that re-opened on re-admission. The IDON stated it was important to check the resident's LALM settings to ensure they were accurate, for skin maintenance and wound management. The IDON stated side rails should be checked for proper placement, to prevent entanglement, and for resident safety. The IDON stated charting should be completed before the end of the staff's shift. During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, revised 1/2026, the P&P indicated, the purpose of the procedure was to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. The P&P indicated any other nursing observations that are indicated or ordered for every shift observance required documentation every shift.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 and LVN 3 administered medications at scheduled medication administration times for two of three sampled residents (Resident 1 and Resident 2). This failure placed Resident 1 and Resident 2 at risk for medication errors and adverse health outcomes. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included end stage of renal disease ([ESRD] a medical condition in which a person's kidneys cease functioning on a permanent basis) and dependence on renal dialysis (when kidneys no longer function well enough to keep them alive, requiring them to rely on regular, ongoing treatments to filter waste, remove excess fluids, and balance electrolytes from their blood). During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 5/2/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included history of falling, end stage renal disease ESRD (End Stage Renal Disease-irreversible kidney failure) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 5/2/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/8/2026, the MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for upper body dressing and personal hygiene and was dependent on staff for toileting hygiene and putting on and taking off footwear. During a review of Resident 1's Order Summary Report (OSR), dated 5/2/2026, the OSR indicated Resident 1 had the following medication orders:1. Atorvastatin (medication to treat high amount of fats, such as cholesterol and triglycerides, in the blood) 20 milligrams (mg, a unit of measure) for hyperlipidemia (high amounts of fats or lipids in the blood), one tablet at bedtime.2. Sevelamer Carbonate (medication to treat high phosphorus level in the blood) 800 mg for ESRD, give three tablets in the evening.3. Carvedilol 25 mg for hypertension (HTN-high blood pressure), give one tablet two times a day.4. Clonidine 0.1 mg for HTN, give one tablet two times a day.5. Levetiracetam 500 mg (medication used to prevent and control seizures [sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), give one tablet two times a day. During a review of Resident 1's Medication Administration Record (MAR), dated 5/1/2026 to 5/13/2026, the MAR indicated Resident 1 was scheduled to receive the following medications:a. Atorvastatin 20 mg was scheduled for 9:00 p.m. b. Sevelamer Carbonate 800 mg three tablets were scheduled for 5:00 p.m.c. Carvedilol 25 mg was scheduled for 9:00 a.m. and for 5:00 p.m.d. Clonidine 0.1 mg was scheduled for 9:00 a.m. and for 5:00 p.m.e. Levetiracetam 500 mg was scheduled for 9:00 a.m. and for 5:00 p.m. During a review of Resident 1's Medication Administration Audit Report (MAAR), dated 5/4/2026, the MAAR indicated LVN 2 did not administer the following medications to Resident 1 as scheduled:a. Atorvastatin 20 mg was administered to Resident 1 at 12:09 a.m. instead of 9:00 p.m.b. Sevelamer Carbonate 800 mg three tablets were administered to Resident 1 at 6:42 p.m. instead of 5:00 p.m.c. Carvedilol 25 mg was administered to Resident 1 at 6:42 p.m. instead of 5:00 p.m.d. Clonidine 0.1 mg was administered to Resident 1at 6:42 p.m. instead of 5:00 p.m.e. Levetiracetam 500 mg was administered to Resident 1at 6:42 p.m. instead of 5:00 p.m. During an interview on 5/12/2026 at 3:39 p.m. with LVN 2, LVN 2 stated on 5/4/2026 LVN 2 administered Resident 1's medications late. LVN 2 stated medications were administered late because LVN 2 got behind during medication administration. LVN 2 stated it was important to administer medications at the scheduled time because residents need the medications and if medication was administered late, it might be too close to the next medication administration time. 2. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular and often very rapid heart rhythm) and ESRD. During a review of Resident 2's H&P, dated 4/24/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required maximal assistance (helper does more than half the effort to complete the activity) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's OSR, dated 4/22/2026, the OSR indicated Resident 2 had the following medication orders:a. Renvela 800 mg (medication to treat high phosphorus level in the blood), give one tablet with meals.b. Prednisone 5 mg (medication used to suppress the immune system and reduce inflammation), give one tablet once a day.c. Eliquis 5 mg for atrial fibrillation, give one tablet two times a day.d. Gengraf 25 mg (medication to suppress the immune system), give one capsule every 12 hours.e. Allopurinol 100 mg (medication used to treat gout for gout [painful swelling and redness of the joints]), give one tablet once a day on Monday, Wednesday, Friday.f. Vancomycin 125 mg (medication used to treat infections), give one capsule once a day.g. Tamsulosin 0.4 mg (medication used to treat urinary symptoms caused by an enlarged prostate), give one capsule once a day.h. Lactobacillus capsule (used to restore the natural balance of bacteria in the digestive tract), give one capsule once a day. During a review of Resident 2's MAR, dated 4/23/2026 to 4/27/2026, the MAR indicated Resident 2 was scheduled to receive the following medications:a. Renvela 800 mg was scheduled for 7:15 a.m., 12:15 p.m., and 5:15 p.m.b. Prednisone 5 mg (medication used to suppress the immune system and reduce inflammation) was scheduled for 7:15 a.m.c. Eliquis 5 mg for atrial fibrillation was scheduled for 9:00 a.m. and 5:00 p.m.d. Gengraf 25 mg (medication to suppress the immune system) was scheduled for 9 a.m. and 9 p.m.e. Allopurinol 100 mg (medication used to treat gout for gout [painful swelling and redness of the joints]) was scheduled for 9 am.f. Vancomycin 125 mg (medication used to treat infections0 was scheduled for 9 a.m.g Tamsulosin 0.4 mg (medication used to treat urinary symptoms caused by an enlarged prostate) was scheduled for 9 a.m.h. Lactobacillus capsule (used to restore the natural balance of bacteria in the digestive tract) was scheduled for 9 a.m.During a review of Resident 2's MAAR, dated 4/24/2026, the MAAR indicated LVN 3 did not administer the following medications to Resident 2 as scheduled:a. Renvela 800 mg was given to Resident 2 at 11:13 a.m. instead of at 7:15 a.m.b. Prednisone 5 mg was given to Resident 2 at 11:13 a.m. instead of at 7:15 a.m.c. Eliquis 5 mg for atrial fibrillation was at 11:13 a.m. instead of at 9 a.m.d. Gengraf 25 mg was given to Resident 2 at 11:13 a.m. instead of at 9 a.m.e. Allopurinol 100 mg was given to Resident 2 at 11:13 a.m. instead of at 9 a.m.f. Vancomycin 125 mg was given to Resident 2 at 11:13 a.m. instead of at 9 a.m.g Tamsulosin 0.4 mg was given to Resident 2 at 11:13 a.m. instead of at 9 a.m.h. Lactobacillus capsule was given to Resident 2 at 11:13 a.m. instead of at 9 a.m. During an interview on 5/14/2026 at 1:06 p.m. with LVN 3, LVN 3 stated it was acceptable to administer a medication one hour before or one hour after the scheduled time. LVN 3 stated it was important to administer medications at the scheduled time because residents might have a second dose and it would not be safe to administer medications close together. LVN 3 stated if medications were not administered at the scheduled time, licensed nurses were not following doctor's orders. LVN 3 stated LVN 3 administered medication at the scheduled time. LVN 3 stated LVN 3 did not remember what happened during the medication administration and did the medication administration documentation at a later time. LVN 3 stated LVN 3 did not remember if LVN 3 moved to the next resident medication administration before documenting Resident 2's medication administration. During an interview on 5/14/2026 at 3:36 p.m. with Director of Nursing (DON), the DON stated medications must be administered one hour before or one hour after their scheduled time. The DON stated medications had a therapeutic effect and needed to be administered according to doctor's orders and at the time doctor had scheduled them. The DON stated the risk of administering medications late was it could cause negative side effects. During a review of facility's policy and procedure (P&P) titled Medication Administration, dated 2023, the P&P indicated medications were to be administered within 60 minutes of scheduled time. The P&P indicated the individual who administered the medication dose records the administration on the resident's MAR directly after the medication is given. The P&P indicated Pour-Pass-Chart (refers to the standard, step-by-step medication administration process used by nurses and caregivers. It stands for the three core phases of handling drugs: Pouring (preparing), Passing (administering), and Charting) was the acceptable method for medications preparation, administration, and documentation.

Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 3) received necessary care and services when: 1. Resident 3 did not receive the necessary assistance during mealtimes. 2. Resident 3 had the appropriate call light to request assistance.3. Resident 3 received appropriate care for a skin issue. 4. Resident 3's mobility assessments (a clinical evaluation used to determine how safely and independently a person can move, change positions, and carry out daily tasks) reflected Resident 3's current physical abilities. These failures had the potential for Resident 3 not receiving appropriate and necessary care timely. During an observation on 5/12/2026 at 1:11 p.m. in Resident 3's room, Resident 3's food tray had a full boneless chicken and chopped carrots. Food was untouched. Resident 3's face was extremely dry and flaky and observed skin flakes on Resident 3's shirt. During an observation on 5/13/2026 at 10:06 a.m. in Resident 3's room, Resident 3's food tray had a full pancake, one sausage patty, 1 milk carton and 1 cup of coffee. Food was untouched. Resident 3's face was extremely dry and flaky and observed flakes on Resident 3's sweatshirt. During an observation on 5/13/2026 at 10:25 a.m. in Resident 3's room, Resident 3's call light was clipped to the left side of Resident 3's sweatshirt. Resident 3 pulled the call light, and it pulled Resident 3's sweatshirt down. Resident 3 had trouble reaching the call light with the right hand. Resident 3 had no control over left upper extremity. Resident 3 was unable to push red button on call light system. Resident 3 pulled call light and brought it up to Resident 3's mouth and used Resident 3's teeth to operate the call light. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included left side hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and dysphagia (difficulty swallowing). During a review of Resident 3's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 11/1/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 3/26/2026, the MDS indicated Resident 3 required set up assistance for eating. The MDS indicated Resident 3 required maximal assistance (helper does more than half the effort to complete the activity) for oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 3 was dependent on staff for toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off footwear. During a review of Resident 3's Care Plan Report (CPR), with a revision date of 10/3/2025, the CPR indicated Resident 3 needed assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) due to poor balance, unstable gait, and left sided weakness. The CPR interventions included assisting Resident 3 to set up to eat. During a review of Resident 3's Joint Mobility Evaluation (JME, a clinical assessment that measures the flexibility, range of motion, and physical function of joints), dated 3/26/2026, the JME indicated Resident 3's left fingers had 75% to 100% of range intact (a minimum loss of motion). During a review of Resident 3's electronic medical record, there was no care plan regarding Resident 3's flaky skin on the face found in the medical record. During a review of Resident 3's electronic medical record, there was no facial skin assessment found in the medical record. During an interview on 5/13/2026 at 10:10 a.m. with Resident 3, Resident 3 stated Resident 3 had not eaten because Resident 3 was waiting for someone to assist Resident 3 by opening milk carton and to add milk to the oatmeal and coffee. Resident 3 stated Resident 3 asked Certified Nursing Assistant (CNA) 1 to assist with food set up and CNA 1 stated CNA 1 would return to help but CNA 1 did not return to help. Resident 3 stated food was always served in full portions, and staff never cut the food into smaller pieces. Resident 3 stated Resident 3 could not use a knife and a fork at the same time because Resident 3 only had one working arm. Resident 3 stated Resident 3 could not open Resident 3's left hand and Resident 3 was not able to move left wrist up and down. Resident 3 stated Resident 3 did not ask staff to cut Resident 3's food because Resident 3 knew staff would not do it because staff did not even want to open the milk carton. Resident 3 stated Resident 3 knew Resident 3's food was cold by now, but Resident 3 would still eat it. Resident 3 stated if staff did not want to help Resident 3 with food set up then Resident 3 would not eat. Resident 3 stated Resident 3 felt mad and sad at the same time because Resident 3 did not receive the support Resident 3 needed. Resident 3 stated Resident 3 felt ignored and not cared for. During an interview on 5/13/2026 at 10:28 a.m. with Resident 3, Resident 3 stated Resident 3 always had a problem using the call light and sometimes Resident 3 did not use the call light because it was too much work. Resident 3 stated Resident 3 struggled to reach the call light and Resident 3 could not push the red button on call light with Resident 3's right fingers. Resident 3 stated Resident 3 could bend right fingers a little but had no strength. Resident 3 stated the only way to push the call light was with Resident 3's teeth. Resident 3 stated Resident 3 wished there was another way to call for assistance, something easier for someone like Resident 3 that had mobility limitations. During an interview on 5/13/2026 at 10:43 a.m. with CNA 1, CNA 1 stated CNA 1 brought breakfast food tray to Resident 3. CNA 1 stated CNA 1 did not set up food or drinks for Resident 3. CNA 1 stated CNA 1 did not cut Resident 3's food into smaller pieces. CNA 1 stated CNA 1 did not return to assist Resident 3 because CNA 1 got busy with other residents. CNA1 stated CNA 1 knew Resident 3 could not use left hand but CNA 1 thought Resident 3 was okay to eat without assistance. CNA 1 stated Resident 3 had appropriate call light because Resident 3 had no problems using the call light. CNA 1 stated CNA 1 did not know what Resident 3 had on face. CNA 1 stated Resident 3's face was always dry and flaky and Resident 3 always scratched it. CNA 1 stated CNA 1 did not know if licensed nurses (in general) applied anything on Resident 3's face to help with the itchiness. During a concurrent interview and record review on 5/15/2026 at 9:39 a.m. with Director of Rehabilitation (DOR), Resident 3's JME, dated 3/26/2026, was reviewed. The JME indicated Resident 3's left fingers had minimal range of motion limitations. The DOR indicated Resident 3 was able to open left fingers with passive range of motion (the movement of a joint or body part that is produced entirely by an external force-such as a physical therapist, a caregiver, or a mechanical machine). The DOR stated all residents got reevaluated quarterly for their joint mobility. The DOR stated during Resident 3's joint mobility reevaluation, the rehabilitation department should have done a thorough assessment and included in the assessment that Resident 3 required more assistance due to not being able to use Resident 3's left hand during mealtimes and using the call light. The DOR stated nursing staff (in general) should have notified rehabilitation department about Resident 3 not being able to hold a fork and a knife at the same time to cut Resident 3's food. During a concurrent observation and interview on 5/15/2026 at 9:52 a.m. with DOR in Resident 3's room, Resident 3 struggled to reach the call light that was clipped to Resident 3's left side of sweatshirt. Resident 3 pulled the call light toward Resident 3 and could not push the red button on call light with Resident 3's right fingers. Resident 3 placed call light to Resident 3's mouth and pushed the call light button with Resident 3's teeth. The DOR stated Resident 3 should have been better assessed by rehabilitation department and the call light given to Resident 3 was not appropriate. The DOR stated the call light was not appropriate for Resident 3 because Resident 3 struggled to use the call light and it took a while for Resident 3 to push call light. The DOR stated this call light was not safe for an emergency. Resident 3 attempted to open left hand and Resident 3's hand mobility was limited. DOR stated Resident 3 had 50 % range of motion. The DOR stated Resident 3 required more assistance during mealtimes. The DOR stated Resident 3's food should be smaller in size because Resident 3 could not cut it. The DOR stated Resident 3's food and drinks should be set up by staff before leaving the room. During an interview on 5/15/2026 at 10:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 3 required set up assistance during mealtime because Resident 3 could not use left hand. LVN 1 stated set up assistance is assisting Resident 3 with taking lids off from food and drinks, open milk cartons, remove plastic wrap off food plates, add condiments to food and ask Resident 3 if Resident 3 wanted food cut into smaller pieces. LVN 1 stated staff must notify residents when food has arrived and not leave the room because food might get cold. During an interview on 5/15/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated call lights were used to better assist residents with their needs. The DON stated the facility provided a button call light or a pad call light to residents. The DON stated a pad call light was used by residents that have mobility issues and was contracted. The DON stated Resident 3 was not provided with the correct call light because Resident 3 could not use it the button call light. The DON stated Resident 3 using his mouth to push the call light was not treating Resident 3 with dignity and respect. The DON stated the rehabilitation department was responsible for assessing residents and for recommending the appropriate call light for residents. The DON stated Resident 3 required set up assistance during mealtimes. The DON stated set up assistance was to put food tray at Resident 3's bedside table, open cartons, make utensils accessible, help with food condiments, and cut food. The DON stated it was not acceptable to have residents eat without utensils. The DON stated Resident 3 only had one working hand and Resident 3 did not receive the assistance Resident 3 required. The DON stated Resident 3 could not eat because Resident 3's food was not set up appropriately to meet Resident 3's needs.During an interview on 5/15/2026 at 3:12 p.m. with the DON, the DON stated DON was aware of Resident 3's face dryness and flakiness. The DON stated the DON was not aware if Resident 3 currently received any medication or treatment for the face. The DON stated the DON did not document Resident 3's skin issue, did not notify Resident 3's physician and the DON did not ensure Resident 3 received care for skin issue. The DON stated the DON did not do anything for resident 3's skin issue and DON should have completed a change of condition and referred Resident 3 to see a dermatologist (medical doctor focused on diagnosing, treating, and preventing conditions and diseases affecting skin, hair, nails, and adjacent mucous membranes). During a review of facility's Policy and Procedure (P&P) titled Quality of Care, dated 12/2025, the P&P indicated the facility would ensure each resident received quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and care plan. The P&P indicated at any time, it is recognized by any of the team members that a resident condition or care needs have changed, the licensed nurse or nurse supervisor would be made aware, for example when:There's a change in ability or decline in physical function and change in ability to eat or drink. The P&P indicated a nurse would communicate the change to other departments as appropriate and updated communications will be available during morning report. The P&P indicated each department notified will perform their own evaluation and assessments to determine if he change requires further intervention and implement actions accordingly. The P&P indicated the nurse would transcribe the treatment and plan of care relative to the change of condition on the resident electronic medical record. [NAME] a review of facility's P&P titled Call Light, dated 1/2026, the P&P indicated the facility would provide a resident a means of communication with nursing staff. During a review of facility's P&P titled ADL, Services to Carry Out, dated 3/2026, the P&P indicated the facility would provide residents with the appropriate treatment and services to maintain or improve his/her abilities. The P&P indicated residents who are unable to carry out activities of daily living (ADLs) would receive necessary services to maintain good nutrition, grooming, personal hygiene, and oral hygiene.

Based on interview and record review the facility did not immediately notify the family for one of three sampled residents (Resident 1) regarding Resident 1's fall on 5/4/2026. This failure violated Resident 1's right and had the potential for Resident 1's family member (FM 1) of not being informed of Resident 1's change in condition and not making an informed decision (decision based on facts, relevant information, and clear understanding of potential risks, benefits, and alternatives) regarding Resident 1's fall. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included history of falling, end stage renal disease ESRD (End Stage Renal Disease-irreversible kidney failure) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 5/2/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/8/2026, the MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for upper body dressing and personal hygiene and was dependent on staff for toileting hygiene and putting on and taking off footwear. During a review of Resident 1's Nursing Progress Notes (NPN), dated 5/4/2026 and timed at 10:40 p.m., the NPN indicated Resident 1 had a fall on 5/4/2026 at 9:45 p.m. The NPN indicated Resident 1 was found (on the floor) in a supine position (flat on the back with face and torso/trunk facing upward) with right leg still on the bed. The NPN indicated Resident 1 had no contact person on file. During a review of Resident 1's Change in Condition Evaluation form (CIC), dated 5/4/2026 and timed at 10:09 p.m., the CIC indicated Resident 1 had a fall on 5/4/2026 during the night. The CIC indicated Resident 1 was observed on the floor while Resident 1's legs were on the bed. The CIC indicated under resident representative notification section Resident 1 had no contact person. During an interview on 5/13/2026 at 9:49 a.m. with Resident 1, Resident 1 stated Resident 1 fell on 5/4/2026. Resident 1 stated Resident 1 was trying to reach for the television remote control and Resident 1 got momentum and fell off the bed. Resident 1 called and informed FM 1 about the fall on 5/4/2026. Resident 1 stated Resident 1 was surprised that no one from the facility notified FM 1 about Resident 1's fall on 5/4/2026. Resident 1 stated FM 1 should have been notified of Resident 1's fall because a fall was important. During an interview on 5/13/2026 at 12:40 p.m. with FM 1, FM 1 stated no one from the facility called FM 1 on 5/4/2026 to inform FM 1 that Resident 1 fell. FM 1 stated on 5/6/2026 FM 1 received a call from Licensed Vocational Nurse (LVN) 1 and LVN 1 informed FM 1 that an X-ray (picture or digital image of the inside of the body) of Resident 1's leg was going to be taken. RP 1 stated LVN 1's call was not to notify FM 1 of Resident 1's fall but to inform FM 1 of the X-ray. FM 1 stated FM 1 was upset that the facility failed to notify FM 1 of something so important to Resident 1 and FM 1. FM 1 stated FM 1 visits Resident 1 every day and could not believe FM 1 was not notified of Resident 1's fall on 5/4/2026 until 5/6/2026. During an interview on 5/13/2026 at 2:42 p.m. with LVN 1, LVN 1 stated LVN 1 did not know about Resident 1's fall on 5/4/2026 until 5/5/2026. LVN 1 stated LVN 1 called FM 1 on 5/6/2026 and notified FM 1 of Resident 1's fall on 5/4/2026. LVN 1 stated FM 1 was upset that no one notified FM 1 of the fall when it happened. LVN 1 stated resident representatives and family were required to be notified after a resident (in general) falls out of courtesy and because they had the right to know what was going on with their family members. During an interview on 5/13/2026 at 3:26 p.m. with LVN 2, LVN 2 stated on 5/4/2026 at 10:00 p.m. LVN 2 heard Resident 1 shouting for help. LVN 2 stated when LVN 2 entered Resident 1's room, Resident 1's upper body was on the floor, and the lower part of Resident 1's body was on the bed. LVN 2 stated LVN 2 did not call Resident 1's family because Resident 1 did not have a family phone number listed. LVN 2 stated LVN 2 asked Resident 1 for a phone number for a family member to notify them of the fall but the family member did not answer the phone. LVN 2 stated it was important to notify residents' family members to keep families informed of changes that happen to residents. LVN 2 stated if family members were not informed of falls, they would get upset. During an interview on 5/15/2026 at 3:12 p.m. with the Director of Nursing (DON), the DON stated that after a resident (in general) has a fall their representative and/or family must be notified of the fall. The DON stated resident representative and/or family must be notified because a fall was a significant change in condition for a resident and it was an emergency. The DON stated resident representatives and/or family have the right to be informed of any changes with the residents and it was their right to be informed. The DON stated licensed nurses were responsible for notifying resident representatives and/or families of changes in condition and the DON did not know why FM 1 was not notified of Residents 1's fall. The DON stated the night shift nurse should have followed up and attempted to call FM 1, but they did not. The DON stated after DON was informed of Resident 1's fall, the DON should have called FM 1, but the DON did not. The DON stated no one followed up to call Resident 1's family. During a review of facility's Policy and Procedure (P&P) titled Fall Management System, dated 4/2026, the P&P indicated when a resident sustains a fall, the resident representative would be notified of the fall and the resident status.

Based on observation, interview, and record review, the facility failed to implement the care plan to prevent a resident from falling for one of 11 sampled residents (Resident 10).This failure had the potential to increase the risk of serious injury to Resident 10 after a fall.During a review of Resident 10's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 10 was originally admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing); major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and fracture (a partial or complete break in the bone) of unspecified part of neck of left femur (upper part of left thigh bone).During a review of Resident 10's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 10 showed no evidence of acute change in mental status and cognitive pattern (the way a person thinks, learns, remembers, and processes information). The MDS also indicated Resident 10 was dependent (helper does all of the effort to complete the activity) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 10's Change In Condition Evaluation (CIC), dated [DATE], the CIC indicated Resident 10 was found sitting on the floor on the right side of Resident 10's bed and Resident 10's back was against the wall.During a review of Resident 10's Care Plan Report (CPR), initiated on [DATE], the CPR indicated Resident 10's bed should be in the lowest position to minimize the risk of injury.During an observation on [DATE] at 10:40 AM inside Resident 10's room, Resident 10 was lying in bed which was not in the lowest position. Resident 10's bed frame was not lowered close to the floor.During a concurrent observation and interview on [DATE] at 10:05 AM with Certified Nursing Assistant (CNA) 3 inside Resident 10's room, Resident 10's bed was not in the lowest position. CNA 3 stated Resident 10 needed supervision to sit up and lay in bed, and to transfer in and out of bed/wheelchair. CNA 3 stated Resident 10's bed was not in the lowest position but should be kept in the lowest position to reduce the risk of falls.During an interview on [DATE] at 10:18 AM with Resident 10, Resident 10 stated on [DATE] Resident 10 fell as Resident 10 was trying to go back to bed from the wheelchair because Resident 10's wheelchair was too far from the bed. Resident 10 stated when Resident 10 fell on [DATE] Resident 10's bed was not in the lowest position.During an interview on [DATE] at 12:35 PM with the DON (Director of Nursing), DON stated Resident 10 was found on the floor and had been at a high risk of falling. DON stated staff should have supervised Resident 10, Resident 10's bed must be in the lowest position, and call light must be within reach for Resident 10's safety as stated in the facility's P&P.During a review of the facility's policy and procedure (P&P) titled, Fall Management System, dated 4/2025, the P&P indicated The facility provides an environment that remains as free of accident hazards as possible and to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs .

Based on interview and record review, the facility failed to promptly respond to call lights (a device used by a resident to signal his or her need for assistance from staff) and/or promptly respond to a resident's request for toileting assistance for two of four sampled residents (Residents 6 and 11).This failure placed Resident 6 and Resident 11 at risk for a delayed emergency response, accidents, or prolonged incontinence (lack of voluntary control over urination or defecation/bowel movement) and had the potential to result in Resident 6 and Resident 11 feeling like their concerns were unheard and to feel frustrated.a. During a review of Resident 6's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted Resident 6 on 12/12/2025 with diagnoses which included cellulitis (an infection of the skin and deep underlying tissues) of right lower limb, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 6 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 6 required supervision or touch assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff for bathing, lower body dressing, and putting on/taking off footwear. During an interview on 4/22/2026 at 2:15 PM with Resident 6, Resident 6 stated that sometimes Resident 6 waited a long time for facility staff (in general) to answer Resident 6's call light. Resident 6 stated Resident 6 would wait 30 minutes for staff (in general) to answer the call light. Resident 6 stated the weekend was the time it took staff (in general) a long time to answer Resident 6's call light. b. During a review of Resident 11' s FS, the FS indicated Resident 11 was originally admitted to the facility on [DATE] with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) , type 2 diabetes mellitus, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness or impaired movement on one side of the body). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 showed no evidence of acute change in mental status and cognitive pattern (the way a person thinks, learns, remembers, and processes information. The MDS indicated Resident 11 was dependent on staff (helpers do all the effort to complete the activity) for toileting, lower body dressing, and with putting on/taking off footwear. During an interview on 4/22/2026 at 12:55 PM with Resident 11, Resident 11 stated the facility staff's (in general) call light responses were delayed with waiting times of approximately 30 minutes. Resident 11 also stated call light response delays increased during the night, which was frustrating for Resident 11 whenever Resident 11 needed to be cleaned. During an interview on 4/23/2026 at 12:35 PM with the Director of Nursing (DON), DON stated answering the call lights promptly at all times was essential to attending to residents' needs especially when residents were dependent on staff for care. During a review of the facility's policy and procedure (P&P) titled, Dignity and Respect, undated, the P&P indicated, All residents shall be treated with kindness, dignity and respect. The staff shall display respect for residents when speaking with, caring for or talking about them, as constant affirmation of their individuality and dignity as human beings . During a review of the facility's P&P titled, Call Light, with review date of 6/2025, the P&P indicated, Answer the light/bell within a reasonable time.

Based on interview and record review, the facility failed to promptly notify one of three sampled residents' (Resident 8's) doctor of Resident 8's fever and complaint of pain when urinating.This failure had the potential for Resident 8 to not receive timely treatment for Resident 8's pain and fever.(Cross Reference F842)During a review of Resident 8's Face Sheet, (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted Resident 8 on 10/8/2020 and readmitted Resident 8 on 4/1/2026 with diagnoses including pancytopenia (having low levels of red blood cells, white blood cells and platelets), muscle weakness, and acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood).During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 8's cognitive skills (ability to make daily decisions) were intact. The MDS indicated Resident 8 was dependent (helper does all the effort to complete the activity) on staff for toileting hygiene. The MDS indicated Resident 8 required substantial/maximal assistance (helper does more than half the effort to complete the activity) from staff for bathing and lower body dressing. The MDS indicated Resident 8 required partial/moderate (helper does less than half the effort to complete the activity) assistance from staff for upper body dressing and personal hygiene.During an interview on 4/23/2026 at 10:05 AM with Resident 8, Resident 8 stated Resident 8 had a fever the previous evening on 4/22/2206. Resident 8 stated Resident 8 thought Resident 8 presently had another fever. Resident 8 stated Resident 8 felt a burning pain whenever Resident 8 urinated, since the previous evening on 4/22/2026.During an interview on 4/23/2026 at 10:10 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LVN 1 received report from the previous shift nurse (unidentified) that the nurse gave Resident 8 Tylenol (medication used to treat fevers and mild pain) for Resident 8's fever. LVN 1 stated the nurse on the previous shift should have contacted Resident 8's doctor regarding Resident 8's complaint of pain and fever. During a concurrent interview and record review on 4/23/2026 at 10:26 AM with Registered Nurse (RN) 1, Resident 8's elNTERACT Change in Condition Evaluation (CIC), dated 4/22/2026, was reviewed. The CIC indicated Resident 8 had a fever and complained of pain and a burning sensation when urinating on 4/22/2026. The CIC indicated Resident 8's doctor was notified but that the nurses were still waiting for orders from Resident 8's doctor. RN 1 stated the facility staff normally communicated with Resident 8's doctor via text from a facility cell phone. RN 1 stated the facility staff should have called the facility's Medical Director when Resident 8's doctor did not reply with orders to address Resident 8's complaints of pain and a fever. During a concurrent telephone interview and record review on 4/29/2026 at 12:11 PM with LVN 2, Resident 8's CIC, dated 4/22/2026, was reviewed. The CIC indicated Resident 8 had a fever and complained of pain and a burning sensation when urinating on 4/22/2026. The CIC indicated Resident 8's doctor (MD 1) was notified but that the nurses were still waiting for orders from MD 1. LVN 2 stated LVN 2 texted MD 1 around 6:30 pm on 4/22/2026 but did not receive a reply from MD 1. LVN 2 stated LVN 2 texted MD 1 twice during the shift but did not receive a reply from MD 1. LVN 2 stated LVN 2 should have reached out to the Medical Director when LVN 2 could not get ahold of MD 1. LVN 2 stated the CIC was incorrect when LVN 2 documented that LVN 2 notified MD 1of Resident 8's change in condition since MD 1 did not reply to LVN 2's text messages.During a concurrent interview and record review on 4/23/2026 at 2:14 PM with the Director of Nursing (DON), the DON presented a document showing screen shots of the text messages sent to MD 1 on 4/22/2026 regarding Resident 8's changes in condition. The screen shots indicated a text message was sent to MD 1 on 4/22/26 at 7:02 pm and again at 10:28 pm. The screen shot indicated MD 1 did not reply to both messages sent. The DON stated the facility staff should have reached out to the Medical Director when MD 1 did not respond to the text messages. The DON stated the way staff verified if MD 1 was notified of Resident 8's change in condition was if MD 1 replied to the text message. The DON confirmed MD 1 did not respond to the text messages sent on 4/2/2026. The DON confirmed MD 1 was not notified of Resident 8's change in condition on 4/22/2026.During a telephone interview on 4/23/2025 at 3:12 PM with Nurse Practitioner (NP) 1, NP 1 stated NP 1 worked with MD 1. NP 1 stated neither MD 1 nor NP 1 were made aware of Resident 8's fever and pain on 4/22/2026.During a review of the facility's policy and procedure (P&P) titled, Change in Condition, revised 4/2025, the P&P indicated, .There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached.

Based on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Residents 48, 50, and 64) who required supervision while smoking (breathing in smoke from cigarettes [tobacco wrapped in paper]) had an environment free of accident hazards (risk) by failing to:1. Implement the facility's Policy and Procedure (P&P) titled, Smoking Policy, which indicated no lighting materials (e.g. matches, lighters), tobacco products, or smoking devices (e.g. tobacco cigarettes, cigars) will be allowed to be kept in the possession of the residents, either on their person or in the facility. 2. Ensure Residents 48, 50, and 64 were not in possession of smoking materials (cigarettes and lighters). 3. Implement Resident 48, 50 and 64's Care Plans (CPs) interventions to keep Resident 48, 50 and 64's smoking materials at the Nurses' Station and ensure for staff to observe Resident 64 while smoking in designated areas (smoking patio).These deficient practices had the potential for Residents 48, 50, and 64 to turn on their lighters, smoke cigarettes unsupervised inside the facility, cause fire that could affect the health, safety, and wellbeing of all 135 residents in the facility, staff, visitors and result in serious harm, injury, hospitalization and or death.On 7/7/2025 at 5:33 pm, while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The IJ was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility failing to safely secure/store lighters and cigarettes for Residents 48, 50 and 64 to prevent accident hazards such as fire in accordance with the facility's Smoking Policy.On 7/8/2025 at 2:43 pm, the facility submitted an acceptable IJ Removal Plan (IJRP, a detailed plan with interventions to immediately correct the deficient practices in the IJ). While onsite at the facility, the SSA verified and confirmed the facility's implementation of the IJRP through observation, interview, record review, and determined the IJ situation of fire hazard was no longer present. The SSA removed the IJ situation on 7/8/2025 at 6:45 pm in the presence of the ADM and the DON.The facility provided an acceptable IJRP as follows:A. Immediate Corrective Actions:1. On 7/7/2025, lighters and cigarettes were immediately confiscated (removed) by the ADM and the DON from Residents 48, 50 and 64. The confiscated lighters were safely secured in a locked box, located in Station 1 Nurse's Station.2. On 7/7/2025, the ADM met with Residents 48, 50, and 64 to review the facility's smoking policy. During this meeting, it was reinforced that residents (all residents in the facility) were not permitted to keep any lighting materials such as matches or lighters, tobacco products, or smoking devices in their possession or anywhere within the facility. Residents 48, 50, and 64 were reminded that all lighters and smoking paraphernalia (lighters and cigarettes) must be stored in the locked box located at Station 1 Nurse's Station.3. On 7/7/2025, the Assistant Director of Nursing (ADON) immediately completed a change of condition evaluation for Residents 48, 50, and 64. This evaluation assessed any acute injuries or changes in condition of Residents 48, 50 and 64. The ADON also re-educated Residents 48, 50 and 64 regarding the facility's smoking policy and confirmed Residents 48, 50 and 64's understanding of fire safety risks.4. On 7/7/2025, the ADON completed smoking evaluations for Residents 48, 50 and 64. Each resident's care plan was reviewed and updated. These updates reflected the need for increased supervision regarding smoking materials and to ensure adherence to the facility's policy on the proper storage of lighters and other smoking-related items.B. Identification of Other Residents Having the Potential to be Affected:1. All residents in the facility were potentially at risk of being affected.2. On 7/7/2025 at 6 pm, the ADON completed the Smoking Evaluation Assessment of the other four residents (Residents 32, 61, 91 and 123) who smoked cigarettes. These residents did not have the same findings (no lighters or cigarettes were found in Residents 32, 61, 91 and 123's possessions).3. On 7/7/2025, the facility's Department Heads conducted a comprehensive facility wide room rounds for all 135 residents who are residing in the facility. All 135 residents' rooms and bedside areas were thoroughly assessed, and no lighters or smoking materials were found in 135 residents' possessions or stored at the bedside.4. On 7/8/2025, the facility completed the Smoking Assessment Evaluations for all 128 residents, excluding the 7 known smokers (individual who inhales smoke from cigarettes/Residents 32, 48, 50, 61, 64, 91 and 123) who had already been evaluated.5. On 7/8/2025, the facility's Interdisciplinary Team (IDT- group of health care workers who worked together to share information and collaborate the plan of care for the residents) and designees completed rounds to meet with all 135 residents. During these rounds, the facility's smoking policy was discussed with all 135 residents.C. Actions Taken to Prevent Reoccurrence:1. On 7/7/2025 - 7/8/2025, facility's staff received an in-service training from the Clinical Lead Resource regarding the smoking policy.2. Starting 7/7/2025, licensed nurses will monitor/check every shift for smoking paraphernalia at residents' bedsides or their possessions and will be documented in the electronic medication administration record. If smoking paraphernalia is found, the licensed nurses will educate the residents, reinforce the smoking policy and remove the items.3. On 7/7/2025, the Visitor's Log was revised to include acknowledgement and review of the facility's smoking policy with all visitors. The smoking policy will be readily available at the reception desk.4. On 7/7/2025, the Smoking Policy was posted on the consumer board, and the smoking patio code will be updated on a weekly basis.5. Starting 7/8/2025, staff from the Activities Department, Human Resources, Director of Staff Development (DSD) and their designees completed a skills competency assessment to verify facility staff's understanding of the smoking policy. Training emphasized the importance of ensuring that residents who smoke do not possess lighters or any smoking materials outside of supervised use.6. Starting 7/8/2025, every shift. Certified Nursing Assistants (CNAs) will monitor for smoking paraphernalia at residents' bedside or their possessions and report immediately their findings to the Charge Nurse or Registered Nurse (RN) Supervisor for follow up.7. Starting 7/8/25, Department Heads will conduct room rounds three to five times a week for a period of three months to verify that no smoking materials are stored at the residents' bedside or kept in the possession of the residents.8. During the next resident council meetings, the smoking policy will be reviewed, emphasizing safety risks.9. Starting 7/8/2025, for any identified residents who smoke [cigarettes], their care plans will clearly include interventions for monitoring adherence to the smoking policy and proper storage, alongside fire safety education. 10. On 7/8/20255, licensed staff received in-service training by the Clinical Lead resource regarding Out on Pass (Resident has permission to temporarily leave the facility for a short time) Policy and the importance of checking the residents upon the resident's return for any smoking paraphernalia.D. Monitoring to Ensure Ongoing Compliance:1. The DON will insignificantly increase oversight by conducting random room rounds across all shifts, three to five times a week, for the next three months. Any findings or noncompliance issues will be immediately reported to the Quality Assurance (QA, a systematic process focused on ensuring that products or services meet specific requirements and quality standards) Committee for thorough review and development of further recommendations to ensure resident safety and policy compliance.2. The ADM will conduct random unannounced spot checks of all designated smoking areas to verify strict adherence to the facility's smoking policy and safe environment for all. Any findings or noncompliance issues will be immediately reported to the QA,) Committee for thorough review and development of targeted recommendations to maintain policy integrity and resident safety.3. The ADM will regularly report the results of all monitoring activities to the QA Committee. This will include tracking and trending findings from reports and audits to ensure sustained substantial compliance with the facility's policies and standards.Findings: a. During a review of Resident 48’s admission Record (AR), the AR indicated the facility admitted Resident 48 on 3/12/2025 with diagnoses that included anxiety (intense, excessive, and persistent worry and fear about everyday situations), bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, alternating between periods of elevated mood [a state of abnormally elevated mood, energy, and activity] and periods of depression [persistent sadness, loss of interest, and a range of other symptoms that can significantly impair a person's ability to function in everyday life]). During a review of Resident 48’s Smoking Evaluation (SE) dated 6/17/2025, the SE indicated Resident 48 was a smoker. The SE indicated Resident 48 smoked three (3) to four (4) times a day (morning, afternoon, evening and night). The SE indicated for Resident 48’s safety, Resident 48 needed to use adaptive clothing (bibs and aprons are made from flame-retardant materials to prevent burns to clothing and skin)/device/assistance while smoking and required supervised smoking. During a review of Resident 48’s untitled CP, dated 6/17/2025, the CP indicated Resident 48 had a potential for injury related to smoking. The CP interventions included for facility ‘s staff to maintain smoking materials at the nurse’s station or other designated areas and to monitor to assess compliance with the facility’s smoking policy. During a concurrent observation inside Resident 48’s room and interview with Resident 48 and Certified Nurse Assistant 1 (CNA 1) on 7/7/2025 at 11:30 am, Resident 48 was lying in bed. Resident 48’s room was located next to Resident 15. Resident 15 had chronic obstructive pulmonary disease (COPD, lung disease characterized by long-term poor airflow) and was on continuous oxygen use at 2 liters (L, unit of measuring volume of a liquid or gas) via (through) nasal cannula (NC, tube which on one end splits into two prongs which are placed in the nostrils [opening of the nose] to deliver oxygen [colorless/odorless gas]). Resident 48 stated Resident 48 had been smoking for many years. Resident 48 stated Resident 48 kept cigarettes and lighter in Resident 48’s possession. Resident 48 stated Resident 48’s family member brought cigarettes and lighter to Resident 48 during visitation. Resident 48 stated Resident 48 would smoke anytime Resident 48 wanted to smoke. CNA 1 stated CNA 1 did not know Resident 48 had cigarettes and lighter in Resident 48’s possession. During a concurrent observation at Station 1 Nurse’s Station and interview on 7/7/2025 at 11:40 am with Licensed Vocational Nurse 1 (LVN 1), a blue box was seen on the top shelf inside Station 1 Nurse’s Station. The blue box was locked with residents’ smoking materials. LVN 1 stated Resident 48 did not have cigarettes and lighter locked up inside the blue box. During an interview on 7/7/2025 at 11:57 am with the AD, the AD stated Resident 48 was a smoker and Resident 48 needed supervision while smoking. The AD did not know Resident 48 kept cigarettes and lighter in Resident 48’s possession. The AD stated all residents’ cigarettes and lighters should be kept and locked in a box at Station 1 Nurse’s Station for the safety of the residents and prevent potential fire hazard. During an interview on 7/7/2025 at 12:21 pm with the facility’s DON, the DON stated Resident 48 “admitted (confess to be true, typically with reluctance)” that Resident 48 currently had cigarettes and lighter in Resident 48’s possession. The DON stated the DON did not know how Resident 48 had cigarettes and lighter in Resident 48’s possession. The DON stated all residents who smoke were not allowed to keep cigarettes and lighters inside the residents’ room because of fire risks and to ensure the safety of all 135 residents in the facility from fire. During an interview on 7/7/2025 at 12:54 pm with the ADM, the ADM stated the ADM retrieved one (1) functional white lighter and 1 pack of cigarettes (20 sticks) from Resident 48. The ADM stated the ADM did not know Resident 48 had cigarettes and lighter in Resident 48’s possession and did not know how Resident 48 obtained the cigarettes and lighter. The ADM stated that all smokers were not allowed to keep cigarettes and lighters in their possessions inside their rooms to prevent them from lighting the cigarettes up for the safety of all 135 residents in the facility. b. During a review of Resident 50’s AR, the AR indicated the facility admitted Resident 50 on 2/9/2023 and readmitted on [DATE] with diagnoses that included heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs) and a pacemaker (a medical device that helps the heartbeat regularly). During a review of Resident 50’s untitled CP, revised 4/25/2025, the CP indicated Resident 50 had the potential for injury related to smoking. The CP interventions included explaining the smoking policy to Resident 50, maintaining smoking materials at the nurses’ station, and monitoring Resident 50 to assess compliance with the facility’s smoking policy and individual plan. The CP goal indicated for Resident 50 to be compliant with smoking protocols, individual smoking plan, and follow the smoking policy. During a review of Resident 50’s SE dated 5/15/2025, the SE indicated, for Resident 50’s safety, Resident 50 needed to use adaptive clothing/device/ assistance while smoking and required supervised smoking. During an interview on 7/7/2025 at 12:13 pm with Resident 50, Resident 50 stated Resident 50 kept Resident 50’s cigarettes and lighter in Resident 50’s possession and smoked in the patio. Resident 50 shouted and refused to answer how long Resident 50 had cigarettes and lighter in Resident 50’s possession. During an interview on 7/7/2025 at 12:58 pm with the facility’s DON, the DON stated the DON was not aware Resident 50 had kept Resident 50’s cigarettes and lighter at Resident 50’s bedside. The DON stated Resident 50 could only smoke with supervision and no residents were allowed to keep cigarettes in their possession according to the facility’s policy on smoking. The DON stated all cigarettes and lighters needed to be kept locked at Station 1 Nurse’s Station. The DON stated residents who smoke (Residents 32, 48, 50, 61, 64, 91 and 123) were not allowed to keep lighters at their bedside for safety. The DON stated, due to oxygen being flammable (easily catch fire), there was a potential risk the whole facility could catch fire when smokers had lighters and cigarettes in their possession. During a concurrent observation in the hallway and interview on 7/7/2025 at 1:25 pm with the ADM, one box of cigarettes and one yellow lighter were in a clear bag with Resident 50’s name on the bag. The ADM stated the items were taken from Resident 50 on 7/7/2025 and the lighter in Resident 50’s possession was functioning (working). c. During a review of Resident 64’s AR, the AR indicated the facility admitted Resident 64 on 5/9/2022 and readmitted on [DATE], with diagnoses that included anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear) and palliative care (specialized medical care for people living with a serious illness focused on providing relief from the symptoms of the illness). During a review of Resident 64 untitled CP revised 2/21/2025, the CP indicated Resident 64 had the potential for injury related to smoking. The CP goal indicated for Resident 64 to be compliant with the facility’s smoking protocol and individual smoking plan. The CP interventions included maintaining Resident 64’s smoking materials at the nurse’s station or other designated area and monitoring Resident 64 to assess compliance with facility smoking policy/individual plan. The CP interventions also indicated for staff to observe Resident 64 while smoking in designated areas. During a review of Resident 64’s SE dated 2/21/2025, the SE indicated Resident 64 smoked 4 to 5 times per day. The SE indicated for Resident 64’s safety, Resident 64 needed to use adaptive clothing/devices/assistance while smoking and required supervised smoking. During a review of Resident 64’s Minimum Date Set (MDS, a resident assessment tool) dated 5/21/2025, the MDS indicated Resident 64 had short term memory (memory that helps you remember for a short time) problem. During a review of Resident 64’s Interdisciplinary Team (IDT) Brief Interview for Mental Status (BIMS, a screening tool used to assess cognitive function, particularly in long-term care settings) assessment dated [DATE], the IDT BIMS Assessment indicated Resident 64 had severely impaired cognition status (ability to think and process information). During an interview on 7/7/2025 at 12:15 pm with Resident 64, Resident 64 stated Resident 64 had a lighter and cigarettes inside Resident 64’s pocket. During an interview on 7/7/2025 at 12:16 pm with the AD, the AD stated Resident 64 should not have lighters because it would not be safe for Resident 64 to smoke inside Resident 64’s rooms due to fire hazard. The AD stated the only location for smoking would be the facility’s smoking patio. The AD stated no residents could keep cigarettes and lighters at the bedside. During an interview on 7/7/2025 at 1:23 pm with the ADM, the ADM stated there were 40 sticks of cigarettes and a blue lighter retrieved by the ADM from Resident 64’s pocket. The ADM stated Resident 64 could have bought the cigarettes when Resident 64 went out on pass. During an interview on 7/7/2025 at 1:29 pm with Resident 64, Resident 64 stated Resident 64 found the lighter last night (7/6/2025) inside the pocket of Resident 64’s jacket. Resident 64 stated Resident 64 bought the cigarettes when Resident 64 went outside of the facility during an out on pass. During an interview on 7/7/2025 at 2:23 pm, CNA 7 stated Resident 64 was independent and would go anytime to the smoking patio because Resident 64 had access to the pin code (a passcode used in the process of authenticating a user accessing a system or a door) to the smoking patio. CNA 7 stated Resident 64 would go to the smoking patio even if it was not the scheduled smoking time because Resident 64 had access to the pin code to the smoking patio. CNA 7 stated, if Resident 64 would come and go to the smoking patio anytime, facility staff (in general) would not be able to monitor Resident 64 while smoking. During an interview on 7/7/2025 at 5:15 pm, with the facility’s DON and ADM, the DON and ADM stated Resident 64 needed to be monitored and supervised when smoking. During an interview on 7/8/2025 at 4:00 pm, with the ADON, the ADON stated only a designated person (assigned staff) should know the access pin code to the smoking patio to ensure residents who smoke would be supervised when smoking. The ADON stated the residents who smoke should not have the access pin code to the smoking patio. During a review of the facility’s P&P titled, “Smoking Policy,” revised 4/2024, the P&P indicated, “Designated smoking areas outside the building are available for this purpose based on the facility smoking schedule with assigned staff to supervise. No lighting materials (e.g. matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the residents, either on their person or in the facility. If it is determined that a resident is a safe smoker (someone who smokes in a way that reduces risk to others) all smoking materials will still be retained by nursing staff.”

Based on interview and record review, the facility failed to implement its policies and procedures (P&P) titled, IV (an intravenous [within a vein] line is a soft, flexible tube placed inside a vein, usually in the hand or arm) Administration (send directly into the vein), and Central Venous (a thin, flexible tube that is inserted into a vein, usually below the right collarbone [a bone at the base of the front of the neck] and Midline Catheter (a catheter inserted in the upper arm with the tip located just below the axilla [armpit]) Care, and follow the manufacturer's instructions for care of the central venous catheter (CVC - an indwelling device inserted into a large, central vein to administer fluid, medication, and/or treatment) for one of one sampled resident (Resident 1) by failing to: 1. Ensure Registered Nurse Supervisor (RNS) 3 flushed (method of clearing intravenous [IV- into or within a vein] line) Resident 1's permanent catheter (Permacath- a type of CVC used for short-term or long-term hemodialysis [a treatment to filter wastes and water from the blood, as the kidneys did when the kidneys were healthy]) with saline (a solution of salt in water) after the completion of the IV infusion (a method of putting fluids into the bloodstream) and documented the procedure in Resident 1's clinical record (chart). 2. Ensure RNS 3 clamped (to hold or press tightly together with a securing device) and capped (covered or closed with a cap) Resident 1's Permacath when the Permacath was not in use. As a result, on 5/10/2024 at 12:45 AM, Resident 1 experienced massive (very large) bleeding from Resident 1's Permacath. Resident 1 was transferred and admitted to the General Acute Care Hospital (GACH) 1's Intensive Care Unit (ICU- unit in hospital providing intensive care for critically ill or injured residents/patients) on 5/10/2024 at 1:14 AM for further evaluation and treatment. Cross Reference F842 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility originally admitted Resident 1 on 4/25/2024, and readmitted Resident 1 on 5/7/2024, with diagnoses that included type 2 diabetes mellitus (a condition in which the body had trouble controlling blood sugar and using it for energy), anxiety disorder (involved persistent and excessive worry that interfered with daily activities), end stage renal disease (ESRD- a medical condition in which a person's kidney ceased functioning on a permanent basis), and dependence on renal (kidney) hemodialysis treatment. During a review of Resident 1's History and Physical (H&P) dated 4/28/2024, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Physician Order (PO) dated 5/4/2024, the PO indicated, Resident 1 had an order for heparin sodium injection solution (medication used to thin the blood and prevent blood clots) 5000 unit per milliliter (unit/ml- unit of measurement), inject 5000 unit/ml subcutaneously (beneath the skin) every 12 hours for deep vein thrombosis (DVT- blood clot in a deep vein, usually in the legs) prophylaxis (prevention). During a review of Resident 1's PO dated 5/7/2024, the PO indicated, Resident 1 had an order to inspect Resident 1's dialysis site/Permacath to Resident 1's right upper chest for color, warmth, redness, edema (swelling), and/or bleeding every shift and to contact Resident 1's Primary Physician/Medical Doctor 1 (MD 1) if present. During a review of Resident 1's Untitled Care Plan (CP) dated 5/8/2024, the CP indicated, Resident 1 needed hemodialysis related to ESRD. The CP interventions included for staff to monitor, document, and report to MD 1 as needed for any signs and symptoms (s/sx) of infection to access site (Permacath) such as redness, swelling, warmth or drainage, and any s/sx of bleeding. During a review of Resident 1's Nurse's Dialysis Communication Record (NDCR) dated 5/9/2024, timed at 8:20 AM, the NDCR indicated, Resident 1 left the facility for Resident 1's dialysis treatment (on 5/9/2024) at 8:20 AM and returned to the facility (on 5/9/2024) at 12:30 PM. The NDCR indicated, Resident 1 had a CVC (Permacath) to Resident 1's right chest. The NDCR dated 5/9/2024 indicated there was no documentation the facility staff (assigned staff) assessed Resident 1's CVC site for redness, swelling, drainage, and/or bleeding as required on the NDCR. During a review of Resident 1's PO dated 5/9/2024, the PO indicated, Resident 1 had an order to administer Dextrose (a form of glucose [sugar]) IV solution 10 percent (%- unit of proportion) at 100 milliliters per hour (ml/hr- unit of measurement) due to hypoglycemia (low blood sugar) and Resident 1's inability to swallow. During a review of Resident 1's PO dated 5/9/2024, the PO indicated, Resident 1 had an order that staff may use Resident 1's Permacath for intravenous administration of medication. During a review of Resident 1's IV Medication Administration Record (IVMAR) dated 5/9/2024, the IVMAR indicated on 5/9/2024, at 3 PM, RNS 2 started to administer Dextrose IV solution 10% at 100 ml/hr intravenously for Resident 1. During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 5/10/2024, the MDS indicated Resident 1 had intact cognition (ability to think and process information). The MDS indicated Resident 1 required setup or clean-up assistance (helper assisted only prior to or following the activity) for eating and oral hygiene. The MDS indicated Resident 1 depended (helper provided all the effort or the assistance of two or more helpers was required for the resident to complete the activity) on staff for toileting hygiene, showering/bathing, lower body dressing, rolling left and right, and toilet transfer. During a review of Resident 1's Paramedic (a person trained to give emergency medical care to people who were injured or ill) Report (PR) dated 5/10/2024, timed at 12:25 AM, the PR indicated, paramedics arrived at the facility on 5/10/2024 at 12:29 AM, and at Resident 1's bedside at 12:30 AM for complaint of Resident 1 bleeding. The PR indicated, the paramedics found Resident 1 in bed bleeding from Resident 1's dialysis port (extension tubing that made it easier to access the vein through the Permacath). The PR indicated, facility staff (Licensed Vocational Nurse [LVN] 3) had Resident 1's bleeding controlled with direct pressure and a towel. The PR indicated, facility staff (RNS 1) clamped (closed/fastened) Resident 1's (Permacath) port on Resident 1's right chest near the exit site of Resident 1's Permacath. The PR indicated, Resident 1's bleeding was controlled and Resident 1's vital signs (measurements of the body's most basic functions) were stabilized (to maintain at a given or unfluctuating level or quantity). The PR indicated, Resident 1 was transferred to GACH 1. During a review of Resident 1's Progress Notes (PN) dated 5/10/2024, the PN indicated, (on 5/10/2024) at 12:30 AM, LVN 3 noted massive bleeding from Resident 1's Permacath dialysis site possibly from ruptured (burst/leaked) catheter and missing locks (a device designed to bind or constrict or to press two or more parts together so as to hold them firmly). The PN indicated, staff (LVN 3) applied pressure and ice pack on the (catheter's) site. The PN indicated, Resident 1's oxygen saturation (O2 sat- a measure of how much oxygen is in the blood) was decreasing. The PN indicated, RNS 1 increased Resident 1's supplemental oxygen to 10 to 15 liters per minute (L/min- unit of flow rate) via non-rebreather mask (a device that gives oxygen, usually in an emergency). The PN indicated, staff (CNA 1) called 911 and the paramedics arrived after five to seven minutes and took Resident 1 to GACH 1 on 5/10/2024, at 12:45 AM. During a review of Resident 1's Change in Condition Evaluation (CICE) dated 5/10/2024, timed at 12:45 AM, the CICE indicated, on 5/10/2024, untimed, LVN 3 noticed that Resident 1 was acting slightly abnormal. The CICE indicated, Resident 1's room light was off, and LVN 3 noticed a dark colored spot near Resident 1's right side. The CICE indicated, LVN 3 turned on Resident 1's room light and saw a large amount of blood (location not indicated). The CICE indicated, LVN 3 called Certified Nursing Assistant (CNA) 1 and CNA 1 called 911 (a phone number used to contact the emergency services). The CICE indicated, LVN 3 applied pressure (location not indicated) to stop the bleeding. The CICE indicated, LVN 3 notified MD 1 on 5/10/2024 at 1:18 AM. During a review of Resident 1's GACH 1 Emergency Department Provider Note (EDPN) dated 5/10/2024, timed at 1:14 AM, the EDPN indicated, the ambulance brought in Resident 1 from the facility for bleeding from Resident 1's right chest wall dialysis catheter. The EDPN indicated, per the paramedics, Resident 1 was found in a pool of blood, blood-soaked sheets, with approximately 300 ml of blood on the floor. The EDPN indicated, per the paramedics, it was unclear how long or how Resident 1's Permacath opened. The EDPN indicated, upon Resident 1's arrival to GACH 1 ED, Resident 1 appeared pale, altered, anxious, and hypotensive (having low blood pressure [BP, the pressure of circulating blood against the walls of blood vessels]) with BP of 84/67 millimeters of mercury (mmHg) (Normal BP= 120/80 mm/hg). The EDPN indicated, while in GACH 1 ED, Resident 1 received one (1) unit of packed red blood cells (PRBC- blood transfusions used to improve blood oxygen [the amount of oxygen you have circulating in your blood] carrying capacity and restore blood volume). The EDPN indicated, Resident 1 would be admitted to GACH 1's ICU for further evaluation and treatment. During a review of Resident 1's GACH 1 Renal Consultation Note (RCN) dated 5/10/2024, timed at 7:29 PM, the RCN indicated, Resident 1 presented to GACH 1 with significant (serious/notable) bleeding from Resident 1's Permacath site. The RCN indicated, apparently the clamp (a device designed to constrict and press two or more parts together to hold them firmly) was opened, and the cap (cover) was not on the catheter. During an interview on 5/17/2024 at 7 AM with RNS 1, RNS 1 stated at approximately 12:30 AM on 5/10/2024, Licensed Vocational Nurse (LVN) 3 paged RNS 1 to come to Resident 1's room. RNS 1 stated when RNS 1 entered Resident 1's room, RNS 1 observed LVN 3's hands applying pressure on Resident 1's right upper chest where Resident 1's Permacath was located. RNS 1 inspected Resident 1's Permacath and noticed that blood was coming out from the two (2) extension tubing ports (a form of tubing used to add length to an existing infusion tubing) of Resident 1's Permacath. RNS 1 stated RNS 1 manually clamped the tubing above the 2 ports of Resident 1's Permacath and continued to apply pressure on Resident 1's right upper chest. RNS 1 stated RNS 1 observed the clamps and caps were missing from the 2 ports of Resident 1's Permacath. RNS 1 stated RNS 1 asked LVN 3 to get an ice pack and get a clamp from the dialysis kit (a kit with medical supplies and dialysis equipment) at Resident 1's bedside. RNS 1 stated RNS 1 clamped Resident 1's Permacath tubing above the 2 ports of the Permacath. RNS 1 stated the paramedics came within a few minutes and took Resident 1 to the hospital (GACH 1). RNS 1 stated RNS 1 did not see any caps or clamps on Resident 1's bed and RNS 1 did not know why the caps and clamps were missing from Resident 1's Permacath tubing. RNS 1 stated RNS 1 received training for care of Permacath/CVC in October of 2023. RNS 1 stated Resident 1's Permacath needed to be clamped and capped always when it (the Permcath) was not in use to prevent blood from flowing out of the ports. RNS 1 stated when Resident 1's Permacath was unclamped or uncapped, Resident 1 could be at risk for bleeding from the Permacath ports which could lead to complications such as blood loss and shock (a life-threatening condition that occurred when the body was not getting enough blood flow). During an interview on 5/17/2024 at 9:05 AM with RNS 2, RNS 2 stated on 5/9/2024 at around 2:30 PM, Resident 1 had low blood sugar. RNS 2 stated LVN 4 notified MD 1 and MD 1 ordered to give Dextrose 10 intravenous solution to Resident 1. RNS 2 stated RNS 2 was unable to insert a peripheral (away from the center) IV line on Resident 1. RNS 2 stated LVN 4 notified MD 1 of Resident 1's poor IV access and MD 1 ordered to use Resident 1's Permacath. RNS 2 stated RNS 2 started the Dextrose 10 IV infusion via Resident 1's Permacath (on 5/9/2024) at approximately 3 PM and endorsed (hand over or report) the IV infusion to RNS 3 (on 5/9/2024) at approximately 3:40 PM. During an interview on 5/17/2024 at 9:43 AM with RNS 3, RNS 3 stated RNS 3 received report from RNS 2 on 5/9/2024 (unable to recall time) that Resident 1 was receiving IV fluids via Resident 1's Permacath. RNS 3 stated the IV infusion was completed (on 5/9/2024) at 11:30 PM so RNS 3 disconnected the IV tubing from Resident 1's Permacath and flushed Resident 1's Permacath with 10 ml of saline. RNS 3 stated RNS 3 clamped Resident 1's Permacath extension tubing and capped the ports of Resident 1's Permacath. During an interview on 5/17/2024 at 11:25 AM with LVN 3, LVN 3 stated (on 5/10/2024) at approximately 12:25 AM, LVN 3 was at Resident 1's room door when LVN 3 saw Resident 1's hands on the headboard of Resident 1's bed. LVN 3 stated LVN 3 noticed a dark spot on the right side of Resident 1's gown while Resident 1's room light was off. LVN 3 stated LVN 3 immediately went inside Resident 1's room, turned on the light, and observed a big spot of blood on the right side of Resident 1's body. LVN 3 stated LVN 3 lifted Resident 1's blanket, bedsheet, and gown to see where the blood was coming from. LVN 3 stated Resident 1's Permacath dressing was covered with blood. LVN 3 stated LVN 3 observed drops of blood slowly dripping out from Resident 1's Permacath ports. LVN 3 stated LVN 3 did not see the caps at the end of Resident 1's Permacath extension tubings. LVN 3 stated LVN 3 immediately applied pressure on Resident 1's right chest and yelled out for help. LVN 3 stated CNA 1 came and LVN 3 instructed CNA 1 to call 911. LVN 3 stated RNS 1 came inside Resident 1's room and immediately requested for a bag of ice from another staff (LVN 2) to put on Resident 1's Permacath site. LVN 3 stated RNS 1 continued to apply pressure on Resident 1's Permacath site using RNS 1's hands. LVN 3 stated RNS 1 instructed LVN 3 to get a clamp from the dialysis kit. LVN 3 stated RNS 1 clamped the 2 tubes above the 2 ports of Resident 1's Permacath then the bleeding stopped. LVN 3 stated the paramedics came within a few minutes, assessed Resident 1, and told LVN 3 that Resident 1's Permacath was still intact (unbroken/undamaged). LVN 3 stated the paramedics took Resident 1 to GACH 1. During a follow-up interview on 5/17/2024 at 2:43 PM with RNS 3, RNS 3 stated (on 5/9/2024, unable to recall time) RNS 3 flushed Resident 1's Permacath with saline and clamped Resident 1's Permacath tubing after the IV infusion completed but did not document it. During an interview on 5/17/2024 at 4:07 PM with the Director of Nursing (DON), the DON stated licensed nurses (LVNs and RNs) must inspect and monitor the CVC/Permacath site for signs of redness, swelling, bleeding, pain, or any changes in condition. The DON stated it was important to clamp and cap the Resident 1's CVC/Permacath when it was not in use to prevent bleeding which could cause complications such as hypotension, blood loss, shock, or even death. During a review of Resident 1's GACH 1 Discharge Summary (DS) dated 5/18/2024, timed at 9:03 AM, the DS indicated, Resident 1 was admitted with hypotension (low blood pressure) and anemia (low red blood cells [a type of blood cell that delivered oxygen to the tissues in the body]). The DS indicated, Resident 1 had bleeding from Resident 1's Permacath and received blood transfusion and medication change while in GACH 1. During a review of the facility's P&P titled, IV Administration, revised in 1/2024, the P&P indicated, all central lines were capped or had an extension set applied. The P&P indicated; a closed system (a natural physical system that does not allow transfer of matter in or out of the system) was utilized on all continuous central vascular access lines. During a review of the facility P&P titled, Central Venous and Midline Catheter Care, revised in 1/2024, the P&P indicated, once the administration or infusion was complete, lock the catheter using saline. The P&P indicated, if the catheter was not in use, ensure it remained patent by locking it with saline every 24 hours. The P&P indicated, document date and time of procedure, individual's response to the procedure, signature, and credentials. The P&P indicated, if flushing a CVC, add amount of saline used. During a review of Resident 1's Permacath Patient Information Packet (PPIP- manufacturer's instructions for care), undated, the PPIP indicated, extension clamps should only be open for aspiration (to draw in or out using a sucking motion), flushing, and dialysis treatment. The PPIP indicated, to prevent accidents, assure the security of all caps and bloodline connector prior to and between treatments. The PPIP indicated, never remove the cap at the end of the catheter. The PPIP indicated, cap and clamps of the catheter must be kept closed when not being used for dialysis.

Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan to prevent a fall (unintentionally coming to rest on the ground) for one of two sampled residents (Resident 1), who was assessed as high risk for fall and had a history of falls, by failing to: Develop and implement a plan of care to address Resident 1's behavior of turning off the bed pad alarm (a device with a sensor and monitor to alert staff when a resident attempts to leave the bed), in accordance with the facility's Policy and Procedure titled Comprehensive Resident Centered Care Plan and Fall Management System. This deficient practice resulted in Resident 1's fall on 4/27/2023 at 4:45 am and Resident 1 sustained a right hip fracture (break in the bone). On 4/27/2023 at 7:05 pm, the facility transferred Resident 1 to General Acute Care Hospital 1 (GACH 1) for medical management due to Resident 1's right hip fracture. Cross Reference: F689 Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility admitted Resident 1 on 5/6/2022, with diagnoses including cerebral infarction (stroke, sudden death of brain cells in a localized area due to inadequate blood flow), and generalized muscle weakness. During a review of Resident 1's Physician's Order, dated 10/3/2022, the Physician's Order indicated for staff (in general) to apply a pad alarm when in bed to alert staff if getting out of bed unassisted, due to poor safety awareness. During a review of Resident 1's Fall Risk Assessment, dated 11/10/2022, the Fall Risk Assessment indicated, Resident 1 was assessed as high risk for falls due to intermittent confusion, history of fall on 10/3/2022, and required assistance with bowel/bladder elimination (toileting). During a review of Resident 1's Facility Incident Report, dated 11/19/2022, and timed at 8:25 am, the Facility Incident Report indicated, on 11/19/2022 at 6:40 am, Licensed Vocational Nurse 2 (LVN 2) found Resident 1 lying on the floor on Resident 1's right side, at the end of Resident 1's bed, facing the closet. The report indicated, Resident 1 stated Resident 1 tried to go to the bathroom and lost his balance. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/15/2023, the MDS indicated, Resident 1 had severely impaired cognition (unable to think and process information). The MDS indicated, Resident 1 required extensive assistance (resident involved in activity while staff provide weight bearing support) with one-person physical assistance for bed mobility (how resident moves to and from lying position, turns to side and positions body while in bed), transfers (how resident moves between surfaces including to and from bed, chair, and wheelchair), toilet use, and personal hygiene. The MDS indicated, Resident 1 required the use of walker and wheelchair for ambulation (walking). During a review of Resident 1's Care Plan titled, Resident at Risk for Fall or Injury due to Generalized Weakness, initiated on 2/15/2023, the care plan indicated interventions including for nursing staff to apply a pad alarm in bed and to check for placement of the bed pad alarm for proper functioning every shift. During a review of Resident 1's Progress Notes, dated 4/27/2023, at 4:45 am, the notes indicated, LVN 1 saw Resident 1 lying on the floor next to Resident 1's bed. LVN 1 reported the incident to Registered Nurse Supervisor 2 (RN2) and RNS 2 assessed Resident 1. The notes indicated Resident 1 stated he turned off the bed pad alarm because he (Resident 1) did not want to hear the noise from the bed pad alarm while getting up to get his wheelchair. During a review of Resident 1's Progress Notes, dated 4/27/2023 at 10:29 am, the notes indicated, LVN 3 notified Resident 1's Medical Doctor 1 (MD 1) regarding Resident 1's complaint of uncontrolled pain (unrated). During a review of Resident 1's Progress Notes, dated 4/27/2023, at 4:21 pm, the notes indicated, LVN 3 observed Resident 1 guarding (protecting) Resident 1's right hip and Resident 1 complained of 10 out of 10 (10/10) pain (a pain scale from 0 to 10; 10 being the worst pain and 0 for no pain) on the right hip. The notes indicated LVN 3 called MD 1 and MD 1 ordered STAT (immediate) X-rays (digital image of an internal part of the body) of the right hip and right knee. During a review of Resident 1's X-ray result of the right hip, dated 4/27/2023, the X-ray result indicated, Resident 1 had a displaced (not aligned) subcapital (fracture occur in the neck of the thighbone) fracture of the right femoral (relating to the thigh bone) neck and the shaft (part of the long bone) of the femur (thigh bone) was displaced laterally (sideways). During a review of Resident 1's Physician's Order, dated 4/27/2023, and timed at 4:59 pm, the Physician's Order indicated, to transfer Resident 1 to GACH 1 due to right hip fracture. During a review of Resident 1's GACH 1's Orthopedic (medical specialty focuses on treating injuries/deformities of the bones or muscles) Consultation Notes, dated 4/27/2023, at 11:14 pm, the notes indicated, MD 2 discussed with the medical team and considered a surgical plan for Resident 1's right hemiarthroplasty (surgical procedure that involves replacing part of the hip). During a review of Resident 1's GACH 1's Computed Tomography (CT- detailed internal images of the body) Scan without contrast (a dye, substance to add color that helped show abnormal areas inside the body) of the pelvis (lower part of the trunk between abdomen and thighs) result, dated 4/27/2023, at 11:35 pm, the CT result indicated, Resident 1 had an acute displaced angulated (end of bone fragments are at an angle of each other) subcapital fracture of the right femoral neck. During an interview on 5/5/2023, at 1:30 pm, with the facility's Director of Nursing (DON), the DON stated, Resident 1 had an order for bed alarm and the alarm needed to be turned on and kept in place for Resident 1's safety. During an interview on 5/5/2023, at 2:01 pm, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated, Resident 1 was alert and had a history of turning off Resident 1's bed pad alarm from time to time (unspecified dates). CNA 2 stated, this was not a new behavior for Resident 1. CNA 2 stated, she would turn on Resident 1's bed pad alarm, each time she observed Resident 1 turned off the bed pad alarm. During an interview on 5/5/2023, at 2:18 pm, with RNS 1, RNS 1 stated, she worked at the facility once a week as a part time employee. RNS 1 stated, she was aware Resident 1 had a history of disabling the alarm by removing the cord from the bed pad alarm. During an interview on 5/5/2023, at 2:33 pm, with the facility's DON, the DON stated, prior to Resident 1's fall on 4/27/2023, there was one incident (unspecified date) she (DON) saw Resident 1 turned off Resident 1's bed pad alarm. The DON stated, she did not develop a care plan to address Resident 1's behavior of turning off the bed pad alarm. During an interview on 5/5/2023, at 2:43 pm, with LVN 1, LVN 1 stated, on 4/27/2023 at approximately 2 am, she observed Resident 1 held the bed pad alarm on Resident 1's right hand. LVN 1 stated, she took the bed pad alarm away from Resident 1 and instructed Resident 1 not to touch the bed pad alarm. LVN 1 stated, on 4/27/2023 at 4:45 am, she found Resident 1 lying on the floor. During an interview on 5/5/2023, at 3:23 pm, with the facility's DON and a concurrent review of Resident 1's care plans for fall, the DON stated, there was no care plan developed and implemented to address Resident 1's behavior of turning off or removing Resident 1's bed pad alarm. The DON stated, the facility did not have a policy on Bed Pad Alarm. During a phone interview on 5/9/2023, at 7:43 am, with RNS 2, RNS 2 stated, Resident 1 had an order for the bed pad alarm due to Resident 1 had a history of getting out of bed without calling for assistance. RNS 2 stated on 4/27/2023, before 4:45 am (unspecified time), LVN 1 reported to her (RNS 2) Resident 1 turned off Resident 1's bed pad alarm around 2 to 3 am. RNS 2 did not answer when the surveyor asked what were RNS 2's interventions/instructions when LVN 1 reported to her (RNS 2) that Resident 1 turned off Resident 1's bed pad alarm. RNS 2 stated, she was aware Resident 1 always turn the alarm off. During an interview on 5/10/2023, at 6:04 am, with CNA 1, CNA 1 stated, on 4/26/2023 at around 11 pm, she saw Resident 1 lying on Resident 1's bed, and the bed pad alarm was off. CNA 1 stated, she (CNA 1) changed Resident 1's adult brief (disposable underwear), then turned Resident 1's bed pad alarm back on. CNA 1 stated, on 4/27/2023 at around 4:45 am, LVN 1 informed her (CNA 1) Resident 1 was lying on the floor in Resident 1's room. CNA 1 stated, she ran to Resident 1's room and saw Resident 1's bed pad alarm was off. CNA 1 stated, Resident 1 told CNA 1 Resident 1 got up from the bed and Resident 1 turned off his bed pad alarm because the pad alarm would make too much noise. CNA 1 stated, Resident 1 had a history of turning off the bed pad alarm from time to time (unspecified dates). During an interview on 5/16/2023, at 3:16 pm, with the DON, the DON, stated there were no care plans developed nor Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their patients) meeting conducted to address Resident 1's behavior of turning off Resident 1's bed pad alarm. The DON stated Resident 1's behavior of turning off the bed pad alarm needed to be communicated so the issue can be addressed by the IDT. During a review of the facility's Policy and Procedure titled, Fall Management System, dated 6/2021, indicated, Residents with high risk factors identified on the Fall Risk Evaluations will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing risk factors and will consider the particular elements of the evaluation that put the resident at risk. Interventions for fall prevention may include but not limited to sensor pads/alarms, low bed, floor mat, toileting program, etc. During a review of the facility's Policy and Procedure titled, Comprehensive Resident Centered Care Plan, revised 2/2023, indicated, The care plan is developed by the IDT which may include, but is not limited to the following professionals: Attending Physician, Registered Nurse responsible for the resident, Nursing Assistants responsible for resident care and others as necessary.

Based on observation, interview and record review, the facility failed to notify the physician for one of two sampled residents (Resident 1) who had a change in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), that started on 6/17/2022. On 6/17/2022, Resident 1 complained of right hip pain. The facility's nursing staff did not inform Resident 1's attending physician (Physician 1) of Resident 1's pain until 6/20/2022 (three days later) at 10:39 am. Resident 1's X-ray (a test that produces images of the body structures) of the right hip result dated 6/21/2022, indicated a right hip fracture (broken bone). Resident 1 remained in the facility until 6/29/2022 when the resident was transferred to an Orthopedic (medical provider who specializes in disorders of the bones) Surgeon ' s (Physician 2 ' s) office for an orthopedic consultation. As a result, Resident 1 did not receive a medical evaluation and or treatment on 6/17/2022 regarding the resident ' s right hip pain. On 6/29/2022, Physician 2 called 911 (emergency services) and transferred Resident 1 to a General Acute Care Hospital 1 (GACH 1). Resident 1 was admitted to GACH 1 and underwent an open reduction internal fixation (ORIF, surgery to fix severely broken bone) of his right hip on 7/2/2022. Cross reference F684 Findings: A review of Resident 1 ' s Admission Record indicated the resident was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s untitled Care Plan, dated 4/14/2022, indicated the resident was at risk for pain and the nursing interventions were to assess the resident ' s pain level, document and notify the resident ' s physician of increasing and/or unrelieved pain. A review of Resident 1's History and Physical dated 4/16/2022, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/20/2022, indicated Resident 1 was sometimes able to make his needs known and had severely impaired cognition (ability to make decisions). The MDS indicated Resident 1 required extensive to total assistance with activities of daily living (ADL). A review of Resident 1's Occupational Therapy (OT, a form of therapy that encourages rehabilitation through the performance of activities required in daily life) Treatment Encounter Note, dated 6/17/2022, untimed, indicated Resident 1 complained of constant right hip pain with movement to right lower extremity. The note indicated Occupational Therapist 1 (OT 1) recommended a right hip X-ray and notified the charge nurse (unidentified). A review of Resident 1's Physical Therapy (PT, form of therapy that uses exercises and physical activities to help condition muscles and restore strength and movement) Discharge Summary dated 6/23/2022, indicated Resident 1 refused therapy on 6/17/2022 due to right hip pain. The discharge summary indicated Physical Therapist 1 (PT 1) communicated to the nursing staff (unidentified) regarding the change in Resident 1's condition and recommended an X-ray. The discharge summary indicated to discontinue therapy until X-ray results and Physician 1's order. A review of Resident 1's late entry Progress Note dated 6/20/2022, timed at 9:05 am, indicated the Director of Rehabilitation (DOR) reported to the nursing staff (unidentified) about Resident 1's right hip pain. The DOR indicated in the notes per nursing staff (unidentified), still waiting for Physician 1's instructions and order. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR) Communication Form dated 6/20/2022, timed at 10:35 am, indicated Resident 1 was noted with increased weakness and generalized body pain. The SBAR documentation indicated Resident 1 verbalized that his pain was 3 out of 10 (a pain scale wherein 0 means no pain and 10 means worst pain possible). Resident 1 had no redness, swelling, or discoloration. The SBAR documentation indicated Physician 1 was notified on 6/20/2022 at 10:39 am and Physician 1 ordered blood tests. The SBAR indicated the x-ray was requested/suggested. A review of Resident 1's X-ray of the right hip result dated 6/21/2022, indicated the resident had a fracture of the intertrochanteric (bony protrusions on the femur or thighbone) portion of the right hip with [CONDITION(S)] (a condition in which bones become weak and brittle). A review of Resident 1's Progress Note dated 6/21/2022, timed at 11:58 am, indicated Resident 1's X-ray result was reported to Physician 1. The note indicated Physician 1 gave new orders. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. May have orthopedic consult for fracture of the right hip with [CONDITION(S)]. 2. Hold PT and OT services until orthopedic consult. 3. Non-weight bearing (no weight can be placed) to right lower extremity until orthopedic consult. 4. Start [MEDICATION(S)] (medication used to prevent and treat certain types of bone loss) 70 milligrams (mg, unit of measurement), give one tablet by mouth in the morning every Saturday for [CONDITION(S)]. A review of Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Progress Note dated 6/29/2022, timed at 3:47 pm, indicated Physician 2's staff (unidentified) informed the facility ' s staff (unidentified) Resident 1 would be transferred to GACH 1 for evaluation of right hip fracture. The note indicated Physician 1 was aware. A review of Resident 1's Emergency Department (ED) Documentation from GACH 1 dated 6/29/2022, indicated Resident 1 was found to have a right hip fracture. The ED documentation indicated Resident 1 had an orthopedic follow-up appointment, had X-ray done, and was directed to come to ED for evaluation. The ED documentation indicated Resident 1 made grimaces upon log roll (a maneuver used to move a person without flexing the spinal column) of right lower extremity. The ED documentation indicated to admit Resident 1 for surgery within 24 hours. A review of Resident 1's Orthopedic Consultation Note from GACH 1 dated 6/29/2022, indicated Resident 1's right lower extremity was shortened and in externally rotated position (rotation away from the center of the body). Resident 1 with pain with log roll (to maintain alignment of the spine while turning and moving). The note indicated Resident 1 required fracture stabilization and surgical fixation. A review of Resident 1's Discharge Documentation from GACH 1 dated 7/8/2022, indicated Resident 1 reported right hip pain and inability to walk. The documentation indicated Resident 1 ' s X-ray of the right hip (dated 6/29/22) showed moderately displaced comminuted (bone that is broken in at least two places) right intertrochanteric fracture. The documentation indicated Resident 1 had ORIF of the right proximal femur (the bone of the thigh, extending from the hip to the knee) on 7/2/2022. Resident 1 was discharged back to the facility on [DATE]. During an interview on 7/15/2022 at 10:05 am, Physician 2 stated Resident 1's treatment was delayed. Physician 2 stated any individual with any kind of hip fracture needed to be evaluated in an emergency setting and with an emergency physician due to high mortality (the state of being subject to death) and morbidity (the condition of suffering from a disease) rates. Physician 2 stated often time, individuals with hip fractures also have comorbidities (existence of more than one disease or condition at the same time) that needed to be addressed. During an interview on 7/15/22 at 12:40 pm., the Assistant Director of Nursing (ADON) stated on 6/20/22, Resident 1 complained of generalized body pain and needed increased assistance with ADL. The ADON stated Physician 1 was notified and ordered blood test and X-ray. Resident 1's X-ray (dated 6/21/2022) showed right hip fracture with [CONDITION(S)]. The ADON stated Physician 1 was notified and was aware of the new fracture. The ADON stated Physician 1 ordered to start Resident 1 on [MEDICATION(S)] and orthopedic consultation. The ADON stated Resident 1 went for his orthopedic consultation with Physician 2 (on 6/29/2022). The ADON stated Physician 2 informed the facility that he called 911. The ADON stated Physician 2 stated Resident 1's fracture required further evaluation and needed to be seen at the hospital. The ADON stated Resident 1 was readmitted to the facility from GACH 1 on 7/11/2022, after ORIF surgery. During an observation in Resident 1 ' s room and concurrent interview on 7/15/2022 at 1:38 pm, Resident 1 did not respond to his name and kept his eyes closed. During an interview on 7/15/2022 at 1:50 pm, Registered Nurse 1 (RN 1) stated Resident 1's X-ray result (dated 6/21/2022) showed displaced (a gap from where the bone breaks) hip fracture. RN 1 stated the ADON was the one who notified Physician 1. RN 1 stated any resident with displaced fracture, the physician (in general) would order to transfer to the hospital but for Resident 1, Physician 1 ordered an orthopedic consultation. During an interview on 7/15/2022 at 2:52 pm, Physician 1 stated for a resident (in general) with hip fracture, the resident required to go out to the hospital to be evaluated. During a concurrent telephone interview and a review of Physician 1's orders dated 6/21/2022, Physician 1 stated the facility ' s staff did not notify him of Resident 1 ' s fracture. Physician 1 stated he would not order [MEDICATION(S)] because he was not an orthopedic physician. Physician 1 stated the [MEDICATION(S)] was not his order. Physician 1 stated if the facility notified him of Resident 1's hip fracture, he would have ordered for Resident 1 to be transferred to the hospital for evaluation. Physician 1 stated if the fracture was old then orthopedic consultation will be fine. Physician 1 stated the orthopedic consultation was not his order. Physician 1 stated hip fracture required to be taken care of right away. During an interview on 7/15/2022 at 3:04 pm, the Director of Rehabilitation (DOR) stated on 6/17/22, PT 1 notified her, and the nursing department staff (unidentified) that Resident 1 complained of right hip pain. The DOR stated this was the first time Resident 1 complained of right hip pain. The DOR stated she followed up with the nursing department staff (unidentified) on 6/20/2022 (3 days later). During a telephone interview on 8/22/2022 at 1:48 pm, OT 1 stated PT 1 informed him of Resident 1's complaint of right hip pain and recommendation for X-ray of the hip. OT 1 stated on 6/17/2022, Resident 1 also complained to him of pain to the right hip with right leg movement. OT 1 stated he informed the charge nurse (unidentified) and recommended to get an X-ray of the hip. OT 1 stated he worked with Resident 1 in bed and only performed upper body gentle range of motion exercises at that time. OT 1 stated he assisted Resident 1 with his dinner meal. OT 1 stated prior to 6/17/2022, Resident 1 did not complain of pain during therapy. During a telephone interview on 8/23/22 at 8:40 am, PT 1 stated on 6/17/2022, Resident 1 complained of right hip pain and would get combative when PT 1 tried to touch Resident 1's right leg. PT 1 stated she informed the charge nurse (unidentified), RN 2, and the ADON. PT 1 stated she recommended to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an attempt telephone interview on 8/24/2022, at 10:05 am, RN 2 was not available and did not return the call. During a follow-up telephone interview on 8/24/2022, at 11:55 am, Physician 1 stated he did not recall if the facility notified him of Resident 1 ' s complaint of right hip pain on 6/17/2022. Physician 1 stated if the resident (in general) complained of pain or has possible injury after a fall, he would order an X-ray to check for fracture or send the resident to the hospital for evaluation depending on the severity of the injury. Physician 1 stated he did not recall the facility notifying him about Resident 1's right hip fracture. Physician 1 stated, I don't think they notified me about the fracture. Physician 1 stated if the facility notified him, he would have ordered to send Resident 1 to the hospital for evaluation. During a follow-up telephone interview and concurrent review of Resident 1's medical record on 8/24/2022, at 1:45 pm, the ADON stated she was not aware of Resident 1's complaint of right hip pain on 6/17/2022. The ADON stated on 6/20/2022, the CNA (unidentified) notified her of Resident 1's complaint of generalized pain and weakness for the last three days. The ADON stated Physician 1 was notified of Resident 1's change in condition on 6/20/2022 at 10:39 am. Physician 1 ordered blood tests and X-ray of the right hip. The ADON stated on 6/21/2022 at 11:58 am, she notified Physician 1 of Resident 1's x-ray results via text message regarding the x-ray showed right hip fracture with [CONDITION(S)]. The ADON stated Physician 1 ordered for orthopedic consultation, to hold PT and OT services, no weight bearing to right lower extremity and start medication for [CONDITION(S)]. The ADON stated any change in resident condition must be reported to the charge nurse right away and communicated to the physician. A review of the facility's policy and procedures titled Acute Condition Changes - Clinical Protocol revised in 12/2012, indicated phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status. The policy indicated the nursing staff would contact the physician based on the urgency of the situation. For emergencies, they would call or page the physician and request a prompt response (within approximately one-half hour or less). The attending physician (or practitioner providing backup coverage) would respond in a timely manner to notification of problems or changes in condition and status. If necessary, the physician would order diagnostic tests or evaluate the resident directly. The physician would help identify and authorize appropriate treatments.

Based on observation, interview and record review, the facility failed to prevent cockroaches infestation (the presence of an unusually large number of cockroaches (roaches, a small insect that can carriers and spreads infectious diseases)) in the facility's kitchen for 96 of 96 residents. This deficient practice resulted in the presence of nine live German cockroaches (a small species of cockroach) of various stages of development crawling on the kitchen's wall, underneath the two-compartment sink, and placed 96 residents at risk of serious diseases caused by contaminating human food with germs (small living thing/cell, especially one which causes diseases) that the cockroaches pick up in the toilets and garbage dumps. On July 14, 2020, at 2:55 p.m. and 4:45 p.m., the surveyor and the Registered Environmental Health Specialist (REHS, a health inspector who inspects various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections) conducted a join inspection and observed nine live cockroaches in the facility's kitchen, specifically under the two-compartment sink. On July 14, 2020, at 6:00 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was declared and the facility's Administrator was notified of the findings. On July 16, 2020, at 4:35 p.m., the IJ was removed in the presence of the Administrator after the implementation of Plan of Action (POA, action to correct the deficient practices) was verified and confirmed onsite through observation, interview, and record review. The accepted POA included the following actions: 1. The pests control company increased pest control services from twice a month to three times per month. 2. The Dietary Supervisor provided in-service to include for dietary staff to report any pests and penetrations in the kitchen walls to the Dietary Supervisor or designee for immediate corrective action. 3. The Maintenance Supervisor sealed all cracks and gaps and repaired all missing grouting material. Findings: A review of the County of Los Angeles, Department of Public Health, Effective Management of Cockroach Infestation, undated, publichealth.lacounty.gov/eh/docs/specializedenvcormanagement, indicated that cockroaches may become pests in any structure that has food preparation or storage areas. Cockroaches contaminated food and eat utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high numbers. Cockroaches that live outdoors could come into contact with human excrement (waste matter/feces) in sewers or with animal fecal matter and had the potential to transmit bacteria that cause food poisoning when they entered the facility's kitchen. A review of the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated July 1, 2019 https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. The guidelines indicated pest included cockroaches from inside the health care facilities that can serve as agents for the mechanical transmission of microorganisms (small living thing/cell), or as active participants in the disease transmissions process by serving as a vector (a live carrier that transfers infectious pathogens/germs) to animal and or human. A review of the facility's most current pest control service report, dated June 25, 2020, indicated Pest Control Technician 1 (PCT 1) applied treatment (pesticides/chemicals to kill or control pests) to the facility's exterior, and there were no signs or presence of cockroaches. The report indicated PCT 1 did not apply the treatment in the kitchen. A review of the facility's census report, dated July 14, 2020, indicated there were 96 residents residing in the facility. During an observation and interview with the Maintenance Assistant on July 14, 2020, at 2:55 p.m., nine live German cockroaches of various stages of development were walking on the wall, underneath the two-compartment sink and behind the stove. (German cockroaches are known to carry disease-producing organisms that spread different forms of gastroenteritis (inflammation of the stomach and the small intestine) such as food poisoning, diarrhea and other illnesses. German cockroaches also carry several allergens which may cause people to exhibit skin rashes, watery eyes, sneezing, congestion of nasal passages, and asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing)). The Maintenance Assistant stated he saw nine live cockroaches. During an interview on July 14, 2020, at 2:58 p.m., the Dietary Supervisor (DS) stated that staff from the pest control company comes to the facility twice a month and applies treatment. The DS stated staff from the pest control company was scheduled to come to the facility tonight to apply treatment. During an interview on July 14, 2020, at 3:35 p.m., the Administrator stated PCT 1 had been to the facility on [DATE], and he did not see any cockroaches, at that time. The Administrator stated that during the daily stand-up meeting, this morning, Kitchen Staff 1 (KS 1) reported to him that there were cockroaches in the kitchen. The Administrator stated he instructed the Maintenance Supervisor to contact the pest control company to treat the kitchen. During an observation on July 14, 2020 at 5:30 p.m., the REHS completed the investigation and informed the Administrator that there were seven live cockroaches beneath the two-compartment sink and two live cockroaches behind the stove. The REHS told the Administrator that the facility's kitchen is officially closed and to stop serving food to the residents. A review of the REHS's Official Inspection Report, dated July 14, 2020, indicated that there were three live nymph (immature) cockroaches and four live adult cockroaches beneath the two-compartment sink. The report indicated there were two live adult cockroaches and two dead adult cockroaches behind the stove. A review of the facility's undated policy and procedure, titled Pests Control, indicated the facility is maintained free of insects and rodents by having an effective pest control program. The policy indicated the facility shall contract with a pest control company to visit and inspect the facility at contracted intervals and on an as needed basis.

Based on observation, interview, and record review the facility failed to provide a safe environment for residents who were at risk for wandering (a going about from place to place), elopement (left the facility without staff knowledge), and at risk for falls, when: 1. The facility's nursing staff did not reassess the residents after they eloped, develop, and revise care plans for elopement, document elopement episodes, and report elopements to the Department for six residents (Resident 2, 9, 10, 12, 14, and 16) out of 20 sampled residents. 2. The facility nursing staff did not timely help two residents (Resident 1 and 2) out of 20 sampled residents. Resident 1 needed to urinate and required assistance transferring from the bed to the bedside commode (a chair with a toilet seat), and Resident 2 required extensive assistance with a one-person physical assist for bed mobility, transferring, and walking in corridor. These deficient practices resulted in Resident 2, 9, 10, 12, 14, and 16 eloping from the facility and Resident 1 and 2 had unwitnessed falls and placed the health and safety of the residents in jeopardy. On 9/13/19 at 5:17 PM, an Immediate Jeopardy (IJ-a noncompliant situation which would likely to cause serious harm to the health and safety of the residents) situation was called in the presence of the administrator and the director of nursing (DON). The survey team verbally notified the administrator and the DON of the facility's failure to provide a safe environment for residents who were at risk for wandering elopement, and at risk for falls. On 9/17/19 at 5:30 PM, the Immediate Jeopardy was removed in the presence of the administrator after the survey team verified and confirmed the plan of action and the facility implemented the plan of action that included the following: In-services given by the clinical consultant, to the licensed, non-licensed, and registry staff regarding: 1. Elopement for cognitively impaired residents, who get out of exit doors unsupervised. 2. Reporting of any change of condition, including elopement and/or attempts for elopement. 3. Monitoring by staffs to ensure the safety of residents, who were at high-risk for elopement and at risk for falls. Findings: On 9/13/19 at 7:52 AM, during an observation, the facility had six exit doors. Five of the six exit doors did not have a wander guard door alarm system (alerts staffs when a door opens and a resident wearing a wander guard bracelet is detected in the monitored area) in place. The main entrance door (leading to station 2) had a wander guard door alarm system in place. In Station 3, the main entrance door and the fire exit door led to the parking lot. During a concurrent observation and interview on 9/13/19 at 8:07 AM, the maintenance supervisor (MS) was asked to identify doors which have direct access outside of facility. The MS stated the two doors that led to the parking lot were the front door and the door next to room [ROOM NUMBER] in station 3. The MS stated both doors opened easily but only the front door had a wander guard system in place. The MS and surveyor walked out of door located at end of station 3 at 8:09 AM by easily pushing handle. Fire alarm was audible, and no staff noticed to open door and look outside. The MS turned alarm off the fire alarm at 8:12 AM. During an interview on 9/13/19 at 1:33 PM, the MS stated the main entrance door of the facility was unlocked between 5 AM to 8 PM daily and had a wander guard alarm system. During an interview on 9/13/19 at 2:13 PM, the Minimum Data Set Nurse (MDSN) stated wandering was defined as a resident not having a sense of direction. The MDSN stated elopement was defined as a resident leaving the facility without signing out or without a responsible party (RP) picking up the resident. The MDSN stated elopement was dependent on the cognitive status (level of awareness with perception, reasoning, judgment, intuition, and memory) of a resident. The MDSN stated that a cognitively impaired resident would be considered as eloped from the facility once the resident crossed the main entrance door. The MDSN stated that an alert and oriented resident would be considered eloped from the facility once the resident reached the parking lot, at the end of the main entrance walk way, By the fire lane. The MDSN stated the facility policy for elopement was to call a, Code amber, when the facility staff were unable to locate the resident. The MDSN stated once a resident was found after an elopement, a pain assessment, elopement assessment, and notification to the physician and responsible party (RP) would be done. During an interview on 9/13/19 at 3:53 PM, the MDSN stated the admission process for all residents admitted to the facility included an elopement assessment. During an interview on 9/13/19 at 3:55 PM, the director of nursing (DON) stated elopements were considered an unusual occurrence and should be reported. The DON stated alert residents were considered to have eloped from the facility if they leave the parking lot. The DON initially stated the parking lot was considered safe for both alert and cognitively impaired residents. The DON stated the residents that eloped were at risk for injury due to the cars passing by. During a concurrent observation and interview, on 9/14/19 at 11:56 AM, the administrator stated the residents were only able to exit the facility through the front door and there were no other easily accessible exits. The administrator stated the doors could not be opened by the residents. At 12:08 PM, the administrator walked through the exit door near station 3 easily by pushing in the handle. The administrator stated the exit door opened easily. The administrator stated residents could not elope, because there was a, Retaining wall. The retaining wall was a planter (a container in which ornamental plants are grown) measuring approximately 20 inches tall in front of the door and approximately 10 feet from the parking lot. During an observation, on 9/14/19 at 12:18 PM, the MS was asked to measure the height of the retaining wall, and the retaining wall's height measured at 16 inches. The distance from the retaining wall to the parking lot was 12 feet 3 inches. During a concurrent interview and record review on 9/14/19 at 12:47 PM, the administrator provided the facility's undated policy for Elopement. The administrator stated he created the policy on 9/14/19. The policy indicated the definition of elopement as a cognitively impaired resident leaving the facility or safe area without authorization or supervision. The policy did not address alert residents or chemically impaired residents. The administrator stated elopement were only applicable to cognitively impaired residents. The administrator stated reporting of elopements was only necessary if residents were not found by the facility staff. During an interview, on 9/14/19 at 2:12 PM, LVN 4 stated Situation, Background, Assessment, Recommendation (SBAR) reports were not done for eloped residents (Resident 2, 9, 10, 12, 14, and 16). LVN 4 stated the administrator asked her to falsify the reports by back dating the SBAR forms to 8/24/19. LVN 4 stated she refused and submitted a signed declaration (a document that recites facts pertinent to a legal proceeding). a. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Fall Risk assessment dated [DATE] indicated Resident 2 was at high risk for falls. A review of Resident 2's History and Physical (H&P), dated 8/23/19, indicated the resident had fluctuating capacity (on and off ability) to understand and make decisions. A review of Resident 2's Care Plan, dated 8/24/19 indicated, resident was at risk for falls and interventions included a prompt response on the call light and meeting the resident's needs. A review of Resident 2's Elopement/Wandering Risk assessment dated [DATE], indicated Resident 2's score was 13 and was considered at high risk for elopement (a score of 9 or higher indicated a risk for elopement) and attempted to leave the building. A review of Resident 2's Change in Condition Progress Notes dated 8/24/19 at 2:53 PM, indicated Resident is wandering out of facility, refused to be redirected, went to other resident's room and urinated, attempted to hit staff when redirected to his room. A review of Resident 2's medical records indicated Resident 2 did not have a wandering care plan dated 8/24/19. A review of Resident 2's SBAR (Situation, Background, Assessment , Recommendation (SBAR) Communication Form and Progress Note, dated 8/24/19 timed at 8:32 PM, indicated, At around 4:00p.m., Staff was called by a staff in the front patio about a resident need help and undersigned responded immediately and seen resident sitting on the floor by room [ROOM NUMBER] window. A review of Resident 2's Care Plan dated 8/24/19, indicated, Elopement risk due to dementia, non-complaint (sic) to redirection. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/29/19, indicated Resident 2 required extensive assistance with a one-person physical assist for bed mobility, transferring, and walking in corridor. A review of Resident 2's SBAR Communication Form and Progress Note, dated 9/8/19 timed at 2:24 PM indicated Resident 2 had unwitnessed fall in his room. Resident 2 hit his lower back and complaint of pain level 10/10 (measurement of pain level with zero for no pain and 10 for severe pain). The medical doctor was notified, and X-ray (diagnostic exam to see bones and other things inside the body) of the lower back was ordered. A review of Resident 2's Care Plan, dated 9/8/19, indicated resident was found sitting on the floor. The interventions included to keep call light within reach. During an observation and interview with Resident 2, on 9/11/19 at 8:18 AM, Resident 2's call light observed turned on (a light illuminated outside Resident 2's room). Licensed Vocational Nurse 1 (LVN 1) observed standing at a medication cart, aware of call light on, and did not respond to the call light. Resident 2's call light was still on at 8:22 AM, and at 8:23 AM, Resident observed attempting to get out of the chair with an unsteady balance and tried to pull his pants up. Resident 2 stated no one came to help him, and he needed help putting his pants on. During an interview, on 9/11/19 at 11:09 AM, LVN 1 stated due to short staffing, Resident 2 walked up and down the halls without supervision. A review of Resident 2's Care Plan, initiated on 9/16/19, indicated resident with episodes of wandering into other residents' rooms. A review of Resident 2's SBAR Communication Form and Progress Note dated 9/16/19 and timed at 11:28 PM indicated Resident 2 noted with episode of wandering into other residents' rooms. A review of Resident 2's Change in Condition Progress Notes, dated 9/16/19 timed at 11:37 PM, indicated at 10:05 PM, Resident 2 observed sitting on his right side, facing towards the door on the right-side area of head of his bed being attended by staff. Resident 2 assessed and had no pain or injury. Three facility staffs assisted Resident 2 back to bed. During a phone interview on 10/1/19 at 12:11 PM, Registered Nurse 1 (RN 1) stated that Resident 2 was a wanderer and required close monitoring. During a telephone interview and concurrent review of Resident 2's medical records, on 10/25/19 at 2:46 PM, Medical Record Staff 1 (MRS 1) stated Resident 2 had care plan for episodes of wandering into other residents' room initiated on 9/16/19 and was unable to locate any care plan for wandering prior to 9/16/19. b. A review of Resident 9's Admission Record indicated the resident was admitted to the facility, on 3/2/18, and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 9's H&P dated 3/3/19, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 9's Elopement/Wander Risk assessment dated [DATE], indicated Resident 9 was not at risk for elopement. The risk assessment indicated Resident 9's elopement risk score was 8. A review of Resident 9's Elopement/Wander Risk assessment dated [DATE], indicated Resident 9 was at risk for elopement. The risk assessment indicated Resident 9's elopement risk score was 14 because of the resident attempting to leave the facility 1-2 times within a week. During an observation on 9/11/19 at 11:48 AM, Resident 9 was sitting in her wheel chair outside of her room, and there was no wander guard bracelet visible on either wrist. During an interview on 9/11/19 at 2:12 PM, Certified Nursing Assistant 5 (CNA 5) stated Resident 9 had a history of [REDACTED]. CNA 5 stated Resident 9 had left the facility many times, and all staff in the facility was aware of her exit seeking behavior. CNA 5 stated during her shift (3 PM to 11 PM) she saw Resident 9 wheeling herself in the parking lot. CNA 5 stated she went outside and wheeled the resident back to the nursing station. A review of Resident 9's Care Plan, initiated on 9/13/19, indicated resident was an elopement risk due to resident noticed with episode of wandering in hallways and episodes of attempting to exit the front entrance. During a telephone interview and concurrent review of Resident 9's medical records, on 10/25/19 at 2:53 PM, MRS 1 stated Resident 9's care plan for elopement and also used for wandering was initiated on 9/13/19. Resident 9 had no care plan for elopement and wandering prior to 9/13/19. c. A review of Resident 10's Admission Record indicated Resident 10 was admitted to the facility, on 7/30/19, with [DIAGNOSES REDACTED]. A review of Resident 10's H&P, dated 7/31/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 10's Admission MDS dated [DATE], indicated Resident 10 required limited assistance with a one-person physical assist for bed mobility, transferring, and walking in corridor. A review of Resident 10's Elopement/Wandering Risk assessment dated [DATE], indicated Resident 10's score was 10 and was considered at high risk for elopement, and the facility staff should monitor Resident 10 frequently. A review of Resident 10's Change in Condition Progress Notes dated 8/15/19 at 7:52 AM, indicated, At 1 AM found Resident drinking Vodka. The document indicated Resident 10 had gone out earlier and bought the alcohol and 2 packs of cigarettes. A review of Resident 10's Change in Condition Progress Notes dated 8/15/19 at 4:02 PM, indicated, Family notified Resident left to facility and was found at the liquor store. Resident was found with cigarettes (sic). Resident was brought back to the facility family notified will continue to monitor. During an interview on 9/11/19 at 11:09 am, Licensed Vocational Nurse 1 (LVN 1) stated the staff calls off and the staffing on the weekends was terrible. LVN 1 stated nightshift (11 PM to 7 AM) only had one CNA for each station, but they normally have four CNAs for each station. LVN 1 stated it was hard to complete what she has to do when the facility was short staffed. LVN 1 stated due to insufficient staffing, a resident (Resident 10) eloped from the facility. LVN 1 stated Resident 10 was not in his room and she later found him at a liquor store. A review of Resident 10's medical records indicated Resident 10 did not have a care plan for at high risk for elopement. During an interview and concurrent review of Resident 10's medical records, on 9/13/19 at 4:04 PM, the Minimum Data Set Nurse (MDSN) verified Resident 10 did not have a care plan for elopement. The MDSN stated Resident 10 should have had a care plan, because resident was a high risk for elopement and the facility should have initiated interventions. d. A review of Resident 12's Admission Record indicated resident was admitted to the facility, on 1/12/19, and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 12's H&P dated 1/21/19, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 12's elopement/wander risk assessment dated [DATE], indicated Resident 12 was not at risk for elopement. The risk assessment indicated Resident 12's elopement risk score was 7. During an observation on 9/11/19 at 11:59 AM, Resident 12 was sitting in the dining room in her wheelchair, with no wander guard visible on either wrist. During an interview on 9/11/19 at 4:24 PM, CNA 5 stated on 9/10/19 during the 3-11 PM shift, Resident 12 was wheeling herself down the front walkway towards the parking lot. CNA 5 stated the resident frequently tries to leave the facility and does not have a wander guard. CNA 5 stated she notified LVN 3 of the elopement. During an interview on 9/11/19 at 4:35 PM. LVN 3 stated Resident 12 was demented (irrational thoughts and behaviors), but alert enough to express concerns. LVN 3 stated Resident 12 displays exit seeking behaviors once in a while, and had displayed this behavior for a long time. LVN 3 stated Resident 12 had displayed exit seeking behaviors for a long time and the facility staff are aware. LVN 3 stated on 9/10/19 Resident 12 was found outside in the front entrance patio going towards the parking lot. LVN 3 stated she brought the resident back into the facility and Resident 12 stated she wanted to go home to Monterey park. LVN 3 stated Resident 12 was not high risk because the resident only tried to leave the facility occasionally. LVN 3 stated she did not document the incident because she felt only if a resident goes beyond the parking lot a report must be made. A review of Resident 12's elopement/wander risk assessment dated [DATE], indicated Resident 12 was at risk for elopement. The risk assessment indicated Resident 12's elopement risk score was 10 because of the resident attempting to leave the facility 1-2 times within a week. A review of Resident 12's Care Plan, initiated on 9/13/19, indicated resident was an elopement risk due to resident noted with episodes of attempting to exit the front door. During a telephone interview and concurrent medical records review, on 10/25/19 at 2:55 PM, MRS 1 stated Resident 12's care plan for elopement and also used for wandering was initiated on 9/13/19, and Resident 12 had no other elopement and wandering care plan prior to 9/13/19. e. A review of Resident 14's Admission Record dated 4/19/19, indicated the resident was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident 14's H&P dated 4/20/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 14's SBAR communication form dated 6/6/19, indicated the resident eloped from the facility to go to his brother's auto shop. A review of Resident 14's MDS dated [DATE], indicated the resident required extensive assistance with walking. A review of Resident 14's elopement/wander risk assessment dated [DATE], indicated Resident 14 was not at risk for elopement. The risk assessment indicated Resident 14's elopement risk score was 6. A review of Resident 14's Care Plan, initiated on 9/14/19, indicated Resident 14 with history of elopement and left facility without out on pass (OOP) order. f. A review of Resident 16's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 16's Initial History and Physical dated 5/15/19, indicated the resident had the capacity to understand and make decisions. A review of Resident 16's MDS indicated Resident 16 required extensive assistance in bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident 16 required supervision while eating. A review of Resident 16's Progress Notes, dated 6/5/19, indicated Resident 16 eloped from the facility and was at a nearby restaurant. A review of Resident 16's Care Plan dated 9/14/19 indicated Resident 16 previously eloped from the facility on 6/5/19. The Care Plan interventions indicated to monitor the resident during routine rounds and to monitor for changes in behavior or wandering. During an interview on 9/16/19 at 1:14 PM, Registered Nurse Supervisor 2 (RNS 2) stated that Resident 16 had one history of elopement from the facility. RNS 2 stated that Resident 16 was found, unsupervised, across the street, by facility staff, at a fast food restaurant on 6/5/19. A review of the facility's policy for Wandering, Unsafe Resident, revised date 12/2008, indicated the facility will institute a detailed monitoring plan for residents identified as high risk for elopement. The facility indicated to notify the Administrator and the Director of Nurses (DON) immediately for any resident discovered to be missing from the unit or facility. A review of the facility's policy for Baseline Comprehensive Care Plan - IDT Conference, dated 11/2017, indicated the facility would develop a comprehensive, person-centered care plan for each resident. A review of the facility's policy for Unusual Occurrence Reporting, revised date 12/2007, indicated the facility was required by federal and state regulations to report unusual occurrences or other reportable events which affect the health, safety, or welfare of residents. A review of the facility's policy for Elopement, revised by the administrator on 9/17/19, defined elopement as when a cognitively impaired resident leaves the premises or safe area without authorization and/or any necessary supervision to do so. The policy defined safe areas for cognitively impaired residents as all indoor common areas (areas available for all residents). Safe areas for alert residents were the same with the addition of front walkway patio. The policy indicated all residents were to be assessed for elopement risk upon admission and all elopement attempts or occurrences are to be documented and reported. A review of the facility's policy titled, Advanced Situation Background Assessment and Recommendation (SBAR) Change of Condition Documentation (undated), indicated any sudden change in resident's condition needed to be communicated to the physician and an SBAR form completed. g. A review of Resident 1's Admission Record, dated 2/28/19, indicated the resident was admitted with [DIAGNOSES REDACTED]. A review of Resident 1's Care Plan, dated 6/9/19, indicated Resident 1 was at risk for falls. The interventions to prevent falls included anticipating and meeting the resident's needs and reviewing information post falls to determine cause and prevent future falls. A review of Resident 1's Situation Background Assessment and Recommendation (SBAR) communication form, dated 8/29/19 at 7:00 AM, indicated the resident was found on the floor in her room and no injury noted. The SBAR indicated the resident was trying to reach for her cell phone and fell . A review of Resident 1's Progress Notes, dated 9/1/19 at 11:45 PM, indicated the resident was found on the floor with her head resting against the frame of the bedside table. Resident 1 had no change in level of consciousness, no bumps, or swelling noted. A review of Resident 1's Interdisciplinary Team (IDT, a team of health care professions, who work together to establish plans of care for residents) meeting, dated 9/4/19 at 2:59 PM, indicated Resident 1 fell , on 9/1/19, because she had to urinate and attempted to transfer herself from the bed to the bedside commode. A review of Resident 1's Progress Notes, dated 9/6/19 at 11:42 PM, indicated Resident 1 was heard calling for help, when Licensed Vocational Nurse 5 (LVN 5) entered the room Resident 1 was sitting on the floor beside her bed next to the bedside commode. Resident 1 stated to the staff member she needed to use the commode. LVN 5 assisted Resident 1 to the commode, assessed her after she was finished using the commode, and no injury was noted. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 9/7/19, indicated Resident 1's cognitive (relating to or involving the processes of thinking and reasoning) skills was moderately impaired and required extensive assistance with transferring from bed to chair or commode. The MDS indicated Resident 1 was occasionally incontinent for urinary and bowel continence. A review of Resident 1's SBAR form, dated 9/10/19 at 8:52 AM, indicated Resident 1 was found lying on the floor after attempting to transfer herself to the bedside commode. During a concurrent observation and interview on 9/11/19 at 7:50 AM, Resident 1 was heard yelling from the hallway in Spanish calling for help me and saying, Please. Companion 1 (COM 1) was observed sitting outside of Resident 1's room. COM 1 stated she was assigned to watch the other resident but would also observe Resident 1 since she was in the room. COM 1 stated the resident had been yelling for a while and the resident screams all the time. During a concurrent observation and interview, on 9/11/19 at 8:00 AM, Resident 1 stated she was in a lot of pain and felt as if her bladder was going to burst. Resident 1 observed laying diagonally across her bed with her left foot hanging over the edge of the bed. Resident 1 stated she had been calling for an hour, because she needed to urinate. Resident 1 was alert to person, place, and time. Resident 1 stated this happens all the time. Resident 1 stated she had fallen before because she had called for help to the commode and no one would go, so she had to try and get herself on the commode. During an observation on 9/11/19 at 8:15 AM, CNA 4 entered Resident 1's room and assisted her to the bed side commode. CNA 4 stated the resident had to urinate and needed to be changed. During an interview on 9/11/19 at 8:50 AM, CNA 4 stated Resident 1 had to urinate. CNA 4 stated Resident 1 had been waiting a while, but she was busy caring for another resident. CNA 4 stated CNAs were expected to answer call lights, but answering the call light was hard to do, because the facility was often short staffed. CNA 4 stated Resident 1 has ended up on the floor because staff has not been able to get to the resident on time. A review of Resident 1's SBAR form dated 9/12/19 at 8:15 AM, indicated Resident 1 was found lying on the floor. The SBAR form indicated the resident was alert and able to make needs known. Resident 1 complained of pain to the back of her head. A review of Resident 1's Care Plan, initiated date 9/12/19, indicated resident was found lying on the floor. The inventions included call light within reach, bilateral floor mats, apply bed pad alarm, and offer or take resident to the bathroom every two hours. A review of the facility's policy for Answering the Call Light, revised date 9/2003, indicated call lights were to be answered as soon as possible. The policy indicated when residents were not be able to use their call light, staff needed to check on these residents frequently.

Based on interview and record review, the facility failed to monitor and provide Peripherally Inserted Central Catheter (PICC, a thin, soft, long catheter/tube that is inserted into a large vein to administer nutrition, medications, and for blood draws) line care for one of two sampled residents (Resident 1) including: 1. Failure to monitor Resident 1's external (outside) PICC line site, every week, as ordered by the Physician. 2. Failure to monitor Resident 1's PICC line arm circumference (the enclosing boundary of the arm), every week, as ordered by the Physician. 3. Failure to Assess Resident 1's PICC site every shift as ordered by the Physician. 4. Failure to ensure that Resident 1's PICC line with two lumens was flushed routinely from 3/3/17(admission) to 3/9/17. 5. Failure to ensure Registered Nurses 1, 2, and 3 (RN 1, 2, and 3), who were caring for Resident 1, were able to detect for signs and symptoms of PICC infection, and monitor for PICC line migration (when the tip of the PICC line had moved into a smaller vein which it increases the risk of [MEDICAL CONDITION] (blood clot)). 6. Failure to ensure the facility's policy and procedure indicate a standardized method for nursing staff to assess the PICC line external measurement and arm circumference to ensure early detection of PICC line infection and migration. These deficient practices resulted in Resident 1 was hospitalized for [REDACTED]. Findings: A review of Resident 1's Record of Admission indicated the resident was initially admitted to the facility on [DATE], and was readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED].)). A review of Resident 1's Comprehensive Resident Assessment, dated 3/3/17, indicated the resident was admitted to the facility with a double lumen (two tubings and two caps) PICC line on the left upper arm. The assessment did not indicate other information regarding the PICC line such as arm circumference and external PICC line length. A review of Resident 1's Physician Orders, dated 3/3/17, indicated: 1. Total [MEDICATION NAME] Nutrition electrolytes solution (TPN, multiple electrolyte additive for intravenous infusion (administration of fluids into a vein) to maintain electrolyte), at 60 cubic centimeter per hour (60 ml/hr), intravenously, for poor oral intake, for a total of 1560 ml in 24 hours. 2. Monitor IV (intravenous/PICC) site every shift and indicate: 1 = problem free; 2 = redness; 3 = swelling; 4 = pain and 5 = needed changing. 3. Measure PICC line arm circumference every week, on Saturday. 4. Measure external PICC line site every week, on Saturday. A review of Resident 1's Nurses Progress Notes, dated 3/4/17, timed at 10 p.m., indicated the resident was started on TPN. A review of Resident 1's Medication Records (MAR), dated 3/4/17 (the first Saturday), indicated there was no measurement for Resident 1's PICC line arm circumference nor the external PICC line site. A review of Resident 1's Physician and Telephone Orders dated 3/9/17, indicated to flush the PICC line with 10 ml of normal saline every shift for IV management. A review of Resident 1's Medication Records (MAR), dated 3/11/17 (the second Saturday), indicated Resident 1's external PICC line insertion site was 0 (zero) inches. A review of Resident 1's MAR, dated 3/3/17 to 3/12/17, indicated the resident's PICC line with two luments was not routinely flushed from 3/3/17 to 3/8/17 until it was ordered by the Physician on 3/9/17. A review of Resident 1's MAR, dated 3/11/17 to 3/12/17 indicated the resident's PICC line site was assessed as: 1. 1 = problem free, on 3/11/17, for 11 p.m. to 7 a.m. shift. 2. 3 = swelling, on 3/11/17, for 7 a.m. to 3 p.m. shift. 3. 3 = swelling, on 3/11/17, for 3 p.m. to 11 p.m. shift. 4. 1 = problem free, on 3/12/17, for 11 p.m. to 7 a.m. shift. 5. There was no assessment for Resident 1's PICC site, on 3/12/17, for 7 a.m. to 3 p.m. shift. The MAR indicated [REDACTED] 6. There was no assessment for Resident 1's PICC site, on 3/12/17, for 3 p.m. to 11 p.m. shift. The MAR indicated [REDACTED] A review of Resident 1's Nurses Progress Notes, dated 3/12/17, timed at 4:03 p.m., indicated Resident 1 had an elevated temperature of 101.3 and 103.7 degrees Fahrenheit respectively. The progress noted indicated Resident 1's oxygen saturation (oxygen in the blood) was at 91 % on room air (normal levels between 95% to 100 %). The progress note indicated Resident 1 was transferred to a General Acute Care Hospital (GACH) via 9-1-1 (emergency paramedics). A review of the Resident 1's GACH Discharge Instructions indicated Resident 1 was admitted on [DATE], and discharged on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Imaging Report from the GACH, dated 3/12/17, indicated a venous duplex scan (ultrasound) of the left arm showed an acute, partially occlusive thrombus (blood clot) within the left internal jugular vein (a major blood vessel that drains blood from important body organs and parts, such as the brain, face, and neck). A review of Resident 1's Progress Notes, dated 3/22/17, indicated the resident was readmitted back to the facility from the GACH. The progress note indicated Resident 1 received [MEDICATION NAME] (an anticoagulant that helps prevent the formation of blood clots.) injection for [MEDICAL CONDITION] ([MEDICAL CONDITION]/blood clot in the deep veins) [MEDICATION NAME]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/29/17 indicated the resident had clear speech. The MDS indicated Resident 1's cognitive (reasoning) skills for decision-making was poor, and the resident required extensively assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living for bed mobility, transfers, toilet use, and personal hygiene. On 3/21/18, at 12 p.m., during a telephone interview with Resident 1's Family Member 1 (FM 1), she stated on 3/11/17, FM 2 noted Resident 1's left upper arm was swollen while the TPN was infusing into the swollen arm. FM 1 stated that FM 2 notified the licensed nurse (unidentified) and the licensed nurse notified Resident 1's Physician. FM 1 stated on 3/12/17, she called the facility and Licensed Vocational Nurse 1 (LVN 1) told her that Resident 1's left upper arm was really swollen and very warm. On 4/6/18, at 1:20 p.m., a review of Resident 1's Care Plan for IV therapy, dated 3/3/17, indicated that the resident had a PICC on the left upper arm. The nursing interventions included care for the PICC line, observe the site for signs and symptoms of infection. A concurrent interview was conduct with the facility's Assistant Director of Nurses (ADON) regarding to why the nursing staff was infusing TPN via Resident 1's PICC line while the PICC line site was swollen, the ADON stated the resident required TPN as ordered. On 4/6/18, at 3:35 p.m., during an interview, Registered Nurse 1 (RN 1) stated he was the RN who changed Resident 1's PICC line dressing on 3/4/17. RN 1 could not provide documentation indicated Resident 1's PICC arm circumference and external PICC line were measured. RN 1 stated the measurements should be done during every PICC line dressing change to check if the PICC line was intact, and to ensure there was no swelling. RN 1 stated swelling is a sign of PICC line infection. On 4/11/18, at 2:25 p.m., during an interview with RN 2 regarding Resident 1's external PICC length, on 4/11/17, was measured at zero. RN 2 stated the licensed nurse measured the PICC line from the insertion site up to the lumen, or the hub of the tubing. RN 2 stated the measurement was less than one inch and the licensed nurse could not enter less than one inch that is why the licensed nurse entered zero. RN 2 stated, I'm not sure which one was right. RN 2 stated some licensed nurses measured the PICC line from the insertion site up to the tip of the lumen/hub to include measurement of the tubing after the hub. RN 2 stated, I'm confused too. During the same interview, RN 2 stated the best practice was to assess and measure the PICC site arm circumference and external catheter length upon admission. RN 2 stated the measurement during admission could be used to establish the baseline and to ensure that PICC line complications are detected immediately. On 4/11/18, at 2:40 p.m., during an interview, RN 3 stated during admission, nursing staff did not assess and measure the PICC line due to the PICC line was underneath the dressing, and staff could not see the PICC site. RN 3 stated she measured Resident 1's arm circumference and PICC length in inches. RN 3 stated if the measurement indicated a zero, it means there was no PICC tubing observed outside of the insertion site. On 4/11/18, a review of the facility's policy titled Care of Peripheral Central Lines, undated, indicated that PICC line care is performed utilizing strict sterile technique (a procedure used by medical staff to prevent the spread of infection). A concurrent interview with the ADON she stated she could not find other policy regarding PICC site measurement and external PICC length, and PICC site care. According to the article published by AHRQ (agency for Healthcare Research and Quality) Patient Safety Network, titled Preventing PICC Complications, Whose Line Is It? dated 12/2012 (https://psnet.ahrq.gov/webmm/case/289/preventing-picc-complications-whose-line-is-it), indicated that infection and [MEDICAL CONDITION] are the two most common serious complications associated with PICCs or any other central venous catheters. Because [MEDICAL CONDITION] can lead to infection, early identification and treatment of [REDACTED]. Educating providers about signs and symptoms of [MEDICAL CONDITION] and infection is necessary to hasten identification and treatment, avoiding significant morbidity. Immunocompromised residents are at greater risk for infection and required close observation and careful aseptic practices. The article indicated that additional lumens in the catheter increases the risk of infection. The article indicated that a plan should be initiated to provide for daily site assessment, routine flushing, sterile dressing changes, and medication administration.

Based on interview and record review, the facility failed to implement its policy and procedure in reporting an altercation, including those that represent resident to resident abuse, to the attending physician for one of two sampled residents (Resident 1). Resident 2 choked Resident 1 on [DATE] inside their shared room and Resident 1's attending physician was not informed that Resident 1 was a victim of a choking incident so that the attending physician could give orders to examine Resident 1 for any injuries. This deficient practice resulted in delayed intervention for Resident 1. On [DATE], five days after the choking incident, Resident 1 was transferred to a general acute care hospital (GACH) due to his neck tilted to the right. The resident had a cervical (c-spine or neck) C4-C5 (cervical fourth to fifth vertebrae or bone) anterolisthesis (forward displacement of the spine) with C5 fracture (broken bone) and severe cord compression (pressure on the spinal cord) and became paralyzed (loss of the ability to move one or more muscles). Resident 1 had a [MEDICAL CONDITION] (tube inserted through a hole in the neck) to assist in his breathing and a gastrostomy (a surgical opening through the abdomen into the stomach used for feeding and medications) as a route to receive nutrition. This deficient practice also resulted in Resident 1 to experience fear for his life and safety. Findings: On [DATE] at 10:45 a.m., an unannounced complaint visit was conducted regarding Resident 1 being choked by Resident 2 on [DATE] and Resident 1 had sustained a neck fracture. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated [DATE], indicated the resident had a clear speech, and was usually able to express ideas and wants. The MDS indicated Resident 2 needed extensive assistance (resident involved in activity; staff providing weight bearing support) with bed mobility, transferring, and walking. The resident used a walker or wheelchair as mobility devices and had no limitations in range of motion (the range through which a joint can be moved) in his upper and lower extremities. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], with the admitting [DIAGNOSES REDACTED]. A review of Resident 1's MDS, dated [DATE], indicated the resident had a clear speech, and was able to express ideas and wants. The MDS indicated Resident 1 was unable to walk and he needed extensive assistance with bed mobility, transferring, and locomotion on the unit (how the resident moves between locations in his room and adjacent corridor on the same floor). A review of Resident 1 Situation, Background, Assessment, Recommendation (SBAR, a framework for communication between members of the health care team about a resident's condition) and Progress note, dated [DATE] at 10:26 a.m., indicated Resident 1 stated he was taking a nap when his roommate, Resident 2, came to the side of his bed and started yelling that he (Resident 1) was in his (Resident 2's) bed. Resident 1 stated Resident 2 stood up and tried to choke him and pull him out of the bed. Resident 1 appeared to be frightened. Body checked performed with no apparent injuries notes. No discolorations or changes to the skin noted. The SBAR and progress note indicated Resident 1's primary physician (MD 1) was notified on [DATE] at 2 p.m., regarding the resident-to-resident altercation. A review of Resident 1's Resident Transfer Record, dated [DATE] indicated Resident 1 was transferred to GACH due to change in mobility level to the upper extremity, stiff neck with tilting to the right. A review of Resident 1's GACH record titled, Consultation, dated [DATE], indicated, Resident 1 had a worsening neck pain, difficulty in walking, weakness in his upper extremities, and breathing issues. Resident 1 was admitted to the emergency room last night. CT scan (computed tomography, a type of x-ray that produces images of the specific part of the body) of the cervical (neck) spine showed that Resident 1 has a C4-C5 anterolisthese with C5 fracture and severe cord compression. Resident 1 was currently intubated in the ICU (intensive care unit, a special hospital unit with specialized equipment and specially trained personnel to care for seriously ill patients) after coding (a medical emergency, especially in a hospital, when a patient's heart stops beating or his or her lungs stop functioning) last night. A review of Resident 1's GACH record titled Operative Report, dated [DATE], indicated the operation performed were a [MEDICAL CONDITION], upper gastrointestinal endoscopy (a procedure that allows your doctor to look at the inside lining of your esophagus, your stomach, and the first part of your small intestine) and percutaneous endoscopic gastrostomy (PEG, a procedure in which a tube is passed into the stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). During a telephone interview with FM 1, on [DATE] at 1:50 p.m., she stated that Resident 1 was currently in the intensive care unit (ICU). During a telephone interview with Resident 1's primary physician (MD 1), on [DATE] at 12 p.m., he stated he remembered getting a call from the facility that Resident 1 was having weakness and the facility wanting to transfer him to GACH (on [DATE]). MD 1 stated the emergency room doctor called him from the GACH and updated him what was going on with Resident 1 regarding the [MEDICAL CONDITION]. MD 1 stated, And after that I didn't hear anything back. During the interview, MD 1 stated he went to the hospital and spoke to FM 1 who told him that Resident 1 was choked by another resident. MD 1 stated, I did not know any of this. I went to the facility the next day and spoke to the administrator and I asked him what happened because I was not aware of the choking. The administrator was surprised. I mean what could he say? If the facility called me and told me my resident was choked by another resident I would have ordered tests or transferred him to the hospital. The facility calls me all the time regarding other issues falls, medication, change of conditions, but this is something very important more than a medical issue. Something like this happens and we need to act upon it. These kinds of things do not happen that often. I never got a call regarding (Resident 1) being choked by another resident. During an interview with Licensed Vocational Nurse (LVN) 2, on [DATE] at 2 p.m., she stated, Yes, I remember the incident. I was on lunch break when it happened. The certified nurse assistant (CNA) came and got me. LVN 2 stated that when she went to see Resident 1, he was in the room in the bed and Resident 2 was not in the room. LVN 2 stated that Resident 1 looked very scared, and Resident 1 informed her that Resident 2 tried to choke him. LVN 2 stated she left a message on MD 1's pager and Registered Nurse (RN) 1 possibly notified Resident 1's daughter. LVN 2 stated, on [DATE] at 3:27 p.m., that she did not contact MD 1 again. LVN 2 stated that she told the incoming nurse during the nurse-to-nurse report and that they should follow up. During an interview, on [DATE] at 2:10 p.m., RN 1 stated, after reviewing the Situation, Background, Assessment, Recommendation (SBAR) and Progress note, dated [DATE] at 10:26 a.m., that she spoke to FM 1 after the incident. RN 1 stated FM 1 knew about the incident right away because Resident 1 called her on his cell phone. RN 1 stated she did not call MD 1 to notify him about the resident-to-resident altercation. RN 1 stated the SBAR and progress note indicated MD 1 was notified about the resident-to-resident altercation on [DATE] at 2 p.m. During an interview, on [DATE] at 2:30 p.m., the director of nursing (DON) stated, Now that I talked to LVN 2, she said she left a message to MD 1. The DON stated LVN 2 should have documented in her notes and on the SBAR that she left a message to MD 1. The DON stated the SBAR looked like LVN 2 talked to MD 1 and notified MD 1 about the altercation. The DON stated LVN 2 should have documented that she left a message so that the next shift could have followed up with MD 1. During an interview with the DON, on [DATE] at 1:55 p.m., she stated that they separated both residents (Resident 1 and Resident 2) immediately as soon as Resident 1 informed the facility staff member regarding being choked by Resident 2. At 4:02 p.m., the DON stated, when asked if the physician must be notified, the DON stated, Yes we have to. There should be a follow up phone call to physician. When asked how many times they have to try to notify the physician that a change of condition had occurred with a resident, the DON stated that they must try until the physician could answer. When asked if a resident being choked was considered a change in condition, DON stated it is considered a change in condition. During an interview with FM 1, on [DATE] at 11:05 a.m., she stated that Resident 1's neck was fine prior to the incident (on [DATE]) and that Resident 1 was even able to feed himself and move around. FM 1 stated that Resident 1 was now paralyzed and since he was not able to move, Resident 1 had developed pressure sores (damaged skin caused by staying in one position for too long). While crying on the phone, FM 1 stated, They were not doing what they were supposed to do. They did not protect him. They did not follow procedure. If they sent him sooner to the hospital, maybe he would not be paralyzed. I visited him every day. If I had not been there that Wednesday, he would have died because I noticed what happened to him and when he was in the emergency room , his heart and breathing stopped. He should have gone straight to the hospital on that day. FM 1 stated that Resident 1 told her, Honey they are letting me die. A review of the undated facility's policy and procedure titled Resident to Resident Altercations, indicated all altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Nursing Supervisor, Director of Nurses and to the Administrator. If two residents are involved in an altercation, staff will: notify each resident representative (sponsor) and Attending Physician of the incident.

Based on interview and record review, the facility failed to provide appropriate care and treatment to a resident, who was a victim in a resident to resident altercation, to ensure injuries were not sustained for one of two sampled residents (Resident 1). Resident 2 choked Resident 1 on [DATE] inside their shared room and Resident 1's attending physician was not informed that Resident 1 was a victim of a choking incident so that the attending physician could give orders to ensure Resident 1 could be examined for any injuries. This deficient practice resulted in delayed intervention for Resident 1. On [DATE], five days after the choking incident, Resident 1 was transferred to a general acute care hospital (GACH) due to his neck tilted to the right. The resident had a cervical (c-spine or neck) C4-C5 (cervical fourth to fifth vertebrae or bone) anterolisthesis (forward displacement of the spine) with C5 fracture (broken bone) and severe cord compression (pressure on the spinal cord) and became paralyzed (loss of the ability to move one or more muscles). Resident 1 had a [MEDICAL CONDITION] (tube inserted through a hole in the neck) to assist in his breathing and a gastrostomy (a surgical opening through the abdomen into the stomach used for feeding and medications) as a route to receive nutrition. This deficient practice also resulted in Resident 1 to experience fear for his life and safety. Findings: On [DATE] at 10:45 a.m., an unannounced complaint visit was conducted regarding Resident 1 being choked by Resident 2 on [DATE] and Resident 1 had sustained a neck fracture. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated [DATE], indicated the resident had a clear speech, and was usually able to express ideas and wants. The MDS indicated Resident 2 needed extensive assistance (resident involved in activity; staff providing weight bearing support) with bed mobility, transferring, and walking. The resident used a walker or wheelchair as mobility devices and had no limitations in range of motion (the range through which a joint can be moved) in his upper and lower extremities. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], with the admitting [DIAGNOSES REDACTED]. A review of Resident 1's MDS, dated [DATE], indicated the resident had a clear speech, and was able to express ideas and wants. The MDS indicated Resident 1 was unable to walk and he needed extensive assistance with bed mobility, transferring, and locomotion on the unit (how the resident moves between locations in his room and adjacent corridor on the same floor). A review of Resident 1 Situation, Background, Assessment, Recommendation (SBAR, a framework for communication between members of the health care team about a resident's condition) and Progress note, dated [DATE] at 10:26 a.m., indicated Resident 1 stated he was taking a nap when his roommate, Resident 2, came to the side of his bed and started yelling that he (Resident 1) was in his (Resident 2's) bed. Resident 1 stated Resident 2 stood up and tried to choke him and pull him out of the bed. Resident 1 appeared to be frightened. Body checked performed with no apparent injuries noted. No discoloration or changes to the skin noted. The SBAR and progress note indicated Resident 1's primary physician (MD 1) was notified on [DATE] at 2 p.m., regarding the resident-to-resident altercation. A review of Resident 1's Resident Transfer Record, dated [DATE], indicated Resident 1 was transferred to GACH due to change in mobility level to the upper extremity, stiff neck with tilting to the right. A review of Resident 1's GACH record titled, Consultation, dated [DATE], indicated, Resident 1 had a worsening neck pain, difficulty in walking, weakness in his upper extremities, and breathing issues. Resident 1 was admitted to the emergency room last night. CT scan (computed tomography, a type of x-ray that produces images of the specific part of the body) of the cervical (neck) spine showed that Resident 1 has a C4-C5 anterolisthese with C5 fracture and severe cord compression. Resident 1 was currently intubated in the ICU (intensive care unit, a special hospital unit with specialized equipment and specially trained personnel to care for seriously ill patients) after coding (a medical emergency, especially in a hospital, when a patient's heart stops beating or his or her lungs stop functioning) last night. A review of Resident 1's GACH record titled Operative Report, dated [DATE], indicated the operation performed were a [MEDICAL CONDITION], upper gastrointestinal endoscopy (a procedure that allows your doctor to look at the inside lining of your esophagus, your stomach, and the first part of your small intestine) and percutaneous endoscopic gastrostomy (PEG, a procedure in which a tube is passed into the stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). During a telephone interview with FM 1, on [DATE] at 1:50 p.m., she stated that Resident 1 was currently in the intensive care unit (ICU). During an interview with licensed vocational nurse (LVN 1), on [DATE] at 2:20 p.m., she stated Resident 1 informed her that Resident 2 tried to choke him and pull down the light that was over his head. LVN 1 stated she tried to calm Resident 1 down. LVN 1 stated Resident 1 said to her, Get me out of this room, he is trying to kill me. During a telephone interview with Resident 1's primary physician (MD 1), on [DATE] at 12 p.m., he stated he remembered getting a call from the facility that Resident 1 was having weakness and the facility wanting to transfer him to GACH (on [DATE]). MD 1 stated the emergency room doctor called him from the GACH and updated him what was going on with Resident 1 regarding the [MEDICAL CONDITION]. MD 1 stated, And after that I didn't hear anything back. During the interview, MD 1 stated he went to the hospital and spoke to FM 1 who told him that Resident 1 was choked by another resident. MD 1 stated, I did not know any of this. I went to the facility the next day and spoke to the administrator and I asked him what happened because I was not aware of the choking. The administrator was surprised. I mean what could he say? If the facility called me and told me my resident was choked by another resident I would have ordered tests or transferred him to the hospital. The facility calls me all the time regarding other issues falls, medication, change of conditions, but this is something very important more than a medical issue. Something like this happens and we need to act upon it. These kinds of things do not happen that often. I never got a call regarding (Resident 1) being choked by another resident. During an interview with LVN 2, on [DATE] at 2 p.m., she stated, Yes, I remember the incident. I was on lunch break when it happened. The certified nurse assistant (CNA) came and got me. LVN 2 stated that when she went to see Resident 1, he was in the room in the bed and Resident 2 was not in the room. LVN 2 stated that Resident 1 looked very scared, and Resident 1 informed her that Resident 2 tried to choke him. LVN 2 stated she left a message on MD 1's pager and Registered Nurse (RN) 1 possibly notified Resident 1's daughter. LVN 2 stated, on [DATE] at 3:27 p.m., that she did not contact MD 1 again. LVN 2 stated that she told the incoming nurse during the nurse-to-nurse report and that they should follow up. During an interview, on [DATE] at 2:10 p.m., RN 1 stated, after reviewing the Situation, Background, Assessment, Recommendation (SBAR) and Progress note, dated [DATE] at 10:26 a.m., that she spoke to FM 1 after the incident. RN 1 stated FM 1 knew about the incident right away because Resident 1 called her on his cell phone. RN 1 stated she did not call MD 1 to notify him about the resident-to-resident altercation. RN 1 stated the SBAR and progress note indicated MD 1 was notified about the resident-to-resident altercation on [DATE] at 2 p.m. During an interview, on [DATE] at 2:30 p.m., the director of nursing (DON) stated, Now that I talked to LVN 2, she said she left a message to MD 1. The DON stated LVN 2 should have documented in her notes and on the SBAR that she left a message to MD 1. The DON stated the SBAR looked like LVN 2 talked to MD 1 and notified MD 1 about the altercation. The DON stated LVN 2 should have documented that she left a message so that the next shift could have followed up with MD 1. During an interview with the DON, on [DATE] at 1:55 p.m., she stated that they separated both residents (Resident 1 and Resident 2) immediately as soon as Resident 1 informed the facility staff member regarding being choked by Resident 2. At 4:02 p.m., the DON stated, when asked if the physician must be notified, the DON stated, Yes we have to. There should be a follow up phone call to physician. When asked how many times they have to try to notify the physician that a change of condition had occurred with a resident, the DON stated that they must try until the physician could answer. When asked if a resident being choked was considered a change in condition, DON stated it is considered a change in condition. During an interview with FM 1, on [DATE] at 11:05 a.m., she stated that Resident 1's neck was fine prior to the incident (on [DATE]) and that Resident 1 was even able to feed himself and move around. FM 1 stated that Resident 1 was now paralyzed and since he was not able to move, Resident 1 had developed pressure sores (damaged skin caused by staying in one position for too long). While crying on the phone, FM 1 stated, They were not doing what they were supposed to do. They did not protect him. They did not follow procedure. If they sent him sooner to the hospital, maybe he would not be paralyzed. I visited him every day. If I had not been there that Wednesday, he would have died because I noticed what happened to him and when he was in the emergency room , his heart and breathing stopped. He should have gone straight to the hospital on that day. FM 1 stated that Resident 1 told her, Honey they are letting me die. A review of the undated facility's policy and procedure titled Resident to Resident Altercations, indicated all altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Nursing Supervisor, Director of Nurses and to the Administrator. If two residents are involved in an altercation, staff will: notify each resident representative (sponsor) and Attending Physician of the incident.

Based on observation, interviews, and record reviews, the facility failed to provide necessary care and supervision to prevent injury for 1 of 1 sampled resident (Resident 1) who was identified as at high risk for falls and needed extensive assistance (staff provide weight-bearing support) from staff during dressing and toileting. The certified nursing assistant (CNA 1) helped Resident 1 to the bathroom on 8/4/14 and left the resident in the bathroom unsupervised. The occupational therapist (OT) assessed the resident as needing contact guard assist ((CGA), staff needed to put one or two hands on the resident's body to help with balance) for lower body dressing (donning and doffing pants, socks, shoes, underwear), and stand by assist ((SBA) for toileting, staff needed to be close by for safety, in case the resident lost balance or needed help to maintain safety during the task being performed). Resident 1 attempted to put his underwear on by himself and fell to the floor. This deficient practice resulted in Resident 1 falling to the floor, sustaining a left hip fracture requiring a transfer to a general acute care hospital (GACH) for two days for orthopedic consult (branch of surgery concerned with conditions involving the musculoskeletal system) and pain control for severe pain. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), a (standardized assessment and care screening tool), dated 5/28/2014, indicated Resident 1's cognition was intact (the brain/mind processed information in a normal way). The resident was able to make his needs known and understand others, but required extensive assistance from staff with a one person physical assist for transferring, personal hygiene, and toilet use. The resident used a walker, wheelchair, and left lower extremity prosthesis (an artificial body part, such as a leg) to get around the facility. During an observation, on 8/22/14, at 1:05 p.m., Resident 1 was lying in bed. The resident's left hip area was covered with green color bruises. During a concurrent interview, Resident 1 stated he fell and broke his hip. When asked how was the pain, the resident stated, Oh this pain is killing me. On 8/22/14, at 1:10 p.m., during an interview, Resident 1 stated he fell in the bathroom. The resident stated it was a routine for the nurse to help him to the bathroom and leave him. The resident stated when he was done using the bathroom he would clean himself up, and push the call light for the nurse to help him out of the bathroom. The resident stated he had done this routine many times in the past. Resident 1 stated, this time when he stood to pull his underwear up, his body turned and he fell to the floor. Resident 1 stated after he landed on the floor, he saw his nonskid sock (socks with rubber bottoms to help prevent falls) was on crooked (the rubber part of the sock was on top of his right foot instead of the bottom,) On 8/22/14, at 2:10 p.m., during an interview, CNA 1 stated on 8/4/14, Resident 1 asked her to help him to the bathroom, so she brought the wheelchair to the resident. CNA 1 stated the resident was able to transfer himself to the wheelchair, then she pushed the resident to the bathroom. CNA 1 stated while in the bathroom, the resident transferred himself from the wheelchair to the toilet by grabbing on the two grab bars in the bathroom (on the left and right of the toilet.) CNA 1 stated she pushed the wheelchair out of the bathroom, closed the bathroom door for privacy, and left the room to help other residents. CNA 1 stated she had taken care of Resident 1 before, and was familiar with the resident's needs. CNA 1 stated whenever she helped Resident 1 to the bathroom; the resident would transfer himself from the wheelchair to the toilet, cleaned himself, pull his underwear up (fully clothed), and push the call light for her to bring the wheelchair back to the bathroom. CNA 1 stated all she needed to do for the resident was to bring the wheelchair and push him out of the bathroom. CNA 1 stated Resident 1 liked to be independent (do things by himself); he did not like the staff to help with the tasks, and he would normally perform all the tasks by himself. CNA 1 stated the resident was wearing a non-skid sock but she did not check to see if the sock was properly placed. A review of a Fall Risk Assessment (an assessment of the resident's status in eight clinical condition parameters such as: level of consciousness, history of falls, ambulation, elimination status, vision status, gait/balance, systolic blood pressure, medications, and predisposing diseases), dated 7/4/14 and 8/4/14, indicated that Resident 1 had a score of 14. According to the assessment, a total score of 10 or above represents a high risk for falls. A review of Resident 1's nursing care plan, dated 6/29/14, indicated the resident was at risk for fall or injury due to left leg amputation, generalized weakness, improper posture, receiving hypertension and psychoactive medications. The staffs approach interventions were to keep close observation during activities to minimize potential for fall and to have physical therapist/occupational therapist (OT/PT) evaluation done if indicated. A review of nursing care plan, dated 6/29/14, indicated Resident 1 required assistance in transferring, dressing, toilet use, and personal hygiene due to multiple medical conditions. The staff interventions were to assist the resident with transfer, locomotion, and toileting. A review of the Occupational Therapy Discharge Summary, dated from 7/29/14 to 8/1/14, indicated for lower body dressing the resident needed CGA and for toileting the resident needed SBA. During an interview with the occupational therapist (OT) on 8/22/14, at 2:30 p.m., she stated the resident was assessed as not safe (potential for fall and injuries) to be by himself for toileting and lower body dressing because the resident could not perform those tasks safely by himself. The OT further stated if the resident was assessed to be safe, she would document independent in her assessment instead of CGA and SBA. The OT stated according to the resident's condition and her assessment, staff needs to be with the resident at all times during toileting because it was not safe for the resident to be by himself. On 8/22/14, at 3:15 p.m., during an interview, the licensed vocational nurse (LVN 1) stated while she was passing her morning medication she heard a loud noise coming from Resident 1's room. LVN 1 stated as she rushed into the resident's room and opened the bathroom's door she saw the resident lying on the floor on his left side. LVN 1 stated at that time there was no other staff with the resident or near by the resident's room. LVN 1 stated Resident 1 was able to perform some tasks by himself, but for toileting, the resident needed supervision (staff to be there with the resident.) LVN 1 stated even when the resident asked staff to provide privacy, staff needed to provide privacy by closing the bathroom door, but to stay in the room with the resident to periodically check on the resident for safety. LVN 1 stated after the resident fell , she asked CNA 1 why she did not stay in the room to check and help Resident 1. CNA 1 stated she left the room because other residents called her for help. A review of the physician's orders [REDACTED]. A review of Resident 1's final x-ray report dated 8/4/14, indicated the resident sustained [REDACTED].) A review of a physician's orders [REDACTED]. A review of the emergency department triage note, dated 8/04/14, at 1:03 p.m., indicated Resident 1 arrived from the nursing home for a slip and mechanical ground level fall in the bathroom, leading to injury to left hip. The resident complained of left hip pain, rating 7 on a scale of 0 to 10 (0 = no pain, 7 = severe pain, and 10 = unimaginable pain.) The resident received trauma (Ultram, pain medication) 50 milligrams (mgs) tablet one time for left hip pain. A review of the GACH's medication record, dated 8/4/15 to 8/6/14, indicated Resident 1 required and received four dosages of morphine (pain medication) 2 mgs via intravenous push (IVP) for severe pain, and seven dosages of Norco (pain medication) 5/325 mg tablets by mouth for moderate pain. A review of the GACH's orthopedic consultation report dated 8/4/14 indicated Resident 1 sustained a left hip fracture after a fall at the skilled nursing facility where he resides. The report indicated the resident's pain may be treated conservatively with bed rest for 2-4 weeks, pain control, and serial radiographs (x-ray) on a weekly basic due to multiple medical problems. According to the report, surgery may still be done in the near future if the fracture should displace or the resident had severe hip pain. A review of the facility's investigation report, dated 8/4/14, indicated the resident had the capacity to understand and make decision. The resident was aware that he needed assistance and he understood the risks and consequences, including a fall with serious injury. The resident stood up and tried to pull his underwear without calling for help, as a result he fell and sustained a hip fracture. A review of the interdisciplinary team (IDT) notes, dated 6/30/14 and 7/8/14 (prior to the fall incident) indicated there was no documentation regarding the team's identifying Resident 1's refusal of staff's help during toileting and/or risks regarding fall being explained to the resident. A review of the facility's policy and procedure titled, Routine Nursing Care dated 1/1/2002, indicated toileting-assistance will be provided for all residents at a level determined by the functional skills of the resident. According to the facility's undated policy and procedure titled, Assisting a Resident to walk to the Bathroom indicated to provide the resident with as much privacy as possible, tells the resident to call or signaled for you; wait outside the door, if permitted. A review of the Occupational Therapy Evaluation and Plan of Treatment, dated 8/12/14, indicated the resident was readmitted to the facility after being admitted to the hospital secondary to a fall and subsequent hip fracture on the left hip resulting in no out of bed activity by the doctors and conservative hip fracture management with complete bed rest.

Based on observation, interviews, and record reviews, the facility failed to provide necessary care and supervision to prevent injury for 1 of 1 sampled resident (Resident 1) who was identified as at high risk for falls and needed extensive assistance (staff provide weight-bearing support) from staff during dressing and toileting. The certified nursing assistant (CNA 1) helped Resident 1 to the bathroom on 8/4/14 and left the resident in the bathroom unsupervised. The occupational therapist (OT) assessed the resident as needing contact guard assist ((CGA), staff needed to put one or two hands on the resident's body to help with balance) for lower body dressing (donning and doffing pants, socks, shoes, underwear), and stand by assist ((SBA) for toileting, staff needed to be close by for safety, in case the resident lost balance or needed help to maintain safety during the task being performed). Resident 1 attempted to put his underwear on by himself and fell to the floor. This deficient practice resulted in Resident 1 falling to the floor, sustaining a left hip fracture requiring a transfer to a general acute care hospital (GACH) for two days for orthopedic consult (branch of surgery concerned with conditions involving the musculoskeletal system) and pain control for severe pain. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), a (standardized assessment and care screening tool), dated 5/28/2014, indicated Resident 1's cognition was intact (the brain/mind processed information in a normal way). The resident was able to make his needs known and understand others, but required extensive assistance from staff with a one person physical assist for transferring, personal hygiene, and toilet use. The resident used a walker, wheelchair, and left lower extremity prosthesis (an artificial body part, such as a leg) to get around the facility. During an observation, on 8/22/14, at 1:05 p.m., Resident 1 was lying in bed. The resident's left hip area was covered with green color bruises. During a concurrent interview, Resident 1 stated he fell and broke his hip. When asked how was the pain, the resident stated, "Oh this pain is killing me." On 8/22/14, at 1:10 p.m., during an interview, Resident 1 stated he fell in the bathroom. The resident stated it was a routine for the nurse to help him to the bathroom and leave him. The resident stated when he was done using the bathroom he would clean himself up, and push the call light for the nurse to help him out of the bathroom. The resident stated he had done this routine many times in the past. Resident 1 stated, this time when he stood to pull his underwear up, his body turned and he fell to the floor. Resident 1 stated after he landed on the floor, he saw his nonskid sock (socks with rubber bottoms to help prevent falls) was on crooked (the rubber part of the sock was on top of his right foot instead of the bottom,) On 8/22/14, at 2:10 p.m., during an interview, CNA 1 stated on 8/4/14, Resident 1 asked her to help him to the bathroom, so she brought the wheelchair to the resident. CNA 1 stated the resident was able to transfer himself to the wheelchair, then she pushed the resident to the bathroom. CNA 1 stated while in the bathroom, the resident transferred himself from the wheelchair to the toilet by grabbing on the two grab bars in the bathroom (on the left and right of the toilet.) CNA 1 stated she pushed the wheelchair out of the bathroom, closed the bathroom door for privacy, and left the room to help other residents. CNA 1 stated she had taken care of Resident 1 before, and was familiar with the resident's needs. CNA 1 stated whenever she helped Resident 1 to the bathroom; the resident would transfer himself from the wheelchair to the toilet, cleaned himself, pull his underwear up (fully clothed), and push the call light for her to bring the wheelchair back to the bathroom. CNA 1 stated all she needed to do for the resident was to bring the wheelchair and push him out of the bathroom. CNA 1 stated Resident 1 liked to be independent (do things by himself); he did not like the staff to help with the tasks, and he would normally perform all the tasks by himself. CNA 1 stated the resident was wearing a non-skid sock but she did not check to see if the sock was properly placed. A review of a Fall Risk Assessment (an assessment of the resident's status in eight clinical condition parameters such as: level of consciousness, history of falls, ambulation, elimination status, vision status, gait/balance, systolic blood pressure, medications, and predisposing diseases), dated 7/4/14 and 8/4/14, indicated that Resident 1 had a score of 14. According to the assessment, a total score of 10 or above represents a high risk for falls. A review of Resident 1's nursing care plan, dated 6/29/14, indicated the resident was at risk for fall or injury due to left leg amputation, generalized weakness, improper posture, receiving hypertension and psychoactive medications. The staffs approach interventions were to keep close observation during activities to minimize potential for fall and to have physical therapist/occupational therapist (OT/PT) evaluation done if indicated. A review of nursing care plan, dated 6/29/14, indicated Resident 1 required assistance in transferring, dressing, toilet use, and personal hygiene due to multiple medical conditions. The staff interventions were to assist the resident with transfer, locomotion, and toileting. A review of the "Occupational Therapy Discharge Summary", dated from 7/29/14 to 8/1/14, indicated for lower body dressing the resident needed CGA and for toileting the resident needed SBA. During an interview with the occupational therapist (OT) on 8/22/14, at 2:30 p.m., she stated the resident was assessed as not safe (potential for fall and injuries) to be by himself for toileting and lower body dressing because the resident could not perform those tasks safely by himself. The OT further stated if the resident was assessed to be safe, she would document "independent" in her assessment instead of CGA and SBA. The OT stated according to the resident's condition and her assessment, staff needs to be with the resident at all times during toileting because it was not safe for the resident to be by himself. On 8/22/14, at 3:15 p.m., during an interview, the licensed vocational nurse (LVN 1) stated while she was passing her morning medication she heard a loud noise coming from Resident 1's room. LVN 1 stated as she rushed into the resident's room and opened the bathroom's door she saw the resident lying on the floor on his left side. LVN 1 stated at that time there was no other staff with the resident or near by the resident's room. LVN 1 stated Resident 1 was able to perform some tasks by himself, but for toileting, the resident needed supervision (staff to be there with the resident.) LVN 1 stated even when the resident asked staff to provide privacy, staff needed to provide privacy by closing the bathroom door, but to stay in the room with the resident to periodically check on the resident for safety. LVN 1 stated after the resident fell , she asked CNA 1 why she did not stay in the room to check and help Resident 1. CNA 1 stated she left the room because other residents called her for help. A review of the physician's orders [REDACTED]. A review of Resident 1's final x-ray report dated 8/4/14, indicated the resident sustained [REDACTED].) A review of a physician's orders [REDACTED]. A review of the emergency department triage note, dated 8/04/14, at 1:03 p.m., indicated Resident 1 arrived from the nursing home for a slip and mechanical ground level fall in the bathroom, leading to injury to left hip. The resident complained of left hip pain, rating 7 on a scale of 0 to 10 (0 = no pain, 7 = severe pain, and 10 = unimaginable pain.) The resident received trauma (Ultram, pain medication) 50 milligrams (mgs) tablet one time for left hip pain. A review of the GACH's medication record, dated 8/4/15 to 8/6/14, indicated Resident 1 required and received four dosages of morphine (pain medication) 2 mgs via intravenous push (IVP) for severe pain, and seven dosages of Norco (pain medication) 5/325 mg tablets by mouth for moderate pain. A review of the GACH's orthopedic consultation report dated 8/4/14 indicated Resident 1 sustained a left hip fracture after a fall at the skilled nursing facility where he resides. The report indicated the resident's pain may be treated conservatively with bed rest for 2-4 weeks, pain control, and serial radiographs (x-ray) on a weekly basic due to multiple medical problems. According to the report, surgery may still be done in the near future if the fracture should displace or the resident had severe hip pain. A review of the facility's investigation report, dated 8/4/14, indicated the resident had the capacity to understand and make decision. The resident was aware that he needed assistance and he understood the risks and consequences, including a fall with serious injury. The resident stood up and tried to pull his underwear without calling for help, as a result he fell and sustained a hip fracture. A review of the interdisciplinary team (IDT) notes, dated 6/30/14 and 7/8/14 (prior to the fall incident) indicated there was no documentation regarding the team's identifying Resident 1's refusal of staff's help during toileting and/or risks regarding fall being explained to the resident. A review of the facility's policy and procedure titled, "Routine Nursing Care" dated 1/1/2002, indicated toileting-assistance will be provided for all residents at a level determined by the functional skills of the resident. According to the facility's undated policy and procedure titled, "Assisting a Resident to walk to the Bathroom" indicated to provide the resident with as much privacy as possible, tells the resident to call or signaled for you; wait outside the door, if permitted. A review of the "Occupational Therapy Evaluation and Plan of Treatment", dated 8/12/14, indicated the resident was readmitted to the facility after being admitted to the hospital secondary to a fall and subsequent hip fracture on the left hip resulting in no out of bed activity by the doctors and conservative hip fracture management with complete bed rest.

Based on observation, interview, and record review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR - an emergency procedure performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing) in the event that a person has no pulse or weak pulse (a rhythmical throbbing of the arteries as blood is propelled through typically felt in the wrists or neck) and is not breathing or not breathing adequately, in accordance with the facility's policy and procedure titled, "Cardiopulmonary Resuscitation and Basic Life Support," for one of two sampled residents. (1). Resident 1, who had a Physician order [REDACTED]. room. CNA 1 then called Licensed Vocational Nurse (LVN) 1 for help and LVN 1 called Registered Nurse (RN) 1 for assistance. RN 1 assessed the resident as being unresponsive and not breathing; however, CNA 1, LVN 1, and RN 1 did not immediately start the CPR. Instead, Resident 1 was placed on the bed, while CNA 1 was cleaning him. LVN 1 stated she ran out of the resident's room to get a pulse oximetry (a machine used to measure the oxygen level in the blood) and the blood glucose monitoring machine (checks the level of sugar in the blood). RN 1, who brought the large oxygen tank that was almost empty, also left the room to get another oxygen tank, and to check the resident's code status (the words used to describe the procedures that can be performed on a patient if the heart stops or the lungs fail) which was found in his clinical record. It was only after identifying the resident's code status as full code, and after calling the paramedics, did RN 1 tell the staff to initiate CPR. The delay in initiating CPR when Resident 1 was found to be unresponsive and not breathing led to the resident's death. The Certificate of Death indicated Resident 1's place of death was at the facility and the immediate cause of death was cardiopulmonary arrest (a sudden stop in effective blood circulation due to failure of the heart to contract effectively or not contracting at all). Findings: On [DATE] at 7 a.m., an unannounced visit was made to the facility to investigate an entity self-reported incident reporting Resident 1's death at the facility. At 7:10 a.m., in an interview with the Director of Nursing (DON), she stated on [DATE], during the ,[DATE] shift, Resident 2 flagged CNA 1, stating "man down." The DON stated when CNA 1 entered Resident 1's room, she found him lying face down on the floor with the lower half of his body in the bathroom and the upper half in the room. She then called LVN 1 and with the assistance of RN 1, they performed CPR and called the paramedics. When the paramedics arrived at the scene, they stated the resident had expired. At 8 a.m., in an interview with Resident 2, she stated as she was standing in the doorway, she witnessed Resident 1 crashing down to the floor without saying anything. She then flagged a nurse to come and help. At 10:20 a.m., CNA 1 stated she was flagged by Resident 2, stating "man down." CNA 1 stated she saw Resident 1 face down on the floor, unresponsive. She then called LVN 1 on her communication radio and went to the door to flag her down. When asked if she initiated CPR at that time, she stated no. CNA 1 further stated LVN 1 came and both of them tried to take Resident 1's vital signs, but they were not able to obtain them. CNA 1 stated RN 1 called CNA 2 to help put the resident to bed. When they put the resident to bed, he was observed to have blood on his face and bowel movement on his shirt. CNA 1 stated she tried cleaning him up. CNA 1 stated LVN 1 did not start CPR at the time because RN 1 and LVN 1 left the room to get an oxygen tank. CNA 1 stated she also noticed the big oxygen tank brought in by RN 1 was kind of low on oxygen. At 9:27 a.m., LVN 1 stated she was a couple of rooms down the hallway when CNA 1 flagged her to Resident 1's room. When she entered the room, she saw Resident 1 with his face down on the floor, wearing only a shirt. LVN 1 stated the resident was not responding and/or breathing. LVN 1 stated when she opened one of the resident's eyes, the eye was not moving. When asked if she started CPR at that time, LVN 1 stated no. According to LVN 1, she called RN 1 on her communication radio to come to Resident 1's room, and when RN 1 inquired about the resident's blood sugar levels, LVN 1 stated she ran out of the room to get the pulse oximetry (a machine used to measure the oxygen level in the blood), and the blood glucose monitoring machine (checks the level of sugar in the blood) to bring back to the room. LVN 1 stated when she returned to the room, she saw RN 1 had brought a large oxygen tank, but she stated that was not going to work because it did not have enough oxygen in the tank. RN 1 then asked for another tank. According to LVN 1, she and RN 1 both left Resident 1 in order to get another tank. At 10:48 a.m., CNA 2 stated on the day of the incident, he was called on the communication radio to go to Resident 1 to assist the others in putting him back to bed. CNA 2 stated the resident's carotid (neck) pulse was very weak, and at the same time, LVN 1 told them the resident was not breathing. CNA 2 stated LVN 1 was checking for the resident's blood sugar levels at the same time RN 1 brought a large oxygen tank, which he thought was kind of empty. According to CNA 2, they did not start CPR because RN 1 and LVN 1 both left the room to get a smaller oxygen tank and an oxygen concentrator. During the interview, CNA 2 was asked if anyone started CPR by starting chest compressions when the resident was not breathing and had a very, very weak pulse, CNA 2 stated no. Further interview with CNA 2, he stated that right before the paramedics arrived, he was told to start CPR by doing chest compressions while LVN 1 delivered oxygen using an ambu bag (a self-inflating bag that is hand-held used to provide oxygen to patients who are not breathing or not breathing adequately). CNA 2 stated he started CPR before the paramedic's arrival and once they arrived, the paramedics told him to stop because they wanted to hook the resident up to a machine. On [DATE] at 2:30 p.m., RN 1 stated on [DATE] at 4:50 p.m., LVN 1 called her to Resident 1's room, so she grabbed a big oxygen tank, and asked LVN 1 about the resident's blood sugar levels because he had a hypoglycemic (low blood sugar) reaction before. RN 1 stated when she entered the room, the resident was still lying on the floor. She tapped the resident's shoulders several times and called out his name but he was not responding and was not breathing. So RN 1 stated she instructed the staff to place the resident on the bed. Further interview with RN 1 indicated she left Resident 1's room to check his code status (describes what type of intervention (if any) a health care team will conduct in the event of a medical emergency), and found he was full code, that was when she called the paramedics for assistance. RN 1 stated since the big oxygen tank she brought initially was almost empty, upon return, she grabbed another tank and brought it back to the room. At that time, LVN 1 told her the resident's oxygen saturation (which measures the saturation of oxygen in the blood, with normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low) was at 85 percent (normal adult ranges are between 90 to 100 percent). According to RN 1, they then administered oxygen using a non-breather mask (a mask used to deliver oxygen) and started CPR. RN 1 stated that shortly after they started CPR, the paramedics arrived and she told someone else to take over in order to answer their questions. According to RN 1, the paramedics then connected the resident to the electrocardiogram machine (a machine that checks for problems with the electrical activity of the heart). At 5 p.m., the paramedics stated the resident had expired. During the interview, RN 1 stated she was the designated team leader responsible for directing team members during the code. RN 1 was asked that instead of leaving the resident, could she have asked someone else to gather the supplies and to check the chart for the resident's code status, she paused and stated, "I guess yes." RN 1 was also asked why she did not instruct CNA 1 and LVN 1 to start the CPR when they first found the resident unresponsive and not breathing, she stated because the resident had a weak pulse. When RN 1 was asked how weak (beats per minute) the resident's pulse was, she stated it was just very weak. A review of the clinical records indicated Resident 1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - Standardized Assessment and Care Planning Tool) assessment dated [DATE], indicated Resident 1 was alert and oriented, needed extensive assistance (staff provide weight bearing support) from staff for toileting, personal hygiene, and was frequently incontinent (lose control) of bowel and bladder functions. The POLST dated [DATE], indicated Resident 1's legal decision maker indicated to perform CPR in case of a medical emergency. A review of the Licensed Personnel Weekly Progress notes dated [DATE] at 4:50 p.m., indicated RN 1 was called to Resident 1's room and saw the resident lying on the floor. The notes indicated the staff placed the resident on the bed and noted there was injury to his mid forehead with minimal bleeding. First aid was done. The resident was unresponsive at this time but RN 1 was able to palpate (feel) a weak carotid pulse. However, the notes did not indicate how weak was Resident 1's pulse. The Licensed Personnel Weekly Progress notes, dated [DATE] at 4:52 p.m., indicated RN 1 documented Resident 1's oxygen saturation reading was at 80 percent on room air (without using artificial oxygenation). The notes indicated oxygen at 15 liters per minute using a non-breather mask (is a device used in medical emergencies that requires oxygen therapy but used when the patient can breathe unassisted,) was administered which only increased the oxygen saturation to 87 percent. The progress notes further indicated the resident's blood pressure, respirations, and the carotid pulse could not be obtained. The notes indicated CPR was initiated by other staff while RN 1 called paramedics for assistance. At 4:55 p.m., when the paramedics arrived, the facility gave report before the paramedics took over the treatment. At 5 p.m., "paramedic pronounced resident expired/asystole (absence of heartbeat) from the electrocardiogram (EKG - a test that checks for problems with the electrical activity of the heart) result." According to the death certificate, Resident 1's place of death was at the facility and the immediate cause of death was cardiopulmonary arrest (a sudden stop in effective blood circulation due to failure of the heart to contract effectively or not contracting at all). A review of the American Heart Association Adult Basic Life Support for Healthcare Providers (a quick reference) dated 2011, indicated when the resident is unresponsive, not breathing or has no normal breathing, first activate emergency response system (call for help or send someone to get help). Check the pulse. If there is definite pulse, give 1 breath every 5 - 6 seconds, and recheck the pulse every 2 minutes. If there is no pulse, begin cycle of 30 chest compressions, followed by 2 breaths, and keep repeating until help arrives. The facility's policy and procedures for emergency procedure - Cardiopulmonary Resuscitation dated ,[DATE], it indicated [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body. The chances of surviving a sudden [MEDICAL CONDITION] may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions decrease CPR effectiveness. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless it is known that a do not resuscitate order (do not do CPR) and or there are obvious signs of irreversible death. The facility shall designate a team leader who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. The facility's policy also indicated the procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility basic life support (BLS) training material. The BLS sequence of events referred to as C-A-D (chest compressions, airway, and breathing) is initiated when the adult victim is unresponsive and not breathing normally without assessing the victim's pulse.

Based on observation, interview, and record review, the facility failed to thoroughly investigate a resident's fall incidents by ensuring that all risk factors were identified, evaluated and analyzed according to the facility's policy and procedure for one out of 24 sampled residents (Resident 6). This failure resulted in Resident 6's repeated occurrence of an avoidable fall incident, two fall incidents for the month of 5/13, and laceration (a deep cut or tear) to the top of his head requiring 24 surgical staples (special medical tool used to keep deep cuts closed) at the acute care hospital. Findings: A review of the Resident 6's clinical record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].), history of stroke (blood flow to a part of the brain stops), diabetes (a metabolic disease in which the body's inability to produce any or enough insulin causing elevated levels of sugar in the blood leading to dizziness and drunk-like behavior), and history of craniotomy (a surgical opening in to a skull to expose the brain). The Minimum Data Set (MDS, an assessment and care screening tool), dated 7/26/13, indicated Resident 6 had memory problems, usually understand or is understood, required extensive assistance (weight bearing support and at times requires full staff performance) for bed mobility, transferring, ambulation, dressing, hygiene, and was continent (had control) of bowel and bladder functions. The care plan titled at risk for falls and serious injury, dated 4/25/13, identified Resident 6 to be at risk due to multiple medications (use of three different medications that could contribute to his risk for falls) and hypnotic (medication used to induce sleep) use. The interventions included to provide assistance as needed. On 4/26/13, the same care plan identified the resident forgetting his single point cane; he leaves it behind wherever he sits down. The interventions included to maintain hazard free environment (not specific) and to remind the resident to always have his cane within his reach when ambulating. The physician's orders [REDACTED]. A review of the licensed personnel weekly progress notes, dated 5/6/13 at 3:20 p.m., indicated Resident 6 claimed he fell in the morning. The investigation report, dated 5/6/13, indicated the resident said while he had his cane, he lost his balance and fell in front of the sink when washing his hands. The plan was to constantly remind the resident to use the call light when needing help, and to frequently check (did not indicate how often) the resident in order to assist him with his needs as anticipated. There was no documented evidence the staff attempted to evaluate Resident 6's use of Restoril (hypnotic) medication and the combination of its use with the other medications (antihypertensive medications used for treatment of [REDACTED]. A review of the medication record, dated 5/5/13 at 9:30 p.m., prior to the incident, indicated Resident 6 was administered Restoril for insomnia. There was no documented evidence the staff attempted to provide non-pharmacological intervention prior to the administration of Restoril. Furthermore, there was no documentation that staff were monitoring the resident's hours of sleep. According to the U.S. National Library of Medicine National Institute of Health (a government website) and according to the medication record dated 5/13, the side effects of Restoril was listed as blurred vision, drowsiness, and dizziness. A review of the licensed personnel notes, dated 5/10/13 at 12:30 a.m., indicated Resident 6 fell for the second time. The notes indicated he was found lying on the floor in the hallway with the linen barrel on top of his legs. There was no indication the resident was using his cane. A review of the investigation report, dated 5/10/13, indicated the resident sustained [REDACTED]. Resident 6 came back to the facility with 24 staples to top of his head. A review of the medication record, for 5/9/13 at 9 p.m., prior to the second fall incident, indicated Resident 6 was administered Restoril again for insomnia. According to the facility's investigation report, dated 5/10/13, indicated Resident 6 was wearing his regular slippers and was holding on to the hamper which was not a stable or strong support causing him to fall. The plan was to provide a hazard free environment (not specific), observe and monitor the resident's whereabouts when hampers and or other wheeled objects are being used in the hallway (not specific). There was no documented evidence the staff attempted to evaluate Resident 6's use of Restoril (hypnotic) medication and the combination of its use with the other medications (antihypertensive medications used for treatment of [REDACTED]. Furthermore, there was no documented evidence the staff investigated, identified and re-evaluated the use of the cane. On 9/15/13 at 11:48 a.m., during an interview, the director of nursing (DON) could not provide further evidence of collection and evaluation of all risk factors for the two falls including the use of Restoril and re-evaluation for the use of multiple medications. The DON could not tell why the resident was not using his cane on 5/10/13 at 12:30 a.m. and if he was reminded to use the cane prior to the fall (one of the interventions on the risk for fall care plan), and further evaluation of the resident's environment by keeping it hazard free when the resident needed to use an assistive device while ambulating as per plan of care. On 9/23/13 at 3:08 p.m., the resident was observed walking with a walker down the hallway, stood still and fell asleep while standing. On 9/24/13 at 8:30 a.m., the resident was walking with his walker close to the nurses' station then fell asleep while standing in front of the station. On 9/25/13 at 9:30 a.m., the licensed vocational nurse (LVN 5) said the resident's behavior of falling asleep while standing has been ongoing. When asked why the staff were documenting that there were no side effects of sleepiness, on the medication administration record, she did not answer. A review of the facility's policy and procedure for clinical protocol for falls, revised 4/2007, indicated to assess all current medications especially those associated with dizziness or lethargy, risk factors for using multiple medications, environmental hazards. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management.